bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP405: Automated Detection of Hemorrhagic Stroke From Non-Contrast Computed Tomography: A Machine Learning Approach
Authors: Aboutaleb Pakinam , Barman Arko , Lopez-Rivera Victor , Lee Songmi , Vahidy Farhaan , Fan James , Savitz Sean , Giancardo Luca , Sheth Sunil A
Published: June 2021

Introduction:
Automated neuroimaging analysis is being used increasingly in the acute ischemic stroke (AIS) evaluation. However, current algorithms do not factor in an assessment of intracranial hemorrhage (ICH) in the workflow. In this study we present a machine learning (ML) algorithm that uses brain symmetry information to detect ICH.

Methods:
We prospectively collected non-contrast CT (NCCT) images on patients that presented to the Emergency Department for AIS evaluation between 2017 and 2019. Patients were included if they underwent technically adequate NCCT imaging. Diagnoses of ICH, AIS and non-stroke were confirmed by experienced neuroradiologists as well as review of the clinical record. A ML algorithm which integrates symmetry features as well as standard features for the whole brain was trained on 80% of the sample and validated on the remaining images. Training was performed without any prior segmentation. Evaluation of the model performance was conducted using receiver-operator curve and area under the curve (AUC) analysis. Results are given as median [IQR] and [AUC 95% CI].

Results:
Among the 568 patients that met inclusion criteria, median age was 65 [55-76], 47% were female and 34% were white. 128 (23%) patients were determined to have ICH and 440 as non-ICH (70% AIS and 30% non-stroke). Among ICH patients, 108 (84%) had a supratentorial ICH. When analyzing the regions of the CT images that most strongly contributed to the algorithm’s diagnostic decisions, they corresponded with the regions of ICH (Fig. 1A). On the external validation data set, the algorithm successfully detected ICH (Fig. 1B) with high accuracy (AUC 0.99 [0.97-1.00]).

Conclusion:
We have developed a symmetry-sensitive ML method that can with very high fidelity identify ICH in an automated fashion. Without prior training, the algorithm autonomously was able to learn ICH location. These results may help contribute to an automated imaging workflow for all stroke evaluations, not just AIS.
Abstract WP406: Training and Validation of Deepmedic Machine Learning Tool for Automated Hematoma Segmentation and Volume Analysis on CT Using Multicenter Data
Authors: Nurmsoo Sean , Guida Alessandro , Wong Alex , Aviv Richard I , Demchuk Andrew , Gladstone David J , Flaherty Matthew L , Dowlatshahi Dar , Gubitz Gord , Phillips Stephen J , Weeks Adrienne , Pickett Gwynedd E , Volders David , Vandorpe Robert , Huynh Thien
Published: June 2021

Introduction:
We sought to train and validate an automated machine learning algorithm for ICH segmentation and volume calculation using multicenter data.

Methods:
An open-source 3D deep machine learning algorithm “DeepMedic” was trained using manually segmented ICH from 208 CT scans (129 patients) from the multicenter PREDICT study. The algorithm was then validated with 125 manually segmented CT scans (48 patients) from the SPOTLIGHT study. Manual segmentation was performed with Quantomo semi-automated software. ABC/2 was measured for all studies by two neuroradiologists. Accuracy of DeepMedic segmentation was assessed using the Dice similarity coefficient. Analysis was stratified by presence of IVH. Intraclass correlation (ICC) with 95% confidence intervals (CI) assessed agreement between manual vs. DeepMedic segmentation volume; and manual segmentation and ABC/2 volume. Bland-Altman charts were analyzed for ABC/2 and DeepMedic vs. manual segmentation volumes.

Results:
DeepMedic demonstrated high segmentation accuracy in the training cohort (median Dice 0.96; IQR 0.95 - 0.97) and in the validation cohort (median Dice 0.91; IQR 0.86 - 0.94). Dice coefficients were not significantly different between patients with IVH in the training cohort; however was significantly worse in the validation cohort in patients with IVH (Wilcoxon p<0.001). Agreement was significantly better between DeepMedic and manual segmentation (PREDICT: ICC 0.99 [95%CI 0.99 -1.00]; SPOTLIGHT: ICC 0.98 [95%CI 0.97 - 0.99]) than between ABC/2 and manual segmentation (PREDICT: ICC 0.92 [95%CI 0.89 - 0.95]; SPOTLIGHT: ICC 0.95 [95%CI 0.93-0.97]). Improved accuracy of DeepMedic was demonstrated in Bland-Altman charts (Fig 1).

Conclusion:
ICH machine learning segmentation with DeepMedic is feasible and accurate; and demonstrates greater agreement with manual segmentation compared to ABC/2 volumes. Accuracy of the machine learning algorithm however is limited in patients with IVH.
Abstract WP41: Age-Specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients With Acute Ischemic Stroke: A Community-Wide Perspective
Authors: Chaudhry Saqib A , Akhtar Iqra N , Hassan Ameer E , Chaudhry Mohammad Rauf A , Gill Mohsain , Siddiq Farhan , Suri Fareed K , Gomez Camilo R , Qureshi Adnan I
Published: June 2021

Background:
Relatively limited information is available about trends over time in the use of endovascular treatment in patients of different ages hospitalized with acute ischemic stroke and the association between use of thrombectomy treatment and hospital outcomes in age strata. We performed this analysis to evaluate trends in the utilization of endovascular treatment in acute ischemic stroke by age strata in real-world practice.

Methods:
We conducted this study by identifying patients admitted with a primary diagnosis of ischemic stroke in the United States from 2007 to 2016 using the Nationwide Inpatient Sample. International Classification of Diseases, ninth revision, and tenth, Clinical Modification (ICD-9-CM, ICD-10-CM) codes were used to identify patients admitted for ischemic stroke and undergoing endovascular treatment.

Results:
Of the 4,590,533 patients admitted with ischemic stroke, 269,922 (5.88%) received intravenous thrombolytic treatment, and 51,375 (1.12%) underwent endovascular treatment. There is almost 12-fold significant increase in the use of endovascular treatment patients admitted with acute ischemic stroke between 2007 to 2016. Patients who were 75 years and older experienced a marked increase in the receipt of endovascular treatment over time (0.12% 2007; 1.91% 2016; trend p<0.0001). We observed statistically significant improvement in outcomes including minimal disability (6.3% to 18.8%; trend p<0.0001) and in hospital mortality (25.0% to 16.5%; trend p<0.0001) in patients 75 years and older treated with endovascular treatment in study period. We observed similar trend of outcomes in each of the other age-specific groups under study (<55, 55-64 and 65-74 years).

Conclusions:
Our findings indicate a recent increase in the use of endovascular in middle-aged and elderly patients with acute ischemic strokes. The impact of endovascular treatment on hospital outcomes was observed in each of our age strata understudy though the magnitude of absolute and relative benefit varied according to age.
Abstract WP417: Relevance of Lobar Cerebral Microbleeds in Patients With Deep Intracerebral Hemorrhage
Authors: Tsai Hsin-Hsi , Gokcal Elif , Chen Szu-Ju , Tsai Li-Kai , Chen Ya-Fang , Tang Sung-Chun , Yen Ruoh-Fang , Jeng Jiann-Shing , Gurol Edip
Published: June 2021

Background:
Markers of cerebral small vessel disease (cSVD) severity and prognosis in strictly lobar or strictly deep intracerebral hemorrhages (ICH)/cerebral microbleeds (CMB) are well defined but data are scarce for mixed-location ICH/CMB. We aimed to compare neuroimaging features and outcomes between deep ICH patients with and without lobar CMBs.

Methods:
Patients with first-ever deep ICH from a prospectively maintained single-center registry were analyzed. Demographics, risk factors and neuroimaging markers of cSVD including CMBs, cortical superficial siderosis, enlarged perivascular spaces (EPVS), white matter hyperintensity volumes (WMH) and brain atrophy scores (range 0-15) were compared between deep ICH patients with lobar CMBs and those without lobar CMBs. The follow-up data were analyzed for ICH recurrence, ischemic stroke (IS) and all-cause mortality.

Results:
Of 208 patients, 98 (47.1%) had lobar CMBs. Patients with L-CMBs were older (65.3±12.1 vs. 57.4±12.5, p<0.001) and more likely to be hypertensive (98% vs. 90.9%, p=0.037) than those without L-CMBs. Deep CMBs (83.7% vs 56.4%, p<0.001), lacunes (53.1% vs 31.8%, p=0.003) and severe basal ganglia EPVS (40.8% vs 17.3%, p<0.001) were more common in patients with L-CMBs. Patients with L-CMBs had higher volumes of WMH (17.4 ml [IQR 9-38] vs 4.8 ml [IQR 1-13], p<0.001) and atrophy scores (4 [IQR 2-7] vs 3 [IQR 0-6], p=0.007) as compared to patients without L-CMBs. During a median follow-up of 21 months, the ICH recurrence rate was similar between groups (p=0.2), but higher incident IS (3.0 vs 0.0 per 1000-person-months, p=0.016) and all-cause mortality (4.9 vs 1.5 per 1000-person-months, p=0.026) were observed in patients with L-CMBs. In a cox regression model, the presence of lobar CMBs was independently associated with a composite outcome measure (ICH/IS/mortality) after adjusting for age, hypertension, WMH volume, lacune, BG-EPVS and atrophy scores (odds ratio: 2.9, 95%CI:1.01-8.4 p=0.046).

Conclusions:
Presence of lobar CMBs in patients with deep ICH is associated with parenchymal markers of more severe cSVD and poor prognosis, suggesting a more advanced vasculopathy compared to patients with strictly deep ICH.
Abstract WP419: Effect of Race-Ethnicity and Ct Angiography on Acute Kidney Injury During Blood Pressure Treatment for Intracerebral Hemorrhage
Authors: Boslet Emma H , Shah Nayna , Simonetto Marialaura , Bustillo Antonio , O'Phelan Kristine H , Koch Sebastian
Published: June 2021

Background:
Lowering blood pressure intensively in acute intracerebral hemorrhage (ICH) is associated with acute kidney injury (AKI). Blacks have a higher incidence of ICH as well as kidney disease. In addition, CT angiography (CTA), which may also be associated with AKI, is often done in acute ICH. Our objective was to investigate the relationship between aggressive BP management, CTA, race ethnicity and the risk of developing AKI in patients presenting with ICH.

Methods:
Patients with spontaneous ICH hospitalized in 2017 and 2018 were included. Patients with underlying arteriovenous malformations, brain metastases, and aneurysms, were excluded. We calculated the difference between the highest and lowest systolic blood pressure (SBP) during the first 24 hours of admission. Creatinine levels at admission were compared to the highest creatinine during the first 7 days after admission. AKI was defined as absolute increase in creatinine of >0.3 or 50% increase from baseline creatinine. Linear regression models were used to assess the association between SBP difference, history of CTA and AKI.

Results:
A total of 289 patients were included (mean±SD age 63±13), 40% were women, 41% Hispanics and 47% blacks. The majority of the patients underwent CTA (71%). The prevalence of AKI was high (30%). Blacks showed a significantly higher SBP compared to whites and Hispanics (p=.02), but no difference was found in AKI incidence (33% in Blacks vs. 27% in Caucasians and Hispanics (p=0.7). Higher BUN, creatinine and SBP on admission were associated with AKI (p=.001, p<.0001, and p=.0001, respectively). Those who developed AKI had a greater mean drop of SBP in 24 hours compared to those who did not (103mmHg vs. 84mmHg, p=.0007) and a higher prevalence of diabetes (p=.0013). In fully adjusted models, AKI was associated with SBP drop (p=.0003), but not with race/ethnicity (p=.6) or CTA (p=.06).

Conclusion:
We confirm, in a real-life ICH population, the association between intense blood pressure lowering and development of AKI. Race/ ethnicity and CTA were not independently associated with AKI. Our findings do not suggest that obtaining a CTA in acute ICH poses significant additional risks on developing AKI.
Abstract WP427: Implementing an Algorithm Emphasizing Telestroke for Patients With an Acute Cerebrovascular Event in a Rural Setting
Authors: Dancer Rachel , Ahmann Jessica , Madler Billie , Manchak Michael , Pitt Shannon
Published: June 2021

Background and Purpose:
A stroke may occur without warning and deficits can range from mild deficits to death. Improved outcomes are associated with decreased time to revascularization of cerebral tissue. The time sensitive nature of stroke care contributes to the challenges associated with caring for individuals suffering from stroke who live far from a stroke center. The American Stroke Association (ASA) guidelines include a recommendation for the implementation of telestroke. The technology is preferred over telephone consults and is an effective method to determine eligibility of fibrinolytic therapy.

Methods:
The project was implemented in a stroke ready facility in a rural area and supported by an urban care center that is recognized as a comprehensive stroke center. Stroke education was provided to the rural site and an algorithm utilizing the telestroke technology was implemented. Times from door to CT (computed topography) scan, door to fibrinolytic therapy, and door to transfer time were tracked for 90 days to compare average times to baseline data using a one-tail t-test. Statistical significant was determined with a p-value <0.05.

Results:
There were 27 patients that presented during the collection period, with a baseline comparison of 39 patients over an 11-month period. Overall, each category had a decrease in time, with significant differences noted in door to CT and door to transfer time. The average door to CT time with telestroke decreased on average by 14.1 minutes from baseline data to a new average of 8.6 minutes. Door to transfer time with telestroke decreased by 42.2 minutes from baseline to a new average of 121.4 minutes. Additionally, during the collection period, fibrinolytic therapy initiation doubled, resulting in 48% receiving therapy. Due to the faster times, 35% of patients were able to receive a thrombectomy at the tertiary site.

Conclusions:
In conclusion, this study demonstrates promising results for the continuation of telestroke use in rural treatment sites for acute cerebrovascular events to decrease time to interventions for optimal outcomes.
Abstract WP43: Anti-Coagulation Therapy Prior to Mechanical Thrombectomy is Associated With Reduced Procedure Time and Low Proportion of Fibrin in Retrieved Thrombus
Authors: Maekawa Kota , Kazuto Kobayashi , Takanori Sano , Masunari Shibata , Tadashi Yabana , Yutaka Naito , Fumitaka Miya
Published: June 2021

Introduction:
Very few studies have investigated the relationship between the histopathology of the retrieved thrombus by mechanical thrombectomy for large vessel occlusion and anti-coagulation agents before mechanical thrombectomy. A study in vitro showed that clots of patients with anti-coagulation agents were dissolved easily compared to those of patients with aspirin.

Hypothesis:
Anti-coagulation therapy prior to mechanical thrombectomy is associated with reduced procedure time and low proportion of fibrin in retrieved thrombus.

Methods:
All retrieved thrombus was stained with hematoxylin-eosin. Embolic debris underwent quantitative analysis to quantify three main components: red blood cells, white blood cells and fibrin, by color based segmentation. Patients were assingned to receive either mechanical thrombectomy with anti-coagulation agents (AC-MT group) or mechanical thrombectomy alone (MT group). Considering influence by stroke etiology, patients with non-cardioembolism were excluded.

Results:
From August 2015 to Dec 2018, 226 consecutive patients were treated in our hospital by MT for acute large vessel occlusion. Histopathologic analysis of retrieved thrombus from 119 patients with acute stroke. 92 patients with cardioembolism were included. Patients were assigned to AC-MT group (n=35) or MT group (n=57). Clinical backgrounds were not significantly different. PT-INR was higher in AC-MT group. (1.32 vs 1.06; p<0.01) The proportion of patients with recombinant tissue plasminogen activator was not significantly different (26% vs 43%; p=0.12). AC-MT group had shorter puncture to recanalization time (median 38 vs 54 minutes; p<0.01) and tendency to reduce number of maneuvers [median 2 (range 1-4) vs 2 (range 1-6); p=0.06]. AC-MT group had lower proportion of fibrin in retrieved thrombus (44.3% vs 77.3%, p<0.01).

Conclusion:
Anti-coagulation therapy prior to mechanical thrombectomy is associated with reduced procedure time and low proportion of fibrin in retrieved thrombus.
Abstract WP430: Implementation of Inpatient Stroke Champions Leads to Improved Inpatient Code Stroke Metrics
Authors: Lapsys Katherine V , Belmonte Jasmine Rochelle B , De La Pena-Gamboa Nathalie , Dhanji Raeesa , Cuenca Regina I , Manalo Chriselda G , Sta Maria Ariane G , Del Rosario Janet C , Perez Claudine M , Punsalang Lorina , Mkrtumyan Alvina , Gaffney Denise , Leido Joyce , McCartney David L , Ajani Zahra , Le Duy , Sangha Navdeep
Published: June 2021

Introduction:
Stroke Champions (SC) are AHA recommended designated inpatient nurses that serve as expert resources for their units to ensure that evidence-based practices for stroke care are implemented. Inpatient Code Strokes (ICS) are difficult to recognize which results in delayed treatment. The purpose of this study is to determine if there was an improvement in inpatient acute stroke metrics with the addition of SC in the hospital.

Methods:
Over a 12-month period at a Comprehensive Stroke Center (CSC), 12 nurses in the inpatient stroke units were trained as SC. This training consisted of advanced education in CSC metrics, guidelines and required documentation. SC provided peer-to-peer education, served as expert resources, conducted comprehensive chart reviews, shift huddles, and “on the spot” feedback to nurses and physicians. The metrics were examined pre and post intervention and included: Symptom Recognition Time (SRT) to CT interpretation, SRT to tPA bolus time, and SRT to groin puncture. SRT is equivalent to Emergency Department door time for inpatient strokes. Statistical analysis was performed using T-test and the Mann-Whitney test.

Results:
There were 114 pre-SC and 101 post-SC ICS. There was a trend toward more patients being accurately diagnosed with a TIA or stroke (75.3% post vs. 65.8% pre-SC; p=0.06). The SRT to CT interpretation time for patients who received tPA improved from 43 to 35 mins. The number of patients treated with tPA increased from 10 to 17. SRT to tPA bolus time trended toward improvement from 57 to 42 mins (p=0.07). SRT to groin puncture time in patients who received both tPA and thrombectomy trended toward improvement from 81 vs. 65 mins (p=0.07). There were twice as many inpatient thrombectomy cases in post-SC (n=23) vs. pre-SC (n=12).

Conclusion:
The knowledge and expertise provided by SC resulted in a higher percentage of ICS having a final diagnosis of stroke. This demonstrates an increased accuracy of stroke specific symptom recognition by the inpatient nursing teams. There was improved SRT to tPA bolus and groin puncture time. This is the only study that shows implementation of the AHA recommended SC program improves inpatient code stroke recognition and treatment metrics.
Abstract WP432: Stroke Survivor and Informal Caregiver Involvement to Address Mental Health in Stroke Recovery
Authors: Beauchamp Jennifer E , Casameni Montiel Tahani , Varughese Tina , Savitz Sean , Sharrief Anjail , Engebretson Joan
Published: June 2021

Background and Purpose:
Stroke survivor (SS) and informal caregiver ([IC]; e.g., unpaid spouse) mental well-being are connected with symptoms of psychosocial distress negatively affecting both. The purpose of this study was to implement the principles of patient-centered measurement by working with a team of SS, IC, and researchers to explore what mental health needs matter to a cohort of SS and IC.

Methods:
An 18-question mental health survey was created with input from 2 SS, 2 IC, and experts in neurology and nursing and distributed to community-dwelling SS (n=26) and IC (n=14). Subsequently, two semi-structured group interviews were conducted. Interviews were stratified by role (n=7 SS and n=3 IC) to attain homogeneity in order to encourage open dialogue.

Results:
Among 40 SS and IC, 65% were SS and 35% were IC with a mean age of 62 years. Overall, frustration (69%), stress (64%), worry (47%), anxiety (42%), and depression (31%) were the predominant mental health needs identified among both groups. Both SS (46%) and IC (46%) equally reported intolerant or close-minded cultural backgrounds to mental health issues. The majority of SS and IC identified peer-support and support groups as essential aspects when addressing mental health support during the stroke recovery period.

Conclusions:
This survey identified a number of mental health issues that matter to SS and IC. Our results raise the need to focus on interventions that will address patient-centered mental health outcome measurements that reflect what matters to the SS and IC and incorporate these patient and caregiver centered outcomes in stroke recovery clinical trials.
Abstract WP436: Sensory Distraction to Help Decrease Agitation in Stroke Patients
Authors: Dahl Stephanie , Lynch Deborah , Hallberg Elizabeth , Collier Vanessa
Published: June 2021

Background:
Dysphagia is a common complication after stroke. To ensure adequate nutritional intake, nasogastric (NG) or other feeding tubes may be inserted. Post-stroke agitation and aggression can occur in 15 to 35% of stroke survivors as early as 4 days after stroke. At Rush University Medical Center (RUMC), it is common for the Stroke Unit patients to have feeding tubes and any other tubes necessary for treatment. It is a growing concern that agitated stroke patients self-remove feeding and other tubes requiring reinsertion and/or limb restraints. Although historically sensory modulation has not been heavily utilized in stroke patients, sensory based treatment objects in psychiatric inpatient units have been reported to reduce the use of restraints.

Purpose:
The purpose of this quality improvement project was to decrease agitation in stroke patients using sensory distraction objects (SDO). The goal of this project was to decrease the use of limb restraints and prevent patient self-removal and staff reinsertions of feeding and other tubes during this study period.

Method:
This project targeted stroke patients in the RUMC 12 West Tower Unit who were agitated, restless, impulsive, or anxious. Each patient was given a SDO, such as a plastic ring toy, glitter ball, activity belt, or a silk handkerchief attached to their gown. A decision tree was used to assign a SDO based on the patient’s cognitive and motor function. The Agitation Behavior Scale (ABS) was used to measure agitation in stroke patients; the scale was used pre- and post-implementation. Post-implementation assessment was done within one hour after the SDO is given. The use of limb restraints and patient self-removal of feeding and other tubes was observed.

Conclusion:
The project included 15 participants. Eleven out of 15 patients showed a decrease in agitation with a distraction object using the ABS. Only 20% of participants pulled out their feeding or other tube and two patients required restraints during the study period. In conclusion, this project did showcase a decrease in agitation for stroke patients using a SDO and decreased the use of limb restraints. The SDO prevented patient self-removal and staff reinsertion of feeding and other tubes.
Abstract WP437: Where Are We Located Now With Artificial Neural Network? Application of Deep Learning for the Development of Culturally Sensitive Social Support Interventions for Dementia Caregivers
Authors: Yoon Sunmoo , Tipiani Dante , Broadwell Peter , Luchsigner Jose
Published: June 2021

Introduction:
Little is known about culturally sensitive interventions for Hispanic and African American family caregivers for persons living with vascular dementia. Applications of deep-learning neural networks have expanded rapidly in recent years, from the first uses in character recognition (1989) to the high-profile AlphaGo (2016) from Google DeepMind. The purpose of this study is to visualize topics from health literature that use deep learning, exploring the techniques’ ability to provide a foundation for developing culturally sensitive Twitter-based social support interventions for Hispanic and African American dementia caregivers.

Methods:
The corpus of deep learning literature was extracted from 506 studies mentioning deep learning from PubMed library. Text mining was conducted using AutoMap to identify topics and semantic relations from the corpus. Results were visualized as network clusters of frequently applied topics and isolated topics.

Results:
Literature applying deep learning are limited to 1) imaging and radiology, 2) genomics, 3) cancer (N=506 studies). Topics on dementia and drug discovery were identified as an emerging area for the adaptation of deep learning techniques (Figure 1). Only seven journals in the PubMed library were identified as having published more than 10 studies applying deep learning methods.

Conclusion:
Despite its popularity in art and science research, deep learning is at an early stage of adoption in health science, largely focused on limited topics, e.g., imaging and disease diagnosis. Applying deep learning methods may provide insights for developing culturally sensitive Twitter-based interventions for Hispanic and African American dementia caregivers. Implementing education on applying deep learning to imaging and vascular-dementia prediction may be a good start to adapt, deepen and broaden the scope of health analytics to improve vascular dementia patients’ health outcomes.
Abstract WP438: Monthly Patient Stroke Education Prevalence Rounds Increase Nursing Engagement While Positively Affecting Quality Patient Outcomes
Authors: Brown Dena R , Buttrick Maureen F
Published: June 2021

Background and Purpose:
Understanding stroke and factors in the prevention of stroke are fundamental in improving quality outcomes and patient healthcare compliance. Daily individualized patient education is an accreditation requirement, and as a certified stroke center the goal is to exceed national care standards for patients with stroke. Documentation of daily individualized patient education compliance was found to be below the required expectations with initial audits. Bedside nurses were surveyed on documentation requirements of every stroke patient, and a knowledge gap was identified. The purpose of this quality initiative was to improve compliance of daily individualized stroke education and increase bedside nursing accountability and engagement in the care of stroke patients.

Methods:
The quality initiative consisted of a monthly one day snapshot of daily stroke education documentation compliance (average n=34). Results are shared with executive nursing leadership, unit managers and bedside nurses. Stroke Champions facilitate one-on-one education with their nursing peers when opportunities for improvement of required stroke education have been identified. This nurse driven collaboration was augmented with daily education reminders during unit huddles, patient stroke education posters on the unit, and caregiver award recognition for those nurses with high compliance.

Results:
Significant improvements in documentation of daily individualized stroke education were found following the stroke prevalence education initiative. A pre-initiative audit was conducted 4th quarter of 2015, revealing compliance was at 65%. After implementation, 2016 compliance improved to an overall 86%; 2017 was 84%; 2018 was 90% and the first half of 2019 remains at 90%.

Conclusions:
In conducting monthly stroke prevalence rounds, nurse driven collaboration has shown significant improvements in consistently documenting daily individualized stroke education, therefore increasing required patient stroke education compliance and producing the potential for better outcomes for patients.
Abstract WP44: Less Infarct Volume Growth in Early Window Mechanical Thrombectomy Compared to Late Window in Emergent Large Vessel Occlusion
Authors: Andrapalliyal Nirmal , Handshoe Lacy Samuel , Mulpur Bhageeradh , Uchino Ken , Hussain M. Shazam
Published: June 2021

Background:
While clearly beneficial based on outcome analysis, there has been limited data regarding prevention of further infarct growth in late (6-24 hour) compared to the early window (<6 hour) mechanical thrombectomy (MT). More expedient revascularization in the early group prevents further growth, but the presence of good collaterals in late window patients may prevent infarct progression over time. The aim of this study is to compare infarct growth between early and late window intervention.

Methods:
We reviewed consecutive patients presenting to a comprehensive stroke center from January 2016 to December 2018 with emergent large vessel occlusion (ELVO) undergoing MT. Standard protocol included pre-procedural MRI imaging and only those with post-procedural MRI were included. Patients were divided into early (<6 hour from onset to arterial puncture) and late (6-24 hour from onset to arterial puncture) groups. Infarct volume on MRI was measured using region of interest analysis by investigators blinded to group. MRI growth between pre- and post- MT MRI was compared using both absolute difference (post minus pre volume) and ratio (pre:post volume).

Results:
Among 117 patients meeting inclusion criteria, 40 (34.2%) patients had early and 77 (65.8%) late interventions. Those in the early group showed a trend toward lower infarct volume growth compared to those in the late group (16.0 +/- 42.9 vs 31.4 +/- 60.9 mL growth, p = 0.16). Ratios of pre to post MT infarct volume was significantly different in early and late intervention group (1.07 +/- 1.6 vs 0.63 +/- 0.33, p = 0.02), signifying less infarct growth in the early group.

Conclusion:
In patients with ELVO for whom MT was performed, there was less infarct growth in the early time window compared to the late window.
Abstract WP441: Clinical Documentation Improvement Quality Project to Improve Risk Adjusted Mortality in Ischemic Stroke
Authors: Yadav Randheer S , Lakhani Sushil , Forrest Cassanda , Gough Bryan , Hinduja Archana , Mainali Shraddha , Olcese Vanessa , Strohm Tamara , Howell Ravyn , Glenn Jessica , Grose Noah , Kittle Martina , Powers Ciaran , Heaton Sharon , Lee Vivien H
Published: June 2021

Introduction:
Vizient clinical database-resource manager (CDB/RM) is an alliance of Academic Medical Centers and their affiliated hospital that collects data to enhance patient care by aligning cost, quality and market performance. The observed-to-expected mortality (O/E) is a risk-adjusted measure of a hospital’s mortality and is based upon documentation of specific variables associated with mortality.

Methods:
Our comprehensive stroke program participates in Vizient CDB/RM. We defined observed mortality as the rate of patient deaths in the hospital each month. Expected mortality is calculated as the sum of all individually calculated risks with conditions that affect severity, for discharges each month. The O/E ratio is calculated by dividing observed mortality by the expected mortality. An O/E ratio score higher than 1.0 means the hospital’s mortality is higher than expected.

Results:
We identified the most common discharge diagnosis-related group (DRG) codes for ischemic stroke used by our neurovascular service in 2018. We used the Academic Medical Center Hospital: Risk Modeling Summary for 2016 to determine the model group that was relevant for our population. We chose Model group 23 as the highest yield, as that model covers nearly half our volume based upon our frequently used DRG codes. The team used a shared mortality risk factor standard template to improve documentation practices. The Quality Intervention (QI) plan was implemented July 22, 2019 using an interdisciplinary approach. Clinical teams were educated on specific documentation of variables associated with in-hospital mortality. Vizient CDB/RM data on stroke mortality will be reviewed in September 2019 to determine the effect of the QI on mortality O/E ratio for our ischemic stroke population.

Conclusions:
Our comprehensive stroke program implemented a clinical documentation improvement QI plan to improve Vizient CDB/RM Risk Adjusted Mortality for our ischemic stroke population. We expect that improving appropriate documentation will assist coding specialist to capture the severity of cases, which should improve the mortality O/E ratio.
Abstract WP443: Brain Matters Competition
Authors: Chambers Kathleen
Published: June 2021

Our goal was to improve patient metrics of stroke care by implementing competition among caregivers in the emergency department (ED). Patient metrics of stroke care are being tracked very closely for all stroke center organizations across the nation. Every year brings on challenges of meeting new evidenced based clinical practices metrics. This can be an ongoing challenge in healthcare. We recognized the need to improve our stroke care process numbers. Half of stroke survivors are left with some neurological deficit. Avoiding complications by providing time sensitive and systematic process is crucial to promote best outcomes for stroke patients. The timed targets for essential interventions during a stroke patients arrival to any ED include door to provider in < 10 min, door to stroke activation in < 15 min door to CT in < 20 min (new 2019), door to drug < 60 min (85% of cases), door to drug < 45 min (75% cases) and door to drug in 30 min (50% of cases – new 2019). Although our hospital was near the 20 min for door to CT we saw room for improvement. Refining the process from pre-arrival has a direct impact on treatment and intervention times later in the ED. Our door to drug posed more of a challenge from the previous year so we knew we had work to do. Using a competitive atmosphere in achieving outcomes is becoming more recognized as a powerful tool to promote engagement and motivation of caregivers in the healthcare system. We started with our EMS providers and established best door to CT time recognition. The RN’s with the best door to drug (< 45 min) were also acknowledged. 2018 year end data door to CT =21 min door to drug < 60 min (95%) < 45 min (33.3%) 2019 thru May door to CT =16 min, door to drug <60 min (100%), < 45 min (78%), < 30 min (33%). Overall metrics got better. Staff were engaged in the process of stroke care. Overall tPA times decreased from 47 min (2018) to 39 min (2019).
Abstract WP444: Influencing Factors on the Compliance in Ischemic Stroke Patients Treated With Remote Ischemic Conditioning
Authors: Chang Hong , Zhao Jie , Qiao Yuchen , Zheng Ruan , Cao Wenya , Yao Hui , Fan Kaiting , Yang Xin
Published: June 2021

Objectives:
To investigate the treatment compliance of remote ischemic conditioning in patients with ischemic stroke, and determine its associated influencing factors.

Methods:
A retrospective survey of ischemic stroke patients treated with remote ischemic conditioning was conducted. Treatment compliance was obtained and analysed in patients with one-year training of remote ischemic conditioning. The influencing factors on patients’ compliance were determined by univariate and multivariate regression analysis.

Results:
The history of hypertension, the number of follow-ups, and the physiological, psychological and environmental dimensions of the comfort scale were related to patient compliance, out of which the number of follow-ups and physiological comfort were independent influencing factors of compliance (P<0.05).

Conclusion:
In future researches, if we can comprehensively consider the patient’s efficacy, comfort, compliance and other factors, choose the optimal treatment dose, and improve the RIC nursing process accordingly, then this will provide the basis for clinical implementation and scientific research of RIC.
Abstract WP447: Early Mobilization After 12 Hours Post-Thrombolysis is Safe and Reduces Length of Stay in Minor Stroke Patients
Authors: Packard Laurel , Tubergen Tricia , LaCroix Hattie , Gritters Danielle , Ames Nicholas , Packard Donald , Wills Nicole , Zachariah Joseph , James Elysia , Goosen Andrea , Frye Angela , Wees Nabil , Khan Nadeem , Min Jiangyong , Singer Justin , Khan Muhib
Published: June 2021

Background:
Bed rest of 24 hours post-thrombolysis is recommended for acute ischemic stroke patients. We sought to compare outcomes and in-hospital complications of 12- and 24-hour bed rest protocols following thrombolysis in minor stroke patients.

Methods:
Consecutive patients age >18 years with a diagnosis of ischemic stroke that received tPA only and who had an initial National Institute of Health Stroke Scale (NIHSS) 0-5 between 1/1/2017 and 3/30/2019 were included. Stroke mimics and patients who underwent mechanical thrombectomy were excluded. The standard practice bed rest order for the 24 hour protocol prior to 07/15/2017 was compared with the 12 hour bed rest order protocol after that date. The primary outcome was length of stay. Secondary outcome measures included symptomatic intracerebral hemorrhage (sICH), deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days and modified rankin scale (mRS) at 90 days.

Results:
Of the 106 patients identified, 36 patients were in the 24-hour protocol and 70 were in the 12-hour bed rest protocol group. There was significant difference for length of stay in the 24-hour bed rest protocol (2.9 days) compared with the 12-hour bed rest protocol (2.0 days) (p=0.032). Compared with the 24-hour bed rest group, the rates of sICH (p=NS), DVT (p=NS), PE (p=NS), pneumonia (p=NS), favorable discharge disposition (p=NS), 30 day readmission (p=0.NS) and 90 day mRS 0-2 (p=NS) were not different between the groups. Time to mobilization was significantly different between the two groups (24 hour group:2043.2 ± 680.1 minutes; 12 hour group:1221.0 ± 527.8) (p<0.0001).

Conclusion:
Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with significantly earlier patient mobilization and reduced length of stay without any adverse outcomes. A randomized trial is needed to verify these findings.
Abstract WP448: Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis is Safe and Reduces Length of Stay for Minor Stroke Patients
Authors: Tubergen Tricia , Packard Laurel , Gritters Danielle , LaCroix Hattie , Goosen Andrea , Wills Nicole , Zachariah Joseph , James Elysia , Singer Justin , Wees Nabil , Khan Nadeem , Min Jiangyong , Khan Muhib
Published: June 2021

Background and Purpose:
Acute Stroke Patients treated with intravenous tissue-type plasminogen activator (tPA) require intensive care unit (ICU) monitoring for 24 hours post-treatment due to risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of shorter ICU monitoring for minor stroke patients treated with tPA.

Methods:
Consecutive patients age >18 years with a diagnosis of ischemic stroke that received tPA only and who had an initial National Institute of Health Stroke Scale (NIHSS) 0-5 between 1/1/2017 and 3/30/2019 were included. Stroke mimics and those who underwent thrombectomy were excluded. Standard practice 24 hour ICU stay prior to 05/15/2018 was compared with 12 hour ICU stay after that date. The primary outcome was length of stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and modified rankin scale (mRS) at 90 days.

Results:
Of the 122 patients identified, 77 patients were in the 24-hour protocol and 45 were in 12-hour ICU stay protocol groups. There was significant difference in length of stay for the 24-hour ICU stay protocol (2.8 days) compared with the 12-hour ICU stay protocol (1.8 days) (
P
<.001). Compared with the 24-hour ICU stay, the rates of sICH (
p
= .65), DVT (
p
= NS), PE (
p
= NS), pneumonia (
p
= 1.00), favorable discharge disposition (
p
= .26), 30 day readmission (
p
=0.06) and 90 day mRS 0-2 (
p
= .37) were not different between the groups.

Conclusion:
Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with without any adverse outcomes. A randomized trial is needed to verify these findings.
Abstract WP458: Effect of Olmesartan / Azelnidipine Combination Tablets on Ambulatory Blood Pressure and Cognitive Function in the Post-Stroke Patients
Authors: Matsumoto Shuji
Published: June 2021

Background and aims:
In patients with severe hypertension, or history of stroke, the lower limit of cerebral blood flow (CBF) autoregulation is shifted to a higher blood pressure (BP) than in healthy subjects. The aim of this study was to compare the effects of olmesartan/azelnidipine combination (OLM/AZ) vs high-dose of olmesartan on ambulatory blood pressure (ABPM), cognitive function, and rehabilitation outcome in the post-stroke patients with hypertension.

Methods:
A total of 36 patients, 20 men and 16 women, aged 58-72 years, with sitting diastolic BP >90mmHg and systolic BP >140mmHg were eligible for participation in the present study. We randomly assigned 36 patients to either the OLM/AZ group or high-dose olmesartan group for 12 weeks. At the end of a 2-week wash-out period and after 12 weeks of active treatment, 24-h noninvasive ambulatory BP monitoring (ABPM) was performed, and cognitive function was evaluated through neuropsychological testing. In addition, rehabilitation outcome measurements were also collected during study period.

Results:
Both treatments significantly reduced ambulatory BP. However, the OLM/AZ produced a greater reduction in 24-h, day-time and night time ABPM values. High-dose olmesartan did not induce significant changes in any of the cognitive function test scores, whereas at 12 weeks OLM/AZ significantly improved the neuropsychological test score (Digid span test, Token test, Digital symbol test, Trail making test part A and B) (p< 0.01). Patients treated with OLM/AZ showed effective rates of improvement in hand (38.9%), upper extremities (55.6%) and lower extremities (72.2%), measured by Brunnstrom stage; these improvements were significantly different from those in high-dose olmesartan group for the total (P< 0.05) scores.

Conclusions:
These results suggest that in hypertensive post-stroke patients treatment with OLM/AZ produces a slightly greater reduction in ambulatory BP than high-dose olmesartan, and unlike this latter, improves some of the components of cognitive function, particularly psychomotor speed, attention and mentation. Our results suggest that OLM/AZ may improve cognitive function and rehabilitation outcome in hypertensive stroke patients in whom CBF autoregulation is impaired.
Abstract WP459: Advanced Practice Providers versus Neurology Residents: Similar Stroke Code Quality Metrics and Functional Outcomes
Authors: Martin Heather , Packard Laurel , Gritters Danielle , LaCroix Hattie , Tubergen Tricia , Zachariah Joseph , James Elysia , Combs Jordan , Brazitis Michelle , Zleik Bashar , Wees Nabil , Khan Nadeem , Min Jiangyong , Singer Justin , Mazaris Paul , Khan Muhib
Published: June 2021

Background:
Advanced Practice Providers (APPs) are important members of stroke code teams. However, the impact of APP involvement on quality metrics and functional outcomes is unclear. We sought to evaluate if APPs perform similarly to neurology residents for stroke code quality metrics and functional outcome at 90 days.

Methods:
We retrospectively analyzed data of consecutive patients who underwent thrombectomy in a single center cohort. Demographics, National Institute of Health Stroke Scale (NIHSS), last known normal (LKN) to emergency department (ED) presentation time, ED door to skin puncture time, recanalization (mTICI IIb/III) rates, and modified rankin scale (mRS) at 90 days were compared between neurology residents and APPs. A multiple logistic regression was used to determine factors independently associated with a favorable mRS at 90 days.

Results:
A total of 172 patients were included in the study of which 80 (47%) were managed by neurology residents. Both groups (residents vs. APPs) were balanced for age (
p
=0.87), NIHSS (
p
=0.18), LKN to ED Door time (
p
=0.19), ED door to skin puncture time (
p
=0.08), recanalization rate (
p
=0.28), and favorable outcome (mRS 0-2) (
p
=0.27). The multiple logistic regression model found patients with recanalization were 8.9 times more likely to have a favorable outcome. Age and initial NIHSS were found to be negative predictors of mRS (Table 1). Resident or APP involvement in the stroke code process did not impact outcome (
p
=0.08).

Conclusion:
APPs achieve similar acute stroke code metrics and functional outcomes when compared to neurology residents. Further studies are needed to confirm our findings.
Abstract WP467: Challenging the National and Regional Targets and Achieving Door-to-Needle in 25 Minutes or Less at a Comprehensive Stroke Center
Authors: Sinogui Cynthia , Mitchell Hillary , Moiseyenko Anna , Keear Leslie , Smith Maraget , Zrelak Pat , Terwilliger Kristen , Lucena-cabalbag Kristianne , Olsen Katherine , Bitar Jamil , Jacobson Wendy , Bujari Zaklina , Molina Claudia , Ambatali Shela , Bennet John , Evans Natasha , Lim Anecita , Ohki Jessica , Maharaj Ashleen , Kavoosi Jennifer
Published: June 2021

Background:
The American Heart/ American Stroke Association (AHA/ASA) established national 60 and 45-minute alteplase treatment targets ensure timely administration of alteplase in patients with acute ischemic stroke (AIS). To challenge the 21 facilities of our integrated health system, our organization established a treatment target of 30-minutes or less. To raise the bar further, our local facility set a treatment target of 25-minutes or less.

Purpose:
To streamline and standardize rapid assessment and treatment for AIS patients receiving alteplase in 25-minutes or less at a CSC.

Methods:
Baseline data and process timeline were reviewed, and the workflow was evaluated using real-time observations conducted by front-line staff. Staff, physicians, and former patients involved in cases that met the 30-minute target were interviewed. Several Plan-Do-Study-Act cycles were performed. An interdisciplinary subcommittee meets weekly to review cases for compliance and evaluation for process sustainability. An in-depth review is conducted for all cases outside the 25-minute treatment target. AHA/ASA exclusion criteria are allowed.

Results:
Baseline data was reviewed yielding 18% compliance to the target of 25-minute or less (3/16). Changes were implemented in April 2018. Between April 2018 and July 2019 of the 107 cases treated, 55% of cases were within 25-minutes, 81% within 30-minutes, 85% with 45-minutes, and 95% in 60-minutes. Keys to decreasing times were use of timer, a designated timekeeper, announcement of time increments, and revisions of the process. Data and other graphics were posted in the Stroke Alert vestibule as a visual aid for staff. Collaboration between departments was integral in driving change.

Conclusion:
Challenging national and organizational treatment targets and revising workflows were effective ways to sustain alteplase treatments times of 25-minutes or less.