bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP234: What Stroke Survivors and Families Need to Know For Decision-making During Acute Ischemic Stroke Care - A Qualitative Research Study
Authors: Cheng Eric , Ayad Miriam , Gialde Elizabeth , Chhatriwalla Emily , Spertus John A , Rymer Marilyn , Summers Debbie , Saver Jeffrey , Decker Carole
Published: July 2021

Background:
Explaining the benefits and risks of tissue plasminogen activator (tPA) is typically done through hurried verbal explanations in the emergency department, but it may not be understood by patients and caregivers. However, spending more time to explain the risks and benefits may delay the administration of tPA. We sought to develop a decision aid tool to facilitate this communication.

Methods:
A multidisciplinary research team searched available materials of stroke descriptions intended for a lay audience. The research team and medical illustrator also developed different formats of presenting results from the NINDS tPA trial. We conducted focus groups of stroke survivors and their caregivers at two medical centers to provide feedback on what information should be communicated and how it should be presented.

Results:
To date, we have convened three focus groups. We have enrolled 12 stroke survivors with a mean age of 54. Two had received tPA. We also enrolled three caregivers with a mean age of 68. Survivors typically did not recall being educated about acute stroke or its treatment during the hospitalization. Participants preferred broadening the definition of a “good” outcome to functional independence (i.e. modified Rankin score of 0-2) over a narrower one of being symptom-free. They also preferred viewing information about the increased chance of a good outcome rather than the decreased chance of a bad outcome such as death. Participants’ opinions sometimes differed from researchers’, such as the choice of colors to depict good outcome or death and the preference of simple bar graphs over pictographs.

Conclusions:
The different opinions between researchers and patients and caregivers highlight the need to obtain input from all stakeholders in designing effective decision aid tools. Further focus groups are planned to refine the decision-aid tool. We also plan to pilot-test the implementation of this tool in the workflow of managing patients with stroke in the emergency department.
Abstract TP239: Race and the Utilization of Diagnostic Procedures in the Emergency Department for Acute Stroke in the United States
Authors: Lee Young M , Khan Imad S , Ladner Travis R , Ehtesham Moneeb , Singer Robert J
Published: July 2021

Introduction:
In 2007, the AHA recommended the use of the following diagnostic procedures immediately upon admission to the emergency department (ED) for all adult patients with suspected stroke: noncontrast brain CT or brain MRI, electrocardiogram, complete blood count (CBC) including platelets, cardiac enzymes and troponin, electrolytes, urea nitrogen, creatinine, serum glucose, prothrombin time and international normalized ratio (PT/INR), and oxygen saturation. We described the overall rate of utilization of these procedures and assessed for association with race using a national ED survey.

Methods:
We identified 308 ED visits for ischemic and spontaneous hemorrhagic strokes in adults 18 years representing 1.2 million stroke-related ED visits in the US using the National Hospital Ambulatory Medical Care Survey for years 2008-2009. The association between rates of utilization of diagnostic procedures and race was assessed using a Pearson chi-square test.

Results:
Overall the most common and least common diagnostic procedures performed were measurement of oxygen saturation (93%) and PT/INR (40%), respectively. There was no difference in use of CT/MRI (82.3% vs 82.7%,
p
=0.952), electrocardiogram (79.3% vs 80.7%,
p
=0.875), CBC (82.4% vs 93.9%,
p
=0.093), cardiac enzymes and troponin (55.7% vs 60.9%,
p
=0.523), electrolytes (57.4% vs 70.0%,
p
=0.153), urea nitrogen and creatinine (70.0% vs 68.5%,
p
=0.858), serum glucose (63.8% vs 66.8%,
p
=0.721), PTT/INR (37.3% vs 50.8%,
p
=0.139), and oxygen saturation (91.9% vs 98.7%,
p
=0.063) in blacks and whites, respectively.

Conclusion:
In terms of race, we found no significant difference in the rate of ED utilization of diagnostic procedures for acute stroke in the US. The overall rates of adherence to the 2007 AHA guidelines for diagnosis of acute stroke differed by diagnostic procedure. While there was almost universal measurement of oxygen saturation, less than half of acute stroke patients had a PT/INR analysis.
Abstract TP240: Simulation-Based Learning Improves Neurology Resident Training in Acute Stroke Care
Authors: Tai Waimei , Baumann J.j. , Melamed Esther , Vora Nirali , Schwartz Neil
Published: July 2021

Introduction:
Acute “stroke codes” are stressful for the new neurology resident who must lead a multi-disciplinary team and quickly integrate information to make high risk time-sensitive decisions. While other disciplines have used simulation technology for years for cardiac arrest codes, neurology has just begun utilizing this resource.

Objective:
To improve neurology trainees’ execution of a multi-disciplinary acute stroke code using simulation experience

Methods:
We identified three learning objectives for the simulation experience: assess tissue plasminogen activator (tPA) eligibility, utilize appropriate order sets, and communicate effectively. Scripts for two emergent scenarios were developed: ischemic stroke requiring i.v. tPA and warfarin-associated intracranial hemorrhage requiring coagulopathy reversal. A standardized patient (SP) was trained. Neurology residents in their first week of training were the learners. Six residents attended a four-hour training session in the Simulation Center at Stanford University. Half of the trainees participated in the scenario while the others observed through live video. The SP acted the part in a fully-equipped, mock emergency room. Monitors, controlled remotely, displayed vital signs which changed to reflect interventions performed. Screens also displayed radiologic data. Trainees communicated with the stroke fellow and nursing regarding the plan of care and placed orders through an electronic medical record in training mode. Debriefing occurred after each scenario. Evaluations were completed and collected.

Results:
Trainees had positive experiences and felt more comfortable with the stroke code after the training. On a 1-5 scale, learners rated quality of teaching (average 4.6); learning from the scenario (4.8); overall organization (4.2); facilities (5); and overall evaluation (4.6).

Conclusions:
Simulation training offers a valuable opportunity to enhance neurology resident’s comfort in running stroke codes. Additional studies are required to measure long-term retention of acquired skills and training effect on systems and clinical outcomes.
Abstract TP251: The Direct and Indirect Impact of the Acute Stroke Nurse Role on Thrombolysis Treatment Times and Rates
Authors: Coote Skye , Loh Poh Sien , Moore Andrea , Bladin Chris
Published: July 2021

Background:
The Acute Stroke Nurse (ASN) role at Box Hill Hospital is a business hours (weekday 8am - 4.30pm) first responder role designed to fast track acute stroke patients through thrombolysis screening in the Emergency Department. Since 2004, this role has been filled in either a full-time (FT) or part-time (PT) capacity, except for a 5-month period in 2010 where the role was vacant. We sought to explore the influence of having a full-time ASN, compared to part-time or no ASN, on thrombolysis rates and times.

Methods:
Data was extracted from the hospital’s stroke thrombolysis database for the period 2004 to 2012. Comparisons were made for those patients seen by the ASN, when FT and PT and those who saw medical staff only. Statistical comparisons were made using Mann-Whitney Rank Sum test.

Results:
Almost half (43% n=182) of the 428 thrombolysis cases occurred during business hours, the ASN attended 84% of cases when the role was filled FT and 15% when PT. No difference was seen in median door-to-CT times (25 minutes.) Faster median door-to-needle times were achieved during business hours when the patient was seen by the ASN compared to those who were not (66 mins vs. 83 mins, p=<0.001.) Faster times were seen when the ASN role was FT (68 min) or PT (79 min) compared to vacant (89 mins, p=0.006,) with more patients treated within 60 minutes of arrival (35% FT, 27% PT and 8% vacant, NS). While the ASN only works within business hours, faster door-to-needle times were seen after hours when the ASN role was filled FT and PT compared to vacant (87mins and 100 mins vs. 103 mins, p=0.013;) and treatment was only commenced under 60 minutes when the ASN was employed FT.

Conclusion:
The Acute Stroke Nurse role seems to have a positive impact on thrombolysis treatment times and rates, with the best results being achieved during and outside business hours when the ASN is employed FT.
Abstract TP270: Correlation Between Prostaglandin D2 DP1 Receptor Effects on Cerebral Blood Flow and Stroke Outcomes
Authors: Ahmad Abdullah , Maruyama Takayuki , Narumiya Shuh , Dore Sylvain
Published: July 2021

Background and Purpose:
The association of PGD2 with vasculature and blood makes it a prime candidate to be investigated in stroke. We have shown earlier that DP1
-/-
have greater brain damage after MCAO and excitotoxicity. Here, we test whether DP1 agonist BW245C treatment after stroke improves cerebral blood flow (CBF), consequently minimizing anatomical and functional deficits.

Methods:
First, to determine if BW245C can change basal CBF, WT and DP1
-/-
mice were given a single i.p. injection of vehicle or 0.02, 0.2, 2.0mg/kg BW245C, and CBF was recorded for 2h. Next, to determine whether BW245C can prevent brain damage after MCAO, WT and DP1
-/-
mice were subjected to 60min MCAO and 96h reperfusion. Immediately at reperfusion, mice were given a single i.p. injection of vehicle or 0.02, 0.2, 2.0mg/kg BW245C. These mice were also tested for various functional outcomes. Further, to determine if BW245C can improve CBF after stroke, BW245C was given during occlusion and changes in penumbra and core CBF were continuously recorded. Finally, to address potential compensatory mechanisms, effect of BW245C on stroke outcomes was also tested in DP1-/-.

Results:
BW245C treatment significantly increased the basal CBF in WT whereas in DP1
-/-
it remained unchanged. The infarction volume was significantly (p<0.05) reduced to 38.7±8.1% in 0.2mg/kg BW245C treatment group as compared with the control group (51.2±7.1%) and vehicle group (52.7±8.6%). The BW245C treatment also reduced the functional deficits significantly. Interestingly, BW245C also resulted in considerable increases in penumbra and core CBF immediately before reperfusion. Analysis revealed a strong correlation between attenuation in infarction and CBF improvement in penumbra immediately at reperfusion (p<0.02) and at 60min after reperfusion (p<0.005). The infarction in DP1
-/-
was significantly higher (66.3±11.4%) than the WT control mice (51.2±7.1%), and BW245C treatment didn’t change the final outcome in DP1-/-.

Conclusions:
Overall the data suggests that stimulation of the DP1 receptor after stroke improves CBF, and minimizes brain damage and functional deficits. This ongoing work is providing novel mechanistic pathways to better explain the neuroprotective mechanisms of DP1 receptor in stroke.
Abstract TP273: High Fat Diet Worsens Long Term Stroke Outcome
Authors: Li Weiguo , Prakash Roshini , Ma Handong , Ergul Adviye
Published: July 2021

Introduction:
Obesity is a risk factor for stroke and diet-induced obesity is the most common type of obesity in humans. Yet, the effects of high fat diet (HFD) on neurovascular function and the extent of ischemic brain injury after ischemic stroke are not well understood. Previously we showed that HFD worsens functional hyperemia, vascular function and short-term (24 h) outcomes of ischemic brain injury induced by 3/21 h middle cerebral artery occlusion (MCAO)/reperfusion. The goal of this study is to test the hypotheses that HFD beginning early in life will exacerbate vascular injury and worsen long-term outcomes after focal cerebral ischemia.

Methods:
Starting at 4 weeks, Wistar rats were fed control (CD) or HFD diet for 8 weeks. The outcomes of cerebral ischemia were evaluated after 90 min MCAO and 5 d reperfusion by measuring neurological deficit, infarct size and hemorrhagic transformation (HT) frequency and severity. The sham groups were treated with same diet and surgical process without artery occlusion.

Results:
The HFD group had significantly increased body weight and adiposity. In MCAO animals, the infarct volume (37.02 ± 3.68% vs. 19.25 ± 5.52%, p<0.05), HT occurrence (5 out of 7 vs. 2 out of 8) and excess hemoglobin (100.9 ± 55.8 vs. 18.6 ± 4.7 mg/g protein) were greater in the HFD group. After ischemia and reperfusion, the HFD animals showed worse neurological function compared to the CD group. There was no difference between the sham groups.

Conclusion and Translational Impact:
These results indicate that the HFD started in the early life time lowers the threshold of ischemia to induce HT, exacerbates neurovascular injury and worsens the long term outcomes of focal cerebral ischemia. Given that obesity and stroke incidences are on the rise in young population, diet control should be implemented early to prevent and/or reduce ischemic brain injury.
Abstract TP337: Feasibility of Cognitive Testing in Patients with Acute Ischemic Stroke
Authors: Alderman Susan , Vahidy Farhaan , Bursaw Andrew , Savitz Sean
Published: July 2021

Introduction:
Acute Ischemic Stroke (AIS) research protocols are initiated within hours of stroke onset and need to be executed without hindering patient care. The CASTLe Study at our center quantifies cognitive deficits in mild strokes and TIAs within 24 hours of symptom onset. There are a number of patient activities that may pose challenges to this testing. We sought to determine the feasibility of our protocol in the acute stroke setting.

Methods:
The protocol entails a battery of 8 cognitive tests, to be completed within 24 hours of symptom onset. Approximately 60 minutes of uninterrupted time is required with the patient. We identified five major categories of potential impediments to this testing i.e. physicians’ rounds, administration of treatment, diagnostic procedures, nursing care tasks, and family interaction. We developed procedures that included coordination with nursing staff, collaboration with the treating team, and communication with close family. We timed these tests between patient care activities and allowed the family members to stay but not interact during testing. We used a “Do Not Enter” sign for the duration of testing. We scheduled our tests around planned diagnostic procedures.

Results:
A total of 27 patients have been enrolled in 6 months, all but one (96.3%) had testing completed within the stipulated 24-hour time window. The mean ± SD testing time was 49.4 ± 12.8 minutes. The patient on whom testing was not completed resulted in a protocol deviation. This was due to an unscheduled diagnostic test. Furthermore, testing was rescheduled or interrupted beyond normal expectation for two patients, both owing to diagnostic procedures. These however did not result in protocol deviations. One research coordinator (RN) learned all cognitive tests and was able to fully complete the protocol without difficulties.

Conclusion:
We were able to achieve optimal enrollment and successful completion of testing for most of our patients via pro-active planning and coordination. An intimate knowledge of clinical activities and hospital procedures is imperative for scheduling, without which, time sensitive study procedures cannot be completed as designed, generating unwarranted protocol deviations and compromising quality of research.
Abstract TP35: Reperfusion? Angiography and Serial Perfusion MRI Reveal Distinct Features of Endovascular Therapy for Middle Cerebral Artery Stroke
Authors: Liebeskind David S , Scalzo Fabien , Sanossian Nerses , Starkman Sidney , Johnson Mark S , Ali Latisha K , Kim Doojin , Vespa Paul M , Rao Neal M , Yallapragada Anil , Jahan Reza , Tateshima Satoshi , Gonzalez Nestor R , Duckwiler Gary R , Viñuela Fernando , Alger Jeffry R , Salamon Noriko , Saver Jeffrey L ,   for the UCLA Stroke Investigators
Published: July 2021

Background:
TICI scores are routinely used to measure reperfusion on angiography after endovascular therapies for acute stroke. Reperfusion may also be quantified by Tmax parameter changes on serial perfusion MRI before and after treatment. Such definitions of reperfusion used in trials may vary and we therefore investigated the correlation between TICI and quantification of Tmax changes on serial MRI in proximal middle cerebral artery (MCA) stroke cases treated with endovascular therapy.

Methods:
Consecutive acute ischemic stroke patients treated with endovascular therapy for proximal or M1 MCA occlusions with serial perfusion MRI at baseline and 3-6 hours after treatment were analyzed. TICI scores were noted for reperfusion on angiography. Reperfusion on serial MRI was separately defined as interval volume of Tmax>6s lesion size, dichotomous change by > 70% reduction in Tmax>6s, and voxel-wise changes across all Tmax values.

Results:
57 stroke patients (mean age 64±20 years, 68% female) with M1 MCA occlusions imaged with perfusion MRI both before and after treatment with endovascular therapy were studied. TICI angiographic outcomes included 8 TICI 0, 4 TICI 1, 22 TICI 2a, 22 TICI 2b and 1 TICI 3. Both the interval volume of Tmax>6s lesion size and voxel-wise changes across all Tmax values varied extensively. Dichotomous reduction in Tmax>6s lesion volume by 70% was noted in only 12.9% of cases, with reduction by 60% in 19.4%, and by 50% in 30.6%. TICI reperfusion did not correlate with either: interval volume of Tmax>6s lesion size, dichotomous change by > 70% reduction in Tmax>6s, or voxel-wise changes across all Tmax values. Even when only TICI 2a/2b/3 or TICI 2b/3 cases were analyzed, no correlation could be established between the TICI angiographic measure of reperfusion at post-procedure with the change in Tmax lesion from baseline to 3-6 hours after revascularization.

Conclusions:
Reperfusion measured by TICI at angiography and changes in Tmax on serial perfusion MRI provide distinct information, likely reflecting heterogeneity and different vascular phases (arterial vs. microcirculation). Determining the clinical impact of such reperfusion measures on recovery after stroke remains paramount.
Abstract TP365: Think Big: Weekly Stroke Education for Registered Nurses on the Stroke Unit
Authors: Robertson Betty
Published: July 2021

Background:
Nurses play a pivotal role in all phases of care of the stroke patient. Stroke Nurses have responded to the challenge of making stroke systems of care a reality in recent years. We wanted our stroke nurses to use evidence-based practice to organize and deliver stroke services and facilitate optimal outcomes for stroke patients. One of the most important components of a Stroke Program is having a designated unit where patients receive specialized stroke care. Nurses who are a part of a stroke center should be trained to recognize medical complications that can arise in someone who has suffered a stroke. One of the most important reasons why primary stroke centers are the premier places for the treatment of strokes is that, by having specialized stroke units, patients have better outcomes. Is weekly stroke education for RNs on the stroke floor helpful to the nurses?<br Does it influence or impact the way they care for their patients?

Methods:
Since information,research and even nursing staff is always changing, education needs to be provided to nurses taking care of stroke patients so they have the latest and greatest knowledge to share with their patients and loved ones. We asked the staff what topic they wanted to cover and posted a suggestion box on the unit entitled “Ask a Stroke Nurse,” analyzed the attendance and did a survey to get the nurses’ feedback. Collectively we decided the best way to capture all staff on all shifts was to do weekly in-services and education sessions covering everything from Journal articles, updates about the program, interesting case studies, breaking science and even guest speakers from other departments.

Conclusion:
The survey showed that 96% of RNs on the stroke floor found the weekly education very valuable. 96% found that it positively impacted their practice,additionally, 91% said it greatly increased their knowledge about stroke & TIA. We will continue weekly education and continue to get feedback from the nurses. This endeavor has proven to be a very successful. We were pleased to see the positive comments from the staff about how much they enjoy and look forward to the classes each week.
Abstract TP371: Does Symptom Onset to Primary Stroke Center Time Points Affect Stroke Outcome?
Authors: Chee Bryant H , Raman Rema , Ernstrom Karen , Guzik Amy , Hemmen Thomas , Meyer Brett C , Meyer Dawn
Published: July 2021

Background:
Treating acute ischemic stroke (AIS) within 4.5 hours, and with door to needle time of <60min may optimize recovery. It is unknown if onset to PSC time goals is a predictor of outcome. The purpose of this study was to examine effects of symptom onset to PSC time goals on recovery.

Methods:
A retrospective analysis of prospectively collected UCSD SPOTRIAS data was performed. IV rtPA AIS patients were included if they were treated within 270 minutes, and had known 90 day mRS. In-hospital strokes were excluded. Primary outcome was good 90 day mRS(0-2) as predicted by: onset to needle, onset to imaging, onset to stroke code, onset to neuro exam, onset to labs, and onset to decision. Logistic regression was performed (categorized by quartiles).

Results:
291 patients were included (49.8% female, mean age 70.6, median NIHSS 10). Group differences included: HTN (p=0.0002), A.fib (p=0.0005), pre-stroke mRS (p<0.0001), and ethnicity (p =0.0112). Good outcome occurred in 45.0%. Comparing good to poor outcome groups: Mean onset to arrival was 70.6min vs. 62.5min (p=0.13). Mean onset to needle was 140.1min vs. 134.9min (p=0.18). There were no differences in other onset to time goals. Controlling for pre-specified covariates and multiple comparisons, onset to arrival (F-test p=0.09), onset to needle time (F-test unadj p=0.06), onset to stroke code (F-test unadj p=0.20), onset to neuro exam (F-test unadj p=0.28), onset to imaging (F-test unadj p=0.11), onset to lab (F-test unadj p=0.86), and onset to decision (F-test p=0.045) were not significant predictors of 90 day outcome.

Conclusions:
In an academic center providing comprehensive stroke services, onset to time goals was not a significant predictor of 90 day outcome. Expedited care processes in comprehensive stroke centers may compensate for differences in outcomes based on onset time. These results should be validated in a larger cohort in PSCs vs. CSCs.
Abstract TP373: Classification of sICH in Stroke Center Hospitals: Reliability in Question
Authors: Swatzell Victoria , Cudlip Fern , Alexandrov Andrei V , Alexandrov Anne W
Published: July 2021

Background:
Measuring sICH is an important accountability of Stroke Centers. Since the NINDS rt-PA Study, the sICH definition has changed as knowledge of reperfusion-associated hemorrhagic transformation has grown. We aimed to determine what sICH definition was used by Stroke Centers and how this impacts sICH rates.

Methods:
Stroke Centers were invited to participate in a survey with the option to complete it via SurveyMonkey
TM
or by mail. Instructions to adhere to the sICH definition adopted in policies/procedures were provided, and to ask for clarification from Stroke Team members if needed. Data were assembled in SPSS, and analyzed using descriptive statistics and Student t-tests.

Results:
229 responses were received representing 84% of U.S. states and the District of Columbia; 31% represented academic medical centers and 69% community hospitals. 64% of respondees were responsible for collecting the stroke quality data that supports certification. Overall tPA treatment rate for the sample was 8.7% + 6.4 (median 7%), with an overall reported sICH rate of 9.5% + 16.4 (median 5%). Official definitions supported sICH for 86% of responding hospitals, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.” Only 17% identified the definition for sICH adopted by TJC for Comprehensive Stroke Center reporting. Among those that adhered to the TJC definition, sICH rates were significantly lower at 3%+2.3 (median 3%; t=4.7; mean difference = 7.7%; p<.0001, 95% CI 4.4-10.95), compared to 10.6%+17.5 (median 6%).

Conclusions:
Our study documents a significant need for education and inter-rater reliability monitoring of the use of sICH classification after intravenous tPA to ensure accuracy in local quality improvement processes, as well as the validity of data submitted to national stroke registries. Additionally, because sICH associated with reperfusion therapy is a new measure undergoing testing by TJC that could ultimately be tied to future pay-for-performance and public reporting, consensus on its definition as well as reliable sICH classification will be essential to future Stroke Center evaluation.
Abstract TP376: Effect of Organized Stroke Education Program of Stroke Unit for Acute Stroke Patients to Increase Medication Compliance after Discharge
Authors: Yu Hee Seon , Jeong Hyeseon , Yoon Nayoung , Song Hee-Jung , Kim Jei
Published: July 2021

Background and purpose:
Interdicipinary education program of stroke unit might be important to improve secondary prevention by increase of medication compliance and maintenance of relationship with physician. The present study evaluated that our education program of stroke unit including education materials for stroke prevention and man-to-man education schedule of stroke unit is helpful to increase the medication compliance and future follow-up rate for first-ever stroke patients.

Methods:
We first developed education materials, which were consisted of mechanisms and clinical characteristics of stroke, and importance of medication maintenance for secondary stroke prevention. Then man-to-man education was provided for patients who admitted stroke unit (Education group) from January to June of 2012. Medication maintenance rate at 3 months and follow-up rates checked 1 and 3 months after discharge were evaluated. Then, to evaluate the education effects, the rates of Education group were compared ones of No-Education group who were treated in general ward with no organized stroke education from January to June of 2010.

Results:
Total 392 patients (178; No-Education, 214; Education group) were enrolled. Among patients who admitted to stroke unit, 96.7% were educated by 2 stroke coordinators during admission period. The follow-up rates after discharge were slightly higher in Education group within 1month (89% vs 82%,
p
<0.05). Maintenance of the follow-up was significantly higher in Education group after 3months (83% vs 61%,
p
<0.05) than No-Education group. Maintenance rates of antithrombotic medication was highly achieved in the Education group (98% vs 89%,
p
<0.05) during follow-up period of 3 months.

Conclusions:
We observed that the educational effect of stroke unit is well maintained till 3 months after discharge. The high follow-up rate and good medication compliance could be obvious benefits of interdisciplinary working stroke unit.
Abstract TP396: Does Implementation of Enhanced Data Quality Assurance Procedures Improve Data Quality in Stroke Registries? Experience from the University of Texas Houston Stroke Registry
Authors: Rahbar Mohammad H , Gonzales Nicole R , Ardjomand-Hessabi Manouchehr , Tahanan Amirali , Sline Melvin R , Peng Hui , Pandurengan Renganayaki , Vahidy Farhaan S , Tanksley Jessica D , Delano Ayodeji A , Malazarte Rene M , Savitz Sean I , Grotta James C
Published: July 2021

Background:
Limited information has been published regarding standard procedures to ensure data quality in stroke registries. We share our experience regarding the establishment of enhanced quality assurance (QA) procedures for the University of Texas Houston Stroke Registry (UTHSR) and test whether these QA procedures have improved data quality in UTHSR.

Methods:
All 5092 patients’ records that were abstracted and entered in UTHSR, between January 1, 2008 and December 31, 2011, were considered in this study. A random subset of 30 records was used for re-abstraction of 24 key variables by two abstractors. From these 30 records, a subset of 13 was re-abstracted by a team of experts as the “gold standard”. We assessed inter-rater reliability (IRR) between the two abstractors as well as each abstractor with the gold standard. Depending on the scale of variables, IRR was assessed with Kappa or by intra-class correlations (ICC) using a 2-way, random effects ANOVA. For assessment of data quality we re-abstracted another set of 41 patients’ records and all discrepant entries were adjudicated by a team of experts. We used Chi-square test for trend to assess whether a significant improvement in data quality has been achieved during 2008-2011.

Results:
The error rate dropped from 3.8 in 2008 to 1.6% in 2011, with a significant (P < 0.001) downward trend in the error rate over the 4 years. The two abstractors had an excellent IRR (Kappa or ICC > 0.75) on almost all 24 variables checked. The only variable that had moderate reliability (0.40 ≤ Kappa ≤ 0.75) was mode of arrival to hospital. Agreement between each abstractor and the gold standard for both categorical and continues variables were also excellent, except for mode of arrival to hospital.

Conclusions:
Establishment of a rigorous data quality assurance for our UTHSR has helped to improve the quality of data. We have observed an excellent IRR for almost all key variables in UTHSR. We recommend training of chart abstractors and systematic assessment of IRR between the abstracted data with that of the gold standard for data quality assurance processes.
Abstract TP397: Validation of a Pneumonia Score in Acute Stroke
Authors: Schepp Sara K , Becker Kyra J , Longstreth W.T. , Tirschwell David L
Published: July 2021

INTRODUCTION:
Accurate prediction of pneumonia (PNA) risk after stroke would 1) allow clinicians to target interventions to patients at highest risk, and 2) help researchers to determine the efficacy of those interventions. We previously derived a PNA risk score based on data available at the time of admission, purposefully leaving out information on swallowing function, which may not be available at time of admission. Items for the 11-point score and point values were: age > 75 (2), male (1), National Institutes of Health Stroke Scale score > 10 (2), mechanical ventilation (4), coronary artery disease (1), chronic obstructive pulmonary disease (1). In a retrospective single-hospital cohort of 1,924 patients with acute ischemic stroke and intracranial hemorrhage (ICH), we used medical records and discharge diagnosis codes to derive the score: C-statistic = .79 (95% CI, .76 - .81). In the current study, we tested whether the score could accurately predict PNA in two other cohorts.

METHODS:
The one cohort (n=398 with acute ischemic stroke or ICH) was obtained retrospectively and presented to various hospitals within the same city during a time period prior to the derivation cohort. Data on predictor variables and the outcome of PNA were obtained from medical records and discharge diagnosis codes. The other cohort (n=89 with acute ischemic stroke) was a subset of the derivation cohort. Data were collected prospectively, and the diagnosis of PNA was ascertained using rigorous criteria that included clinical, radiographic, and culture data.

RESULTS:
Within the retrospective cohort, PNA was diagnosed in 46 (12%), and the score achieved a C-statistic of .71 (95% CI, .66 -.75). Within the prospective cohort, pneumonia was diagnosed in 9 (10%), and the C-statistic for the score was .88 (95% CI, .79 -.94).

CONCLUSION:
The predictive value of the PNA score was validated in two additional cohorts, one with data collected retrospectively and the other, prospectively. The score performed best within the prospective cohort, but sample size was relatively small and the 89 patients were a subset of the derivation cohort. Further refinement and validation of the score is planned.
Abstract TP403: Presence Of Severe Aphasia Reduces Benefit From Thrombolytic Therapy
Authors: Stolzenburg Joanna , Hametner Christian , Hacke Werner , Ringleb Peter A
Published: July 2021

Background:
Patients with severe aphasia are underrepresented in randomized clinical trials because of difficulties getting an informed consent. We wanted to know, if the presence of a severe aphasia influences benefit or risk from thrombolytic therapy.

Methods:
Retrospective analysis of a prospectively collected dataset of patients treated with thrombolytic therapy. For this analysis we included every patient with a supratentorial infarction treated with rtPA or thrombectomy between 1998 and 2011. Aphasia was graded at admission following item 9 of the NIHSS by an experienced speech-and-language-pathologist. All patients were treated following institutional SOP at an ICU or a certified stroke unit. Outcome was assessed using the modified Rankin scale (mRS) three months after treatment; good clinical outcome was defined as mRS 0-2. Symptomatic intracranial hemorrhage (sICH) was defined as in ECASS2. Univariate (Fisher’s exact or Mann-Whitney U tests) and multivariate (logistic regression) analyses were applied using outcome parameters as dependent and those variables having a p-value of <0.1 in univariate tests as independent variables. The NIHSS was corrected for this analysis by subtracting the aphasia-score.

Results:
Overall 1.345 patients were analyzed: 645 had no, 76 mild, 190 moderate and 433 a severe aphasia. After adjustment for sex, side of infarction, type of treatment, hypertension, diabetes, CAD, atrial fibrillation, age, NIHSSc presence of severe aphasia was negative predictive for a good clinical outcome (OR 0.46; 95%CI 0.33-0.65; p<0.0001). In addition severe aphasia was associated with increased mortality after adjustment for sex, type of treatment, hypertension, diabetes, smoking, previous stroke, CAD, PAD, atrial fibrillation, age and NIHSS (OR 1.85; 95%CI 1.32-2.61; p=0.0004). There was no clear association with the risk of suffering from a sICH (p=0.096).

Conclusion:
In this analysis we discovered that patients with severe aphasia had a lower chance of being clinically independent after thrombolytic therapy and had a higher mortality compared to patients with no or mild aphasia. This is probably due to the involvement of larger brain areas - especially cortical territories - in patients with severe aphasia.
Abstract TP418: Delayed Detection Of Atrial Fibrillation After Ischemic Stroke Or Transient Ischemic Attack
Authors: Zurru Maria C , BRESCACIN LAURA , Alonzo Claudia , Villarroel Victor , Orzuza Gabriela , Camera Luis , Waisman Gabriel , Cristiano Edgardo
Published: July 2021

Background and purpose:
detection of atrial fibrillation (AF) after ischemic stroke is crucial, because anticoagulation is mandatory in order to decrease recurrence risk. However, there is no agreement regarding the optimal method to detect paroxysmal AF after the event. The aim of this study was to evaluate predictors for delayed detection of AF after ischemic stroke (IS) and transient ischemic attack (TIA).

Methods:
PROTEGE-ACV is a multidisciplinary stroke quality improvement program coordinated by internists and neurologists within a Buenos Aires healthcare system aimed to optimize secondary stroke preventive care after IS or TIA. Demographic data, vascular risk factors profile control and management were evaluated at the inclusion visit, and IS was categorized according to TOAST classification.

Results:
From 01/2007 to 04 /2012, 872 ischemic stroke patients were included; mean age was 75 ± 10 years-old and 55% were female. Twenty two percent were cardioembolic and 7% undetermined with more than one mechanism with AF as one of them; 14% of patients had history of AF or diagnosis at hospitalization. Incident AF was diagnosed in 101 (21%) of 473 patients with two or more years of follow-up.. Diagnosis of AF was associated with age older than 80 years (OR 1.96 95% CI 1.25-3), history of hypertension (OR 2.4 95% CI 1.25-4.8), chronic renal failure (OR 2.65 95% CI 1.54-4.55) and stroke recurrence (OR 2.96 95% CI 1.66-5.26).

Conclusion:
delayed diagnosis of AF was common in this cohort of patients with IS or TIA. Identification of risk factors is important in order to perform a close follow-up of these patients and to determine the best method for this purpose, in order to reduce recurrence risk.
Abstract TP8: Safety And Outcome After Endovascular Reperfusion Therapy In Elderly Patients With Acute Ischemic Stroke
Authors: Prabhakaran Shyam , Sheth Kevin N , Terry John B , Nogueira Raul G , Horev Anat , Nguyen Thanh N , Gandhi Deeraj , Wisco Dolora , Glenn Brenda A , Tayal Ashis H , Ludwig Bryan , Hussain Muhammad S , Jovin Tudor G , Clemmons Paul F , Cronin Carolyn , Tian Melissa , Gupta Rishi
Published: July 2021

Background:
Age is a strong predictor of outcomes following acute ischemic stroke (AIS). Conflicting data exist on whether endovascular reperfusion therapy (ERT) should be offered to patients over 80 years of age. We compared the safety and efficacy of ERT in elderly (> 80 years) compared to non-elderly (< 80 years) patients with AIS.

Methods:
We collected data from a large multi-center prospective registry of AIS patients treated with ERT. Data were available on demographics, initial severity, angiographic results, hemorrhagic complications using the ECASS criteria, and 3-month functional outcomes using the modified Rankin Scale (mRS). The thrombolysis in myocardial infarction (TIMI) score was used to grade reperfusion. We compared baseline factors, procedural results, and clinical outcomes in those over > 80 years versus those < 80 years. P-value < 0.05 was considered significant.

Results:
Among 1077 patients with anterior circulation AIS, 223 (20.7%) were > 80 years. Elderly patients were more likely to have atrial fibrillation (54.3% vs. 31.4%, P < 0.001) but less likely to have diabetes (16.1% vs. 24.6%; P=0.046) or smoking (13.2% vs. 32.6%, P<0.001) history. Both groups were similar in other baseline factors, initial NIHSS score, location of occlusions, time from onset to groin puncture. TIMI 2 or 3 reperfusion was achieved in 64.5% of those > 80 vs. 70.7% in those < 80 (P=0.080). Rates of symptomatic hemorrhage and any intracranial hemorrhage were not different between groups. Good outcome at 3 months (mRS 0-2) was noted in 16.5% of elderly compared to 41.5% of non-elderly patients (P<0.001). Amongst elderly patients, the only independent predictor of good outcome was initial NIHSS score (adj. OR 0.882, 95% CI 0.821-0.948); good outcomes were achieved in 32.1% of those with NIHSS score < 10, 16.8% with NIHSS score 11-20, and only 5.9% with NIHSS score > 20.

Conclusions:
Patients > 80 years account for over one-fifth of those treated with ERT in this large registry and had worse outcomes compared with those < 80 years despite similar initial severity, time to treatment, and procedural results. Other factors such as increased baseline disability, more rapid time to completed infarction, and reduced neural plasticity may be contributing to these findings.
Abstract TP84: Delayed Ipsilateral Intraparenchymal Hemorrhage After Neuroform Stent Assisted Coiling of Intracranial Aneurysms
Authors: Kadkhodayan Yasha , Delgado Almandoz Josser E , Fease Jennifer L , Crandall Benjamin M , Scholz Jill M , Anderson Ruth E , Tubman David E
Published: July 2021

Background:
Delayed ipsilateral intraparenchymal hemorrhage (IPH) has been reported following technically successful treatment of intracranial aneurysms using flow-diverting stents (Pipeline embolization device) in 8.5% of patients and does not appear to be related entirely to dual antiplatelet therapy. We report a similar phenomenon in Neuroform-assisted coiling.

Methods:
Neuroform-assisted coiling patients were entered into a prospective registry at our institution. Procedural and 30 day complications were recorded. Delayed ipsilateral IPH cases within 30 days were reviewed.

Results:
Between 11/2002 and 7/2012, 98 patients had Neuroform-assisted coiling of 100 cerebral aneurysms, 8 acutely ruptured. Intra-procedurally, there were 3 thromboembolic events and 4 hemorrhages due to vessel or aneurysm perforation (not necessarily symptomatic). After the procedure but within 30 days follow-up (available for 92 patients), there were 6 TIA’s, 2 minor strokes and 1 SAH. There were 2 cases of ipsilateral IPH (2%). One was a 60-year-old man who had stent-assisted coiling of an ACOM aneurysm (Neuroform from right A1 into left A2). He was on aspirin 81 mg and clopidogrel 75 mg daily with a PRU (P2Y12 reaction units) of 72 on day of procedure. Despite decreasing clopidogrel dosing to every other day, he had a frontal lobe IPH 7 days later (Figure 1) with a PRU of 59. The other IPH (Figure 2) occurred in a 70-year-old man 14 days after Y-stent assisted coiling of an MCA aneurysm. He was on clopidogrel 75 mg and warfarin (INR 2.0) for prior pulmonary embolism and dural venous sinus thrombosis. Both patients recovered without neurological deficit.

Conclusion:
Recently described in flow diversion, delayed ipsilateral IPH is not limited to flow-diverting stents. Though less frequent, a potential for this may exist following any intracranial stenting procedure, possibly related to hemorrhagic conversion of microembolic phenomenon while on dual antiplatelets or anticoagulation.
Abstract TP86: Prevalence of Bicuspid Aortic Valves and Thoracic Ascending Aortic Aneurysms in Patients Treated for Intracranial Aneurysms
Authors: Goyal Manu S , Gottumukkala Ravi , Bhalla Sanjeev , Kates Andrew M , Zipfel Gregory J , Derdeyn Colin P
Published: July 2021

INTRODUCTION:
Prior studies have suggested an increased prevalence of intracranial aneurysms (ICA) in patients with bicuspid aortic valves (BAV) and thoracic ascending aortic aneurysms (TAA). We tested the hypothesis that if true, conversely, the prevalence of BAV and TAA should be increased in patients with ICA.

METHODS:
We identified and reviewed the clinical records of patients treated for an ICA at our institution between 2002 and 2011. Only those with an echocardiogram report in their clinical record were included for further analysis. The prevalence of BAV and TAA in this cohort was determined based on the echocardiogram reports, medical records, and, when available, cross-sectional chest imaging. Proportion confidence intervals were calculated and compared to population prevalence estimates.

RESULTS:
Of 1051 patients with ICA, 321 had available echocardiogram reports that included assessment of the aortic valve. Of these, 85 also had cross-sectional chest imaging. Of the 321 patients, 2 were reported to have a BAV (0.6%, 95% CI 0 - 2.5%), similar to population prevalence estimates for this condition. In this same cohort, there were 15 (4.7%, 95% CI 2.7 - 7.8%) patients with a TAA. Among the 85 patients with cross-sectional chest imaging, the prevalence of TAA exceeded that expected for a community age- and gender-matched population (see Figure, gray lines represent upper and lower limits of normal).

CONCLUSIONS:
This retrospective analysis suggests an increased prevalence of TAA, but not BAV, in patients with ICA.
Abstract WMP101: Stroke Performance Measures are Improved at Hospitals Certified as Primary Stroke Centers Compared to Other Accredited Hospitals
Authors: Alberts Mark J , Range Jean , Hampel MJ , Morton David , Watt Ann , Cantwell Vicki , Troy Joseph , Loeb Jerod M
Published: July 2021

Background:
Primary Stroke Centers (PSCs) certified by The Joint Commission (TJC) have been recognized since 2003, yet doubt still exists regarding the extent they improve patient care compared to hospitals that are not certified PSCs. We compared various performance measures between such hospitals to examine this issue.

Methods:
Patient data from accredited hospitals that were not certified PSCs were compared to data from accredited hospitals that were TJC certified PSCs in 2009-2011. In 2009, 11 non-PSC certified accredited hospitals reported on the Stroke Core Measure set ; in 2010, this number rose to 40, and in 2011, 56 non-certified accredited hospitals reported on the Stroke Core Measures. During the same period (2009, 2010 and 2011 respectively), 38, 99, and 111 Certified Primary Stroke Centers reported on the Stroke Core Measure set as part of their accreditation requirement. Data were obtained from TJC ORYX database. At the measure level, a logistic mixed effects model was used to compare measure rates among hospitals.

Results:
Data were available from 284,261patients (29,207at non-PSCs and 255,054 at PSCs). The measures analyzed were VTE prophylaxis (STK1), discharge on antithrombotics (STK2), anticoagulation for A fib (STK3), use of IV t-PA (STK4), use of antithrombotics by day 2 (STK5), discharge on statins (STK6), stroke education (STK8), and consideration of rehabilitation (STK10). For all measures combined, the rate of compliance ranged from 74% vs. 91% (non-PSC vs. PSC, 2009) to 85% vs. 95% in 2011. All composite measures had higher compliance rates at certified PSCs vs. non-PSCs (p < 0.0001). Each individual measure differed significantly (p < 0.0001 for each), with STK4 having the largest difference (24% vs. 72%, non-PSC vs. PSC) and STK2 having the smallest (95% vs. 99%). Other measures showing large differences included STK8 (70% vs. 89%), STK 1 (79% vs. 93%), and STK6 (83% vs. 94%).

Conclusions:
PSCs certified by TJC met each stroke performance measure at a higher rate compared to non-PSC hospitals reporting stroke performance measure data. These differences narrowed somewhat over time but remained significant in 2011. Further research is warranted to examine the impact of all aspects of PSC certification on stroke patient care quality.