bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP354: The Rural Health Care Penalty: Urban-rural Disparities in Stroke Center Performance
Authors: Gropen Toby I , Beasley Mark , Wira Charles , Egan Abigail , Madsen Tracy E , Magdon-Ismail Zainab
Published: June 2021

Goal:
To determine hospital and stroke system characteristics associated with higher levels of stroke center performance.

Methods:
We included all Centers for Medicare and Medicaid Services designated Acute Care Hospitals and Critical Access Centers (ACH/CAC) from January 1, 2005 to December 31, 2014. Higher stroke center performance was defined as earning a performance achievement award (PAA) on a predefined set of 7 evidence-based measures in a national quality program, Get-With-The-Guidelines-Stroke (GWTG-S). Generalized Estimating Equations were used to model characteristics associated with attaining a PAA over nine years of data. Hospital variables included total, ischemic and hemorrhagic stroke discharge volumes; medicaid discharge volume; patient race/ethnicity; ownership; rurality (Truven Health MarketScan); and state and/or national stroke center certification. Stroke system variables included emergency medical service (EMS) stroke routing protocol; stroke center directives (legislation, regulation, or department of health initiatives); and location in a region with a stroke consortium.

Results:
As a percentage of all ACH/CACs, GWTG-S hospitals with PAA increased significantly over time from 0.001% (5/4530) in 2005 to 24% (1086/4526) in 2014 (linear and nonlinear p’s<0.0001). Variables associated with PAA status at the p<0.05 level were included in the combined analysis. Significant independent predictors of PAA status included urban location (p<0.0001); total (p=0.0016) and ischemic stroke (p<0.0048) discharge volumes; national stroke center designation (p<0.0001); and presence of state stroke center directives (p=0.0012). EMS routing was not statistically significant but there was an EMS-by-time interaction; hospitals with EMS routing had a significantly increased rate of earning PAA (p = 0.0463).

Conclusions:
There has been rapid improvement in stroke center performance from 2005 to 2014. Urban location, higher hospital discharge volume, national stroke center designation, and state stroke directives are independently associated with better stroke center performance. After controlling for hospital and stroke system factors, there are significant urban-rural disparities in stroke center performance.
Abstract WP358: Comprehensive Integrated Stroke System: A Novel Approach to Optimizing Cerebrovascular Disease Care
Authors: Lopez-Rivera Victor , Sheth Sunil A , Savitz Sean I , Lee Songmi , Fan James , Blackburn Spiros , Sheriff Faheem G , Chen Peng R , Kim Dong , Harrison Nicole , Wells Meredith , Day Arthur L
Published: June 2021

Introduction:
There is a need to deliver endovascular stroke therapy (EST) locally and rapidly, due to the time sensitivity of acute ischemic stroke (AIS). However, the optimal distribution of resources, and means to maintain quality outcomes in patients with diseases that benefit from concentrated care at specialized centers, including subarachnoid hemorrhage (SAH), is unknown.

Methods:
We performed a multicenter, observational cohort study across our 11-hospital network from Jan 2017 - Feb 2019, identifying AIS patients who received EST. From Jan 2017 - Aug 2017, there was one CSC in the system. Starting in Aug 2017, we implemented an Integrated Stroke System (ISS), in which 3 additional centers became CSCs, practices were standardized across a single physician group covering all 4 CSCs, and SAH care was centered at the original CSC, while EST was performed at 3 new CSCs. Logistic regression adjusted for age, sex, NIHSS, direct vs. transfer arrival, and time from onset to recanalization was used to assess likelihood of good outcome, defined as discharge to home or rehabilitation. Results are given as median [IQR] and OR [95% CI].

Results:
Among 478 patients who received EST, median age was 68 [57-78], 47% were female, and 37% were white. Over the course of the study (Fig. 1), the number of monthly EST cases increased; EST volume at our original CSC remained stable, and an increasing EST was performed at the new CSCs (p<0.01). Monthly SAH case volume remained unchanged at the original CSC (29 cases vs. 30 cases, p=0.68). After implementation of our ISS, there was a decrease in the time from arrival to groin puncture (107 min [88-125] vs 92 min [67-120]; p<0.01). Among patients presenting 0-6 hours, there was a significant improvement in likelihood of good outcome after ISS (OR 2.59 [1.06-6.35]; p<0.05).

Conclusions:
By restructuring our stroke system of care and extending EST capability, we observed increased EST utilization and improvement in quality of care for AIS patients.
Abstract WP37: Endovascular Thrombectomy Practice Pattern Across the Nihss Spectrum
Authors: Kenner-brininger Amelia , Olson-Mack Lindsay , Calzone Lorraine , Koenig Kristi L , Hemmen Thomas M
Published: June 2021

Background:
Endovascular thrombectomy (EVT) after Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. However, most guidelines recommend EVT for patients with NIHSS greater than 5 and caution EVT in severe stroke. We analyzed data from a stroke registry to learn about ‘real-world’ use of EVT across stroke serverity. Most clinical trials focus on academic medical centers. Our analysis reports on data from all centers within a region.

Methods:
The San Diego County EMS Stroke Registry represents data from 10 EVT ready centers. We included all AIS cases with NIHSS between 0 and 42 from July 2016 through December 2018. Patients were grouped into three categories: 1) NIHSS 0-5, 2) 6-25, 3) 26-42. We analyzed frequency of EVT use, last known normal (LKN) to skin puncture time, admission NIHSS in EVT cases, and hospital discharge dispositon of EVT cases.

Results:
Of 7,050 AIS cases, 662 (9.4%) received EVT from July 2016 to December 2018. Group (G) 1: 80 of 4184 cases received EVT (1.9%), G2: 470 of 2502 cases received EVT (18.8%), G3: 112 of 364 cases received EVT (30.8%). Rate of EVT in all AIS and for each NIHSS group did not change (all AIS: p=.24, G1: p=.59, G2: p=.15, G3: p=.57). Mean (±SD) NIHSS among all AIS was 7.4 (±8.5); among EVT cases it was 17.2 (±8.6). Mean (±SD) LKN to skin puncture (hours) was G1: 9.2 (±12.1), G2: 5.8 (±5.8), G3: 5.5 (±5.3) (p=.000001). Mean (±SD) age (years) of EVT cases was G1: 65.5 (±15.4); G2: 71.9 (±15.6); , G3: 77.1 (±14.0) (p=.00001). Discharge to home among EVT cases was Group 1: 50.0%; 2) 26.5%; 3) 9.8%; to a non-acute health care facility: G1) 28.8%, 2) 39.5%, 3) 44.6%); in-hospital death 1) 10.0%, 2) 13.6%, 3) 25.0%.

Conclusion:
Patients with mild and severe stroke present a significant subpopulation of patients undergoing EVT in this sample. Overall, one in three stroke patients with NIHSS above 25 underwent EVT; less than one in five stroke patients with low NIHSS underwent EVT. Over time there has been no change in the number of patients receiving EVT and no change in EVT use within NIHSS groups. Half of patients with low NIHSS were discharged home; one in four patients with high NIHSS expired in hospital. As hospitals embraced EVT, the use of the procedure among patients with low or high NIHSS has remained consistent.
Abstract WP371: Role of Troponin as a Biomarker for Predicting Outcome After Ischemic Stroke: A Meta-Analysis
Authors: Alhazzani Adel A , Kumar Amit
Published: June 2021

Background:
After acute ischemic stroke, a higher level of troponin has been considered as an important biomarker for predicting mortality. The aim of the study was to quantitatively assess the prognostic significance of the effect of baseline troponin levels on mortality in patients with acute ischemic stroke using a meta-analysis approach.

Design:
The following electronic databases, PubMed, EMBASE, SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials , TRIP Database, ClinicalTrials.govwas used for getting the relevant article from literuare. Data were extracted in standardized data collection by two independent investigators. Any disagreements were resolved by consensus. All the statistical analyses were performed in STATA software.

Results:
18 studies were included in the present meta-analysis involving a total of 8723 patients. The pooled results suggested that the elevated serum troponin level was associated with in -hospital mortality (RR 2.39, 95% CI 1.37 to 3.41), at the end of last follow up mortality (RR 1.75; 95% CI 1.38 to 2.11) and for overall mortality (RR 1.82; 95% CI 1.47 to 2.17). Sensitivity analysis by removing a single study by turns indicated that there was no obvious impact of any individual study on the pooled risk estimate. No significant publication bias was observed.

Conclusion:
Our findings indicate that a higher level of troponinmight be an important prognostic biomarker for in hospital and follow up mortality in patients with acute ischemic stroke. The study might have clinical implications by using troponin as a prognostic biomarker for patient stratification and early intervention.
Abstract WP375: Gender Differences in Etiologies of Stroke-Related Deaths in an Era of Availability for Stroke Intervention
Authors: Bautista Alyssa , Polineni Sai P , Chaturvedi Seemant
Published: June 2021

Background:
Stroke is a disease that affects women unequally more than men. With the aging of the US population, stroke prevalence is projected to increase, especially among elderly females. In an era of stroke where the availability of treatment for acute stroke and its early complications continues to rise, we sought to determine if there are identifiable differences for causes of stroke-related death among women and men.

Methods:
We used a registry of stroke deaths following acute ischemic stroke at a single academic center from 2009 to 2017. Past medical history, in-hospital data, and cause of death was retrospectively collected from chart review. Female baseline characteristics were compared to male. Causes of deaths among females >/=65 versus <65 were compared using student’s t- and
x
2
tests.

Results:
Among all stroke deaths (n=162), there were 72 (44.%) females, 90 (55.6%) males, with a mean age of 73 and 69, respectively. The proportion of smokers was higher among men (60.2% v 28.6%, p<0.001). Other medical history and social history did not have baseline differences. Among causes of death, there was no difference seen between female and male groups for malignant edema (43.1 v 33.3%,p=0.20), index stroke (2.8 v 3.3%,p=1.00), systemic complication (27.8 v 35.6%, p=0.29), withdrawal of care (12.5 v 22.2%,p=0.11); however among post-treatment hemorrhage/complications, a trend was seen towards females that did not reach statistical significance (13.9 v 5.6%,p=0.07). Of these female deaths from post-treatment complications, 6 or 60% received both IV thrombolysis (IV-tPA) and endovascular treatment (EVT), while the minority received either (30% IV-tPA, 10% EVT). Comparing causes of death among elderly females >/=65 versus <65, there were no differences as well (malignant edema 43.1 v 42.9%, p=0.98; index stroke 3.9 v 0%, p=1.00; systemic complications 27.5 v 28.6%, p=0.92; post-treatment complications 17.7 v 4.8%, p=0.26; withdrawal of care 7.8 v 23.8%, p=0.11).

Conclusion:
The trend for higher rate of post-treatment complications in women deserves further study in larger datasets. Women could be at higher risk for hemorrhage following IV-tPA and EVT due to older age.
Abstract WP377: Heart Rate Variability Biofeedback Improves Cardiac Autonomic Function in Patients With Acute Ischaemic Stroke: A Randomized Controlled Study
Authors: Siepmann Timo , Ohle Paulin , Simon Erik , Sedghi Annahita , Pallesen Lars P , Barlinn Jessica , Puetz Volker , Barlinn Kristian
Published: June 2021

Introduction:
In patients with acute ischaemic stroke (AIS) dysregulation of cardiac function with decreased heart rate variability (HRV) due to impaired integrity of the autonomic nervous system is a frequent complication which is associated with increased mortality and worsening of clinical outcome. HRV biofeedback has previously been suggested to improve cardiac autonomic function by increasing parasympathetic tone.

Hypothesis:
We hypothesized that HRV biofeedback can be used to complement stroke unit care and alleviate autonomic cardiac dysfunction following AIS.

Methods:
We randomly allocated patients with AIS to either receive 9 sessions of HRV (n=24) or sham (n=24) biofeedback in addition to standard stroke unit care. These patients underwent detailed assessment of autonomic cardiac function including analysis of HRV via standard deviation of NN intervals (SDNN) and spectral analysis. Furthermore, we assessed vasomotor and sudomotor autonomic function, severity of autonomic symptoms and neurological and functional outcomes.

Results:
We included 48 patients (19 females, ages 65±14 years, baseline NIHSS 2.2 ± 2.2, mean ± standard deviation). Patients who had undergone HRV biofeedback displayed improved cardiac function compared to baseline (SDNN 72.6 ± 52.4 ms vs. 45.5 ± 34.7 ms, p<0.01) which was not seen in those who received sham biofeedback (p=ns). Similar changes were seen on spectral analysis measures of parasympathetic function (p<0.01). Improvement of autonomic cardiac function following HRV biofeedback was paralleled by decreased severity of autonomic symptoms (p<0.05). Contrasting our observation of an increase in predominantly parasympathetic parameters such as CVNN, sympathetic measures of sudomotor and vasomotor function remained unchanged in both groups (p=ns). Neurological and functional outcomes were unchanged immediately post intervention, however 3-month follow up is yet to be completed.

Discussion:
HRV biofeedback can modulate autonomic cardiac function post AIS to increase HRV and alleviate autonomic symptoms which might be beneficial in facilitating recovery from functional impairment. This seems to be mediated by a predominantly parasympathetic mechanism of action.
Abstract WP378: Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis
Authors: Cerecedo Lopez Christian D , Cantu Aldana Alejandra , Patel Nirav J , Aziz-Sultan Mohammad A , Frerichs Kai U , Du Rose
Published: June 2021

Background:
The role of tight glycemic control in the management of acute ischemic stroke remains uncertain.

Objective:
Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke.

Methods:
We searched PubMed, CENTRAL, and EMBASE for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70 - 135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed- and random-effects models. Outcomes were death, independence and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment.

Results:
Twelve RCTs including 2,734 patients were included. When compared to conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99 [95% CI, 0.79 - 1.22], I
2
0%), independence at ≥90 days follow-up (pOR, 0.95 [0.79 - 1.14], I
2
0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014 [-0.15 - 0.17], I
2
0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR 5.2 [1.87 - 14.42], I
2
20%).

Conclusion:
Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.
Abstract WP38: Optimum Technique for Complete Revascularization After First Pass in Mechanical Thrombectomy
Authors: Boyanpally Anusha , Patel Pratit , Jumah Fareed , Khandelwal Priyank
Published: June 2021

Background:
The benefits of endovascular revascularization using the Aspiration vs Stent retriever vs Combined approach in patients with acute ischemic stroke remain uncertain due to lack of evidence from randomized controlled trials. The ASTER trial has shown that aspiration was as successful as stent retriever in revascularization rates in patients in with large vessel occlusion receiving EVT. However, there is a lack of studies that compared the combined approach with aspiration or stent alone.

Methods:
We retrospectively reviewed consecutive patients presenting with AIS with LVO from February 2016 to May 2019. Of the 157 patients, 101 patients who presented with LVO in M1 segment or ICA terminus occlusion were included in the study. Patients were divided based on the first pass EVT technique into Aspiration, Stent retriever and Combined (Aspiration+Stent) groups. The primary outcomes were 1st pass TICI 3 and 1st pass successful recanalization (TICI 2b or TICI 3). Secondary outcomes were number of passes in successful thrombectomies and TICI 2b rates after 1st pass.

Results:
A total of 101 patients with M1 and ICA terminus occlusion were included; female 56 (55.4%); male 45 (44.6%); mean age 67.84 years; of whom 32 (31.7%) have received aspiration, 20 (19.8%) stent, and 49 (48.5%) received both. This study showed that primary outcome 1st pass TICI 3 was 50% in aspiration group, 53.1% in combined group, and 30% in stent group with p value of 0.68. 1st pass successful recanalization (TICI 2b and TICI 3) results showed 60% in aspiration group, 55.1% in combined group, and 60% in stent group with p value 0.42. Number of passes in successful thrombectomies were 1.43, 1.54, and 1.59 mean in aspiration, combined and stent cohorts respectively. TICI 2b rates after 1st pass were 15.6%, 2%, and 25% in aspiration, combined and stent population with p value 0.21.

Conclusion:
In our cohort, both aspiration alone and combined (aspiration+stent retriever) were equally effective in achieving TICI 3 recanalization after first pass. Although the combined approach which is more expensive, has been widely used recently, there may be no additional benefit of this technique compared to aspiration. Randomized controlled studies are needed to further delineate results of different methods.
Abstract WP392: Intravenous Thrombolysis in Therapeutically Anticoagulated and Thrombocytopenic Ischemic Stroke Patients Does Not Increase Hemorrhage Rates
Authors: Barazangi Nobl , Sorensen Sigrid , Chen Charlene , Wong Christine , Yee Alan , Ke Michael , Gao Billy , Grosvenor David , Bedenk Ann , Tong David
Published: June 2021

Introduction:
IV rt-PA guidelines exclude therapeutically anticoagulated or thrombocytopenic patients. These exclusion criteria may limit thrombolytic therapy to patients who might benefit, especially with the increased use of novel oral anticoagulants (NOACs). The objective of this study is to determine if IV rt-PA is safe, especially in this patient population.

Methods:
Retrospective analysis of IV rt-PA treated patients receiving oral anticoagulation (warfarin (INR
>
1.7)), novel oral anticoagulant (NOAC), therapeutic heparin, low-molecular weight heparin (LMWH), or with thrombocytopenia (platelets < 100K). Patients were treated using SMART criteria (consent obtained for off label rt-PA use). Safety was evaluated by symptomatic intracerebral hemorrhage (sICH) rate ≤36hr after treatment.

Results:
81 patients were identified. 35 patients received therapeutic warfarin and 1 had coagulopathy (unclear etiology); mean INR=2.2 (range 1.7-3). 5 received therapeutic IV heparin, 6 full dose (1 mg/kg BID) LMWH, and 22 therapeutic NOACs. 12 had thrombocytopenia (mean platelet count 77K). There was a consistent increase in NOAC use in this cohort; 25% of the patients were taking NOACs from 2012-14, increasing to 71% from 2015-17. Out of all patients, 7 received intra-arterial (IA) rt-PA, and 8 thrombectomy. There were 3 sICH (3.75%), none in patients taking NOACs; for all sICHs there were mitigating factors that contributed (undiagnosed malignancy, adjunctive IA rt-PA, incorrect time of onset). Two developed hematoma at the catheter site with no clinical effect.

Conclusions:
These data suggest that IV rt-PA can be safely administered in therapeutically anticoagulated and thrombocytopenic patients, and sICH rates were similar to the NINDS cohort. The use of IV rt-PA in these patients may increase eligibility for acute stroke therapy, particularly where IA therapy is unavailable. Furthermore, preliminary results for patients taking NOACs indicate a good safety profile in this growing subpopulation.
Abstract WP393: In-Hospital Mortality and Level of Care for Patients With Intracerebral Hemorrhage: A Population-Based Instrumental Variable Analysis for the State of Texas
Authors: Sujit Sheeba J , Bambhroliya Arvind , Meeks Jennifer R , Chapman Cole , Alex Katie M , Attia Maria , Wang Henry E , Miller Charles , Savitz Sean I , Vahidy Farhaan S
Published: June 2021

Background:
Prior observational studies suggest lower in-hospital mortality (IHM) among intracerebral hemorrhage (ICH) patients treated at higher levels of care (LOC). However, comparisons across non-certified (NC), primary certified (PSC), and comprehensive certified centers (CSC) have not been reported; particularly accounting for changing certification status. Also, unmeasured confounding in observational designs can bias estimates. We performed an instrumental variable (IV) analysis of population level TX state data for association between IHM and LOC.

Methods:
We analyzed TX in-patient discharges for years 2010 - 2015. Adult, non-traumatic and non-transferred ICH discharges were tagged using ICD-9 codes. Patients’ location was estimated using population weighted centroid for their zip code. Hospitals’ location was geo-coded and certification status (by quarter) was determined from publicly available data. The differential distance of the patient to their closest certified hospital vs closest NC hospital was used as a ‘randomization’ variable (IV). We tested for IV strength and its association with risk of mortality. The IV model was a 2-stage least squares regression (2-SLSR). We report exponentiated IV estimator (IVE) and 95% CI.

Results:
Based on our criteria and non-missing data, 18,178 discharges were included, mean (SD) age 67.7 (15.5), 50.2% female, 60.0% White and 27.7% Hispanic. Overall, 46.1% discharges were from certified hospitals and IHM was 24.6%. The 2-SLSR demonstrated a significantly lower IHM for ICH discharges from certified hospitals as compared to NC hospitals (IVE, CI: 0.80, 0.74 - 0.97). However, this effect was not observed for comparison between PSC and CSC hospitals (IVE, CI: 0.98, 0.82 - 1.17). The F-static for IV strength was 118 and 249 (recommended > 10). The IV was neither associated with outcome (IHM) nor with measured confounders (severity of illness, age).

Conclusion:
In a state with large urban - rural divide, IHM reduction was associated with care of ICH patients at certified hospitals. However, similar benefits were not observed across two levels of certification. Factors leading to reduced IHM at certified hospitals need to be studied further and incorporated in health systems redesign for ICH patients.
Abstract WP40: Balloon Guide Catheter Utilization With Continuous Aspiration Prior to Intracranial Vascular Embolectomy (BGC-CAPTIVE) Associated With Greater Recanalization
Authors: Le Weiyi , Jayaraman Mahesh V , Baird Grayson L , Mac Grory Brian C , Burton Tina M , Cutting Shawna , Haas Richard A , McTaggart Ryan A
Published: June 2021

Background:
Among thrombectomy techniques, Continuous Aspiration Prior to Intracranial Vascular Embolectomy (CAPTIVE) is associated with higher rates of recanalization. Initially, CAPTIVE was performed without a balloon guide catheter (BGC). We aimed to determine the association between BGC usage with final recanalization as well as first pass effect in patients with anterior circulation emergent large vessel occlusion.

Methods:
We retrospectively reviewed consecutive patients with ICA and M1 occlusions treated with thrombectomy using CAPTIVE over a 45-month period. Post-treatment angiograms were scored by an experienced neurointerventionalist who was blinded to BGC usage and clinical outcome. For both BGC and non-BGC groups, we compared degree of recanalization (using the mTICI 2c scale), first-pass successful recanalization (mTICI 2c/3), and time to recanalization. We examined these results for all patients as well as based on clot location (ICA vs. M1).

Results:
357 patients met criteria (median age: 73, median NIHSS: 17) for whom BGC was used in 37/70 (53%) with ICA and 116/287 (40%) with M1 occlusion. Odds of successful reperfusion increased 2.4-fold and odds of complete reperfusion increased 3-fold using BGC (both p<.01). Odds of successful first-pass recanalization (mTICI 2c/3) increased 5-fold for ICA occlusions (p=.004) and 1.7-fold for M1 (p=.03) (See Figure). Recanalization time with BGC for ICA occlusions was faster (22 vs. 36 min, p=.02) but there was no difference in time for M1 occlusions (24 vs. 26 min).

Conclusions:
BGC usage with the CAPTIVE technique is associated with higher recanalization rates, markedly higher first pass effect (mTICI 2c/3) for both ICA and M1 occlusions, and faster recanalization for ICA occlusions.
Abstract WP403: Trends and Predictors of Intracranial Hemorrhage in Patients With Advanced Heart Failure on Left Ventricular Assist Device From 2005 to 2014 in the U.S.
Authors: Kim Hyun Woo , Markovic Daniela , Brott Thomas G , Meschia James F , Pham Si M , Patel Parag C , Goswami Rohan M , Lin Michelle P
Published: June 2021

Introduction:
Left ventricular assist device (LVAD) is known to extend survival in patients with advanced heart failure but it is associated with intracranial cranial hemorrhage (ICH). In the last decade, the use of LVAD substantially increased along with advances in LVAD technology, but there is limited data regarding the trends of ICH risk and predictors in patients with LVAD.

Methods:
We included the patients aged≥18 years with primary diagnosis of LVAD hospitalized in the US from 2005 to 2014 using the National Inpatient Sample. We computed the survey weighted percentages with ICH across the 10-year study period and assessed whether the proportions changed over time. Predictors of ICH were evaluated using the multivariable logistic regression model. All analyses were appropriately adjusted for the survey design variables to account for the complex survey design.

Results:
Of 33,246 hospitalizations, 568 (1.7%) had ICH. The number of LVAD placement has increased from 873 in year 2005 to 5,175 in year 2014. However, the risk of ICH remained largely unchanged from 1.7% to 2.3% (linear trend: p=0.604). The adjusted odds of ICH was increased with the presence one of the following variables: female sex (odds ratio [OR]: 1.58, 95% confidence interval [CI] 1.03-2.43), history of ischemic stroke (OR: 3.13, 95% CI 1.86-5.28), and Charlson Comorbidity Index (CCI) of ≥3 (OR: 77.40, 95% CI 10.03-597.60).

Conclusions:
Despite advances in LVAD technology and its increased use in patients with advanced heart failure, the risk of ICH has remained relatively unchanged. High CCI and history of ischemic stroke were associated with higher odds of ICH in patients with LVAD. With the advent of magnetically levitated centrifugal-flow LVAD, future trend of ICH may change and further research efforts are needed to prevent ICH in patients with LVAD.
Abstract WP410: Hemoglobin Levels and Poor Outcome in Intracerebral Hemorrhage: An Exploratory Analysis of Individual Patient Data Across Multiple Studies
Authors: Acosta Julian N , Leasure Audrey C , Kuohn Lindsey , Petersen Nils , Sansing Lauren , Matouk Charles C , Testai Fernando , Langefeld Carl D , Woo Daniel , Qureshi Adnan , Mayer Stephan A , Sheth Kevin N , Falcone Guido J
Published: June 2021

Introduction:
Observational evidence from single center studies indicates that lower admission hemoglobin (Hb) levels are associated with poor outcome after spontaneous intracerebral hemorrhage (ICH). We combined data from three multicenter studies to test the hypothesis that Hb levels inversely correlate with functional outcome in ICH.

Methods:
We conducted a meta-analysis of individual patient data from the clinical trials ATACH-II and FAST and the multi-ethnic study ERICH. We included participants with available Hb and outcome data. We used multivariable logistic regression to test for association between admission Hb levels and 3-month dichotomized (0-3 versus 4-6) modified Rankin Scale (mRS), adjusting for the variables contained in the ICH score. We pooled study-specific estimates using inverse-variance weighted, fixed effects meta-analysis.

Results:
A total of 4106 ICH patients were included in the analysis. Each additional g/dL of admission Hb was associated with a 12% (OR 0.88, 95%CI 0.85-0.91; p<0.001) and 8% (OR 0.92, 95%CI 0.88-0.96; p<0.001) reduction in the odds of poor outcome in unadjusted and adjusted analyses, respectively (Table 1). Dose-response analyses indicated a linear relationship between Hb levels and poor outcome across the entire evaluated range (Figure 1, test-for-trend p<0.001). In metanalysis, there were not significant associations between Hb and ICH volume or expansion (both p>0.05).

Conclusion:
Lower hemoglobin levels are associated with poor outcome in ICH. Further studies of the underlying biological mechanisms are warranted. If replicated, this pathway could become an appealing target to be tested in clinical trials.
Abstract WP412: Important Role of Scavenging Receptors on Hemoglobin-Injected Intracerebral Hemorrhage Model
Authors: Ashouri Rani , Ahmad Abdullah S , Kamat Pradip , Dore Sylvain
Published: June 2021

Introduction:
Clinical and experimental studies have linked the presence of oxidative damage and neuroinflammation from free hemoglobin (Hb) to the innate immune response. CD36 has been identified as a macrophage/microglia surface receptor as part of a scavenging system, notably by RBC phagocytosis. CD163 is another surface receptor binding to Haptoglobin-Hb complexes with high affinity and Hb with lower affinity. These receptors participate in the clearance of extravasated erythrocytes and Hb, and also prevent triggering a pro-inflammatory cascade.

Hypothesis:
We hypothesize CD36 and CD163 knockout would play a role in oxidative stress and inflammation as indicated by neurological function, hemispheric, cortical volumes, and iron staining.

Methods:
Wildtype and CD36
-/-
, CD163
-/-
and double CD36
-/-
xCD163
-/-
mice were injected with 40μL of cerebrospinal fluid (vehicle) or stroma-free Hb. Behavioral rotarod, latency of fall and ambulatory distance tests were utilized to score neurological dysfunction. Brain sections were stained with Cresyl violet and Perls’ Prussian blue. Scanned images were analyzed by an observer blinded to genotypes using algorithm positive pixel counts.

Results:
At 24h, the CD36
-/-
xCD163
-/-
mice resulted in an average neurological deficit score of 4.75 (n=9, p<.001), CD36
-/-
of 6.34 (n=8, p<.05), CD163
-/-
of 6.50 (n=10, p<.05) and WT of 8.23 (n=13). The CD36
-/-
ipsilateral and contralateral hemispheric volumes increased respectively 12.4±1.6% (n=11, p=.0005) and 19.4±2.7% that of WT mice (n=6, p=.0001). Double knockouts showed 4.3±1.1% and 6.8±1.9% decreases in ipsilateral and contralateral cortical volumes (n=6, p=.0422, p=.0396). The CD36, CD36
-/-
xCD163
-/-
and CD163
-/-
showed 68.5±13.7% (n=10, p=.003), 41.2±10.3% (n=10, p=.0317), and 30.0±9.8% (n=7, p=.0216) increase in iron staining than WT mice, respectively.

Conclusions:
Together, the behavioral data, the variations in brain volume, and the significant changes in deposited iron suggest the CD36 and CD163 receptors do play major roles in brain damage and neurological deficits following intracranial bleeding and could be targeted as a potential therapeutic intervention.
Abstract WP426: Implementation of a Stroke Nurse Navigator in Addition to Stroke Care Path Improves Readmission Rates
Authors: Pope Leslie , Stettner Peggy , Henderson Melanie , Hackett Chris , Noah Patty , Cerejo Russell
Published: June 2021

Background and Purpose:
Inpatient care during the acute and post-acute phases is complex and requires an interdisciplinary approach. High quality metrics have become an integral part of achieving value-based care. The addition of Bundled Payments for Care Improvement Advanced will continue to drive Stroke Centers to deliver high quality, low cost care during the acute phase and the 90 days post discharge. A pilot program was implemented to create a stroke care pathway and incorporate stroke nurse navigators in the interdisciplinary team to improve patient outcomes and quality metrics. Acute stroke patients are followed by nurse navigators throughout the hospitalization and for 90 days post discharge.

Methods:
A retrospective analysis of a prospectively collected database was carried out. This database incorporated data from the electronic medical records and crossed referenced with insurance claims data. We included patients admitted to our stroke center from January 2017 until December 2018. The stroke care path was initiated in May of 2017. We collected quality metrics including length of stay, readmission rates, inpatient therapy days as well as 90 day total episode costs. Patient demographics and clinical data were also collected.

Results:
We identified 1407 patient that met inclusion criteria. 48.3% of these patients were pre-care path. All cause re-admissions significantly decreased from 10.1% to 5.3% (OR 0.49; 95%CI 0.33 - 0.74, p <0.001) after the implementation of the care pathway. Length of stay reduced from 6.3 to 5.9 days post carepath. Inpatient therapy days have increased from 3.3 days to 4.7 days per hospitalization. Total costs per episode decreased from $41,576 to $40,580.

Conclusions:
The implementation of nurse navigators in addition to standardized care pathway led to significant reduction in readmission rates, increased inpatient therapy utilization days, increased patient and decreased overall episode costs.
Abstract WP433: Factor Associated With Significant Delay in Acute Stroke Triage Process
Authors: Kongmuangpuk Mananchaya , Fongsri Usanee , Pakdeewongse Rojana , Sinlapadeelerdkul Roongnapa , Pengtong Waitayaporn , Tapin Wachirapan , Pinyopasakul Wanpen , Hunnangkul Saowalak , Ampornjarut Pongsathorn , Nittayaboon Kittiya , Nilanont Yongchai
Published: June 2021

Background:
Benefit of revascularization in acute ischemic stroke declines over time. Any delay in acute stroke care contributes to poor treatment outcome. We aimed to identify factors associated with the delay in the process of acute stroke triage.

Methods:
All patients presented at the emergency room at the Siriraj Hospital, Mahidol University, Thailand under stroke fast track protocol (ASFP) from January 2015 to March 2017 were reviewed. Demographic data, stroke subtypes, time measures, initial NIHSS were recorded. Delay in triage was defined as either door to first physician
>
10 minutes or door to activate stroke fast track
>
15 minutes. Multivariable logistic regression model were performed to identify independent variables associated with triage delay.

Results:
A total of 1,000 patients were enrolled under ASFP with a mean age of 63.5+15.3 years and 53.9% were male. Triage delay was found in 11.2%. Factors associated with a delay in stroke triage were inaccurate presenting symptom(s) OR17.69 (95% CI 10.86, 28.82), dizziness and dysphagia as an initial presentation OR 3.26 (95% CI 1.64, 6.48) and OR 8.02 (95% CI 1.31, 49.28) respectively and uncertain chief complaint OR 3.35 (95% CI 1.56, 7.19).

Conclusion:
Unclear chief complaint, dizziness and vertigo as an initial symptoms and inaccurate presenting symptoms significantly associated with the delay in acute stroke triage in an emergency department. Further research is needed to clarify if strategic questioning could help nurses and ER physicians in reducing this delay.
Abstract WP434: Incidence of Deep Venous Thrombosis Following Endovascular Revascularization via the Femoral Artery Due to Acute Ischemic Stroke
Authors: Chiba Nozomi , Mori Takahisa , Yoshioka Kazuhiro
Published: June 2021

Introduction:
Deep venous thrombosis (DVT) occasionally occurs in lower extremities in stroke patients and possibly causes symptomatic venous thrombosis (VT). To prevent DVT in our stroke center, patients put on both foot pumps and elastic knee stockings after admission. However, in patients who underwent emergency endovascular revascularization via the femoral artery, DVT may often occur because of hemostasis procedures after femoral artery puncture in addition to paralysis and postoperative rest.

Hypothesis:
Incidence of DVT following endovascular revascularization via the femoral artery probably occurs in the femoral artery ipsilateral to femoral artery puncture.

Methods:
We included acute stroke patients who 1) were admitted from April 2017 to March 2019, 2) underwent emergency endovascular revascularization via the femoral artery, and 3) underwent lower extremity ultrasonography (le-US) to detect DVT during hospitalization. We investigated incidence of DVT in lower extremity with reference to our Stroke Database.

Results:
During study period, 56 patients met our inclusive criteria. Their median age was 78.5 years old, female gender was 34 (60.7%) and median hospital stay was 9.0 days. Le-US was conducted about 3.5 days after admission. Le-US detected DVT in 15 patients (26.8%, 15/56). Among them, 10 patients had DVT in the lower thigh vein (17.9%, 10/56) and 5 patients had DVT in the femoral vein ipsilateral to femoral artery puncture (8.9%, 5/56). Hemostasis procedures possibly induced DVT in the femoral vein, although it was uncertain whether hemostasis procedures had some relation to DVT in the lower thigh vein. No symptomatic VT occurred in the 15 patients during hospitalization.

Conclusion:
Incidence of DVT occurs 8.9% in the femoral vein ipsilateral to femoral artery puncture in the patients after endovascular revascularization. Some strategy is required to prevent any DVT in the femoral artery ipsilateral to femoral artery puncture.
Abstract WP449: Code Swarm Decreases Neuro Interventional Door to Groin Times
Authors: Findura Kimberly , Montgomery Kelly , Fussner Julie M
Published: June 2021

Background:
Each minute of an untreated large vessel occlusion in an ischemic stroke patient can result in the death of 1.9 million neurons. Decreasing the time from stroke onset to the time of treatment is critical to preserving a patient’s cognitive function and improving the long-term outcomes. Thrombectomy using stent retrievers is now leading to faster and more complete reperfusion. This treatment is reflected in the new Target: Stroke Phase III campaign to decreased door to groin times for eligible acute ischemic stroke patients. At University Hospitals Cleveland Comprehensive Stroke Center the time period of patient arrival into the procedure room to obtaining groin access was identified as a contributor to delays in treatment.

Hypothesis:
A larger number of Interventional Radiology (IR) nurses and technicians responding could have a significant impact on decreasing the time required to prepare a patient in the interventional room for a thrombectomy if there was a unified alert system and process.

Methods:
In March 2019, a process was initiated to call a “Code Swarm” on the Vocera ™, a peer to peer departmental messaging system. This “Code Swarm” notifies all available trained IR staff to convene in the IR procedure room and assist in the patient preparation for the exam and intervention. Delegation of necessary tasks are assigned by the IR nurse, to include patient education, patient assessment, vascular access, hand off report, cardiac monitoring, and medication administration. Rapid patient preparation allows for faster “IR door to groin” access and treatment.

Results:
Data for a 9 month period that included 55 patients that underwent a mechanical thrombectomy was analyzed. Baseline 6 months data prior to the implementation of Code Swarm demonstrated an average IR door to groin access time of 26.6 minutes. After the implementation of Code Swarm, the data demonstrated an improvement down to an average time of 10.3 minutes. This is a 39% decrease in the IR door to groin access times.

Conclusion:
Unified alert system and expectation of all hands on deck exhibits a Magnet culture of nurses who evaluate and reorganize the nursing practice environment to achieve high quality patient outcomes and improve care efficiency.
Abstract WP451: “Development, Feasibility and Validation of “Stroke Home Care” Application in a Resource Limited Setting: A Proof of Concept Study”
Authors: Kumar Ashok , Khurana Dheeraj , Pattanaik Smita , Kumar Mukesh , Modi Manish , Kaur Sukhpal , Ghai Sandhya , Narayanan CK , Nagi Manisha
Published: June 2021

Introduction:
Stroke rehabilitation and caregivers training is central to improve post stroke care and reduce caregivers’ burden. Mobile applications(app) may provide a patient and caregiver centric modality to improve stroke care

Aim:
To develop and evaluate feasibility of a medical application for delivering post stroke care.

Methods:
A mobile app was developed on an android operating system following a preliminary assessment of post stroke complications to train caregivers. App consists of videos of home based care strategies for bedsore prevention, feeding, mouth care, ROM exercises, catheter care, psychological support to patients etc. App includes awareness videos on stroke, problems faced after stroke, follow up schedule, feedback option. App feasibility was assessed among 25 bedridden stroke survivors and their caregivers selected purposely. App validation was done by 16 stroke experts including neurologists, nurses, psychologists, physiotherapists using semi-structured-questionnaire for data collection. Following this, final "Stroke Home Care" app was developed.

Results Feasibility:
Mean age of patients and caregivers was 52.6±14.8 and 32.4±8.9years, respectively. 64% patients females, 75% caregivers males. 56% lived in rural. Median NIHSS 14 (IQR: 12-17). Complications were 56% Ryle’s tube, 72% Foley’s catheter, 12% bedsore. 64% caregivers were graduates. 52% sons. All caregivers responded that app contents, videos and language was understandable and appropriate. 92% preferred ‘Hindi’ language. All agreed to App enhancing their stroke knowledge. All were satisfied.

Validation:
Mean age of experts was 33.2±4years. 75% females. 56% nursing experts and postgraduates,19% MDs. 50% Nursing teachers, 19% Neurology fellows. None faced any app installation problem. 81.3% experts highly satisfied with app functions, its contents, voice clarity, video clarity and duration, contents’ sequence, understandability.

Discussion/Conclusion:
“Stroke Home Care” App is feasible, pragmatic and user-friendly for use by caregivers of stroke survivors in a resource limited setting/developing country. It should be tested by an RCT to evaluate its efficacy in reducing post stroke complications and reducing caregivers’ burden.
Abstract WP452: Nurses Use Real-Time Patient Identification Tool to Improve Care Coordination for Transient Ischemic Attack Patients
Authors: Homoya Barbara , Damush Teresa , Rattray Nicholas , Miech Edward , Myers Laura , Marks Danielle , Baskerville James , Fahner Jeff , Perkins Anthony , Murphy Lauren , Cheatham Ariel , Myers Jennifer , Williams Linda , Bravata Dawn
Published: June 2021

Background:
Programs emphasizing early evaluation and management have reduced 70% of transient ischemic attack (TIA) patients’ recurrent events. One barrier to guideline-concordant care is inadequate care coordination.

Purpose:
Our objective was to evaluate adoption of nurse care coordination programs on TIA care quality at two Veteran Health Administration (VHA) facilities.

Methods:
Nurse care coordination programs with real-time patient identification and using Consolidated Framework for Implementation Research (CFIR) to guide local adoption, were evaluated at 2 VHA facilities. Programs were coordinated by an Emergency Department (ED) Nurse Navigator or Neurology Stroke Nurse Coordinator. The nurses used a Patient Identification Tool which was updated daily and displayed: TIA patient’s name, event and discharge dates, diagnosis, visit type (ED or inpatient), and primary care team. Nurses reviewed patients’ charts for key care components (e.g., medications), identified gaps in care, and provided follow-up. TIA care quality was evaluated by Without Fail Rate (WFR) which describes the facility-level proportion of patients who received all eligible processes of care (anticoagulation for atrial fibrillation, antithrombotics, brain imaging, carotid artery imaging, hypertension control, moderate/high intensity statin, neurology consultation).

Results:
We compared the WFR before (Fiscal Year [FY] 2017) and after (FY2019) implementation of the care coordination programs: Site-1, 59.6% (N=48) to 71.4% (N=30), p=0.332 (not significant); Site-2, 15.9% (N=47) to 38.5% (N=29), p=0.045 (significant). The individual process of care with greatest improvement was high/moderate potency statin at Site-1 (68.4% to 82.6%, p=0.250 [not significant]) and neurology consultation at Site-2 (39.5% to 80.8%, p=0.001 [significant]).

Conclusions:
Nurse care coordination programs using real-time patient identification were associated with improved quality of care. These broadly generalizable programs were important components of a comprehensive, multidisciplinary quality improvement initiative. Healthcare systems interested in improving care for TIA patients may find real-time patient identification useful in coordinating their care.
Abstract WP453: Factors Associated With Dietary Patterns For Stroke Prevention In Young Adults
Authors: Perrin Stacy M
Published: June 2021

Background/Purpose
Hypertension, diabetes, and obesity have contributed to increased stroke rates in young adults; these risk factors are more prevalent among young adult African Americans (YAAA). Cardiovascular risk factors often result from poor lifestyle choices—diet; therefore preventable, as with most strokes. The purpose of this secondary data analysis was to explore relationships among perceptions of stroke risk, competence to live a healthy lifestyle, health literacy, and dietary patterns to reduce stroke risk in YAAA.

Methods:
A cross-sectional, correlational analysis was conducted using baseline data from the Stroke Counseling for Risk Reduction (SCORRE) study. SCORRE was guided by the Health Belief Model and used self-report questionnaires and biophysiological measures to assess the variables of interest in a community-based sample. Data were analyzed using Mann-Whitney
U
tests, Spearman’s Rho correlations and ANOVA.

Results:
Participants (
N
=116) had a mean age of 25 (
SD
=4.5) years, were mostly female (74%), college students, and averaged three modifiable stroke risk factors. Participants had poor dietary patterns based on the five AHA Life Simple 7
®
dietary recommendations; they averaged 1.6 (
SD
=1.0). Participants perceived a low risk of future stroke (
M
=2.5,
SD
=2.2); 53% had inaccurate risk perceptions. Health literacy levels (
M
=4.4,SD=1.1) and perceived competence to live healthy (M=5.9, SD=1.1) were high. There was no association with health literacy/accuracy of perceived stroke risk (
p
=.064); health literacy did not moderate the relationship between perceived competence to live healthy and dietary patterns. However, higher perceived risk of future stroke (

r
s

= -.22,
p
=.020) and lower perceived competence to live healthy (

r
s

=.27,
p
=.003) were significantly associated with poorer dietary patterns.

Conclusions:
As the incidence of stroke in young adults increases, the need for primary prevention interventions that focus on YAAA and dietary behaviors is paramount, regardless of health literacy levels. Assessing the perceived risk of future stroke and perceived competence to live healthy could help to identify those YAAA who may need more education and resources to achieve dietary recommendations for stroke risk reduction.