bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P262: Using Scarce Stroke Care Resources for the Greatest Impact: Examining Ontario’S Stroke Report Card 2011/12
Authors: Linkewich Beth , Khan Ferhana , Hall Ruth
Published: March 2022

Background:
In 2011 the Ontario Stroke Evaluation and Quality Committee created Ontario’s Stroke Report Card, consisting of twenty indicators with potential to influence system performance and flow of stroke patients across the care continuum. Anecdotal evidence demonstrates clinical connections between indicators.

Objective:
To determine statistical relationships among indicators to inform system planning and improvement.

Methods:
Using the FY 2011/12 regional stroke report cards, we performed Pearson correlation analysis, reporting statistical significance at <0.05 for clinically relevant associations among indicators. Eight indicators used FY2010/11 Ontario Stroke Audit data and ten used FY2011/12 Canadian Institute for Health Information administrative databases and one used the Ontario Home Care Database, FY 2010/11.

Results:
Nine of nineteen indicators had statistically significant correlations with other indicators, specifically: 1) arrival to hospital within 3.5 hours of symptom onset is associated with fewer patients going directly to long-term care (LTC) (r=-0.53, p=0.05) in the subsequent year; 2) acute inpatient admissions are associated with an increased proportion of acute Alternative Level of Care (ALC) days (r=0.55, p=0.04); 3) proportion of acute ALC days are associated with an increase in proportion of rehab ALC days (r=0.55, p=0.04); 4) admission to inpatient rehab has an inverse relationship with proportion of severe stroke patients in inpatient rehab (r=-0.84, p=0.0002), and 5) with proportion of stroke patients going from acute to LTC (r=-0.68, p=0.008); and 6) higher Functional Independence Measure® efficiency is associated with shorter time to admission into rehab (r=-0.81, p=0.0004).

Conclusion:
Correlations between report card indicators identified opportunities to plan, allocate resources, and improve stroke system care. By focusing efforts on key areas, there is a potential for broader impact on multiple indicators. Although strong correlations were observed between indicator performance, future research will examine change in performance to assess whether the associations remain over time.
Abstract W P264: Perception of Educational Benefits of Online National Institute of Health Stroke Scale Training by Nursing Staffs
Authors: Danner Jill , Quintanilla HIllary , Hancok Sarah , Howell Martha , Kim Jongyeol
Published: March 2022

Background:
Primary Stroke Center at University Medical Center (UMC) in Lubbock, Texas requires nursing staffs who are directly caring for stroke patients to obtain NIHSS training by certification via an online training program by NINDS and/or AHA. One of quality improvement programs by UMC is to evaluate the compliance and reliability of neurologic assessment of stroke patients by nursing staff.

Purposes:
The purpose of this study is to evaluate the current perception and effectiveness of online training for quality improvement.

Methods:
We performed survey on licensed staff members in the Emergency Department (ED), Medical Intensive Care Units (MICUS) and one Medical Surgical Unit (MSU) to determine perception on the effectiveness of the current online education (OE) and on the inter-rater reliability between staffs and units.

Results:
164 nurses completed the survey: 81 from ED, 63 from MICU, and 20 from MSU. 55% of staff rated the OE as excellent, 33% as good, and 12% as poor. 42% believed inter-rater reliability was excellent, 32% as good and 19% rated the intra-rater reliability as poor. Regarding how comfortable they were with performing the NIHSS exam, 11% rated themselves as poor, 29% as good, and 65% as excellent. The staffs performed three NIHSS exam (range 0– 40) on average after their training. Extinction and inattention, limb ataxia, dysarthria, and language were felt most difficult to assess, which was similar to previous studies. The majority of group which rated inter-rater reliability as poor worked at the ED and MICU. Some of the suggestions include hands-on training with standardized patient, hands-on training of intubated patients with simulation, regular onsite and online education, and enjoyable education materials.

Conclusions:
In conclusion, NIHSS online training is an effective way to train nursing staffs but additional and regular educations are needed after the initial online training. Based on the evaluation data, Stroke Program at UMC is developing NIHSS training program utilizing standardized patients in simulation and will implement in education for quality improvement in clinical practice and inter-rater reliability.
Abstract W P27: Predictive Factors of Clinical Outcome and Hemorrhage after Acute Ischemic Stroke Treated by Mechanical Thrombectomy with Stent-retriever
Authors: Pierot Laurent , Soize Sébastien , Barbe Coralie , Kadziolka Krzysztof , Serre Isabelle
Published: March 2022

Purpose:
The study attempts to identify notable factors predicting poor outcome, death and intracranial-hemorrhage in patients with acute ischemic stroke undergoing mechanical thrombectomy with stent-retriever.

Methods:
Patients with acute ischemic stroke treated with the Solitaire FR device were retrospectively analyzed from a prospectively collected database. We assessed the effect of selected demographic characteristics, clinical and imaging factors on poor outcome at 3 months (modified Rankin score 3-6), mortality at 3 months and hemorrhage at day 1 (symptomatic and asymptomatic).

Results:
From May 2010 to April 2012, 59 consecutive patients with an acute ischemic stroke underwent mechanical thrombectomy. At 3 months, 57.6% of the patients were functionally independent (mRS 0-2) and mortality was 20.4%. Multivariate analyses revealed that a thrombus length>14mm (p=0.02; OR 7.55; CI 95% 1.35-42.31) and longer endovascular procedure duration (p=0.01; OR 1.04; CI 95% 1.01-1.07) were independently associated with poor outcome. A higher baseline ASPECT score (p=0.04; OR 0.79 per point; CI 95% 0.63-0.99) and successful recanalization (p=0.02; OR 0.07; CI 95% 0.01-0.72) were independent predictors of good functional outcome. Baseline ASPECT score (p<0.01; OR 0.65; CI 95% 0.54-0.78) independently predicted symptomatic intracranial hemorrhage at day1.

Conclusions:
Baseline ASPECT score reflects symptomatic hemorrhage risk and functional outcome at 3 months. Thrombus length measured on MRI play an important role on functional outcome at 3 months after thrombectomy. Further analyses are needed to determine its importance in the selection of patients for mechanical thrombectomy.
Abstract W P285: Communication is the Driver of an Efficient Health Care Team
Authors: Crockett Deb , Tan Kristyna , Shull Alissa , Sandt Janice
Published: March 2022

Background:
Comprehensive Stroke Centers provide hyperacute stroke care within hours of symptom onset. Patients benefit from this intervention but still have needs that have yet to be addressed. Health care must be delivered efficiently while meeting the expectations of the public. A methodical solution achieves excellent outcomes for providers, payers, and patients.

Purpose:
The goal of the health care team is to provide a clear assessment and discharge planning process that enhances communication amongst team members. With an annual volume increase of 10-20%, throughput is a daily challenge at this academic hospital due to rotating physicians and students.

Methods:
A comprehensive assessment is documented in the electronic medical record within 24 hours of admission by the case management team. This assessment includes screening for depression and need for respite services. A resource guide is immediately provided to the patient and family. Five days a week, the health care team is assembled for “patient care huddles”. These are attended by the vascular neurologist, case management social worker and nurse, speech and physical therapy, stroke program coordinator, pharmacist, utilization review, research coordinator, neurology residents, and each bedside nurse. The 2 minute per patient discussion centers on “plan for the day, plan for the stay”.

Results:
The number of ischemic stroke and TIA patients has increased 25% over two years. In the same time period, the average length of stay index has decreased from 1.17 to 1.00 and the average cost index is 1.08. Patient satisfaction, as measured by Press Ganey, is at the 98
th
percentile for stroke patients over the last two years.

Conclusion:
Communication among all team members is enhanced through daily patient care huddles and allows discharge planning to start at admission. Comprehensive assessments leading to efficient discharge planning can be achieved without compromising patient satisfaction or increasing costs or length of stay. Throughput is impacted by an efficient, cohesive team.
Abstract W P289: Hyper Acute Stroke Nurse Initiative Improves Time to Initiation of Reperfusion Therapy
Authors: Dofredo Melissa , West Angela , Loper Nick , Taves Arlene , Sia McGee Lety
Published: March 2022

Background:
Following Primary Stroke Center designation in 2008, several factors contributed to our hospital's influx of stroke patients. In 2010, the Emergency Medical System covering our county began diverting stroke patients to our facility. In 2011, our 400+ bed medical center became the only organization capable of providing endovascular treatments in the region. This catalyzed another surge of stroke patients transferred to our hospital from outside facilities. Nurses and physicians in the ED noted increased workloads in an attempt to deliver stroke care in a timely manner. In May 2013, the innovative Hyper Acute Stroke (HAS) nurse was created to meet the time sensitive needs of our expanding stroke population.

Purpose:
The purpose of this initiative is to show the addition of the HAS nurse would improve time to IV tPA and endovascular intervention in stroke care, as well as physician and nurse satisfaction.

Methods:
With strong administrative and medical support, the Stroke Program Director and 15 critical care neuroscience nurses formed the HAS team. Initial training for the HAS nurse comprised of NIHSS certification and enhancement of neuroscience knowledge. Orientation included training with the Stroke Program Director on inter-facility transfer processes, response to ED Code Strokes, and formation of stroke care algorithms. Upon training completion, daily rotation ensured 24/7 HAS nurse coverage. Pre and post HAS nurse performance measures for IV tPA door to needle (DTN) and door to endovascular intervention times were analyzed. Physician and nursing satisfaction was also surveyed pre- and post HAS nurse involvement.

Results:
Data refers to the 12 months pre HAS compared to data post HAS nurse. When comparing pre HAS to post HAS time periods, DTN decreased from an average of 82 minutes to 38 minutes, while door to endovascular intervention decreased from an average of 136 to 111 minutes. Physician and nurse satisfaction improved since the institution of the HAS nurse.

Conclusions:
In conclusion, when responding to Code Strokes or assisting with transfers requiring emergent endovascular intervention, HAS nurse involvement improved time to intervention, and physician/nurse satisfaction.
Abstract W P293: Using Smart Phrases in an Electronic Medical Record to Document the Plan of Care and Decision Making Process During Time Sensitive Acute Ischemic Stroke Patient Interventions
Authors: Perez Amy
Published: March 2022

Background and purpose:
Documenting the physician’s decision making process in acute ischemic stroke intervention is a requirement of the Joint Commission to meeting the Comprehensive Stroke Center certification standard of involving the patient and/or family in the decision making process (DSSE. 1.). Due to the emergent nature of treating an acute ischemic stroke, the physician documentation may not clearly depict this process. The use of smart phrases in the electronic medical record (EMR) can help expedite this step while still providing individualized treatment.

Methods:
Smart phrases are written by the clinician in such a way that addresses the most common clinical situations. Smart phrases lay the foundation progress note, decreasing the likelihood of omitting important patient care information. The physician can make the smart phrases a part of their own EMR template. This can save documentation time as well as meet the required documentation standards from Comprehensive Stroke Center certification.

Conclusion:
The use of smart phrases has proven to be a time saver in documentation. Smart phrases have also provided a method for more standardized documentation. They aid the physician in including pertinent information necessary to demonstrate the decision making process and plan of care for the treatment of acute ischemic stroke patients. The success of using smart phrases has spread to other disciplines such as nursing and rehabilitation services.
Abstract W P294: Integration of TeleStroke into an Established Telemedicine System
Authors: Isom Kristen C , Summers Richard L , Henderson Kristi
Published: March 2022

Background and Purpose:
Most acute stroke patients first present to the emergency department. Emergency personnel are often encouraged to maintain a low threshold for stroke activations to capture all potential candidates for early treatment options. However, a national shortage of neurologists has placed a strain on the stroke specialists providing oversight for all these activations. Our stroke team faced a situation in which there were a limited number of neurologists and consistent coverage was not possible to satisfy primary stroke center qualifications. We report on the development of a hybrid system in which neurology oversight was provided by telemedicine consultation for times in which our neurologists were not available.

Methods:
Telestroke services were integrated into an established telemedicine system already servicing 17 EDs for general emergency consultations. The system has been in operation for ten years seeing over 425,000 patients with a technical failure rate of 0.00025%. In this protocol, the client ED is considered an extension of the ED of the comprehensive stroke center and activations are simultaneously initiated at both the telemedicine and consultant sites to engage the stroke specialists. After activation, the neurologist is video-conferenced into the telemedicine consultation by way of a personal ipad. Neuroimages are available to the neurologist at the telemedicine consulting site by cloud technology.

Results:
This telemedicine system is experienced in remotely assisting in stroke management. There is a first line triage of stroke patients by emergency physicians at a comprehensive stroke center with input from a stroke neurologist. If the case requires a neurointerventionalist then rapid transport to the comprehensive stroke center is facilitated by having routed the consultation through an emergency telemedicine system. By integrating with an established system, the telestroke service was operational within 45 days of the agreement.

Conclusions:
By using this innovative hybrid approach which utilizes a combination of both local neurologists and telemedicine consultations we were able to meet the coverage requirements for stroke center certification.
Abstract W P297: Streamlining Processes to Decrease Arrival Time to Groin Puncture in the Neuroendovascular Suite
Authors: Connelly Kerrin M , Thomas Jacob
Published: March 2022

Purpose:
To describe strategies to decrease the arrival to groin puncture time in the neuroendovascular suite of a Comprehensive Stroke Center

Background:
Non physician staff in the neuroendovascular suite of a Comprehensive Stroke Center sought to streamline processes within the neuroendovascular suite in order to facilitate faster patient arrival to groin puncture times.

Methods:
Strategies employed to decrease arrival time to groin puncture:

• Dedicated neuro angiography technologists

• Dedicated CT technologists

• Dedicated anesthesia staffing

• Neuro angiography technologists cross trained to perform CT scans

• RNs crosstrained to cover both angiography suite and ICU

• CT scan and angiography suite embedded in ICU

• Education of ED personnel regarding capabilities and protocols to trigger interventional consideration for Emergency Department (ED) patients

• Process for bypassing the ED for patients transferred from outside facilities

• Anesthesia education and response time

• Anesthesia supplies and vent set up at all times for immediate procedure start

• Communication tree for notification of off hours cases

• Angiography tray and patient table set up at all times to allow for immediate procedure start

Results/Conclusion
There are various methods available to decrease arrival time to groin puncture within the neuroendovascular suite. Response times over the past six months have been well under benchmark times of 30 minutes. Decreasing time to groin puncture increases the possibility of faster recanalization, potentially leading to more favorable outcomes.
Abstract W P299: Interventions for Caregivers of Stroke Survivors: A Decade Update of the Literature
Authors: Morris Ruth M , White Carole L , Cantu Adelita G , Trevino Misty M
Published: March 2022

Background:
Family caregivers (CGs) are taking on increasingly complex care for their loved ones with stroke related to increased survival after stroke and shorter hospital stays. Research has highlighted the demands of caregiving on the psychological, physical, and social health of the CG. The purpose of this systematic review was to summarize the latest evidence on effective interventions for CGs of stroke survivors (SSs).

Methods:
The review included clinical trials that evaluated interventions for CGs of SSs. Using multiple databases, the search strategy included published English-language studies between 2002 and 2012. Two independent reviewers extracted information and evaluated study quality using an author-developed tool. Effect sizes were calculated if information was available.

Results:
From an initial search of 106 studies, 16 met inclusion criteria and were included. Most interventions were multi-faceted, including elements of education, support, stress management, and skill building. Studies varied in the time from stroke that the intervention was provided and also in the length of the intervention, with most lasting between 1 and 12 weeks. While 50% of interventions were delivered face-to-face, 2 studies were web-based and 6 studies were delivered by telephone only or a combination of in-person and telephone. A variety of outcomes, most commonly psychological distress, caregiver burden, and quality of life, were measured with effectiveness of the intervention shown on at least one outcome measure in 50% of studies. Interventions that included skill building were more likely to show a significant effect, with small to medium effect sizes. Limitations of the reviewed studies include insufficient power in many studies to detect significant differences, under-representation of minority populations, high rates of losses to follow-up, and lack of theory-based interventions (only 40% described an underpinning theory).

Conclusions:
Interventions that deliver specific skills to perform the physical care needed by the SS and/or to manage the SSs emotional responses to the stroke as well as the CGs responses to the role were consistently effective in decreasing psychological distress and burden.
Abstract W P302: Impact of Post-Stroke Medical Complications on 30-Day Readmission Rate
Authors: Shah Sonia V , Corado Carlos , Bergman Deborah , Curran Yvonne , Bernstein Richard , Naidech Andrew , Prabhakaran Shyam
Published: March 2022

Background:
While many predictors of 30-day readmission after stroke are non-modifiable, some factors may be modifiable. We assessed the hypothesis that medical complications predict 30-day readmission.

Methods:
A single-center prospective cohort study of ischemic stroke and transient ischemic attack (TIA) patients was conducted. We identified patients admitted between August 2012 and June 2013 and who survived to 30-day follow-up or died during a readmission within 30 days. Patients readmitted within 30 days of discharge were identified by telephone assessment. We evaluated the association between 30-day readmission and 15 pre-specified post-stroke medical complications in addition to baseline characteristics, in-hospital course and treatments, and discharge status using univariable and multivariable statistics. A p-value < 0.05 was considered significant.

Results:
Among 415 patients (mean age, 67.5 ± 15 years; 47% female; 65% white; 78.1% ischemic stroke), 89 (21.4%) patients had at least 1 medical complication during hospitalization. The most common complications were urinary tract infection (6.7%), venous thromboembolism (4.8%), and pneumonia (4.1%). Initial NIHSS score was strongly associated with medical complications (p<0.001). Sixty-three (15.2%) patients were readmitted within 30 days. Readmitted patients were more likely to have had medical complications (33.3% vs. 19.3%, p=0.013). On multivariable logistic regression analysis, cardioembolic or large-artery atherosclerotic subtype (adj. OR 2.24, 95% CI 1.29-3.89) and initial NIHSS score (adj. OR 1.07, 95% CI 1.03-1.11) predicted readmission. Of potentially modifiable factors (not including initial NIHSS score or stroke subtype), any medical complication was the only predictor of readmission (adj. OR 2.09, 95% CI 1.61-3.76).

Conclusions:
While stroke severity and stroke subtype are non-modifiable predictors of 30-day readmission, medical complications after ischemic stroke or TIA may mediate that risk and identify a subset for targeted intervention. Specific approaches may include prevention of infections and venous thromboembolism and improving post-discharge transitions of care.
Abstract W P312: Pre-Hospital and Hospital Data Linkage in an Organized Stroke System of Care: A Pilot Study
Authors: Chennupati Rishitha , Trajcevski Goce , O'Neill Kathleen , Stein-Spencer Leslee , Kiely Mark , Beck Eric , Mehotra Sanjay , Prabhakaran Shyam
Published: March 2022

Objective:
Quality improvement within organized stroke systems of care, where policies such as diversion to primary stroke centers (PSC) integrate pre-hospital strategies with hospital performance and patient outcomes, are dependent on accurate linkage of emergency medical services (EMS) and hospital patient data. Currently, such linkage is difficult due to patient privacy concerns, heterogeneous and discrete databases, and variability in data collection. The objective of this pilot project was to create and validate a linkage algorithm for EMS and hospital data from 2 primary stroke centers (PSC) in Chicago.

Methods:
A retrospective analysis of the Get With The Guidelines (GWTG) Stroke registry identified confirmed stroke patients treated at 2 regional PSCs during the first 2 months of 2013. Data from the EMS SafetyPAD database on all patients arriving to those 2 PSCs during the same period were also retrieved. These datasets were provided in CSV format without patient identifiers and inserted it into the Oracle Database for schema matching. We then used a deterministic matching process using 4 non-identifying variables (destination hospital, arrival date/time, age, and gender) in both pre-hospital (EMS) and hospital (GWTG) datasets to create an algorithm for probabilistic matching. A time difference of 30 minutes was used for arrival time to allow for the human error in the time documentation. The algorithm was first evaluated at PSC 1 then validated against data from PSC 2.

Results:
At PSC 1, there were 13 EMS arriving stroke patients during the study period. Of these, 11 were matched (84.6%) to EMS records using the deterministic matching algorithm. At PSC 2, there were 7 EMS arriving stroke patients during the same period, of which 5 (71.4%) were matched to EMS records. The overall matching rate was 80%. In the 4 non-matches, inaccurate date/time entry occurred.

Conclusions:
Implementing a pre-hospital to hospital data linkage system is feasible using 4 commonly included non-identifying data elements. Quality improvement initiatives such as decreasing scene-to-hospital time and assessing pre-hospital stroke assessment tools would be greatly facilitated by having these databases linked.
Abstract W P316: Improved Detection and Treatment of Post-Stroke Depression Utilizing Patient Health Questionaire-9 (PHQ-9) Screening over Standard Methods
Authors: Hooker Allison , Tatum Evan , Roels Christina
Published: March 2022

Background and Purpose:
Post-stroke depression is common, with an estimated prevalence of 30-35%. This study assessed the null hypothesis that PHQ-9 screening is equivalent to standard care (suicide screening + provider assessment) in detection of post-stroke depression. A secondary outcome was to assess the optimal timing and setting to perform PHQ-9 screening after stroke.

Methods:
PHQ-9 screenings and modified Rankin Scales were conducted in a prospective study population (n=49) at three time points - inpatient within 48 hours of admission for stroke, 7 days after discharge at the outpatient stroke clinic, and by telephone at 90 days. Actionable treatment of depression defined as psychiatry referral and/or initiation of antidepressants were recorded. A retrospective control group (n=125), prior to initiation of the PHQ-9, was reviewed to determine baseline rates for treatment of depression.

Results:
PHQ-9 screening increased actionable treatment of depression over standard methods from 5.6% to 18.4% (p=0.009, 95% CI 1.6-25% increase) with similar baseline characteristics of age (p=0.406), gender (p=0.9), and antidepressant therapy prior to admission (p=0.377) between groups. 20.4% of the study population had a score of ≥ 10 (depression) at one time point and 59% of the study population had a score of ≥5 signifying minimal symptoms of depression at one time point. 51% experienced an increase in their PHQ-9 from inpatient screening to the outpatient stroke clinic. A significant number, 28.6%, were lost to follow-up at 90 days. In multivariate analysis, predictors of high PHQ-9 scores in stroke patients were young age (p=0.015) and trend with prior antidepressant use (p=0.06). Gender was insignificant (p=0.266).

Conclusions:
PHQ-9 screening significantly increased our detection and treatment of post-stroke depression and sub-optimally treated pre-morbid depression. The outpatient stroke clinic seems to be the optimal time point for screening due to increased scores and the difficulty in obtaining scores at 90 days. Young age and prior antidepressant use predispose high PHQ-9 scores post-stroke.
Abstract W P322: Quality of Life Measurements in Patients with Transient Ischemic Attack and Minor Stroke
Authors: Caprio Fan Z , Corado Carlos , Bergman Deborah , Curran Yvonne , Bernstein Richard , Cella David , Naidech Andrew , Prabhakaran Shyam
Published: March 2022

Background and Purpose:
Transient ischemic attack (TIA) and minor ischemic stroke patients typically have no or negligible residual deficits or disability. We sought to evaluate patient-reported quality of life (QOL) at 3-months in patients with TIA or minor stroke with no residual deficits.

Methods:
From a single-center prospective cohort study of ischemic stroke and transient ischemic attack (TIA) patients, we identified patients admitted between August 2012 and April 2013 with TIA and minor stroke 1) with no residual deficits, defined as NIHSS of 0 at 24 hours; 2) discharged home with modified Rankin Scale (mRS) < 2; and 3) without recurrent stroke prior to 3-month follow-up. Functional status was assessed by structured telephone interviews and patient-reported outcomes using Neuro-QOL and PROMIS short-form tests at 3 months. The modified Rankin scale (mRS), Barthel Index (BI), and 8 domains of QOL were measured: upper extremity (UE) function, lower extremity (LE) function, mobility, applied cognition-general concerns, applied cognition-executive function, depression, social satisfaction, and fatigue. We assessed the proportion with impaired QOL, defined as > 1 standard deviation from mean of 50 on T-scores for each QOL domain.

Results:
Among 91 patients meeting our study criteria (mean age 65.9 years, 52% female, 67% white, median initial NIHSS score 0), mRS was 0 in 84.6% and 1 in 15.4% of patients at 3 months while BI was 100 and 95 in 94.5% and 5.5%, respectively. On QOL assessments, 6.6% had impaired UE function, 4.4% impaired mobility, and 8.8% any impaired physical function. Only 2.2% had abnormal cognitive, depression, fatigue, or social satisfaction scores. Any reported impairment of QOL was noted in 10 (11.0%) patients overall.

Conclusions:
Despite having no disability on standard objective disability scales, over 10% of patients with TIA or minor stroke report a reduction in quality of life at 3 months. As they may be more sensitive to mild impairments, patient-reported physical and cognitive function may more useful as endpoints in future studies of TIA or minor stroke than standard disability rating scales.
Abstract W P326: Evaluating Low Rates of Oral Anticoagulant Prescribing for Secondary Stroke Prevention in Ontario
Authors: Shah Reema , Li Shudong , Stamplecoski Melissa , Kapral Moira K
Published: March 2022

Background:
Evidence for benefit of oral anticoagulation (OAC) therapy for stroke prevention in atrial fibrillation (AF) is well established, however, many observational studies have shown underuse and high rates of discontinuation of OAC in primary and secondary stroke prevention. The purpose of this study was to identify: 1) factors associated with low rates of OAC prescribing after stroke or TIA, and 2) factors associated with lack of adherence to warfarin within one year of stroke/TIA.

Methods:
Data from the Ontario Stroke Registry were used to identify a cohort of patients with AF and ischemic stroke or TIA admitted to 11 stroke centers in Ontario, Canada between 2003 and 2011. Patient demographic and clinical characteristics were compared in those prescribed and not prescribed OAC at hospital discharge and within one year of stroke/TIA. Warfarin adherence was determined using prescription claims data from the Ontario Drug Benefits database for patients over the age of 65. Multiple logistic regression was used to determine independent predictors of OAC prescribing at discharge and low warfarin adherence one year after stroke/TIA.

Results:
Of the 5781 patients identified, 4235 (73%) were prescribed OAC at hospital discharge. Overall, older patients were less likely to receive OAC at discharge (OR for each additional year 0.98, 95% CI 0.98 to 0.99), as were those with TIA compared to ischemic stroke (OR 0.70, 95% CI 0.60 to 0.82), prior gastrointestinal bleed (OR 0.47, 95% CI 0.36 to 0.62), renal disease (OR: 0.68, 95% CI 0.47 to 0.97), dementia (OR: 0.73, 95% CI 0.60 to 0.90), and those admitted from a longterm care facility (OR: 0.53, 95% CI 0.40 to 0.70). Patients with greater stroke severity (Canadian Neurological Score 4-8 compared to CNS >8) were more likely to receive OAC (OR 1.3, 95% CI 1.1 to 1.5). In contrast, at one year, patients with greater stroke severity (CNS <4 compared to CNS >8) were less likely to be adherent to warfarin therapy (OR 0.25, 95% CI 0.10 to 0.62).

Conclusions:
Age, dementia, and longterm care residence are predictors of OAC underuse in secondary stroke prevention and represent key areas to be targeted for quality improvement initiatives.
Abstract W P330: Antithrombotic Treatment Patterns Among Patients with Non-Valvular Atrial Fibrillation in a Managed Care Setting
Authors: An JaeJin , Lang Daniel T , Jazdzewski Kristin P , Le Paul T , Niu Fang , Rashid Nazia , Ershoff Dan , Meissner Brian , Makenbaeva Dinara , Bruno Amanda
Published: March 2022

Background:
Antithrombotic therapy (warfarin or aspirin (ASA)) has been recommended to reduce the risk of stroke in patients with NVAF. The purpose of this study was to describe antithrombotic treatment patterns and baseline differences for managed care patients newly diagnosed with NVAF.

Methods:
Patients age ≥18 years and newly diagnosed with NVAF (index date) were identified between 01/01/2006_12/31/2011 within Kaiser Permanente Southern California databases and followed until 12/31/2012. Prescriptions, anticoagulation clinic information, and international normalized ratio (INR) monitoring were used to create 4 treatment groups: 1) continuous warfarin, 2) discontinuous warfarin (≥1 treatment gap >80 days), 3) ASA only, and 4) no antithrombotic therapy. Descriptive statistics were used to compare groups.

Results:
A total of 28,776 patients were identified with median follow up of 2.5 years. Among the 81% of patients (23,297) with ≥1 CHADS
2
risk factor for stroke at baseline: 27.4% were continuously treated with warfarin, 22.0% discontinued warfarin, 28.5% were on ASA only, and 22.1% received no therapy. Using the Rosendaal method, median time in INR range 2-3 for all warfarin-treated patients was 59%, which does not include patient-specific ranges. ASA users were older (mean±SD age: 77.6±10.8) compared to continuous warfarin users (73.7±9.6, p<0.001). Continuous warfarin users had higher rates of comorbidities: hypertension, diabetes, and stroke compared to the ASA group (stroke: 4.4% vs. 2.2% respectively, p<0.001), whereas the ASA and no therapy groups had higher rates of congestive heart failure, myocardial infarction, and bleeding (bleeding: 9.0% ASA, 9.8% no therapy, 6.5% continuous warfarin, p<0.001). CHADS
2
scores were slightly higher for ASA users compared to continuous warfarin or no therapy (2.04±0.92 ASA, 2.01±0.90 continuous warfarin, 1.93±0.93 no therapy, p<0.001).

Conclusion:
Patients with newly diagnosed NVAF have varied treatment patterns and baseline comorbidities including rates of stroke and bleed. Future studies should evaluate risks and benefits associated with these real world treatment patterns.
Abstract W P335: Variation and Trends in the Documentation of National Institutes of Health Stroke Scale (NIHSS) Among GWTG-Stroke Hospitals
Authors: Reeves Mathew J , Smith Eric E , Fonarow Gregg , Zhao Xin , Xian Ying , Peterson Eric D , Schwamm Lee H , Olson DaiWai M
Published: March 2022

Background:
Despite its clinical importance NIHSS is often not documented in routine practice and in stroke registries. We describe trends in NIHSS documentation by GWTG-Stroke hospitals, the relationship between hospital documentation rates and reported NIHSS, and identify hospital- and patient-level factors associated with documentation.

Methods:
We analyzed NIHSS documentation in 1,159,981 acute ischemic stroke patients admitted to 1,682 GWTG-Stroke hospitals between 2003-2012. We used multivariable logistic regression models to identify hospital- and patient-level predictors of NIHSS documentation. Because of rapid increases in NIHSS documentation in recent years, multivariable analyses were restricted to the 2011-2012 period.

Results:
The overall NIHSS documentation rate was 51% and the mean NIHSS score was 6.8. Between 2003 -2012 mean hospital-level NIHSS documentation increased from 27% to 70%. The mean hospital-level NIHSS documentation rates and NIHSS score were inversely related (r = -0.228, p <0.0001), but this relationship was driven primarily by hospitals with documentation rates of<20% (Figure). Multivariable analysis indicated that NIHSS documentation was impacted by arrival mode, last known well-to-arrival time, and was higher at primary stroke centers and hospitals with larger case volumes (Table).

Conclusion:
Evidence of selection bias in reporting NIHSS was limited to hospitals with low documentation rates. Documentation of NIHSS was influenced by both hospital and patient-level factors and was higher in patients who were candidates for thrombolysis treatment. Documentation of NIHSS has improved dramatically in recent years.
Abstract W P352: Clopidogrel-Statin Interaction in Secondary Prevention After Ischemic Stroke: A Randomized Double Blind Placebo Controlled Crossover Study
Authors: Siepmann Timo , Heinke Denise , Kepplinger Jessica , Barlinn Kristian , Puetz Volker , Gahn Georg , Bodechtel Ulf
Published: March 2022

BACKGROUND:
In secondary prevention after ischemic stroke variability in individual responsiveness to clopidogrel is a clinically relevant problem. Among possible mechanisms that may contribute to this phenomenon, clopidogrel-statin interactions are discussed. Particularly, competitive metabolization of lipohilic statins (i.e. simvastatin) and clopidogrel by cytochrome P450 (CYP) 3A4 was suggested to reduce the inhibitory effect of clopidogrel on platelet aggregation. In contrast, hydrophilic fluvastatin is predominantly metabolized by CYP 2C9 and is therefore assumed not to alter clopidogrel efficacy. We assessed the hypothesis that simvastatin, in contrast to fluvastatin, reduces clopidogrel-mediated platelet inhibition.

METHODS:
We performed a randomized double blind placebo controlled crossover study in 13 patients with acute ischemic stroke. After an initial 13 day period in which all patients received 75 mg clopidogrel/day, one group (n=6) was randomized to additionally receive 20 mg simvastatin/day and placebo for 13 days. During this period the other group (n=7) received 80 mg fluvastatin and placebo in addition to clopidogrel. Regimens were crossed over after a 13 day wash-out period during which patients received clopidogrel only. Switched regimens were then continued for another 13 days. Assessment of ADP-induced platelet aggregation, plasma levels of clopidogrel active metabolite and coagulation was performed at baseline, at each regimen change and at study completion.

RESULTS:
We studied 7 female and 6 male patients, ages 63.9±3 years (mean±SD). Plasma levels of clopidogrel active metabolite and platelet aggregation were unaltered when simvastatin or fluvastatin were added to treatment with clopidogrel. Simvastatin decreased prothrombin ratio (decrease from 109±10,5% to 103±11%, p<0,05) when combined with clopidogrel but there was no such change after treatment with fluvastatin and clopidogrel.

CONCLUSIONS:
This study indicates that neither fluvastatin nor simvastatin alter clopidogrel-mediated platelet inhibition. In co-administration of simvastatin and clopidogrel we observed decrease in prothrombin ratio which could be due to simvastatin-induced reduction of prothrombin fragment 1 and 2 activity.
Abstract W P353: Benign Natural History of Occlusion in Asymptomatic Carotid Stenosis
Authors: Bogiatzi Chrysi , Spence J David
Published: March 2022

Introduction:
One commonly stated reason for stenting of asymptomatic carotid stenosis is to prevent carotid occlusion. However, the Circle of Willis provides substantial protection against occlusion, so this objective may be misguided. In the NASCET trial, patients with near occlusion of the internal carotid had a lower risk of stroke than did patients with lesser degrees of stenosis. We studied the effects of progression to occlusion among patients with asymptomatic stenosis of the internal carotid artery (ICA).

Methods:
We studied the outcome of all consecutive patients in our clinic database with asymptomatic carotid stenosis of ≥60% at baseline between 1991 and 2010, who were followed for at least two years with carotid ultrasound and clinical evaluation.

Results:
370 patients were included; mean age ± SD 68.8 ± 10.3; 210 (56.8%) were men. Systolic blood pressure was 149.8 ± 22.2, low-density lipoprotein 2.3 ± 1.1 mmol/L, smoking pack-years 24.5 ± 23.3. Only one individual (0.03%) with near occlusion of the ICA developed a new ipsilateral internal carotid artery (ICA) occlusion within a year. This patient experienced episodes of ipsilateral amaurosis fugax before the occlusion (which occurred after he was referred for endarterectomy), but remained asymptomatic after the ICA was totally occluded.

Conclusion:
Occlusion of asymptomatic carotid stenosis is a rare and usually benign occurrence. In patients with asymptomatic carotid stenosis. The risk of stroke from carotid occlusion is well below the risk of stroke from stenting. Preventing ICA occlusion is not a valid reason to perform carotid stenting in patients with asymptomatic carotid stenosis.
Abstract W P357: Glycemic Control or Dual Endothelin Receptor Antagonism Reverses Diabetes-Mediated Dysfunctional Cerebral Neovascularization and Remodeling Patterns
Authors: Kaczmarek Jessica , Abdelsaid Mohammed , Fagan Susan , Ergul Adviye
Published: March 2022

OBJECTIVES:
Diabetes targets micro and macrovascular endothelium leading to cardiovascular complications including stroke and cognitive impairment. We previously showed that 1) endothelin-1 (ET-1), the most potent vasoconstrictor with growth promoting properties, contributes to diabetes-mediated cerebrovascular dysfunction and remodeling, and 2) glycemic control started at the onset of diabetes prevents these vascular pathologies in part by decreasing the activation of the ET system. We recently demonstrated that diabetes causes dysfunctional cerebral neovascularization but whether these changes can be reversed remained unknown. The current study tested the hypothesis that glycemic control or dual ET receptor antagonism reverses established pathological neovascularization of the brain in diabetes.

METHODS:
Diabetic male Goto-Kakizaki (GK) rats were administered either vehicle, metformin (300 mg/kg/day), or the dual ET
A
/ET
B
receptor antagonist bosentan (100 mg/kg/day) for 4 weeks (w) starting at 18 weeks of age after pathological neovascularization occurs. At termination (22 w), brain sections were imaged by confocal microscopy and vascular density, tortuosity, vascular volume, and surface area in the cortex and striatum regions were measured by 3-dimensional reconstruction of isolectin stained vasculature using Z-stacked images.

RESULTS:
Metformin and bosentan treatment reduced all indices of neovascularization compared with untreated 22-w old GK rats (Table, n=3, *p<0.05). Blood glucose levels (mg/dL) in untreated, metformin-treated, and bosentan-treated rats were 242±25, 126±4, and 199±21, respectively. Mean arterial blood pressure was consistent across the groups.

CONCLUSION:
These results suggest that glycemic control with metformin or use of dual ET
A
/ET
B
receptor antagonist is effective in reversing established pathological neovascularization and offers therapeutic potential.
Abstract W P362: Krupple-Like Factor 11 Mediates Blood-Brain Barrier Dysfunction in Ischemic Stroke
Authors: Yin Ke-Jie , Hamblin Milton , Zhang Jifeng , Zhu Tianqing , Chen Yuqing E
Published: March 2022

The blood-brain barrier (BBB) is one of the primary targets of cerebral ischemic insults. Extensive studies have shown that breakdown of BBB integrity initiates a devastating cascade of events and eventual neuronal loss in cerebral ischemia. Thus, it is important to identify mechanisms by which loss of BBB integrity can be reduced under ischemic stroke conditions. Kruppel-like factors (KLF) are members of the zinc finger family of transcription factors and play key roles in cellular growth and differentiation. Up to now, the function of the KLF family in the cerebral vasculature is largely unexplored. KLF11 is a member of the KLF family with high expression in vascular endothelium. Mutations or variations in KLF11 gene are closely associated with human type 2 diabetes mellitus, a major risk factor for stroke. Previously, we have demonstrated that peroxisome proliferator-activated receptor γ-mediated cerebral vascular protection during ischemic insults needs recruitment of KLF11 as its critical coactivator. However, the functional significance and mechanisms of KLF11 itself in regulating cerebrovascular pathogenesis are totally unknown in ischemic stroke. Here we have shown that KLF11 expression is significantly decreased in the cerebral vasculature, cerebral cortex, and cultured BMECs after
in vivo
and
in vitro
ischemic stimuli. KLF11 genetic deficiency leads to increased BBB permeability in mouse brain after middle cerebral artery occlusion as well as increased leukocyte-endothelial rolling and adhesion in the vascular wall. Moreover, we also demonstrated that gain-of-KLF11 function by adenovirus can significantly inhibit BMEC death after exposure to Oxygen Glucose Deprivation. Mechanistically, we found several potential KLF11 binding sites in the promoter region of selective endothelial tight junctions. Genetic deletion of KLF11 in mice significantly reduced cerebral expression of Claudin 5 and ZO-1 mRNAs. These findings suggest that KLF11 functions as a novel master regulator in BBB pathologies after ischemic stroke. Elucidating the molecular mechanisms of KLF11-mediated BBB protection may lead us to discover novel pharmaceutical targets for the development of effective therapies against ischemic stroke.
Abstract W P37: Laterality of the Posterior Cerebral Artery is Associated With a Smaller Volume of Brain Tissue at Risk in Patients With Acute Anterior Circulation Arterial Occlusion
Authors: Hernandez-Perez Maria , Perez de la Ossa Natalia , Massuet Anna , Diaz Rocio , Cuadras Patricia , Dorado Laura , Lopez-Cancio Elena , Gomis Meritxell , Millan Monica , Davalos Antoni , Munuera Josep
Published: March 2022

Background:
Laterality of the posterior cerebral artery (LPCA) in acute stroke has been related with a better leptomeningeal collateral circulation and with improved functional outcome at 6 months in patients treated with IV tPA. We aim to study the association between LPCA and the amount of brain tissue at risk of infarction in patients with anterior circulation arterial occlusion.

Methods:
From our prospective database of ischemic stroke we selected patients with anterior circulation arterial occlusion who underwent multimodal MRI < 12h of symptom onset. We considered LPCA when the following criteria were accomplished: a) ipsilateral PCA to the occlusion site was extended in 1 or more segments compared to the contralateral PCA and b) ipsilateral P4 segment was visible on axial TOF images. Two independent readers blinded to clinical data retrospectively assessed the presence of LPCA (k=0.65). We analyzed the association between LPCA and the volume of ischemic penumbra at baseline (Tmax>6s) and the final infarct volume (CT 24h). Good outcome was defined as mRS ≤ 2 at 90 days.

Results:
Seventy-two patients were included in the study (mean age 67y, 45% male). LPCA was present in 39 (54.1%). There were no differences between groups with or without LPCA, except a lower baseline NIHSS in the LPCA group (15 vs 19; p=0.003). Proportion of patients treated with reperfusion therapies was similar between groups. Patients with LPCA had a smaller lesion in Tmax>6s (54 vs 79cc; p=0.02), smaller final infarct volume (47 vs 111cc; p=0.013), and higher proportion of good outcome (52.8% vs 27.3%; p=0.03). In a multivariate analysis, LPCA was independently associated with smaller lesion volume on Tmax>6s (B -18, IC95% [-36,-0.3]), smaller final infarct volume (B -64.8, IC95% [-100,-29]) and better clinical outcome (OR 4.66, IC95% [1.04,20.8]).

Conclusion:
LPCA sign in patients with anterior circulation arterial occlusion is associated with smaller volume of brain tissue at risk resulting in smaller infarct volume and better clinical outcome. These findings suggest favorable leptomeningeal collaterals.