bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract MP58: Motor Cortex and Spinal Cord Transcriptome After Post-Stroke Optogenetic Neuronal Stimulation
Authors: Cheng Michelle Y , Uchino Haruto , Chiang Terrance , Kim Anika , Cao Zhijuan , Lee Alex , Steinberg Gary
Published: March 2021

Background:
Post-stroke brain stimulation is a promising neurorestorative technique to promote recovery. However, the underlying molecular mechanisms driving recovery are still unclear. Here we investigate the molecular changes in both the primary motor cortex and the cervical spinal cord after large cortical stroke in mice receiving repeated optogenetic stimulations in the ipsilateral primary motor cortex (iM1).

Methods:
C57Bl6 male mice (8 weeks) underwent stereotaxic surgery to express Channelrhodopsin2 in excitatory neurons in iM1, with optical fiber implanted in the same location. After five weeks the mice underwent a transient middle cerebral artery occlusion to induce stroke. Optogenetic stimulations were given daily from post-stroke days (PD) 5-14. Non-stimulated mice were used as controls. Rotating beam test was used to evaluate functional recovery after stroke. At PD 7 and 15, ipsi- and contralesional primary motor cortex (iM1 and cM1) and cervical spinal cords (iSp and cSp) were dissected and processed for RNA sequencing.

Results:
Repeated iM1 stimulations resulted in a robust recovery on the rotating beam test at PD14, with significant improvement in distance traveled (p<0.05). RNA sequencing analysis (stimulated vs non-stimulated mice) revealed differential transcriptome in both motor cortex and spinal cord. Higher number of differentially expressed genes (DEGs) were observed in the ipsilesional regions (iM1 and iSp). At PD 7, stimulated mice exhibited upregulation of activity-dependent and neuroplasticity-related genes in iM1. Interestingly, at PD15, cholesterol metabolism and neuroinflammatory related genes in iM1 were downregulated. The expressions of the genes were negatively correlated with behavioral recovery. Higher number of DEGs were altered in the spinal cord than motor cortex, suggesting more dynamic molecular changes occur in this area during the post-stroke reinnervation processes. Expressions of synaptogenesis related genes were altered in both iSp and cSp at both timepoints.

Conclusions:
These transcriptome data reveal important insights into the molecular signaling involved in post-stroke stimulation-induced recovery and provide potential drug targets for enhancing recovery in stroke patients.
Abstract MP59: Retinal Vascular Metrics Predict Pial Collateral Status in Patients With Acute Ischemic Stroke
Authors: Khan Adnan , Kamran Saadat , Boever Patrick D , Gerrits Nele , Saqqur Maher , Petropoulos Ioannis N , Ponirakis Georgios , AKHTAR NAVEED , Shuaib Ashfaq , Malik Rayaz
Published: March 2021

Background:
The extent of the pial collateral circulation may determine outcomes in an acute ischemic stroke. Experimental studies suggest that retinal vessel metrics and geometric patterning may predict the pial collateral status. We have undertaken a translational study to quantify and relate retinal vascular metrics to the grade of pial collaterals in patients with acute ischemic stroke.

Method:
35 patients admitted with acute stroke underwent computed tomography angiography (OCT) and were graded as having good (n=20)(47.55 ± 10.65 years) or poor (n=15) (48.93 ± 10.91 years) pial collaterals and compared to healthy controls (n=21)(44.26 ± 10.15 years). Retinal images were generated using OCT and central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), artery-to-vein ratio (AVR), segmented fractal analysis and lacunarity, tortuosity index and fractal dimensions (capacity D
0
, information D
1
and correlation D
2
, curve asymmetry, singularity length and f-alfa-max using MONA software) were quantified.

Results:
Age (
p
=0.709), BMI (
p
=0.451), total cholesterol (
p
=0.845), triglycerides (
p
=0.679), LDL (
p
=0.953), HDL (
p
=0.361) and HbA
1c
(
p
=0.210) were comparable but the national institute of health stroke scale (
p
=0.031) and modified Rankin Scale (
p
=0.048) were higher in patients with poor compared to good collaterals. CRAE (
p
=0.114), CRVE (
p
=0.946), AVR (
p
=0.114), lacunarity (
p
=0.442), tortuosity index (
p
=0.681), fractal analysis (
p
=0.656), curve asymmetry (
p
=0.619) and singularity length (
p
=0.944) did not differ between patients with poor compared to good collaterals. However, fractal capacity D
0
(1.673 ± 0.029 vs 1.654 ± 0.025,
p
=0.042), fractal information D
1
(1.610 ± 0.027 vs 1.591 ± 0.024,
p
=0.036), fractal correlation D
2
(1.581± 0.028 vs 1.564 ± 0.024,
p
=0.060), and f alfa max (1.674 ± 0.027 vs 1.654 ± 0.025,
p
=0.030) were higher in patients with poor compared to good collaterals.

Conclusion:
This study shows differences in retinal vessel fractal dimensions between acute stroke patients with poor compared to good pial collaterals. This represents a non-invasive imaging method to define the pial collateral status and develop personalized intervention management strategies in acute ischemic stroke patients.
Abstract P113: Impact of Covid-19 Pandemic on the Pre-Hospital Evaluation and Presentation of Ischemic Stroke at a Non-Urban Comprehensive Stroke Center
Authors: Velasco Cesar , Richardson Alicia M , Padmanaban Varun , Reichwein Raymond K , Church Ephraim , Simon Scott , Wattai Brandon , Buchle Scott , Cockroft Kevin M
Published: March 2021

Introduction:
Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on non-urban areas with minimal community transmission is less well understood.

Methods:
Using a prospectively maintained pre-hospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis.

Results:
In January, February, March, and April 2019 10, 11, 17 and 19 patients, respectively were transported in comparison to 19, 14, 10 and 8 during the same months in 2020. From January through April 2019 there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020. The slopes of these trend lines are significantly different (3.30; 95%CI 0.48 - 6.12 versus -3.70; 95%CI -5.76 - -1.64, P = 0.001). There were no significant differences in demographics, comorbidities, symptom severity, or stroke discharge diagnoses between the two time periods. However, the median interval from LKW to time of EMS dispatch was significantly longer in January to April 2020 (12
+
273 min) compared to the same time period of January through April in 2019 (7
+
115 min).

Conclusion:
Our data indicate not only a decrease in patient transport volumes but more alarmingly, significantly longer intervals to EMS activation for suspected stroke care. These results suggest that even in a non-urban location without widespread community transmission patients were delaying or avoiding care for severe illness such as stroke.
Abstract P114: A Nurse-Led Multi-Component Behavioral Activation Program to Improve Treatment Decision-Making and Health Outcomes in Patients With Atrial Fibrillation
Authors: LI Wai Chi Polly , Yu Doris
Published: March 2021

Introduction:
Atrial fibrillation (AF) is a complex condition that requires a multifaceted management approach to reduce disease- and treatment-related complications. However, under-prescription of oral anticoagulant (OAC), non-adherence, suboptimal anticoagulation and risk factor control leave patients to increased risks of adverse outcomes.

Methods:
This mixed-methods study comprised a randomized controlled trial and an exploratory qualitative study. Community-dwelling patients with AF but no OAC treatment (N = 89) were randomized to receive either the Nurse-led Multi-component Behavioral Activation (N-MBA) program or standard care. The N-MBA program equipped patients as an active agent to manage their AF. Firstly, the nurse enabled patients to be aware of their stroke risk by using a decision-aid, then empowered them to discuss OAC use with physicians actively and be responsible for the medication and lifestyle-related self-care for stroke prevention. A purposive subsample (n=10) from the N-MBA program were interviewed for their engagement experience.

Results:
As compared with those received the standard care, the N-MBA group showed significantly greater intention to use OAC, and their OAC treatment option was more compatible with physician’s decision at immediate post-test (
p
= .002). They also reported greater improvements on health-related quality of life (HRQoL) (immediate post-test:
p
= .023; 6-month post-test:
p
= .047) and AF knowledge (immediate post-test:
p
= .004) after attending the program. The N-MBA program was highly receptive with excellent attendance (92%) and mean satisfaction score (4.94/5.00 ± 0.88). The participants expressed that the decision-aid enabled them to make the OAC treatment decision through better understanding of their stroke risk, pros and cons of different treatments. Through attending the interactive health counseling, they found themselves as more assertive to discuss the treatment options with their physicians. Together with the prompt access of a nurse for advice, they perceived themselves as capable to perform AF-related self-care.

Conclusions:
The preliminary analysis showed that the N-MBA program is feasible and effective to optimize treatment decision making and HRQoL in AF patients.
Abstract P118: Process Improvement for Stroke/EMS Run Sheets Available in Medical Record
Authors: Watts Tammy
Published: March 2021

Background and Purpose:
When stroke patients arrive to the hospital, it is imperative to have a clear picture of what occurred during transport from home, scene or other facility. The stroke team encountered difficulties in obtaining emergency medical services (EMS) run sheets in real time. We also found that these records, even when obtained, were often not scanned into the electronic medical record (EMR).

Methods:
We created a plan of action with our ED Stroke Champions, which involved development of an automated system to streamline the process of the run sheet scanning into EMR. In December 2019 barcode scanning devices were purchased and placed in the ED to facilitate this process. Ongoing education of the new process was conducted via email to notify our EMS partners of these changes, as well as face to face discussions whenever possible. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. The process was that the EMS partners would:•receive the patient’s medical record number with barcode•stop at a central scanner•send the EMS run sheet directly into the EMR This process began on December 16, 2019. Three days before, another email went out to all EMS partners describing the process with a visual aide. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED.

Results:
In November 2019, 20 eligible ground EMS run sheets were sent to the Medical Records department for EMR scanning. After review, 13 (65%) were found scanned into the EMR. A review of January-July 2020 showed the following eligible scanned run sheets into EMR.•January 2020, 1 out of 21 (4.5%)•February 2020, 4 out of 26 (1.5%)•March 2020, 2 out of 17 (12%)•April 2020, 5 out of 15 (33%)•May 2020, 12 out of 18 (67%)•June 2020, 7 out of 7 (100%)

Conclusions:
With implementation of an automated process, significant improvement has been seen in obtaining and scanning run sheets. This will lead to better decision making regarding acute treatments in stroke patients.
Abstract P123: Comparing Process, Performance Measures and Clinical Outcome Between Mobile Stroke Unit and Usual Care in Underserved Areas
Authors: Nilanont Yongchai , Shukij Karuna , Pengtong Waitayaporn , Kongmuangpuk Mananchaya , Wongmayurachat Kanokkarn , Saposnik Gustavo , Nittayaboon Kittiya , Chanyagorn Pornchai , Wongsawat Yodchanan , Sirovetnukul Ronnachai , Chakorn Tipa , Riyapan Sattha , Kaweeta Chitapa , Chotik-anuchit Songkram , Churoj Anchalee , Tongdee Trongtam , Hunnangkul Saowalak , Thabmontian Ploypailin , Saeheng Pornthep , Nopmaneejumruslers Cherdchai , Vamvanij Visit
Published: March 2021

Background:
The efficacy of mobile stroke units (MSU) in improving acute ischemic stroke (AIS) care in developing countries is unknown. We compared performance measures and treatment outcomes between MSU and usual care.

Methods:
We enrolled patients >18 years of age with a diagnosis of AIS who presented with onset to door < 4.5 hours and stroke code was alert either at the Siriraj MSU (SiMSU) or at the emergency department (ED). The same AIS treatment guideline for intravenous tPA or endovascular treatment (EVT) were applied in both groups. Demographic data, type(s) of reperfusion therapy (tPA and/ or EVT) were recorded. Stroke onset to door (OD), door to CT (DCT), door to needle (DN), and door to puncture (DP) time were collected. Stroke outcome was measured by the modified Rankin Score (mRS) at 3 months.

Results:
A total of 519 AIS patients (130 from SiMSU and 389 from ED) were enrolled between June 2018 and December 2019. The mean age (
+
SD) was 66 (
+
13.9), 254 (48.9%) were male. AIS key process time measures were significantly shorter in the SiMSU with a mean
+
SD DCT time of 7
+
4.9 vs 16
+
13.7 minutes (p< 0.01), DN time of 21
+
7 vs 34
+
13.8 minutes (p< 0.01) and DP time of 71
+
20 vs 94
+
44.6 minutes, (p<0.01) in SiMSU and ED respectively. Although EVT rate was similar, intravenous tPA rate was significantly higher in SiMSU 59.2% vs 34.4% (p< 0.01). The mRS of 0-2 at 3 months was significantly higher in SiMSU than the ED (67.5% vs 57.9%, p=0.01).

Conclusions:
The SiMSU significantly shortened door to reperfusion treatment, increased access to IV t-PA and improved stroke outcomes by reducing disability at 3 months when compare to standard of care (i.e. ED arrival). This working paradigm could be implemented in other similar healthcare settings to improved AIS care.
Abstract P124: Stroke Patient Transfer Destination is Influenced by Hospital Affiliation
Authors: Zachrison Kori S , Amati Viviana , Schwamm Lee H , Yan Zhiyu , Nielsen Victoria , Christie Anita , Reeves Mathew J , Sauser Joseph , Lomi Alessandro , Onnela Jukka-Pekka
Published: March 2021

Background:
Acute ischemic stroke (AIS) patients are frequently transferred between hospitals, however it is not clear whether these transfers are optimized with respect to proximity and quality of the destination hospital. Our primary object was to identify hospital characteristics associated with sending and receiving AIS patients.

Methods:
Using a comprehensive statewide dataset, we identified all AIS patient transfers occurring between all 78 Massachusetts (MA) hospitals from 2007 and 2015. Hospital variables included hospital quality reputation (US News & World Report), hospital capabilities (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliations (same vs. not). We also included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with patient transfers. This method decomposes events into a decision to transfer, and if so, the receiving hospital destination, and models them using a discrete-choice framework.

Results:
Among 73,114 AIS admissions in MA during the 8-year study period, there were 7,189 (9.8%) transfers. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital included teaching hospital status, hospitals of the same or higher quality, the same or higher stroke center status, and the same hospital affiliation (Table).

Conclusion:
Patients experiencing AIS in MA are frequently transferred between hospitals. After accounting for multiple relevant hospital characteristics, hospital affiliation remains an important factor in determining transfer destination. While there may be some benefits to hospital affiliation, stroke systems of care should be designed to maximize patient benefit and leverage interfacility transfer accordingly.
Abstract P138: Improving Emergency Medical Services Documentation of Time Last Known Well
Authors: Bluma Dot , Link Reeve Jessica , Godersky Susan M
Published: March 2021

Background and Purpose:
In a systems of care model, Emergency Medical Services (EMS) reporting a patient’s last known well (LKW) time to the receiving hospital is crucial for activation of the hospitals Acute Stroke Team. There is evidence that LKW is critical information for determining an acute ischemic stroke patient’s eligibility for advanced stroke therapy which includes intravenous Alteplase and/or mechanical endovascular reperfusion therapy. The 70 Wisconsin (WI) Coverdell Stroke Program (Coverdell) hospitals represent 80% of stroke admissions in WI. Coverdell developed a pre-arrival report card in Q3 2018 in which LKW was a tracked measure. Data entered into Get With The Guidelines®- Special Initiatives (SI) tab was collated to create the report card. After analysis of the data it was determined our performance improvement (PI) project would be to improve EMS’s documentation and reporting of time LKW. In Q3 2018, of those cases entered into the SI tab, EMS reporting a LKW time was 50%. Since LKW is not always obtainable, the project goal was set at 60%.

Methods:
We recognized implementation of this PI initiative would require a multi-prong approach. To assist EMS agencies in understanding the difference between LKW and symptom onset, we developed a document entitled,
The Importance of an Accurate Last Known Well and Symptom Onset Time
. A Coverdell team member attended WI’s EMS Physician Advisory Committee meetings where LKW data was discussed. In addition, an Emergency Department Physician hosted a webinar where the presentation highlighted the importance of documenting LKW. This webinar was recorded and sent to EMS agencies and hospitals. For loop closure and with the support of the WI’s EMS Director, LKW became a validated field for EMS in the WI Ambulance Run Data System.

Findings:
In Q2 2019 there was an improvement in documented LKW as evidenced by an increase to 59.2% The data has remained consistent even as more hospitals have begun to enter the data as demonstrated by the increasing N.

Conclusion:
The actions taken by the Coverdell program in educating EMS providers on the rationale and importance of LKW documentation was successful. However, additional efforts are required to reach and maintain the project goal of 60% with an additional stretch goal to 70%.
Abstract P14: Per Pass Clot Retrieval Technique: Interim Analysis of the Excellent Registry
Authors: Siddiqui Adnan H , Waqas Muhammad , Andersson Tommy , De Meyers Simon F , Fiehler Jens , Hacke Werner , Hanel Ricardo , Jovin Tudor , Liebeskind David S , Yoo Albert J , Zaidat Osama O , Haussen Diogo C , Inoa Violiza , Woodward Keith , Humphries William E , Jabbour Pascal M , Francois Olivier , Dashti Shervin R , Bozorgchami Hormozd , Levy Elad , Budzik Ronald , Schirmer Clemens , Taqi Muhammad A , Estrade Laurent , De Leacy Reade A , Boor Stephan , Hussain Shazam , Puri Ajit S , Estrade Laurent , Nogueira Raul G
Published: March 2021

Background:
EXCELLENT (NCT03685578) is a large, prospective, single-arm, multicenter, international registry of mechanical thrombectomy (MT) with EmboTrap as the first attempted device in routine clinical practice. The study collects per pass data on procedural and technical details that are based on interventionalists’ preference, providing an opportunity to assess current practices in MT across multiple international high-volume stroke centers.

Methods:
Subjects treated according to standard of care were eligible for inclusion in the study if EmboTrap was used in the first MT pass. Interim analysis focusing on procedural details and per pass clot retrieval technique was performed based on 689 subjects enrolled by 79 physicians across 26 international sites (US, Belgium, Germany, France) between Sept 2018 and Jul 2020.

Results:
Mean #passes was 2.1 (median=1, max=10), 50.3% subjects had only 1 pass and 84.8% had 3 or fewer. Per pass use of stent retriever, aspiration, balloon guide, intermediate catheter and long sheath catheter, along with technique details (e.g. incubation time, device positioning, co-aspiration) are summarized in Table 1. Rates and reasons for device changes are also given.

Conclusion:
Interim analysis of the ongoing EXCELLENT registry informs on current practice patterns in MT. This is the first report of detailed per pass clot retrieval strategies in a large international multicenter cohort.
Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey
Authors: Yavagal Dileep R , Saini Vasu , Inoa Violiza , Gardener Hannah E , Martins Sheila O , Fakey Manav , Ortega Santiago , Mansour Ossama , Leung Thomas , Jadhav Ashutosh P , Potter-Vig Jennifer , Sylaja P N , Demchuk Andrew M ,   MT2020 Global Executive Committee
Published: March 2021

Introduction:
The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice.

Methods:
A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5
th
to May 15
th
, 2020.

Results:
There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%).

Conclusion:
Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.
Abstract P142: The Impact of Regional Socioeconomic Status on Stroke Center Certification in the Northeastern United States
Authors: Chapman Emily , Yaeger Kurt , Mocco J D
Published: March 2021

Introduction:
The northeastern United States has been a national leader in stroke healthcare delivery. The current roster of designated comprehensive, primary, thrombectomy-capable and acute stroke ready centers is the result of respective state initiatives. Access to certified stroke centers (SCs) varies by county as states have widely varied certification processes and typically rely on certifying organizations (COs) to identify stroke centers. Previous research has found an association at the national level between likelihood of stroke certification and local socioeconomic status.

Objective:
This study describes the relationship between socioeconomic status of patient populations in the Northeast U.S. and their access to quality stroke care by comparing median household income and wealth in counties with and without certified SCs.

Methods:
Population and median household income for 218 counties in Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont were collected from the U.S. Census (2010), stroke epidemiological data were collected from the Center for Disease Control, and Area Deprivation Index (ADI) data (ranked within the U.S.) were collected from the Neighborhood Atlas, a project that quantifies disadvantage. Median household income has been used to quantify local population wealth and ADI to analyze community health risks. Certification data were mined from quality check databases for The Joint Commission and Det Norske Veritas, the most commonly used COs, and yielded 259 certified centers. Linear regression characterized the relationship between income and ADI with number of certified SCs, stroke incidence and stroke mortality.

Results:
Higher income (p<0.001) and lower ADI (p<0.001) were associated with having more certified SCs (p<0.001). Counties with a higher stroke incidence had significantly more certified SCs (p=0.01).

Conclusions:
Throughout the counties of the Northeastern U.S., access to quality stroke care depends on local wealth and resources. At the same time, the current analysis indicates that SC certification distribution does appear to correlate to those counties where stroke incidence is highest.
Abstract P152: Missed Treatment Opportunities and Earlier Stroke Detection Among Hospitalized Patients With Acute Cerebral Infarction
Authors: Siegler James E , Patel Parth , Romiyo Prasanth , Thau Lauren , Heslin Mark , Smith Ainsley , Chen Austin , Little Dena , Thon Jesse M
Published: March 2021

Background:
In preparation for a quality improvement study, we queried our prospective stroke registry for patients who might benefit from prophylactic monitoring in order to estimate the time advantage to monitoring.

Methods:
A prospective, single center registry of adult patients (9/20/19-6/30/20) was queried for in-hospital acute anterior circulation strokes. Indications for hospitalization as well as delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored.

Results:
Of 540 consecutively evaluated adults with acute stroke, 68 (12.6%) developed an anterior circulation infarction while hospitalized, 32 (47.1%) of whom were female with a median age of 66 years (IQR 60-77) and median NIHSS of 14 (IQR 4-22). Four patients (5.9%) received intravenous thrombolysis although another 20 (29.4%) would have been eligible for thrombolysis if not for a delay in symptom recognition. An internal carotid, M1, or M2 occlusion was observed in 13 patients (19.1%), 8 of whom were treated at a median of 198 minutes after LKW (IQR 102-670; Figure). In patients treated endovascularly or with thrombolytics, the delay from LKW to symptom recognition accounted for 55.5% of the delay in care.

Conclusions:
One-third of patients in this single-center cohort would have been eligible for thrombolysis were it not for delays in symptom recognition. The delay to groin puncture exceeded 3 hours for over half of patients with proximal anterior occlusions. Earlier detection using prophylactic monitoring devices has the potential to reduce this major impedance to stroke care and ultimately improve outcomes.
Abstract P161: The Effect of Simulation Based Education on Nursing and EMS Stroke Care
Authors: Collin Christina A , DeGennaro Carol M , Fitch Sean M , Panza Gregory A , Hickey Kristen M
Published: March 2021

Background:
Treatment options for acute ischemic stroke (AIS) now include mechanical thrombectomy. As a result, primary stroke centers (PSC) must quickly identify large vessel occlusion (LVO) patients, treat them with alteplase when appropriate and transfer them to a comprehensive stroke center (CSC) for potential mechanical thrombectomy. Given the need for expedited care in the emergency department, collaboration with emergency medical services (EMS) in the pre-hospital setting and timely administration of alteplase prior to transfer to the CSC have been identified as practice gaps.

Purpose:
To examine the effect of an educational stroke simulation session on the knowledge and confidence level of registered nurses (RN) and EMS providers who care for patients with acute stroke receiving alteplase.

Methods:
Simulations were 60 min, in groups of 4-5 RNs and 1-2 EMS providers, and focused on neurological assessment, administration of alteplase, and rapid transfer when a LVO is suspected and/or identified. Participants completed a pre and post simulation survey assessing confidence levels of nurse role actions and knowledge of stroke care (Table 1). A paired samples t-test examined differences in confidence levels and total percent of correctly answered questions on the survey, pre versus post simulation. A McNemar test examined differences in the proportion of participants that correctly answered each question on the test pre versus post simulation.

Results:
Following the stroke simulation, the confidence levels of nurses increased for all nurse role actions (all
P
s<0.01; Table 1) and there was an increase in the number of correct answers for 3 of the 6 test questions (all
P
s<0.05; Table 1), as well as the total percent of correctly answered test questions (
P
<0.001).

Conclusions:
Simulation based education can be an effective training tool for improving the knowledge and confidence of nursing and EMS providers in the management of AIS.
Abstract P169: Assessing Racial Disparity in Emergency Medical Transport of Suspected Stroke Patients
Authors: Rao Nitya , Chang Joshua , Paydarfar David
Published: March 2021

Introduction:
Numerous studies have found evidence of disparities in the treatment and health outcomes of patients with acute ischemic stroke. As minimizing time to treatment is essential in acute ischemic stroke management, we aimed to assess for racial disparities in emergency stroke transport. Emergency transport times are dependent on the geographic distribution of patients and hospitals, but previous studies have not controlled for racial variation in spatial distributions when assessing for disparity.

Methods:
Using a novel dataset of 2,518 unique entries with detailed spatial and temporal information on all suspected stroke transports conducted by a public emergency medical service in Central Texas over eight years, we conducted one-way ANOVA tests with post-hoc pairwise t-tests to assess how mean hospital transport time varied by patient race and developed a spatially-independent metric of emergency transport urgency.

Results:
Results are reported as means with standard errors and p-values from post-hoc pairwise testing. We found that mean transport time to a hospital was 2.5 minutes shorter for black patients (10.9 +/- 0.274 minutes) compared to white patients (13.4 +/- 0.174 minutes) with p < 0.0001. However, white patients’ transport times to a hospital were found to be, on average, 4.1 +/- 0.085 minutes shorter than expected compared to 3.4 +/- 0.124 minutes shorter than expected for black patients (p = 0.00015). Using a novel transport urgency index, we demonstrate that these findings represent race-based variation in spatial distributions rather than racial bias in emergency medical transport.

Conclusion:
In summary, these results highlight the importance of closely examining spatial distributions when utilizing spatial data to investigate geographically-dependent research questions.
Abstract P176: Improving Door to Needle Times With CT Telestroke
Authors: Jamieson Sarah , Lesko Alexandra C , Baraban Elizabeth , Yanase Lisa R
Published: March 2021

Introduction:
Thrombolytic treatment of acute ischemic stroke (AIS) during night-time hours and weekends is associated with prolonged door to needle (DTN) times. A CT suite telestroke unit (CTTU) was installed at two urban stroke centers to expedite treatment for AIS patients. The purpose of this study was to determine whether CTTU evaluation would decrease DTN times on nights and weekends.

Methods:
A retrospective chart review included patients 18 years and older presenting with AIS to the emergency department and treated with IV alteplase on a week-night (4pm-8am) or weekend (Friday 4pm - Monday 8am) between January 2019- February 2020. The distribution of median DTN times were compared for the following groups: (1) Pre-CTTU installation (January 1, 2019-July 28, 2019) versus post-CTTU installation (July 29, 2019 - February 29, 2020), regardless of telestroke usage (“intention to treat”), (2) Pre-CTTU (using traditional telestroke and excluding bedside evaluations) versus post-CTTU (using CTTU and excluding bedside evaluations) (“per-protocol”) and (3) Post-CTTU period use of traditional telestroke versus CTTU (“post-CTTU group”). Analyses were performed using the Mann-Whitney U test.

Results:
A total of 111 patients met inclusion criteria with 44 (39.6%) treated in the pre-CTTU period and 67 (60.4%) treated in the post-CTTU period. After installation, CTTU was utilized in 38.8% (n=26) of cases, traditional telestroke in 44.8% (n=30), and the remaining 16.4% (n=11) were evaluated at bedside. The intention-to-treat analysis showed no difference between the pre-CTTU and post-CTTU groups (44.0 minutes vs 44.0 minutes, p=0.909). The per-protocol analysis showed faster DTN times in the Post-CTTU group compared to the Pre-CTTU group (38.5 minutes vs 44.0 minutes, p=0.128), but the difference was not significant. The post-CTTU group analysis showed median DTN times significantly improved using CTTU compared to traditional telestroke (38.5 minutes vs 48.0 minutes, p=0.011).

Conclusion:
The use of CT telestroke in the evaluation of acute ischemic stroke patients decreased DTN time when a stroke neurologist is not on-site.
Abstract P177: Provider Perspectives on Improving Telestroke Usability - A Qualitative Study
Authors: Blaginykh Elena , Uchino Ken , Brown Dena R , KHAWAJA Zeshaun
Published: March 2021

Background:
Telestroke is an integral part of acute stroke systems of care. To further grow telestroke and maintain quality, we surveyed telestroke stakeholders’ experience.

Methods:
We conducted open-ended, semi-structured interviews with stroke program managers, hub neurologists, emergency department physicians and nurses in a telestroke network in an academic medical center. The goal of the interviews was to understand stakeholders’ experience with telestroke including their perceptions of telestroke values, barriers, and solutions. The data analysis was performed using qualitative methods guided by a grounded theory approach.

Results:
Face-to-face interviews with 44 stakeholders, including 8 hub neurologists, 7 stroke program managers, 15 emergency physicians, and 14 emergency department nurses were completed. The values provided by telestroke were consistent: empowering emergency physicians in treatment decisions, increasing access to a comprehensive stroke care, and improving health outcomes. The stakeholders also agreed that the main utilization barriers were unmatched role expectations, technical issues, and patient-provider detachment. Other barriers were specific to certain stakeholder groups. Stroke program managers emphasized the importance of the unified criteria for telestroke activation. Hub neurologists highlighted the lack of interoperability of the electronic health records system and the variation in nurse training. Nurses reported inadequate dissemination of the telestroke updates during night-shifts. Emergency physicians were concerned about the lack of emergency department representation at telestroke meetings. The stakeholders were actively managing arising issues through developing their own strategies and reporting the problems to the telestroke program.

Conclusion:
Stakeholders perceive telestroke as a necessary tool that assure high quality care. However, addressing the barriers to optimal telestroke use might improve provider and patient experience.
Abstract P179: Impact of Transportation Mode on Outcome of Mechanical Thrombectomy
Authors: Smith Colin , Almallouhi Eyad , Nankee Cassie , Fayyaz Habiba , Al Kasab Sami , Holmstedt Christine A
Published: March 2021

Introduction:
It is well established that mechanical thrombectomy (MT) improves functional outcome in stroke patients with a large vessel occlusion and salvageable brain tissue. In this study, we evaluate the impact of transportation mode on outcomes of patients undergoing MT.

Methods:
The prospectively maintained data from medical charts of consecutive patients transferred to a single comprehensive stroke center (CSC) for thrombectomy from January 2017 to December 2019 was reviewed. Clinical outcome was measured at a 90-day follow up with National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Multivariate logistic regression analysis was used to assess the relationship between helicopter transportation and favorable 90-day outcome in MT patients.

Results:
A total of 135 MT patients underwent the procedure following interhospital transfer by helicopter or ground ambulance. 60/135 (44%) of the patients were transferred by air. On univariate analysis there was no significant differences in age (median of 66 vs. 68 years; p=0.23), sex (31% vs. 36% men; p=0.605) or race (31% vs. 44% white; p=0.344) between the air vs. ground groups. Also, baseline NIHSS did not differ (95% CI 12.0-15.69 vs. 14.06-17.31; p=0.136). Total of 56 (41.5%) patients received tissue plasminogen activator (tPA) (25 air vs. 31 ground; p=0.97) and the overall door to groin time was similar in both groups (85.17 vs. 83.96 minutes; p=0.86). NIHSS at 90-day follow up was significantly lower in those taken by helicopter compared to ground transit (95% CI 4.60-11.26 vs. 11.50-17.61; p=0.015). Air transportation was independently associated with good long-term functional outcome on multivariable logistic regression after controlling for age, sex, race, tPA and transportation time (OR 3.757 95% CI 1.23-11.4; p=0.02).

Conclusions:
Air transportation in MT patients was independently associated with better long-term functional outcome. The association between helicopter transit and long-term function is shown to be independent of transit time.
Abstract P189: Using Telemedicine Eliminates The Weekend/after-hours Effect In Acute Ischemic Stroke Patients Receiving Thrombolysis During A Deadly Pandemic
Authors: Diaz Rojas Maria V , Wu Tzu-ching , Zhu Liang , Ankrom Christy T , Zha Alicia , Jagolino-Cole Amanda L , Cossey TC
Published: March 2021

Stroke care has been shown to be worse for patients presenting overnight/weekends (off-hours) to centers compare to those presenting during business hours (on-hours).Telemedicine (TM) helps provide safe management of stroke patients. The UT Teleneurology (UTT) hub provides acute neurological coverage by stroke specialists to 18 spoke centers. To our knowledge, the effect of the Covid-19 pandemic on the “weekend effect” has not been studied. The objective is to compare TM consult volumes and time metrics of stroke patients who received tPA via TM off-hours with those on-hours during the pandemic. In a retrospective query of the UTT registry from 3/20 - 6/20, we identified 122 stroke patients who received tPA - 109 were included in our analysis - 2 were excluded after quality check, 11 were excluded as inpatient strokes. We compared baseline characteristics and time metrics between the off-hours (5pm-7:59am, weekends) and on-hours (weekdays 8am-4:59pm) patients (Table 1). We also compared the number of TM consults between the height of the pandemic (3/20 - 6/20) and the previous year (3/19 - 6/19). Of 109 patients, 72 were managed via TM during off-hours, 37 during on-hours. Baseline characteristics were similar between groups. There were no differences in time metrics including door to needle time. Of note, there was no difference in the number of acute TM consults or patients receiving tPA. There were fewer routine TM consults during the pandemic, and a trend toward fewer phone consults. There was no difference in time metrics between the patients treated off-hours vs on-hours in the pandemic period. TM may be advantageous over in-person neurology coverage during crises, and is consistent regardless of the hour/day. Contrary to other studies, the number of acute TM consults and patients receiving tPA did not differ between the study periods. Routine consults decreased during the pandemic - perhaps coinciding with state closure mandates/fewer hospitalized stroke patients.
Abstract P19: Developing an Innovative Visual Fields Rapid Assessment Device (VRAD) for Acute Telestroke Use
Authors: Solenski Nina J , Haughey Heather , Allende J. A
Published: March 2021

Background:
Acute telestroke evaluations rely on the ability to rapidly and accurately calculate the NIH Stroke Scale. Remote visual field deficit (VFD) testing is often challenging, requiring trained bedside assistance particularly in rural hospital settings. These deficits account for up to 3 points on the NIHSS, which is enough to affect treatment decisions and impact outcomes.

Objective:
To create a simple, rapid, and robust screening telemedicine peripheral device to standardize visual field testing during acute telestroke consults and to reduce reliance on bedside assistants for this task.

Methods:
A one-size-fits-all device was designed such that an LED stimulus is located in each quadrant of the peripheral visual field. Bioengineers, neuro-ophthalmologists, and vascular neurologists collaborated in the development of the prototype. A randomized investigator-blinded pilot clinical trial is in progress. Stroke patients with fully-mapped visual fields were selected. The device, in the form of glasses, is easily placed on the patient’s face, and LED lights are flashed in the standard 8 fields, via a repeatable algorithm, during a simulated acute telestroke encounter. Lights are visible to the remote teleprovider for interpretation of the responses. Patients and examiners will be surveyed for feedback on ease of use of the device (primary outcome). Results from device will be compared to in-person confrontational testing and to previously recorded Humphrey mapped deficits in this same patient population (secondary). Validation is set at a sensitivity of 90% compared to confrontational or to the Humphrey static visual field test results.

Results/Conclusion:
Remote testing of VFDs in acute telestroke patients is difficult, especially in smaller community rural hospitals. We developed a simple and rapidly applied facial device that can assist the teleprovider in VFD evaluations, potentially affecting treatment options of thrombectomy, thrombolytics, or transfer. An on-going pilot study will test the sensitivity of the device against confrontational and static VF assessments. Innovative telestroke peripherals represent the future of the next generation of diagnostic tools specifically engineered fo remote acute stroke patient evaluations.
Abstract P191: A Large Cohort Study Predicting the Temporal Course and Rate of Improvement in Stroke Patients Admitted to Inpatient Rehabilitation Facilities
Authors: Taleb Shayandokht , Parker Dorothea , Hsieh Billie , Rahbar Mohammad H , Wozny Joseph , TAHANAN AMIRALI , Gupta Resmi , Green Charles , Wewior Natalia , Paladugu Sreelekha , Wewior Natalia , Norris Dominique , Russell Mary , Savitz Sean I
Published: March 2021

Introduction:
We sought to predict the course and rate of functional improvement and length of stay (LOS) in patients with ischemic and hemorrhagic strokes admitted to inpatient rehabilitation facilities(IRF).

Aim:
To study the course and associating factors affecting functional outcomes among a large cohort of stroke patients admitted to IRFs.

Methods:
The cohort consists of stroke patients admitted to 5 IRFs in Houston, between 4/17-8/19. Higher order polynomial (quartic, cubic, quadratic) regressions were fitted to predict the temporal relationship between FIM score improvement and LOS, and based on goodness of fit statistics, cubic polynomial fit was selected. Effects of interactions were tested and later dropped from the final model because of non-statistical significance. Models were adjusted for age, gender, stroke type (hemorrhagic vs ischemic), and stroke severity based on NIHSS.

Results:
The demographics of patients are presented in table 1. Among 679 patients, the univariate analyses reflected that age (F=24.2,
p
<0.001), admission NIHSS score (F=67, p<0.001), stroke type (F=25.2,
p
<0.001), and admission FIM (F=283, P<0.001) were significant factors predicting IRF LOS. History of previous stroke, diabetes, hypertension, and hyperlipidemia did not have any significant effects on LOS. In multiple regression model, age at onset (β=-0.18, p<0.001), hemorrhagic vs ischemic stroke (β=3.02,
p
<0.01) were significant predictors of total FIM change score when adjusting for stroke severity and gender. Total FIM change score was positively correlated with LOS at IRF with a steep improvement in the first 15 days of IRF stay which plateaued afterwards in patients with 1-30 days of IRF stay (Fig. 2).

Conclusion:
Patient’s age, ischemic vs hemorrhagic stroke were the most significant predictors when deriving the relationship between total FIM score and LOS while adjusting for stroke severity and patient’s gender, which plateaued after 2 weeks of IRF stay.
Abstract P2: Results of a Prospective Observational Cohort Study of Tenecteplase as Standard of Care Stroke Thrombolytic
Authors: Warach Steven J , Miley Jefferson T , Mawla Manzure , Miller Samantha , Ding Ming-Chieh , Allen Leigh , Misra Lotika , Jefferson John , Davision Holly , Shah Darshan , Tsui Annie , Ellington Kent , Krishna Vivek , Paydarfar David ,   for Dell Med Sch Ascension Texas Stroke Service
Published: March 2021

Background:
Our 10-hospital network (2 CSCs, 2PSCs, 6 non-SCs) switched our standard stroke thrombolytic from alteplase (ALT) to tenecteplase (TNK; 0.25 mg/kg) in September 2019.

Methods:
We designed a two-year prospective cohort analysis of key processes and clinical outcomes for TNK-treated patients with planned quarterly assessments of feasibility and safety. The TNK cohort is compared to the retrospective historical cohort of all unique patients at these hospitals treated with ALT during the prior 2-year period (n=354). Analysis were taken from a local REDcap registry that recorded data fields required for Stroke Center certification and submission to Get-With-The Guidelines (GWTG). Interim results through three quarters ending June 30, 2020.

Results:
151 patients were treated with TNK. The samples TNK v ALT were well matched on age (median, IQR) 66.0 (55.0, 76.0) v 67.0 (55.0, 78.8) and NIHSS at admission (median, IQR), 8 (4, 13) v 8 (4, 15). Symptomatic ICH (ECASS 3 definition) occurred in 2.0% of TNK and 2.3% of ALT treated patients; all but one symptomatic ICH occurred in patients treated with both thrombolytic and endovascular therapies. All cause in-hospital mortality was 3.3% and 6.8%, respectively. No differences were observed in early outcomes of discharge to home (52%, 53%) or independent ambulation (46%, 45%). Day 90 Rankin Score (last observation carried forward for missing values) was available only for TNK: mRS 0-1 in 46.4% (95%CI 38.6%-54.3%), 0-2 in 55.6% (95%CI 47.7%-63.3%). A significantly greater proportion of patients were treated with the lytic within 45 minutes of hospital arrival after the switch to TNK using Get-With-The-Guidelines DTN time criteria (Table), most notably at the primary stroke centers.

Conclusions:
To date, the transition to TNK was associated with reductions in DTN times and in Drip-and-Ship transfer times (see related abstract). No differences were seen on early indices of safety or efficacy.