bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department
Authors: Davis Nicolle W , Bailey Meghan , Buchwald Natalie , Farooqui Amreen , Khanna Anna
Published: March 2021

Background/Objective:
There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration.

Methods:
A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question.

Results:
The mean door to needle time is 53.74 minutes (
+
38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival (
p
= .001) and having a stroke nurse present (
p
= .022) are significant predictors of door to needle time in the emergency department (ED).

Conclusion:
While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.
Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study
Authors: Yaghi Shadi , Mistry Eva , De Havenon Adam H , Leon Guerrero Christopher , Nouh Amre , Liberman Ava L , Giles James A , Liu Angela , Nagy Muhammad , Kaushal Ashutosh , Azher Aidan , Mac Grory Brian C , Fakhri Hiba , Espaillat Kiersten , Asad Syed Daniyal , Pasupuleti Hemanth , Martin Heather , Tan Jose T , Veerasamy Manivannan , esenwa charles , Cheng Natalie , Moncrieffe Khadean , Moeini-Naghani Iman , Siddu Mithilesh , Scher Erica , Trivedi Tushar , Torres Jose L , Ishida Koto , Lord Aaron , Khan Muhib , Keyrouz Salah G , Furie Karen L , Henninger Nils
Published: March 2021

Background and Purpose:
Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke.

Methods:
We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders.

Results:
In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206).

Conclusion:
Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.
Abstract P125: The First Year of Pre-Hospital Triage for Emergent Large Vessel Stroke Across a Large New York City Health System
Authors: Kim Brian D , Morey Jacob , Marayati Naoum Fares , Wheelwright Danielle , Roche Tara L , Mensching Connor , Masigan Peterson , Gomes Nalda , Fiano Emily , Skliut Maryna , Tuhrim Stanley , Stein Laura K , Mocco J D , Redlener Michael , Fifi Johanna T
Published: March 2021

Introduction:
On April 1 2019, New York City EMS began a triage protocol using a modified Los Angeles Motor Scale (S-LAMS for addition of speech) to identify potential endovascular thrombectomy (EVT) eligible patients in the field (S-LAMS 4-6 with last known well (LKW) <5 hours). These patients are routed to the nearest thrombectomy capable center, driving past potentially closer primary stroke centers.

Methods:
Patients brought by EMS to a large multicenter health system across NYC for the year following April 1, 2019 were extracted from a prospectively collected stroke database. S-LAMS triage positive (STP) patients were assessed for diagnostic accuracy and treatment times. They were compared with a cohort that underwent EVT during the same period, but triaged as S-LAMS triage negative (STN).

Results:
STP patients (N=145) were 56.6% women, mean age of 70, median baseline mRS of 0, S-LAMS score of 5, and arrival NIHSS of 13. Stroke was diagnosed in 110 (75.8%) patients, 32 intracerebral hemorrhage and 78 ischemic. Of the ischemic, 45 were large vessel occlusion stroke (ELVO) and 34 underwent EVT (PPV of 0.31 for ELVO). STN patients (N=65) with LKW of < 5 hours were brought by EMS and underwent EVT; 34 were brought directly to EVT capable centers, and 36 required transfer for EVT. Mean time to hospital arrival from EMS scene arrival was significantly longer for STP patients than STN patients (38 vs. 29 minutes, p<0.01). Mean ambulance travel time was significantly longer for STP patients than STN patients (10 vs. 7 minutes, p<0.01). Mean tPA administration time from EMS scene arrival was not significantly different between STP (N=41) and STN patients (N=40) (90 vs. 91 minutes, p=0.89). Mean arterial access time for EVT from EMS scene arrival was significantly shorter for STP patients than STN patients (137 vs. 200 minutes, p<0.01).

Conclusions:
Pre-hospital stroke triage using the streamlined S-LAMS scale is comparable with other pre-hospital scales in predictive value for ELVO. While pre-hospital evaluation and transport times are longer, they add minimal delay to the hospital arrival, do not affect tPA times, and improve times to EVT in a large, urban environment. Further analysis on effect of the triage protocol on patient outcomes is warranted.
Abstract P128: Impact of the COVID-19 Pandemic in Houston on Stroke Care in a Health System of 10 Stroke Centers
Authors: Reddy Sujan T , Wu Tzu-ching , Rajan Suja S , Tahanan Amirali , Rahbar Mohammad H , Indupuru Hari Kishan R , Chen Luyao , Jiang Xiaoqian , Savitz Sean I
Published: March 2021

Introduction:
We assessed the impact of COVID-19 pandemic on stroke admissions and care metrics within a health system of 10 stroke centers, with 4 comprehensive stroke centers (CSC) in the greater Houston region.

Methods:
Between January-June 2019 and January-June 2020, we compared the proportion of ischemic strokes (total & direct CSC presentations) & intracerebral hemorrhage (ICH) relative to total admissions using logistic regression, and among the direct CSC presentations, we compared door to tPA and thrombectomy times using Wilcoxon Rank Sum.

Results:
A total of 4808 cases were assessed (Table 1). There was an initial drop of ~30% in cases at the pandemic onset (Fig.1). Numerically fewer patients in the 2020 period were seen at primary and CSCs (Table 1). Compared to 2019, there was a significant reduction in transferred patients [N(%), 829 (36) vs. 637 (34), p=0.02], in hospital strokes [N(%), 111 (5) vs. 69 (4), p=0.04], and mild strokes (NIHSS 1-5) [N (%), 891 (43) vs. 635 (40),p=0.02], and no significant differences in the proportions of total ischemic strokes [OR (95% CI)=0.92 (0.79, 1.06), p=0.23], direct CSC presentations [OR (95% CI) =0.96 (0.86, 1.08), p=0.48] and ICH [OR (95% CI) =1.14 (0.98, 1.33), p=0.08] in 2020 (Fig. 1). Among the direct ischemic strokes at CSCs, there were similar mean (SD) (mins) door to tPA [44 (17) vs. 42 (17), p=0.14] but significantly prolonged door to thrombectomy times [94 (15) vs. 85 (20), p=0.005] in 2020.

Conclusion:
COVID-19 pandemic led to reduced mild stroke admissions, transfers and in hospital stroke alerts, & prolonged door to thrombectomy times. Identifying reasons to mitigate this discrepancy is crucial for next pandemic preparedness.
Abstract P130: QTc Prolongation in Acute Medullary Infarction Maps to the Dorsal Vagal Nucleus
Authors: Je Goun , Sun Yuyao , Keyhanian Kiandokht , Henninger Nils
Published: March 2021

Objective:
To determine the spatial relationship between acute medullary infarction and QTc prolongation.

Background:
Ischemic stroke has been associated with QTc-prolongation which increases the risk of cardiac arrhythmia and sudden cardiac death. In particular, pathological arrhythmia and unexpected sudden cardiac death has been described after acute medullary infarction (AMI). Nevertheless, it is not well understood why only as subset of patients with AMI develop significant cardiac arrhythmia. To gain insight into this issue, we sought to determine the possible anatomical structures relating to QTc-prolongation in patients.

Methods:
We retrospectively reviewed 1072 consecutive adult patients admitted for an acute ischemic stroke or a transient ischemic attack, who presented within 4.5 hours from the last known well time and had an admission ECG available. 724 patients had brain MRIs and among these, 13 (1.8 %) patients had an AMI and were included. For an unbiased lesion analyses, medullary infarcts were manually outlined on diffusion weighted MRI and manually co-registered with an anatomical atlas. Infarct lesions were then superimposed on each other as stratified by normal versus prolonged (men > 430 ms, women > 450 ms) QTc to determine the area of greatest degree of congruence.

Results:
76.9 % of patients (10 out of 13, 9 men and 1 woman) had a prolonged QTc (476.9 ± 43.3 ms for men, 515 ms for women). There was no significant difference in electrolyte levels and preexisting comorbidities between subjects with normal and prolonged QTc. Among patients with QTc prolongation, the greatest degree of congruence of the infarct location was the dorsal vagal nucleus (DVN, 7 out of 10 patients).

Conclusions:
Our unbiased lesion segmentation approach identified the DVN a key anatomical substrate related to QTc-prolongation. Biological plausibility of our data and the presence of a causal link between the DVN and cardiac arrhythmia stems from the prior animal experimental data showing that selectively silencing the DVN via a pharmacogenetic approach caused QTc-prolongation in the rat. Further studies with more patients and high-resolution, volumetric MRI are needed to confirm our findings.
Abstract P131: What Drives Greater Assimilation of Telestroke in Emergency Departments?
Authors: Uscher-Pines Lori , Sousa Jessica , Zachrison Kori S , Guzik Amy K , Schwamm Lee H , Mehrotra Ateev
Published: March 2021

Objective:
Although many emergency departments (EDs) have telestroke capacity, it is unclear why some EDs consistently use telestroke and others do not. We compared the characteristics and practices of EDs with robust and low assimilation of telestroke.

Methods:
We conducted semi-structured interviews with representatives of EDs that received telestroke services from 10 different networks and had used telestroke for a minimum of two years. We used maximum diversity sampling to select EDs for inclusion and applied a positive deviance approach, comparing programs with robust and low assimilation. Data collection was informed by the Consolidated Framework for Implementation Research. For the qualitative analysis, we created site summaries and conducted a supplemental matrix analysis to identify themes.

Results:
Representatives from 21 EDs with telestroke, including 11 with robust assimilation and 10 with low assimilation, participated. In EDs with robust assimilation, telestroke workflow was highly protocolized, programs had the support of leadership, telestroke use and outcomes were measured, and individual providers received feedback about their telestroke use. In EDs with low assimilation, telestroke was perceived to increase complexity, and ED physicians felt telestroke did not add value or had little value beyond a telephone consult. EDs with robust assimilation identified four sets of strategies to improve assimilation: strengthening relationships between stroke experts and ED providers, improving and standardizing processes, addressing resistant providers, and expanding the goals and role of the program.

Conclusion:
Greater assimilation is associated with standardized workflow, leadership support, ongoing evaluation and quality improvement efforts, and mechanisms to address resistant ED providers.
Abstract P133: Geospatial Mapping of Prehospital Delay in Acute Ischemic Stroke and Association With Social Vulnerability
Authors: Dhand Amar , Nieves Amber , Jarman Molly , Bergmark Regan , Semco Robert , Ader Jeremy , Fonarow Gregg C , Smith Eric , Reeves Mathew J , Saver Jeffrey L , Schwamm Lee H , Sheth Kevin N
Published: March 2021

Introduction:
Prehospital delay, defined as the delay between symptom discovery and hospital arrival, remains a major barrier to timely acute stroke treatments. Delay is worse in socially vulnerable populations. A geospatial map of prehospital delay may identify high-risk areas and highlight the role of community social vulnerability in delay. We hypothesized that a community’s social vulnerability would be associated with delay.

Methods:
We analyzed national Get With The Guidelines ischemic stroke data between 2015 and 2017. We calculated the median arrival time (symptom discovery-to-door times) for each Zip Code Tabulation Area (ZCTA), and created geospatial map using ArcGIS. The primary exposure variable was the Center for Disease Control’s Social Vulnerability Index (SVI), and its 4 subcomponents. The SVI is a composite metric of community vulnerability using U.S. Census data (0, least vulnerable to 1, most vulnerable). To account for clustering within ZCTAs, we performed a multilevel linear regression of community-level SVI and patient-level prehospital delay.

Results:
During the study period, 149,774 patients had an ischemic stroke in 16,949 ZCTAs. Across patients, the median time of arrival was 140 mins, IQR was 60-459 mins, and range was 1-1439 mins. Arrival by 2h occurred in 46% of patients. Multilevel regression showed a strong positive association between the SVI and prehospital delay, evident in the maps (Figure). For every 10% increase in the SVI, the arrival time increased by 38 minutes [CI, 30 - 47] (p<0.001). Considering the 4 SVI subcomponents, delay was most strongly associated with socioeconomic status, household composition, and housing/transportation, but not minority status/language.

Conclusion:
Using geospatial mapping of prehospital delay across the United States, we show that community SVI is strongly associated with delayed ischemic stroke arrival. These maps help identify communities to target for stroke preparedness campaigns.
Abstract P136: Feasibility and Safety of an Expedited Emergency Department TIA Evaluation
Authors: Garg Anisha , Maran Ilavarasy , Vlieks Kelsey , Neuschatz Kaile , Coppola Anna , Poskus Kelly , Johnson Jennifer , Davis Melissa A , Minja Frank , Jasne Adam , Sansing Lauren H , Schindler Joseph L , Malhotra Ajay , Sharma Richa
Published: March 2021

Introduction:
Transient ischemic attack (TIA) can portend impending stroke, but it is unclear whether a TIA evaluation necessitates inpatient admission. We assessed feasibility and safety of a TIA protocol in the emergency room for low-risk TIA patients.

Methods:
We studied low-risk TIA patients (ABCD2 score < 4, no significant vessel stenosis) before (January 2018-July 2019) and after (August 2019-March 2020) the implementation of an expedited, emergency room TIA protocol at a comprehensive stroke center. The pre-intervention cohort consisted of TIA patients in the institutional Get-With-The-Guidelines database who met pre-specified criteria (
Figure
) and were admitted. The post-intervention patients met the same criteria and underwent an expedited MRI with selected sequences. If the MRI showed no ischemia, patients were scheduled with rapid, outpatient stroke clinic follow-up and outpatient echocardiogram as indicated. We compared differences in outcomes of interest between the pre-and post-intervention cohorts including length of stay, radiographic and echocardiogram findings, and recurrent neurovascular events within 30 days.

Results:
In total, 120 TIA patients met criteria (71 pre-intervention, 49 patient post-intervention). Demographic and clinical characteristics were similar except the pre-intervention pathway had a higher proportion of patients with a smoking history and presenting symptom of aphasia and dysarthria. Median time from MRI order to completion was 2.3 hours in the post-intervention cohort. Median length of stay was 7.7 hours (IQR 5.2-9.7) in the post-intervention cohort compared to 28.8 hours (IQR 24.4-42.4) pre-intervention. There were no differences in neuroimaging or echocardiographic findings and 30-day re-presentation for stroke, TIA, or mortality.

Conclusions:
Our study demonstrates the feasibility and suggests safety of an expedited TIA protocol. Further study is needed to determine its generalizability.
Abstract P143: Worse Discharge Outcomes of Stroke Patients During the Covid-19 Pandemic: A Dual-Network Experience
Authors: Cummings Cori , Almallouhi Eyad , Al Kasab Sami , Barnes Holly , Shah Manan , Giurgiutiu Dan-Victor , Switzer Jeffrey A , Holmstedt Christine A
Published: March 2021

Background and Purpose:
The novel coronavirus of 2019 (COVID-19) has been associated with worse outcomes for hospitalized patients across the US and worldwide. Our study investigates the effect of the pandemic on functional outcomes for patients presenting with stroke-like symptoms in two high-volume Tele-Stroke networks.

Methods:
We performed retrospective chart review of 7689 consecutive patients seen through two Tele-Stroke networks (Medical University of South Carolina and Augusta University) from July 2019 through May 2020. Discharge outcomes were assessed using modified Rankin scale (mRS). We dichotomized patients to preCOVID-19 pandemic (July 2019 to February 2020) and during COVID-19 pandemic (March to May 2020).

Results:
During COVID, a higher percentage of patients received intravenous tissue plasminogen activator (tPA) (14.2% vs 11.3% before, p=0.001), despite a similar baseline NIHSS. Also, patients during the pandemic had a shorter symptom-onset to hospital door time (288 vs 353, P=0.012). Demographics were similar between groups, other than older age in patients presenting during COVID (66.02 vs 65.15 before, p=0.04) (table 1). During the pandemic, a higher percentage of patients had a poor functional outcome, as defined by mRS 3-6 (35.7% vs 30% before, p=0.012), and a higher percentage died or were discharged to hospice (7.0% vs 5.1%, p=0.000).

Conclusions:
Despite earlier ED presentation and increased tPA administration, our results demonstrate worse discharge outcomes during the pandemic in two large telestroke networks. Changes in workflow and resulting delays during COVID-19 may explain these findings.
Abstract P149: Regional Transfer Protocols Can Improve Transfer Times and Reduce Length of Stay for Thrombectomy Candidates Seen on Telestroke
Authors: Joseph Michele M , Jagolino-Cole Amanda L , Trevino Alyssa D , Zhu Liang , Zha Alicia M , Ankrom Christy M , Savitz Sean I , Cossey TC , Wu Tzu-Ching
Published: March 2021

Introduction:
Our telestroke (TS) network instituted a regional transfer protocol (RTP) that allows for stroke patients in need of higher level of care to be pre-accepted and transferred to the nearest appropriate comprehensive stroke center (CSC). We studied the impact of the RTP on resource utilization and time metrics in patients transferred for evaluation of intra-arterial thrombectomy (IAT). Before the RTP, all potential IAT patients were transferred to one central CSC. After the RTP was initiated, the network had the capability to transfer to two additional CSCs within the same health system that are strategically located in the Houston area.

Methods:
We identified patients evaluated via TS in spoke emergency rooms that were subsequently transferred for IAT evaluation from 1/1/2016 to 12/31/2017 - one year prior and one year after the RTP. Baseline demographic characteristics, transfer and IAT metrics, and outcomes were compared for the two time periods.

Results:
Of 220 patients, 102 patients were transferred pre-RTP, and 120 were transferred to the three CSCs post-RTP. There were no significant differences in baseline characteristics, except fewer patients received tPA post-RTP (Table 1). In total, 30 patients (29%) pre-RTP and 42 patients (35%) post-RTP underwent IAT (p=0.38). Post-RTP, there was a trend toward faster travel times (median 40 vs 32 minutes, p=.07) and transfer initiation times to hub arrival times (median 109 vs 100.5 minutes, p=0.09). Door to groin puncture times were not statistically different between the two time periods. Post-RTP patients had a significantly shorter length of stay (median 6 vs 5 days, p=0.03).

Conclusions:
Regional transfer protocols can potentially help reduce transfer times and length of stay for stroke patients at CSCs that were initially seen by TS at community hospitals; however, larger sample size is needed to study its impact on other IAT-related metrics and clinical outcomes.
Abstract P15: Does Atrial Fibrillation Impact 90-Day Outcome in Acute Ischemic Stroke Patients Treated With rt-PA and/or Endovascular Treatment?
Authors: Bavarsad Shahripour Reza , Shifflett Benjamin R , Labin Edward , Barminova Anna , Figurelle Morgan , Meyer Brett C , Meyer Dawn M
Published: March 2021

Background:
Patients with acute ischemic stroke (AIS) due to atrial fibrillation (a fib) may not have as favourable of a response to intravenous thrombolysis or endovascular treatment (ET) compared to other stroke subtypes. The purpose of this study was to compare the 90-day outcome in patients with and without a history of a fib treated with IV rt-PA and/or ET.

Method:
Consecutive stroke code activations were retrospectively analyzed from January 2004-June 2020 at an academic comprehensive stroke center. Patients were included if they were treated with IV rt-PA and/or ET within 24 hours of stroke onset. Patients were stratified into the six groups: 1- No history of a fib with ET only, 2- History of a fib with ET only, 3- No history of a fib with IV rt-PA plus ET, 4- History of a fib with IV rt-PA plus ET, 5- No history of a fib with IV rt-PA only, 6- History of a fib with IV rt-PA only. Primary outcome was 90 day modified Rankin Scale (mRS) with favourable outcome defined as mRS 0-2. Baseline demographics were compared and pairwise Wilcoxon Rank was used to assess group differences followed by multinomial regression. Analyses were both unadjusted and adjusted for baseline NIHSS, age, sex, baseline blood pressure, pre-stroke mRS, smoking status, and baseline glucose.

Results:
We identified 720 AIS patients who received acute treatment (IV rt-PA: n=578; ET: n=100; IV rt-PA+ET:n=18). There was a significant difference in sex (p=0.005); Hispanic ethnicity (p=0.002); current smoking (p=<0.001); current alcohol use (p=0.03), CHF (p=0.01); and age (p<0.0001) between groups. Baseline NIHSS was significantly higher in Group 4 (23, SD 8, p=<0.001). In adjusted analysis, there were significantly more patients with mRS 1 (p=0.03) and mRS 2 (p=0.01) in Group 5 compared to group 6. There was no significant difference in “favourable outcome” in adjusted analyses both between groups and in patients with and without afib overall (OR: 3.10, 95% CI: 0.19-50.97, p=0.43).

Conclusion:
In this study, afib did not have a significant impact on 90-day outcome in AIS patients treated with IV rt-PA, ET, or both. This study supports the acute use of IV rt-PA in the atrial fibrillation population despite anecdotal comments that cardioembolic strokes do not improve with thrombolysis.
Abstract P150: Effects of State Mandated Stay-At-Home Orders on Timely Presentation of Ischemic Stroke Patients During the Covid-19 Pandemic
Authors: Barton Trevor , Van Vliet Rebecca , Fanale Chris , Wagner Jeffrey
Published: March 2021

Introduction:
The ability to treat an acute ischemic stroke depends on the patient’s timely presentation to the hospital from their last known well time. During the coronavirus disease 2019 (COVID-19) pandemic, individual state governments enacted stay-at-home orders to slow the transmission of the disease. We collected data from hospitals across four state-based networks where we provide stroke telemedicine coverage to ascertain the effects of these mandates.

Objectives:
We sought to evaluate the effects of stay-at-home orders on the number of patients evaluated and treated for ischemic stroke during the COVID-19 pandemic, and to evaluate the difference in treatment rate while states were under state-at-home orders versus while they were not.

Methods:
We retrospectively examined stroke alerts from March 1
st
to May 30
th
, 2020. We tabulated total number of stroke alerts, number of IV alteplase and intra-arterial (IA) treatment recommendations, number of less severe strokes (NIHSS 0-6) and more severe strokes (NIHSS 7-41). Treatment rates were calculated and compared by state-based network before, during, and after the stay-at-home orders.

Results:
We found that the total number of alerts per week fell by 27.33% during the stay-at-home orders across all state networks. The total number of patients treated with alteplase and total number of patients treated with IA therapy per week also dropped by 29.31% and 13.69%, respectively. The alteplase and IA treatment rate increased by 10.57% and 13.85%, respectively, during the stay-at- home orders. The percentage of total strokes considered more severe slightly increased during these orders, by 5.54%.

Conclusion:
During the government mandated stay-at-home orders, the total number of patients evaluated for stroke alerts decreased, as did the total number of patients treated either with alteplase or IA therapy. However, with the decrease in number treated, the rate at which patients were treated with alteplase, IA, or both, increased. The percentage of total strokes that were considered more severe slightly increased. In conclusion, while stay-at-home orders kept many stroke patients home, the most severe stroke patients continued to present to the hospital and were treated in a timely manner via telemedicine.
Abstract P153: SARS-CoV-2 (COVID-19) Protection Efforts on Acute Stroke Treatment
Authors: Greenwood Jessica , Belnap Starlie , Bedgio Rodney , Dabus Guilherme , Linfante Italo , De Los Rios La Rosa Felipe
Published: March 2021

Introduction:
It is unclear how the interventions designed to restrict community and in-hospital exposure to the SARS-CoV-2 virus affected the care for stroke patients seeking acute treatment. The objective of the following study was to determine the impact COVID-19 has had on the treatment times for patients evaluated as acute stroke alerts at Baptist Hospital of Miami (BHM). A co-primary objective of the study was to assess the risk of contracting SARS-CoV-2 within 2 weeks from hospital discharge.

Methods:
This retrospective, two phase study was conducted between December 2019 and April 2020. In phase one, we assessed time from symptom onset to hospital arrival, number of strokes with witnessed onset, and in-hospital treatment times pre & post implementation of Covid-19 preventive exposure measures. In phase two of the study, a telephone survey was conducted on the post implementation group to assess the risk of patients developing symptoms or testing positive for SARS-CoV-2 from hospital admission up to two weeks post discharge.

Results:
Phase I demonstrated there was a 40% decline in stroke volume, but no significant delay to seek medical attention post implementation of the SARS prevention strategies. On average individuals in the pre-group (n=155) waited approximately 260 minutes (SE=24) to seek medical attention vs. 203 minutes (SE=27) minutes for the post-group (n=87). However, there was nearly a six-fold increase in the percentage of cases with unknown symptom onset post implementation of COVID-19 safety precautions. There was significant delay in administering IV alteplase, increasing from 24 mins (n=16) to 33 mins (n=21) post implementation; delays observed for endovascular treatment were not significant (pre, n=13 mean= 73 mins, post n=12 mean= 82 mins). The volume of patients treated with either IV alteplase and/or endovascular treatment remained similar. Phase II of the study is on-going, results will be available for the ISC.

Discussion:
The COVID-19 crisis in our community was associated with a six-fold increase in the percentage of cases with unknown stroke onset time. Besides a marked decrease in stroke volume, we did not evidence significant delays to either seek or provide acute stroke care outside a modest increase in door to needle time.
Abstract P155: The Network Effect on Inter-Facility Transfers Among Regional Stroke Certified Hospitals
Authors: Ifejika Nneka L , Wiegand Jared , Harbold Hunter , Botello Adrian A , Novakovic Robin , Cannell Michael B
Published: March 2021

Introduction and Purpose:
Timely inter-facility transfer of thrombectomy-eligible patients is a mainstay of Stroke Systems of Care. We investigated transfer patterns among stroke certified hospitals in the Dallas-Fort Worth Metroplex (19 counties, 9,286 sq mi, >7.7 million people), by hospital network and stroke center status.

Methods:
In Feb 2020, all 44 North Central Texas Trauma Regional Advisory Council (NCTTRAC) hospitals identified network status, stroke designation and geographic location. Stroke Assessment and Large Vessel Occlusion (LVO) screening tool use was evaluated. The distance between the sending and receiving facility was calculated using GPS coordinates. If the closest Comprehensive Stroke Center (CSC) was not used, the average distance between the selected and the closest CSC was geospatially mapped via R statistical analysis software (Vienna, Austria) gmapsdistance package.

Results:
Of the 44 facilities, 6 were Acute Stroke Ready Hospitals (ASRHs), 27 were Primary Stroke Centers (PSCs), 11 were CSCs (Fig 1). Seventy-seven percent (n=34) were part of four hospital networks. All facilities used stroke assessment tools; 57% completed LVO screening. Seventeen percent of ASRHs (n=1) and 56% of PSCs (n=15) conducted inter-facility transfers. Sixty percent of non-network facilities transferred to the closest CSC. Of the remaining 40%, the average distance between the closest and the selected CSC was 1.5 miles (min max 0.2-2.9). Seventeen percent of network facilities transferred to the closest CSC. Among the remaining 83%, the average distance between the closest and the selected CSC was 4.1 miles (min-max 1-8).

Conclusions:
Non-network facility status increased the likelihood of transfer to the closest Comprehensive Stroke Center. Transfer distance variability among network facilities may contribute to delays in reperfusion therapy.

Figure 1
. Transfer Patterns (in Blue) of Dallas Fort-Worth Metroplex Hospitals by Stroke Center Designation
Abstract P162: Racial and Gender Disparities in a Stroke Clinical Network
Authors: Yarbrough Karen L , Chima Udachi , Ezunagu Nneka , Gonzalez Karen L , Leonard Nicole , Lu Rong , Maloney Theresa , Schrier Chad , Stine Shelle , Truitt Barbara F , Chaturvedi Seemant
Published: March 2021

Introduction:
Earlier studies have suggested that disparities in stroke care exist for racial and gender groups. Our objective was to examine compliance with defect free care for these groups in a stroke clinical network. Defect free care gauges compliance with the delivery of selected core metrics reflecting best practices. The stroke clinical network providers and stakeholders have been meeting for over 5 years to share best practices and perform improvement projects. The Stroke Clinical Network consists of nine stroke centers located in rural, suburban and urban geographical regions.

Methods:
Stroke coordinators at nine stroke centers (8 PSCs and 1 CSC) used the GWTG registry to obtain Defect-Free reports using the filters: male, female, African American and white. Populations included patients with a diagnosis of stroke, ICH and SAH. Data was collected for Jan 2016-December 2019. The proportion of defect free compliance was calculated for these subgroups: African American, white, male and female.

Results:
There was not a difference in defect free care compliance between African American and white stroke populations (AA defect free 90% 2355/2583; white defect free 89% 4176/4685). The range for defect free compliance for AA was 70-98%. The lowest score of 70% was in an urban hospital. The range for defect free compliance for whites was 82-97%. There was not a difference in defect free care between male and female patients (female defect free 92% 5311/5771; male defect free 90% 4646/5211). The range for defect free compliance for females was 78-98%. The range for defect free compliance for males was 70-98%. For all patients in the stroke clinical network defect free care compliance was 91% (9957/10982).

Conclusions:
In a geographically diverse Stroke Clinical Network there were no disparities in defect care compliance due to gender or race. Future plans include performing a deep dive of the individual care measures to identify opportunities for improvement. The results indicate having an effective Stroke Clinical Network in which best practices and standardization of care are achieved provides an effective strategy to improve defect-care compliance across a network of hospitals.
Abstract P164: The Impact of the Expanded EVT Window on Acute Stroke Services: A Large Northwest Telestroke Network Experience
Authors: Lowenkopf Theodore , Corless Leslie , Baraban Elizabeth
Published: March 2021

Background:
Telestroke has led the technological revolution in providing acute medical services to rural areas in the United States since the beginning of this century. In January 2018 the American Stroke Association made a level IA recommendation to expand the treatment time window for endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) from 6 to 24 hours for anterior circulation stroke based on perfusion imaging. Our study is the first to our knowledge to report the effect of the expanded time window on acute stroke consult and treatment volumes in a large rural supporting telestroke network.

Methods:
Stroke registry data from two tertiary care facilities from a 22 hospital telestroke network supporting a large (> 78,000 mi
2
) primarily rural Northwest geographic region were used. Data included stroke patients arriving within 24 hours of last known well (LKW) between January 2017 and March 2019. Patients arriving January 2017 to December 2017 were grouped into the PRE-expanded time window and those arriving April 2018 to March 2019 into the POST-expanded time window. Stroke subtypes, transfers, telestroke consults (via phone or video), and EVT treatments were compared across time periods. Analyses were performed using Pearson’s chi square test, corrected for multiple comparisons.

Results:
A total of 1117 patients arrived with stroke symptoms within 24 hours of LKW, 567 (50.8%) in PRE and 550 (49.2%) in POST-window. The percentage of all stroke subtypes were not significantly different in the PRE and POST patient groups (p=.720). However, the percent of telestroke consults increased by 12.1% from 62.3% to 74.4% (p<.001) but the percent of video consults remained similar (25.9% vs 25.8%). The total number of transfers (142 vs 141) and percentage of transfers among AIS patients (25.0% vs 25.6%) from partner to hub did not change. The percentage of thrombectomies among transfers rose by 8.7% with the expanded time window, but was not statistically significant [p=0.118].

Conclusions:
In a large Northwest telestroke rural network the expanded EVT treatment time window led to a marked increase in all telestroke consults but did not impact video consults, transfer, or percentage of patients treated.
Abstract P165: Characteristics and Predictors of Mimics and Confirmed Strokes in a Stroke Alerts System at a Large Urban Medical Center
Authors: Kowalski Robert G , Pospishil Jamie , Leech Jarrett D , Jones William J
Published: March 2021

Background:
Stroke alert systems provide rapid evaluation of suspected strokes to aid timely thrombolysis and mechanical thrombectomy. Given consequences of delayed or missed diagnosis, these systems are intentionally more sensitive than specific for confirmed stroke. However, substantial physician and hospital resources are involved. We sought to evaluate characteristics and predictors of stroke mimics and confirmed strokes in a large stroke alert program.

Methods:
The study is a retrospective investigation of the stroke alert system at the University of Colorado Hospital. Variables included patient, clinical, stroke and stroke alert characteristics, and outcome. Variables were compared for patients with confirmed stroke, and mimics.

Results:
Stroke alerts were evaluated in 125 patients over a one-month period in 2019. Median age was 60 years (IQR 47-72), 52% were female, 51% were white, and 24% black or African American. Median initial NIHSS score was 4 (IQR 1-11), and onset was outside the hospital in 70%. One third of stroke alerts were confirmed stroke or TIA, and 66% were mimics. Most stroke alerts were called by the departments of Emergency Medicine (78%), Medicine (10%) and Surgery (9%). The most common of more than 40 stroke alert symptoms and combinations were weakness (45%), aphasia (20%), altered mental status (16%) and facial droop or numbness (each 14%). Stroke mimics were more likely to be female (58% female vs. 41% male, OR 2.206, 95% CI 1.025-4.745, p=0.041), had better initial NIHSS scores [3 (IQR 1-9) mimics vs. 6 (IQR 2-15) stroke, p=0.015), and were more often discharged to home (77% mimics vs. 51% strokes, OR 2.051, 95% CI 1.269-3.316, p=0.004). Stroke onset location and service initiating stroke alert were not associated with confirmed stroke. Weakness was the only symptom associated with confirmed stroke (58% stroke vs. 37% mimics, OR 2.447, 95% CI 1.137-5.268, p=0.021).

Conclusions:
Of stroke alerts in our institution, two thirds were stroke mimics, and these were more likely to be female patients. Weakness as a stroke alert symptom, alone or with other symptoms, was associated with confirmed stroke. Additional study is warranted to improve specificity and optimize utilization of physician and hospital resources in stroke alert programs.
Abstract P168: Who Are You Going to Call?: Emergency Physician Stroke Champions
Authors: Veznedaroglu Erol , Kurtz Thomas , Binning Mandy J , Liebman Kenneth M , Hakma Zakaria , Greenberg Karen J
Published: March 2021

Introduction:
A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients.

Methods:
Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology.

Results:
Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor.

Conclusion:
Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.
Abstract P170: Stroke Coordinator Roles and Developmental Needs Around the Globe: An MT2020 International Survey
Authors: Alexandrov Anne W , Aroor Sushanth , Biby Sharon , Potter-Vig Jennifer , Kumar Soni Swatantra , Fakey Manav , Inoa Violiza , Yavagal Dileep R ,   MT2020 Global Executive Committee
Published: March 2021

Background:
Stroke Coordinators (SC) are commonly utilized in US Stroke Centers, ensuring provision of evidence-based service, overseeing quality improvement, and supporting interdisciplinary and community education. Mission Thrombectomy 2020 (MT2020) partnered with the Association of Neurovascular Clinicians (ANVC) to understand how SCs are utilized outside the US and to compare developmental needs for this role across the world.

Methods:
A brief survey was constructed to capture information about the use of SCs and their duties, including personnel utilized to execute the role and areas deemed important for role development. The survey was disseminated through the MT2020 and ANVC membership rosters; returned data were assembled in SPSS (version 25) and analyzed using descriptive and X 2 statistics.

Results:
A total of 70 surveys were returned from 16 countries (63% USA). Survey responders were SCs (41%), physicians (39%), program managers (19%) and APPs(1%), and 49% were from CSCs/TSCs with 40% PSC and 11% ASR/other hospital; 92% had someone completing SC duties with MDs more commonly in the SC role outside the USA (63%) versus RNs in the USA (95%; X 2 =25.2, p<0.001). Table 1 lists role differences between USA and other countries. Of the 70% of respondents interested in receiving SC development resources, the aspect deemed most important was “Improvement of Stroke Nursing Knowledge/Care” (71% non-USA/81% USA). “Development of Stroke Systems of Care” was deemed second most important by non-USA hospitals (53%), followed by “Development of Government Policy” (35%).

Conclusions:
Non-USA Stroke Centers have significant SC development needs that differ markedly from those within the USA. MT2020 provides an important platform to engage international programs and the MT2020-ANVC partnership is well positioned to further stroke nursing care and SC development globally.
Abstract P175: Dizziness-Related Symptoms are Associated With Delayed Diagnostic Imaging in Patients With Intracerebral Hemorrhage
Authors: Doelfel Savannah R , Moody Scott , Chuck Carlin C , Kalagara Roshini , Zhou Helen , Stretz Christoph , Madsen Tracy E , Mahta Ali , Wendell Linda C , Thompson Bradford B , Furie Karen L , Reznik Michael E
Published: March 2021

Background:
Acute dizziness can present diagnostic challenges for emergency department (ED) clinicians because of the potential for an underlying cerebrovascular cause. Although various strategies may aid in diagnosing cases caused by stroke, it is unclear whether dizziness due to intracerebral hemorrhage (ICH) is associated with delays in diagnostic imaging.

Methods:
We performed a single center cohort study on consecutive ICH patients admitted over 2 years. We retrospectively abstracted initial reported symptoms and aggregated patients with dizziness, vertigo, lightheadedness, or nausea under the category of dizziness-related symptoms. After excluding patients with ED intubation due to potential procedural delays, we calculated time from initial ED arrival to first computed tomography (CT) scan. Using linear regression, we determined associations between dizziness-related symptoms and ED-to-CT time after adjusting for demographics and time from symptom onset, with additional analyses considering the presence of typical stroke symptoms and cerebellar ICH.

Results:
Of 427 patients, 110 (26%) presented with dizziness-related symptoms and 36 (8%) had cerebellar ICH. In univariate analyses, patients with dizziness-related symptoms had longer ED-to-CT times than other patients (median [IQR] 51 [21-144] vs. 32 [14-92] min, p=0.007), as did those with cerebellar ICH (71 [27-182] min). In our primary adjusted model, dizziness-related symptoms were associated with longer ED-to-CT times (+26 min [95% CI 6-46]). This imaging delay was further compounded in a subgroup analysis of patients without typical stroke symptoms (+45 min [95% CI 7-84], and in a separate model considering patients with cerebellar ICH (+48 min [95% CI 17-80]).

Conclusions:
Dizziness-related symptoms are associated with delayed diagnostic imaging in patients with ICH, which suggests the need for increased early awareness and urgency in these cases.