bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP241: Value Stream Analysis Reduces Door-To-Needle Times in Acute Stroke
Authors: Bentaleb Abdeljalil , Golding Larisa , Southee Susan , Eberly Lewis B
Published: July 2021

Introduction:
An important goal in treating acute stroke is minimizing door-to-needle times, consistent with evidence based practice and quality goals. Utilizing methods to streamline the process of patient and information flow in the emergency department (ED) is necessary to reduce treatment times.

Hypothesis:
Use of value stream analysis to improve efficiency in processing acute stroke patients in the ED should reduce door-to-needle times.

Methods:
Value stream is the movement of patient and information to deliver the desired outcome. The process from door to treatment was divided into individual steps. We defined process time (the time each step takes) and wait time (the time between each step). The mission was to identify which steps were absolutely necessary before a patient could receive IV-tPA, and to streamline those steps to reduce the process time. All patients who received IV-tPA in 2011 and thus far in 2012 are shown in the graph. Each bar represents an individual patient.

Results:
Prior to stream analysis, our average door-to-needle time was 122.2 minutes. After the process was rolled-out, the average door-to-needle time was down to 73.8 minutes. Before stream analysis we treated 7.6% of our IV-tPA patients in less than 60 minutes. After analysis we treated 69.2% of patients in less than 60 minutes. The number of patients treated rose from 11 in 2011 (5%) to 17 thus far in 2012 (mid-year, projected 15%). We also found that the number of thrombectomy treated patients was reduced from 39% prior to analysis to 23% following analysis, perhaps partly due to reduced processing time and more patients evaluated within the window for IV-tPA.

Conclusion:
Streamlining the process of patient flow in the ED by value stream analysis resulted in several outcome improvements in acute stroke patients:

1) Reduced door-to-needle times.

2) Increased number of patients treated within the golden hour.

3) Increased number of patients treated with IV-tPA.
Abstract WP257: A New microCT-based Blood-Brain Barrier Imaging to Study Hemorrhagic Transformation of Ischemic Stroke
Authors: Park Jin-Yong , Je Kang-Hoon , Lee Su-Kyoung , Kim Jeong-Yeon , Kim Dong-Eog
Published: July 2021

Background:
The breakdown of the blood-brain barrier (BBB) can accelerate the progression of cerebral ischemic injury, and vice versa. Hemorrhagic transformation (HT) of ischemic stroke is linked with the loss of the BBB integrity, which has been reported to have a biphasic dynamics: a significant reduction in BBB permeability at 24h after reperfusion.

Objectives:
To develop a new microCT-based in vivo BBB imaging technique for small animals and investigate if (1) acute HT after ischemic stroke could be predicted with the severity of earlier BBB dysfunction and (2) BBB opening is biphasic regardless of the HT.

Methods:
Focal cerebral ischemia was induced by transient occlusion of middle cerebral artery (tMCAO) for 1h in 11-week-old C57/BL6 mice (n=29). Thereafter, serial microCT imaging was performed 5min after ipsi-lesional intra-carotid infusion of iopromide (240μl, 5min) at 4h, 24h, and 48h after the tMCAO. Then, animals were sacrificed after intravenous injection of 2% Evans-Blue (EB) and the extent of BBB damage was visualized in the ex vivo brain sections by measuring EB leakage with a near-infrared fluorescent (NIRF) imaging machine.

Results:
microCT signal due to the leakage of iopromide into the infarct lesion was clearly observed at 5min after each infusion at 4h, 24h, and 48h after stroke, which gradually decreased over 60~180min, and then completely disappeared. The iopromide-leakage on microCT corresponded closely with the EB-leakage on NIRF imaging and the infarct lesion on TTC staining. At 48h after tMCAO, the leakage of iopromide (arbibrary-unit, A.U.) was more extensive in the animals with parenchymal hematoma (n=13) than in those without (n=16): 26.3±11.7A.U. vs. 9.8±5.9A.U. (p<0.001). At 24h, iopromide-leakage was non-significantly lower in the former (8.2±8.2A.U.) than in the latter (17.6±12.7A.U., p=0.07). At 4h, it did not differ between the groups (10.6±8.3A.U. vs. 7.9±5.4A.U., p=0.50). In both groups, compared with the 4h time-point, iopromide-leakage was not significantly attenuated at 24h.

Conclusions:
We introduce a new BBB imaging technique for small animals in vivo and show that acute HT could not be predicted with earlier microCT BBB imaging. Regardless of the HT, the biphasic BBB opening was not observed.
Abstract WP26: Improved Clinical Outcome of Acute Basilar Artery Occlusion Since Introduction of Endovascular Thrombectomy Devices
Authors: Ringleb Peter A , Kellert Lars , Moehlenbruch Markus , Nagel Simon , Boesel Julian , Rohde Stefan
Published: July 2021

Background:
Survival and functional outcome of patients with acute basilar artery occlusion (BAO) are highly dependent on vessel recanalization. Therefore intra-arterial thrombolysis is recommended in international guidelines. For several years, thrombectomy-devices are used for intra-arterial therapy. We analyzed if the use of those devices modified the outcome of patients with BAO in our institution.

Method:
Retrospective analysis of prospectively collected data on consecutive patients with acute BAO since 1998. In July 2009 for the first time a thrombectomy device was used in a patient with BAO. Thereafter the cohort was split into two chronological groups. All patients were treated at a dedicated neurological ICU following institutional SOPs. Functional outcome was assessed three months after treatment using the modified Rankin Scale (mRS); good clinical outcome was defined as mRS 0-2. Symptomatic intracranial hemorrhage (sICH) was defined as intracranial blood on follow-up imaging up to 36 hours after treatment associated with clinical worsening of at least 4 points of the NIHSS or leading to death.

Results:
From the entire cohort of N=124 patients, n=91 patients were treated before and n=33 after July 2009. A “bridging concept” (i.e. IVT + IAT) was applied in 20% vs. 64% of the patients before and after July 2009, respectively. Complete recanalization (TICI 3) was achieved in 45% before and 77% after July 2009 (p=0.005). SICH occurred in 7% of the earlier and 3% of the later cohort (p=0.67); good clinical outcome was observed in 10% of the earlier and 33% of the later cohort (p=0.004); mortality was 57% in the earlier and 30% in the later group (p=0.01). After adjustment for baseline imbalances (proportion of patients with previous stroke, time until first treatment) the differences remained significant for good clinical outcome (OR 3.86; 95%CI 1.27 - 11.7; p=0.017) and mortality (OR 0.38; 95%CI 0.15-0.99; p=0.047).

Conclusion:
Modern thrombectomy-devices as well as the increased use of bridging approaches for treatment of BAO have significantly improved good clinical outcome and attenuated mortality. Especially in patients with BAO - where endovascular treatment strategies are common clinical practice - those devices should be used more frequently.
Abstract WP260: Pravastatin Improves Short-term Survival Rate Following Cardiac Arrest and Cardiopulumonary Resuscitation In Mice
Authors: Nakayama Shin , Taguchi Noriko , Tanaka Makoto
Published: July 2021

Statins (HMG-CoA reductase inhibitors) exert numerous pleiotropic effects and have been shown to attenuate ischemic injury in different rodent models of cerebral focal ischemia. Few studies have examined the effect of statins on post cardiac arrest syndrome. This study conducted cardiac arrest and cardiopulmonary resuscitation (CA/CPR) in mice and tested the hypothesis that intravenous statin after CPR improves survival rate and neurological outcomes.

Methods:
Adult male mice (20-26 g) were subjected to CA induced by intravenous (IV) KCL. After 8 min of CA, CPR was initiated with IV epinephrine, ventilation with 100% oxygen and chest compressions (rate 300/min). At 1 hr after return of spontaneous circulation, mice were treated with either IV injection of pravastatin (3mg/kg) or vehicle. Four days after CA/CPR, neurobehavioral assessments were performed and brains were removed for histological evaluation in hippocampus and caudateputamen.

Results:
No difference was found between two groups in body weight, duration of CPR and dose of epinephrine. Survival rate at 4 days after CPR was significantly higher in pravastatin group compared with vehicle group (66.7%; n=24 vs 48.4%; n=33). Neurobehavioral scores in pravastatin group were better than vehicle group at 2 to 4 days after CPR. Body weight loss in vehicle group at 4 days after CPR was higher than pravastatin group (-19.4±1.8% vs -13.4±2.0%), which indicates loss of feeding activity. Histological damages in hippocampus and caudateputamen were not statistically different between two groups (pravastatin: 23.8±7.0% vs vehicle: 35.2±9.2% in hippocampus) (pravastatin: 49.4±7.2% vs vehicle: 60.5±7.8% in caudateputamen). All values are presented as mean±SEM.

Conclusions:
Single IV injection of pravastatin after CA improved short-term survival and neurobehavioral score in the mouse experimental CA model. Neuronal damage in the brain region was comparable to vehicle group. These data suggest that pravastatin given after CA would be beneficial in the post resuscitation phase via systemic pleiotropic effects such as anti inflammatory response and improved vascular reactivity.
Abstract WP268: Roles And Regulation Of Ketogenesis In Cultured Astroglia And Neurons Under Hypoxia
Authors: Takahashi Shinichi , Iizumi Takuya , Abe Takato , Suzuki Norihiro
Published: July 2021

Purpose:
Although exogenous ketone bodies (KBs), acetoacetate (AA) and β-hydroxybutyrate (BHB) can serve as alternative energy substrates in neural cells under starvation, the exact roles and the regulation of ketogenesis in the brain remain uncertain. The present study examined the ketogenic capacity of cultured rat astroglia under hypoxia and possible roles and the regulation of KBs in neuronal energy metabolism.

Methods:
Primary neurons and secondary astroglia were prepared from SD rats. Palmitic acid (PA) and L-carnitine (LC) were added to the nutrient medium. AA and BHB produced and released in the medium during 24h were measured using the cyclic thio-NADH method.
14
C-labeled acid-soluble products (i.e., KBs) and
14
CO
2
produced from [1-
14
C]PA were measured to assess the role of PA and KBs as energy substrates in the TCA cycle. [U-
14
C]lactate or [1-
14
C]BHB was used to compare the oxidative metabolism of the end-products of glycolysis with those of the β-oxidation of fatty acid. Some cells were placed in a hypoxic chamber (1%O
2
) for 12h-24h to evaluate the effects of hypoxia and re-oxygenation on KB metabolism.

Results:
PA (100 μM) and LC (1 mM) induced higher KB production (mean ± SD in pmol/μg /24h, n=6) in astroglia (AA: 40.8 ± 1.3, BHB: 9.6 ± 1.4) than in neurons (AA: 0.3 ± 1.5, BHB: 2.2 ± 2.7), while CO
2
production from PA was less than 5% of the KB production in astroglia. KB production was augmented by AICAR (500 μM), a cell-permeable AMPK activator (AA: 66.8 ± 8.7, BHB: 12.7 ± 0.9) as well as hypoxia (AA: 59.4 ± 5.1, BHB: 30.0 ± 14.4) in astroglia. [1-
14
C]BHB oxidation (mean ± SD in pmol/μg/h, n=4) in neurons (2.9 ± 0.6) was about 1.5 times as high as that in astroglia (1.8 ± 0.1). [U-
14
C]lactate oxidation in astroglia (14.0 ± 4.6) was not affected by addition of BHB (13.3 ± 4.7) in astroglia, while that in neurons (21.5 ± 2.8) was reduced by 15% (18.1 ± 1.2,
P
<0.05).

Conclusions:
Astroglia responded to hypoxia by enhancing KB production in the presence of PA and LC, and KBs produced by astroglia might serve as a neuronal energy substrate for the TCA cycle in place of lactate, since pyruvate dehydrogenase is susceptible to ischemia. The activation of astroglial ketogenesis may reduce ischemic cell damage after stroke.
Abstract WP269: Increased Sensitivity to recombinant Tissue Plasminogen Activator (rtPA)-induced Lysis in vitro of Thrombi Produced in Human Platelet Rich Plasma containing Dabigatran
Authors: van Ryn Joanne , Kink-Eiband Monika , Fischer Davina , Schurer Johanna , Clemens Andreas
Published: July 2021

Dabigatran is a direct thrombin inhibitor approved for the prevention of stroke in patients with atrial fibrillation. It significantly reduced ischemic and hemorrhagic stroke in these patients vs warfarin. However, in patients treated with dabigtran who developed a stroke, there remain unresolved issues regarding thrombolysis therapy, both in terms of timing of lytic treatment to minimize hemorrhage risk and also lytic dose. It is hypothesized that if the fibrin network in a thrombus formed in patients on dabigatran treatment is altered and is less compact, then it may be more sensitive to lysis at lower doses of rtPA.

Thrombi were produced in human platelet rich plasma (PRP) in the presence of low conc. of dabigatran (0, 30, 75 ng/ml). PRP was supplemented with 594-Alexa fluorescent labelled human fibrinogen. Thromboplastin (Thromborel
®
) and 200mM CaCl
2
were added and this was incubated at 37°C for 60 min to allow clot formation. Thrombi were removed from PRP and washed twice in saline. They were then added to human plasma from the same subject containing increasing conc. (0-250 IU/ml) of rtPA (Actilyse
®
) and incubated for 2 hrs under continual stirring conditions at 37°C. Lysis was measured as amount of fluorescence released into plasma from the thrombus over 2hrs.

Preformed thrombi added to plasma containing only dabigatran underwent no lysis. Lysis of preformed control thrombi (in the absence of dabigatran) occurred in a conc-dependent manner when incubated with rtPA and maximal lysis was achieved with 300 IU/mL. Thus further experiments were performed with ≤250 IU/ml rtPA to look for potential synergistic effects with dabigatran. Clots preformed in PRP containing either 30 or 75 ng/mL dabigatran were more susceptible to rtPA-induced lysis, with maximal lysis achieved with 100 IU/mL rtPA, and ~ 90% lysis was achieved with 50 IU/mL rtPA.

These data provide evidence that thrombi preformed in low concentrations of dabigatran appear to be more susceptible to thrombolysis with rtPA than those preformed in the absence of dabigatran, thus lower concentrations of rtPA achieve a similar degree of thrombolysis under these experimental conditions. This may imply that in patients that suffer a stroke while on dabigatran therapy, lower doses of tPA may also be effective.
Abstract WP283: Medical Treatment Matters: Using Headdfirst Results To Enhance The Lessons From The European Hemicraniectomy Trials For Stroke
Authors: Frank Jeffrey I , Schumm Phil , Thisted Ronald ,   HeADDFIRST Investigators
Published: July 2021

Introduction:
HeADDFIRST was a randomized trial to evaluate the benefit of surgical decompression for brain swelling from large supratentorial cerebral hemispheric infarction (LSCHI). Subsequently, several similar European trials have been completed. Several unique aspects about HeADDFIRST findings provide specific lessons about patient selection and the significance of medical management to outcome, particularly in the context of these trials.

Methods:
All patients were screened for eligibility (age 18-75, NIHSS > 18, and CT demonstrating at least compete MCA territory infarction by specific imaging criteria). Those without exclusions and consented were treated by a standardized medical treatment protocol. Those with > 4 mm of pineal shift or > 7.5 mm of anteroseptal shift within 96 hours of stroke onset were randomized to the medical treatment only (MTO) or surgical + medical treatment (SMT) arms with struct adherence.

Results:
40 patients were registered, and 26 developed the requisite brain swelling for randomization. All of those consented who failed to develop the degree of brain swelling required for randomization survived. The 180-day mortality was 40% and 35.7% in the MTO and SMT arms, respectively. From the pooled meta-analysis of the European trials’ the 12-month mortality was 71% and 22% in the medical and surgical arms.

Conclusion:
1. HeADDFIRST medical treatment outcomes were profoundly better than the European trials, suggesting some significance to our medical treatment protocol differences and the strict adherence.

2. HeADDFIRST randomization criteria accurately differentiates between survivors vs. those with a high risk of non-survival with LSCHI.
Abstract WP29: Early U.S. Experience with the Trevo Retriever Device: A Multi-Center Analysis
Authors: Alexander Michael J , Veznedaroglu Erol , Feng Lei , Duckwiler Gary , Siddiqui Adnan , Richards Boyd , Chao Kuo
Published: July 2021

Introduction:
The Trevo Retriever device (Stryker Neurovascular, Mountain View, CA) received FDA clearance as a 510K device in August 2012 for clot retrieval in acute ischemic stroke within eight hours of symptom onset. This study is an early look at the initial U.S. experience with the device following FDA clearance, examining the clinical results of the some of the first cases performed in the U.S.

Methods:
This was a retrospective analysis of prospectively collected clinical data from the early U.S. experience using the Trevo Retriever device. All physician operators were in-serviced on the use of the device and technique prior to first clinical use. Of the first patients treated, 6 were MCA occlusions, and 1 ICA occlusion. Four of the patients received intravenous tPA prior to their intervention, the remaining three patients did not did not qualify for IV tPA. The mean NIHSS pre-procedure was 19.

Results:
The Trevo device could be delivered across the intraluminal clot in all seven cases. There was a 100% success rate in revascularization of the target territory as judged by TICI score 2b or 3. One case resulted in an ACA embolus that was successfully revascularized. There was an average of 2.0 passes of the device to achieve this revascularization rate (range 1-4), with 71% of the cases needing 1 or 2 passes, and the remaining 3 or 4 passes. The mean time from femoral access to revascularization was 44 minutes (range 18-93 minutes, median 31 minutes). The average clot length was 11 mm. The clot was characterized as soft/friable in 2 cases, intermediate/rubbery in 3 cases, and hard/fibrous in 2 cases. The 24 hour post-procedure NIHSS was improved in 86% of the patients treated, and the mean NIHSS at 24 hours was 10 (range 0-27). Five of the seven patients had an improvement on the NIHSS of 9 points or greater.

Conclusions:
The technical success rate, as measured by a TICI score of 2b or 3, was excellent (100%) in this initial U.S. experience. With a high revascularization rate and a few number of passes, this shortened the endovascular revascularization time, and resulted in improved clinical exam in 6 of the 7 patients within 24 hours post-procedure.
Abstract WP309: Association of Molecular Markers with Perihematomal Edema and Clinical Outcome in Intracerebral Hemorrhage
Authors: Li Na , Liu Yan Fang , Ma Li , Worthmann Hans , Raab Peter , Wang Yilong , Wang Yongjun , Gao Yi Pei , Dengler Reinhard , Weissenborn Karin , Zhao Xingquan
Published: July 2021

Background and Purpose:
Perihematomal edema (PHE) contributes to secondary brain injury in intracerebral hemorrhage (ICH). Increase of matrix metalloproteinases (MMPs) and growth factors (GFs) is considerably involved in blood-brain barrier disruption and neuronal cell death in ICH models. We therefore hypothesized that increased levels of these molecular markers are associated with PHE and clinical outcome in ICH patients.

Methods:
Fifty-nine patients with spontaneous ICH admitted within 24 hours of symptom onset were prospectively investigated. Noncontrast CT was performed on admission for diagnosis of ICH and quantification of initial hematoma volume. MRI was performed on day 3 in order to evaluate PHE. Concentrations of MMP-3, MMP-9, as well as vascular endothelial growth factor (VEGF) and Angiopoietin-1(Ang-1) on admission were determined by enzyme-linked immunosorbent assays. Clinical outcome was assessed by modified Rankin Scale (mRS) at 90days.

Results:
Increased MMP-3 levels were independently associated with PHE volume (P<0.05). Cytotoxic edema (CE) surrounding the hematoma was seen in 36 (61%) cases on 3-day MRI. CE did not correlate with the level of any of the biomarkers studied. Levels of MMP-3 ≥12.4 ng/ml and MMP-9 ≥192.4 ng/ml but not VEGF and Ang-1 predicted poor clinical outcome at 90 days (mRS>3) independent of stroke severity and hematoma volume at baseline (OR 25.3, P=0.035; OR 68.9, P=0.023; respectively).

Conclusion:
Metalloproteinases 3 and 9 seem to be significantly involved in secondary brain injury and outcome after primary ICH in humans and thus should be further evaluated as targets for therapeutic strategies in this devastating disorder.
Abstract WP326: Randomized-Controlled Study on the Effects of Hand Bathing on Stroke Patients in Convalescence - Subjective Improvements in Hand Movement and Increased Positiveness in Talking
Authors: Yano Rika , Haseyama Miki
Published: July 2021

Background and Purpose:
Depressed stroke patients are more likely to drop out of rehabilitation. Hand bathing is a term used to describe a uniquely Japanese hygiene care in which a nurse washes and stimulates the patient’s hands in warm water while talking to each other. The purpose of this study was to verify, by a randomized-controlled study, the hypothesis indicated in the author’s preliminary studies that hand bathing makes stroke patients more conscious of their hand movement on the affected side and talk more positively.

Methods:
Stroke patients in convalescent phase in the Brunnstrom stages I to V were randomly allocated to the hand-bathed group (23 patients) or the control (21 patients). Both groups received a 15-minute intervention four times within a week. Before and after each intervention, the visual analogue scale (VAS) was assessed for hand movement, edema, and numbness/pain, the tip palm distance was measured, and the QOL was assessed using the QUIK-R. The t-test and repeated measures ANOVA were used to analyze the data. A verbatim record of all conversation was subjected to morphological analysis, TF-IDF, and TF analysis of nouns and adjectives.

Results:
The hand-bathed group felt improved hand movement significantly more after the first and fourth interventions (F=4.41,p=.013). No significant difference was detected between the two groups in the VAS for edema, numbness/pain, and heavy feeling in hands. Positive adjectives were used more often by the hand-bathed group after the second, third and fourth interventions (F=3.58, p=.016). In the hand-bathed group, the average score of QOL questions on socializing and sense of contentment/well-being improved significantly after interventions (p=.003)

Conclusions:
The finding supported the said hypothesis in that hand bathing leads to subjective improvement in hand movement of stroke patients in convalescent phase and makes them talk more positively. It has additionally been indicated that hand bathing also helps them become more sociable and have a better sense of contentment and well-being.
Abstract WP34: Factors Associated with Reduced use of Stroke MRI: an Analysis of Practice Patterns
Authors: Burke James F , Skolarus Lesli E , Callaghan Brian C , Morgenstern Lewis B , Kerber Kevin A
Published: July 2021

Background:
Guidelines support the use of Magnetic Resonance Imaging (MRI) in the evaluation of acute stroke, however the perceived value of MRI information to providers in different clinical scenarios is not known. We aimed to identify patient characteristics associated with lower MRI use as means of identifying possible clinical scenarios where providers may perceive MRI to be less valuable.

Methods:
Stroke hospitalizations (principal ICD-9-CM 433.x1, 434.x1, 436) were identified from the State Inpatient Databases (SID) from 2003-2009 for 12 states. MRI utilization was identified using revenue codes and ICD-9 procedure codes. Patient characteristics were abstracted from the hospitalization record. Multi-level logistic regression with a random hospital-level intercept was used to estimate the association between patient characteristics (demographics, vascular risk factors, stroke mimics, comorbidities, regional socioeconomic status) and MRI. Effect sizes were estimated using posterior probabilities with all covariates held at their means. Sensitivity analyses accounting for the distribution of MRI contraindications were performed.

Results:
670,309 hospitalizations were included in our sample; 51% of the population received MRI. From the model (area under ROC 0.82), age and potential cardioembolic source (atrial fibrillation, congestive heart failure, myocardial infarction) were associated with a lower probability of MRI utilization (table). The predicted probability of MRI in a 50 year old was 63.7% (95% CI 61.5%-65.9%) compared to 41.6% (39.4%-43.9%) in an 80 year-old. In sensitivity analysis, the association between cardioembolic sources and lower MRI use remained significant after accounting for extreme assumptions about the distribution of MRI contraindications.

Conclusions:
In routine care, MRI may have less perceived value by providers in stroke patients who are older and have a potential cardioembolic source.
Abstract WP351: Using Standard Work to Improve the Discharge Process on a Neurology Division
Authors: Donnelly Rose M , Tranor Tim , Griffin Julie , Foreman Kalcee , Ford Adrienne , Wallis Katie , Carpenter David , Van Stavern Renee B , Dinwiddie Tom , Antonacci Becky , Triplett Heather , Solomon Sondra , Thomas Calvin , Harris Hilary , Wellen Mary , Davis Michelle , Hoff Brian
Published: July 2021

Background and Issues:
Patient volume increased significantly over first half of 2011 on the Neurology Service. Bed occupancy increased by 14% over previous year and bed availability became a major constraint. Data showed, patients were discharged late in the day or sometimes stayed an extra night because discharge orders were released too late to place patients in rehab or skilled nursing facilities. Only 16% of patients were discharged by 2:00 pm due to communication barriers and inadequate information exchanged between multidisciplinary teams. There was also an issue with inconsistent acceptance criteria from primary placement facilities which resulted in a longer length of stay.

Purpose:
Primary goal of project was to free up capacity on the Nursing Division to accommodate the increase in patient volumes without increasing staffing or the number of available beds.

Methods:
In September 2011, a multidisciplinary team was assembled to understand causes of the problems and develop solutions to resolve. Solutions implemented include working with partner Rehab and Skilled Nursing Facilities to define standardized Acceptance Guidelines to ensure issues could be addressed before day of discharge. Also, processes for releasing discharge orders were redesigned so orders were more frequently written and placed “on hold” the day before expected discharge. A mobile computer was issued to physician rounding teams so orders could be released during rounds instead of batch-released in the afternoon. Additionally, team communication was significantly improved by standardizing a daily multidisciplinary team huddle and implementing a visual communication board to track key information about patients to proactively plan for discharge.

Results:
The overall length of stay of patients on the Neurology Service decreased from 4.26 days in 2011 to 3.69 days in 2012.

Conclusions:
Many variables contributed to the decrease in length of stay for patients in this study. No decisive conclusions can be made about the effectiveness of any particular variable. Other variables during this timeframe likely contributed, however the authors of this study presented the most likely factors. Although the findings are exciting, further analysis is needed to isolate the main drivers.
Abstract WP352: Stroke Rounds: An Organizational Approach to Core Measures Improvement
Authors: Counters Mandi , Barna Amy , Krage Beth
Published: July 2021

Background & Purpose:
In 2011 our team realized a deficiency in nursing knowledge of stroke patient care and Stroke Core Measures, after discovering that our stroke education scores were 84% overall for the year. An innovative stroke rounding process was launched following hospital-wide education regarding stroke patient care and the Stroke Core Measures with the purpose of increasing bedside nursing knowledge and competency with these topics.

Methods:
A rounding worksheet was created using the Stroke Core Measures. Stroke rounds are completed three times weekly by the Neuroscience Nurse Educator, Clinical Nurse Leader, and bedside nurse. A discussion with the nurse includes chart review, completion of a rounding worksheet, and individualizing stroke care plan goals. This may progress to obtaining additional orders and/or consulting additional disciplines.

Results:
Preliminary data for the second quarter of 2012 identifies that stroke education scores increased to 100% as of the end of April. Review of the stroke rounding worksheets identified that initiation of stroke education is occurring earlier in patients’ hospitalizations. Anecdotal reports from nurses indicate increased knowledge of Core Measures and comfort in caring for stroke patients. A formal facility-based survey to nursing will be completed prior to presentation in 2013.

Conclusions:
Success with rounds in the stroke unit precipitated the process in critical care. Both units now are utilizing the process and have received positive feedback from nursing staff.
Abstract WP354: Hospitalized Stroke Patient Falls Rates Reduced by 50% after Stroke Survivor Focus Group
Authors: Gray Kimberly
Published: July 2021

Stroke survivors are well known to fall both in the hospital and in the community settings. Fall prevention literature recommends the use of a variety of interventions, or fall ’bundles’, to reduce hospitalized patient falls. The organization’s stroke collaborative practice team (SCPT) began monitoring hospitalized stroke patient fall rates in 2010. Even when the hospital’s organizational rates dropped, stroke patient fall rates did not. It was noted that there were no bundle strategies specifically targeting the array of disabilities that can be caused from a stroke, nor what is it clear what they should be. Thus, a falls focus group was conducted with the hospital’s stroke survivor and caregiver support group in 2011. The purpose of the meeting was to discuss their experiences with falls, review fall prevention strategies from our organization, and see if they had any suggestions that may prevent hospitalized stroke patients from falling. Over 20 stroke survivors and caregivers attended a videotaped meeting. All stroke survivors, and several caregivers, indicated with a show of hands, that they fell at home and/or while in the hospital. A robust discussion followed where many verbalized that as a result of their deficits, such as impulsivity, memory changes or aphasia, their felt our current fall bundle would not prevent a stroke patient from falling. They felt having someone in the room was a best practice and if no one could be in the room, they recommended using bed alarms. Based on their feedback, the SCPT created a new practice so all stroke patients would be placed on a bed alarm on admission. This allows everyone time to adjust to limitations cause by any new disabilities. Inpatient rehabilitation also added low beds. Data collected January to June 2011 showed on average 2 stroke patients fell each month. The new practices were implemented over the next several months. Data from November 2011- June 2012 showed fall rates dropped to approximately 1 a month, or a 50% reduction in hospitalized stroke patient falls. The value of the patient and family experience can be a powerful tool in improving performance and outcomes. Incorporating their feedback on fall prevention strategies in our organization has helped reduce hospitalized stroke patient falls.
Abstract WP360: Utilization of the National Institutes of Health Stroke Scale: Challenges and Interventions
Authors: Yanko Janette R , Lang Stacey
Published: July 2021

Background and Issues
The National Institutes of Health Stroke Scale (NIHSS) is a valuable tool that assists in the diagnosis and treatment path of stroke patients. In addition, the NIHSS can provide an objective measurement of the patient’s neurological status and progress throughout the acute care hospitalization. Even though the tool’s validity, impact on patient care, and usefulness in post discharge disposition decision-making is well known, it is not used as a standard tool in every institution that treats stroke patients.

Purpose
A survey was developed to gather information about the administration of the NIHSS in order to ascertain its usage rate and any perceived barriers would deter its usage. Based on the results, a plan was developed for to assist in overcoming the barriers and for providing more effective usage of the NIHSS.

Methods
An NIHSS Utilization Survey was sent to hospitals across the country. Fifteen questions queried educational practices, competence, usage rate, challenges, and effectiveness related to the NISHH. The results from 194 respondents were compiled an analyzed.

Results
The results showed that the main use for the NIHSS was to determine eligibility to receive t-PA; very few used it for developing plans for patient care beyond t-PA eligibility. A few of the barriers identified in the application of the NIHSS included time required to perform the exam, inconsistent scoring among examiners, especially with comatose or uncooperative patients, and lack of adequate teaching resources for educating examiners regarding how to use the scale.

Conclusion
Many institutions face the similar issues regarding the usage of and performance in administering the NIHSS. A continued focus on addressing these issues, including methods for modifying NIHSS education practices and assuring competency and inter-rater reliability, is needed to effectively enhance NIHSS accuracy and incorporation into patient care treatment plans for achieving optimal outcomes.
Abstract WP382: The Cost of Ischemic Stroke: The Superiority of Marginal over Total Cost Estimation and Its Impact on National Cost Estimates
Authors: Simpson Annie N , Ellis Charles , Kazley Abby S , Bonilha Heather S , Zoller James S
Published: July 2021

Introduction
Cost of illness for ischemic stroke has historically been reported as mean cost per case over a time period. Such cost include expenditures made for comorbid conditions, and may result in an over-estimation of the economic burden of stroke on the nation. Without accurate estimates, policymakers cannot plan appropriately for the ageing US population.

Hypothesis
The 1-year marginal cost of stroke is less than the 1-year total cost of stroke for South Carolina (SC) Medicare beneficiaries.

Methods
A cost of illness analysis was performed from the Medicare perspective. SC Medicare billing files for 2004 and 2005 were used to estimate the mean 12 month cost of stroke for 2,976 Medicare beneficiaries hospitalized for ischemic Stroke in 2004. Using nearest neighbor propensity score matching, a control group of 5,952 non-stroke beneficiaries were matched on age, race, gender and comorbid conditions.

Results
The total cost estimated for stroke patients for 1 year was $81.3 million. The cost for the matched comparison group without stroke, but with similar age, gender, race and comorbid conditions was significantly less at $54.4 million (p<0.0001). Thus, the 2004 marginal costs to Medicare due to ischemic stroke in SC are estimated to be $26.9 million. If this difference is inflated to 2012 dollars and projected to estimate the 2012 one year burden of ischemic stroke nationally, total annual stroke costs would be overestimated by $4.89 billion.

Conclusions
Accurate estimates of cost of care for conditions, such as stroke, that are common in older patients with a high rate of comorbid conditions require the use of a marginal costing approach. Overestimation of cost of care for stroke may lead to erroneous funding allocation and prediction of larger savings than realizable from stroke treatment and prevention programs. Given the trend of policies based on cost savings, overestimation poses a danger of limiting services that patients may receive. Thus, it is important to use marginal costing for stroke program estimates, especially with the increasing public focus on evidence-based economic decision making to be expected with health reform.
Abstract WP387: Stroke Mortality In Japan Increases On Weekends Altough Those In Comprehensive Stroke Centers Remain Unchanged. -J-ASPECT Study
Authors: Nishimura Kunihiro , Iihara Koji , Kada Akiko , Nakai Michikazu , Nakagawara Jyoji , Ogasawara Kuniaki Ogasawara , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Miyachi Shigeru , Nagata Izumi , Kamitani Satoru , Toyoda Kazunori , Mori Hisae , Kataoka Hiroharu , Matsuda Shinya
Published: July 2021

Objective
Weekend disparities in stroke care were well known. The aim of this study is to examine the association between day of admission and the mortality of Stroke in Japan. Moreover, we examine if comprehensive stroke center (CSC) could overcome the weekend effect.

Methods
We analyzed the Nationwide registry of claim data(J-ASPECT study) in 378 certified training institutions of the Japan Neurosurgical Society and/or the Japan Stroke Society, which included patients discharged with a primary diagnosis of cerebral infarction in 2011. The definition of CSC was followed by the article of McKinney et al. (Stroke. 2011;42:2403-2409.)

Results
A total of 68,718 patients were admitted with a primary diagnosis of cerebral infarction during the study period while 10,141 patients were admitted to comprehensive stroke centers. As a result, thirty-day mortality was statistically greater in patients admitted on weekends compared to weekdays (9.1% versus 8.3%;
P
= 0.0004). The age and sex adjusted risk of death at 30 days which derived from multivariate logistic regression were also significantly greater for weekend admission (odds ratio, OR= 1.11; 95% CI, 1.04 to 1.18). This association was robust using hierarchical logistic regression which adjusted for institute difference. (OR= 1.06, 95% CI, 1.01 to 1.12) .The mortality of patients in hospitals with stroke care units showed no difference between weekends and weekdays (p=0.398) while the difference was significant for patients, not in a stroke care unit (p=0.046).Furthermore, there was no significant difference in 30-day mortality for patients admitted to CSCs between weekends and weekdays (p=0.418) while patients who were not admitted to CSCs showed the significant mortality difference between weekends and weekdays (p=0.041). The risk of mortality was 2% decreased with the satisfaction of every one criterion for comprehensive stroke care unit. (OR=0.98, 95% CI 0.97 to 0.99) adjusted for weekend effect.

Conclusions
Patients with stroke admitted on weekends in Japan had a significantly higher risk of death than weekdays within 30 days. There was no significant weekend difference of stroke mortality at hospitals with stroke care units and comprehensive stroke centers.
Abstract WP4: Conscious Sedation With Dexmedetomidine For Acute Stroke Patients Undergoing Intrarterial Therapy.
Authors: Jumaa Mouhammad A , Lin Ridwan , Zaidi Syed F , Linares Guillermo , Jadhav Ashutosh , Jankowitz Brian , Jovin Tudor G
Published: July 2021

Background:
The aim of this pilot study was to prospectively determine safety and feasibility of Conscious sedation (CS) with dexmedetomidine in stroke patients undergoing intra-arterial therapy (IAT).

Methods:
This industry sponsored prospective single arm study was conducted with institutional IRB approval. The following data points were collected: demographics, pre-procedure NIHSS, mean time to treatment, treatment modalities, sedation and procedure times and the use of adjunctive sedation medications. Outcome measures included intraprocedural pain scores and Richmond agitation sedation scale (RASS), recanalization score, intraprocedural complications, conversion to GA, modified Rankin scale at 30 days as well as a personal account of the patients experience during the procedure.

Results:
Fifty- one patients were enrolled in this study of which 41 patients underwent acute stroke therapy and were included in this analysis.

Baseline characteristics are included in table 1. Site of occlusion was the MCA in 27 patients, ICA-terminus in 10 patients and BA in 4 patients. IAT was performed using the MERCI device in 30 patients, Penumbra device in 3, manual aspiration in 5, and angioplasty and stenting in 3 patients. Adjunctive IA tPA was administered in 6 patients.

All patients tolerated treatment under CS. The mean procedural RASS was 0 and the mean pain score was 1. Thrombolysis in Cerebral Ischemia (TICI) 2B/3 recanalization was achieved in 32 patients (78%). Two intra-procedural wire perforations (5%) were recorded. Ten patients (24%) had a mRs of < 2 at 30 days and 6 patients died (14%). Thirty-one patients described their experience. Only 6 patients were able to remember having the procedure of which 1 had a negative experience.

Conclusion:
To our knowledge, this is the first prospective study to evaluate the safety and efficacy of CS in stroke patients who undergo IAT. In our cohort, CS was safe, feasible and well tolerated.
Abstract WP406: Out of Pocket Costs for Pediatric Stroke Care
Authors: Plumb Patricia , Seiber Eric , Dowling Michael M , Lee JoEllen , Bernard Timothy J , deVeber Gabrielle , Ichord Rebecca , Bastian Rachel , Lo Warren D
Published: July 2021

Objective:
Direct hospital costs have been reported for children who have had stroke, and are similar to direct costs for adults. There has been no information regarding the indirect costs families encounter that are not covered by insurance (i.e. out-of-pocket) costs. Knowing the magnitude of these costs will give a more complete understanding of the economic impact of childhood stroke. This study describes out-of-pocket costs families paid in the first year after a child’s ischemic stroke.

Methods:
22 of 70 possible subjects were prospectively recruited at 4 centers in the US and Canada in 2008 and 2009 for the “Validation of the Pediatric NIH Stroke Scale” study, and their out-of-pocket costs were tracked for 1 year. Parents reported expenses every three months, including wages lost for hours they did not work, non-reimbursed costs for medical visits or other health care, and mileage. They provided estimates of annual income. We calculated total out-of-pocket costs in US dollars. We also reported costs as a proportion of annual income to account for regional differences in income.

Results:
Total median out-of-pocket cost for one year was $4354 (range 0-$28,666). Wage earners in two families lost their jobs. Out-of-pocket costs were greatest in the first three months after the incident stroke, with the largest proportion due to lost wages, followed by non-reimbursed healthcare, lodging, and transportation. Lost wages remained high in the second quarter, but fell by the third and fourth quarters. Healthcare costs remained stable for the 4 quarters. For the entire year median out-of-pocket costs represented 6.8% (range 0-81.9%) of annual income.

Conclusions:
Out-of-pocket expenses are significant for families following a child’s ischemic stroke. These median out-of-pocket expenses of $4300 are of particular concern given that the median American household has cash savings of only $3,860. These results can be combined with previous reports of childhood stroke costs to model the overall costs of childhood stroke. Childhood stroke creates an under-recognized cost to society because of decreased parental productivity due to lost hours from work.
Abstract WP425: Predictive Value Of Daily Physical Activity And New Onset Of Vascular Events In Patients With Mild Ischemic Stroke.
Authors: Kono Yuji , Yamada Sumio , Kamisaka Kenta , Iwatsu Kotaro , Araki Amane , Fujioka Yusuke , Yasui Keizo , Hasegawa Yasuhiro , Koike Yasuo
Published: July 2021

Introduction:
Daily physical inactivity is associated with a substantially increased risk of cardiovascular events. However, the target level of daily physical activity is remained unclear. We aimed to evaluate the impact of physical activity on long-term vascular events in patients with mild ischemic stroke.

Methods:
We designed prospective observational study and enrolled 142 ischemic stroke patients with modified Rankin Scale 0-1 (mean age: 63.9±9.2). We measured daily step count as a variable of daily physical activity after 6-month from stroke onset. Other clinical characteristics including age, body mass index, blood pressure, blood labo test, carotid echo findings and medications were also assessed. The primary outcome was hospitalization due to stroke recurrence, myocardial infarction, angina pectoris, and peripheral artery disease. Survival curves were calculated by Kaplan-Meier survival analysis, and hazard ratios for recurrence were determined by univariate and multivariate Cox proportional hazards regression models.

Results:
After 1130.2±372.8 days of follow-up, 29 vascular events (19 stroke recurrence, 10 coronary heart disease) occurred, and the patients were divided into two groups: survival (n=113) and recurrenct (n=29). Daily step counts (
P
=0.003) and plaque score (
P
<0.001) were significantly lower in the recurrent group than survival group. Univariate and multivariate Cox proportional hazards analysis revealed daily step counts and plaque score to be independent predictors of new vascular events. A daily step counts cutoff value of 6000 steps per day was determined by the analysis of receiver-operating characteristics with sensitivity 69.4% and specificity 79.4%. Kaplan-Meier survival curves after log-rank test showed significantly lower event rate in over 6000 steps group as compared to less than 6000 steps group (
P
=0.023).

Conclusion:
In conclusion, our data indicate that daily physical activity evaluated by step counts may be useful for forecasting prognosis in patients with mild ischemic stroke. Daily step counts of 6000 steps may be a first target level to reduce new vascular events.