bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP29: A Propensity-Matched Analysis of Outcomes for Patients With M2 Branch Occlusions at Endovascular Stroke Centers
Authors: Ovando Renee , Lucus Lindsay , Baraban Elizabeth , Tarpley Jason W
Published: January 2019

Introduction:
Endovascular therapy (EVT) for Emergent Large Vessel Occlusion (ELVO) is recommended for patients with acute proximal MCA (M1 segment) occlusions (Class I, level A evidence), but the benefits of EVT are uncertain in patients with M2 and more distal occlusions. The purpose of this study was to compare the efficacy and outcomes of EVT-treated M2 ELVOs with EVT-treated M1 ELVOs, and to examine the outcomes of EVT-trerated M2 ELVO patients with those whose M2 ELVOs were not treated.

Methods:
Data were obtained from a multi-hospital system of patients from January 2014 and May 2018. Two propensity score (PS)-based nearest-neighbor matching analyses were used to match similar patients who had 1) EVT-treated M1 vs EVT-treated M2 ELVOs and 2) EVT-treated vs non-EVT-treated M2 ELVOs. Outcomes included length of stay (LOS), rate of successful reperfusion, discharge disposition, symptomatic intracranial hemorrhage (sICH), and discharge mRS. Chi-squared, Fisher’s exact, and Mann-Whitney U tests were used to compare matched patients.

Results:
Overall, 160 patients with EVT-treated M2 ELVOs, 350 with EVT-treated M1 ELVOs, and 113 with non-EVT-treated M2 ELVOs were included. Propensity score analyses resulted in 118 matched patients with EVT-treated M2 and EVT-treated M1 occlusions and 70 matched patients with EVT-treated and non-EVT-treated M2 ELVOs. M2 ELVOs made up 20% of all LVO patients. Treated M1 and M2 ELVOs were similar with respect to baseline NIHSS and outcomes. When attempted, intra-arterial reperfusion of M2 ELVOs was achieved at comparable rates to M1 ELVOs with equal rates of sICH (1.7%). Higher NIHSS was associated with EVT of M2 ELVOs (15.00[8.50,21.00] vs 7.00[4.00,17.75]; p<0.001). Rates of mortality trended more favorably in treated M2 ELVOs (12.9% vs 20%), which was not statistically significant (p=0.362).

Conclusions:
EVT for M2 ELVOs is as safe and effective as EVT for M1 vessel ELVOs. Rates of successful reperfusion, discharge mRS, LOS, sICH, discharge disposition and mortality are similar among EVT treated M2 and EVT treated M1 ELVOs. Though not statistically significant, EVT for patients with M2 ELVOs resulted in favorable trends toward higher survival rates of potential clinical significance.
Abstract WP294: Ems Telehealth Triage by the Neurointerventionalist and Limited Non Contrast Ct Triage Shorten Hospital Process and Increase Treatment Rates for Mechanical Thrombectomy
Authors: Mueller-Kronast Nils H , Kaushal Ritesh , Malek Ali R , Cueva Wilson , Metha Sonal
Published: January 2019

Background:
Rapid Mechanical thrombectomy (MT) has been associated with improved clinical outcomes, and significant reductions in the hospital arrival to skin puncture interval have been achieved since publication of the 5 seminal MT trials. The benefit of advanced imaging has been questioned, especially for patients arriving within 6 hours from symptom onset.

Method:
After a successful pilot, 2 of the 4 endovascular capable hospitals in our network in an urban South Florida region transitioned to prehospital triage through telehealth evaluation at the scene with emergency medical services directly by the neurointerventionalist (NI) for patients with score based clinical high probability of Large Vessel Occlusion (LVO). The NI could then activate the NI team at his discretion prior to hospital arrival, if sufficient clinical markers for LVO were felt to be present. Also, a streamlined CT imaging protocol consisting only of non-contrast CT and direct transport to the NIR suite for patients deemed appropriate was instituted (Group A). The other 2 hospitals continued the prior CTA and CTP based triage protocol in all patients with activation of the NI team by the emergency room physician (Group B).

Results:
A total of 320 patients underwent MT between 1/2017 and 4/2018, of which 142 patients were treated in the centers which had adopted the streamlined process (Group A), and 178 in centers which utilized CTA and CTP based triage (Group B). The median Door to Puncture interval (DTG) was 62 minutes in Group A compared to 54 minutes (p<0.05) in Group B. In Group 39.7% of MT patients had a DTG ≤45mins and 19.1% ≤30 mins, compared to 29.2% and 12.9%, respectively. The rate of symptomatic hemorrhage (sICH) was numerically lower in hospitals Group A (NS). The proportion of all ischemic stroke patients treated with MT increased to 21.4% in Group A compared to 12.6% in hospitals Group B (p<0.05).

Conclusion:
Direct Telehealth EMS triage by the Neurointerventionalist, along with a streamlined imaging protocol can significantly decrease time to puncture and increase utilization of and access to MT without associated increased risk of sICH.
Abstract WP297: Impact of the Extended Thrombectomy Window on a Large, Comprehensive Stroke Center Run Telestroke Network
Authors: Guzik Amy K , Bishop Laura E , Barghouthi Tamara T , Vu Quang D , El Husseini Nada , Reynolds Patrick S , Tegeler Charles H , Bushnell Cheryl D
Published: January 2019

Background:
The Wake Forest (WF) Telestroke Network, founded in 2009, is the largest in North Carolina serving 20 hospitals. WF Baptist Medical Center is a Comprehensive Stroke Center (CSC) and referral site for endovascular therapy from many regional hospitals, including 11 within our telestroke network. In December 2017, following dissemination of the DAWN and DEFUSE trial results, we adopted a 24 hour thrombectomy window at WF. In January 2018, education was provided at telestroke sites to facilitate identification of candidates for extended thrombectomy (ET). It has been unclear how the extended window will impact CSC systems. We evaluated the impact of ET on telestroke calls, transfers, and thrombectomy volumes within our state and regional telestroke network.

Method:
Telestroke activations and consultations within our state network for the months pre and post ET protocol implementation were compared (July -December 2017 vs January - May 2018). Stroke transfers from regional telestroke hospitals and resultant thrombectomy procedures conducted at WF were compared (July - November 2017 vs December 2017-June 28 2018). Patients transferred for primary hemorrhage were excluded. Monthly volumes were compared using the Kruskal-Wallis Test.

Results:
Monthly network activations increased, though not significantly, following education on ET window (median 109.5 vs 153 p = 0.07). Monthly consultations remained steady (median 50.5 vs 54 p= 0.20). Stroke transfers per month remained steady (median 28 vs 27 p= 0.74) while thrombectomies increased (median 1 vs 4 p=0.03).

Conclusions:
Though thrombectomy volumes increased, the impact on telestroke consultations and transfer volumes at our institution has not been substantial since adoption of the 24 hour thrombectomy window. While the ET window has led to more calls to our 20 site telestroke network, likely for triage of later presenting patients, it was not significant in this small sample. Further evaluation will examine this trend. Regional transfers to WF have remained stable, as the majority of patients with large stroke are transferred for inpatient stroke care. With a previously established transfer arrangement, the extended window has not led to overtriage from our regional hospitals.
Abstract WP299: Telestroke Program Participation and Improvement in Door-To-Needle Times
Authors: Blech Benzion , O'Carroll Cumara B , Zhang Nan , Demaerschalk Bart M
Published: January 2019

Background:
Telestroke care has become a vital feature of expert stroke care for rural hospitals in recent years. The Telemedicine for Arizona Rural Residents (STARR) program was developed in 2006 by the Mayo Clinic in Arizona in order to provide stroke expertise across the region. However, little data currently exists to determine efficacy of telestroke programs on accepted stroke care metrics, such as door-to-needle times.

Hypothesis:
Participation of spoke sites in a telestroke program improves stroke care over time, as defined by currently-accepted metrics, such as door-to-needle time.

Methods:
A retrospective analysis was performed on the telestroke database from Mayo Clinic, Arizona, between the years of 2011 to 2018. Patients who received IV-tPA for an acute ischemic stroke were included in the analysis. Patients who did not have radiographic or clinical symptoms of an acute ischemic stroke, as well as those who did not receive IV-tPA, were excluded from the analysis. Univariate linear regression was performed to look for associations between variables and defined outcomes.

Results:
565 patients were identified who received IV-tPA via telestroke consultation and met inclusion criteria between 2011 to 2018. Average last known normal (LKN) to needle time decreased across all sites from 176 minutes in 2011 to 147 minutes in 2018, with univariate linear regression showing a trend of decreased time averaging 3 minutes per year, which was statistically significant (p = 0.0084). Average door-to-needle times decreased from 112 minutes in 2011 to 81 minutes in 2018, with univariate linear regression modeling showing a decreasing trend of 3.5 minutes on average per year (p < 0.001).

Conclusions:
Telestroke participation may be associated with improved stroke care metrics over time, with our analysis illustrating improved LKN-to-needle and door-to-needle times among participating spoke sites.
Abstract WP300: Characteristics and Prognosis of Transfer Patients to a Comprehensive Stroke Center in the Stroke Belt
Authors: Fadairo Abimbola , Gazi Melissa , Gropen Toby I
Published: January 2019

Background:
The stroke belt has a higher stroke mortality rate compared to other regions of the United States with Alabama recording about 3,000 deaths yearly. The University of Alabama at Birmingham (UAB) is the only comprehensive stroke center (CSC) in Alabama equipped to manage the most complex stroke patients.

Objective:
The purpose of this study was to determine the characteristics and prognosis of patients transferred to a comprehensive stroke center in the stroke belt.

Methods:
Data was abstracted from the electronic health records of patients admitted to the stroke service between 2016 and 2018. We assessed differences between transfer and non-transfer patients in terms of demographics, stroke severity, insurance, administration of alteplase (t-PA) and thrombectomy (IA). We also evaluated the relationship between the Alabama state stroke designation of the originating hospital including non-stroke centers (level 0), acute stroke ready hospitals, ASRH (level 3), primary stroke centers, PSC (level 2) and direct admissions to UAB (level 1) and characteristics and prognosis of patients.

Results:
1107 patients were assessed for the study with 402(36%) being transfers. Race, NIHSS,TPA and IA use, discharge disposition were associated with the level of stroke center, as shown in the table. Level 2 centers transferred patients with more severe strokes, and a higher proportion of TPA and IA use. Non-transfer patients had the best outcome with Home as their primary discharge location compared to patients transferred from level 2 stroke centers.

Conclusion:
About 36% of our stroke discharge volume is a result of patients transferred to UAB from outside hospitals. We conclude that Level 2 stroke centers are appropriately transferring patients with more severe stroke to CSCs compared to transfers from non-stroke centers and acute stroke ready hospitals. Some of the patients transferred to a CSC from non-stroke centers and ASRHs could be managed at PSCs.
Abstract WP312: Application of the e-NIHSS at a Tertiary Care Stroke Center: Experience and Results
Authors: Fowler Susan B , Floyd Kylie B , Rosado Christian A
Published: January 2019

Background and Purpose:
Stroke is a time sensitive emergency with proper identification and rapid evaluation critical. The National Institutes of Health Stroke Scale (NIHSS) is used to quantify stroke severity. The NIHSS favors detection of signs and symptoms indicative of anterior circulation strokes, especially MCA territory. Capturing signs and symptoms associated with posterior circulation strokes is limited in the present NIHSS.

Methods:
This prospective study explored if the e-NIHSS utilized by stroke nurse responders correlated with the diagnosis of posterior circulation stroke determined by the neurologist based on clinical and radiographic findings. A secondary objective was to determine ease of use, including time for completion, of the expanded items on the NIHSS.

Results:
In 40 assessments, there were no positive findings using the e-NIHSS; in these 40 cases, the CT or MRI was negative for acute stroke. In 4 cases, positive e-NIHSS findings (3 - CN XII: tongue turns to one side and 1- Trunk Ataxia: falls back to one side) were noted but imaging was negative for acute stroke. In 5 patients, tongue (N=4) and trunk ataxia (N=1) were positively assessed with resulting positive imaging for anterior circulation stroke. Nine patients were diagnosed with a posterior circulation stroke based on imaging with 3 having trunk ataxia identified by nurse stroke responders. Subjective findings included complaints of nausea/vomiting, dizziness, lightheadedness, and/or headache. Sensitivity was calculated at 33%, specificity 82%, positive predictive value 25%, negative predictive value 87%, and 74% accuracy.

Conclusions:
Findings are limited to small sample size (N=96) and low incidence of posterior circulation strokes. The additional 6 e-NIHSS items are easy to assess except standing the patient was found to be challenging physically and timewise. Assessment of soft palate paralysis was not specific to posterior circulation. Trunk ataxia, falling to one side when sitting up, identified posterior circulation compromise.
Abstract WP314: Baltimore City Acute Stroke EMS Routing Pilot Study
Authors: Patrice Kelly-Ann A , Yarbrough Karen , Johnson Brenda , Butler Jaime , Schrier Chad , Lawrence Erin , Marsh Elisabeth B , Phipps Michael , Aycock Anna , Urrutia Victor C
Published: January 2019

Introduction:
New EMS routing protocols are being proposed to divert acute stroke patients, based on the likelihood of having a large vessel occlusion (LVO), directly to Comprehensive Stroke Centers (CSC), in order to reduce the inherent delay of a secondary transfer from a Primary Stroke Center (PSC) to a CSC. Within Baltimore City, transfer from a PSC to a CSC for mechanical thrombectomy (MT) adds, on average, an additional 90-minute delay in achieving reperfusion.

Aim:
To determine the feasibility and safety of an EMS routing protocol in which, patients determined to have an LVO-related acute stroke, based on use of a stroke severity score in the field, are directed to the nearest CSC bypassing closer PSCs within Baltimore City.

Methods:
A prospective observational study was conducted over a six-month period, from September 2017 to March 2018. Acute stroke patients with a LAMS of ≥4 were taken by EMS to the nearest CSC, bypassing closer PSCs, as long as the travel time did not exceed an additional 30 minutes. Data collected at the three CSCs included transport times, IV-tPA and MT use in the diverted patients, time from onset to treatment and 90-day functional outcomes. Descriptive statistics were used to analyze the data.

Results:
Forty-five patients with LAMS of ≥4 were diverted to a CSC. Approximately 50% (20/45) had a final diagnosis of acute ischemic stroke and 35% of those were eligible for an intervention, either IV-tPA or MT or both. Average onset to IV-tPA bolus time was 114 minutes (93-163 minutes). Average onset to groin puncture was 197 minutes (192-202 minutes). There were 4 in-hospital deaths. Among survivors, the 90 day modified Rankin Scale (mRS) ranged from 0-3. Mean field transport time was 17 minutes (range: 4-63 minutes). None of the re-routed patients were ineligible for IV-tPA due to additional time to CSC. There were no reported adverse outcomes due to increased travel time associated with diversion.

Conclusion:
Implementation of EMS routing protocols to divert acute stroke patients suspected of having an LVO past PSCs to CSC within cities is feasible and appears safe. The limitations of this study include small size, short duration and small region of implementation. Further study is warranted on a larger scale both in population and geographic area.
Abstract WP326: Factors in Acute Ischemic Stroke Predicting Pre-Hospital Notification by Emergency Medical Services
Authors: Gill Rick , de la Pena Paula , Ray Jessica , Eriksson Niklas , Durazo-Arvizu Ramon , Schneck Michael , Bar Barak , Morales Vidal Sarkis , Gomez Camilo , Biller Jose , Ruland Sean
Published: January 2019

Introduction:
Acute ischemic stroke (AIS) treatment is time sensitive and every 15 minutes saved in treatment results in 1 additional month of disability-free life in patients treated with thrombolysis. Pre-notification by Emergency Medical Services (EMS) has shown to reduce door to CT scan time, door to needle time for thrombolysis and increase the number of patients treated with thrombolysis. Determining which factors contribute to recognition and emergent treatment of stroke in the emergency department (ED) which are not recognized in the field can help improve models of pre-hospital notification.

Objective:
To determine which factors predict pre-hospital notification by EMS in patients with AIS treated with emergent therapy.

Methods:
We retrospectively reviewed our institutional database for all patients arriving through the ED by EMS who underwent acute stroke treatment from 2007-2018. All patient's arriving by EMS were dichotomized by the presence or absence of pre-hospital notification. We assessed the impact of demographic, clinical [NIHSS, FAST scores ((Face, Arm, Speech, Time) dichotomized into 0-1 or 2-3)], and diagnostic (vascular territory) factors on the likelihood of pre-hospital notification by EMS. A multivariate logarithmic regression analysis with assessment for confounding factors was applied.

Results:
A total of 183 patients were identified. The presence of 2 or 3 FAST criteria increased the odds of pre-hospital notification by EMS by 3.07 (p = 0.022, 95% CI 1.17-8.05) when adjusted for age. The vascular territory involved did not independently predict the likelihood of pre-hospital notification. We did not identify any significant confounders in the multivariate analysis.

Conclusions:
Patients with AIS receiving emergent treatment are over three times more likely to benefit from pre-hospital notification by EMS when presenting with 2 or 3 FAST criteria. Pre-hospital notification of AIS has established itself as a means to expedited clinical and radiographic evaluation and faster and more frequent treatment on hospital arrival. Improving EMS triage of AIS patients presenting with symptoms not well represented in the FAST criteria represents a stroke systems of care performance and quality improvement opportunity.
Abstract WP34: ASPIRE: Aspiration Thrombectomy as the Primary Modality in Endovascular Stroke Treatment: Pooled Analysis of the 3D Stent-Retriever, ASTER, THERAPY, COMPASS and MR CLEAN Trials
Authors: Nogueira Raul G , van de Graaf Rob A , Mocco J , Siddiqui Adnan , Lapergue Bertrand , Piotin Michel , Turk Aquilla , Berkhemer Olvert A , Lingsma Hester , Majoie Charles B , Samuels Noor , Yoo Albert , Frei Donald , Zaidat Osama O , Khatri Pooja , Dippel Diederik W
Published: January 2019

Background:
Given the overwhelming evidence for the benefit of stent-retriever thrombectomy, a future trial of primary aspiration thrombectomy (PAT) against best medical therapy (BMT) alone has become unethical and impractical. Therefore, alternative approaches are needed to further investigate the impact of PAT in the outcomes in large vessel occlusion (LVO) strokes. The aim of this project is to assess the effectiveness of PAT plus BMT (including IV t-PA if indicated) compared to BMT alone in patients with anterior circulation LVO strokes.

Methods:
A systematic search of the medical literature and trial registries (EMBASE, Pubmed Medline, Cochrane trial registry, clinical trials.gov and ISRCTN) was conducted to trace randomized clinical trials (RCT) that evaluated PAT as a first treatment approach for LVO strokes. Four prospective RCTs employing aspiration thrombectomy as a primary treatment modality in one arm were identified: THERAPY (n=108; 55 PAT), Penumbra 3D Stent-Retriever (n=198; 100 PAT), ASTER (n=381; 192 PAT) and COMPASS (n=270; 134 PAT). Data from the PAT arms from these four RCTs and controls from the MR CLEAN (n=500; 267 controls) and THERAPY (53 controls) trials will be pooled. Treatment effect on the primary outcome (90-day mRS ordinal shift analysis) will be analyzed with multivariable ordinal regression analysis in the propensity matched dataset, after adjusting for remaining differences in distribution of baseline prognostic factors, to increase power. Adjustments will be made for age, sex, baseline NIHSS, collateral score, pre-treatment ASPECTS, admission glucose levels, time from stroke onset to qualifying imaging. The effect will be expressed as an adjusted common odds ratio, with 95% confidence interval. Treatment effects for secondary outcomes will be estimated in a similar approach, with the appropriate regression method.

Results:
The data will be analyzed by an independent statistical group (Erasmus MC, University Medical Center Rotterdam, the Netherlands). The results will be available and reported at the time of the ISC 2019.

Conclusion:
This pooled data project will provide unique and high-level evidence concerning the effect of aspiration thrombectomy on functional outcome after acute ischemic stroke.
Abstract WP360: Sex Differences in Patient Centered Outcomes Obtained from Electronic Medical Records in the Greater Cincinnati Northern Kentucky Stroke Study
Authors: Madsen Tracy E , Sucharew Heidi , Alwell Kathleen , Demel Stacie L , De Los Rios La Rosa Felipe , Flaherty Matthew , Ferioli Simona , Jasne Adam , Moomaw Charles J , Mackey Jason , Slavin Sabreena J , Star Michael , Walsh Kyle , Woo Daniel , Kissela Brett M , Kleindorfer Dawn O
Published: January 2019

Introduction:
Previous data have shown worse post-stroke outcomes in women than men based on non-patient centered outcomes (modified rankin score (mRS)) obtained via patient contact. Our aim was to compare sex differences in post-stroke outcomes in a population-based cohort using patient-centered outcome measures obtained from the electronic medical record (EMR).

Methods:
Patients with ischemic stroke (IS) who presented to a single healthcare system (4 hospitals and outpatient facilities) in Northern Kentucky during 1/2015-12/2015, a subsample of the Greater Cincinnati Northern Kentucky Stroke Study, were included. Those who died prior to study time points were excluded. Cases of IS were ascertained by trained study nurses using ICD codes and EMR review. Outcomes (mRS and quality of life (EQ5D)) were estimated from EMR, a method previously shown to have good interrater agreement with telephone follow-up. EQ5D measures health-related quality of life across 5 dimensions. Utility weighted mRS (UW-mRS) were calculated by applying validated weights to mRS. Outcomes at 3- and 6-months were compared by sex using ordinal logistic regression for mRS and linear regression for UW-mRS and EQ5D, adjusted by demographics, pre-stroke mRS, stroke severity, and co-morbidities.

Results:
We included 382 cases; 51% were women, 94% were white. Women were older (median (IQR) 71 (61-81) vs. 66 (57-77)) than men, but pre-stroke mRS was similar (median (IQR) 1 (0-3) vs. 1 (0-2)). NIHSS was similar by sex (median 3 IQR (1-6) vs. 2 (1-5)). After adjustment, 3- and 6-month outcomes were similar by sex.

Conclusions:
In our cohort, sex differences in unadjusted outcomes may be related to age, pre-stroke functional status, co-morbidities, and depression, as differences were not present in adjusted models. Relatively minor strokes in our cohort may also explain similar outcomes by sex. Future studies should strive to identify intervenable targets to improve patient-centered outcomes post-stroke.
Abstract WP37: Real-World Applicability of Thrombectomy in Anterior Circulation Large Vessel Occlusion Strokes Treated in the Extended Window: Analysis of the Prospective Trevo Registry
Authors: Nogueira Raul G , Haussen Diogo , Gupta Rishi , Budzik Ron , Baxter Blaise , Krajina Antonin , English Joey , Malek Ali , Shields Ryan , Sarraj Amrou , Zhang Yanchang , Morgan Patricia , Narata Ana Paula , Bartolini Bruno , Veznedaroglu Erol , Liebeskind David
Published: January 2019

Background:
Two recent trials showed a strong benefit of thrombectomy in the extended window. However, these studies were performed in selected centers and utilized strict inclusion criteria. We aim to evaluate the outcomes of thrombectomy in a large prospective cohort treated outside the rigid clinical trial setting.

Methods:
Trevo Registry patients with ICA, MCA-M1 or M2 occlusions and pre-morbid mRS0-2 were categorized according to time-from-last-seen-well (TLSW) to puncture as early (0-6hours) vs. late (6-24hours). Uni- and multivariate analyzes were performed to identify good outcome (90-day mRS0-2) predictors. Subgroup analyses were performed for the basic DAWN (age >=18, NIHSS >=10, ICA or M1 occlusion, pre-morbid mRS 0-1) and DEFUSE 3 (age 18-90, NIHSS >=6, ICA or MCA-M1 occlusion, mRS 0-2) trial criteria.

Results:
As compared to the late (n=430), early patients (n=1173) were older (70 vs 68, p=0.011) and had higher IV tPA use (69 vs 25%, p<0.001), lower smoking frequency (33 vs 40%, p=0.011), larger baseline infarcts (21.2 vs 15.6 cc, p=0.045), less frequent ICA occlusions (18 vs 24%, p=0.015), and a trend towards higher admission NIHSS (16 vs 15, p=0.09). Despite significantly longer TLSW to puncture (3.5 vs 9.6 h, p<0.001), late patients had similar rates of mTICI2b-3 (92 vs 94%, p=0.20), good outcomes (60 vs 56%, p=0.128), symptomatic ICH (1.5 vs.1.4%, p=0.84), and 90-day-mortality (10.9 vs.11.4%, p=0.79). Age (OR 0.96, 95%CI [0.96-0.97]), admission-NIHSS (0.91 [0.89-0.93]), baseline mRS (0.49 [0.40-0.60]), ASPECTS >= 6 (1.37 [1.07-1.75]), DM (0.58 [0.44-0.77]), and time to treatment (0.98 [0.97-1.00]) were independent predictors of good outcomes. Imaging modality did not predict outcomes. Similar findings were observed in the early versus late DAWN-like (n=709 vs 257) and DEFUSE 3-like (n=855 vs 273) cohorts. There was great similarity between the outcomes of the Trevo Registry subsets vs their analogous RCTs: early DAWN-like vs SWIFT Prime (90-day mRS 0-2: 57.5 vs 60%; 90-day mRS 6: 11.% vs 9%), Late DAWN-like vs DAWN (50.2 vs 48.6%; 10.6 vs 18%), and Late DEFUSE 3-like vs DEFUSE 3 (52 vs 45%; 10.3 vs 14%).

Conclusions:
Our study provides favorable data for the generalizability of the safety and efficacy of thrombectomy in the “real-world” setting.
Abstract WP373: Lost tPA Opportunities in a Telestroke Network
Authors: Veerapaneni Poornachand , Nallaballe Krishna , Sheng Sen , Rohan Samant , Onteddu Sanjeeva Reddy , Brown ALIZA , Wissler Deonna , Duncan Calvin , Joiner Renee
Published: January 2019

Background:
Thrombolytic therapy with IV alteplase (tPA) is recommended for selected patients who can be treated within 4.5 hours of ischemic stroke symptoms onset or patient last known well. We tried to identify various neuropsychiatry disorders presenting as stroke codes in our telestroke network along with specific reasons for stroke patients not getting tPA and frequency of actual strokes which were misdiagnosed as other disorders which we labeled as lost tPA opportunities.

Methods:
We performed a retrospective analysis of prospectively collected data of the first six months of 2018. During which time 628 patients were seen as telestroke consults with the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) program. Among these 229 patients received tPA. Final discharge diagnosis was obtained for 379 patients who did not receive tPA and were classified into various groups. Emphasis was given to patients who were given a discharge diagnosis of stroke but did not receive tPA. All of their charts were reviewed for reasons not giving tPA, which were again quantified into various groups or if they were misdiagnosed as non-strokes on initial assessment.

Results:
Among the 379 patients who did not receive tPA final discharge diagnosis was TIA in 121 patients (31.9%), stroke in 96 patients (25.3%), encephalopathy in 84 patients (22.1%) followed by Headache and Pain Syndromes (10%), Dizziness (2.6%), Seizures (2.6%), Conversion (1.8%), Intra Cranial Hemorrhage (1%), Neoplasm (1%) and Other (1.3%). Retrospective Chart review of the 96 stroke patients showed that among those 29 patients were outside the 4.5 hours’ window, 27 patients had low NIHSS, 13 patients refused tPA, 13 patients had abnormal labs, 11 were misdiagnosed (1.75% of total stroke codes) and 3 were recrudescence of old stroke symptoms.

Conclusions:
Administration of tPA in ischemic stroke patients is being limited by various reasons but true lost tPA opportunities amount to a very small percentage (1.75%) of the total stroke codes in our telestroke network.
Abstract WP375: "Endovascular Go" to Puncture Time for Endovascular Thrombectomy in Acute Ischemic Stroke
Authors: Kansagra Akash P
Published: January 2019

Introduction:
Quality metrics for thrombectomy measure timeliness of treatment using door-to-puncture time. Due to the different modes of patient presentation, “door” time may herald anything from the arrival of an undifferentiated patient in need of complete clinical, radiological, and serological evaluation, to a differentiated patient in need of no additional workup. Thus, there is potentially great variation in “door-to-puncture” time between these groups even in the face of similar stroke team performance. In this work, we propose an alternative metric, “endovascular go”-to-puncture time, that is more consistent across modes of presentation.

Methods:
Clinical data for thrombectomies at our hospital between January 2015 and June 2018 were contemporaneously recorded by clinical nurses and data analysts. Patients were classified as “ED” if they presented initially to our hospital, “Transfer” if they presented initially to another hospital, and “Inpatient” if they were inpatients in our hospital at the time of stroke onset. Door time was defined as the time of patient arrival to our ED, or for inpatients, the time of stroke onset. “Endovascular go” time was defined as the later of door time or time of neuroimaging completion. Puncture time was defined as the time of first skin puncture.

Results:
Median door-to-puncture time was 86 mins for ED patients, 51 mins for transfer patients, and 136 mins for inpatients (Table). Median “endovascular go”-to-puncture time was 63 mins for ED patients, 43 mins for transfer patients, and 69 mins for inpatients. Across all patients, SD of door-to-puncture time was 81 mins, compared to SD of “Endovascular Go”-to-puncture time, which was 23 mins.

Conclusions:
For thrombectomy patients, “endovascular go”-to-puncture time is more consistent across different presentation modes than the conventional door-to-puncture time. This metric may allow for simplified quality guidelines that apply to all modes of presentation.
Table:
Abstract WP388: Improvement of Adherence to Performance Measures in Patients With Acute Ischemic Stroke by Using Automatic Extraction of Electronic Medical Records: Baseline Characteristics of the Network of Shanghai Stroke Service System (4S)
Authors: Dong Yi , Fang Kun , Wang Xin , Chen Shengdi , Liu Xueyuan , Guan Taiyang , Cai Dingfang , Li Gang , Liu Jianmin , Liu Jian R , Liu Jian R , Zhuang Jianhua , Wang Panshi , Chen Xin , Li Zixiao , Wang Yilong , Wang Yongjun , Dong Qiang
Published: January 2019

Introduction:
Several stroke quality control and outcome projects have demonstrated the success in improving stroke care quality through structured process. However, Chinese healthcare systems are challenged with its overwhelming numbers of patients, limited resources and large regional disparities. This study aims to Improve quality of stroke care to address regional disparities.

Methods:
The Shanghai Stroke Service System (4S) was established as a regional network for stroke care quality improvement in Shanghai. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Thirty-six hospitals including 10 regional stroke centers and 25 district stroke centers. Registry began enrolling all patients with diagnosed acute ischemic stroke (AIS) in 2017. Primary outcome is to evaluate the differences in quality metrics performance before and after the implementation structured quality improvement process.

Results:
Among 14461 patients with AIS registered, patient’s average age was 73 years old with 4958 women (34.2%) in 2017. Compared to the data from the previous registry, web-based database enrolled more patients (3175 in 2014, 4815 in 2015, 12387 in 2016, p<0.001). With the best use of resource(Table1), AIS patients in 4S were more likely to receive performance measures than those of previous registry (composite measure 83%, Figure 1A). A trend of gradually decreased hospital mortality and rate of unplanned re-admission within 30 days was observed in 4S hospitals (Figure 1B).

Conclusions:
The study has helped to identify areas stroke care deficiencies and improvement. Despite of challenges of healthcare in China, 4S proved the feasibility and potentially effective as a regional stroke network model for quality improvement. This model could be duplicated at other large cities or regions in China. Clinicaltrials.gov Identifier NCT02735226
Abstract WP392: Non-English Speakers Present Faster with More Severe Strokes
Authors: Roberts Mallory , Fara Michael , Wheelwright Danielle , Giovanni Brian , Morey Jacob , Persaud Steven , Fifi Johanna , Tuhrim Stanley , Stein Laura
Published: January 2019

Introduction:
With the continued expansion of acute stroke treatment options, urban tertiary referral centers such as ours are treating an increasingly diverse patient population. As we attempted to better understand barriers to improved door to treatment times in our acute stroke code protocol, we postulated that there might be differences in severity of presentation and swiftness of acute stroke care based on English fluency.

Methods:
Through a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we compared National Institute of Health Stroke Scale (NIHSS) at presentation, time to presentation, and time to treatment of fluent English speakers to patients who were not fluent in English. We analyzed data from 667 acute stroke codes from January 2017 to March 2018 with Statistical Package for the Social Science (SPSS) using two-tailed t-tests.

Results:
In-Hospital stroke codes included 415 English speakers and 97 non-English speakers, while Outside Hospital (OSH) transfers comprised 92 English speakers and 35 non-English speakers. Non-English-speaking patients had higher average NIHSS scores at time of acute stroke presentation (11 vs 8 (p=0.013) in-hospital and 17 vs 13(p = 0.007) OSH transfer). Last known well (LKW) to stroke code time upon arrival to our center was significantly shorter in non-English speakers compared to English speakers coming from an OSH (315 minutes vs 515 minutes, p = 0.016), but there were no statistically significant differences between language groups for in-hospital codes’ LKW to stroke code times. There were no statistically significant differences in acute treatment times, but in the OSH transfer group, average LKW to groin puncture was 349 minutes for non-English speakers compared to 545 minutes for English speakers (p=0.085).

Conclusions:
This data suggests that at our center, non-English speakers present with more severe strokes and present more quickly. Increased stroke severity may partially explain an observed trend towards faster times from LKW to thrombectomy for non-English speakers transferred from an OSH.
Abstract WP398: Impact of a Direct Ambulance-to-CT Stroke Protocol on Race, Sex, and Language Disparities in Stroke Treatment Times
Authors: Hemphill Kafi R , Kim Anthony S , Chilingirian Ani M , Reilly Amanda L , Varshney Juhi U , Hemphill J C , Madhok Debbie Y
Published: January 2019

Introduction:
Prior studies have documented disparities in key acute stroke care metrics, with women and minorities more likely to have treatment delays and less likely to receive IV tPA.

Objective:
To evaluate whether implementation of a direct ambulance-to-CT stroke protocol reduces race, sex, and primary language disparities in stroke treatment times.

Methods:
We identified patients with confirmed strokes that had been transported by ambulance to our emergency department before and after implementation of a direct ambulance-to-CT protocol for suspected stroke at our urban safety-net hospital. We used the Mann-Whitney U test to compare median door-to-CT (DTC) and door-to-needle (DTN) times by sex, race, and primary language during the pre- and post-intervention periods.

Results:
A total of 106 stroke patients in the pre-intervention group and 119 in the post-intervention group were included in this analysis. The pre-intervention group included 57 (53.8%) women, 20 (18.9%) whites, and 68 (64.2%) English-speaking patients. The post-intervention group included 58 (48.7%) women, 26 (21.9%) whites, and 77 (64.7%) English-speaking patients. A total of 48 pre-intervention patients and 47 post-intervention patients received tPA. Overall, median DTC and DTN times were significantly lower in the post-intervention group compared to the pre-intervention group (21 minutes vs. 10, p<0.0001; 39 vs. 30, p=0.006). There were no significant differences in DTC or DTN times by sex, race, or primary language in the pre-intervention group, but women had longer median DTN times than men (34 vs. 24, p=0.02) in the post-intervention group.

Conclusions:
While no significant disparities in stroke treatment times by sex, race, or primary language were identified in the pre-intervention period, implementation of a direct ambulance-to-CT protocol was associated with greater improvements in DTN times for men than for women.
Abstract WP401: Improving Door-to-Needle Time and Functional Outcomes in Patients Treated With Intravenous Thrombolysis
Authors: Tran Demi C , Yu Wengui , Shafie Mohammad , Abcede Hermelinda , Stradling Dana
Published: January 2019

Background and Objectives:
The benefit of Intravenous (IV) tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) is time-dependent. It is therefore essential to identify and treat eligible patients quickly. Our study aimed to investigate if the implementation of a new institutional stroke protocol reduces door-to-needle time (DNT) and improves outcomes in patients receiving tPA.

Design and Methods:
This is a retrospective study of patients treated with IV tPA at UC Irvine Medical Center between January 1, 2013 and December 31, 2017. A new acute stroke protocol was implemented in January of 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IV tPA before getting blood test results unless patient was taking anticoagulant, and to give IV tPA in the CT suite. The patients were divided into two groups: pre-intervention and post-intervention groups. Outcome measures include DNT for IV tPA, functional outcome per modified Rankin Scale (mRS) at discharge, rate of symptomatic intracerebral hemorrhage (sICH), and mortality. Statistical analysis was performed with unpaired t-test for continuous variables and χ2 test for categorical data.

Results:
Among the 294 consecutive patients receiving IV tPA, 90 were in the pre-intervention group between January 1, 2013 and December 31, 2014, and 204 were treated over a 36-month period in the post-intervention group between January 1, 2015 and December 31, 2017. Median DNT was significantly lower in the post-intervention group (42 ± 39.2 minutes vs 63 ± 32.2 minutes, P <0.001). The mRS at discharge was also significantly lower in the post-intervention group (2.91 ± 1.93 vs 3.41 ± 1.92, P<0.05). There was no significant difference in rate of sICH (2.0% vs 2.2%) and mortality (6.8% vs 6.5%) between the two groups.

Conclusions:
In this single center study, simple performance improvement initiative was shown to reduce DNT for IV tPA and to improve functional outcome at discharge significantly without increased risk of sICH or mortality. The interventions outlined in this study were safe and easily implementable at any hospitals in the U.S. and other countries.
Abstract WP410: Effect of a Neurohospitalist Service on Length of Stay of Ischemic Stroke Patients
Authors: Chakrabarti Satabdi , Vivar Carolina , Cummings Christopher , Beckett Lisa , Baldwin Kelly , Noto Anthony
Published: January 2019

Neurohospitalist programs have been hypothesized to improve the cost and quality of care. Since data supporting the cost-effectiveness of neurohospitalist programs is lacking, this study aims to compare the LOS of patients discharged with a diagnosis of ischemic stroke after implementation of a neurohospitalist program in a tertiary care center. A retrospective review was performed utilizing data obtained through Premier Quality Advisor to evaluate LOS for all patients discharged from Geisinger Medical Center in Danville, Pennsylvania diagnosed with ischemic stroke between July 2014 and July 2018. A neurohospitalist service was introduced in July 2016 and observed LOS was compared to expected LOS pre- and post-implementation. Data for expected LOS was obtained through CareScience Analytics Risk-adjusted regression analysis of hundreds of hospital systems utilizing Premier Quality Advisor. To further control for case complexity as a confounding variable of LOS, we excluded patients discharged by critical care and surgical services. A total of 1,856 patients were discharged with the principal diagnosis of ischemic stroke over the four-year study period. Pre-implementation 890 patients were discharged with an observed geometric mean LOS (GMLOS) of 3.47 days compared to an expected GMLOS of 3.66 days (variation -0.19, p<0.01). Post-implementation 322 patients were attended by hospital medicine with an observed GMLOS of 4.43 days, expected GMLOS of 3.93 days (variation 0.51, P<0.01). Over the same period the neurohospitalist service discharged 643 patients with an observed GMLOS of 2.97 days, expected GMLOS of 3.27 days (variation -0.3, P<0.01). In conclusion, the neurohospitalist service significantly reduced the length of stay of ischemic stroke patients compared to expected values. Absolute length of stay was also reduced compared to care pre-implementation and care provided by the medicine hospitalists. This data supports the hypothesis that neurohospitalists improve the quality and cost-effectiveness of stroke care.
Abstract WP420: Incidence of Contrast Induced Nephropathy Among Different Stroke Subtypes After Adoption of New Emergency Brain Imaging Protocol for Acute Stroke - A Single Center Perspective
Authors: King Jason L , Eklund Kelsey A , Ross Stephen R , Xu Chao , Hollabaugh Kimberly , Sidorov Evgeny V , Ray Bappaditya
Published: January 2019

Introduction:
Studies demonstrating benefits of mechanical thrombectomy for large vessel occlusion (LVO) in acute ischemic stroke (AIS) has led to increased use of CT angiogram (CTA). Similarly, CTA is frequently performed to diagnose cerebrovascular pathology after intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Such contrast-enhanced CT (CECT) studies in stroke population are often associated with contrast induced nephropathy (CIN). However, incidence of CIN after adoption of increased use of CTA to diagnose LVO for possible mechanical thrombectomy is largely unknown.

Hypothesis:
We investigated the incidence of CIN in acute stroke population after adoption of CECT protocol to diagnose LVO and compared it to patients undergoing CECT study for other indications.

Methods:
Single-center retrospective chart review of patients presenting to the emergency room and investigated with CECT between January 2015 and December 2017. A rise in serum creatinine (SCr) 1.5 times the presenting SCr within first 72 hours of CECT defined CIN. Non-parametric Chi-squared tests were used to make intergroup comparison and a p-value of <0.05 was considered significant.

Results:
Nine hundred and forty-seven charts of patients undergoing CECT were reviewed. Patients with ICH [30/132 (22.7%)] and SAH [17/126 (13.5%)] had significantly higher incidence of CIN as compared to those with AIS [11/150 (7.3%)] and non-stroke [36/494 (6.8%)] etiologies. Patients developing CIN had increased length of stay in all groups with it being statistically significant in non-stroke (p<0.0001) and ICH (p<0.004). Diabetes mellitus was identified as a significant risk factor for CIN in AIS (p=0.0094) and non-stroke population (p=0.0002). Use of antihypertensives during the first 72 hours of admission was significantly associated with CIN (p=0.0025) among non-stroke patients whereas it was not identified to be a risk factor for CIN in stroke cohort. Intravenous hydration was not associated with prevention of CIN in any of the study groups.

Conclusion:
Our study results demonstrate higher incidence of CIN among patients with hemorrhagic stroke and reports risk for developing CIN in AIS is comparable to non-stroke population undergoing CECT in emergency circumstances.
Abstract WP425: Effect of Factor VIII Elevation on Outcomes in Post-tPA Acute Ischemic Stroke
Authors: Samai Alyana A , Monlezun Dominique J , Navalkele Digvijaya , Martin-Schild Sheryl
Published: January 2019

Background:
Elevation of factor VIII (FVIII), a significant part of the clotting cascade, has been shown to increase incidence of acute ischemic stroke (AIS). Intravenous tissue plasminogen activator (IV tPA) is a thrombolytic and is the only FDA-approved treatment for AIS. The effects of FVIII elevation on outcomes in AIS patients treated with IV tPA are unknown.

Methods:
This is a retrospective case-control study using a prospectively collected dataset at a single high-volume stroke center. AIS patients from 2008 to 2015 who were over 18 years old, received IV tPA, and had FVIII levels drawn during their acute hospitalization were included. After adjusting for key covariates, we analyzed whether patients with elevated FVIII (eFVIII), defined as FVIII greater than 150%, experienced significant differences in outcomes compared to those with normal FVIII (nFVIII). Primary outcomes of interest were neuroworsening, defined as an increase in NIHSS score of 2 or more points in a 24-hour period, and poor functional outcome, defined as a modified Rankin Scale score (mRS) greater than 2 at discharge.

Results:
Of 155 patients included, 100 patients (64.52%) had eFVIII. Patients in the eFVIII group had a higher median age (53 vs. 50, p=0.047), were more frequently black (71% vs. 49%, p=0.007), and had higher median NIHSS scores upon admission (8 vs. 6, p=0.028). In adjusted models, patients with eFVIII were 3.19 times more likely to experience a neuroworsening event (OR = 3.19, 95% CI 1.11-9.12) and 4.64 times more likely to have poor functional outcome at discharge (OR 4.64, 95% CI 1.85-11.57) compared to those with nFVIII.

Discussion:
FVIII elevation mitigates the effects of IV tPA on short-term outcomes among patients with acute ischemic stroke. The results of this study support the potential clinical utility of FVIII as a stroke biomarker in the development of patient risk profiles on admission.