bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP322: Additional Factors May Affect Hospital Performance Ratings on Ischemic Stroke Care in California
Authors: Wang Limin , Holliday-Hanson Merry , Parker Joseph
Published: July 2021

Objectives:
A report on ischemic stroke care at California hospitals was based on risk-adjusted 30-day mortality and accounted for many important risk factors (patient demography, clinical characteristics, and stroke severity). Other studies have indicated that geographic location, hospital characteristics and insurance type may also be drivers of differences in quality of care. The effect that these and other factors may have on hospital performance ratings for ischemic stroke is not well understood.

Methods:
Data used were from the California patient discharge data 2011-2013, collected by the Office of Statewide Health Planning and Development (OSHPD). Hospitals were chosen according to their performance in two recent hospital “report cards” on stroke produced by OSHPD. We compared 15 hospitals rated as “Better” with 14 “Worse” hospitals (10615 patients) on patient demographics, geographic location, insurance type, hospital characteristics, tissue-type plasminogen activator (tPA) use and expected 30-day mortality rate.

Results:
Patients admitted to “Worse” hospitals were more likely to be younger, white or Hispanic, and reside in lower income zip codes than “Better” hospitals ( P <0.001). “Worse” hospitals served a significantly higher percentage of patients with Medi-Cal insurance than “Better” hospitals (14.4% vs 9.6%, P <0.001). There were no significant differences in hospital geography or teaching status, bed size or Get With the Guidelines-Stroke Hospitals status between “Worse” and “Better” hospitals. Patients admitted to “Worse” hospitals had similar lengths of stay as those at “Better” hospitals and the transfer rate was also similar. “Worse” hospitals coded significantly fewer secondary diagnoses compared to “Better” hospitals (40.5% vs 53.0%, P <0.005). The tPA usage rate was significantly higher in the “worse” group than the “Better” group (11.5% vs 9.2%, P <0.005). “Worse” hospitals had significantly lower expected 30-day mortality rates compared to “Better” hospitals (8.8% vs 11.6%, P <0.005).

Conclusion:
Hospital performance ratings on ischemic stroke outcome were significantly associated with patient geographic location, socioeconomic status, and insurance type, but were not related to hospital characteristics.
Abstract TP339: Operations Director, Neurosciences Clinical Program, Intermountain Healthcare
Authors: Fotheringham Jeremy , Martinez Julie , Malmberg Elisabeth , Smith Shawn , Thomas Katherine , Hoesch Robert
Published: July 2021

Introduction:
Beginning January 2014, a 245-bed Intermountain Healthcare primary stroke center was using a private Telestroke (SOC) service. On April 1, 2015, Intermountain implemented its own centralized, internal Telestroke service to provide coverage at this primary stroke center and five other hospitals. The Intermountain Telestroke service uses an internal telemedicine platform with employed physicians providing coverage. To clarify, the Intermountain system has a physician answer calls directly; the SOC model uses an intermediary before connecting to the physician.

Hypothesis:
Implementation of a centralized, internal Telestroke service will result in improved physician response and improved time to treatment compared to the private service.

Methods:
The Intermountain Healthcare enterprise data warehouse and SOC summary reports provided the data for this analysis. Wilcoxon-Mann-Whitney test was used to compare physician response time, DTN time, and door to CT time in patients treated during the 15-month SOC era to patients treated by the in house telestroke service.

Results:
From Jan 2014-Mar 2015, 27 patients received IV TPA at the facility, but only 2/27 had door to needle (DTN) time of <60m. The median DTN time in 2014 was 84 min and the median door to CT time was 18 min, strongly suggesting that the neurologist response time of this service was too long to meet AHA standards. Since implementing the Intermountain service, there has been a statistically significant improvement in DTN time. During the SOC time period, the median DTN time was 92.5 min (N = 35). After implementation, the Intermountain service provided a significantly lower median DTN time of 62.5 min (N=4; p = 0.03). The SOC median technician call-back time was 9.2 min (N=85), with an average physician video response time of 32 min (N=79). Intermountain median physician response time is 4 min (N=91). The door to CT time was not significantly different (Jan 2014-March 2015 was 18 min. vs Mar-May 2015, 14 min, N=31).

Conclusions:
The Intermountain Telestroke service outperformed SOC in response time and times to treatment. For healthcare systems that have the resources and expertise, an internal Telestroke service may result in faster times to treatment and better patient outcomes.
Abstract TP341: Risk Factors of Seizure Recurrence in First-ever Post-stroke Seizure
Authors: Tomari Shinya , Tanaka Tomotaka , Matsuki Takayuki , Fukuma Kazuki , Yamagami Hiroshi , Nagatsuka Kazuyuki , Toyoda Kazunori
Published: July 2021

Background:
Both early seizure (ES) and late seizure (LS) are common complications after stroke. However, clinical characteristics, treatments and recurrences after ES/LS remain unclarified.

Methods:
We enrolled the patients with first-ever post-stroke seizures between July 2010 and June 2014, and followed up until June 2015. Seizures were classified into ES (within one week after stroke) and LS (the second week or later). We compared baseline clinical characteristics, status epilepticus, surgery (removal of hematoma, ventricular drainage), neurological deterioration by index stroke (defined as an increase of the NIHSS score by one or more between the baseline and at hospital discharge), and duration of antiepileptic drug (AED) therapy between two groups. We also investigated factors (patients’ background and treatment of seizure) that determined the seizure recurrence after discharge.

Results:
Clinical data were collected for 153 patients (82 men; age, 73.7±12.3, 73 intracerebral hemorrhage and 80 ischemic stroke). ES occurred in 62 and LS in 91 patients. Patients with LS more commonly received surgery (ES 3% vs. LS 17%, p=0.008) and more commonly had neurological deterioration (ES 71% vs. LS 87%, p=0.02) than those with ES. LS received AED therapy more frequently both during hospitalization (ES 71% vs. LS 94%, p=0.0003) and after hospitalization (ES 49% vs. LS 92%, p<0.0001). Seizure recurred in 56 patients (14 ES, 41 LS) after discharge during a median follow-up of 29 months. In a multivariate Cox proportional-hazards model of these patients, independent predictors of recurrence included status epilepticus (HR 2.28,95% CI 1.08-5.17) and LS (HR 3.62,95% CI 1.11-10.09)(p<0.05, respectively).

Conclusion:
Status epilepticus and LS were risk factors of seizure recurrence in first-ever post-stroke seizure.
Abstract TP347: The Effects of Early Anticoagulation Resumption with Apixaban on the Acute Stroke Patients
Authors: Matsuki Takayuki , Toyoda Kazunori , Okamoto Akira , Okata Takuya , Miyata Toshiyuki , Nagatsuka Kazuyuki , Minematsu Kazuo
Published: July 2021

Background and Purpose:
The optimal timing and safety of early anticoagulation using non-vitamin K antagonist oral anticoagulants after acute stroke or transient ischemic attack (TIA) have not been fully investigated. The aims of this study were (1) to assess the risk-benefit profile of early apixaban initiation in stroke/TIA patients and (2) to determine the association between events and plasma concentration of the early apixaban exposure.

Patients and Methods:
We studied acute stroke/TIA patients with non-valvular atrial fibrillation admitted to our hospital and started apixaban from May 2013 to March 2015. The blood samples were drawn just before (0h) and 4 hours (4h) after taking apixaban median 5 (4-6) days of initiation to measure apixaban concentration (C0h, C4h) based on anti-FXa chromogenic assay.

Results:
Of a total 90 patients (66 men, 79±9 y), 8 started apixaban median 3 days (IQR 2-6 days) after TIA, 69 did apixaban median 5 (3-9) days after ischemic stroke, and 13 did median 6 (3-7) days after intracerebral hemorrhage. C0h/C4h was 214±112/320±136 ng/mL in total, 170±100/239±106 ng/ml in 54 patients taking 2.5 mg apixaban BID, and 243±110/375±128 ng/mL in 36 patients taking 5 mg BID. During acute hospitalization (median 19 days), one patient experienced non-fatal gastrointestinal (GI) bleeding (C0h/C4h; 551/546 ng/mL). For median 8.4 (IQR 3.3-12.2) month-follow up in 86 patients who continued apixaban after discharge, three had clinically relevant hemorrhages: 1 subdural hematoma (C0h/C4h; 110/170 ng/mL) and 2 GI bleeding events (331/642, 395/529 ng/mL). The rate of clinically relevant hemorrhages was 6.7 %/year overall. Both C0h and C4h were higher in four patients with bleeding than the others (mean C0h 347 versus 204 ng/mL; p=0.018, C4h 472 versus 308 ng/mL; p=0.012). The receiver operating characteristic curve analysis revealed that C0h over 331 ng/mL predicted the hemorrhagic events with sensitivity 75% and specificity 89% (AUC 0.75). None developed ischemic stroke/TIA during the same period.

Conclusion:
Early starting apixaban after acute stroke/TIA was safe. Bleeding events could occur in patients with trough apixaban exposure over 331 ng/mL.
Abstract TP349: Incidence of Cerebral Ischemia Associated Seizures in Patients With Narrowing or Occlusion of the Ipsilateral Internal Carotid or Middle Cerebral Artery: The EC/IC Bypass Study
Authors: Miran Muhammad Shah , Malik Ahmed A , Suri M.Fareed K , Qureshi Adnan I
Published: July 2021

Background:
Cerebral ischemia associated seizures are well recognized in patients with internal carotid or middle cerebral artery stenosis or occlusion although the incidence is not well documented.

Methods:
We analyzed the data that was collected on 1377 patients with recent hemisphere strokes, retinal infarction, or transient ischemic attacks with atherosclerotic narrowing or occlusion of the ipsilateral internal carotid or middle cerebral artery who were enrolled in the EC/IC Bypass Study. The patients were followed for an average of 55.8 months and any seizures related to cerebral ischemia based on clinical and imaging criteria were ascertained. We calculated the relative risk in pre-defined patient subgroups: Age (<55 and ≥55 years), gender, presenting symptom (transient ischemic attack and ischemic stroke), allocated treatment (bypass surgery and medical treatment), site of stenosis/occlusion (internal carotid artery and middle cerebral artery), and presence or absence of hypertension and diabetes mellitus.

Results:
A total of 64 patients experience one or more cerebral ischemia associated seizures during follow up: first seizure was focal and generalized in 33 and 31 patients, respectively. The incidence of cerebral ischemia associated seizures was 1.7 per 100 person observation years. The relative risk of seizures was higher among patients aged <55 years (relative risk 1.36, 95% confidence interval [CI] 0.8-2.2), women (relative risk 1.1, 95% CI 0.6-2.1), with stroke as presenting symptom (RR 1.9, 95% CI 1.1-3.3), with medical group as allocated treatment (RR 1.2,95%CI 0.7-2.0), with middle cerebral artery as site of stenosis/occlusion(RR 1.13, 95% C.I 0.6-2.0), with diabetes mellitus (RR 1.7, 95% CI 0.96-3.0) or hypertension (RR 1.1, 95% CI 0.7-1.8).

Conclusions:
We provide the incidence of and factors affecting occurrence of cerebral ischemia associated seizures in patients with narrowing or occlusion of the ipsilateral internal carotid or middle cerebral artery
Abstract TP353: Glucose on Admission Associated With Post-stroke Outcome
Authors: Mukarram Faisal , Gottesman Rebecca F , Marsh Elisabeth
Published: July 2021

Introduction:
Studies suggest that an elevated inflammatory profile is associated with increased stroke incidence and worse post-stroke outcome. It is unclear if an elevated inflammatory profile on admission is a useful prognostic marker of poor outcome after stroke, a reflection of a more severe stroke, or a marker of infection or the comorbidities that caused the stroke.

Hypothesis:
We hypothesized that elevated acute phase reactants (APRs) are associated with poor outcome post-stroke, independent of stroke severity and infection.

Methods:
The study used a prospectively collected clinical database of 755 patients admitted for ischemic or hemorrhagic stroke. APRs studied included erythrocyte sedimentation rate (ESR), glucose, platelets, and white blood cell count. Outcome was assessed at discharge using a dichotomous modified Rankin Scale (mRS) score of 3-6 (poor outcome) vs. 0-2 (good outcome), and was evaluated in multivariate logistic regression. Analyses were adjusted for NIHSS, age, sex, race, hypertension, diabetes, and use of antithrombotic medication, and were further stratified by presence/ absence of diabetes, infection (via urinalysis), and by race.

Results:
Elevated ESR (OR: 1.16, 95% CI: 1.00-1.33) and glucose (OR: 1.04 per 10 mg/dL, 95% CI: 1.00-1.09), were each associated with poor outcome, independent of stroke severity (NIHSS). Even in non-diabetics, elevated glucose was associated with 15% non-significantly higher odds of poor outcome per 10 mg/dL (95% CI: 0.998-1.34). However, subgroup analysis of those without infection showed no association between APRs and poor outcome. In race-stratified models, glucose level was significantly associated with poor outcome in African Americans (OR: 1.13, 95% CI: 1.01-1.26), but not in other races.

Conclusion:
Our study shows that ESR is associated with poor outcome after stroke, independently of stroke severity, and that elevated glucose may be associated with increased odds of poor outcome in non-diabetic or African American ischemic stroke patients. Glucose and ESR may play a role in determining prognosis of stroke patients, and therefore point to a potential target for improving outcome of stroke patients.
Abstract TP356: Effect of Stabilization of Blood Pressure of Ischemic Stroke on 3-month Functional Outcome
Authors: Kang Jihoon , Kim Wook-ju , Bae Hee-Joon
Published: July 2021

Background:
At acute stage of ischemic stroke, BP is high and unstable and is stabilized through following few days. Initial high BP is regarded as important prognostic factor, however, there is limited information about change of BP and its effect on outcome.

Method:
From prospective stroke registry, a series of patients who admitted at the Seoul National University Bundang Hospital within 24 hours of ischemic stroke onset were consecutively identified between January, 2010 and November, 2014.

Change of BP was estimated by two steps: first step was within 24-h standard deviation of systolic BP (SBP
SD
) and second one was day-by-day course during first 3 days. The SBP
SD
at each day was dichotomized into high (SBP
SD
> 15 mmHg) and low BPV and determined their secular course. Primary outcome was 3-month poor functional outcome (modified Rankin Scale, 3 to 6). Using classification and regression tree method, proportions of poor outcome were classified and analyzed according to BPV status for 3 days.

Results:
Of enrolled 2545 study subjects (age, 67.1 ± 13.5 year-old; median baseline NIHSS score, 3), SBPmean showed similar values through acute stage (134.5 ± 16.7 on day 1(D1), 132.9 ± 16.7 on D2 and 134.7 ± 16.7 mmHg on D3). The SBP
SD
were 14.4 ± 5.0 (D1), 12.5 ± 4.5 (D2) and 12.2 ± 4.6 (D3) mmHg and proportions of high BPV were 37.3%, 23.0% and 26.6%, respectively.

The association between change of BP and primary outcome were demonstrated (Figure). High BPV on D2 was most important factor (normalized importance = 43.7%) and followed by D3 and D1.

Conclusion:
In ischemic stroke, high BPV at acute stage is rapidly stabilized. When patients sustain or return to the unstable BP, it would be associated with poor functional outcome.
Abstract TP358: Prehospital Diagnosis of Intracerebral Hemorrhage in a Mobile Stroke Treatment Unit
Authors: Vela-Duarte Daniel , Ramanathan Ramnath Santosh , Zafar Atif , Taqui Ather , Winners Stacey , Sheikhi Lila , Cho Sung-Min , Wisco Dolora , Schrock Jon W , Briggs Farren B , Hussain Muhammad Shazam , Uchino Ken ,   On behalf of the Cleveland Pre-Hosp Acute Stroke Treatment (PHAST) Study Group
Published: July 2021

Introduction:
The mobile stroke unit (MSTU) is an on-site pre-hospital treatment team that incorporates laboratory and CT scanner and reduces times to treatment for ischemic stroke thrombolysis. The impact of MSTU on treatment and outcomes of intracerebral hemorrhage (ICH) remains unknown. We report our initial experience with ICH encountered on MSTU.

Hypothesis:
ICH can be quickly identified using MSTU. Hypertension and coagulopathy are common in ICH evaluated on MSTU.

Methods:
We identified ICH cases from the prospectively collected database encounters. Demographics, clinical features, MSTU imaging and repeat imaging characteristics were reviewed. Initial and follow-up hematoma volume was calculated by the ABC/2 method.

Results:
Of 295 encounters on MSTU from July 2014 to July 2015, 20 (6.7%) had intracranial hemorrhage, which comprised of 17 intracerebral, 1 subarachnoid and 2 subdural hemorrhages. Median time to CT diagnosis of ICH from emergency medical dispatch was 31 minutes (interquartile range (IQR) 28-36) and that from last known well was 118 minutes (IQR 39-301). Of the 17 ICH patients, 15 (88%) were hypertensive, with a mean systolic blood pressure of 178.1 and diastolic 91.0 mm Hg. Five (29.4%) individuals were found with INR>1.4, 1 of whom received 4-factor prothrombin complex concentrate. Median NIH Stroke Scale was 11 (IQR 7.5-14.5), and median hematoma volume was 10.7 cc (IQR 4.3-30.8). One patient had significant hematoma expansion as defined by >6 cc or 33% relative volume increase.

Conclusions:
Over 5% of the cases evaluated in the unit presented with ICH, most of whom were hypertensive and had small hematoma volume. MSTU enables early diagnosis of ICH after activation of emergency system, can provide early treatment, and appropriate triage.
Abstract TP371: Comparison of Three Stroke Severity Scales With Mortality Within an Intracerebral Hemorrhage Population: a Population-based Study
Authors: Katz Brian S , Khoury Jane C , Alwell Kathleen , Moomaw Charlie J , Haverbusch Mary , Kissela Brett M , Adeoye Opeolu , Woo Daniel , Flaherty Matthew , Ferioli Simona , Mackey Jason , Martini Sheryl R , De Los Rios la Rosa Felipe , Kleindorfer Dawn
Published: July 2021

Introduction:
The 2015 AHA/ASA guidelines recommend documentation of a stroke severity scale in the initial evaluation for intracerebral hemorrhage (ICH) patients. We describe the distribution of three stroke severity scores and their association with 30 day mortality within a population.

Methods:
We identified all ICH patients ≥ 20 years old in 2010 among residents of the Greater Cincinnati/Northern Kentucky region, a biracial population of ∼1.3 million. We screened area hospitals’ discharge ICD-9 codes for potential cases. Study nurses abstracted relevant information from hospital charts, and study physicians verified the cases of ICH. Data included NIH stroke scale determined retrospectively (rNIHSS) (range of scores (0-42), Glasgow coma scale (GCS) (0-15), and ICH score (0-6). Cases whose rNIHSS could not be evaluated due to coma were assigned a score of 35. Multiple logistic regression was used to examine association with mortality.

Results:
There were 304 ICH patients with ICH scores available. Mean (±SD) age was 69 (±16) years, 160 (53%) were female, and 76 (25%) were black. Median (IQR) values for the severity scores were rNIHSS 7 (1, 22), GCS 14 (9, 15), and ICH score 2 (1, 3) (Figure). Models that examined the scales individually and controlled for age, sex, and race showed odds ratios (OR) (95% CI) for 30 day mortality of 1.5 (1.2, 1.9) for each 5 point increase in rNIHSS, 1.5 (1.4, 1.6) for each 1 point decrease in GCS, and 4.59 (3.34, 6.64) for each 1 point increase in ICH score. With both rNIHSS and ICH score in the same model there was an increased odds of 30 day mortality of 1.5 (1.3, 2.0) for each 5 point increase in rNIHSS and increased odds of 2.8 (1.9, 4.0) for each one point increase in ICH score independently.

Conclusion:
We found that the rNIHSS in combination with ICH score provides additional predictive information with regard to 30 day mortality, and we recommend further prospective study for validation.
Abstract TP385: Decreasing Door-to-Needle Times for Acute Ischemic Stroke Patients
Authors: Venters Kelly , Douglas Jessica , Parker Amber
Published: July 2021

Background and Purpose:
The Joint Commission recommendation is to meet door-to-needle (DTN) times of less than 60 minutes in 50% of tPA recipients. Lake Cumberland Regional Hospital is a certified primary stroke center by The Joint Commission and has strived to develop a process that drives DTN times to less than 60 minutes for acute ischemic stroke patients being treated with tissue plasminogen activator (tPA). Baseline data from 2014 showed tPA compliance was 27% (n=15). In 2015, pre-implementation tPA compliance was 0% (n=3).

Methods:
Guided by a process map outlining time frames for all steps in the tPA administration process, findings were utilized to identify barriers, inefficiencies, and solutions. An educational program was developed and centered on identified barriers. Educational sessions were completed for all emergency department staff. DTN times were analyzed before and after implementation of educational program. A timekeeper role was implemented in the emergency department to increase awareness during cases of tPA administration.

Results:
100% of Emergency Department staff was educated on process map, Joint Commission recommendations, and role of timekeeper. Since completion of educational sessions and implementation of timekeeper role, Lake Cumberland Regional Hospital has met The Joint Commission DTN recommendation in 78% (n=9) of patients treated with tPA. As of August 11
th
, overall DTN compliance for 2015 at Lake Cumberland Regional Hospital was 54%.

Conclusions:
Average DTN treatment times were decreased and compliance with The Joint Commission standard of meeting DTN times of less than 60 minutes in 50% of tPA cases was improved. For continued identification of performance improvement initiatives, debriefings are conducted after each tPA case with all staff involved to discuss strengths, barriers, and opportunities for improvement.
Abstract TP387: An Interdisciplinary Approach to Improving Acute Treatment- Implementation of the Rapid Acute Stroke Protocol
Authors: Wilson N , Gourdine K , Roche T , Nanlal L , Mascitelli J , Shoriah H , Shearer P , Paramasivam S , Mocco J , Mayer S , Fifi J T , Tuhrim S
Published: July 2021

Background:
Recent emergence of evidence for the effectiveness of intra-arterial treatment (IAT) of acute ischemic stroke secondary to large vessel occlusion (LVO) has prompted hospitals to examine the efficiency of their initial evaluation process. Mount Sinai Hospital has taken an interdisciplinary approach to hyper acute stroke care. It streamlined its process focusing on rapid triage of stroke, stroke team assessment, IV tPA administration and detection of LVO.

Rapid Acute Stroke Protocol (RASP), including early stroke team activation by the triage nurse was implemented in December 2014. Triage nurses were trained in the identification of stroke and stroke team activation. Feedback was provided to nursing leadership and individual participants on every treated case. A ‘team member of the month’ was established to promote ongoing enthusiasm and team rapport.

We hypothesized that the combination of new evidence and the introduction of RASP would increase the number of patients treated, decrease time to stroke team assessment and door to puncture (DTP) time.

Method:
In this retrospective review of 51 consecutive patients with AIS treated with IAT from January 2014 until July 2015, the population was divided into two cohorts. Cohort 1 included patients treated from January 2014 through November 2014, prior to RASP initiation. Cohort 2 included patients treated from December 2014 through July 2015. Outcomes included number of patients treated, arrival to stroke team assessment, and DTP time.

Results:
In cohort 1, .9 cases per month were treated with IAT compared to 5.1 per month in cohort 2, a 5.2 fold increase. A greater percentage of these patients arrived in the ED via inter-hospital transfer 56% vs 30%. There was a decrease in arrival time to stroke team assessment for cohort 2 vs cohort 1 (3 vs 9 minutes) and a reduction of 46.6% from DTP time (79 minutes vs 148 minutes p=<.001).

Conclusion:
These findings demonstrate how an interdisciplinary approach to hyper acute care can have a dramatic effect on the stroke patient. Improved prenotification by EMS or the originating hospital contributed to immediate stroke team availability. However, key to RASP was empowering the triage nurse with the responsibility of stroke recognition and activation of the stroke code.
Abstract TP388: Multidisciplinary Stroke Review Process and Prospective Record Review for Quality and Process Improvement
Authors: Doerr Abbigayle M , Lindstrom Anne , Shownkeen Harish , Pittner Laura
Published: July 2021

Background:
The Comprehensive Stroke Center (CSC) standards set by the Joint Commission (TJC) include process and quality improvement. Specifically, there is to be a process to review complex stroke cases for a complications, treatment specific situations and sentinel events. The review is at program level by an interdisciplinary team.

Purpose:
To maintain consistency, function and process related to complex stroke patients. To focus on issues and/or barriers with regards to complex stroke patients. To assure the hospital is meeting requirements set up by TJC for CSC designation.

Methods:
Advance practice nurses (APN) within the stroke program created a stroke summary template using data elements from the inpatient hospitalization of all stroke patients. The summary data is reviewed for positive outcomes and complications related to the complex stroke population including but not limited to: ventriculostomy, decompressive craniectomy, endovascular revascularization, carotid endarterectomy, carotid artery stenting, periprocedural stroke and death. All data is collected and monitored by subcommittee inclusive of APNs and leaders from the stroke, quality and neurointerventional surgery departments. Quarterly, a team of physicians including stroke neurology, neurointerventional surgery, quality, medical executive committee, neurosurgery, emergency medicine, neurocritical care and physical rehabilitation medicine meet to further discuss cases related to the designated criteria above. A stroke review pathway created and designates all unusual findings to be reported to the physician and/or nursing peer review committees for formal inquiry.

Results:
Following implementation of the stroke review process there was documented 100% review of ischemic and hemorrhagic stroke patients with special consideration for intravenous tissue plasminogen activase administration and endovascular treatment of stroke by a interdisciplinary team of physicians and nurses.

Conclusions:
The developed stroke summary and interdisciplinary review process provides opportunities for quality and process improvement initiatives while demonstrating conclusive documentation supporting TJC requirements for CSC program level stroke case review.
Abstract TP394: Stroke Education- Are you REaDy?
Authors: Wolber Nicole E , Paletz Laurie , Steiner Nili , Robertson Betty , Guerra Sonia
Published: July 2021

Introduction/Background:
Patients stay healthier when informed, making communication the key to better outcomes. An informed and educated patient actively participates in their own treatment, improves outcomes, and reduces length of stay. We call and evaluate every patient 30 days post discharge. We found that many reported either not receiving stroke education, or could not recall if they had received it. The principle of Occam’s razor states: “The simplest idea is usually the best idea.” This principle was utilized to solve our problem.

Quality Questions:

1. How do we increase the likelihood that patients will remember that they have received stroke education?

2. How do we assure that patients recall health information provided to them.

Methods:
Stroke patients are given extensive, personalized stroke education during their admission, and reinforced daily by stroke team. Education materials were given to patients in white folders with a Cedars-Sinai logo. Stroke patients are phoned in 30 days and asked a series of 18 questions to assess well-being & assess patient’s experience during hospital stay, and after discharge. These calls revealed an unusual number of patients who were unable to recall being educated or receiving educational materials. We decided to simply change the stroke education folder from white to bright red. We instructed the call center to use the red folder as a prompt to help the patient recall receiving stroke education.

Conclusion:
A collaborative approach was used to ascertain an appropriate stimulus for the patient to recall their stroke specific education. Stroke education had to stand out amidst the myriad of information patients are bombarded with in the hospital. The team came up with the simple idea of using a bright red folder. When patients were called the call center would prompt the patient by saying “The stroke education was given to you in a bright red folder.” Prior to implementation of the red folders, only 81.5% of patients recalled receiving stroke education. After implementation of the red folders, 96.8% recalled receiving stroke education. The principle of Occam’s Razor proved to be correct in our study. A very simple idea such as changing the color of the folders to bright red proved to have very meaningful results.
Abstract TP397: Dedicated Stroke Units With Bedside Monitoring and Better Blood Pressure Control
Authors: Arango Audrey , Korya Daniel , Chukwuneke Florence , Song Yong-Bum , Brar Jaskiran , Mehta Siddhart , Moussavi Mohammad , Panezai Spozhmy , Kirmani Jawad
Published: July 2021

Background and Objective:
Patients with ischemic or hemorrhagic stroke require strict BP control to prevent hemorrhagic transformation or hematoma expansion. Acute elevations in BP are often treated with IV labetalol. Dedicated stroke units often have automated bedside monitoring of vital signs. Standard automated BP monitoring alerts practitioners to trends that lead to more steady control of BP rather than frequent acute interventions. We evaluated patients who were treated in a stroke unit after the institution of automated bedside monitoring. Comparison was made to the number of times the patients were dosed acutely using labetalol with a control group of patients who were not receiving automated bedside monitoring. The objective was to determine if there was a significant difference in care.

Methods:
Patients were evaluated over a 12-month period (2014) after the incorporation of bedside automated BP monitoring in a dedicated stroke unit at a university affiliated, comprehensive stroke center. The number of times each patient during this time frame received IV labetalol for acute elevations in BP was compared with a time period spanning 12-months prior (2013); there was no automated BP monitoring performed. The average interventions were compared with a t-test by using SPSS V22. Comparisons of patient population and type of pathology were matched appropriately.

Results:
Of the 1,326 patients who presented for ischemic or hemorrhagic strokes during the 24-month period evaluated, 25 required multiple injections of IV labetalol for acute BP control. Of these, 12 patients were on automated vital signs and BP monitoring, and 13 were not. The mean number of IV labetalol interventions implemented in the group being monitored was 2.8, while the mean number of treatments given to patients not being monitored was 5.9 (p=.016).

Conclusion:
In our study there is a trend towards better blood pressure control with adequate adjustment of oral medications for monitored patients in our dedicated stroke unit. Prevention of sudden elevations in BP may translate into lower rates of hemorrhagic transformation or hematoma expansion and confer better outcomes in stroke patients. Larger prospective studies are required to corroborate our findings.
Abstract TP40: CT Permeability Imaging Distinguishes Benign Oligemia From “At-Risk” Tissue
Authors: Liu Nan
Published: July 2021

Introduction:
Optimal treatment on the hyper-acute phase of ischaemic stroke is aimed at ensuring reperfusion and survival of viable brain tissue at the margin of the ischaemic event. Although DWI has been validated as highly accurate for the identification of infarct core, the accurate identification of ischaemic penumbra remains elusive.

Hypothesis:
To determine whether K
trans
maps, a permeability parameter indicating BBB dysfunction, combining with perfusion parameters, can identify the really ischaemic penumbra and predict the clinical outcome in acute ischemic stroke.

Method:
Consecutive patients admitted with signs and symptoms suggesting acute hemispheric stroke. K
trans
maps were calculated from PCT data using prototype software, which uses the Patlak model to assess their BBBP. Then K
trans
maps were loaded into ImageJ 1.47 for Mac OS to draw the Regions of interest. The agreements between different groups were calculated using Chi-square tests. The radiological calculated both perfusion and K
trans
maps. Multiple logistic regression analyse and linear regression model were conducted to determine independent predictors of 90-day mRS and FUP-FIV, respectively.

Result:
Of 98 patients, 46 was female. Mean age of all patients was 65.03±14.1 years. Patients with good outcome had less mean age, NIHSS, PCT-FIV, K
trans
-FIV, FUP-FIV
P
<0.001). Patients with poor outcome had higher mean SBP on admission(P=0.003) and less opportunity of successful recanalization(P=0.003). In regression analyses, K
trans
-FIV was the most powerful predictor of clinical outcome(
P=
0.009, OR=1.097), and also the best positive predictors for FUP-FIV (
F
=75.590,
P
<0.0001).

Conclusions:
Combining PCT and K
trans
maps derived from first-pass of PCT can identify cerebral ischemic tissue at risk more precisely than using perfusion parameters alone.
Abstract TP400: Examining Five Year Trends of Documented Tissue Plasminogen Activator Contraindications in Wisconsin
Authors: Scharnott Michelle , Miller Kathryn , Bluma Dot , Serdynski Lynn
Published: July 2021

Background:
Target: Stroke was initiated in 2010 as a national quality improvement effort. This American Stroke Association campaign gave tools, consulting and data analysis to hospitals to improve door to needle time with tissue plasminogen activator (tPA). Along with this effort, the state of Wisconsin continued to work on a stroke system of care as well as education on tPA warnings versus absolute contraindications.

Methods:
This study looked at an average of 40 Wisconsin hospitals and 26,185 ischemic stroke patients in Get With The Guidelines- Stroke over a five year period to determine if there were trends in how hospitals documented contraindications for tPA.

Results:
From 2010 to 2014 Advanced Age and Age >80 decreased as a tPA contraindication by 7.3% and 4.6% respectively. Rapid Improvement decreased from 38% of the tPA contraindications to 35.1% over this time period. Hospitals also listed a 2.5% increase in the amount of patients receiving tPA in an outside hospital before transfer.

Conclusions:
Through efforts such as Target: Stroke, statewide education and systems of care work, Wisconsin hospitals have improved the door to needle time for eligible patients from 18.1% in 2010 to 66.8% under 60 minutes. The data shows that advanced age is not used as often as a contraindication assuming education of age being a warning and not an absolute contraindication has had some effect on treatment decisions. It can also be assumed that referral hospitals are giving more tPA and transferring when necessary as hospitals have increased listing tPA at an outside hospital as a contraindication. Rapid Improvement has fluctuated but is at a five year low
Abstract TP41: Perfusion CT Identifies Ischemic Stroke Patients With a Good Natural History Regardless of Treatment
Authors: Bivard Andrew , Krishnamurthy Venkatesh , Levi christopher , Parsons Mark
Published: July 2021

Introduction:
There remains uncertainty about the benefits of reperfusion therapy in minor stroke. In this study we tested the hypothesis that patients with a small perfusion lesions do not show clinical benefit from reperfusion therapy when using conventional outcome scores such as the modified Rankin scale.

Methods:
A prospective cohort of consecutive ischemic stroke patients who fulfilled standard clinical/NCCT eligibility criteria with additional perfusion and angiography CT before treatment with iv alteplase were collected. Volumetric CT perfusion was retrospectively analysed to identify patients with a small perfusion lesion (defined as a delay time lesion 3 seconds <15mL). The primary analysis compared 3-month mRS as well as acute and 24 hour NIHSS scores in patients with a small perfusion lesion who were treated with rtPA against those who were not using linear regression to generate and odds ratios (OR).

Results:
Of the 1526 patients who were potentially eligible for alteplase therapy, 356 had a perfusion lesion <15mL with 211 being treated and 145 not treated with rtPA. Patients with a small perfusion lesion had similar NIHSS between those who were treated and those not treated (rtPA treated small lesion patients acute NIHSS, 8.2, untreated 8.9, p=0.71). The odds of small lesion patients achieving mRS 0-1 with alteplase was 0.614 (p<0.001). Average 24 hour DWI lesion in treated small perfusion lesion patients 3mL with alteplase treatment and 2.1mL without, p=0.081. The subgroup of patients with a small perfusion lesion associated with a vessel occlusion did however show an improvement in functional outcome (mRS 0-1OR 1.21, p=0.012).

Conclusion:
Ischemic stroke patients with a small perfusion lesion appear to have an excellent natural history regardless of alteplase treatment. Patients with a visible vessel occlusion may have a slight benefit from treatment.
Abstract TP421: Ischemic Preconditioning From Preceding Cerebrovascular Events in Stroke Patients
Authors: Correia Pamela N , Meyer Ivo A , Eskandari Ashraf , Amiguet Michael , Michel Patrik
Published: July 2021

Introduction:
Preconditioning improves acute ischemic stroke (AIS) outcomes in animals and possibly in humans. The influence of a preceding ischemic event (PIE), such as a TIA or AIS occurring at different intervals, sites and for different durations, needs to be studied in humans.

Hypothesis:
We aimed to identify whether a PIE can have a preconditioning effect on a subsequent AIS.

Methods:
Using consecutive AIS from the ASTRAL registry we determined demographics, risk factors, past medical history,stroke mechanism,PIE and other features that were associated with initial stroke severity measured by NIHSS. We used a multivariate linear regression model with NIHSS as the dependent variable to compare groups with and without PIE.

Results:
Of 3501 consecutive AIS patients (43% females, median age 73 y), 996 (28.4%) had preceding PIEs (15.7% TIA, 12.9% ischemic stroke, 2.4% retinal ischemia, 8.8% multiple events). There were 162 acute PIE in the preceding 24 h, and 94 subacute PIE up to 7 d before the stroke, respectively with a median delay between the PIE and the subsequent stroke of 180 days.Results of the adjusted multivariate regression analysis are shown as forest plots below.

Conclusions:
In patients with AIS, we found an independent association between lesser stroke severity and PIE, suggesting a possible beneficial role of ischemic preconditioning in stroke in humans. The effect of timing, severity,location of PIE and long-term outcome of such patients needs to be analyzed in further studies.
Abstract TP424: Acute Stroke Education Video Associated With Improved Stroke Literacy
Authors: Denny M. Carter , Vahidy Farhaan , Shah Rutvij J , Vu Kim Y , Sharrief Anjail Z , Savitz Sean I
Published: July 2021

Introduction:
Interventions are needed to improve stroke literacy and secondary prevention. We developed a video to educate patients hospitalized with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).

Hypothesis:
In a prospective trial, we hypothesized that a stroke video would improve stroke literacy in AIS and ICH patients.

Methods:
A 5-minute stroke education video was shown to AIS and ICH patients admitted to our service from 3/15 to 6/15. Demographics and a cognitive screen (5-min MoCA) were collected. Questions, related to stroke knowledge (n=8), self-efficacy (n=1) and patient satisfaction (n=1), were answered before, after, and 30 days after the video.

Results:
Among 295 screened, 102 patients were enrolled (Table 1). There was a significant difference between pre-video median knowledge score of 6 (IQR 4-7) and the post-video score of 7 (IQR 6-8; p<0.001) and between pre-video and the 30 day score of 7 (IQR 5-8; p=.04). There was a significant difference between the proportion of patients who were “very certain” in recognizing symptoms of a stroke pre- and post-video, which was maintained at 30-days (36% vs. 53%, p=0.001; 36% vs. 56%, p=0.08). The proportion who were “very satisfied” with their stroke education post-video (74%) was significantly higher than pre-video (49%, p=0.001), and this was maintained at 30 days (75%, p=0.004). There was no association between 5-min MoCA scores and stroke knowledge acquisition pre- and post-video scores, p=0.53) or stroke knowledge retention post-video and 30-day scores, p=0.95). MoCA scores correlated with pre-, post- and 30-day knowledge scores (r=0.41, p<0.001; r=0.47, p<0.001; r=0.40, p=0.003). Potential associations between stroke knowledge and behavioral changes will be reported.

Conclusion:
A stroke educational video was associated with improved stroke knowledge, certainty in recognizing stroke symptoms and satisfaction with stroke education. A randomized trial is planned.
Abstract TP437: Clinical Outcomes of the First Neurocritical Care Unit in Korea
Authors: Jeong Jin-Heon , Yeo Minju , Hong Jeong-Ho , Yum Kyu Sun , Chang Jun Young , Han Moon-Ku
Published: July 2021

Introduction:
In neurocritically ill patients, admission to a specialized neurocritical care unit (NCU) is associated with improved outcome. The first NCU in Korea was established on 15 March 2013. In Korea, the data of intensive care unit (ICU) outcome were collected in general ICUs, but there are only sparse data of NCU outcome.

Hypothesis:
The primary object of this study is to evaluate clinical outcomes of neurocritically ill patients in Korea.

Methods:
This study was conducted in 20 NCU beds of a large academic tertiary care hospital. We retrospectively analyzed the clinical data from neurocritically ill patients. A comparison was made between those patients admitted before and after the establishment of NCU. The primary outcome examined was ICU mortality. To evaluate functional outcome, the modified Rankin scale (mRS) at 6 months after NCU admission was obtained from medical records or telephone interview.

Results:
A total of 2487 patients were included, 1572 prior to and 915 after the establishment of NCU. The predominant admission cause were postoperative care and cerebrovascular disease; such as subarachnoid hemorrhage, malignant ischemic stroke, and intracerebral hemorrhage. There were no significant differences between the groups about demographic characteristics and admission Glasgow Coma Scale score. ICU mortality was significantly decreased in patients admitted to NCU (7.3% vs 4.7%, p=0.12). Admission to NCU also significantly decreased length of ICU stay and ventilator days. Among patient admitted NCU, 228 patients (48.1%) showed good functional recovery (mRS 0-2), while 245 patients (51.9%) had unfavorable outcomes (mRS 3-6).

Conclusion:
This is the first report about outcomes of neurocritically ill patients who admitted to NCU in Korea. Admission to specialized NCU and cared by neurointensivist improved outcomes and decreased ICU mortality.
Abstract TP439: Clinical Predictors and Autcomes of Convulsive Status Epilepticus After Subarachnoid Hemorrhage in United States
Authors: Chaudhry Saqib A , Afzal Mohammad R , Rehman Haseeb , Saeed Ali , Riaz Ahmed , Kassab Mounzer , Qureshi Ihtesham A , Qureshi Adnan I
Published: July 2021

Background:
There is limited data on occurrence of generalized convulsive status epilepticus (GCSE) in subarachnoid hemorrhage (SAH) patients at national level.

Objective:
We evaluated the occurrence, associated factors, and outcomes after GCSE in patients hospitalized with SAH in the United States.

Methods:
We analyzed data from the Nationwide Inpatient Sample (NIS2002-2012). Using the primary ICD-9-CM codes 430 for SAH, patients admitted through the emergency department with a diagnosis of SAH were selected for analysis. Patients with GCSE were identified by using ICD-9-CM code 435.3. Multivariate logistic regression was performed to identify independent predictors of GCSE. The association between GCSE and various outcome measures was also assessed after adjusting for potential confounders.

Results:
Out of 286,944 patients hospitalized with SAH, 959 (0.34%) developed GCSE. After adjusting for gender, independent predictors of GCSE in patients hospitalized with SAH included: renal failure [Odd ratio (OR) 2.1 p=0.0084], hydrocephalous [OR 1.9 p<0.0001], sodium abnormalities [OR 1.9 p=0.0001], meningitis [OR 2.3 p=0.0166], sepsis [OR 3.4 p<0.0001], severity score [OR 5.5 p<0.0001] and pneumonia [OR 2.5 p<0.0001]. In multivariate logistic regression model adjusting for age gender and medical comorbidities, patients with GCSE were more likely to be discharged with moderate to severe disability [OR 2.4 , 95% CI 1.5- 3.7]. The in-hospital mortality was higher [OR 1.6, 95%CI 1.1- 2.2] in patients with SAH who developed status epilepticus during the hospitalization.

Conclusions:
Patients with SAH who developed GCSE during the hospital admission have higher rates of death and disability. Certain factors helps predicts the occurrence of GCSE in patients with SAH. Early diagnoses, prophylaxis, and treatment may reduce the rates of mortality and disability.