bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P246: Mode of Arrival for Acute Stroke Patients Directly Impacts Emergency Care Delivery
Authors: Arnold Kelly L , McDaneld Logan , Deprey Mary Jo
Published: March 2022

Background:
Tissue plasminogen activator (tPA) administration is very time sensitive with an odds ratio of a good outcome that is inversely proportional to time from onset to tPA administration. Extensive systems have been put in place to ensure rapid delivery of tPA in emergency medical systems, but little data exists evaluating the success of these systems for patients who arrive via Emergency Medical Services (EMS) vs. private vehicle. This study evaluates this issue using data from a single institution.

Purpose:
The purpose of this study is to gather data on process differences between acute stroke patients arriving via EMS vs. private vehicle and show how the data is utilized to identify areas for improvement in patient care delivery.

Methods:
Data was collected on 138 consecutive acute stroke patients, encompassing patient mode of arrival, as well as time to stroke alert activation, order entry, CT completion, lab results, and where applicable, telemedicine activation and tPA administration. This data was analyzed to evaluate for differences in performance of the stroke alert process based on mode of arrival.

Results:
Overall, the stroke alert process performed better for EMS patients than for patients arriving via private vehicle.

Conclusions:
Statistically significant differences were found between EMS and private vehicle arrival, with far better process performance seen for EMS patients. The delays in care occur initially in the activation of the stroke alert, then are continued throughout the process of care after the stroke alert has been called. In conclusion, recognition that processes do not perform equally in all situations is important in system design, and rigorous performance monitoring is paramount to ensure optimal care of all patients through performance improvement activities.
Abstract T P250: The Impact of a Stroke Navigator in Decreasing Readmission Rates
Authors: Eudy Andrea , Mesler Joan , Vasudevan Arvind , Sombutmai Chut , Reid Angela , Leahy Lindsay
Published: March 2022

Background and Purpose:
Stroke continues to be the third leading cause of death in the United States and the leading cause of adult disability. A recent study published in
Stroke
looked at preventable readmission rates among Medicare beneficiaries with ischemic stroke. The study concluded that there is merit in looking at older age individuals, previous MI, CHF and diabetes as all of these are strong predictors of preventable readmissions. Stroke survivors often lack stroke specific education and continuity of care post discharge, resulting in unnecessary readmission to the hospital. Furthermore, stroke survivors often express the need for more information about stroke and risk factor management. The stroke navigator role is a transitional care role that was implemented to build relationships with patients while in the hospital, by providing stroke specific education, and continuing the relationship post discharge and during follow up care in a secondary stroke prevention clinic. The purpose of this study was to determine the efficacy of the navigator role in decreasing 30 day all cause readmission rates.

Methods:
A retrospective review of the arithmetic observed vs. expected (O/E) all cause readmission rates for all ischemic strokes was analyzed 5 months prior and 5 months following implementation of the navigator role.

Results:
Significant improvements in 30 day all cause readmission rates were found during the 5 months following implementation of the navigator role. The average O/E rate for the 5 months prior to implementation of the navigator role was 1.36 (14.05% observed readmission rate). The average O/E after navigator implementation dropped to 0.68 (6% observed readmission rate).

Conclusions:
Implementation of the stroke navigator role showed improvement in 30 day all cause readmission rates. The decline in readmissions may be due to increased stroke education, understanding of risk factor management, which may enhance compliance to treatment, and close follow up by the stroke navigator, which may identify and prevent complications requiring readmission.
Abstract T P254: Bedside Video Transfer Report: National Institutes of Health Stroke Scale (NIHSS)
Authors: Pullano Michele , Stack Laura E
Published: March 2022

Background:
Transition of the stroke patient from acute care to rehabilitation requires detail focus to ensure high quality consistency of care. Standard transfer report includes phone report; excluding the patient and visual representation of NIHSS. Dual neurological exam is the standard of practice between every registered nurse (RN) hand-off of the stroke protocol patient in our acute care institution. The current challenge is bridging this practice gap between acute care and rehabilitation phases. Additional clinical challenges include readmission rates, patient expectations, NIHSS expertise sharing, and communication.

Purpose:
The purpose is to increase coordination of care of the acute stroke protocol population, between the acute care and rehabilitation RNs. The goal of a live stream bedside video report is to provide real-time visual assessment of a patient’s neurological status prior to transfer. Visual representation of neurological function allows providers to rapidly identify a change in patient status. The ultimate goal is to narrow the acute care discharge to post-acute admission NIHSS range as well as decrease readmission rates.

Methods:
The acute care RN notifies the rehabilitation RN a patient is prepared for transfer. The RNs establish a video connection at the bedside, introduce the receiving RN, explain what to expect through transition, provide a brief SBAR report, followed by the completion of the NIHSS. Upon arrival to the rehabilitation hospital the receiving RN completes the admission NIHSS as an initial component of assessment. The RN will be able to confirm the stability of the patient’s neurological function, establishing an accurate stable baseline admission status.

Results:
The video report was successful in establishing a well communicated/visualized neurological status, and narrowing the gap between NIHSS. The patient’s apprehension towards transfer was minimized; questions were addressed prior to transfer.

Conclusions:
In conclusion, video report with visualization of neurological status and NIHSS exam allows care providers to receive a patient, confidently assess and verify stability of neurological function; increasing the ability to make informed care decisions impacting the stroke patient.
Abstract T P262: Door to Needle Times Reduced With Enhanced Brain Attack Activation
Authors: Barbera Charles , Marks Timothy , Martin Anthony , Sandel Kristen , Bilotta Mary
Published: March 2022

Background:
Current guidelines for care of the acute stroke patient demonstrate that the benefits of tissue plasminogen activator (tPA) are time dependent and recommend it be given within 60 minutes from arrival to the Emergency Department (ED).

Hypothesis:
Door to tPA times would be reduced by using a multidisciplinary approach to acute stroke patients and by transporting them directly to the CT scanner.

Methods:
The community hospital restructured its Brain Attack process after creating a Door to Needle team to evaluate and expedite the care of the acute stroke patient. This multidisciplinary team was assembled in order to plan, implement, and study the new Brain Attack alert process. The team is activated via a touchscreen in the ED, many times prior to patient arrival. Stable patients who do not require airway intervention are taken directly to a newly renovated CT scan anteroom for initial assessment, point of care anticoagulation testing, and initial NIH stroke scale. In addition, education concerning the new process, as well as acute stroke care in general was presented to 35 local EMS services by emergency physicians and an EMS outreach coordinator.

Results:
In July of 2012, 54 Brain Attacks were evaluated with a median door to CT time of 41 minutes and door to CT interpretation time of 51 minutes. The new Brain Attack process was implemented on December 3, 2012. During the first month of the new process, 51 Brain Attacks were evaluated with median door to CT time of 28 minutes and door to CT interpretation time of 38 minutes. This represents a decrease in time to CT acquisition and interpretation of 13 minutes. tPA was given to 4 patients in July 2012 with only one patient (25%) receiving the medication in <60 minutes. In December, 4 patients received tPA, 3 (75%) within the 60 minute window.

Conclusions:
Patients who received tPA were treated more expeditiously after implementation of the restructured activation process. 75% of tPA patients were treated within the 60 minute timeframe as recommended by current guidelines. EMS also provided extremely positive feedback concerning the education and restructured Brain Attack activation.
Abstract T P263: Nursing Leadership Teach-Back Initiative Improves Stroke Patient Satisfaction Scores
Authors: Fussner Julie M , Supan Erin , Sindelar Danielle , Murphy Christopher , Smith Natalie , Kuzma Edward
Published: March 2022

Introduction:
The purpose of this project is to improve stroke patient and family knowledge of secondary stroke prevention and improve satisfaction scores at University Hospitals Comprehensive Stroke and Cerebrovascular Center (UHCSCC) using the Teach-Back process for patient education. The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey, the national, standardized publicly reported survey of patients’ perspective on hospital care, was used to evaluate the effectiveness of the project.

Methods:
Nursing leadership from the Stoke unit and the Neuroscience ICU developed a discharge Teach-Back checklist for stroke patients. The checklist included the following topics: Risk factors, Signs and Symptoms, EMS activation, Medications, Follow up, Diet, Smoking cessation, Medication compliance and Rehab plans or home care assistance. For a 6 month period on the day of discharge, one of the nursing leaders met with each patient and/or family to assess and reinforce their level of understanding on all of the topics on the checklist. The leader verified that the patient and family had viewed the stroke education video, had been given the appropriate written materials and answered any questions.

Results:
To assess the effectiveness of this initiative three questions on the HCAHPS survey were used: “How often did nurses explain things in a way you could understand?” “How often did the hospital staff tell you what the new medicine was for?” And “Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” The survey response “Always” increased from 73% to 82% for nursing explanations in an understandable manner and from 71% to 91% for staff explanations of new medications. The survey response “Yes’’ increased from 75% to 92% for staff explanations of symptoms or problem to look for.

Conclusions:
Publicly reporting of HCAHPS results creates incentives for the hospitals to improve quality of care. At UHCSCC stroke patient satisfaction scores improved with the Teach-Back project conducted by the nursing leadership team.
Abstract T P265: Optimizing Team Expertise to Improve Door to Drug Times for Ischemic Stroke
Authors: Sorenson Denise , Raynor Randi B
Published: March 2022

Background and Purpose:
Presbyterian Medical Center (PMC) utilized a multi-faceted team approach in 2012 to reduce door to t-PA times for eligible ischemic stroke patients and achieved a median door to drug time of 55 minutes. In 2013 the team set a new goal of a median door to drug time of 50 minutes. One of the barriers identified by team members was unavailability of t-PA at the bedside, and the team took on the challenge of finding solutions to overcome this obstacle with the support of medical and administrative leadership.

Methods:
The team outlined a collaborative process using the Plan Do Study Act model recommending that Pharmacists respond to ED Code Stroke pages with a t-PA tackle box and mix t-PA at the bedside. Concerns with this process included inappropriate utilization of resources and time away from the pharmacy, especially during off-shifts. Advantages included bedside expertise and optimization of patient safety. The team agreed to pilot the process for the first 9 cases (30% of 2012 t-PA cases). The pilot process included 2-way team feedback, recognizing responder pharmacists, and celebrated door to drug time times under 40 minutes with a Target Stroke certificate.

Results:
On the first day of implementation there were two simultaneous Code Stroke patients in the ED, and two pharmacy teams responded. One patient was deemed by the Stroke Neurologist to be a t-PA candidate, and had a door to drug time of 37 minutes. Pharmacists felt engaged in the process and respected by the team. After the first nine cases, the median door to drug time was reduced by 32.7% to 37 minutes (from 55 minutes in 2012), and the current “best time” is 19 minutes. Responding pharmacists were surveyed and all agreed or strongly agreed that the new process has made a significant improvement in the care of acute stroke (4.5 / 5 Likert Scale).

Conclusions:
These results validated the efforts of the PMC stroke team to further refine t-PA processes to achieve optimal outcomes for acute stroke patients treated at our facility. Through this new process our stroke team responders have become increasingly competitive regarding timely stroke care, opening new avenues to improve median door to drug times even further.
Abstract T P295: Identifying Unmet Needs 30-days Following Ischemic Stroke: The Post Stroke Checklist
Authors: Morrison Kathy , Reichwein Raymond K , Chinchilli Vernon M , Graybeal John M , Vonhauser Julie M , Feng Xue , Good David C
Published: March 2022

Background:
Stroke care often focuses on acute intervention and treatment, but important long-term sequelae are sometimes overlooked and may not be captured in standard outcome measures.

The Post Stroke Checklist (PSC) is a simple tool recently developed by a global panel of stroke experts to identify the unmet needs of stroke survivors. It consists of 11 items addressing a variety of important medical, functional and social issues. The intent is to improve stroke survivor follow-up and ensure that treatable complications are identified and referred for treatment.

Methods:
The PSC was administered at 30 days post ischemic stroke in 126 recently hospitalized patients in the outpatient clinic of a Comprehensive Stroke Center. Items were originally scored by a nurse and reviewed with a stroke physician. Age range (median) was 31-97 (68) years. All patients were also scored with Barthel Index (BI), NIH Stroke Scale (NIHSS), and modified Rankin Scale (mRS) during the clinic visit. Actionable items were identified by positive responses to any question on the PSC. The number of patients with actionable items was tabulated.

Results:
The median (range) BI was 100 (10-100), NIHSS was 1 (0-28), and mRS was 1 (0-4). The PSC identified actionable items in 79/124 (64%) patients. In 39/79 (49%) patients, more than one actionable item was identified. The most common items were depression/anxiety 32 (26%), cognitive dysfunction 28 (23%), decreased ability to perform instrumental ADL’s 18 (15%), and any new pain 13 (10%). All other items were scored positively in less than 10% of patients. The PSC was judged acceptable by both stroke professionals and patients, who felt the items on the PSC identified important issues that otherwise, may have been overlooked in a clinic setting.

Conclusions:
The PSC proved to be a useful tool at 30 days to identify important unmet needs in stroke survivors with mild deficits. The next step in this research is to evaluate patients at 90 days post stroke, when a larger range of deficits is expected.
Abstract T P296: Diagnostic Testing in Acute Stroke Patients- The Weekend Waiting Game
Authors: Mathias Sally V , Lee Jessica D
Published: March 2022

Background:
Inpatient hospital stays contribute considerable costs to our total healthcare expenditures in the US. Increased lengths of stay can lead to increased costs. At the University of Kentucky, there appears to be delays in care in patients admitted over the weekend compared to those who are admitted during weekdays, due to availability of certain testing, such as MRI and transthoracic echocardiogram. This may lead to delays in delivering appropriate care, increase in length of stay, and possibly costs.

Methods:
We retrospectively reviewed charts for patients admitted to the University of Kentucky Chandler Medical Center between September to November 2012. Patients were divided into two groups based on the day of the week tests were ordered. Group 1 included patients on whom MRI or echocardiogram was ordered between Monday through Thursday. Group 2 included patients on whom tests were ordered Friday through Sunday. Results were compared using the two sample t-test.

Results:
A total of 275 MRIs were performed on stroke patients. For Group 1 (n=168) procedures, mean time to completion was 13.2 hours +/- SD 12.6. For Group 2 (n=97), the mean time to completion was 20.7 hours +/- SD 19.5 (p=.002). A total of 272 echocardiograms were performed. For group 1 (n=171), mean time to completion was 17.4 hours +/- SD 11.2. For Group 2 (n=97), the mean time to completion was 33.4 hours +/- SD 21.6, (p<.0001).

Conclusion:
There was a 57% increase in the time needed to complete MRI and 92% increase in the time needed to complete echocardiogram when it was ordered on the weekend. This represents a significant delay in care and may impact lengths of stay. The hiring of additional MRI and echocardiogram technicians could reduce delays in patient care and lengths of stay. This in turn may reduce costs for both patients and the system.
Abstract T P299: Effects of Quality Improvement Initiative on Time to Intra-Arterial Therapy in Acute Ischemic Stroke
Authors: Holmes Stephanie E , Conners James J , Cutting Shawna , Song Sarah Y , Chen Michael , Lopes Demetrius , Moftaker Roham , Keigher Kiffon , Stark-Riemer Wendy , Diebolt Elizabeth , Toll Valerie , Lee Vivien H
Published: March 2022

Background:
Acute stroke treatment is recognized to be time dependent. We sought to assess the effects of a quality improvement (QI) initiative called “Stroke60” on reducing time to intra-arterial therapy (IAT) for acute ischemic stroke patients transferred from an outside hospital to an academic center.

Methods:
We reviewed acute ischemic stroke transfer patients who underwent attempted IAT for suspected large vessel occlusion. The time to IAT (tIAT) was defined as time from arrival at our institution to groin puncture. Stroke60 QI protocol entailed early notification of parallel service lines prior to patient arrival. We compared 2 cohorts of patients: pre-Stroke60 (January 1, 2010 to May 1, 2012) and post-Stroke 60 (May 1, 2012 to August 1, 2013). We collected data on demographics, National Institutes of Health Stroke Scale (NIHSS), frequency of neuroimaging (CT, CT angiogram/perfusion, or MRI brain) prior to IAT, and tIAT.

Results:
Seventy-nine transfer patients underwent urgent cerebral angiogram for acute ischemic stroke (52 pre-Stroke60, 27 post-Stroke60). The mean age was 60.5 (range, 17 to 84 years) and the mean NIHSS was 19.5. Comparing post-Stroke60 with pre-Stroke60, there was no significant difference in age (p= 0.1), gender (p= 0.2), race (p= 0.8), or NIHSS (0.7). Stroke60 implementation resulted in a reduction of mean tIAT by 18 minutes (52.7 vs. 34.3 min, p= 0.04). Among the entire cohort, 25% (20/79) underwent neuroimaging prior to IAT. Neuroimaging prior to IAT was associated with increased delay of mean tIAT (74 min vs. 37 min, p= 0.0001). The post-Stroke60 cohort was more likely to have imaging prior to IAT compared to the pre-Stroke60 cohort (10% vs. 56%, p< 0.0001).

Conclusion:
Despite being associated with an increased use of imaging from 10% to 56%, the “Stroke60” QI initiative was associated with a significant reduction in tIAT for acute ischemic stroke transfer patients. Further studies aimed at improving time to acute stroke therapies are warranted.
Abstract T P308: Re-assessment of Lipid Profiles in Stroke Patients Post-hospital Discharge - Room for Improvement
Authors: Phelan Michael P , Katzan Irene , Schold Jesse , Sharp John , Procop Gary W
Published: March 2022

Introduction:
According to guidelines patients receiving a lipid-lowering agent at discharge for stroke should receive follow-up lipid profile. Our measure takes the currently collected STK-6, one step further and tries to identify whether these patients receive follow-up lipid testing by comparing non-abstracted electronic health record data to abstracted data.

Methods:
Data was extracted from the Cleveland Clinic EMR (Epic Systems, Inc.) utilized by the Cleveland Clinic Health System (10 hospitals and 16 family health centers). The cohort was based on patients with an admission for stroke from 2008 to 2012 utilizing STK-6 criteria. We examined this cohort for whether they received a lipid panel within the 12 months after the discharge date and limited patients to those that received follow up encounters at our healthcare system. Demographic factors including age, gender, race, ethnicity, distance to hospital, primary diagnosis for hospitalization and presence of comorbid conditions were also extracted. This data was compared to our abstracted publically reported STK-6 data which comes from claims data.

Results:
Of the 508 patients included in results for STK-6 reporting, only 391 (77%) were also identified through the EMR. Of these, 274 patients had follow up at least one year within the healthcare system. Only 97(35%) patients had lipid panel lab results indicated in the EMR within one year of discharge. Testing was not statistically different based on patient characteristics: patients < 70 yrs vs 70+ (37% vs 30%, p=0.27), whites vs non-whites (35% vs. 36%, p=0.93), males vs. females (39% vs 30%, p=0.12). There was no significant difference in distance to the hospital from patients primary residence either between those without and with follow up lipid testing (mean distance=39 miles vs.17 miles, p=0.22).

Conclusions:
Follow up lipid testing following stroke discharge is not consistently performed among patients treated at a large healthcare system. There are not any highly significant differences in testing based on patient demographic characteristics or distance to the hospital. Further understanding of the reasons for poor follow up testing is required as well as evaluating concordance of the data pulled from the EMR when compared to abstracted data.
Abstract T P310: The Acute Carotid Clinic: A Paradigmatic Shift to Facilitate Reduced Wait Times for Carotid Artery Stenting in Ontario
Authors: Turkel-Parrella David , Manoel Airton L , Marotta Thomas R , Montanera Walter , Sarma Dipanka , Bharatha Aditya , Kaderali Zul , Weeks Adrienne , Effendi Khaled , Ben-Israel David , Spears Julian
Published: March 2022

Introduction:
North American guidelines on stroke prevention recommend carotid artery revascularization for symptomatic carotid disease within 2 weeks of the index event. Achieving this benchmark has proven historically challenging in the context of the universal coverage afforded by the Ontario Health Insurance Plan (OHIP), which is the sole provider of healthcare in Ontario (approximately 13.5 million people). Recent literature has indicated that wait times for carotid revascularization are unacceptably high. We sought to examine how the implementation of a dedicated Acute Carotid Clinic (ACC) in a Canadian academic stroke center would impact this public health dilemma.

Methods:
Retrospective analysis was preformed on 48 consecutive patients with symptomatic carotid artery disease who underwent endovascular treatment (carotid stenting) via the Acute Carotid Clinic’s expedited evaluation process over a 13-month period (July 2012 to July 2013). All patients were triaged based on direct physician referral with concurrent vascular imaging demonstrating high-grade carotid stenosis in the appropriate vessel. Patients were not placed on wait lists, and seen urgently.

Results:
The average time from consultation to revascularization was under 1 week (mean time 6.7 days). Historical controls of average wait times in Ontario for Carotid Endartarectomy have been previously published at 25.7 days. The percentage of patients who achieved revascularization within 2 weeks of the index event was 38%. Previously published series from Ontario for Carotid Endartarectomy showed 8 to 30% of patients were revascularized within 2 weeks of the index event.

Conclusion:
The paradigm of an Acute Carotid Clinic could allow for the rapid triage, assessment, and treatment of symptomatic carotid disease for the 13.5 million residents of Ontario. Adoption of this paradigm by other centers in Ontario could significantly reduce the burden of cerebrovascular disease in the province. Further research and government wide initiatives could be aimed at increasing the awareness of referring physicians to this expedited evaluation process.
Abstract T P314: Hemorrhagic Stroke Model to Predict In-House Mortality: A Single Center Cross-Validation Study
Authors: Yan Sandra , Camacho Elvis , Bruce Samuel , Kellner Christopher , Claassen Jan , Schmidt Michael , Connolly Edward
Published: March 2022

Background:
Although hemorrhagic strokes have high mortality rates, few models attempt to predict outcomes post ictus. A 2013 study by Smith and colleagues in JAHA used a national database to develop a risk score for predicting in-hospital mortality rates for stroke patients, assigning weighted point values to demographic and clinical variables based on a logistic regression model. We assessed the hypothesis that this risk score could be applied to a hemorrhagic population at a single tertiary center.

Methods:
The full cohort of 1872 patients consisted of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) patients admitted to a single tertiary center and enrolled into two separate prospective databases. There were 1560 consecutive patients enrolled in the SAH database between 1996 and 2013, and 312 consecutive patients enrolled in the ICH database between 2009 and 2013. Receiver operating characteristic analysis was performed on the entire cohort and subsets of SAH and ICH patients, and area under the curve (AUC) and 95% confidence intervals (CI) were generated. The analysis was repeated using only the combined age and admission National Institutes of Health Stroke Scale (NIHSS) components of the score. Delong’s test was used to compare AUCs.

Results:
The AUC and 95% CI for the overall cohort with the entire inclusion criteria was 0.89 (0.87-0.91), compared to 0.86 from the original study. Limited to ICH only and SAH only, the AUCs and 95% CIs were 0.90 (0.87-0.93) and 0.89 (0.86-0.91), respectively, compared to 0.82 and 0.89, respectively, in the original study. The combined age and NIHSS score alone had AUCs and 95% CIs of 0.89 (0.87-0.91), 0.90 (0.86-0.93), and 0.88 (0.86-0.91) for the overall cohort, ICH only, and SAH only, respectively. These AUCs were not significantly different from those associated with the total risk score.

Conclusions:
The risk score demonstrated outstanding discrimination for in-hospital mortality in this cohort. The combined age and NIHSS components alone showed similarly outstanding discrimination for in-hospital mortality, and held the added benefit of increased ease of calculation. Further studies are needed to assess the utility of this risk model in other populations.
Abstract T P317: Diagnostic Imaging Performed in TIA Patients Identified in the Emergency Department: Frequency, Yield and Relationship to 90-Day Outcomes
Authors: Nasiri Mojdeh , Oostema John A , Brown Michael , Pratt Jacob , Reeves Mathew J
Published: March 2022

Introduction:
Patients who present to the Emergency department (ED) with transient ischemic attack (TIA) receive a wide variety of imaging tests. We describe the use, yield, and prognostic implications of diagnostic imaging undertaken in a cohort of TIA patients.

Methods:
Patients with a high clinical suspicion of TIA were prospectively identified over a 12 month period in 4 community-based EDs. A TIA diagnosis was confirmed following independent physician review. Chart data were abstracted and 90-day outcomes (incident stroke, recurrent TIA, cardiovascular-related hospitalization, or death) were collected at telephone follow-up. Relative risk (RR) and 95% confidence intervals (CI) were used to quantify the association between test results and outcomes.

Results:
Of 336 confirmed TIA patients, 319 (95%) had 90-day follow up data. The mean age was 66, 46% were male, 32% non-white, and 74% were hospitalized. Overall, 15% had a 90-day outcome event. Nearly all patients (98%) received brain imaging (CT and/or MRI) (Table). An acute or sub-acute infarct was identified in 4.2% of CT and 17.9% of MRI studies. Carotid artery imaging (Doppler, CTA, or MRA) was performed in 87% of patients, and stenosis >50% was found in 17%. Echocardiography (TTE and/or TEE) was performed in 66% of cases and identified potential cardioembolic sources in 12%.

Acute or sub-acute infarction on brain imaging and stenosis >50% on carotid imaging were both significantly associated with 90-day outcomes, but cardioembolic sources on echocardiography were not (Table). There was a trend towards positive MRA or Doppler studies being more strongly associated with 90-day outcomes (RR= 2.13 and 1.92, respectively) than CTA (RR= 1.16).

Conclusion:
In this TIA cohort, brain, carotid artery, and cardiac imaging were all frequently acquired. Acute or sub-acute brain infarction and carotid artery stenosis were both associated with adverse outcomes at 90 days, whereas echocardiography was not.
Abstract T P319: Reducing Health Disparities for African-American Men: Under-Recognized Factors in Stroke Recovery
Authors: Blixen Carol , Perzynski Adam , Moore Shirley , Sila Cathy , Pundik Svetlana , Smyth Kathleen , Tatsuoka Curtis , Sajatovic Martha
Published: March 2022

Introduction:
African-Americans (AA) have double the stroke rate, are younger and have more post-stroke complications than other Americans. There is a need for approaches that improve outcomes for AA stroke survivors. Unfortunately, little is known about which approaches are acceptable and effective for this high risk group.

Objectives:
To identify salient and modifiable barriers to post-stroke care among young (<age 65) AA men and members of their immediate social support network. Results informed refinement of a stroke recovery intervention for AA men.

Methods:
Ten AA stroke survivors and their care partners (CPs) (n=7) participated in focus groups and advisory board meetings. Survivors had stroke or transient ischemic attack within the past year, were community-dwelling, and had a Barthel ADL Index >60. Focus groups conducted with a semi-structured interview guide identified self-perceived barriers and facilitators to care among AA men and their CPs. Group interviews were conducted until theoretical saturation occurred. Thematic analysis of audio-recorded and transcribed sessions and the constant comparative method were used to generate constructs (themes).

Results:
Survivor mean age was 53 (range=34-64 years). Mean Barthel was 95.5 (SD=7.6). CPs were all AA women, mean age of 54 (range=49-61). Five CPs were wives (n=5) while others were fiancée (n=1) and niece (n=1). Participants cited multiple personal, social, and societal challenges to stroke recovery. While hypertension and smoking risks were acknowledged, psychological factors (stress, depression, PTSD, anger/frustration, change in personal identity, and communicating their own unique needs as AA men), were the most frequently noted barriers. Facilitators included family support, stress reduction and moderation of dietary habits.

Conclusions:
Biological risk reduction education may not capture all salient aspects of health management for AA stroke survivors. Men in this study identified psychological self-management barriers as critical impediments to good health outcomes. Incorporation of these factors into stroke care may help reduce health disparities for minority men.
Abstract T P320: Echocardiographic and Clinical Parameters Associated with Adverse Long-Term Outcomes in Non-Hemorrhagic Stroke Patients: Prediction Model Development and Validation.
Authors: Arora Jaspreet , Murthy Avinash , Arora Jaspreet , Du Le , Bulibek Batyrjan , Cagino Leigh , Khawaja Hussian , Torosoff Mikhail
Published: March 2022

Background:
and hypothesis: We sought to develop and validate the long-term non-hemorrhagic stroke outcome prediction model based on demographic, clinical, and echocardiographic parameters.

Material and Methods:
Univariate and multivariate logistic regression modeling of long-term survival based on demographic, clinical, and echocardiographic data was performed in 325 consecutive non-hemorrhagic stroke subjects (original cohort). ANOVA, chi-square, Kaplan-Meier, and logistic regression tests were employed. Prediction rules were developed and applied to 1305 patients (validation cohort). The study was approved by the institutional IRB.

Results:
Only age (hazard ratio 1.6 per decade over 40 years old, 95%CI 1.3-2.2, p<0.001), renal failure (hazard ratio 6.2 95%CI 24.3, p<0.001), and aortic root sclerosis (hazard ratio 2.9 95%CI 1.4-5, p=0.004) were associated with increased all-cause mortality in univariate and multivariate logistic regression analyses. Based on the hazard ratios, risk score was developed with 2 points given for each decade of age over 40 years old, 6 for renal failure, and 3 for aortic root sclerosis. Long-term mortality was compared between 3 groups: low risk (0-5 points), moderate risk (6-10 points), and high risk (more than 11 points).

In the original cohort, Kaplan-Meier mean survival estimates were 60+/-1.4 months in low risk, 45+/-2.2 in moderate risk, and 37.4+/-3.3 months high-risk groups (p<0.001). In the validation cohort, Kaplan-Meier mean survival estimates were 53+/-0.8 months in low risk, 47+/-1.3 in moderate risk, and 33+/-2.1 months high-risk groups (p <0.001). When renal function was removed from the analysis, age and aortic root sclerosis still successfully identified patients with poor long term outcomes: 53+/-0.8 months in low risk, 47+/-1.3 in moderate risk, and 34+/-2.4 months high-risk groups (p <0.001).

Conclusions:
In non-hemorrhagic stroke survivors, long-term prognosis can be predicted with prospectively validated model based on age, presence of aortic root sclerosis, and renal dysfunction. Using such simple, readily available model may help the clinician to identify this high-risk patient group with adverse outcomes, enabling appropriate management and resource utilization.
Abstract T P321: Perinatal Stroke in the Canadian Cerebral Palsy Registry: Disease-Controlled Risk Factor Analysis
Authors: Williams Elizabeth , Oskoui Maryam , Dagenais Lynn , Shevell Michael , Kirton Adam ,   Canadian CP Registry Investigators
Published: March 2022

Objective:
Perinatal stroke causes most hemiparetic cerebral palsy (CP). Pathophysiology is usually idiopathic with few case-control risk factor studies. Comparisons to related disease states have not been done in perinatal stroke and may provide unique insight. The Canadian CP registry (CCPR) is multi-regional and population-based with imaging results and >70 risk factor variables. We hypothesized that CCPR perinatal stroke could be defined with distinct risk factor profiles within CP populations.

Methods:
The CCPR enrolls children with CP across 13 Canadian centres. Systematic chart reviews and parental interviews acquire standardized data on >150 variables including risk factors and imaging. Data current to June 2013 was extracted (RedCAP) and analyzed (SPSS). Imaging reports for hemiparetic CP cases were classified as: (1) definitive stroke, (2) probable stroke, (3) not stroke (alternate diagnosis), or (4) inconclusive. Risk factor variables were compared between definitive stroke and two disease control groups: (1) hemiparetic CP, not stroke and (2) all other CP. Univariate analysis (Chi-Square, t-test) informed multivariate logistic regression (associations expressed as odds ratios, 95% confidence intervals).

Results:
At extraction, 1168 children were enrolled (57% male, median 42±23mos). Hemiparetic was the single most common CP phenotype (323, 28%). Definitive perinatal stroke was common (158, 49%) compared to definitively not stroke (109, 34%). Strokes were arterial (103, 66.6%) or venous (52,33.3%). Comparing stroke to non-stroke hemiparetic CP found seven univariate associations but none persisted on multivariate analysis. Comparing stroke to other CP types, the following factors were independently associated with stroke: preeclampsia (2.35;1.11-4.95;p=0.025), prematurity (0.165;0.093-0.293; p<0.001), maternal drug use (5.03;2.05-12.35;p<0.0001) and possibly male gender (1.47;0.997-2.19;p=0.058).

Conclusions:
Perinatal stroke can be examined within CP registries. Disease-specific risk factors may include previously (male gender) or inconsistently (preeclampsia) reported associations and novel factors (maternal drugs). Disease-controlled approaches may inform perinatal stroke pathogenesis.
Abstract T P322: In-hospital Outcomes of Acute Ischemic Stroke in the Pediatric Population
Authors: Nasr Deena , Rabinstein Alejandro , Brinjikji Waleed
Published: March 2022

Objective:
To determine trends in tPA utilization, treatment outcomes and predictors of mortality for pediatric patients with acute ischemic stroke.

Materials and Methods:
Using the Nationwide Inpatient Sample (NIS) from 2001-2010, pediatric patients (age < 18 years) with the primary diagnosis of ischemic stroke were identified. We studied time trends of utilization of intravenous rtPA and outcomes after thrombolysis. We also analyzed the associations of demographic factors, comorbidities, and complications of acute ischemic stroke with in-hospital mortality.

Results:
A total of 7,379 patients were included in this study. In-hospital mortality was 4.5%. The co-morbidities associated with the highest rates of in-hospital mortality were mitochondrial disorders (19.5%, P<0.0001) and hypercoagulable states (10.9%, p<0.0001). The main complications associated with increased mortality were intracranial hemorrhage (19.9%, p<0.0001), sepsis (13.2%, p<0.0001) and pneumonia (9.3%, p=0.0007). tPA utilization rate was 1.3% (99 patients). tPA utilization increased from 0.9% of patients in 2001-2005 to 1.9% of patients in 2006-2010 (P<0.0001). While patients who received tPA did not have higher mortality rates than non-tPA patients (0.0% versus 5.5%, P=0.06), there was an increased discharge-to-long-term-facilities rate in the tPA group (50.8% versus 12.1%, P<0.0001).

Conclusion:
Acute ischemic stroke in the pediatric population is associated with a higher mortality rate when related to mitochondriopathies or hypercoagulability. Patients suffering complications such as intracranial hemorrhage, sepsis and pneumonia have higher mortality. rtPA utilization is increasing in pediatric patients with acute ischemic stroke. Pediatric patients receiving tPA have a low risk of fatal hemorrhage. Although patients receiving rtPA have higher rates of morbidity, this may be related to worse stroke severity in these cases.
Abstract T P325: Parental Knowledge in Childhood Arterial Ischemic Stroke
Authors: Stojanovski Belinda , Donnan Geoffrey A , Monagle Paul T , Churilov Leonid , Mosley Ian , Mackay Mark T
Published: March 2022

Objective:
Recognizing stroke symptoms and taking appropriate action are vital first steps in stroke care in adults but data are lacking in children. Our objective was to describe stroke knowledge and care seeking behaviour in parents of children presenting to the Emergency Room with stroke.

Methods:
Structured parental interview to determine stroke symptom knowledge. Event driven process modeling and value focused engineering were used to select questions with the fundamental objectives being correct recognition of stroke symptoms and correct action (call 911). The Stroke Action Test (STAT), a validated instrument with stroke scenarios was used to determine care seeking behaviour; 21 items are stroke specific. The correct response is to call 911.

Results:
A total of 34 parents were interviewed. The most common unprompted stroke symptoms given were limb (94%) or face weakness (78%) and speech disturbance (66%). 14 (41%) of parents remembered at least one item of the Face Arm Speech Time (FAST) acronym. 8 (24%) could remember all 4 items. Prompted recognition of AHA SUDDENS symptoms (yes I would think of stroke) included face (88%) or limb (77%) numbness/weakness, confusion/speech problems (77%), trouble walking/incoordination (47%), visual symptoms (35%) and headache (38%). 26 (77%) of parents knew of stroke treatments; 37% were aware of anti-thrombotic treatments but only 12% were aware of thrombolysis. Median STAT score was 10 (IQR 6-14), meaning parents called 911 for 48% of stroke scenarios. Questions with >1 symptom (focal weakness and speech disturbance) had highest correct responses (84%) and visual disturbance or dizziness had the lowest correct responses (12.5%).

Conclusions:
Parental knowledge varies across stroke symptoms and care seeking behaviour is suboptimal. Few parents are aware of thrombolysis. Initiatives to link knowledge to appropriate action are urgently needed if children are to receive the benefits of hyper-acute therapies.
Abstract T P328: Hypertension is Associated With Increased Mortality in Children Admitted With Ischemic Stroke
Authors: Adil Malik M , Caceres Alfredo , Qureshi Adnan I , Jordan Lori C
Published: March 2022

Objective:
To assess the association between hypertension (HTN) and outcome after ischemic stroke in children from a large national sample.

Methods:
Using the Healthcare Cost and Utilization Project Kids’ Inpatient Database, children (1-18 years) with a primary diagnosis of ischemic stroke (ICD-9 codes 433-437.1) that also had a diagnosis of elevated BP (ICD-9 code 796.2) or HTN (ICD-9 codes 401 and 405) from 2003, 2006, and 2009 were identified. Clinical characteristics, discharge outcomes, and hospital costs were assessed. Multivariate logistic regression was used to assess the relationship between hypertension and in-hospital mortality or discharge outcomes; after adjusting for age, gender, and renal failure.

Results:
Of 2,590 children admitted with ischemic stroke, 156 (6%) also had a diagnosis of HTN (although HTN is likely underdiagnosed as age and sex adjusted BP values ≥95
th
percentile are required). HTN was associated with renal failure in 10% of the children. Concurrent HTN was associated with increased mortality among patients with ischemic stroke compared to those without HTN (7.4% vs. 2.8%; p=0.01), increased length of stay (mean 11±17 days vs. 7±12 days; p<.0001) and higher hospital costs (mean $85,569±137,854 vs. $50,992±96,349; p<.0001). After adjusting for age, gender and renal failure, children with HTN had three folds higher odds of in-hospital death [odds ratio (OR) 3.3, 95% confidence interval (CI) (1.4-8.0, p=0.005)] and lower odds of none to minimal disability at discharge (Table).

Conclusion:
HTN was associated with a 3 times greater odds of death in the hospital for children presenting with ischemic stroke and may represent a potentially modifiable risk factor for poor outcome.
Abstract T P330: Migraine and Risk of Intracerebral Hemorrhage in the Ethnic/racial Variations of Intracerebral Hemorrhage (ERICH) Study
Authors: Koch Sebastian , Elkind Mitchell S , Moomaw Charles J , Brown Mark W , Martini Sharyl R , Osborne Jennifer , Langefeld Carl D , Woo Daniel
Published: March 2022

Background:
The role of migraine headache as a risk factor for intracerebral hemorrhage (ICH) is less well defined than it is for ischemic stroke. Previous studies of migraine and ICH have been limited by the small number of ICH cases analyzed. We hypothesized that a history of migraine headaches is a risk factor for ICH in the ERICH study.

Methods:
ERICH is a multi-center, prospective, case-control study of a racial-ethnically mixed population with ICH. Controls were identified through random digit dialing to match cases by age (+/- 5 years), sex, race/ethnicity (non-Hispanic white, non-Hispanic black and Hispanic) and geographic area. Records of cases were reviewed for past medical history and data on ICH presentation. All cases and controls underwent a comprehensive interview which includes questions regarding headache history. Based on those responses subjects were categorized as having any headache (more than once a month), migraine headaches and migraine with aura.

Results:
A total of 740 cases were matched with controls. Mean age of cases and controls was 58±12 years, 55% were male, 44% non-Hispanic black, 31% non-Hispanic white and 25% Hispanic. Cases were more likely to report a history of migraine (17.3 vs. 14.1%; p=0.076), migraine with aura (5.4 vs. 4.2%; p=0.20) and any headache (38.4 vs. 16.0%; p<0.0001). Cases of ICH with migraine were younger (55.2±13.1 vs. 61.7±14.6 years; p<0.001), more likely to be women (53 vs. 39%; p=0.0004) and reported significantly more substance use, with no difference in ICH location when analyzed by lobar vs. sub-cortical or anterior and posterior circulation distribution.

Conclusion:
A history of headache was associated with ICH in this preliminary analysis of ERICH data, although we were not able to confirm that migraine is a risk factor for ICH. Analysis of additional cases as ERICH continues recruitment may clarify the role of migraine in ICH. The increased prevalence of any headache reported by cases requires cautious interpretation as it may represent recall bias.
Abstract T P336: Risk of Stroke and Vascular Events and Response to Antiplatelet Therapy in Young Adults with Recent Lacunar Strokes: The SPS3 Study
Authors: Pikula Aleksandra , Coffey Christopher S , Lau Helena W , White Carole L , Kase Carlos S , Benavente Oscar
Published: March 2022

Background:
Incidence of lacunar strokes increases with age. Young stroke adults have better survival rate, but due to longer life expectancy they are at higher risk of stroke recurrence.

Objective:
The aim of this study was to examine stroke recurrence and major vascular events in young adults with lacunar strokes, and to explore the effectiveness of antiplatelet therapy for secondary stroke prevention among participants in the Secondary Prevention Small Subcortical Stroke trial (SPS3).

Methods:
The SPS3 study was a double blind, multicenter secondary stroke prevention trial for patients with symptomatic lacunar infarcts. It evaluated the use of antiplatelets (aspirin+clopidrogel vs aspirin) for stroke prevention. Outcomes were ischemic strokes (IS), hemorrhagic strokes (ICH), major vascular events (MVE), and deaths. Univariate analyses were used to compare the frequency rates of these events among young (<50 yrs) and older adults (50+yrs). Interactions between the outcomes and antiplatelet therapy based on age were also examined.

Results:
Of 3020 patients, 323 (11%) were <50 year old (mean age 46, 67% M). Mean follow-up was 3.4 years. There were no differences on risk of ischemic stroke recurrence or MVE in two groups. The younger group had a 4-fold reduced risk of death (p<0.001) and significantly lower risk of ICH (p=0.03). There was an interaction between age and antiplatelet therapy for all strokes (p=0.02), IS (p=0.04) and MVE (0.01). The young group in the aspirin+clopidogrel arm had lower risk of all strokes (HR=0.51;95%CI:0.25-1.04.p=0.06), of ischemic strokes (HR=0.62;95%CI:0.30-1.27,p=0.2) and of major vascular events (HR=0.45;95%CI:0.23-0.88,p=0.02).

Conclusion:
In this exploratory analysis, dual antiplatelet therapy with aspirin+clopidogrel significantly reduced the risk of all strokes, major vascular events and deaths among young adults with recent lacunar strokes. The risk of bleeding was not increased. Response to antiplatelet therapy in young adults with stroke may differ from that in older adults, thus our results deserve further investigations.