bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP210: Transthoracic Echocardiographic Predictor for Long-Term Outcomes in Real-World Korean Patients With Atrial Fibrillation-Related Stroke: A Multi-Center Cohort Study
Authors: Jung Jin-Man , Seo Woo-Keun , Kim Jeong-min , Park Kwang Yeol , Song Tae-jin , Kim Yong-jae , Kim Bum Joon , Heo Sung Hyuk , Oh Kyung-mi , Kim Chi Kyung , Yu Sungwook , Park Jong-ho , Choi Jay Chol , Park Man-seok , Kim Joon-tae , Bang Oh Young , Chung Jong-won , Hwang Yang-ha , Kim Geong-moon
Published: January 2019

Background:
While transthoracic echocardiography (TTE) is performed to find out potential embolic sources and certain cardiac abnormalities as a routine workup of stroke, clinical implication of echocardiographic findings for long-term outcomes in atrial fibrillation (AF)-related stroke patients has been unknown.

Methods:
This was a sub-study of K-ATTENTION (Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts), a multicenter-based cohort composed of prospective stroke registries from 11 tertiary centers. All stroke survivals enrolled in this study underwent TTE during hospitalization. Echocardiographic findings included left atrial (LA) diameter, left ventricular ejection fraction (LVEF), LV end-diastolic dimension (LVEDV), stenosis and regurgitation of mitral and aortic valves, and peak trans-mitral filling velocity/mean mitral annular velocity during early diastole (E/e’ ratio). Indexed-LA size was acquired as dividing LA size by body surface area. LV systolic function was grouped into normal (LVEF≥55%), mild (55%>LVEF>40%), and severe (LVEF≤40%). Level of E/e’ ratio associated with LV filling pressure was divided into normal (<8), borderline (8-15) and increased (≥15). Outcomes of interest were recurrent stroke, coronary artery disease, and vascular, and all-cause death. We used Cox regression multivariable analyses adjusted by confounding factors.

Results:
A total of 1952 patients were finally included. Over a mean follow-up of 1.72±1.31 years, 140 patients had recurrent stroke, 36 had coronary artery disease, and of 236 fatalities, 33 died of a vascular cause. Multivariable analyses demonstrated that severe LV systolic dysfunction was associated with a higher risk of coronary artery disease (hazard ratio [HR] 3.80, 95% confidence interval [CI] 1.53-9.41), vascular death (HR 3.59, 95% CI 1.42-9.10) and all-cause death (HR 2.29, 95% CI 1.47-3.56).

Conclusions:
LV ejection fraction could be important predictor for long-term outcomes in AF-related stroke.
Abstract WP213: Age-specific Black-white Differences in 30-day Post-Stroke Fatality in the National Regards Study
Authors: Howard Virginia J , Albright Karen C , McNeill Stephanie A , Kwon Soo Y , Lichtman Judith H , Kleindorfer Dawn O , Kissela Brett M , Rhodes J D , Safford Monika M , Howard George
Published: January 2019

Introduction:
Previous studies have suggested that post-stroke case fatality in blacks is similar to or lower than that in whites. Black-white (B-W) differences in case fatality have not been examined within age strata.

Methods:
This study was conducted in REGARDS, a national population-based cohort enrolled in 2003-2007, followed for stroke events through September 30, 2017 and deaths through March 31, 2018. Medical records of suspected stroke events were retrieved and adjudicated by physicians. Case fatality (defined as death within 30-days of stroke event) following ischemic stroke was examined within age strata (45-64, 65-74 and 75+) among REGARDS participants aged 45+ who were stroke-free at baseline. Logistic regression was used to examine B-W differences in case-fatality after adjustment for sex, additional adjustment for the “Framingham risk factors,” and additional adjustment for socio-economic status (income and education).

Results:
There were 1,104 physician-adjudicated incident ischemic stroke events among 28,253 participants over a median of 9.4 years of follow-up. Case fatality was 9.8% (63/643) in whites and 6.1% (28/461) in blacks (B-W Odds Ratio (OR) = 0.60; 95% CI: 0.39 - 0.95). Case fatality significantly increased across age strata in whites (p
trend
≤ 0.0001) but not blacks (p
trend
= 0.85) (see table.) At ages 45-64, the sex-adjusted B-W case fatality OR was 1.33 (95% CI: 0.56 - 3.11), and decreased to 0.42 (95% CI: 0.19 - 0.93) for ages 75+ (p
trend
= 0.013). Adjustment for risk factors and SES did not mediate the trend for lower case fatality in blacks at older ages (p
trend
= 0.012).

Conclusions:
These data confirm the lower stroke case-fatality in blacks compared to whites across the age-span of our study, and suggest that the benefit among black stroke patients is greatest at older ages.
Abstract WP217: Light Alcohol Increment May Have Protective Effect on Cardiovascular Disease Occurrence Among Nondrinkers
Authors: Chang Jun-Young , Choi seulggie , Jang Se Young , Park Sang Min
Published: January 2019

Introduction:
Light to moderate amount of alcohol intake may have preventive effect on cardiovascular disease. Even though the benefit of light to moderate alcohol consumption, nondrinkers are not advised to start drinking. The purpose of our study is to evaluate the association between alcohol consumption increment and primary prevention of major adverse cardiovascular events (MACE), such as stroke, coronary artery disease, or cardiovascular death, among nondrinkers.

Methods:
The National Health Insurance Service (NHIS) data collected from 2007 to 2013 was used for the analysis. Among the subjects who completed data on their drinking status both the first (2007-2008) and the second (2009-2010) medical checkup, the subjects who respond not to drink at all at the first NHIS medical checkup were included. Alcohol increment, measured by glass per day at the second medical checkup, was categorized into 0, 0< ≤1, 1< ≤ 2, 2< ≤4, >4. Hazard ratios (HRs) and 95% confidence interval (CI) for alcohol increment and MACE occurrence were calculated using Cox regression analysis.

Results:
Among 284511 subjects who performed both first and second medical checkup, nondrinker was 115870 (40.7%). Compared with the group who maintain nondrinking at the second checkup, the risk of MACE significantly decreased among the subjects with alcohol increment equal or less than 1 glass per day (HR 0.78, 95% CI 0.64-0.93). The risk of stroke, coronary artery disease, and all cause death were also decreased only the group with alcohol increment equal or less than 1 glass per day (stroke, HR 0.89, 95% CI 0.60-0.99; coronary artery disease, HR 0.74, 95% CI 0.56-0.98; all cause death, HR 0.75, 95% CI 0.58-0.97). The protective effect of light alcohol increment (0< ≤1) on MACE was not maintained among the subgroup with female, history of hypertension, current smoking.

Conclusion:
Light alcohol increment equal or less than 1 glass per day from nondrinking significantly reduced the risk of MACE occurrence.
Abstract WP22: A New Technique for the Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography
Authors: Qureshi Adnan I , Gurkas Erdem , Aytac Emrah , Asif Ahmer , Waqas Muhammad A , Wallery Shawn S
Published: January 2019

Background:
Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography.

Methods:
We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size 0.466 mm
3
). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.5 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0=reduction, 1=no change, 2=increase) and total rCBV change scores were summated. The rCBV score values were averaged between the two observers for each patient. Mean arterial pressure was monitored at baseline and at 1 minute intervals post nicardipine administration for 5 minutes.

Results:
Twenty-five patients with internal carotid artery stenosis (n=18; 0%-90% in severity) or extracranial vertebral artery stenosis (n=7; 0%-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; p=0.68 by ANOVA). There was an average (±SD) reduction of mean arterial pressure of 14mmHg ± 7.5 after intra-arterial nicardipine. There was no correlation between the magnitude of mean arterial pressure reduction post nicardipine (regression coefficient -0.13; p=0.38) or between the severity of stenosis (regression coefficient -0.04; p=0.29) and rCBV change scores.

Conclusions:
We describe a new technique for selective assessment of cerebral vasodilatory response in the affected arterial distribution during catheter-based cerebral angiography.
Abstract WP222: Relationship between Lambl’s Excrescences and Embolic Strokes of Undetermined Source
Authors: Salehi Omran Setareh , Chaker Salama , Lerario Michael P , Merkler Alexander E , Navi Babak , Kamel Hooman
Published: January 2019

Background:
About one-fifth of ischemic strokes lack a determined etiology and can be classified as embolic strokes of undetermined source (ESUS). Lambl’s excrescences are commonly seen on cardiac valves during echocardiography, and only a few studies have addressed whether they may be a source of thrombus formation and subsequent embolization. We therefore evaluated whether Lambl’s excrescences are associated with ESUS.

Methods:
We performed a case-control analysis using data from the Cornell AcutE Stroke Academic Registry (CAESAR), a prospective registry of all patients with stroke at our hospital since 2011. Stroke etiologies were adjudicated by a panel of neurologists using the TOAST and ESUS criteria. We included only patients who underwent transthoracic (TTE) or transesophageal (TEE) echocardiography within 6 months of hospital discharge. Cases were all ESUS patients and controls were all patients with non-cardioembolic stroke (small- or large-vessel strokes). Multiple logistic regression was used to evaluate the association between Lambl’s excrescence and ESUS after adjustment for demographics, comorbidities, and mode of echocardiography (TTE vs TEE).

Results:
Among 2,116 patients registered in CAESAR from 2011-2016, 923 patients met the criteria for this analysis, including 530 with ESUS and 393 with small- or large-vessel strokes. Patients with ESUS were more often women and had fewer stroke risk factors. Lambl’s excrescences were identified in 47 (8.9%) patients with ESUS and 11 (2.8%) patients with small- or large-artery strokes. The majority (54/58) of Lambl’s excrescences were visualized on TEE, and ESUS patients were much more likely to undergo TEE. After adjustment for demographics, comorbidities, and mode of echocardiography, we found no association between the presence of Lambl’s excrescences and ESUS (OR 0.9; 95% CI 0.4-2.3).

Conclusion:
While Lambl’s excrescences are commonly seen on echocardiograms performed to evaluate ischemic stroke, we found no association between Lambl’s excrescences and ESUS. These results do not support the hypothesis that Lambl’s excrescences are an occult cause of ESUS.
Abstract WP228: Seasonal Variation of Stroke Subtypes Incidence in Population-based Study in Shiga Prefecture, Japan
Authors: Fujii Takako , Arima Hisatomi , Takashima Naoyuki , Kita Yoshikuni , Miyamatsu Naomi , Tanaka Sachiko , Miura Katsuyuki , Nozaki Kazuhiko
Published: January 2019

Introducution:
Incidence rates of stroke have been shown to have seasonal variations. However, current evidence is limited for Japanese populations. The aim of this study was to investigate seasonal variation in incidence of stroke and its subtypes in a general population of 1.4 million Japanese.

Methods:
Shiga Stroke Registry is an ongoing population-based registry of stroke, which covers approximately 1.4 million residents of the Shiga prefecture in central Japan (located central part of Honshu Island). There is an integrated surveillance system involving the registration of cases among a network of all acute care hospitals with neurology/neurosurgery facilities and smaller hospitals with rehabilitation facilities. A total of 2,753 adult (18 years) cases of stroke (1838 ischemic stroke,713 intracerebral hemorrhage,196 subarachnoid hemorrhage and 6 other/unclassified), who were registered in 2011, were included in the present analysis. Incidence of stroke in each month of the year was estimated using 2011 vital statistics by a Poisson regression model with adjustment for age and gender.

Results:
The age- and gender-adjusted incidence rates of total stroke were 180, 176, 177, 162, 163, 149, 134, 128, 133, 152, 144, 177per 100,000 person-years from January to December, respectively. Incidence rates in summer were lower in summer (July to September) than those in winter (December to February) or spring (March to May). Similar patterns were also observed for both ischemic stroke and intracerebral hemorrhage although seasonal variation was much more remarkable for intracerebral hemorrhage.There were no clear differences between summer and winter for incidence rates of subarachnoid hemorrhage.

Conlusions:
Incidence rates of ischemic stroke and intracerebral hemorrhage seem to be high in winter and spring based on large-scale population-based stroke registry in Japan.
Abstract WP23: Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Acute Ischemic Stroke Patients
Authors: Knox Joseph , Ch'ang Judy , Murph Daniel , Halbach Van , Higashida Randall , Dowd Christopher , Hetts Steven , Amans Matt , Cooke Daniel
Published: January 2019

Introduction:
Arterial access is a technical consideration of mechanical thrombectomy that may affect procedure time. Few studies exist detailing the impact of aortic arch and carotid anatomy on procedure times and patient outcomes.

Methods:
We included 56 patients who underwent embolectomy with successful revascularization for acute ischemic stroke in the anterior circulation from a period of 01/2016-05/2018. The average age was 71 (+/- 17 years) with 39% being male. We calculated anatomic variables on the affected side from CT angiograms immediately prior to embolectomy including the medial-to-lateral span, as well as the anterior-to-posterior span, of both the aortic arch and carotid arteries. In addition, the take-off angle of the respective vessel (left common carotid or right brachiocephalic) was calculated. Charts were reviewed for procedural times and epidemiologic information (HTN, HLD, DM, CAD and Afib). Modified Rankin Scale (mRS) was calculated from PT/OT and outpatient neurology notes. Partial correlation coefficients were performed between anatomic variables, temporal variables and outcome variables after adjustment for age, gender and epidemiologic information.

Results:
There was a significant positive correlation between procedure time (time at groin puncture to time at reperfusion) and take-off angle. There were no other significant correlations between anatomic measures and procedure time. In addition, there was as a significant positive correlation between both procedure time and time from last seen normal to reperfusion and delta mRS (the difference between pre-stroke and post-stroke mRS). See table 1 for correlations.

Conclusion:
These results suggest that patients with larger take-off angles have an association with longer procedural times and worse outcomes. If these patients can be effectively identified prior to the procedure, operators could feasibly use a non-femoral access method initially to reduce procedure time.
Abstract WP234: Seasonal Differences in Sleep and Incident and Recurrent Strokes: Evidence From the Stroke Warning Information and Faster Treatment (SWIFT) Study
Authors: Roberts Eric T , Goldmann Emily , Appleton Noa , Boden-Albala Bernadette
Published: January 2019

Introduction:
Studies have documented seasonal patterns in stroke outcomes. While results are equivocal most report increased rates of these outcomes in the winter-spring and hypothesize this is explained by ambient temperature. Sleep disturbance, which also varies by season, may also explain this pattern. In this analysis we leverage a unique cohort to test whether incident or recurrent strokes vary by season, and whether this co-varies with sleep disturbance.

Methods:
Data comes from SWIFT, a stroke preparedness RCT conducted in northern Manhattan. Season of stroke was classified as winter (W; Dec - Feb), spring (Sp; Mar - May), summer (Su; Jun - Aug), fall (F; Sept - Nov). We restricted our analysis to the period Feb 2005 - Jan 2009. Incident strokes were individuals enrolled at baseline without radiological or clinical evidence of prior stroke. Recurrent strokes were captured as part of follow-up protocol. Sleep was measured with the MOS sleep scale, a 12 item questionnaire that produces 8 validated scales. For brevity, we report results using the sleep problem index 2 (9 questions). We assessed seasonal variation in stroke incidence using a one-way goodness of fit chi-square test assuming a distribution based on the number of days per season. The relationship between seasonal variation in stroke and sleep was assessed using ANOVA.

Results:
A total of 835 incident strokes were enrolled (25% white, 15.5% black, 53.1% Hispanic, 6.4% other; 49.8% female; mean age 63.4±15.6). Incident stroke was not significantly different by season (24.3% W; 22.8% Sp; 28.6% Su; 24.3% F; p=0.09). Mean sleep problems did not vary by season (32.3 W; 30.8 Sp; 31.9 Su; 31.4 F; p=0.86) for incident strokes. A total of 120 first recurrent strokes were captured (20.8% white, 17.5% black, 5% Hispanic, 6.7% other; 49.2% female; mean age 66.0±15.0). Recurrent stroke was significantly different by season (21.7% W; 14.2% Sp; 36.7% Su; 27.5% F; p<0.01). Mean sleep problems did not vary by season (32.4 W; 29.9 Sp; 31.7 Su; 35.1 F; p=0.70) for recurrent strokes.

Conclusion:
We find no variation in incident strokes but an increased proportion of first recurrent strokes in the summer. Neither incident nor recurrent strokes co-varied with sleep problems. Future studies in non-urban samples are warranted.
Abstract WP238: Race-Ethnic in Stroke Type and Outcome Among Hyperacute Cerebrovascular Disease Patients
Authors: Avila-Rinek Gilda , Sanossian Nerses , Starkman Sidney , Liebeskind David S , Sharma Latisha , Valdes-Sueiras Miguel , Restrepo Lucas , Conwit Robin , Hamilton Scott , Saver Jeffrey L
Published: January 2019

Background:
Prior studies have suggested race-ethnic differences in functional outcome, mortality, and use of comfort care after stroke, but have been limited by analysis of single stroke subtypes, lack of 3-month outcomes, and uncertainty whether delayed access to acute care was moderating response patterns.

Methods:
We analyzed all patients with final diagnoses of acute cerebral ischemia or intracranial hemorrhage enrolled within 2 hours of onset in the multicenter, prehospital NIH FAST-MAG trial. Self- or family-reported race-ethnicity was analyzed for relation to presenting stroke features, stroke subtype, and 3-month outcome.

Results:
Among 1616 hyperacute cerebrovascular disease patients (76.4% acute cerebral ischemia, 23.6% intracranial hemorrhage), race-ethnic frequencies were: white, non-Hispanic (W) - 55.5%, Hispanic (H) - 23.1%, Black (B) - 13.6%, Asian (A) - 8.4%. Ischemic vs hemorrhagic stroke differed by race-ethnicity, with hemorrhagic strokes more common in Hispanics (34.0%) and Asians (28.1%), compared with Whites (19.8%) and Blacks (17.8%), p = 0.0001. Age at time of stroke was highest in Whites (mean 73.1), vs H (65.5), B (63.5), A (66.9); and presenting severity (NIHSS) highest in A (mean 13.5) and H (12.7), vs W (10.7) and B (10.8). A greater dimorphic spread in 3 month outcomes was seen in W than in the other race-ethnic groups: Whites had more excellent (mRS 0-1) 3 month outcomes - W- 42.2%, B- 35.0%, H -28.4%, A-28.0%, p = 0.002; but Whites also had higher mortality by 3m - W-18.2%, A- 15.6%, H-13.0%, B-10.6%, p = 0.007. The race-ethnic difference in mortality was driven by hemorrhagic rather than ischemic strokes: ICH mortality - W-41.7%, A-19.4%, H-19.0%, B-18.2%; IS mortality: A-14.4%, W-13.5%, H-10.5%, B-9.4%.

Conclusions:
In this multicenter study of acute cerebrovascular disease in a diverse US region, notable race-ethnic differences included higher frequencies of hemorrhagic vs ischemic stroke among Hispanics and Asians; and more excellent, but also more fatal, 3 month outcomes among Whites. These patterns likely distinct different race-ethnic risk factor profiles shaping incident stroke type, as well as divergent sociocultural influences upon robust rehabilitation care and comfort care measures.
Abstract WP246: Long Term Risk of Hip Fracture After Ischemic Stroke
Authors: Salehi Omran Setareh , Murthy Santosh , Navi Babak B , Kamel Hooman , Merkler Alexander E
Published: January 2019

Introduction:
The recent Insulin Resistance Intervention after Stroke trial found that pioglitazone decreased the risk of stroke and myocardial infarction in patients with insulin resistance and a recent cerebrovascular event. However, by 5 years, patients receiving pioglitazone had a significantly increased risk of bone fracture requiring surgery or hospitalization compared to patients who received placebo (5.1% versus 3.2%). Data is lacking on the long-term real-world risk of bone fracture among patients with ischemic stroke.

Methods:
We performed a retrospective cohort study using inpatient and outpatient claims data between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients who were ≥65 years old and hospitalized with ischemic stroke, defined by validated
International Classification of Diseases, Ninth Revision, Clinical Modification
diagnosis codes. We excluded patients who had a prior or concurrent hip fracture diagnosis at the time of ischemic stroke. The primary outcome was hip fracture requiring hospitalization. Survival statistics were used to calculate incidence rates and Kaplan-Meier statistics were used to calculate cumulative rates of hip fracture.

Results:
Among the 1,952,305 beneficiaries in our sample, 60,099 patients developed an ischemic stroke in the absence of a prior or concomitant hip fracture. During 4.5 (±2.2) years of follow-up, the incidence of hip fracture was 1.6 (95% CI, 1.5-1.6) per 100 person-years in the patients with ischemic stroke versus 0.6 (95% CI, 0.6-0.6) per 100 person-years in patients without ischemic stroke. The cumulative 5-year rate of hip fracture was 7.6% (95% CI, 7.2-8.0%) among patients with ischemic stroke compared to 2.8% (95% CI, 2.8-2.9%) among the remaining Medicare beneficiaries.

Conclusions:
We found that the 5-year cumulative risk of hip fracture in the overall population of Medicare beneficiaries with ischemic stroke was approximately 7.5%.
Abstract WP273: Transesophageal and Transthoracic Echocardiography for Detecting Risk and Prognostic Factors in Embolic Stroke of Undetermined Source
Authors: Tateishi Yohei , Kanamoto Tadashi , Nakaoka Kenjiro , Fukushima Kaori , Kitanosono Hiroko , Shima Tomoaki , Ota Rie , Nagaoka Atsushi , Yoshimura Shunsuke , Miyazaki Teiichiro , Shiraishi Hirokazu , Morofuji Yoichi , Horie Nobutaka , Izumo Tsuyoshi , Tsujino Akira
Published: January 2019

Background:
It is unclear whether biomarkers of cardiac dysfunction are associated with embolic stroke of undetermined source (ESUS), while large patent foramen ovale (PFO) could relate to it.

Method:
We retrospectively review patients with ischemic stroke who underwent transesophageal echocardiography (TEE) from April 2012, to April 2018. The peak transmitral filling velocity/early diastolic mitral annular tissue velocity (E/e’) on transthoracic echocardiography was used to estimate diastolic dysfunction. PFO and left atrial appendage (LAA) flow velocity were evaluated by TEE. We compared risk factors, clinical characteristics and biomarkers of cardiac dysfunction (brain natriuretic peptide [BNP], left atrial diameter, E/e’, the presence of systolic dysfunction [EF<40%], and LAA flow velocity) adjusted for age and sex between ESUS with and without large PFO. We evaluated outcome at 90 days of ESUS patients who had biomarkers of cardiac dysfunction compared to that of ESUS patients with large PFO.

Results:
Among 294 patients with ESUS, 163 patients underwent TEE (55%). Of these, 24 patients (15%) had large PFO. Compared with ESUS patients with large PFO, those without large PFO had higher BNP (adjusted odds ratio 1.02, 95% confidence interval; 1.00-1.03, p=0.002) and higher E/e’ (1.25, 1.06-1.48; p=0.003). Left atrial diameter, EF<40% and LAA flow velocity were similar between ESUS with and without large PFO groups. (p=0.165, p=0.622 and p=0.859). ESUS patients without large PFO with both BNP level > 50 pg/ml and E/e’ > 12, which were median values, had worse clinical outcome compared to patients who have less cardiac biomarkers and patients with large PFO. (p=0.005)

Conclusion:
ESUS Patients without large PFO often have biomarkers of cardiac dysfunction. The clinic outcome of ESUS patients without large PFO who have biomarkers of cardiac dysfunction could be worse than that of ESUS patients with large PFO.
Abstract WP283: High Rates of ASPECTS Decay Leading to Ineligibility for Thrombectomy in Patients Transferred to a Comprehensive Stroke Center Covering a Large Geographic Area
Authors: Ahmed Syed Uzair , Whelan K Ruth , Hunter Gary , Peeling Lissa , Kelly Michael E
Published: January 2019

Introduction:
Endovascular therapy has revolutionized acute stroke management associated with large vessel occlusion (LVO). The province of Saskatchewan currently has 8 primary stroke centers (PSC) and 1 comprehensive stroke center (CSC) spread over a large geographical area. Seventy three percent of the population lives outside the Saskatoon metropolitan area, which houses the province’s single comprehensive stroke centre. Geography remains a significant barrier to providing endovascular therapy in a timely manner to eligible patients, knowing that the time to recanalization is a vital variable in clinical outcome. We aim to quantify the distance and time to transfer of patients to the CSC, and determine factors associated with clinically significant evolution of infarct during transfer.

Methods:
We completed a retrospective analysis of all acute stroke patients with LVOs who were transferred from PSCs to the CSC for possible endovascular therapy in Saskatchewan from July 2016 - July 2018. Along with patient, imaging, and outcome specific factors, detailed transfer data including modality, time, and distance were collected.

Results:
Sixty-nine LVO patients were transferred from PSCs to the CSC with intention to treat with mechanical thrombectomy. Upon reassessment at the CSC, 32 patients (46%) no longer qualified for thrombectomy, due to progression of stroke with ASPECTS score decay. Inter-facility deterioration risk factors were assessed using transfer metrics, patient characteristics, and initial imaging findings at the PSC to understand this patient population better. Distance to the PSC and distance from PSC to CSC were the most significant contributors to ASPECTS decay.

Conclusions:
Almost half of the patients transferred to the CSC with intention to treat with endovascular thrombectomy became ineligible during transfer. Since the large geographic area covered by the CSC leads to a significant cost burden associated with transfers, we aim to optimize transfer protocols to better serve the outlying areas.
Abstract WP286: Auto-launching of Interfacility Transport to Referring Hospitals for Presumed Emergent Large Vessel Occlusion Strokes May Decrease Time to Mechanical Thrombectomy and Improve Outcomes
Authors: Zammit Christopher , Gallagher Sarah , Teeter Mary Ann , Lux Jeremy , Leonhardt-Caprio Ann M , Holloway Robert , Pilcher Webster , Mattingly Thomas , Bhalla Tarun , Benesch Curtis
Published: January 2019

Introduction:
Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care.

Methods:
Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC) is NYS-DSC located in Elmira, NY, 115 miles from SMH. Clinical leaders at SMH and AOMC collaborated to engineer a system of care to expeditiously transfer qualifying MT candidates. The system of care, dubbed Code LVO, included the auto-launching of an interfacility transport team (preferable a medical helicopter) to AOMC and notification to the SMH Vascular Neurologist (VN) on ED arrival for any presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours to review the non-contrast Head CT (NCCT) and CTA of the head and neck for an ASPECTS Score >/=6 and an LVO via a cloud-based image sharing platform. We retrospectively reviewed the records of LVO-AIS transfers in a QA database to identify the door-in-door-out (DIDO) time, AOMC door to SMH door (D2D) time, and AOMC door to SMH skin puncture (D2S) time, and the outcomes of patients before and after Code LVO implementation.

Results:
Over an 18-month period pre- Code LVO, there were seven AOMC to SMH LVO-AIS transfers. None underwent MT due to large or completed infarcts on SMH arrival. Seventy-one percent died or went to hospice. The median DIDO time was 93 minutes (range 66-273) and D2D was 239 minutes (range 112-392). Post- Code LVO, six Code LVO evaluations were requested, and three were transferred. All LVO-AIS underwent successful MT, with a median DIDO time of 45 minutes (range 44-60), D2D time of 95 minutes (range 85-102), and DTS time of 141 minutes (124-158) and went to nursing home or acute rehab.

Conclusions:
Auto-launching of interfacility transport to referring hospitals for select presumed LVO-AIS may decrease time to MT and improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.
Abstract WP30: Does Pretreatment With Intravenous Thrombolysis Prevent Infarct in a New Previously Unaffected Territory (INT) in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)?
Authors: Goyal Nitin , Tsivgoulis Georgios , Pandhi Abhi , Krishnan Rashi , Malhotra Konark , Ishfaq Muhammad F , Krishnaiah Balaji , Nickele Christopher , Inoa Violiza , Hoit Daniel , Elijovich Lucas , Atkins Cole , Alexandrov Anne , Alexandrov Andrei V , Arthur Adam S
Published: January 2019

Introduction:
There are contradictory data concerning the preventive role of intravenous thrombolysis (IVT) in preventing infarct in a new previously unaffected territory (INT) in emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We sought to evaluate the potential association of IVT pretreatment with the likelihood of INT complicating MT in a high-volume tertiary care stroke center.

Methods:
Consecutive ELVO patients reated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. INT was defined using standardized methodology proposed by ESCAPE investigators. Collateral status was graded using ASITN/SIR criteria. The association of INT with 3-month functional independence (FI) defined as modified Rankin Scale scores of 0-2 was also investigated.

Results:
A total of 419 consecutive ELVO patients received MT [mean age 64±15 years, 50% men, median NIHSS-score 16 points (IQR:11-20), 69% IVT pretreatment). The incidence of INT was lower in patients treated with combination therapy (IVT & MT) than in patients treated with direct MT respectively (10% vs. 20%; p=0.011). INT occurred more frequently in patients with posterior circulation occlusion (28% vs. 10%; p<0.001). Patients with good collaterals tended to have lower rates of INT (11% vs. 18%; p=0.072). The rates of 3-month FI were lower in patients with INT (30% vs. 50%; p=0.007). IVT pretreatment was not independently related to INT (OR: 0.79; 95%CI: 0.34-1.83) on multivariable logistic regression models adjusting for location of occlusion, collateral status and onset to groin puncture time. INT did not emerge as anindependent predictor of 3-month FI (OR: 0.69; 95%CI: 0.29-1.62) on multivariable analyses.

Conclusions:
IVT pretreatment is not independently associated with lower likelihood of INT in LVO patients treated with MT. INT does not appear to independently affect 3-month functional outcomes.
Abstract WP304: Telemedicine Utilization Practices and Barriers to Use for Stroke Care in North Dakota Critical Access Hospitals
Authors: Barnes Olivia N , Pietrzak Janna , Cook Mindy , Thorson Shila , Hyder S S , Shay Christina M
Published: January 2019

Introduction:
Telemedicine (TM) is a promising solution for providing timely and efficient care for patients experiencing a stroke in rural and underserved areas
.
Although TM services are available in many Critical Access Hospitals (CAHs), wide adoption has been limited by a multitude of barriers.

Purpose:
To describe current utilization practices and identify barriers to utilization of TM services in assessment and treatment of stroke patients in North Dakota CAHs.

Methods:
Directors of Nursing (DONs) at Acute Stroke Ready CAHs in North Dakota were recruited to participate in data collection efforts using a mixed methods approach including a survey and in-person focus groups. An online survey was disseminated via email to DONs (response rate=74%) and a semi-structured interview guide was used to conduct three focus groups (n=16). Sessions were digitally recorded and field notes with abridged transcripts were analyzed for recurrent themes using content analysis.

Results:
Most participants (91.3%) indicated CAH staff have access to TM services that include consultation with emergency medicine physicians, but only 17.4% indicated their services include consultation with a neurologist. Despite wide availability, participants reported staff forget to use existing TM services or are unaware of specific services available. Most frequently used TM services include assistance with patient documentation, medication dosage checks, and assistance with patient transport. Least frequently used TM services include ePharmacist consults and physician assistance with stroke assessments. Identified barriers to utilization of TM services include high confidence level of attending providers in performing independent assessments, staff concerns that decisions will be questioned, and preference of attending providers to directly contact physicians at accepting Primary Stroke Centers.

Conclusions:
While general TM services are widely available in North Dakota CAHs, services are underutilized. Access to specialized neurology services via TM is also limited. Targeted efforts to enhance understanding and utilization of existing TM services, particularly for stroke patients, will be beneficial to improving stroke systems of care in North Dakota.
Abstract WP307: Pre-Hospital Delay for Acute Ischemic Stroke in the New Era: K-Plus Registry
Authors: Nagao Yoichiro
Published: January 2019

Background and Purpose:
Changes in hyperacute stroke treatment emphasize the needs for earlier treatment than ever. Considering there is a limitation to shorten in-hospital delay in acute ischemic stroke, decreasing pre-hospital delay is crucial to achieve earlier recanalization and better clinical outcome. We investigated the factors causing prehospital delay and its relationship with clinical outcome, using the data of a regional multicenter stroke registry: K-PLUS.

Method:
Patients with acute ischemic stroke within 24 hours of the last time known well in K-PLUS, registered from 2013 to 2017, were included. We divided them into two groups according to the period from the last time known well to admission: early admission (within 4 hours) and delayed admission (over 4 hours). Age, sex, prehospital modified Rankin Scale (mRS) score, use of emergency system, location of onset, living places, risk factors, dementia, and previous medical history were compared between the two groups. The relationship between the prehospital delay and prognosis was also examined.

Results:
Of 5,102 patients (median 78 years old; women, 42%), 2,752 (54%) were admitted within 4 hours. As a result of multivariate analysis, mRS 0-2 before onset (odds ratio, 1.2; 95% confidence interval, 1.0-1.5), atrial fibrillation (1.7; 1.5-1.9), immediate symptom detection (2.8; 2.4-3.2), onset outside home (2.5; 2.1-3.0), and emergency system use (2.9; 2.5-3.4) were positively related to, and diabetes (0.7; 0.6-0.8), current smoking (0.8; 0.7-0.9), dementia (0.8; 0.6-1.0), and symptom detection at 6:00-24:00 (0.5; 0.4-0.5) were negatively related to early admission. Early admission was related to directly discharging home independent of age, living at home before admission, NIHSS score on admission, and thrombolytic therapy (1.6; 1.4-1.9).

Conclusions:
We elucidated clinical characteristics related to early admission within 4 hours in acute ischemic stroke patients. Moreover, earlier admission was related to discharging home independent of other factors. Educational activities to general population for early symptom detection and emergency call are necessary for early admission.
Abstract WP313: New Smartphone App Can Contribute to Shortening the Elapsed Time for Reperfusion Therapy
Authors: Sakai Kenichiro , Komatsu Teppei , Mitsumura Hidetaka , Iguchi Yasuyuki , Takao Hiroyuki , Murayama Yuichi
Published: January 2019

Background and Objectives:
Bland new smartphone application (JOIN) provides sharing text, neuroimaging, photos and videos and we are securely able to communicate among stroke team. Our aim is to investigate whether JOIN would shorten the duration from admission to thrombolysis and mechanical thrombectomy in hyper-acute ischemic stroke patients.

Methods:
Between October 2012 to March 2018, acute ischemic stroke patients with thrombolysis and/or mechanical thrombectomy were enrolled. We divided all patients into two groups, 1) pre-JOIIN group as conventional communication system was conducted until September 2015, and 2) JOIN group as we started to use JOIN on smartphone after October 2015. We compared door to image time (DIT), image to needle time (INT), door to needle time (DNT) for thrombolysis, and DIT, image to puncture time (IPT), door to puncture time (DTP) for thrombectomy between pre-JOIN group and JOIN group.

Results:
We retrospectively enrolled 129 patients (66% male, median age 69 years-old, median NIHSS score 8). JOIN group was 53 patients and pre-JOIN group was 76 patients. In all patients, Thrombolysis was 99 patients (alone 69), thrombectomy was 60 patients (alone 30), and combined thrombolysis and thrombectomy was 30 patients. There was no significant difference of DIT between JOIN group and pre-JOIN group (22 min vs. 24 min, p=0.484). Interestingly, DNT, DPT, INT, and IPT in JOIN group were significantly shorter than that of pre-JOIN group (DNT; 62 min for JOIN group vs. 72 min for pre-JOIN group, p=0.039; INT 41 min vs. 48 min, p=0.005; DPT 106 min vs. 129 min, p=0.046; IPT 89 min vs. 117 min, p=0.004; Figure).

Conclusion:
JOIN should play an important role in shortening the elapsed time for reperfusion therapy, especially after undergoing initial brain image.
Abstract WP317: Door-In-Door-Out (DIDO) - Identifying Causes of Interfacility Transfer Delays
Authors: Graves Alex M , Murray Mark , Casper Christy , Kiernan Terri , Hagedorn Danielle , Schoenleber Toni , Wiley Lisa , Maxe Amy , Elder Teresa , Carlson Janet , Chapman Wendy , Bragg Alyssa , Roth Kimberly , Longseth Rachel , Yinger Jami , Putz Tim , Haschker Shelby , Stackpool Kelly , Scaletta Kari , Smith Richard
Published: January 2019

Background:
Delays in endovascular therapy can lead to worse outcomes in stroke patients. Interfacility delays when transferring patients to thrombectomy-capable hospitals are common. We sought to identify causes of such delays and create a standardized transfer process to improve transfer times.

Methods:
A 15-hospital system formed a multidisciplinary team to assess the current state of DIDO processes from data on previous transfers, evaluate current transfer algorithms, and analyze baseline performance. Individual hospital transfer algorithms were compared.

Results:
Data was analyzed for 47 patients transferred from 12 facilities to thrombectomy-capable centers from June 2017 to July 2018 who received ischemic stroke treatment. 71% were from a metro area within 50 miles of a thrombectomy-capable hospital and 29% were from outside the metro area, up to 400 miles away. 80% were transported by air by 9 different agencies.
DIDO times were: 27% less than 90 min; 27% 90 to 120 min; 44% greater than 120 min.
There was minimal opportunity for improvement based on: day of week, NIHSS, and treatment with alteplase. Areas for improvement include: timeliness of door to CT (x-=13 vs 35 min), time to CT read (x-=8 vs 16 min), time to alteplase (x-=48 vs 115 min), and time to transfer (x-=125 vs 148 min), time from arrival to consult with thrombectomy capable centers (x-= 53 vs 86 min), time from consult to dispatch (x-=19 vs 26 min), and time of transfer agency on scene (x-=22 vs 37 min) for metro vs rural hospitals.

Conclusions:
Identified causes of delays include decision to transfer and initiation of dispatch to coordinate transport. A difference in timeliness initial diagnosis and treatment of patients outside metro areas was identified. Last known well (LKW) to arrival for transferred patients revealed a need to educate sending facilities on the expanded treatment windows- only 3 patients had a LKW to arrival time greater than 4.5 hours.
Abstract WP319: Improvement in Stroke Survey Scores for Rural EMS Providers
Authors: Seachrist Eric , Jacob Sneha , Daniels Debra , Petrone Ashley , Adcock Amelia
Published: January 2019

Introduction:
The extended time window for mechanical thrombectomy in acute stroke has added additional challenges to rural regions. Given the topography of the Appalachian region, much of the initial treatment time windows are spent with emergency medical service (EMS) personnel. Few centers in our region are equipped to treat large vessel ischemic strokes and transferring between centers leads to substantial delays and lost treatment opportunities. Now more than ever, EMS providers must understand how to recognize stroke symptoms, know the treatment time windows, and acquire vital pieces of the medical history in order to facilitate appropriate and timely care.

Methods:
We provided basic stroke education to rural EMS providers during the months of August 2017 to May 2018. An eight-question previously validated survey was given prior to and immediately after the education session. Questions included stroke intervention options and time windows, identification of blood thinners, and stroke prevalence and symptoms. Answers were confidential and participates had between 0 and 50 years of experience. In total, 61 pre-surveys and 63 post-surveys were completed.

Results:
A Wilcoxon signed-rank test showed that the education program elicited a statistically significant change in stroke knowledge for EMS providers (
Z
= -4.013,
p
<.001). Median percentage was 57.1 before education and 71.4 after. The question with largest improvement in pre to posttest scores, 44 to 71 percent correct (p=.002), was recognition of stroke symptoms.

Conclusion:
Our study demonstrates that educational sessions can improve stroke knowledge in EMS providers, particularly in the recognition of stroke symptoms. However, the clinical impact of education alone is unclear, especially in the era of extended window mechanical thrombectomy. Future studies incorporating interactive EMS mobile systems are likely needed to address this void.
Abstract WP320: Coaching Stroke Quarterbacks in an Academic Medical Center to Improve Door to Treatment Times
Authors: Leonhardt-Caprio Ann M , Gallagher Sarah A , Chen Shaw-Ree , Zammit Christopher , Risco Jorge ,   UR Medicine Stroke Lean Team
Published: January 2019

Background:
Rapid treatment for acute ischemic stroke (AIS) improves patient outcomes. In an academic medical center AIS treatment often involves a large team including trainees. A clear process allowing for rotating team members and varied experience in AIS care across disciplines is key for timely intervention.

Purpose:
To improve the percentage of patients with door to needle (DTN) and door to puncture (DTP) times within 45 and 90 minutes.

Methods:
A multidisciplinary team including EMS, Emergency Medicine (EM), Nursing, Radiology, Neurology, Neurosurgery, Pharmacy, Surgical Services, and Operations Excellence, along with residents from each specialty, convened for a Lean initiative to reduce door to treatment (DTT) times in an academic Comprehensive Stroke Center. An extensive process map was generated that identified 1) unclear role delineation for EM, Neurology, and Neurosurgery residents, and 2) uncertainty in optimizing the simultaneous processes of history-taking, NIHSS assessment and imaging determination. A model clarifying CT decision–making guidelines and designating a team leader or “Stroke Quarterback” was developed. A three month test of the process was conducted.

Results:
There was a 42% improvement in DTN within 45 minutes and 33.4% improvement in DTP within 90 minutes when compared to the same 3 month period one year prior to the test of change (figure 1). The rate of DTT within goal varied from month to month.

Conclusions:
Despite the varied levels of experience and training of providers at an academic hospital, the acute stroke response team must provide consistent and expeditious care in every instance. Identifying a team leader as a “stroke quarterback” allows for real-time decision-making (audibles), clear delegation of responsibilities (player assignments) based on experience, and utilization of structured processes (playbook). Our model is well-suited for the academic medical center environment and appears to reduce time to treatment.