bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP365: Stroke Nurse Navigator Improves Post-Acute Transition of Care
Authors: Sher Karen , Edgar Armani , Clark Sarah , Staff Ilene , Nouh Amre
Published: June 2021

Background:
Post stroke care is multifaceted and should not end at hospital discharge. Patients often lack understanding of the importance of outpatient care to prevent secondary stroke.

Objective:
To demonstrate the positive impact of a stroke nurse navigator in improving the post-acute transition of care by promoting outpatient follow up after hospitalization.

Methods:
We retrospectively reviewed all patients discharged from our comprehensive stroke center (excluding hospice) with a primary diagnosis of ischemic or hemorrhagic stroke from January -December 2018, yielding 685 patients. We evaluated whether or not our nurse navigator influenced three aspects of follow up: if stroke clinic appointment was made before discharge, if patient attended the appointment and if patient called the clinic after discharge. Four categories were used based on level of navigator contact with the patient: (SC) Seen in-house and called within 30 days after discharge, (S) Seen only, (C) Called only or (N) No navigator contact. Chi-square test of proportions was used to evaluate the statistical significance among all four groups.

Results:
Out of the 685 patients, 77.5% (n=531) were scheduled for clinic follow-up before discharge, 60.7% (n=416) attended the appointment and 20% called after discharge (n=137). The distribution of navigator contact level was (SC) 26.7%, (S) 17.5%, (C) 19.3% and (N) 36.5%. Both seeing and calling the patient was proven to be the most effective in all three areas: appointment made prior to discharge (SC) 89.6%, (S) 82.5%, (C) 74.2%, (N) 68% (
p=<0.001
); patient attended the appointment (SC) 68.9%, (S) 60%, (C ) 65.9%, (N) 52.4% (
p=0.001
) and patient called the clinic after discharge (SC) 26.2%, (S) 15.8%, (C ) 23.5%, (N) 15.6% (
p=0.02
). Of interest, patients who were only called but not seen were more likely to attend the appointment or call the clinic as compared to being seen alone.

Conclusion:
Contact with our nurse navigator increased post-acute follow up in our stroke clinic. An increased number of patient calls associated with navigator interaction showed these patients had a better understanding of the need for continued care. The nurse navigator improves continuity of post-acute care.
Abstract TP366: Significant Reduction in Readmission Using Transitions Nurse
Authors: Espaillat Kiersten , Buckner Paula
Published: June 2021

In an effort to reduce early hospital readmissions, Vanderbilt University Medical Center (VUMC) implemented a transitional care coordinator (TCC) to provide careful coordinated follow up care for stroke patients after hospital discharge. The aim of this study is to compare all cause thirty- day readmission rates of adult patients with a primary diagnosis of stroke before and after the implementation of a stroke services TCC. All adult patients admitted to VUMC with a primary diagnosis of stroke; ischemic, hemorrhagic, and TIA; and readmitted within the first thirty days following hospital discharge between January-June of 2015, 2016, 2017, & 2018 were analyzed. Readmission data from 2015 & 2016, prior to the implementation of the TCC was compared to readmission data from 2017 & 2018, after the TCC was implemented. A total of 1911 charts were reviewed for the timeframe January-June of 2015-2018. In 2015 there were 369 stroke admissions and 120 (33%) were readmitted and in 2016 there were 474 stroke admissions and 112 (24%) readmissions, before the TCC role was implemented. In 2017 there were 540 stroke admissions and 62 (11%) were readmitted and in 2018 there were 528 stroke admissions and 74 (14%) readmissions, after the TCC role was implemented. Hospital readmissions were reduced significantly after implementing a TCC.
Abstract TP370: Role of Stroke Coordinators in Improving Post-Operative Nursing Care for Patients Undergoing Carotid Revascularization Procedures
Authors: Gonzales Isabel , Shaw Sandi , Lightford Mallory , Toumbs Randi , Harrison Nicole , Vahidy Farhaan S
Published: June 2021

Background:
The Joint Commission (TJC) mandates standardized post-operative care for Carotid Artery Stenting (CAS) and Carotid Endarterectomy (CEA). We designed and implemented a standardized and evidence-based medical power plan (MPP).

Purpose:
To address low early utilization of the MPP, stroke coordinators designed and implemented a Quality Improvement (QI) project to: 1) Monitor and improve MPP utilization for CAS/CEA patients in all applicable nursing units, 2) track cases of non-compliance, and 3) determine causes of non-compliance and establish a feed-back loop for staff.

Methods:
Designed in coordination with neurologists, neurosurgeons, and cardiologists; the MPP was implemented in Jan 2016. We monitored MPP order rates and nursing compliance for MPP components such as post-procedure neuro-assessments. An education intervention for post-CEA/CAS nursing care, including NIHSS certification, was provided to nurses across applicable units. Residents and fellows were re-educated on ordering the MPP. Three PDSA cycles were completed. Nursing compliance was shared with leadership and feedback was provided to nursing staff.

Result:
A total of 281 procedures were completed from January 2016 - June 2019. The first quarter (Q1) MPP order rate was 73% and nursing compliance for documenting a neurological assessment was 45%. Each PDSA cycle (Figure 1) was associated with an increase in the MPP order rate. For the years 2017-2019 an order rate of 81%, 85%, and 100% was observed respectively. Nursing compliance with neuro-assessment documentation also demonstrated an annual increase across the same time period (68%, 72% and 97%). The tests for trend in annual ordering and compliance rates were statistically significant (p value for both < 0.01).

Conclusion:
Stroke coordinators play a vital role in improving practice standards and guideline implementation. Stroke coordinator oversight in CAS/ CEA cases positively impacted the MPP order rate and nursing compliance.
Abstract TP371: Stroke Center Heparin Flush Use in Transfemoral Angiography Survey
Authors: Korzewski Margaret , Madden Lori , Schomer Kendra
Published: June 2021

Background and Purpose:
The drug concentration of heparinized saline used for transfemoral catheter angiography flush during different types of cerebral endovascular interventions varies among operators and centers worldwide. While heparin use is recommended during cerebral angiograms to minimize the risk of thromboembolic events, there is a paucity of information regarding protocols for administration of heparinized saline. Higher concentrations of heparinized saline may benefit patients undergoing elective intracranial aneurysm embolization by decreasing the risk of thromboembolism. However, it may place patients undergoing revascularization procedures for acute ischemic stroke at higher risk of symptomatic intracerebral hemorrhage, particularly if they received intravenous tissue plasminogen activator immediately prior.

Methods:
After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of Directors, a survey was electronically distributed by ARIN to its members via the ARIN List Serve. Response to the survey was identified as consent to participate. Subjects were asked to participate if they were currently involved in the management of patients undergoing cerebral angiography with a variety of interventions.

Results:
The most frequently used concentration of heparinized saline flush was 2 units/ml (32.8%-34.8% range, depending on endovascular intervention), and the least frequently utilized concentrations were 3 units/ml and higher than 5 units/ml (4.3%- 5.7% range, depending on endovascular intervention). Mixing and labeling bags with heparinized saline flush was noted to be the responsibility of interventional radiology registered nurse (39%, n= 46), pharmacy (26.3%, n= 31), or the angiography technologist (8.5%, n= 10).

Conclusions:
There are no standard protocols across stroke centers identifying optimal heparinized saline flush solution concentration, preparation and documentation. Replication of this survey among members of the American Society of Neuroradiology is recommended to validate the findings from the current study. If confirmed, a consensus on safety of heparinized saline flush use during neuroradiology interventions is advised.
Abstract TP377: Nurse Entered Stroke Order Sets Improve Emergency Department Metrics at a Comprehensive Stroke Center
Authors: Griffith Tawnae C , Gupta Atul , Aggabao Stacey , Dhanji Raeesa , Gaffney Denise , McCartney David , Mkrtumyan Alvina , Punsalang Lorina , Le Duy , Ajani Zahra , Sangha Navdeep
Published: June 2021

Introduction:
The Joint Commission has established time sensitive metrics for stroke care in the Emergency Department (ED) including door to initial physician evaluation, door to lab and CT order placement, door to lab resulted and door to CT interpretation.

Purpose:
The purpose of this quality improvement project was to assess if nurse entered protocolized order sets for stroke patients would help to improve these metrics.

Methods:
A code stroke order set was initiated independently by nursing staff upon symptom recognition in the ED. The order set included CBC, electrolyte panel, BUN, creatinine, glucose, troponin, PT/INR, aPTT, non-contrast CT head, EKG, swallow screen and continuous cardiac monitoring. Data was collected for 3 months pre and post intervention. All ED nurses were trained on order set entry and their skills were validated. Data was analyzed using a T-Test.

Results:
60 patient pre and 52 post-implementation were evaluated. Door to initial physician evaluation was faster (7 mins pre vs. 5 mins post; p=0.029). Door to lab order placement was faster (8 mins pre vs. 3 mins post; p=0.038). Door to CT ordered was faster (8 mins pre vs. 6 mins post; p<0.01). Door to labs resulted was faster (32 mins pre vs. 27 mins post; p=0.01). Door to CT interpretation was faster (19 mins pre vs. 18 mins post; p=0.04).

Conclusion:
Implementation of nurse entered order sets can improve ED metrics for door to initial physician evaluation, door to lab and CT order placement. This subsequently led to faster interpretation of the CT scan and lab results.
Abstract TP382: Multidisciplinary Collaboration Yields Emergency Medical Services (EMS) Inter-Facility Transfer Document to Ensure Patient Safety
Authors: Glidden Michele , Duzan Angel , Kaufmann Michael , Harrison Beth , Raab Courtney
Published: June 2021

In the current era of advancing stroke care, rapid evaluation and treatment of an acute ischemic stroke should be standard practice based on current evidence and guidelines. Acute stroke treatment with intravenous (IV) thrombolytic should be started at the presenting facility when indicated. After this initial treatment, patients may then be transferred to the next higher level of care via a qualified EMS provider agency. These transfers are completed by either air or ground ambulance services. Patient safety during transport, especially for those receiving IV thrombolytic, must be ensured while minimizing door-in/door out times.

The Stroke Consortium of Indiana (SCI), represents 48 Indiana hospitals and other organizations within the state, prioritized implementation of a stroke interfacility guideline to standardize medical care provided during the transfer process. The State EMS Medical Director joined our consortium to represent the EMS system. A search of existing literature and protocols, as well as inter-state discussions, led to the determination that further development of guidelines currently utilized within the region was needed.

Indiana, like many other Midwestern states, has areas that are underserved by EMS with varying protocols written by a local EMS medical director. There are 833 different EMS provider agencies in Indiana each operating under different local protocols. EMS conducted 658 interfacility transfers for acute stroke treatment in 2018. There are currently 5 comprehensive, 35 primary, and 5 stroke ready centers certified of 118 total hospitals in the state.

During the development of this document, the members of SCI were provided multiple opportunities to give feedback and discussion. The document was finalized, adopted, and is available online at the IDHS website at https://www.in.gov/dhs/3781.htm. The goal of this best practice document is to provide guidance and support for adoption at the local EMS provider agency level and support EMS collaboration with local stroke centers in communities across Indiana. SCI members are encouraged to socialize and implement this guideline at the local level in cooperation with their local EMS agencies.
Abstract TP388: Improved Dysphagia Screening Compliance of Stroke Patients With an Emergency Department Focus
Authors: Williams Danyell , Elliott Kelly , Leicht Rachel
Published: June 2021

Background and Issues:
A common symptom of stroke, dysphagia leaves patients vulnerable to aspiration pneumonia and at risk for poor outcomes, mortality, and increased length of stay and healthcare costs. Evidence-based practice indicates early detection of dysphagia is fundamental in decreasing the risk of aspiration, yet often the opportunity is missed in the process of providing emergent care. Stroke patients should be screened for dysphagia and aspiration risk upon ED arrival using a standardized tool before receiving oral intake.

Purpose:
The goal was to emphasize early dysphagia screening with a standardized screening tool, achieving ≥ 85% compliance in this high-risk population.

Methods:
Cause-and-effect analysis was used throughout the improvement initiative. Focus was applied to staff recognition of stroke patients as high risk for dysphagia and associated complications. A standardized screening tool was adopted. Missed screening opportunities were identified, revealing frequent association with time-sensitive medication administration of antithrombotics in the ED. A six month pilot was conducted in the ED; an alert was programmed into the medication dispensing station to query the user regarding patient dysphagia risk when specific antithrombotics were dispensed. Control charts were used to measure compliance.

Results:
Screening compliance significantly improved more than 23% from 1Q2016 to 1Q2019. The standardized screening tool supported inter-rater reliability. The ED pilot improved compliance to 88%, revealing opportunities to improve screening compliance in acute care units.

Conclusions:
A standardized screening tool and medication alert in the ED improved dysphagia screen compliance, suggesting similar outcomes if implemented on acute care units. Further data will be valuable to hypothesize a negative correlation between sustained dysphagia screening compliance and decreased incidence of healthcare-associated aspiration pneumonia.
Abstract TP394: Inpatient Onset Stroke Protocols in the Era of Value Based Medicine: Can We Remove Effectively Process Inefficiencies?
Authors: Gibson Maryika I , Susemiehl Beth
Published: June 2021

Introduction:
The American Stroke Association guidelines (2018) extension of the window for stroke interventions created an opportunity for quality improvement (QI) efforts in a sub-population designated as In-hospital (Inpatient) strokes (IHS). The new focus on salvageable tissue allows qualified IHS to receive effective reperfusion interventions. To improve outcomes in this population, hospitals are designing protocols and QI initiatives specific to IHS.

Methods:
An analysis of the implementation of a Code Stroke Rapid Response Team (RRT) process in a Primary (PSC) and a Comprehensive Stroke Center (CSC) was performed. We utilized descriptive statistics and cost estimation of centralizing the care of IHS on dedicated units.

Results:
CSC patients had a lower treatment -OR=0.17 CI 95%, and a higher mimics rate -OR= 3.03 95% CI compared to PSC. Cost of intra-hospital transfers was estimated at $5,000 to $8,000. Most of IHS occurred in cardiothoracic and trauma patients. While overall quality metrics improved -symptom discovery to CT 47% under 25 min, discovery to assessment 90% under 10 min, in the CSC the intra-hospital transfers contributed to added expenditures. The false-positive calls documented multiple contraindications to acute interventions.

Conclusions:
When implementing QI programs, hospitals should balance available resources, patients population specifics, and desired outcomes. Creating one-size-fits-all protocols can lead to multiple wastes in complex organizations. In the era of Value-Based Medicine and declining reimbursements, adopting flexible organization-specific and clinically oriented pathways and aligning treatment goals of multi-specialty teams will address the needs of IHS. Utilization of tools specific to early detection of IHS and further studies with a systematic collection, evaluation, and analysis of data is needed. Fostering efficient and consistent team communication and processes that balance quality metrics and fiscal responsibilities based on hospital structural and functional differences should become the next step in designing Code Stroke protocols. Real-World Evidence from sharing results will lead to an improvement in inpatient stroke care and patients’ outcomes- a mission long overdue.
Abstract TP404: Optimizing Length of Stay Through an Integrated Communication Strategy
Authors: Smith Kimberly , Navarro Arianne , Sostand Shanequa , Harrison Nicole , Savitz Sean
Published: June 2021

Background:
At our comprehensive stroke center, the Stroke Unit bed ahead tool allows bed availability to be reported every four hours and identifies patients who may be available for discharge or transfer out of the unit. A Stroke Bed Ahead Algorithm is utilized and information is communicated using a paper format and an online text messaging system called EZ Texting.

Purpose:
The purpose of this study is to improve bed flow through coordination and facilitation of movement in the Stroke Unit and to provide quality control feedback of the efficiency of bed flow within the Stroke Unit. A bed ahead tool is utilized to decrease divert activity of the hospital and decrease length of stay on the Stroke Unit, thereby decreasing length of stay in the hospital.

Intervention:
The Stroke Unit charge and staff nurses evaluate patients appropriate for possible discharge or transfer out of the Stroke Unit. A Stroke Unit capacity text message is then sent out by the Charge Nurse or the Unit Coordinator every four hours starting at 0800. The capacity text message includes the total number of patients and patients pending to be received or transferred out of the unit.

Results:
Utilizing an integrated communication strategy decreased the length of stay of stroke population by 12%.

Implications of Practice:
Implementation of Stroke Unit capacity notification system decreases the length of stay and decreases divert activity of the hospital.
Abstract TP41: Similar Outcomes of Endovascular Ischemic Stroke Treatment Performed by Interventional Radiologists and Neuro Interventional Fellowship Trained Physicians
Authors: Sacks David , Dhand Sabeen , Hegg Ryan , Hirsch Kevin , McCollom Vance , Sarin Shawn , Vadlamudi Venu , Zylak Christopher
Published: June 2021

Introduction:
Endovascular stroke treatment (EVT) may be provided by physicians with varying specialty training. It is possible that physicians without dedicated neurointerventional training will have outcomes inferior to physicians with such dedicated training.

Methods:
Eight academic or community hospitals who provide EVT performed by interventional radiology (IR) and neurointerventional (NI) physicians (neurointerventional radiology, endovascular neurosurgery, or interventional neurology) in the same institution submitted sequential retrospective data limited to the era of modern clot extraction devices. Clinical outcome (modified Rankin score [mRS]) and successful revascularization (modified Thrombolysis in Cerebral Infarction [mTICI]) were compared between specialties, stratified for treating hospital, patient age, stroke severity, and clot location.

Results:
A total of 1079 patients were entered (661 treated by IR and 418 treated by NI) and 90 day mRS was available for 1013 patients (632 treated by IR and 381 treated by NI). For IR vs NI, median stroke onset to puncture was 220 vs 217 minutes (p=0.25), median door to puncture was 67 vs 75 minutes (p=0.18), successful revascularization (mTICI 2b or higher) was 82% vs 84% (p=0.38), symptomatic intracranial hemorrhage was 7.8% vs 6.7% (p=0.58), emboli to new territory was 2.1% vs 4.5% (p=0.22), 90 day mRS 0-1 was 30% vs 35% (p=0.06), and 90 day mRS 0-2 was 43% vs 50% (p=0.03). There was no significant difference in outcomes for clot locations in the internal carotid, M-1, M-2, or basilar arteries. When outcomes were adjusted for hospital, patient age, and stroke severity, physician specialty was not a significant predictor of mRS 0-1 (p=0.687 odds ratio 0.940, confidence interval 0.694-1.272) or mRS 0-2 outcome (p=0.695 odds ratio 0.944, 95% confidence interval 0.707-1.260).

Conclusion:
There was no significant difference in procedural or clinical outcome for EVT performed by IR vs NI physicians.
Abstract TP412: Electroencephalographic Monitoring in Pediatric Arterial Ischemic Stroke
Authors: Waak Michaela , Andrade Andrea V , Walsh Mark , Sparkes Louise , Malone Stephen , Lynch Matthew , Sinclair Adriane J
Published: June 2021

Introduction:
Seizures occur at a high frequency in acute arterial ischemic stroke (AIS) in children however there is very limited knowledge regarding the frequency of electrographic only seizures. Early data suggests that seizures may independently be associated with a poorer outcome in acute brain injury. Without EEG monitoring electrographic seizures will go undetected resulting in a lost opportunity for neuroprotection. The aim of our study was to determine the incidence and risk factors of clinical and electrographic seizures in pediatric AIS.

Methods:
A pilot prospective single center study was performed between July 2018 and July 2019. Patients between 1 month and 18 years of age were eligible. Video EEG monitoring commenced <10 days following stroke onset. A neurologist and a second independent blinded epileptologist reported the EEG’s. Assessments included the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score and the modified Alberta Stroke Program Early Computed Tomography Score (modASPECTS). Clinical management was at the discretion of the treating neurologist. A standardized follow-up assessment was performed at 3 months.

Results:
Of 11 patients who had AIS during the study period, 10 were recruited. Median age was 3.7 years (range 6 weeks -12 years). Mean EEG duration was 26.8 hours. Electrographic seizures occurred in 4 (40%) patients. Of these 4 patients, 2 had clinical seizures prior to EEG onset. In addition, 1 patient had a clinical seizure prior to EEG with no subsequent electrographic seizures seen. Of the 5 patients with seizures, 3 were less than 2 years of age. Overall electrographic seizure burden was high. Only 2 of 10 patients had no cortical infarction however 1 of these patients had electrographic seizures. In comparing the group with electrographic seizures to those without, there was no statistically significant difference in the modASPECTS (median 4.5 (IQR 4) vs. 4 (9), p = 0.9239) and PedNIHSS scores (5 (9.5) vs. 14 (17), p = 0.3425).

Conclusion:
This prospective study demonstrated a high frequency and burden of electrographic seizures in young children with AIS. A larger multi-center study is warranted to define risk factors and outcome determinants with potential for recommendation regarding interventions.
Abstract TP419: Medication Adherence as a Modulator of Ischemic Stroke Recurrence in the Veteran Population - The MISTER-VA Study
Authors: Luthra Sakshi , Crossley Alexander , Butani Pooja B , Suh Hyojin C , Kamali-Grigorian Melisa , Dergalust Sunita , Liu Jeremy , Wu Naomi , Rao Neal M , Wallis Roi Ann , Hinman Jason D
Published: June 2021

Introduction:
Recurrent strokes make up 25% of the annual stroke incidence with 10% of the Veteran population suffering a recurrent stroke within 1 year. The role of adherence to a post-stroke medication regimen and its effect on stroke recurrence is unknown.

Methods:
Veterans evaluated in a vascular neurology specialty clinic from July 2010 to June 2016 underwent a detailed medical chart review and assessment of medication adherence to stroke prevention medications including anti-thrombotic use, anti-coagulants, anti-hypertensives, lipid-lowering therapy, and anti-hyperglycemic therapy. Medication adherence was measured by 90d refill history with >75% medication possession ratio (MPR) indicating adherence. A Framingham Stroke Risk Profile (FSRP) Score was calculated for each patient. Relative risk calculations were generated using a bivariate analysis and means compared via t-test.

Results:
162 of 245 patients who were newly referred to the clinic underwent a detailed chart review and medication adherence profile. In this cohort, 93.8% were male and ranged in age between 35-94 years old (mean 69.2±10.2). The mean age of first stroke was 62.9±10.5 and the frequency of recurrent stroke was 26.5% (43 patients). The median time to recurrent stroke was 2.59 years. The average FSRP score for all subjects was 0.087±0.09 and did not differ between those with or without a recurrent stroke (0.103 vs. 0.082,
p=
0.18). The rate of medication adherence in all subjects was 69.8% and differed greatly between those without and with a recurrent stroke, 79.0% vs. 44.2%, respectively. Median time to recurrent stroke was 2.59 years in those with MPR >75% and 1.91 years in those with MPR <75%. Strict adherence with a stroke prevention medication regimen was associated with a lower risk of recurrent stroke (relative risk = 0.34, 95% CI 0.21-0.57,
p
-value <0.0001) while poor adherence, was associated with a 2.91-fold increased risk (
p
-value <0.0001) of recurrent stroke in the Veteran population.

Conclusion:
In this high-risk Veteran population, strict adherence with a stroke prevention medication regimen is associated with a lower risk of recurrent stroke. Efforts to measure and encourage medication adherence in patients with prior stroke may reduce the risk of recurrence.
Abstract TP42: Association of 24-Hour Blood Pressure Parameters Post-Thrombectomy With Functional Outcomes at Discharge
Authors: Nisar Taha , Tofade Toluwalase , Liberman Ava , Khandelwal Priyank
Published: June 2021

Introduction:
Elevation of blood pressure (BP) post mechanical thrombectomy (MT) can theoretically restore cerebral perfusion to the ischemic brain tissue, but it comes at a risk of causing reperfusion injury. The ideal BP in the 24-hour range after MT has been understudied. We investigated the association of different BP parameters post-MT with the functional outcome at discharge at a tertiary care center.

Methods:
We performed a retrospective chart review of adult patients who underwent MT for an anterior circulation large vessel occlusion at a comprehensive stroke center from July 2014 to March 2018. We recorded the BP values over a period of 24-hours post-MT. A binary logistic regression analysis was performed, controlling for age, pre-thrombectomy NIHSS-scores, thrombolysis in cerebral infarction (TICI)-scores, duration to thrombectomy, with the BP parameters as the predictors. The primary outcome was the functional outcome at discharge. Good outcome was defined as a modified rankin scale (mRS) of 0-2 and a poor outcome as mRS of 3-6, upon discharge.

Results:
69 patients met our inclusion criteria. 39 (56.52%) patients were male. The mean age was 64.80±14 years. The mean pre-treatment NIHSS was 16.18±5. 22 (31.88%) patients had a good outcome (mRS≤2) at discharge. In the logistic regression model, the parameters of higher mean arterial pressure (MAP) variability like coefficient variation (CV) MAP (7.04±6 vs.3.13±5.; OR, 1.13; 95% CI,1.01-1.27; P 0.038) and standard deviation (SD) MAP (6.4±6 vs.2.75±4; OR, 1.15; 95% CI,1.02-1.31; P 0.032) were significantly associated with a poor outcome at discharge. The parameters of average systolic BP, average diastolic BP, and average MAP over 24-hours post-MT were not significantly associated with poor outcomes at discharge.

Conclusions:
Our study demonstrates a significant association between 24-hours-post-MT parameters of higher MAP variability like CV MAP and SD MAP and poor functional outcomes at discharge.
Abstract TP421: Cardiovascular Risk in Patients With Symptomatic Intracranial Atherosclerosis: A Post-Hoc Analysis of the SAMMPRIS Trial
Authors: Yaghi Shadi , de Havenon Adam , Scher Erica , Chang Andrew , Kvernland Alexandra , Dehkharghani Seena , Rostanski Sara , Ishida Koto , Torres Jose , Fernanine George , Merkler Alexander , Mac Grory Brian , Burton Tina , Cutting Shawna , Furie Karen
Published: June 2021

Introduction:
Previous studies have shown an elevated risk of MI (MI) in patients with symptomatic intracranial atherosclerotic disease (sICAD), but the mediators of increased risk of MI or death in these patients remain uncertain. We aim to determine risk factors associated with MI or death in patients with symptomatic ICAD.

Methods:
Patients enrolled in SAMMPRIS had sICAD and were randomized to aggressive medical management (AMM) vs. stenting and AMM. The primary outcome of this post-hoc analysis is MI or vascular death within 2 years of follow-up. We excluded patients who were lost to follow up, had a stroke during follow up, had non-vascular death or death within 30 days of stenting. Patients meeting the inclusion criteria were divided into two groups: those with vs. those without the primary outcome. We used binary logistic regression to determine predictors of incident MI or death within 2 years.

Results:
Of the 451 patients enrolled in SAMMPRIS, 350 patients met the inclusion criteria (reasons for exclusion: 4 deaths occurring within 30 days of stenting, 63 with ischemic stroke, 6 with symptomatic hemorrhage, 7 patients with non-cardiovascular death within 2 years, and 21 lost to follow up). At 2 years, 17 patients (4.9%) had MI/death; 10 patients had MI and 7 had cardiovascular deaths. In a multivariable model, factors associated with MI/death were: history of coronary artery disease (adjusted OR 3.19, 95% CI 1.14 - 8.93, p = 0.027) and systolic blood pressure (adjusted OR per 10 mm increase 1.20, 95% CI 0.98 - 1.44, p = 0.080). This risk was abut 24% with both predictors present and 2.8% with them absent (Figure).

Conclusion:
Higher systolic blood pressure and pre-existing cardiovascular disease were independently associated with incident MI or vascular death in patients with sICAD, despite medical management. Further studies are needed to confirm this association and test interventions to reduce this risk.
Abstract TP422: Comparison of Natural History and Effect of Intracranial Stent Placement Between Patients With Intra-Dural and Those With Sub-Arachnoid Intracranial Arterial Stenosis
Authors: Walia Sargun S , Huang Wei , Lobanova Iryna , Siddiq Farhan , French Brandi R , Gomez Camilo R , Qureshi Adnan I
Published: June 2021

Background:
Intracranial stenosis can be located in intradural or subarachnoid space. It is unclear whether there are any differences in ipsilateral ischemic stroke risk, cerebral hemorrhage and death in response to stent placement in these two locations.

Methods:
We analyzed Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) data. We divided the patients based on location of arterial stenosis: intradural [petrous internal carotid artery (ICA), pre-cavernous ICA, cavernous ICA or pre-posterior inferior cerebellar artery (PICA) vertebral artery] and subarachnoid [post-cavernous ICA, middle cerebral artery, vertebral artery at the level of or distal to origin of PICA, or basilar artery]. Cox proportional hazards analyses were used to determine the effect of intradural versus subarachnoid location on risk of ipsilateral ischemic stroke, cerebral hemorrhage or death during the follow-up period.

Results:
A total of 451 patients with stenosis located in intradural (n=74, 16.4%) or subarachnoid (n=377, 83.5 %) spaces were followed for a mean (SD) period of 29.06 (15.22) months after randomization. The rate of ischemic stroke seen in intradural and subarachnoid spaces was 11.86% and 14.58%, respectively. The rate of cerebral hemorrhage in the intradural and subarachnoid spaces was 1.35% and 2.92 %, respectively. The rate of death in the intradural and subarachnoid spaces was 10.81% and 1.59%, respectively. In Cox proportional hazards analyses, the risk of ipsilateral ischemic stroke (HR 1.08, P = 0.46), cerebral hemorrhage (HR 1.05, P = 0.59) and death (HR 0.9, P = 0.9) was not significantly different between patients with intradural arterial stenosis and those with subarachnoid arterial stenosis. The interaction between location of stenosis and treatment (intracranial stent versus best medical treatment) was not significant for the either ipsilateral ischemic stroke (p= 0.21), cerebral hemorrhage (p= 0.18) or death (p=0.15).

Conclusion:
We did not find any evidence to suggest that there was any difference in natural history or response to intracranial stent placement in patients with intradural location of stenosis compared with those with subarachnoid location.
Abstract TP424: Disparities in Secondary Stroke Prevention Practices for Atrial Fibrillation
Authors: Yarbrough Karen L , Brown Erin , Ezunagu Nneka , Gonzalez Karen , Leonard Nicole , Lu Rong , Maloney Theresa , Schrier Chad , Chaturvedi Seemant
Published: June 2021

Background:
Despite high efficacy in clinical trials for stroke prevention, oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF) remains vastly underutilized in real world practice. Earlier studies have suggested that important subgroups (elderly, women, blacks) may be especially prone to under treatment. Our objective was to examine the patterns of antithrombotic medication use following an AF-related stroke within a Stroke Clinical Network. The Stroke Clinical Network consists of nine stroke centers located in rural, suburban and urban geographical regions.

Methods:
The GWTG registry was queried (calendar years 2014-2018) to identify ischemic stroke patients discharged with AF and age, gender, race and discharge antithrombotic medications. We evaluated patterns of medication use across the entire network and also among women, elderly patients (>80 years), and blacks vs. whites. Fisher’s exact test was used to assess statistical differences between subgroups.

Results:
Among 7,483 IS patients 1,406 had a diagnosis of AF: 70% were White, 25% Black; mean age of 76.9 years (SD +/-12.25 years) with 50% women. In the entire group, the rate of OAC use at discharge was 62%, with no difference based upon sex (p=0.55). Among patients receiving OAC treatment, women had a higher rate of direct oral anticoagulant (DOAC) prescription (53% vs. 48%, p=0.049). There were differences in antithrombotic practices based on age (< 80, mean age 70 years, >80 mean age 86.9 years). In patients <80 years, 68% received OAC therapy, compared to 52% in the elderly group (p<0.0001). Black patients were younger than white patients (70 years vs. 79.3 years) and more likely to receive OAC treatment (71% vs. 60%, p=0.0003).

Conclusions:
In a geographically diverse Stroke Network, we identified that OAC treatment is underutilized following an AF-related stroke, especially in elderly patients. This analysis will provide the Stroke Clinical Network an opportunity to develop interventions to target patient subgroups with low OAC treatment rates. With the aging of the US population, innovative methods are needed to improve the rate of OAC use in elderly patients with AF.
Abstract TP426: Factors Associated With Oral Anticoagulant Non-Use for Patients With Atrial Fibrillation-Related Stroke: The Florida Puerto Rico Atrial Fibrillation Stroke Study
Authors: Sur Nicole B , Koch Sebastian , Wang Kefeng , Di Tullio Marco R , Gutierrez Carolina , Dong Chuanhui , Gardener Hannah , Garcia-Rivera Enid J , Zevallos Juan Carlos , Burgin William Scott , Rose David Z , Goldberger Jeffrey , Romano Jose G , Sacco Ralph L , Rundek Tatjana
Published: June 2021

Background:
Oral anticoagulants (OACs) for stroke prevention in atrial fibrillation (AF) are largely underutilized. We identified pre-admission OAC utilization patterns and factors predictive of OAC non-use in patients hospitalized for AF-related stroke.

Methods:
We included 22,220 patients with ischemic stroke due to previously diagnosed AF enrolled in the Florida Stroke Registry from 2010-2017. A multivariable-adjusted logistic regression model was used to identify factors associated with pre-stroke OAC use for patients with AF-related stroke.

Results:
A total of 16,246 (73%) patients with AF-related stroke were not on OAC pre-stroke. Compared to patients on OAC, non-OAC patients were more likely to be ≥80 years old, have Medicaid/no insurance, lower CHA
2
DS
2
-VASc scores and greater stroke severity at presentation. After adjustment for age, sex, race-ethnicity, insurance status and vascular risk factors, baseline OAC non-use was higher for patients with Medicaid/no insurance (vs. private insurance, (OR 1.34 [95% CI 1.08-1.67]), smokers (OR 1.29 [1.09-1.52] and patients with NIHSS ≥6 (vs. NIHSS≤5, OR 1.18 [1.11-1.26]). A trend towards greater odds of OAC non-use was seen in women (vs. men, OR 1.07 [0.99-1.14, P=0.07]).

Conclusion:
The majority of AF-related stroke patients with known AF were not anticoagulated prior to hospitalization for stroke in our study. Insurance status and smoking status had the greatest influence on pre-stroke OAC use. Anticoagulated patients had lower stroke severity on admission. Further efforts are needed to increase OAC use to reduce the burden of stroke for patients with AF, especially for vulnerable populations.
Abstract TP43: Is Unintended Hypothermia After Endovascular Therapy Associated With Improved Functional Outcome of Patients With Acute Ischemic Stroke?
Authors: Hartmann Christian , Winzer Simon , Siepmann Timo , Pallesen Lars-Peder , Prakapenia Alexandra , Moustafa Haidar , Theilen Hermann , Barlinn Jessica , Gerber Johannes C , Linn Jennifer , Barlinn Kristian , Puetz Volker
Published: June 2021

Introduction:
Hypothermia may be neuroprotective in acute ischemic stroke. Stroke patients with anterior circulation large vessel occlusion (acLVO) who receive endovascular therapy (EVT) are frequently hypothermic after the procedure. We sought to analyze whether this unintended hypothermia was associated with improved functional outcome.

Methods:
We extracted data of consecutive patients (01/2016-04/2019) from our prospective EVT database that includes all patients screened for EVT at our center. We included patients with acLVO who received EVT and analyzed recanalization (mTICI 2b-3) and complications (i.e., pneumonia, bradyarrhythmia, venous thromboembolism) during the hospital course. We assessed functional outcome at 3 months and analyzed risk ratios (RR) for good outcome (mRS scores 0-2) and mortality of patients who were hypothermic (<36°C) compared to patients who were normothermic (
>
36°C) after EVT. We compared the frequency of complications and calculated RRs for good outcome and mortality in the subgroup with recanalization.

Results:
Among 674 patients with anterior circulation ischemic stroke, 372 patients received EVT for acLVO (178 [47%] male, age 77 years [65-82], NIHSS score 16 [12 - 20]). Of these, 186 patients (50%) were hypothermic (median [IQR] temperature 35.2°C [34.7-35.6]) and 186 patients were normothermic (media temperature 36.4 [36.2-36.8]) after EVT. At 3 months, 54 of 186 (29.0%) hypothermic patients compared with 65 of 186 (35.0%) normothermic patients had a good outcome (RR, 0.83; 95%CI 0.62-1.12) and 52 of 186 (27.9%) hypothermic patients compared with 46 of 186 (24.7%) normothermic patients had died (RR, 1.13; 95%CI 0.8-1.59). This relation was consistent in 307 patients (82.5% of all EVTs) with successful recanalization (good outcome: RR, 0.85; 95%CI 0.63-1.14.; mortality: RR, 1.05; 95%CI 0.7-1.57). More hypothermic patients suffered pneumonia (37.8% vs. 24.7%; p=0.003) or bradyarrhythmia (55.6% vs. 18.3%; p<0.001). Venous thromboembolism was distributed similarly (5.4% vs. 6.5%; p=0.42).

Conclusion:
Unintended hypothermia following EVT for acLVO was not associated with improved functional outcome or reduced mortality but an increased complication rate in patients with acute ischemic stroke.
Abstract TP432: Bioavailability of Aspirin in Fasted and Fed States of a Novel Formulation of a Pharmaceutical Lipid-Aspirin Complex
Authors: Angiolillo Dominick J , Bhatt Deepak L , Cryer Byron , Lanza Frank , Dong Jin-Fei , Prats Jayne , von Chong Estela , Deliargyris Efthymios N , Marathi Upendra
Published: June 2021

Introduction:
Lifelong aspirin therapy is recommended after a TIA or stroke, but dyspeptic symptoms frequently lead to non-adherence. Clinicians often recommend that daily doses be taken with food to reduce these side effects. However, food can interfere with absorption, especially with enteric coated aspirin tablets.

Hypothesis:
We evaluated whether food interferes with bioavailability of a new, pharmaceutical lipid-aspirin complex (PL-ASA) liquid-filled capsule formulation.

Methods:
This was a randomized, open label, crossover study in 20 healthy volunteers. Participants fasted for ≥10 hours prior to randomization; if assigned to “fasting” they then received the single 650 mg dose of PL-ASA. If they were randomized to “fed”, they first ate a standard high-fat meal and were dosed 30 minutes later. After a washout period of 10 days each participant crossed over to the other arm and was again dosed with a 650 mg dose of PL-ASA. The primary outcome was the comparison of PK parameters of the primary metabolite salicylic acid (SA) between fasting and fed states.

Results:
Mean age of participants was 36.8 years and 55% were male. The primary SA PK parameters of AUC
0-t
and AUC
0-
infinity
in the fed state were within 88.7% and 88.8% of concentrations in the fasting state consistent with bio-equivalence (FDA guidance >80%). Mean peak SA concentration was about 25% lower and occurred about 1.5 hours later in the fed state (Figure).

Conclusions:
Food had a modest effect on the time required to reach peak SA concentration and on the actual peak SA levels after PL-ASA administration, but did not impact the extent of exposure (area under the curve) compared with intake in a fasting state. These data demonstrate that PL-ASA may be co-administered with food without significant variability in absorption, a recognized limitation of coated aspirin formulations.
Abstract TP434: Machine Learning for Prediction of Early Neurological Deterioration in Acute Minor Ischemic Stroke
Authors: Sung Sang Min , Kang Yoon Jung , Jang Sung Hwan , Kim Nae Ri , Lee Suk Min
Published: June 2021

Introduction:
A significant portion of patients with acute minor stroke have poor functional outcome due to early neurological deterioration (END). The purpose of this study is to investigate the applicability of machine learning algorithms to predict END in patients with acute minor stroke.

Methods:
We collected clinical and neuroimaging information from patients with acute minor stroke with NIHHS score of 3 or less. Early neurological deterioration was defined as any worsening of NIHSS score within three days after admission. Poor functional outcome was defined as a modified Rankin Scale score of 2 or more. We also compared clinical and neuroimaging information between END and No END group. Four machine learning algorithms, i.e., Boosted trees, Bootstrap decision forest, Deep learning, and Logistic Regression, are selected and trained by our dataset to predict early neurological deterioration

Results:
A total of 739 patients were included in this study. Seventy-eight patients (10.6%) had early neurological deterioration. Among 78 patients with END, 61 (78.2%) had poor functional outcomes at 90 days after stroke onset. On multivariate analysis, NIHSS score on admission (P=0.003), hemorrhagic transformation(P=0.010), and stenosis (P=0.014) or occlusion (P=0.004) of a relevant artery were independently associated with END. Compared with four machine learning algorithms, Boosted trees, Deep learning, and Logistic Regression achieved an excellent prediction of END in patients with acute minor stroke (Boosted trees: accuracy = 0.966, F1 score = 0.8 and an area under the curve value = 0.934, Deep learning :0.966, 0.8, 0. 904, and Logistic Regression : 0.966, 0.8, 0.885).

Conclusions:
This study suggests that machine learning algorithms which integrate clinical and neuroimaging information accurately predict END in patients with acute minor ischemic stroke. Further studies based on an extensive data set are needed to predict END accurately for treatment strategies and better functional outcome.
Abstract TP438: Japanese versus Non-Japanese Patients With Transient Ischemic Attack or Minor Stroke: Five-Year Risk of Stroke and Vascular Events
Authors: Uchiyama Shinichiro , Hoshino Takao , Charles Hugo , Kamiyama Kenji , Nakase Taizen , Kitagawa Kazuo , Minematsu Kazuo , Todo Kenichi , Okada Yasushi , Nakagawara Jyoji , Nagata Ken , Yamagami Hiroshi , Yamaguchi Takenori , Amarenco Pierre
Published: June 2021

Background:
We have reported 5-year risk of stroke and vascular events after a transient ischemic attack (TIA) or minor ischemic stroke in patients enrolled into the TIAregistry.org, which was an international multicenter-cooperative, prospective registry (N Engl J Med 2018;378:2182-90). We conducted subanalysis on the 5-year follow-up data of Japanese patients in comparison with non-Japanese patients.

Methods:
The patients were classified into two groups on ethnicity, Japanese (n=345) and non-Japanese (n=3502), and their 5-year event rates were compared. We also determined predictors of five-year stroke in both groups.

Results:
Death from vascular cause (0.9% vs 2.7%, HR 0.28, 95% CI 0.09-0.89, p=0.031) and death from any cause (7.8% vs 9.9%, HR 0.67, 95% CI 0.45-0.99, p=0.045) were fewer in Japanese patients than in non-Japanese patients, while stroke (13.9% vs 7.2%, HR 1.78, 95% CI 1.31-2.43, p<0.001) and intracranial hemorrhage (3.2% vs 0.8%, HR 3.61. 95% CI 1.78-7.30, p<0.001) were more common in Japanese than non-Japanese patients during five-year follow-up period. Caplan-Meyer curves at five-years showed that the rates of stroke was also significantly higher in Japanese than non-Japanese patients (log-rank test, p=0.001). Predictors for stroke recurrence at five years were large artery atherosclerosis (HR 1.81, 95% CI 1.31-2.52, p<0.001), cardioembolism (HR 1.71, 95% CI 1.18-2.47, p=0.004), multiple acute infarction (HR 1.77, 95% CI 1.27-2.45, p<0.001) and ABCD
2
score 6 or 7 (HR 1.96, 95% CI 1.38-2.78, p<0.001) in non-Japanese patients, although only large artery atherosclerosis (HR 3.28, 95% CI 1.13-9.54, p=0.029) was a predictor for stroke recurrence in Japanese patients.

Conclusions:
Recurrence of stroke and intracranial hemorrhage were more prevalent in Japanese than non-Japanese patients. Large artery atherosclerosis was a predictor for stroke recurrence not only in non-Japanese patients but also in Japanese patients.