bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP309: Creating a Crystal Ball: Predicting Successful Rehabilitation for Optimal Discharge Placement
Authors: Ermak David , Reichwein Raymond , Richardson Alicia , Morrison Kathy , Lehman Travis
Published: June 2021

Introduction:
In 2014, the Centers for Medicare and Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) program. Our institution is contracted for a 90 day stroke bundle, making us responsible for all Medicare stroke patient costs. Quarterly review of 2015 financial data (DRG 64 & 65) revealed a significant spend occurs in the post-acute care phase.

Methods:
Detailed analysis and sequencing revealed that of the 40% of patients discharged to an Inpatient Rehab Facility (IRF) 31% were unsuccessful in rehabilitation and instead transitioned to a Skilled Nursing Facility (SNF). Had SNF been initially selected, a cost avoidance of $292,650 would have been appreciated.

Conclusion:
Involvement in the BPCI program has provided insight into the post-acute care of stroke patients. With the advent of BPCI, institutions will be increasingly held fiscally responsible for post-acute care delivery. Ongoing retrospective chart review and collaboration with Physical Medicine and Rehabilitation colleagues is underway to identify key indicators that would project successful rehabilitation. Analysis will include comparison between those who were successfully discharged home after an IRF stay to those that needed a SNF after an IRF stay. This would provide inpatient teams with strategies for predicting the optimal discharge location for stroke patients.
Abstract TP315: D-dimer is Associated With 30-day Mortality in Acute Ischemic Stroke With Active Cancer
Authors: Nam Ki Woong , Kim Chi Kyung , Kim Tae Jung , An Sang Joon , Oh Kyungmi , Kang Min Kyoung , Ko Sang-Bae , Yoon Byung-Woo
Published: June 2021

Background:
Stroke in cancer patients is not rare, but is a devastating event with high mortality. However, the predictors of mortality in stroke patients with cancer have not been well addressed. D-dimer could be a useful predictor because it can reflect both thromboembolic events and advanced stages of cancer. In this study, we evaluate the possibility of D-dimer as a predictor of 30-day mortality in stroke patients with active cancer.

Methods:
We included 210 ischemic stroke patients with active cancer. The data of 30-day mortality were collected by reviewing medical records. We also collected follow-up D-dimer levels in 106 (50%) participants to evaluate the effects of treatment response on D-dimer levels.

Results:
Of the 210 participants, 30-day mortality occurred in 28 (13%) patients. Higher initial NIHSS score, D-dimer levels, CRP levels, frequent cryptogenic mechanism, systemic metastasis, multiple vascular territory lesion, hemorrhagic transformation, and larger infarct volume were related to 30-day mortality. In the multivariate analysis, D-dimer [adjusted OR (aOR) = 2.19; 95% CI, 1.46-3.28,
P
< 0.001] predicted 30-day mortality after adjusting for confounders. Initial NIHSS score (aOR = 1.07; 95% CI, 1.00-1.14,
P
= 0.043) and hemorrhagic transformation (aOR = 3.02; 95% CI, 1.10-8.29,
P
= 0.032) were also significant independently from D-dimer levels. In the analysis of D-dimer changes after treatment, the mortality group showed no significant decrease of D-dimer levels, despite treatment, while the survivor group showed opposite responses.

Conclusions:
D-dimer levels may predict 30-day mortality in acute ischemic stroke patients with active cancer.
Abstract TP318: High White Blood Cell (WBC) Counts Are Predictive of tPA-related Hemorrhage
Authors: Deng Wenjun , Song Bo , Fisher Lindsay , Chou I-Ying Richard , Oyer Maxwell , Wickham Thomas , McMullin David , Buonanno Ferdinando S , Lo Eng H , Ning MingMing
Published: June 2021

Background:
Infection is a major complication of ischemic stroke and contributes to the morbidity and mortality of stroke patients. Although growing evidence highlights the close relationship between inflammation and coagulation/fibrinolysis cascades, little has been reported regarding the influence of tPA on human immune system. Here, we explore changes in white blood cell (WBC) counts pre/post IV tPA and their association with tPA-related hemorrhagic transformation (HT).

Method:
308 tPA-treated ischemic stroke patients were recruited with IRB approval, of which 16 developed HT within 24 hr post tPA. Routine WBC was analyzed at 1 month pre stroke, during stroke onset and during the first 48 hr post tPA.

Result:
We found that WBC was significantly increased within 12 hr post IV tPA and gradually reduced after 24 hr (Figure 1A). However, compared with patients without HT, HT patients had much higher levels of WBC throughout tPA treatment, and their WBC remained above normal even after 48 hr (Figure 1B). More importantly, we also found that HT patients had already developed elevated WBC as early as 1 month before their stroke onset (Figure 1B), which was predictive of tPA-related HT (Figure 1C, ROC AUC = 0.889, p = 0.001). Furthermore, the early elevation in WBC post-tPA was not associated with clinical evidence of infection.

Conclusion:
Our results provide early clinical evidence that in addition to activating fibrinolytic pathway, tPA may also modulate immune system during stroke treatment. In addition, elevated WBC pre-stroke maybe a predictive marker of tPA-related hemorrhage. While elevated WBC early in ischemic stroke was reported to correlate with poorer clinical outcome, the transient peak in WBC post tPA in this patient cohort ultimately had better clinical outcome, and is of interest. Further studies are needed and ongoing to evaluate differential WBC, stroke severity and long term clinical outcome, and to understand the molecular basis of tPA in immune cell modulation.
Abstract TP319: Duplex Assisted Carotid Artery Stenting Without Administration of Contrast Media
Authors: Mizowaki Takashi , Fujita Atsushi , Imahori Taichiro , Uyama Atsushi , Inoue Satoshi , Kohta Masaaki , Hamaguchi Hirotoshi , Sasayama Takashi , Hosoda Kohkichi , Kohmura Eiji
Published: June 2021

Background:
Conventional carotid artery stenting (CAS) with administration of contrast media carries a risk of adverse reactions such as contrast media-induced nephropathy or an allergic reaction.

Objective
We aimed to present a novel technique, that is, duplex-assisted CAS without administration of contrast media and validate its safety and feasibility.

Methods:
Fifteen patients with severe carotid stenosis (≥70 %) associated with chronic kidney disease (CKD) (stage ≥3) or allergy to contrast media underwent duplex-assisted CAS without administration of contrast media. The embolic protection device (EPD) placed in the common carotid artery (CCA) was clearly visible on the longitudinal section (Fig. A) and was then advanced into the internal carotid artery (ICA) by duplex-guidance (Fig. B). When starting the delivery of the stent, the position of the distal stent end is confirmed by duplex monitoring (Fig. C). Postdilatation was performed after the stent (Fig. D arrowheads) deployment if enough expansion of the carotid artery was not achieved. Adequate stent position (Fig. E arrowheads) and technical success was confirmed by duplex images and intravascular ultrasound (Fig. F). Conventional CAS was also performed in 165 patients and used as the control group.

Results:
The technical success rate was 100 % in duplex-assisted CAS group. Combined stroke or death rates during the post-procedural period did not differ significantly between the duplex assisted CAS group (0/15, 0 %) and conventional CAS group (4/165, 2.4 %). None of the 14 patients with CKD in the duplex-assisted CAS group experienced further deterioration of renal function.

Conclusion:
This method seemed to be a safe and effective treatment for patients with CKD or an allergy to contrast media. The most important factor for the indication of duplex-assisted CAS was to obtain the clear visualization of the luminal narrowing with minimal calcification on the longitudinal section of the duplex ultrasonography.
Abstract TP320: Efficacy and Safety of Antiplatelet Therapy for Ischemic Stroke without Large Arterial Occlusion by Intravenous Tirofiban
Authors: Lin Lu , Li Wei , Wang Huan , Wu Ya , Liu Cheng-chun , Li Xiao-shu , Huang Shu-han , Liang Chun-Rong , Feng Wu-Wei , Zhang Meng
Published: June 2021

Introduction:
All over the world, Each year twelve million people develop ischemic stroke and 30-40% of them do not have visible arterial occlusions at presentation.

Hypothesis:
In this study, we aim to investigate whether intravenous antiplatelet agent tirofiban in acute ischemic stroke(AIS) patients without large arterial occlusion(LAO) is effect or safe.

Material and methods:
We performed an open-label study to collect data of patients without LAO and without thrombolytic therapy within 24 hours from the symptom onset.These patients were divided into 2 groups: those who received tirofiban(tirofiban group) and those who did not received tirofiban(control group).The safety endpoint was the incidence of symptomatic intracranial hemorrhage(SICH) within 72 hours. The efficacy outcome measure was the National Institutes of Health Stroke Scale (NIHSS) score improvement at 24 hours and 7 days and modified Rankin Scale (mRS) score ≤1 or return to baseline mRS at 90 days.

Results:
Of 105 subjects, 53 received Intravenous tirofiban and 52 did not receive it. No patients in our trial had SICH. At 90 days, 67.9%(36/53)of the tirofiban group had mRS ≤1 or return to baseline mRS versus 53.8%(28/52)in control group(P=0.032). At 24 hour in the hospital, the NIHSS score improvement was significantly higer in the tirofiban group compared with control group(p=0.004). At hospital day 7 or hospital discharge, the NIHSS score improved significantly in the tirofiban group compared with the control group (p=0.009).

Conclusions:
This study provided data that patients with ischemic stroke who did not have LAO and not receive thrombolysis therapy may benefit from Intravenous Tirofiban.
Abstract TP328: Ischemic Stroke Following Prothrombin Complex Concentrates Administration for Intracerebral Hemorrhage
Authors: Buletko Andrew Blake , Thacker Tapan , Uchino Ken , Frontera Jennifer
Published: June 2021

Intro:
There have been case reports of ischemic infarcts after treatment with prothrombotics for anticoagulation reversal following spontaneous intracerebral hemorrhage (ICH), though there have been no systematic studies evaluating MRI infarction following prothrombin complex concentrate (PCC) or factor eight inhibitor bypassing activity (FEIBA) administration. We evaluated the prevalence of ischemic infarcts on diffusion-weighted imaging (DWI) in ICH patients who received prothrombotics compared to those who did not.

Methods:
We performed a retrospective review of patients admitted with ICH between January 2013 and April 2016 in whom MRI brain with DWI imaging was performed within 2 weeks of admission and prior to digital subtraction angiography. PCC (4-factor Kcentra, weight, and INR based dosing) was administered to patients on warfarin at the time of ictus with a INR≥1.4 and FEIBA (50 u/kg) was given to patients exposed to an oral Factor Xa inhibitor or direct thrombin inhibitor if ICH occurred within 3-5 half lives of the last dose. Acute ischemia was defined as DWI hyperintensity with corresponding apparent diffusion coefficient hypointensity. Perihematoma lesions, and procedure-related infarctions were excluded from analysis. Groups were compared using chi-square and Wilcoxon Rank Sum tests.

Results:
A total of 254 patients were enrolled. Of these, 41 (16%) received either 4-factor PCC (n=33) or FEIBA (n=8). Comparing those who received prothrombotics to those who did not, there was no difference in age (median 68 with prothrombotics and without; p=0.724), sex (44% female in both groups; p=0.977), initial NIH Stroke Scale (median 6 versus 8, p=0.838), or hematoma volume (median 15ml versus 10ml; p=0.207). Patients who received prothrombotics were more likely to have lobar ICH than deep ICH (71% versus 47%; p=0.005). DWI infarctions were found in 16% of patients who receive PCC or FEIBA compared with 22% who did not (p=0.404).

Conclusions:
Our data suggests prothrombotics do not increase the risk of acute ischemic infarcts within two weeks of administration.
Abstract TP33: Statewide Trends in Utilization of Endovascular Treatment and Outcomes: Analysis of Minnesota Hospital Association Data (2014 and 2015)
Authors: Hussein Haitham M , Saleem Muhammad A , Qureshi Adnan I
Published: June 2021

Background:
There is emphasis on understanding the implementation of clinical trial results for clinical practice. The aim of this study is to examine the changes in endovascular procedures utilization after the publication of the recent clinical trials showing benefit of such procedures in patients with acute ischemic stroke (AIS).

Methods:
Minnesota Hospital Association (MHA) database was used to calculate the state wide utilization rates for two periods: prior to (January 1st-December 31st, 2014) and after (January 1
st
-December 31
st
, 2015) publication of randomized clinical trials. MHA collects data from 137 member hospitals for monitoring and reporting healthcare quality and cost across the state. Patients with admitting diagnosis of AIS and those who received endovascular treatment were identified using ICD9 or ICD10 codes. Utilization rates for endovascular treatment were calculated monthly, quarterly, and annually. Discharge to home was considered as the measure of none to minimal disability.

Results:
Of the 13,043 patients admitted with the diagnosis of AIS, 434 patients (mean age 68.5± 25.5 years; 51.2% women) received endovascular treatment. The number of procedures increased from 194 in 2014 to 240 in 2015. Utilization rate was 3.4% in the first quarter of 2014, gradually declined to reach its lowest value (2.6%) in the last quarter of 2014, then steadily increased to reach its peak (4%) in the last quarter of 2015. Procedures performed at comprehensive stroke centers increased from 52% of total procedures in 2014 to 57.5% in 2015 while those performed at primary stroke centers decreased from 22.6% in 2014 to 19.5% in 2015. In 2015, fewer patients had hypertension (50.4% vs. 60.3%; p=0.039) and more patients had chronic kidney disease (28.3% vs. 15.5%; p=0.001). Intracranial hemorrhage and mortality rates were not significantly different between the two years. There was a trend towards higher rate of minimal or no disability at discharge among patients treated in 2015 compared with those treated in 2014 (22.5% versus 18.1%, p=0.25).

Conclusion:
We observed a state wide increase in rate of utilization of endovascular treatment of AIS patients coinciding with the publication of the results of new clinical trials.
Abstract TP340: Resumption of Anticoagulation after Intracerebral Hemorrhage: Risks, Benefits and Impact on Outcome
Authors: Frontera Jennifer A , Nocero John , Katyshev Vladimir
Published: June 2021

Introduction:
The risks, benefits and impact on outcome of anticoagulation following spontaneous intracerebral hemorrhage (ICH) are not well established.

Methods:
Prospectively collected data of ICH patients on full-dose anticoagulation at ictus or after ICH were reviewed between 5/2013 and 4/2016. Composite ischemic (ischemic stroke, venous thromboembolism or myocardial infarction) and hemorrhagic (GI bleed, anemia requiring transfusion, new intracerebral hemorrhage) complications and 12-month modified Rankin scores were compared between those anticoagulated versus not post-ICH.

Results:
Of 174 ICH patients, 54 (31%) were anticoagulated at ictus (N=38 on warfarin; N=13 on heparin/LMWH, N=9 on novel oral anticoagulant [NOAC]). Twenty-five patients were anticoagulated post-ICH in a median of 22 days (range 3-271); 16/54 [30%] resumed anticoagulation, 9 patients started anticoagulation de novo (N=17 warfarin, N=7 NOAC and N=1 LMWH) and 38/54 (70%) did not resume anticoagulation. Compared to those who did not resume anticoagulation, anticoagulated patients were younger, had better ICH and APACHE-2 scores and were more likely to undergo ICH evacuation (all P<0.05). Composite ischemic events trended lower in anticoagulated patients (0.03 versus 0.73 events per patient-year in non-anticoagulated, P=0.093) and there was no difference in composite hemorrhage events (0.17 in anti-coagulated versus 0.63 events per patient-year in non-anticoagulated, P=0.417). Recurrent intracerebral hemorrhage post-discharge occurred in 3 (12%) anticoagulated versus 0 non-anticoagulated patients (P=0.03) in a median of 102 days (range 24-263). In multivariable logistic regression analysis adjusting for ICH score and ICH evacuation, and excluding those who underwent withdrawal of life-sustaining therapy, resumption of anticoagulation was protective against death at 12-months (aOR 0.1, 95% CI 0.02-0.9, P=0.047).

Conclusions:
Anticoagulation post-ICH is associated with fewer ischemic events, but more recurrent ICH post-discharge compared to non-resumption in previously anticoagulated patients. However, mortality rates were lower at 12-months in those who were anticoagulated, even after adjusting for ICH score and ICH evacuation.
Abstract TP343: The 1-1 Haptoglobin Phenotype is Associated With Perihematoma Edema Progression in Acute Intracranial Hemorrhage
Authors: Halstead Michael R , Mould William A , Sheth Kevin N , Rosand Jonathon , Thompson Richard , Levy Andrew , Hanley Daniel F , Goldstein Joshua N , Nyquist Paul
Published: June 2021

Introduction:
Haptoglobin phenotype affects inflammation and may change rate of perihematoma edema formation (PHE) affecting outcomes. We reported better functional recovery in patients with intracranial hemorrhage (ICH) and the Haptoglobin 1-1 phenotype. This may be mediated through Haptoglobin 1-1 effects on PHE.

Hypothesis:
The Haptoglobin 1-1 phenotype has a different rate of PHE compared to 2-1 and 2-2. Different PHE related to Haptoglobin phenotype affects clinical outcomes.

Methods:
We determined Haptoglobin phenotype, ICH volume, and PHE in individuals identified prospectively from ICH cohorts, at Johns Hopkins University hospital (JHU) and the Massachusetts General Hospital (MGH) using established CT methodology. PHE were measured as differences in CT ICH edema volume divided by hours between scans. Associations of Haptoglobin phenotype (1-1 compared to 2-1, 2-2) and rate of PHE (cc/hr) using multivariate analysis adjusting for age, sex, race, diabetes (DM), hypertension (HTN), LDL cholesterol > 130 mm/dl (HDL), smoking, prior ICH, and use of antiplatelet or systemic anticoagulation were determined.

Results:
87 patients were included with the following characteristics: Mean age 61.6 (15), 44 (50%) females, 28 (32%) AA, 64 (74%) HTN, 17 (20%) HDL, 22 (25%) active smokers, 29 (33%) on some form of anticoagulation/antiplatelet and 9 (10%) with prior ICH. We included 57 JHU and 30 MGH participants with different baseline characteristics. There were 9 subjects with Haptoglobin genotype 1-1, 45 with 2-1 and 33 with 2-2, Mean PHE varied within each group. Fully adjusted estimated mean PHE for 1-1 haplotype was 1.84cc/hr (95%CI 0.87-2.28 cc/hr), which was significantly greater than Haplotype 2-1 at 0.29 cc/hr (-0.15-0.72 cc/hr) and Haplotype 2-2, at 0.44 cc/hr (-0.07-0.96 cc/hr).

Conclusion:
In adjusted models, Haptoglobin 1-1 phenotype on average had a significantly increased rate of PHE in the early stages of ICH onset, opposite that predicted by our biological model. Our study suggests Haptoglobin haplotype is associated with PHE and may account for variability in disability and mortality in ICH. Our study is limited by insufficient power to determine haplotype effect on disability and mortality and larger prospective studies are warranted.
Abstract TP345: A Systematic Review of Statins in Animal Models of Intracerebral Hemorrhage and Proposal of a Modified STAIR Criteria for Evaluation of Preclinical Studies in ICH
Authors: Nistal Dominic A , Kellner Christopher P , Wei Daniel , Herrera Diana , Mocco J D
Published: June 2021

Background and Purpose:
Intracerebral hemorrhage (ICH) is a severe form of stroke with limited medical and surgical treatment. Similarly to clinical trials in acute stroke, none of the medications that appeared promising in preclinical testing have panned out in human clinical trials. HMG-CoA reductase inhibitors (e.g. statins) show promise as a therapy for ICH in both animal and human studies. Our aim is to review and assess the quality of preclinical studies on the role of statins in ICH recovery.

Methods:
We identified preclinical trials assessing the efficacy of statins in ICH via a systematic review of the literature according to PRISMA guidelines. In total, 16 studies were identified that described the use of statins in an animal model of ICH and assessed changes in histological outcomes, behavioral scores, or both. Design characteristics were analyzed using Stroke Therapy Academic Industry Roundtable (STAIR) criteria modified for ICH.

Results:
Behavioral outcomes were assessed in 12 of the studies with 100% (n=12) reporting statins significantly improved ICH recovery. Histological hematoma volume and histological Brain Water Content (BWC) outcomes were analyzed in 10 of the studies with 50% (n=5) reporting significant improvement. There was no correlation between STAIR Quality Score and behavioral, histological hematoma volume, and histological BWC outcomes across all studies (n=16), (p=0.75, p-value=0.49, p=0.44).

Conclusions:
Behavioral outcomes in ICH were found to consistently improve with administration of statins suggesting that this medication may be suitable for randomized clinical trials in humans. In addition, the STAIR criteria can be modified to effectively evaluate preclinical studies in ICH.

Key words:
Intracerebral hemorrhage, Intraparenchymal hemorrhage, ICH, stroke, statins, neuroprotection, animal, preclinical trials, review, systematic review
Abstract TP35: Estimation of Red Blood Cells in the Thrombus Using MRI. A Phantom Study with Predetermined Thrombus Components
Authors: Narata Ana Paula , Filipiak Isabelle , Bibi Richard , Cottier Jean Philippe , Janot Kevin
Published: June 2021

Background and Purpose:
Better understanding about thrombus composition seems necessary, as treatment of acute ischemic stroke (AIS) is focus on clot chemical dissolution and mechanical extraction. We propose to evaluate whether magnetic resonance imaging (MRI) can differentiate white from red clots and estimate red blood cells percentage (RBC%) using clots with predetermined components and an index based on MRI signal intensity (SI).

Material and Methods:
5 clots (A=100% fibrin, B=80% RBC, C=50% RBC, D=20% RBC, E=unknown) were fixed in gelatin-manganese solution and studied by: high-resolution 3D T1-weighted (T1MPR), T2-weighted turbo spin echo (T2TSE), T2-weighted gradient echo (T2GE), susceptibility weighted (SWI), fluid-attenuated inversion recovery (FLAIR) and diffusion weighted imaging (DWI) with apparent diffusion coefficient (ADC). SI index was calculated with clot SI and gelatin SI. Statistical analysis compared RBC-clots to fibrin-clot SI index and the correlation of RBC% and SI index in each MRI sequence.

Results:
Each red clot was different from clot A except clot D in FLAIR. Correlation between clots SI index and RBC concentration were found in T1MPR (r=-0.84), SWI (r=-0.79), T2GE (r=-0.72) and FLAIR (r=0.80). Linear regression resolution provided an indirect RBC estimation for clot E: 47.3 % in T1MPR, SWI 41.5%, T2GE 45.1% and FLAIR 50.9%. Histological analysis confirmed clot E composition.

Conclusion:
This in vitro study suggests that MRI can differentiate white from red clots except clots with low RBC% in FLAIR and also provide approximate RBC%.
Abstract TP356: Quality Improvement: Resopnding to In-House Stroke STAT Calls
Authors: Beland Dawn K , Greco-Dugan Judith , Mangan Mallory , Baecker Abby
Published: June 2021

Purpose:
Responding to acute out of hospital stroke (OHS) is frequent for most ED nurses. Responding to acute in-house stroke (IHS) is infrequent for most others. Stroke recognition and treatment is often delayed for IHS; staff may attribute symptoms to other causes. Delays can occur due to a lack of knowledge of stroke code procedures.

Initiative:
Stroke unit staff developed and implemented a protocol in which the expert stroke nurses from the Stroke Unit’s step down respond to IHS Stroke STAT calls throughout the hospital.

Methods:
Initially, responders to Stroke STATs were Neurology residents and the patient’s nurse. In the new protocol, the SD nurse carries a stroke beeper and responds to the IHS Stroke STAT. SD nurses guide and support the bedside nurse, and educate the patient and family. They assist getting to CT scan quickly and promote transfer if needed.

To evaluate the change, times from onset to beeper call and call to CT were compared for the pre and post groups using Wilcoxon Ranked Sum tests; with only 10 patients receiving IV tPA, times for call to treatment are presented descriptively only.

Results:
The Stroke STAT Response protocol went live on July 22, 2015. Times for the essential tasks were compared pre- and post-intervention - 8/1/14 - 3/31/15 and 8/1/15 - 3/31/16. There were 85 IHS calls pre-intervention and 80 calls post. Four IHS patients were treated with tPA in the pre-intervention group and 6 post. The median (interquartile range) times per task, percentage of change and p values are below. While no statistical significance was found, decreases in time to treatment are clinically relevant.

Documentation of onset improved from 87.5% to 96.3%.

Discussion:
Outcomes of this project have been positive. Time from onset to call, CT and treatment decreased as physicians were able to make treatment decisions sooner. It gives the SD nurses more autonomy as they share their expertise hospital-wide. And it gives patients and families the highest quality care they deserve.
Abstract TP358: Driving Down Door to Alteplase
Authors: Jones Amy , Campbell Gladys , Abolins Nicole , Chappell Kendrea
Published: June 2021

Background and Purpose:
Our 921 bed community hospital was awarded Comprehensive Stroke Center status in 2012 and has continued its pursuit for excellence achieving Target: Stroke Honor Roll Elite Plus designation for the past two years. As a Comprehensive Stroke Center our goal is to provide excellent care to the acute ischemic stroke population while decreasing door to Alteplase times. Achieving a door to Alteplase time of less than forty-five minutes in 50% of cases was a significant improvement in our target treatment time; however our team set an internal goal of 30 minutes.

Method:
Our stroke leader team conducted a microscopic review of each phase of our Emergency Department stroke response process known as “Code Purple” to identify opportunities to reduce time. Partnering with Neuro Emergencies and Telemedicine leadership, Emergency Medical Services (EMS), Emergency Department nursing leadership, and Pharmacy, process improvement changes implemented including the addition of an emergency department stroke champion and refinement of our administration processes.

Results:
Program enhancements were initiated in September of 2015. Results as of June 2016 demonstrated that our strategies have shown positive results to date. Our average time from door to Alteplase has decreased from an average of 41 minutes to 32 minutes, patient arrival to brain image complete has decreased from an average of 19 minutes to

14 minutes and brain image read to drug administration has decreased from an average of 12 minutes to 10 minutes.

Conclusion:
Establishing a multi-disciplinary stroke leader team to identify areas for improvement, create and implement goal-supporting processes, and evaluate results has led to the time reduction in major time sensitive measures. These trends are positively reflected in our monthly dashboards. More importantly, we have accomplished the decrease in Alteplase administration times while maintaining the complication rate post-Alteplase below national average.
Abstract TP359: Partnering in the Community to Improve Long Term Stroke Outcomes
Authors: Friedrich Sherri H , Cruz Connie D , Mendelson Sherri G
Published: June 2021

Background:
Stroke mortality has fallen from the third leading cause of death to the fifth; it remains the leading cause of disability. Providers know the appropriate standard of care to preserve life and reduce disability, but treatment is time limited. Patients who present with stroke signs and symptoms (S/S) outside the window for treatment are at risk for lifelong disability. We united with our Faith Community Partnership program (FCPP) to educate local church congregation members about the S/S of stroke.

Purpose:
The aim of our project was to bring community members with stroke symptoms urgently into the emergency care setting so that disability reducing treatments could be rendered.

Methods:
A quality improvement (QI) project was designed using the FCPP to deliver education to members within 32 church communities. Four FCPP nurses along with parish community volunteers distributed FAST cards with stroke S/S at health events starting the second quarter of 2014. The FCPP held at least six events per month; they were attended by 50-100 guests. FCPP workers highlighted the importance of prompt recognition of symptoms as well as emergent activation of Emergency Medical Services.

Results:
The Get with the Guideline’s Registry was accessed; ten quarters of data were reviewed to compare symptom onset to time of arrival at our hospital versus all certificated TJC/AHA/ PSC hospitals. An unpaired two tailed
t
test comparing patients arriving in less than one hour from symptom onset was extremely statistically significant in favor of the QI group, P < 0.0001. Equally statistically significant (p<0.0001) were patients arriving in less than 240 minutes from symptom onset compared to those arriving after 240 minutes. Patient arrival from 61-240 minutes was not quite statistically significant, =0.0746.

Conclusion:
Stroke education within the community affords providers better opportunity to deliver disability reducing treatments.
Abstract TP36: Collaterals Negate Time: Topography and Determinants of Baseline ASPECTS in STRATIS
Authors: Liebeskind David S , Woolf Graham W , Mueller-Kronast Nils , Aziz-Sultan M A , Froehler Michael T , Klucznik Richard P , Saver Jeffrey L , Sanossian Nerses , Zaidat Osama O , Haussen Diogo C , Hellinger Frank R , Yavagal Dileep R , Yao Tom L , Jahan Reza ,   for the STRATIS Investigators
Published: June 2021

Background:
ASPECTS is routinely used to estimate ischemic lesion burden in acute stroke, yet the topography and influence of collaterals has been unexplored. Imaging selection for endovascular therapy in various time epochs may also be simplified with ASPECTS. We leveraged the large-scale registry data of STRATIS to discern the role of collaterals, time and other factors in ASPECTS topography at baseline.

Methods:
The STRATIS Imaging Core Lab, blind to all clinical data, independently determined ASPECTS scores and regional involvement in anterior circulation occlusions. Collateral status on baseline angiography was scored by ASITN grade. Statistical analyses described ASPECTS regional involvement or topography based on arterial occlusion site and other variables available prior to intervention, determining the influence of collaterals and time duration from onset to imaging.

Results:
Baseline ASPECTS (n=573) was median 8.0 (2, 10). ASPECTS regions involved were lenticular nuclei 62.3% (357/573), insula 42.2% (242/573), caudate 23.4% (134/573), M2 13.6% (78/573), M4 9.4% (54/573), M5 9.2% (53/573), M1 4.0% (23/573), M3 2.1% (12/573), M6 1.9% (11/573) and internal capsule 0.2% (1/573). Distinct patterns or topography differentiated ICA, M1 and M2 arterial occlusion sites at angiography. Overall, higher ASPECTS (7-10 vs. ≤ 6) was linked with more robust collaterals (p<0.001) and shorter duration from onset to CT (p=0.001), yet collateral grade was unrelated to time. Ordinal multivariate logistic regression on ASPECTS containing collateral grade and time (from onset to CT) as covariates demonstrated that they were significantly associated (p<0.001 and p=0.0024, respectively) with ASPECTS.

Conclusions:
ASPECTS topography and the extent of ischemic changes are a product of arterial occlusion site, collateral status and time duration. ASPECTS may infer collateral status, a pivotal determinant of outcome in endovascular therapy, irrespective of time from symptom onset.
Abstract TP362: Door to Needle Time Improves With Implementation of an Alteplase Alert Within the Existing Code Stroke Process in a Primary Stroke Center Emergency Department
Authors: Shelton Tonia P , Riley Leticia M , Kibbey Erin K , Heatley Kristine J
Published: June 2021

Background and Purpose:
A Primary Stroke Center Emergency Department (ED) identified the need to decrease Door to Needle Time (DNT) for intravenous administration of Alteplase in order to align with stroke standards and provide optimal patient outcomes.

Methods:
A systematic review of the data collected since September 2014 demonstrated opportunities for improvement with our current Code Stroke process, consequently delaying DNT. Frontline staff identified a delay in the time from the physician’s order to initiation of Alteplase infusion. Based on the identified communication gaps between the physician and nursing staff, two innovative action plans were developed. An Alteplase Alert was implemented within the existing Code Stroke process. In addition to the facility-wide overhead Code Stroke initially placed upon patient arrival, an internal Alteplase Alert is now initiated within the ED once it is determined the patient is a candidate for Alteplase. Once the Alteplase Alert is initiated the charge nurse, an ED tech, and the designated Code Stroke nurse respond immediately to the patient’s bedside to assist the primary nurse in initiating the tasks associated with Alteplase administration. Secondly, a stroke Alteplase tool was designed to ensure continuity of care and team collaboration.

Results:
Data from January 2014 through August 2015 was used to establish the baseline. Prior to implementation, there were 2/17 (11.76%) patients with a DNT less than 60 minutes, with a median time of 84 minutes. After implementation, data from October 2015 through June 2016, demonstrated a decrease in DNT. There were 15/17 (88.23%) patients with DNT less than 60 minutes, with a median time of 51 minutes.

Conclusions:
Implementation of the innovative action plans including the Alteplase Alert and Stroke tool helped to accomplish a goal of improved DNT in an efficient and consistent manner. Application of the aforementioned plans led to immediate results. Over the last 10 months, the DNT has sustained a significant improvement.
Abstract TP365: Design of a Mobile-friendly Website to Reduce Stroke Caregiver Burden: a Focus Group Study
Authors: Caunca Michelle R , Diaz Maria V , De Leon-Benedetti Andres , Hartley Gregory , Czaja Sara J , Wright Clinton B
Published: June 2021

Background:
Stroke is a leading cause of disability in the United States. Family members often have to assume the role of informal caregiver. Despite an abundance of resources, caregiver burden continues to be a major issue, leading to negative outcomes such as depression.

Objective:
To characterize the needs of stroke caregivers in order to inform the design of a mobile-friendly website intervention. We hypothesized that a website intervention, designed using a user-centered design approach, will help equip caregivers for the caregiving role and reduce associated caregiver burden.

Methods:
Focus groups with caregivers of stroke patients were conducted in English (N=3) and Spanish (N=4) to gather data on major obstacles experienced by caregivers. Participants were also asked about the challenging aspects of caregiving and their use of mobile devices.

Results:
Of seven total caregivers (86% Hispanic, 100% female, mean [SD] age=60 [9] years), 86% were smartphone users. The median (interquartile range) score on the short form Zarit Burden scale was 18 (12-20), indicating elevated caregiver burden in our sample. Across all participants, 100% cited lack of training as a major challenge, 86% cited financial difficulties and dealing with patient cognitive issues, 71% reported physical and emotional challenges, 43% participants cited time constraints and patient behavioral issues, and 29% reported problems with patient communication and acceptance of their situation. Using these findings, we designed a Stroke Caregiver Support System prototype by collecting existing resources from publically available sources based on the issues identified by our focus groups. Website usability testing was conducted to gather feedback caregivers and further refine our intervention.

Conclusions:
We plan a small pilot test of this intervention in our community to measure its usability and gather more feedback on acceptability and usefulness of the intervention. Given the prevalence of mobile and internet technology, we believe that a mobile-friendly website may be a practical and easily accessible tool for caregivers as they navigate their new roles.
Abstract TP368: Improving In-House Stroke Code Imaging and Treatment Times
Authors: Ward Erin L , Lighthizer Gail , Uppal Avneesh
Published: June 2021

Background:
In acute ischemic stroke, a blood vessel in the brain is blocked and brain cells die within

minutes; therefore rapid recognition and treatment to restore circulation to the brain is essential.

National guidelines call for a CT scan of the brain to be done within 25 minutes of hospital arrival in

patients presenting with acute stroke to rule out bleeding in the brain. Findings of a hemorrhage would

be a contraindication for thrombolytic therapy. Additional guidelines call for intravenous t-PA (alteplase)

to be administered within 60 minutes of arrival and rapid triage to endovascular therapy in appropriate

patients. Similar goals for rapid treatment should be followed for patients experiencing a stroke while in

the hospital. Urgent treatment with a clot busting medication (alteplase) or with special endovascular

techniques to mechanically remove a clot have been shown to improve outcomes.

Purpose:
A performance improvement plan was developed and initiated in January 2015 to improve the

time to CT, time to t-PA administration, and time to endovascular therapy for patients having a stroke

while hospitalized for other diagnoses (In-House Stroke).

Method
s: The following revisions were made to current practice: Mock Stroke Code Drills for In-House

Stroke Code responders; creation of an In-House Stroke Code algorithm; addition of CT & MRI screening

forms to In-house Stroke Code packet; development of a Stroke Code criteria checklist to assist floor

nurses; implementation of a feedback loop to Stroke Code team reporting imaging and treatment times

along with patient outcomes; addition of a radiology supervisor to the Stroke Code response team.

Results:
“Stroke Code called” to “CT initiated“< 25 minutes improved from 32% in 2013, 30% in 2014, to

60% in 2015. “Stroke Code called” to “IV t-PA (alteplase) administered” < 60 minutes improved from 0%

in 2013, 25% in 2014, to 100% in 2015. “Stroke Code called” to “groin puncture for endovascular

therapy” < 2 hours, 40% for 2013, 43% in 2014 to 50% in 2015.

Conclusion:
These interventions resulted in faster CT imaging and treatment times, thereby providing

the patient with the highest quality patient care.
Abstract TP372: Implementation of a New Intermittent Pneumatic Compression Protocol in a Stroke Unit
Authors: Sanjuan Menendez Estela , Santana Roman Katherine E , Molina Carlos A , Giron Espot Pilar , Ribo Marc , Rodriguez-Luna David , Muchada Marian , Boned Sandra , Pagola Jorge , Juega Jesus M , Sanchis Mireia , Montiel Estefania , Rodriguez Villatoro Noelia , Rubiera del Fueyo Marta
Published: June 2021

Introduction:
Intermittent pneumatic compression (IPC) has demonstrated to prevent deep venous thrombosis (DVT) and improve survival in acute stroke.

Objective:
We aimed to implement a new IPC protocol in our non-invasive stroke unit by applying IPC in the hyperacute stroke phase.

Methods:
All acute stroke patients with high DVT risk and contraindication for pharmacological DVT prophylaxis received IPC treatment. In ischemic stroke patients treated with reperfusion therapies, IPC protocol was planned for 24hours; intracraneal hemorrhage (ICH) patients were treated with IPC during 72hours. Clinical and hemodynamic variables were recorded. Nurses and patients were interviewed for satisfaction with the new protocol.

Results:
From March to August 2015, we enrolled 132 patients: 75 male (56.4%), mean age 71+/-15 y.o., ischemic strokes 103 (79.2%). Time from admission to IPC application 102+/-375min. Duration of treatment in ischemic patients was 37+/-21hours while in ICH was 44+/-26hours. No patient presented DVT in our series. We observed 6 deaths (4.5%) and 66 patients (56.4%) presented other complications, none of them related to IPC. Only at implementation phase nurses referred a relevant work burden with the new protocol compared to classical low-weighed-heparin DVT prophylaxis. After training it only takes a mean of 6±1.5 minutes to apply the treatment. Only 3 patients (2.3%) presented discomfort, 2 of them with early IPC drop off.

Conclusion:
IPC treatment is feasible, safe, and comfortable for stroke patients in the hyperacute phase. It increases work burden for nurses only at the implementation phase.
Abstract TP375: Screening for Nontraditional Stroke Symptoms in Women: What is the Evidence? A Systematic Review
Authors: Colsch Renee
Published: June 2021

Background and Purpose:
Stroke is the fifth leading cause of death in the United States. It is projected by the year 2030, there will be a 20.5% increase in the prevalence of stroke, with women being at highest risk. Women can present with nontraditional symptoms of stroke. The purpose of this review of literature was to determine the accuracy, reliability, validity, and sensitivity of existing stroke screening tools that incorporate nontraditional symptoms, and examine gender differences.

Methods:
A systematic review of peer-reviewed literature was completed in five databases: CINAHL Google Scholar, ProQuest, PubMed, and SCOPUS. Websites were scanned for gray material. Key terms where utilized as text words, title, abstract and medical subject headings to identify related studies of relevance.

Results:
References were screened by title and abstract. Twenty-nine out of 1175 articles met the inclusion criteria. Seven stroke screening tools were identified; Melbourne Ambulance Stroke Screen, Los Angeles Prehospital Stroke Screen (LAPSS), Cincinnati Prehospital Stroke Scale, Ontario Prehospital Stroke Screening Tool, Medic Prehospital Assessment for Code Stroke, the Recognition of Stroke in the Emergency Room, and Face Arm Speech Test. A thematic synthesis approach organizing data according to patterns identified: early recognition of stroke is crucial to timely treatment and better patient outcomes, a difference in stroke symptoms exists between genders, knowledge and awareness of nontraditional stroke symptoms are essential for early identification, current stroke screen tools have a potential for nearly 30% error of non-identification of stroke, and only 2 of 7 screening tools identify more than 1 of 11 non-traditional symptoms with the most encouraging tool (LAPSS) only identifying 3 symptoms (loss of consciousness, confusion, and seizures).

Conclusions:
Evidence suggests limitations exists within current stroke screens. Poor recognition of nontraditional symptoms due to lack of stroke screening tools may delay treatment and worsen patient outcomes. Research is required to identify variables and develop a stroke screening tool that is sensitive and specific to nontraditional stroke symptoms in women.
Abstract TP383: Use of Plan-Do-Study-Act and Clinical Simulation Methodology to Develop a Mobile Prehospital Telestroke System
Authors: Brown Pamela C , Toqeer Qaiser , Heath Kaitlynne , Bennam Poanna , Heath Jamie , Bhatti Muhammad , Mehndiratta Prachi , Ricks Jamie V , Feldman Moshe , Ruiz Andres , Henry Jeneane , Hekmatdoost Kevon M , Madu Theandra , Decker Richard , Fellows Daniel , Whitt Dempsey , Wong Jason , Blankson Baaba , Lavrentyev Vladimir , Rahim Basit , Warren Felton , Ornato Joseph P , Chapman Smith Sherita
Published: June 2021

Background:
When early and accurate identification of stroke occurs in the field by Emergency Medical Service (EMS) providers, the chances of reperfusion increases dramatically. Telestroke has made significant strides over the years and hold promise for potential use in the prehospital setting. However, the introduction of such a novel technology within a healthcare system can be complex.

Purpose:
To describe the use of the combination of clinical simulation and Plan-Do-Study-Act (PDSA) methodology in the design of a mobile prehospital telestroke system.

Methods:
A multi-stakeholder team with representation from the Departments of Neurology and Emergency Medicine, Office of Telemedicine, Center of Human Simulation and Patient Safety, local EMS agency and a telemedicine developer collaborated to develop a mobile prehospital telestroke system over a 6 month time period. Modifications to telemedicine equipment, teleconferencing software and protocol were implemented based on the results of serial PDSA cycles and clinical simulation testing. We used data collected via direct observation notes, survey results and informal interviews during serial PDSA cycles and clinical simulation to test changes to improve our mobile prehospital telestroke system.

Results:
(see image of PDSA chart)

Conclusion:
The combined clinical simulation and PDSA model led to the identification of technical and operational barriers not considered in the original design of the mobile telemedicine platform and placement. Before implementation and financial investment in a mobile prehospital telestroke program, the use of combined clinical simulation and PDSA methodology can improve the quality and optimize the system use. Further PDSA and simulation cycles are needed to improve the design of our mobile system.