bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P207: STOP STROKE©-A Novel Medical Application to Improve Coordination of Stroke Care: A Brief Report on Door to Thrombolysis Times After Initiating the Application
Authors: Dickson Robert , Nedelcut Adrian
Published: July 2021

Hypothesis:
We hypothesized that introduction of a care coordination application to our emergency stroke care would improve time to thrombolysis in acute ischemic stroke (AIS).

Introduction:
The objective of our study was to evaluate the effect of the STOP STROKE© medical application on patient arrival to thrombolytic times for patients arriving at our emergency department with AIS. STOP STROKE© is a novel medical application developed by physicians to improve the coordination and communication tasks essential to rapid assessment and care of patients suffering from AIS.

Methods:
We conducted a retrospective review of the Good Shepherd Health System stroke dashboard between February 2012 and February 2014 (13 months prior to STOP STROKE© and 12 months after). The stroke dashboard is a quality improvement database for acute stroke activations in patients arriving to our level II emergency department with annual volumes of 90,000. We analyzed all data from CMS reportable cases receiving TPA for AIS during the study period. The primary outcome was mean Door-to- Needle (DTN) times before and after initiating STOP STROKE©. Secondary outcome was the effect on the DTN <60 min benchmark.

Results:
During the study period we had 533 stroke activations (200 pre-application and 333 post-application), representing an 80% increase in activations after the app. A total of 85 patients received TPA therapy for AIS (41 pre-application and 44 post-application). Of these, 17 cases were excluded that did not meet CMS criteria for reporting. We observed the mean D2N times post STOP STROKE© decreased 21 min (77 - 56min), a 28% improvement (p=0.001). Further, the patients meeting D2N < 60 min improved from 32% (11/34) to 82% (28/34) after the app.

Conclusions:
In this cohort of patients with AIS, STOP STROKE© improved mean D2N times and number of patients treated within 60 min of arrival. Further we saw an increase in total stroke activations. We conclude our results demonstrate the app’s effect of increasing awareness of suspected AIS and improved coordination of care, evidenced by the magnitude of its effect on treatment times.
Abstract W P214: Identifying Stroke Symptoms in the Field: What are we Missing?
Authors: Olson-Mack Lindsay , Bourdon Darlene , Kelley Barbara , Ludwig Jon , Tafreshi Gilda
Published: July 2021

Introduction:
Emergency Departments (ED) are increasingly activating stroke codes based on assessment of stroke symptoms via Emergency Medical Services (EMS). Accurate assessment of stroke symptoms by EMS facilitates rapid assessment in the ED, leading to prompt diagnosis and treatment during an acute stroke. Delays in treatment can occur when stroke symptoms are not recognized in the field.

Hypothesis:
We hypothesized that trends existed in stroke symptoms most commonly missed by EMS.

Methods:
A retrospective cohort study of 170 records was reviewed, for all patients receiving acute stroke care at an urban hospital from October 2013 to May 2014. Inclusion criteria: stroke code activation by EMS or in the ED, and patient arrival by EMS. Exclusion criteria: stroke code activations after admission to the hospital, and patients arriving via private transportation.

Results:
112 patients met the inclusion and exclusion criteria. 90 patients (80%) had stroke codes were initiated by EMS. The remaining 22 patients had stroke codes initiated by the ED MD after arrival. The records of the 22 patients arriving to the ED without advanced EMS notification were reviewed. Aphasia was documented in the EMS record for 8 patients (36%). An additional 8 patients (36%) with documented stroke symptoms arrived without EMS notification due to improving symptoms or unclear last known well time. Five of the 22 patients (23%) arriving without EMS pre-notification had had aaphasia documented as an initial finding by ED MD, had a stroke code activation and received IV tPA. One of the 5 patients (13%) also had improving symptoms documented by EMS.

Conclusion:
An opportunity exists for improved recognition of aphasia as a stroke symptom by EMS, including both expressive and receptive components. Likewise, further education is needed correlating aphasia with the likelihood of IV tPA initiation in the ED. This study also highlights the importance of recognizing the waxing and waning nature of stroke symptoms. Rapidly improving symptoms should not preclude stroke code initiation via EMS, as some of these patients are still IV tPA candidates.
Abstract W P250: Food Restriction Ameliorates Neuroinflammation and Provides Protection in a Mouse Model of Ischemic Stroke
Authors: Zhang Jia , Hu Xiaoming , Lu Shiduo , Mao Hengyi , An Chengrui , Zhang Wenting , Cao Guodong , Chen Jun , Gao Yanqin
Published: July 2021

Background and Purpose:
Neuroinflammation contributes significantly to the progress of ischemic stroke. Recent research suggests that food restriction could reduce inflammatory responses under some pathological conditions. In this study, we demonstrate that food restriction attenuates both grey matter and white matter damage after cerebral ischemia.

Methods:
Adult male C57BL/6 mice were fed ad libitum (AL) or fed with restricted food (RF; 30% reduction) for 28 days, and then subjected to MCAO or sham operation. Neuronal tissue atrophy and white matter injury were assessed by quantifying the expression of microtubule-associated protein (MAP2) and myelin basic protein (MBP), respectively. Cerebral inflammation was evaluated by immunohistochemical staining of astrocyte and microglia in the ischemic brain. The expression of M1 and M2 markers were further examined to characterize phenotypic changes in brain microglia.

Results:
RF promotes functional recovery up to 28 days after stroke, as revealed by marketly improved performance in food fault test, cylinder test and Morris water maze test. RF mice exhibited significantly reduced neuronal tissue loss (AL, 19.43±2.40mm3; RF, 10.60±1.74mm3; P < 0.05;n=6/group) and white matter injury (Al,, 0.36±0.08; RF, 0.97±0.07; P < 0.05;n=5/group) as compared to AL mice at 28 days after ischemia. Meanwhile, we observed suppressed astrocyte (LF, 3.22±0.26mm2; RF, 2.30±0.19mm2; P < 0.05;n=5/group) and microglia (P < 0.05;n=5/group) activation in RF mice. Furthermore, food restriction increased the percentage of M2 phenotype and reduced the percentage of M1 phenotype in activated microglia (P < 0.05;n=5/group).

Conclusions:
Taken together, food restriction can promote functional recovery. These protective effects might be partially attributed to the effect of food restriction in alleviating neuroinflammation and directing beneficial microglial response after stroke. Our study suggests that food restriction is an effective non-pharmacological approach to promote long-term post-stroke recovery.
Abstract W P263: Alteration In Hippocampal Oscillations After Stroke: A Candidate Biomarker For Stroke-induced Cognitive Impairment
Authors: He Ji-Wei , Nishijima Yasuo , Akamatsu Yosuke , Rabiller Gratianne , Liu Jialing
Published: July 2021

Objective:
Previously we have found that stroke by distal occlusion of the middle cerebral artery (dMCAO) produced injury restricted to the parietal cortex yet hippocampal impairment. Recent advances in functional connectivity suggest that shared neuronal activation patterns or synchronized brain oscillation define brain networks linking anatomically separate brain regions. Using in vivo electrophysiology, the current study aimed to determine the temporal profile of stroke-induced changes in brain oscillation in the hippocampus, a remote brain region that does not suffer from ischemic injury.

Methods:
Adult male rats were subjected to either a permanent left MCAO combined with a temporary bilateral occlusion of the common carotid artery (CCAO), or bilateral CCAO alone, for 1 hour. Bilateral extracellular recording was performed under urethane anesthesia using the 32-channel NeuroNexus probes spanning the cortex and CA1 radiatum layer.

Results:
During reperfusion, a significant decrease in theta-to-delta ratio (T/D) was observed in rats that underwent either dMCAO or CCAO alone. However, a sustained delta predominant state was only observed chronically after dMCAO, suggesting a persistent disruption of hippocampal-neocortical connectivity in the former. In contrast to CCAO, dMCAO also induced a reduced low gamma (30-59 Hz) power, change in dominant theta-frequency and disassociation of theta-gamma coupling.

Conclusions:
Our results indicate that ischemic stroke induces specific changes in hippocampal oscillations that might underlie the observed cognitive impairment. In contrast to stroke, an episode of mild ischemia by temporary CCAO that does not trigger functional impairment also does not evoke persistent changes in hippocampal oscillations. The observed brain oscillation profile specific to dMCAO offers an integrated measurement of the hippocampal-dependent network activity, and may serve as a candidate biomarker for post-stroke cognitive impairment.
Abstract W P27: Quantitative Measurement Of Blood Flow Around Intravascular Thrombus Using CT Perfusion T0 Maps
Authors: Ahn Seong Hwan , D. d’Esterre Christopher , Qazi Emmad M , Goyal Mayank , Demchuk Andrew M , Lee Ting Y , Menon Bijoy K
Published: July 2021

Introduction:
Anterograde blood flow around thrombus and extent of retrograde collateral filling can affect thrombus lysis with IV tPA. Current assessment of blood flow around thrombus is however very subjective. The aim of the present study is to validate a newly devised method to quantify blood flow around thrombus using CT perfusion (CTP) T0 maps.

Methods:
From the Prove-IT stroke-imaging database, perfusion CT and DSA images of stroke patients treated with IV tPA and/or IA thrombolysis were analyzed. We generated maps that measure delay in arrival time of contrast within the intracranial arterial tree (T0 maps) from that of the chosen arterial input function. A “positive sloped” regression line of T0 values from distal clot interface to at least 14 pixels (median 68 pixels) along the artery profile indicated presence of occult anterograde flow. Anterograde flow thus measured using the T0 maps was compared with anterograde flow assessed on first angiography of subsequent IA procedure.

Results:
Of 37 patients (mean age 66 ± 13.5 years, 20 female), 35 (94.6%) were treated with IV tPA before DSA. Median time from CTP to first run angiography was 83 mins (IQR 53-100 mins). Positive slope were noted in 10 patients. Patients who had anterograde flow on first angiography were 10. Compared with anterograde flow on first run angio, positive slope on T0 map had a sensitivity of 80%, specificity of 92.6% and a positive predictive value of 80% and negative predictive value of 92.6%. In patients with anterograde flow on first angiography, median T0 time at proximal clot interface was 0.1 seconds (IQR 0-0.1) and at distal clot interface was 0.7 seconds (IQR 0.5-3.1). In patients without any anterograde flow on first angio, median T0 time at proximal clot interface was 0.1 seconds (IQR 0-0.3) while that at distal clot interface was 3.7 seconds (IQR 2.1-5.6).

Conclusions:
The slope method on CTP T0 maps and measurement of T0 values around clot reliably measure presence of anterograde blood flow through thrombus.
Abstract W P3: Core Infarct Size Agreement Between NCCT And DWI: Implications For Patient Selection For IAT
Authors: Yoo Albert J , Kamalian Shahmir , Sheth Sunil A , Mehrkhani Farhad , Lev Michael H , Liebeskind David S
Published: July 2021

Background:
Pre-treatment infarct volume is an important determinant of outcome after intra-arterial therapy (IAT). Ongoing IAT trials are using MRI DWI and noncontrast CT (NCCT) to quantify core infarction on the Alberta Stroke Program Early CT Score (ASPECTS) for patient selection. However, the degree to which these imaging approaches agree remains uncertain.

Methods:
Consecutive acute ischemic stroke patients over a 2-year period were included in this analysis if they had occlusion of the intracranial ICA or MCA M1 segment and underwent CT and MRI within 1 hour of each other and within 8 hours of onset. Two raters independently scored ASPECTS on both NCCT and DWI in separate reading sessions. Modified DWI-ASPECTS (including only >20% regional involvement) was also scored. Differences were resolved by consensus, and the consensus scores were compared across the three scales using Bland-Altman analysis. Agreement was also assessed based on a dichotomized ASPECTS threshold of 0-5 vs. 6-10 using the kappa statistic.

Results:
There were 74 patients with mean age 69.6 years and median NIHSS 17. Occlusions involved the ICA in 27 (36 %) patients. Mean interval between CT and MRI was 37±15 minutes. The median (IQR) ASPECTS scores were 7 (4-8) on NCCT, 5 (3-7) on DWI (P<0.0001 vs. NCCT), and 7 (4-8) on modified DWI (P=0.42 vs. NCCT). In Bland-Altman analysis, NCCT ASPECTS was mean 1.4 points (95%CI: -1.9 to 4.7 points) higher than DWI ASPECTS, and was mean 0.2 points (95%CI: -3.4 to 3.9 points) higher than modified DWI ASPECTS. For NCCT, DWI, and modified DWI, ASPECTS 6-10 scores were seen in 69%, 41%, and 60% of patients, respectively. The inter-scale agreement for ASPECTS >5 was only moderate between DWI and NCCT (kappa=0.47) and good between modified DWI and NCCT (kappa=0.68). However, differences between modified DWI and NCCT for dichotomized ASPECTS were found in 15% of patients.

Conclusion:
Using ASPECTS, modified DWI has better agreement with NCCT than standard DWI evaluation. However, there is a sizeable proportion of patients where dichotomized ASPECTS differs even with the use of modified DWI. This has important implications for patient selection in clinical trials.
Abstract W P301: A Neurology/Emergency Medicine Co-Management Protocol for the Observation Management of Transient Ischemic Attack
Authors: Ritter Samuel , Baghshomali Sanam , Bushnell Cheryl , Cline David , Guzik Amy , Reynolds Patrick , Hiestand Brian
Published: July 2021

Background:
TIAs are potentially unstable conditions that frequently precede acute ischemic stroke (IS). An evaluation for thromboembolic source and risk is indicated; unfortunately, diagnostic resources for this work up are not immediately available in the Emergency Department (ED). In response to logistic difficulties arranging timely outpatient workup as well as inappropriately long lengths of stay (LOS) on the inpatient Neurology service, we developed a co-management protocol in the ED-based Clinical Decision Unit (CDU). We aimed to evaluate the quality of this model in terms of efficiency and prevention of stroke at 30 days.

Methods:
Eligible patients were those with resolved or minimal symptoms, hemodynamic stability, and no known source of emboli (artificial valve, endocarditis, or atrial fibrillation requiring anticoagulation). The protocol consisted of ongoing ED management with Neurology consultation and determination of the diagnostic evaluation, which could include MRI, cardiac echo, and carotid ultrasound/transcranial Doppler. Patients with IS on MRI or carotid stenosis were admitted; the remainder discharged on antiplatelet medication and Neurology follow-up. Using a retrospective case control design, we reviewed records of consecutive patients managed in the CDU TIA protocol in the first 6 months of 2014. Controls consisted of 100 TIA patients (discharged without confirmed CVA) managed on the Neurology service prior to the implementation of the CDU TIA protocol. Outcomes included LOS and 30 day readmission rate for acute IS.

Results:
There were 127 CDU patients and 100 controls in the sample. After CDU evaluation, 31 patients required further inpatient admission (24%, 95%CI 17-33%) due to demonstration of acute IS or severe carotid stenosis. The average CDU LOS was 12.2 (SD 6.9) hours compared with 42 (SD 35.3) hours in the historical controls (p<0.001 per t-test for unequal variances). No patients discharged from the CDU TIA protocol returned within 30 days with IS (0%, 97.5%CI 0-2.9%).

Conclusion:
An ED/Neurology co-managed CDU-based observation protocol for patients with TIA greatly reduced LOS and variability, with no detected rate of IS readmissions within 30 days of discharge.
Abstract W P315: Outcomes Of In-hospital Cardiopulmonary Resuscitation In Stroke Patients Admitted In The United States, Years 2005-2011
Authors: Adil Malik M , Vidal Gabriel A , Malik Ahmed A , Khursheed Faraz , Saeed Fahad , Qureshi Adnan I
Published: July 2021

Background:
There is no recent study on the outcomes of cardiopulmonary resuscitation (CPR) in stroke patients. We wanted to analyze the outcomes of in-hospital CPR in these patients in comparison with the general population without stroke.

Methods:
Data from all patients admitted to US hospitals between 2005 and 2011 were analyzed. We used the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) primary or secondary procedure codes 99.60 to identify the adult patients (≥18years) who underwent cardiopulmonary resuscitation. Patients who had cardiopulmonary arrest (427.50) as a primary admission diagnosis were excluded to avoid including patients who experienced an out-of hospital event in our analysis. The effect of stroke on discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. Yearly national trends in survival in stroke patients were examined using the Cochran-Armitage trend test.

Results:
Of 648,168 patients who underwent CPR, 43753 (6.8%) were admitted withstroke. Strokeatients who underwent CPR had higher rates of discharge to nursing facility (18.4% versus 14.0% p=<0.0001) but no difference was noted in in-hospital mortality (74.1% versus 74.2% p= 0.9) compared to those without stroke. After adjusting for potential confounders, CPR in patients with stroke had higher odds of discharge to nursing facility [odds ratio (OR) 1.8, 95% confidence interval (CI) (1.6-2.0, p= <.0001)] and death [(OR) 1.11, 95% (CI) (1.06-1.14, p=0.05)]. Survival in stroke patients undergoing CPR improved in 2011 (19 % in the year 2011 vs. 11 % in the year 2005; p=<.0001) as compared with the previous years.

Conclusion:
CPR in stroke patients is associated with significantly higher rates of disability at discharge. Survival appears to be improving over the last 6 years in these patients.
Abstract W P322: Prediction of Intracerebral Hemorrhage Expansion With Clinical, Laboratory, Pharmacologic, and Noncontrast Radiographic Variables
Authors: Chan Sheila , Rao Vivek A , Flint Alexander C
Published: July 2021

Introduction:
Hematoma expansion (HE) is a cause of excess mortality in intracerebral hemorrhage (ICH), and HE is potentially preventable if at-risk patients can be identified. Contrast extravasation on initial computed tomographic angiography (CTA) strongly predicts HE, yet most centers do not integrate CTA into early ICH management. We therefore asked whether other variables available at presentation might be used to predict HE.

Methods:
We searched the electronic medical records of a large integrated healthcare delivery system to identify patients with a hospitalization discharge diagnosis of ICH during a three year period (2008-2010). HE was defined as ICH volume increase by 1/3 or by 12.5mL, as determined by ABC/2 estimation, within 48 hours of presentation. Pre-specified patient variables including age, gender, medical comorbidities, medication use, and in-hospital vital signs were extracted. Stepwise multivariable logistic regression was performed to model HE in patients with at least two head CT scans (HE group), and HE or death by 48 hours among patients with only one head CT (HE+D group). The area under the receiver operating characteristic curve (AUROC) and pseudo r-squared (pseudo-r2) statistics were used to assess model goodness-of-fit.

Results:
For the 2 study cohorts, 91/257 (35%) had HE and 163/343 (48%) had HE+D. In stepwise multivariable logistic regression, antithrombotic use (OR = 1.9, P=0.04) and initial mNIHSS (OR = 1.06, P=0.001) were significant predictors in the HE model (AUROC = 0.6712, pseudo-R2 = 0.0641). In the HE+D model, age (OR = 1.02, P=0.02), initial mNIHSS (OR = 1.07, P<0.001), and initial hematoma volume (OR = 1.01, P=0.03) were significant predictors (AUROC = 0.7579, pseudo-R2 = 0.1722).

Conclusion:
Our model predicting HE+D was better fitted than the HE model. The resemblance to known predictors of ICH mortality in the HE+D model suggests that the improved fit may be driven by mortality rather than HE. CTA contrast extravasation remains the strongest predictor of HE and merits consideration as a standard in early ICH care.
Abstract W P328: Elevated Systolic Blood Pressure on Arrival is Not Associated with Higher Early Mortality in Intracerebral Hemorrhage Patients
Authors: Sands Kara A , Albright Karen C , Kicielinski Kimberly , Shiue Harn , Sisson April , Lyerly Michael , Harrigan Mark
Published: July 2021

Background and Purpose:
The role of blood pressure control in the initial management of patients with intracerebral hemorrhage (ICH) is an active area of clinical investigation. Although ICH score is a validated predictor of in-hospital mortality in patients with ICH, it is not known whether elevated systolic blood pressure (SBP) on arrival is predictive of early mortality. We hypothesized that elevated SBP on arrival would be associated with in-hospital mortality in primary ICH patients.

Methods:
We retrospectively analyzed consecutive spontaneous ICH patients at our institution from 2008-2013. Patients were excluded if they were under the care of a palliative physician. We examined demographics, vascular risk factors, stroke severity (NIHSS), ICH score, and laboratory values.

Results:
A total of 361 spontaneous ICH patients (median age 63, 43% black, 42% female) met inclusion criteria. Over half of ICH patients were transferred into our facility (54%). Sixty-four percent of patients arrived with SBP >160. The association of SBP on arrival and in-hospital mortality is depicted in Figure 1.

Conclusions:
After adjusting for ICH score, SBP was not a significant independent predictor of death during the hospitalization. This finding suggests that clinical trials of blood pressure management of patients with ICH should stratify patients according to ICH score.
Abstract W P350: A Quality Enhancement Project to Capture Actual Weights Prior to Initiation of IV t-PA
Authors: Swearingen Natalie
Published: July 2021

Background/Issues:
The AHA/ASA commends the formation of multidisciplinary quality improvement teams in order to achieve high level organization and efficiency in the treatment of acute stroke. Emanuel Medical Center’s process in obtaining weight information was determined by two provider estimations. Historical review of charts revealed over and under dosing of IV tPA. This quality enhancement project was designed to develop a process to capture actual weights prior to the initiation of IV tPA.

Purpose:
Have 100% acute ischemic stroke patients weighed prior to tPA administration.

Method:
Utilizing Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team consisting of Neurologist, Stroke Coordinator RN, ED Supervisor, and Stroke NP was created to establish a standard method in obtaining weights in the ED. The team identified a shortage of scales, lack of designated location, and absence of weighing patients in the ED workflow as main barriers. Review of current literature and institutional policies led to a proposal for new scales, designated location, development of standardized process for timing of weighing patients, and entering information in chart. Additional interventions involved extensive education of staff through active and passive learning methods with development of an educational module for ED staff. One month post implementation and cycle analysis of PDSA, ED supervisor discovered new stretcher scales required being plugged in for operation. The new clinical practice algorithm includes the following steps: arrival by EMS and taking patient directly to CT; placement on CT table; patient transfer onto stretcher scale post scan; plugging-in scale; obtaining weight; and entering into chart.

Results:
Compliance was 0% (0/3) in the first month of implementation and 100% in the two consecutive months (6/6), and (1/1). All cases reviewed by the Stroke Coordinator and ED supervisor (inter-rater reliability of Cohen’s kappa 0.71). Feedback is given on all cases within 48 hours to the stroke leadership team. ED supervisor provides staff feed-back and analyzes outliers.

Conclusion:
Developing a standard process for capturing actual weights in the ED prior to initiating tPA is feasible utilizing PDSA methodology.
Abstract W P351: A Stroke Above the Rest: A Reengineering of the Interdisciplinary Plan of Care
Authors: West Noella J
Published: July 2021

Background and Purpose:
Patients who are newly diagnosed with a stroke are often overwhelmed due to the devastating nature of their condition. The post-acute phase frequently involves a significant amount of education regarding new medications, treatments, recovery and follow up. Ineffective education may be associated with poor outcomes; therefore information from healthcare professionals should be easily understood by patients and their families. The purpose of this evidence based nursing practice and quality enhancement initiative was to improve the patient outcomes and provide tools to assist patients for reentry into the community.

Methods:
The reengineered plan of care was implemented by the interdisciplinary Stroke Team. Individual education packets were developed based on diagnosis and specific comorbidities, and took into consideration the concept of health literacy. Communication with the primary care provider as well as providing patients with a thirty-day filled prescription prior to discharge assisted with continuity of care. Follow up phone calls reinforced education. Creation of a listserv provided notification of monthly stroke support group meetings and our yearly stroke retreat. Both programs are tailored to the stroke survivor and caregiver, and have been beneficial to the community.

Results:
This interdisciplinary initiative contributed to a steady increase in patient’s ratings of communication with doctors, and with a decrease in hospital length of stay for patients who were treated by the Interdisciplinary Stroke Team. In addition, patient participation in the annual Stroke Retreat and patient participation in community stroke programs have increased.Conclusions
:
Reengineering of the interdisciplinary plan of care improved not only the patient experience, but also better prepared patients and their caregivers for discharge. This quality enhancement initiative was vital in decreasing length of stay and quality of care in the stroke population.
Abstract W P357: Defining Stroke Flow Process in the ED
Authors: Peters Lindsey , Summers Debbie , Hawkins Angela , Wallace Sarah , Olds Karin , Boutwell Christine , Brion Bridget , Crandall Suzanne , Cote Blair
Published: July 2021

Background:
Each month in a large community comprehensive stroke program it is common to have 160-180 code stroke activations requiring multiple clinicians responding to this number of strokes. This volume can lead to role confusion, task duplication and additional unnecessary communication hand-offs.

Purpose:
The scope of this project was to: decrease unintentional care delays by defining and clarifying roles; eliminate task duplications, optimize utilizations of resources; and improve hand-off communication. Additionally, the number of activations was leading to stroke fatigue and inconsistency of team member attending strokes.

Methods:
Lean methodology was utilized to map out stroke patient throughput from January 2012 to July 2013. To visually illustrate the desired future state, swim lane graphics were developed showing the individual roles and a color coded role delineation chart was created showing specific team member responsibilities. A clip board with a timer was passed from nurse to nurse as a baton heightening 60 minute countdown awareness. The final phase of the project prioritized code stroke activations based on acuity into RED and YELLOW stroke alerts. RED signified a patient as a possible candidate for intervention; the YELLOW has longer symptom onset and is evaluated by a minimal team initially and upgraded if necessary.

Results:
The ultimate goal was to improve patient throughput and staff efficiency. The door to needle (DTN) time decreased from a mean of 73 minutes to a mean of 55.9 minutes. The DTN time continued to decrease to a mean of 50.8 by end of 2013. The prioritizing of code stroke into RED and YELLOW has demonstrated efficiency in team members’ time with approximately 25% now paged as yellow.

Conclusions:
Utilizing lean methodology can be lengthy and laborious; even though the project itself was completed the momentum continues to drive process improvement. In 2014 the team initiated EMS going straight to CT and began reviewing door to groin times. The additional process change has further decreased DTN time to 44.7 minutes by June 2014. Fine tuning flow process of patient throughput and role clarification supported management of multiple patients at one time and favors improved patient outcomes.
Abstract W P359: Stroke Symptom Identification: Using a Modified ROSIER SCALE at Emergency Room Triage
Authors: Bergman Deborah ,   Door To Needle DMAIC Quality Improvement Project Team
Published: July 2021

Background and Issues:
Stroke patients can arrive to the emergency room via Emergency Medical Services (EMS) or ambulatory at triage. Processes are already in place to identify stroke patients in the field such as the Cincinnati Pre-hospital Stroke Scale used by the Emergency Management Services (EMS) and early notification to the hospital emergency room staff. Data showed that approximately 68% of stroke patients at this stroke center arrived by or were brought to the hospital by self, family, or coworkers and not by EMS. Our main goal was to improve the process for recognizing stroke symptoms for patients who do not arrive by EMS and minimize delays to activating the Stroke Code Team Page in the triage area.

Methods:
The first step was to identify the barriers or delays that nurses had with initiating a stroke code alert. Stroke code activations were delayed because of uncertainty of who should call it and some nurses did not feel confident in their decision to activate the stroke code alert without consulting the emergency room physician. It was determined that the nurse would feel more empowered if there was more clarity to their roles and responsibilities during the assessment phase and there was an assessment tool available to guide them to the decision to activate the stroke team page. A modified version of the “Recognition of Stroke in the Emergency Room” (ROSIER) scale was implemented for the nurses to evaluate a patient that presents with stroke like symptoms. In addition to clarify their roles a workflow chart was deployed to show each team member their specific roles and responsibilities during this process.

Results:
Prior to the implementation of the ROSIER scale at triage the activation of stroke codes at triage were inconsistent. After education of the ED nurses and implementation of the ROSIER SCALE at triage there was a significant increase in the activations of stroke codes by ED nurses and a decrease in the time from triage to stroke team activation.

Conclusions:
Using an assessment tool like the ROSIER Scale in addition to clarifying the roles and responsibilities of the team can reduce delays to identifying acute stroke symptoms in patients at a busy emergency room triage area and improve opportunities for timely interventions.
Abstract W P364: Advanced Stroke Life Support: Making a Difference in Stroke Care
Authors: Jones Amy , Campbell Gladys
Published: July 2021

Background and Purpose:
A Comprehensive Stroke Center provides many opportunities for interactions with smaller facilities. Needs identified by our community facility partners was a standardized and effective neurological assessment of the stroke patient that could be performed by all staff and staff stroke education. Investigation into the Advanced Stroke Life Support (ASLS) course provided information that would serve as a blueprint to resolve both education needs.

Method:
Six staff members were certified as ASLS Instructors. ASLS course has been provided using didactic and hands on participation for scoring of patients with the Miami Emergency Neurologic Deficit (MEND) exam and stroke education. Participants were given a pre-test at the beginning of the educational experience, followed by a post test at the conclusion of class. Lectures included overview of five major stroke syndromes, basic MEND exam knowledge and scoring requirements, followed by review of treatment options and care provided once hospitalized. The learning opportunity was enhanced by interactive hands on session by each participant through performing the MEND exam on fellow participants and scoring of the MEND exam on scenario based test patients. Use of the interactive practice session with immediate feedback from instructors was key elements of student satisfaction and perceived learning during the educational experience.

Results:
Initial class evaluations and changes in pre and post test scores indicate an increase in participant stroke knowledge. 47 of 50 failed the pre-test with scores ranging from 35 to 85. Upon posttest all participants passed with scores ranging from 80 to 100. There was an increase in proficiency using the MEND exam from the initial practice session to use during the test patient scenarios. Additional survey results will be obtained using post class value analysis survey at least three months after class completion to demonstrate participants’ ability to apply knowledge to practice setting.

Conclusion:
Completion of ASLS course provides an increase of stroke knowledge that promotes application of information learned to care of stroke patients in practice settings.
Abstract W P365: Incorporating Telemedicine Access for Stroke in Vulnerable Alaskan Populations
Authors: Lada Diane , McGraw Janice , Lada Robert A
Published: July 2021

Background and Purpose:
The State of Alaska covers a vast area the size of California, Texas and Montana combined and comprises one-fifth of the total U.S. land mass. The population of approximately 735,132 is spread over 362 communities. The Alaska Native populations comprise 14.7% of the total population of Alaska with most of its members living in remote villages or isolated islands. Two hundred Alaskan communities can be reached only by boat or air. Public health and preventative services are challenging due to inaccessibility during winter months, high winds, volcanic activity, and poor infrastructure. The introduction of telemedicine to critical access facilities has proven effective for not only emergent delivery of stroke interventions but looks to promote access in the primary health setting as well. The purpose of this project was to identify barriers to neurological health and risk factors unique to Alaskans.

Methods:
Guided by a telehealth model of care for emergency Stroke cases, Providence Alaska Medical Center increased access to 5 spoke hospital sites in the Southeast portion of the State in the past six years. As the hub site for the State, Alaskans are placed in a national data base for outcomes, modifiable risk factor management and disability measurement. Interdisciplinary debriefings occur monthly for evidence-based practice agreements.

Results:
Patients have access to the only Cerebrovascular Neurologist in the State with a 50% increase in the delivery of tPA for ischemic stroke. Improved door-to-needle times, increased tPA delivery and interventional radiology, along with a decrease in length of stay has lead the way to developing a more extensive telestroke network within the Providence system.

Conclusions:
Access to primary and emergency neurological care remains a barrier to many Alaskans, especially those living in remote and isolated areas of the State. Using ongoing statistical data compared to other national averages, the telemedicine method of stroke care has proven vital to reducing morbidity and mortality in its large geographical boundaries. Further attention to a telestroke program will only enhance outcomes in the future.
Abstract W P38: Collateral Circulation Status Correlates With Aspects Decay During Inter-facility Transfer After Anterior Acute Ischemic Stroke Patients
Authors: Abdelnour Carla , Rangaraju Srikant , Streib Christopher , Aghaebrahim Nima , Delfyett William , Jovin Tudor , Jadhav Ashutosh
Published: July 2021

Introduction:
The collateral circulation plays an important role in the dynamic process of cerebral ischemia. The aim of this study is to determine if collateral status correlates with the early ischemic changes measured by the rate of Alberta Stroke Program Early CT Scores (ASPECTS) decay in emergently transferred acute ischemic stroke patients with anterior large vessel conclusions.

Material and methods:
We retrospectively analyzed the data of patients referred to our comprehensive stroke center from 7 outside hospitals between January 15, 2006 and January 15, 2014. Collateral status was assessed using an initial CT angiography obtained before treatment, and graded as "Good" (the entire medial cerebral artery reconstitutes with contrast) or "Poor" (partial or no reconstitution of the distal medial cerebral artery), by two independent reviewers (CA and WD).

ASPECTS decay was calculated in the following ways: 1. Absolute ASPECTS decay: (A1-A2)/T, 2. Relative ASPECTS decay: [(A1-A2)/A1]/T 3. Net ASPECTS difference: (A1-A2) and 4. Relative ASPECTS difference: (A1-A2)/A1; where A1= ASPECTS 1st CT, A2= ASPECTS 2nd CT, T= hours between 2 CT scans.

Results:
After reviewing 701 medical records from transferred patients, 51 patients with mean age 65±3 yrs and median initial NIHSS of 17 (IQR 14-21) were selected. In the multivariate analysis, good collateral status was independently associated with lower rates of ASPECTS decay measured by the relative rate of ASPECTS decay (0.04+/-0.01 score/h; p<0.05), the net ASPECTS difference (1.10+/-0.17 score/h, p<0.05) and the relative ASPECTS difference (0.12+/-0.02 score, p<0.05). The relative ASPECTS difference was most strongly associated with collateral status, and an independent predictor of good outcome (p=0.047) and final infarct volume (p=0.001) after controlling for age and NIHSS in a multivariate analysis.

Conclusions:
Good collateral circulation status is associated with lower rates of ASPECTS decay in transferred patients, which also tend to have smaller final infarct volumes and better clinical outcome after 3 months. The analysis of the collateral circulation gives us a better understanding of the pathophysiology in acute ischemic stroke.
Abstract W P384: De-Depress: Detection of Post Stroke Depression in the Outpatient Setting; the Interim Analysis
Authors: Ackerman Daniel , Tzeng Diana L , Pineda Maria C
Published: July 2021

Stroke is a major contributor to death and disability. For those who survive the initial incident, post stroke depression (PSD) represents a significant modifiable contributor to morbidity and mortality. The incidence of PSD is estimated between 9-50%, and may be higher as some prior studies have excluded those with communicative or cognitive impairments. We hypothesize that a depression screening program will significantly increase the rate of PSD detection and treatment, and can be implemented at a minimum of cost. Our primary objective is to evaluate the effectiveness and feasibility of initiating a depression screening program in the outpatient clinic of a comprehensive stroke center.

Methods:
This study is designed as a cross-sectional interventional prospective study with a historical control; divided into two phases. Phase I served as the control, wherein data was derived from a retrospective chart review of all patients newly presenting during 2013 with a diagnosis of ischemic stroke. Those already taking antidepressants or with a known mood disorder were excluded. Phase II began in 3/2014 with the initiation of a depression screen (via two validated screening tools, the Patient Health Questionaire-9 (PHQ-9), and the Aphasia Depression Rating Scale (ADRS)), and is ongoing at this time. Odds ratio, relative risk and absolute risk of a diagnosis of PSD will be calculated using a 2x2 table and the CHI-Squared method and compared with the historical control established in Phase I as well as expected norms.

Interim Results:
During Phase I, 591 new patient charts were reviewed with 268 qualifying for analysis. A diagnosis of PSD occurred in 13 patients (4.9%). The mean time from stroke to follow up was 5.75 months (1.85 in those diagnosed with PSD and 5.95 in those not diagnosed).

Conclusion:
Phase I of the De-Depress trial confirms a prevalence of PSD of 4.9% in the outpatient population of the cerebrovascular clinic at a comprehensive stroke center. We hypothesize that this is a result of under-recognition of this common condition, and will evaluate in phase II the effect of a simple depression screening program, implemented at a minimum of cost in time and resources.
Abstract W P387: Neurological Correlates Of Brain Function After Acute Stroke--A Dense Array EEG Study
Authors: Wu Jennifer , Srinivasan Ramesh , Solodkin Ana , Small Steven L , Cramer Steven C
Published: July 2021

INTRODUCTION:
Measures of brain function can complement assessment of injury to inform clinical decision-making after stroke, but the most useful metrics remain uncertain. An acute stroke alters brain function in widespread areas. We therefore reasoned that a whole brain measure of brain function would be better related to behavioral deficits than a regional measure of brain function.

METHODS:
In 24 patients hospitalized for acute stroke, resting EEG (256 leads) was recorded for 3 min at the bedside and analyzed offline. Two EEG measures of brain function were extracted: [1] whole brain connectivity, which found the EEG frequency (from 1-30 Hz) and seed point (from among the 256 leads) that best fit whole brain coherence with total NIHSS scores, using a partial least squares regression model; and [2] regional brain activity, which found the EEG frequency and lead where spectral power was most strongly correlated with total NIHSS scores. Analyses were repeated focused on NIHSS motor subscores (Q4-6). All models were validated using a leave-one-out approach.

RESULTS:
The 24 patients were age 60.9±13.1yr, 3.5 ± 2.9 d post-onset (range 3hr-12d), and were studied in settings that included ER, ICU, and stroke ward. Whole brain EEG connectivity explained a large fraction of the variance in total NIHSS scores (r^2=0.72); this was achieved in the 2-4 Hz range, with seed over ipsilesional motor cortex, and with model predicting higher NIHSS score when this seed had greater coherence with contralesional frontal/motor regions. Regional brain activity, by comparison, explained a smaller fraction of variance (r^2=0.51), with maximal correlation between total NIHSS and regional EEG power found using a lead over contralesional motor cortex, at 2 Hz. Similar results for whole brain EEG connectivity were obtained when modeling NIHSS motor subscores in the 14 subjects with motor deficits (validated r^2=0.71).

CONCLUSIONS:
Dense array EEG recordings could be obtained early after stroke, rapidly and reliably, and at the bedside in widespread hospital settings. Whole brain connectivity measures corresponded to behavioral state better than measures of regional brain activity do. Results support the utility of EEG as a bedside method for evaluating brain functional status after stroke.
Abstract W P399: Magnetic Resonance Imaging Based Cerebral Blood Flow Changes in Asymptomatic Human Immunodeficiency Virus Infected Subjects
Authors: Sen Souvik , An Hongyu , Menezes Prema , Telfer Megan , Oakes Jonathan , Eron Joseph , Robertson Kevin , Lin Weili , Powers William
Published: July 2021

Background:
Human Immunodeficiency Virus (HIV) infected individuals are at high risk for ischemic stroke. Magnetic resonance imaging (MRI) method of measurement of cerebral blood flow (CBF) and oxygen extraction fraction (OEF) may help assess the stroke risk in asymptomatic HIV subjects.

Objectives:
To evaluate MR measured CBF and OEF in treatment naïve asymptomatic HIV+ subjects and HIV- controls.

Methods:
Treatment naïve asymptomatic HIV+ subjects and age-gender-race matched HIV- controls were assessed for CBF using a pulsed arterial spin labeling (PASL) approach and Oxygen Extraction Fraction (OEF) using MRI T2*-weighted echo-planar imaging (EPI) sequences. All images were acquired using a Siemens 3T MR scanner (Treo, Siemens Medical Systems Inc). Quantitative CBF and OEF measurements were made in the whole-brain, gray matter and white matter and compared between the groups using unpaired t-test.

Results:
A total of 65 subjects of who, 35 treatment naïve HIV+ subjects (Mean age ± SD=30±7,89% male, 31% white, 49% black and 20% others) and 30 age-gender-race matched HIV- controls (Mean age± SD= 31±8,93% male, 37% white, 53% black and 10% others) consented to the protocol. HIV+ subjects compared to HIV- controls had significantly higher whole brain CBF (58.0 ± 13.8 ml/100g/min vs. 51.3 ± 9.0 ml/100g/min; p=0.03) and gray matter CBF (72.9 ± 16.2 ml/100g/min vs. 63.9 ± 9.9 ml/100g/min; p=0.01). However, values for whole brain OEF (0.4 ± 0.04) and gray matter OEF (0.4 ± 0.05) were similar for both groups. White matter CBF in HIV+ subjects (41.5 ± 13.1 ml/100g/min) compared to HIV- controls (37.2 ± 9.2 ml/100g/min) was not significantly higher (p=0.16) while white matter OEF (0.4 ± 0.04 HIV+ subjects vs. 0.4 ± 0.03 HIV-controls) showed no changes.

Conclusions:
The observed increase of whole brain CBF in treatment naïve HIV + subjects compared to HIV- matched controls, without corresponding changes in the OEF appears to be driven by a pronounced significant change in the gray matter compared with the white matter. These changes in CBF without corresponding changes in OEF suggest increase in metabolic activity, and may explain the higher stroke risk in asymptomatic HIV subjects.