Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES

COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.

METHODS

This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).

RESULTS

Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).

DISCUSSION

Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.

TRIAL REGISTRATION INFORMATION

The study was registered under ClinicalTrials.gov identifier NCT04895462.

Spectrum of Hemorrhagic Encephalitis in COVID-19 Patients: A Case Series and Review

Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is an ongoing pandemic that has affected over 400 million people worldwide and caused nearly 6 million deaths. Hemorrhagic encephalitis is an uncommon but serious complication of COVID-19. The etiology of this disease is multifactorial, including secondary to severe hypoxemia, systemic inflammation, direct viral invasion, hypercoagulability, etc. The clinical spectrum of COVID-19-related hemorrhagic encephalitis is also varied, ranging from leukoencephalopathy with microhemorrhage, acute necrotizing hemorrhagic encephalitis (ANHE) involving the cortex, basal ganglia, rarely brain stem and cervical spine, hemorrhagic posterior reversible encephalopathy syndrome (PRES) to superimposed co-infection with other organisms. We report a case series of three young patients with different presentations of hemorrhagic encephalitis after COVID-19 infection and a review of the literature. One patient had self-limiting ANHE in the setting of mild COVID-19 systemic illness. The second patient had self-limiting leukoencephalopathy with microhemorrhages in the setting of severe systemic diseases and ARDS, and clinically improved with the resolution of systemic illness. Both patients were healthy and did not have any premorbid conditions. The third patient with poorly controlled diabetes and hypertension had severe systemic illness with neurological involvement including multiple ischemic strokes, basal meningitis, hemorrhagic encephalitis with pathological evidence of cerebral mucormycosis, and Epstein–Barr virus coinfection, and improved after antifungal therapy.

Bilateral Carotid-Cavernous Fistula: A Diagnostic and Therapeutic Challenge

Carotid-cavernous fistula (CCF) is an aberrant communication between the main trunk or branches of carotid artery and the cavernous sinus. Most of the cases of CCF occur following head trauma, but congenital and spontaneous cases have been reported. We report an interesting case of bilateral CCF with no history of trauma, thus most likely spontaneous form. Since it is rare, it was a diagnostic challenge. The suspicion of this diagnosis was made due to clinical features of headache, signs of increased Intracranial Pressure (ICP) (nausea, vomiting, and worsening headaches during Valsalva), exophthalmos, periorbital edema, periorbital erythema, chemosis, and conjunctival injection in both eyes. It was diagnosed with a 4-vessel angiography (digital subtraction angiography) which is the gold standard and was managed successfully with endovascular coil embolization.

Continued Underutilization of stroke care during the COVID-19 pandemic

Objective

This study aims to investigate the utilization of acute ischemic stroke (AIS) services during the Corona Virus Disease 2019 (COVID-19) pandemic. Based on early observations among healthcare utilization on stroke and other healthcare services, we hypothesized that there would be a persistent significant decline in AIS patients presenting to hospitals as the pandemic has progressed for over a year.

Method

TriNetX, a large research network, is used to collect real-time electronic medical data. Data on utilization of acute ischemic stroke service was collected for the years 2018, 2019, and 2020 for variables including overall stroke volume and the number of patients that received intravenous tissue plasminogen activator (tPA) and mechanical thrombectomy (MT).

Result

We found a 13.2–15.4% decrease in total number of AIS patients in 2020 (n 77231) compared with the years 2018 and 2019 (n 88948 and 91270 respectively, p ​< ​0.001). In the year 2020 Stroke volume was significantly lower in Q4 comparing to Q1 (Q1 vs Q4, p ​< ​0.01, while there were no significant differences in stroke volume between Quarters 2, 3, and 4 in 2020 (Q2 vs Q3, p ​= ​0.39, Q2 vs Q4, p ​= ​0.61, Q3 vs Q4, p ​= ​0.18). The Proportion of patients receiving tPA in 2020 was significantly lower compared to prior years (5.4% in 2020 vs 6.4% in 2018 and 6.0% in 2019, p ​< ​0.01), however, the proportion of patients receiving MT was significantly higher in 2020 than in 2018 (0.024 vs 0.022, p ​< ​0.01).

Conclusion

Despite significant alteration in practices to optimize healthcare delivery and mitigate the collateral impact of the pandemic on care for other conditions, a persistent decline in AIS volumes remains. Delayed presentation, fear-of-contagion, reallocation, and poor availability of health care resources are potential contributors. Prospective evaluation and further investigation for these trends is needed.

Cost-Effectiveness of Emergent MRI during Stroke Alert to Diagnose Stroke Mimics: Single-Center Experience

Objective  The aim of this article was to assess the role of emergent magnetic resonance imaging (MRI) for stroke mimics during a stoke alert (within 45 minutes) in reducing direct cost of management and duration of inpatient stay.

Methods  We did a retrospective chart review of all the patients who received emergent MRI brain during a stroke alert to help make decision about intravenous tissue-type plasminogen activator (IV tPA) administration from January 2013 to December 2015. Using the patient financial resource data and with the help of billing department, we calculated the approximate money saved in taking care of the patients who may have received IV tPA if emergent MRI brain was not available to diagnose stroke mimics as they presented with acute neurologic deficit within IV tPA time window.

Results  Ninety seven out of 1,104 stroke alert patients received emergent MRI. Of these only 17 (17.5%) were diagnosed with acute ischemic stroke (AIS), and 80 (82.5%) as stroke mimics. By doing emergent MRI for suspected stroke mimics, our study showed an approximate total saving of $1,005,720 to $1,384,560, that is, $12,571 to $17,307 per patient in medical expenditure.

Discussion  We suggest modification of stroke pathway from current algorithm “CT+CTA≥IV-tPA/neurointervention≥MRI” to “MRI+MRA≥IV-tPA/neurointervention” for possible stroke mimics, which can reduce the cost, radiation exposure, and duration of hospital stay for stroke mimics.

Conclusion  Emergent MRI is a cost-effective tool to evaluate IV-tPA eligibility for suspected stroke mimics during a stroke alert.

COVID-19 and stroke, a case series and review of literature

BACKGROUND

Corona Virus Disease 2019 (COVID-19) cases continue to increase around the World. Typical symptoms include fever and respiratory illness but a constellation of multisystem involvement including central nervous system (CNS) and peripheral nervous system (PNS) have been reported with COVID-19. Acute ischemic strokes (AIS) have also been reported as a complication.

METHODOLOGY

We analyzed patient characteristics, clinical outcomes, laboratory results and imaging results of four patients with COVID-19 who had AIS.

RESULTS

All four patients were =< 60 years, had hypoxemic respiratory failure secondary to pneumonia, elevated D-dimer and inflammatory markers.

CONCLUSION

Ischemic strokes are known complications in patients with severe COVID-19.

Outcomes of COVID-19 in Solid Organ Transplants

The novel coronavirus disease 2019 (COVID-19) is a global pandemic affecting millions of people worldwide. Solid organ transplant (SOT) recipients are probably at higher risk of severe infection and associated complications from COVID-19. Data on clinical outcomes of COVID-19 infection in SOT recipients are limited. Using the TriNetX database, patients with laboratory-confirmed COVID-19 from January 20, 2020, to July 7, 2020, were included in the study. We compared clinical outcomes comprising hospitalization, need for critical care services, intubation, and mortality among SOT recipients and patients without SOT. Of 30,573 laboratory-confirmed COVID-19 patients, 288 had SOT. Patients with SOT were more likely to be hospitalized (37.2% vs. 12.2%; p < 0.0001), needed critical care services (6.9% vs. 2.3%; p < 0.0001), needed intubation (7.9% vs. 2.0%; p < 0.0001), and had a higher 30-day mortality (11.1% vs. 3.8%; p < 0.0001). Patients in the transplant group were older (55.4 vs. 47.6 years; p < 0.0001) and had a higher prevalence of medical co-morbidities. SOT recipients are at significant risk of adverse COVID-19 related outcomes, including hospitalization, need for critical care services, and 30-day mortality, likely due to multiple co-morbid conditions.

Resident Education During COVID-19 Pandemic: Effectiveness of Virtual Electroencephalogram Learning

Objective

To explore effectiveness of alternative methods of neurology resident electroencephalogram (EEG) learning during COVID-19 pandemic due to social distancing requirements which caused disruption of traditional in-person teaching.

Methods

Virtual EEG learning was instituted using Zoom platform. Residents participated in live, interactive virtual sessions for eight weeks. A pre-test and post-test were administered and a survey was performed at the end of the project.

Results

Based on pre-test and post-test results, there was a significant improvement on average resident test scores. On the survey, 100% agreed (81.8% strongly agreed, 18.2% agreed) that virtual EEG sessions provided a conducive learning environment with easy access while preserving effective communication with the instructor. When compared to traditional EEG reading, 100% agreed (81.8% strongly agreed and 18.2% agreed) that virtual sessions were more accessible, 72.7% agreed (54.5% strongly agreed, 18.2% agreed) that they were more interactive; 81.9% (45.5% strongly agreed, 36.4% agreed) felt more engaged and 90.9% agreed (81.8% strongly agreed, 9.1% agreed) that they were able to attend more sessions. Hundred percent residents (72.7% strongly agreed, 27.3% agreed) felt more confident in their EEG reading and all (81.8% strongly agreed and 18.2% agreed) would sign up for more virtual learning courses.

Conclusions

Virtual EEG education is an efficient method of resident education with improved ease of access while maintaining interactive discussion leading to increased confidence in learners. It should be considered even after resolution of the need for social distancing and its applications in other fields of learning should be further explored.

Incidence of Thrombotic Events and Outcomes in COVID-19 Patients Admitted to Intensive Care Units

Introduction

While coronavirus disease 2019 (COVID-19) mostly causes respiratory illnesses, emerging evidence has shown that patients with severe COVID-19 can develop complications like venous thromboembolism (VTE) and arterial thrombosis as well. The incidence of thrombosis among critically ill patients in the literature has been highly variable, ranging from 25 to 69%. Similarly, reported mortality among critically ill patients has been highly variable too, and it has ranged from 30 to 97%. In this study, we analyzed data from a large database to address the incidence, the risk factors leading to thrombotic complications, and mortality rates among COVID-19 patients.

Material and methods

Data were obtained from TriNetX (TriNetX, Inc., Cambridge, MA), a multinational clinical research platform that collects medical records from 42 healthcare organizations (HCOs). All nominal data were compared using the chi-squared test. Alpha of <0.05 was considered statistically significant. We used Benjamini-Hochberg correction with a false discovery rate of 0.1 to correct for multiple comparisons.

Results

We identified 18,652 COVID-19-positive patients, with a median age of 50.7 years [interquartile range (IQR): 31.8-69.6]; among them, 51.8% (9,672) were males and 48.2% (8,951) were females. Of these patients, 630 [3.37%; median age: 61 years (IQR: 44.9-77.1)] were critically ill, requiring intensive care unit (ICU) care within one month of their diagnosis. Men were over-represented among the ICU patients when compared to women (3.7% vs 3%, p=0.009, Χ²=6.66). African Americans were over-represented among the ICU patients when compared to Caucasians (8.5% vs 4%, p<0.0001, Χ²=76.65). Older patients, i.e., 65 years and older, were over-represented in the ICU compared to patients aged 18-64 years (6.8% vs 2.5%, p<0.0001, Χ²=121.43).

The cumulative incidence of thrombotic events in the ICU population was 20.4% (129/630). Thrombotic events were significantly more common in patients who were 65 years and older when compared to patients in the age group of 18-64 years (24.6% vs 17.31%, p=0.02, Χ²=5.38). Mortality among ICU patients was higher in those who were 65 years and older when compared to the age group of 18-64 years (31.9% vs 17.3% p=0.0003, Χ²=18.41). The overall mortality in the study population was higher in patients who were 65 years and older when compared to patients aged 18-64 years (18.55% vs 1.4%, p<0.0001, Χ²=1915).

Conclusions

Among COVID-19 patients, men, African Americans, and people who are 65 years and older are more likely to have severe disease and require ICU level of care. Patients who are 65 years and older are more likely to have thrombotic events, myocardial infarction (MI), and stroke. Overall mortality and ICU mortality are higher among COVID-19 patients who are 65 years and older.

A Five-Year Analysis of Industry Payments to Sleep Neurologists From 2014 Through 2018

Background and objectives 

Sleep medicine has been one of the fastest-growing medical fields in recent years. The industry plays a big role in developing new medications and devices for both diagnosis and treatment of sleep-related problems. We analyzed payments made by industry to physicians from 2014 through 2018 based on the Open Payments Program data.

Methods

Centers for Medicare and Medicaid Services Open Payment Program and American Board of Psychiatry and Neurology databases were explored to elicit financial relationships between industry and sleep neurologists.

Results

Payments made by industry to sleep neurologists have been steadily increasing from 2014 through 2018. Approximately 16% to 22% of sleep certified neurologists received payments from industry during the study period. Interestingly, the payments made to the top 10% of the sleep physicians contributed approximately 85% to 96% of the total payments. The top two categories to which the highest payments were made were compensation for services and royalty and/or licensing fees. Silenor® (doxepin), Xyrem® (sodium oxybate), Aptiom® (eslicarbazepine acetate), Belsomra® (suvorexant), and Fycompa® (perampanel) were most of the drugs, which made the highest payments, that got approved by the Food and Drug Administration in the last decade.

Conclusions 

It seems that the industry is spending significant amounts of money in educating the physicians and in marketing the newer drugs. This analysis of the data on payments from industry is very useful in identifying any potential conflicts of interest from physicians. Further analyses are needed to study the trends of physician practice behavior and decision making.

Coronavirus Disease 2019 in Patients With Prior Ischemic Stroke

BACKGROUND

It is uncertain if patients with prior ischemic stroke are vulnerable to coronavirus disease 2019 (COVID-19) and its complications.

METHODS

We used TriNetX, a global health collaborative clinical research platform with a large global COVID-19 database. COVID-19 infection was identified with a positive lab value for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and related ribonucleic acid (RNA).

FINDINGS

A total of 604,258 patients with history of ischemic stroke were identified, of which 891 patients (study cohort) were diagnosed with COVID-19. A control cohort with 32,136 patients diagnosed with COVID-19 after January 20th 2020 without a history of ischemic stroke were identified. A comparison between study cohort and control cohort showed patients with prior history of stroke (study cohort) were older (69.5 vs 47.8; p<0.0001) and had more comorbidities contributing to worse clinical outcomes. After propensity matching for demographic variables and comorbidities, only rate of hospitalization (287 vs 231; p=0.0035) and need for critical care services (85 vs 55; p=0.0082) remained statistically significant while intubation (51 vs 43; p=0.39) and death (119 vs 115; p=0.77) showed trends towards worse outcomes but were not statistically significant.  Interpretation: Patients with history of ischemic stroke tend to be significantly older with several comorbid conditions contributing to worse clinical outcomes after COVID-19, which makes them a vulnerable population.

Acute encephalopathy is associated with worse outcomes in COVID-19 patients

Background

Acute encephalopathy with COVID-19 has been reported in several studies but its impact on outcomes remains unclear. We hypothesized that hospitalized COVID-19 patients with encephalopathy have worse COVID-19 related outcomes.

Methods

We used TriNetX, with a large COVID-19 database, collecting real-time electronic medical records data. We included hospitalized COVID-19 patients since January 20, 2020 who had encephalopathy based on ICD-10 coding. We examined clinical outcomes comprising need for critical care services, intubation and mortality among these patients and compared it with patients without encephalopathy before and after propensity-score matching.

Results

Of 12,601 hospitalized COVID-19 patients, 1092 (8.7%) developed acute encephalopathy. Patients in the acute encephalopathy group were older (67 vs. 61 years) and had higher prevalence of medical co-morbidities including obesity, hypertension, diabetes, heart disease, COPD, chronic kidney and liver disease among others. Before and after propensity score-matching for co-morbidities, patients with acute encephalopathy were more likely to need critical care services (35.6% vs. 16.9%, p ​< ​0.0001), intubation (19.5% vs. 6.0%, p ​< ​0.0001) and had higher 30-day mortality (24.3% vs. 17.9%, p 0.0002).

Conclusion

Among hospitalized COVID-19 patients, acute encephalopathy is common and more likely to occur in patients with medical co-morbidities and are more likely to need critical care, intubation and have higher 30-day mortality even after adjusting for age and underlying medical co-morbidities.

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Acute encephalopathy is common in COVID-19 patients.

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Acute encephalopathy is more common in COVID-19 patients with co-morbidities.

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Acute encephalopathy is associated with worse outcomes in COVID-19 patients.

Trends of Industry Payments in Neurology Subspecialties

Background Open Payments is a national disclosure program to promote transparency by the public disclosure of financial relationships between the pharmaceutical and medical device industries and physicians. Objective To explore payments from the industry to physicians in various neurology subspecialties. Methods Open Payments Program (OPP) data (https://openpaymentsdata.cms.gov) on industry-to-physician payments for the years 2014-2018 were extracted for general neurology, neuromuscular, neurophysiology, and vascular neurology. The data were then analyzed to explore trends in payments for various subspecialties and to identify the possible factors underlying these trends. Results Overall, industry-to-physician payments for neurology subspecialties increased by 16% from 2014 to 2018. The introduction of newer drugs in a subspecialty was likely the driving factor for higher industry payments. Nearly half of the total industry-to-physician payments were for the subspecialty of multiple sclerosis (MS)/Neuroimmunology; this coincided with Aubagio and Copaxone being the top two medications associated with the highest industry payments in 2014, Aubagio, and Lemtrada in 2018. A significant increase in spending percentages for headache, neuromuscular disorders, and movement disorders was observed while a relative decrease in the payments for MS/neuroimmunology and epilepsy was identified; these trends coincide with the introduction of new drugs such as Aimovig, Neuplazid, Nusinersen, and Austedo for headache, neuromuscular and movement disorders. Conclusions From 2014 to 2018, the total industry-to-physician payments for neurology subspecialties increased while the distribution of industry-to-physician payments for various neurology subspecialties showed notable changes. The introduction of newer medications in a subspecialty coincided with higher industry payments. Identification of these trends and potential motives of the industry spending is critical to address any potential physician bias in prescribing medications.

When Telestroke Programs Work, Hospital Size Really Does Not Matter

Background  There are still marked disparities in stroke care between rural and urban communities including difference in stroke-related mortality. We analyzed the efficiency of tissue plasminogen activator (tPA) delivery in the spoke sites in our telestroke network to assess impact of telecare in bridging these disparities. Methods  We analyzed critical time targets in our telestroke network. These included door-to-needle (DTN) time, door-to-CT (D2CT) time, door-to-call center, door-to-neurocall, and total consult time. We compared these time targets between the larger and smaller spoke hospitals. Results  Across all the 52 spokes sites, a total of 825 stroke consults received intravenous tPA. When compared with larger hospitals (>200 beds), the smaller hospital groups with 0 to 25 and 51 to 100 beds had significantly lower D2CT time ( p -value 0.01 and 0.005, respectively) and the ones with 26 to 50 and 151 to 200 beds had significantly lower consult time ( p -value 0.009 and 0.001, respectively). There was no significant difference in the overall DTN time when all the smaller hospital groups were compared with larger hospitals. Conclusion  In our telestroke network, DTN times were not significantly affected by the hospital bed size. This shows that a protocol-driven telestroke network with frequent mock codes can ensure timely administration of tPA even in rural communities regardless of the hospital size and availability of local neurologists.

A review of pathophysiology and neuropsychiatric manifestations of COVID-19

INTRODUCTION

The outbreak of coronavirus disease 2019 (COVID-19) has become one of the most serious pandemics of the recent times. Since this pandemic began, there have been numerous reports about the COVID-19 involvement of the nervous system. There have been reports of both direct and indirect involvement of the central and peripheral nervous system by the virus.

OBJECTIVE

To review the neuropsychiatric manifestations along with corresponding pathophysiologic mechanisms of nervous system involvement by the COVID-19.

BACKGROUND

Since the beginning of the disease in humans in the later part of 2019, the coronavirus disease 2019 (COVID-19) pandemic has rapidly spread across the world with over 2,719,000 reported cases in over 200 countries [World Health Organization. Coronavirus disease 2019 (COVID-19) situation report-96.,]. While patients typically present with fever, shortness of breath, sore throat, and cough, neurologic manifestations have been reported, as well. These include the ones with both direct and indirect involvement of the nervous system. The reported manifestations include anosmia, ageusia, central respiratory failure, stroke, acute inflammatory demyelinating polyneuropathy (AIDP), acute necrotizing hemorrhagic encephalopathy, toxic-metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. These data were derived from the published clinical data in various journals and case reports.

CONCLUSION

The neurological manifestations of the COVID-19 are varied and the data about this continue to evolve as the pandemic continues to progress.

Abstract WMP96: Industry Payments to Vascular Neurologists, a Six-Year Analysis of the Open Payments Program From 2013 to 2018

Objective: To analyze and characterize industry payment to vascular neurologists from 2013 to 2018 using open Payments Database.

Methods: This is a retrospective analysis of open payments database, which is available publicly. We calculated the percentage of vascular neurologists in the United States receiving payments and payment characteristics. We have analyzed the top 1% payment to vascular neurologist with detailed payment category analysis, payment regional trends, and sponsors each year. The number of board-certified vascular neurologists is available from the database of the American Board of Psychiatry and Neurology.

Results: From Jan 2013 to Dec 2018, industry payments to vascular neurologists have increased significantly each year, while a relatively stable fraction (17%) of US vascular neurologists received industry payments totaling $ 3,782,222 (6 years combined). The median payment per physician ranges from $ 115 to $ 241, while 90th percentile payments vary from $1,766 to $ 4,988 with a maximum payment up to $190,551. Nine payment categories are available and the highest amounts were paid for "Consulting Fee". The payment proportion from top 10 sponsors consists of 75% of the total amount since 2013. The payment to the south region has a steady growth rate among the other regions and has the highest payment amount of $ 470,551 in 2018. Top 1% vascular neurologists received more than 60% of the total payment. Among the top 1% vascular neurologists, 73% are likely to be key leaders in the field. Among the top 1%, 42% are specialized in neuro-intervention and less than 15% have Authored AHA/ASA guideline papers.

Conclusion: Payments to vascular neurologists is highly skewed with the top 1% receiving around one-third of all payments, less than 15% of these vascular neurologists have authored AHA/ASA guidelines. The industry is known to target key leaders in the field whether this is translating to changes in clinical practice should be looked into more thoroughly.

Abstract TP251: It’s All in the Wrist - Integrating EMS, Telestroke and Stroke Registry Data Systems

Background: States without a recognized directive for stroke care and transport risk the ability to monitor, assess and review stroke patient movement from first medical contact (FMC) to delivery/and/or transfer to hospitals. We are seeking to determine a new tracking program’s efficacy from emergency medical systems (EMS) to telestroke sites and other receiving hospitals utilizing Get-With-The-Guidelines (GWTG) in data reporting.

Hypothesis: We hypothesized that all three entities (EMS, telestroke sites and other hospitals) would record suspected and positive strokes into their electronic databases and integrate the process into their standard of practice, protocols and guidelines.

Methods: Statewide EMS agencies, receiving hospitals in the Arkansas Stroke Registry and telestroke sites received educational training about placing blue wristbands on all suspected strokes. Stroke bands were to be placed on all patients arriving via EMS or privately owned vehicle. The bands contained a unique number sequence for recording in both EMS and hospital GWTG electronic databases. We retrospectively reviewed all prospectively collected data from January 1, 2019 to May 31, 2019 for wristband placement by the EMS systems and determined the percentage match to hospital emergency department (ED) discharge data using the GWTG data and telestroke data.

Results: From the five months of retrospective analysis of prospectively collected data for 5 months showed, 4,668 strokes were seen in hospitals complying with GWTG. Forty-two% of the positive strokes in hospital (EDs) had stroke bands placed. Of these 8.4% had matching stroke wristband numbers to the EMS database. The telestroke system reported 636 consultations with 95% band placement, 39% placed by EMS. Matching telestroke band ID’s to EMS records was 37%. Wristbands placed by EMS were associated with positive screen tests, pre-notification and shortened Door to CT time (p < 0.0021).

Conclusions: Wrist-bands were associated with improved EMS response and provided informed response to hospital care teams. For consistent tracking of positive stroke patient data from FMC to discharge both prehospital and hospital, systems must undergo additional training followed by surveys to determine informed training.

Abstract WP292: Temporal Trends in the Use of Ems Service as a Mode of Arrival by Acute Ischemic Stroke Patients

Intro: Utilization of emergency medical services (EMS) can increase the likelihood of appropriate therapy with IV tPA or endovascular intervention. We investigate the use of EMS services in three large states across the US during the past decade.

Methods: Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 9,251 stroke admissions from 01/2010 - 12/2018. Overall rates of EMS use and temporal trends were computed. Factors associated with EMS use were evaluated with univariate analysis.

Results: Of the 9,251 patients, 29.2 % (2,697/9,251) presented via EMS service. Overtime use of EMS service increased from 29% in 2010-11 to 34% in 2018. Use of EMS increased among severe stroke patients but decreased among mild stroke patients. Patients presenting via EMS were older, more often females while less often African Americans. They had more stroke risk factors, including hypertension, diabetes, atrial fibrillation and previous stroke/TIA. Smokers less often use EMS services. Median NIHSS was higher among patients presenting via EMS, and those with altered level of consciousness used EMS more often. In-hospital intervention rates (IV tPA/endovascular) were higher among patients presenting via EMS.

Conclusion: Our results showed that after extensive EMS education in most parts of the study states, stroke presentation has increased via EMS overtime. Disparity in the use of EMS still exists with African Americans using the service less often. Patients should be encouraged to use EMS services and decrease delay in presentation which can results in higher rates of intervention.

Abstract TP179: No Need to 'Card' Here; Cocaine/Opioid Use in Middle Age and Stroke

Background: Drug overdose from 1999 to 2017 in the US has continued to increase. Rural America has seen an increase in methamphetamine (Meth) users. Meth usage in Arkansas and its effects on stroke incidence and treatment are all largely unknown. Drug abuse can cause an immediate stroke or increase the risk of stroke either by damage to the cerebrovasculature, hypertension, or by affecting vital organs. Here we retrospectively examined strokes from 57 rural communities that self-reported positive for drug use from a large telestroke program for age, thrombolysis, alcohol and smoking use, gender, race, deficit level and symptom to door time.

Hypothesis: Incidence of drug use is greater among younger age groups and increases the incidence of stroke in younger age categories.

Methods: We analyzed consult prospective data from 2015 to 2018 of the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program for consults who self-reported as positive for drug use. We included all stroke assessed consults for age (ranged by decade), thrombolysis (alteplase use), alcohol and smoking use, consult gender, race, initial deficit level at presentation using the national institutes of health stroke scale (NIHSS) and symptom to door time (minutes).

Results: In 2015 to 2018 the number of consults positive for drug use per person were 2,349, 1,747, 1,910 and 1,137 per 100,000, respectively. Sixty-two percent of drug users were in their 40’s and 50’s (p<0.0001) with hypertension (p<0.0001). Drug users were most frequently smokers (73%) and consumed alcohol (39%) at p < 0.0001. Significantly fewer received alteplase (20%, p=0.039). There was no difference of gender in drug use (p=0.08). Almost half of the drug users were consulted for stroke but were not confirmed as stroke (46%, p=0.045). Symptom to door time average was lower in drug users, though not significant at 56.4±10 vs. 68.9±1.9 minutes, p=0.37. There was no effect of race in incidence of drug use, or deficits.

Conclusion: While the incidence of drug use does persist in the rural communities, demographics suggest it is more common in the middle age group than younger patients.

Abstract TP299: Association Between Rates of Dysphagia Screening Failure and Short-Term Outcomes in Patients With Mild Stroke

Intro: Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many patients with mild presentation fail initial screening. We sought to evaluate the rates and predictors of dysphagia screening failure in mild acute ischemic stroke patients (NIHSS < 5).

Methods: Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 8,687 stroke admissions from 06/2008 - 12/2018. Patients with mild stroke (NIHSS<5) were identified and dysphagia failure rate was evaluated. Using univariate and multivariable regression (MV) analysis (using factors with p<0.1, in bold), we evaluated factors associated with dysphagia screen failure in mild stroke patients.

Results: Of the 8,687 patients, 3,614 (41%) had NIHSS < 5. Dysphagia screening failure was seen in 30.2% in the entire cohort while only 10.3% (373/3,614) in patients with NIHSS < 5. Mild stroke patients who failed dysphagia screening were older, more often had stroke risk factors of hypertension, hyperlipidemia, CAD/MI. They had higher median NIHSS and more often had language disturbance on presentation. Patients who failed dysphagia screening were less likely to be discharged home. On MV analysis, age (1.01, 95% 1.00, 1.02), hypertension (1.45, 95% 1.10, 1.91), NIHSS (1.62 95% 1.48, 1.77) and language disturbance at presentation (1.89 95% 1.13, 2.32) were significantly associated with initial dysphagia.

Conclusion: Dysphagia screen failure rates are significantly less frequent in patients with mild symptoms and even lower for those with NIHSS of 0-1 at presentation. Factors associated with failure - older age, higher NIHSS and language disturbance at presentation may help focus efforts to avoid complications in these patients who might otherwise do well. This focused approach of screening patients all patients but targeting mild patients with dysphagia may hold potential for improved outcomes.

Abstract WP120: Welcoming the New Kid on the Block; The Phase IIb Prospective, Randomized, Open-Label, Blinded Endpoint (PROBE) Study of NanO 2 TM Neuroprotection in Large Vessel Strokes

Background: NVX-208 (NanO 2 TM ) was recently examined in a completed randomized, placebo-controlled and double-blinded dose escalation Phase Ib/II safety trial in acute ischemic stroke (AIS) patients and was found to be safe in all dosage levels. Exploratory aims indicated early treatment in the highest NanO 2 TM dose cohort improved clinical outcomes of early NIHSS and 90-day mRS. In the current Phase 2b protocol, NanO 2 TM ’s enhanced oxygen delivery from the blood to tissue will be examined in early AIS subjects with large vessel occlusions (LVO). LVO patients will provide the optimal assessment for NanO 2 TM to maintain penumbra tissue viability. The Phase 2b primary objective will be to assess functional recovery and subject independence.

Drug information: NanO 2 TM is an emulsion of 2% dodecafluoropentane (DDFP) in stabilizers (sucrose, PEG-Telomer-B) and phosphate buffered saline (pH 7.0) that is a highly efficient fluorocarbon oxygen transporter. Compared to previously developed fluorocarbon oxygen carriers, NanO 2 TM carries far more oxygen per gram of fluorocarbon. Because DDFP is not metabolized, almost 100% of administered doses was recovered in the subject’s breath as DDFP.

Hypothesis: NanO 2 TM given early to subjects with LVO ischemic stroke will maintain penumbra tissue viability.

Methods: Phase 2b study sites will include multiple stand-alone and hub and spoke systems located across the United States. Central IRB and safety monitors will provide oversight and support coverage. Key methodology includes providing early first dosage administration of NanO 2 TM or placebo (study treatment) to identify and consent LVO AIS subjects with viable penumbra. For drip and ship patients, second and third doses will be given en route or after arrival at the hub hospital and after revascularization procedures, respectively. Following the third dose, all subjects will receive study treatment dosing out to 24 hours, each dose at 90 minute intervals. 24-hour imagery assessments will confirm infarct volume. All final angiograms and 24-hour imaging data will be sent to core labs for blinded confirmatory review. Subject recovery and independence will be assessed throughout the study to 90 days.

Conclusion: Study projected start date is early to mid-2020.

Women on Hormone Therapy with Ischemic Stroke, Effects on Deficits and Recovery

Background:

Hormone replacement therapy (HT) for post-menopausal women is associated with increased incidence of ischemic stroke risk. Effects of HT on stroke related deficits and functional outcomes in acute ischemic stroke (AIS) are uncertain. We retrospectively examined female consult data for HT use and National Institutes of Health Stroke Score (NIHSS) at baseline and recovery for 2015 and 2016 in a large stroke telemedicine program.

Hypothesis:

The age of women who acknowledged HT use will negatively impact stroke severity and outcomes.

Methods:

We analyzed consult data from two consecutive years for all women and included HT use, current age, and baseline and 24 h NIHSS’s. We included all women consults regardless of IV Alteplase treatment. 24 h NIHSS and three month modified Rankin scale (mRS) were included from women given IV Alteplase.

Results:

Strokes were identified in 523 women and 244 women received Alteplase therapy. Women without HT use numbered 459 and 64 women listed HT use. Mean NIHSS scores regardless of HT use significantly improved 24 h NIHSS vs. baseline NIHSS (p<0.0001). Baseline NIHSS scores were significantly improved in women on HT vs. non-HT users (p=0.01) in women age 50 to 79 years. Although mean NIHSS scores at 24h was not different from HT to no HT use (4.9 ± 1.6 vs. 7.8 ± 0.6, p=0.08) a trend was present for lower NIHSS scores for women 50–79 years. The mRS scores at three months indicated significant improvements among HT users vs. non-HT use (1.46 ± 0.4 vs. 2.51 ± 0.2, p=0.05).

Conclusion:

While cautions persist on the use, route and dosage of HT for risks of ischemic stroke, the HT moderation of AIS deficits and outcomes in women <80 years of age warrants further investigation.

Fabry's disease and stroke: Effectiveness of enzyme replacement therapy (ERT) in stroke prevention, a review with meta-analysis

BACK GROUND AND OBJECTIVE

Fabry's disease, is the most prevalent lysosomal storage disorder and is notorious for its early multi-organ involvement leading to complications, including ischemic strokes and transient ischemic attacks. Since 2001, enzyme replacement therapy (ERT) has become the mainstay treatment for Fabry's patients but the indications are not clearly defined. We did a meta-analysis of the available data to review the benefit of ERT for stroke prevention in Fabry's patients.

METHODS

A literature search was performed from National Center for Biotechnology information (NCBI)/PubMed database without restriction of years for systematic review purposes. A systematic review of clinical cohort studies and trials was performed with pooled analysis of proportions. The pooled proportions and the confidence intervals (CI) for stroke recurrence ratio were calculated for both ERT treatment group and native treatment groups.

RESULT

A total of 7 cohort studies and 2 RCTs involving 7513 participants (1471 on ERT vs 6042 on native treatment) met inclusion criteria. The pooled proportions analysis showed that the stroke recurrence ratio in the ERT treatment group was 8.2% [95% CI 0.038, 0.126] and in native-treatment group was 16% [95% CI; 0.102, 0.217]. Effect differences favored ERT treatment group over native treatment group (p = 0.03).

CONCLUSION

Our meta-analysis based on the currently available data showed that ERT for Fabry's disease has beneficial effect on stroke prevention. Female carriers and atypically affected males could be started on ERT as soon as diagnosis is made. Further studies are warranted to support the role of ERT in stroke prevention.

Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network?

OBJECTIVE

The purpose of this study was to determine reasons for not giving intravenous tissue plasminogen activator to eligible patients with acute ischemic stroke in a telestroke network.

METHODS

We performed a retrospective analysis of prospectively collected data of patients who were seen as a telestroke consultation during 2015 and 2016 with the Arkansas Stroke Assistance through Virtual Emergency Support programme for possible acute ischemic stroke.

RESULTS

Total consultations seen were 809 in 2015 and 744 in 2016, out of which 238 patients in 2015 and 247 patients in 2016 received intravenous tissue plasminogen activator. In 2015 and 2016, out of the remaining 571 and 497 patients, 294 and 200 patients respectively were thought to be cases of acute stroke based on clinical evaluation. The most common reasons for not being treated in 2015 and 2016, respectively, were; (a) minimal deficits in 42.17% and 49.5% cases, (b) falling out of the 4.5-hour time window in 22.44% and 22% cases, (c) patient/next of kin refusal in 18.02% and 16.5% cases. Less common reasons included limited functional status, abnormal labs (thrombocytopenia, elevated international normalised ratio (INR)/prothrombin time (PT)/partial thromboplastin time (PTT), hypo or hyperglycemia etc), recent surgery and symptoms being too severe etc.

CONCLUSION

'Minimal deficits' and 'out of time window' continue to be the major causes for not receiving thrombolysis during acute ischemic stroke in both traditional and telestroke systems. Patient/next of kin refusal was high in our telestroke system when compared to traditional practices. Considering the increasing utility of telestroke this needs to be further looked into, along with the ways to address it.

Abstract TP35: Rates of Endovascular Therapy in Acute Ischemic Stroke Patients With NIHSS < 6 and Outcomes

Introduction: Prior reports showed poor outcomes in patients who did not receive IV tPA after acute ischemic stroke (AIS), due to mild or rapidly improving symptoms. (“too good to treat”, TGTT). Many factors have been associated with poor outcomes in this group of patients. We sought to evaluate individual NIHSS items associated with poor outcomes in these TGTT patients who didn’t receive thrombolysis.

Methods: Using the GWTG stroke registry data from a large comprehensive stroke center in the Northeast, we analyzed 9,215 consecutive stroke admissions from 02/2002 - 04/2018 and identified patients who did not receive IV tPA due to TGTT. NIHSS items were grouped into Level of Consciousness (LOC), Language, Vision, Motor, Sensory and Coordination. Factors associated with poor outcome (defined as all discharge locations other than home) and in-hospital mortality were evaluated by univariate and multivariable regression with significance at p<0.05.

Results: Of the 9, 215 analyzed patients, 444 (4.8%) didn’t received tPA due to being TGTT despite presenting within 4.5 hours of last know well. Patients with poor outcomes were more likely to be older, female, have a history of diabetes, atrial fibrillation, and present more often with deficits in level of consciousness, vision, motor, language and sensation. On multivariable analysis, age (OR 1.06, 95% CI (1.04, 1.08)), diabetes (OR 3.65, 95% CI (2.00, 6.71)), and deficits in LOC (OR 4.91, 95% CI (2.35, 10.24)) and strength (OR 4.65, 95% CI (2.79, 7.74)) were independently associated with poor outcome. Factors independently associated with in-hospital mortality were age, and deficits in LOC and strength.

Conclusion: Half of all patients who did not receive thrombolysis due to TGTT in our sample had poor outcomes and 8.8% of those died in-hospital. Advanced age, and initial deficits in LOC and strength were strong predictors of a poor outcome. When present in milder strokes, these factors warrant careful consideration for tPA use.

Abstract TMP17: Dodecafluropentane Emulsion in Acute Ischemic Stroke, a Phase One Randomized and Controlled Trial

Introduction: In Acute Ischemic Stroke (AIS) the effective therapeutic window remains very short for the vast majority of patients and severely limits those who qualify for acute therapy. The oxygen transporting nanodroplet Dodecafluoropentane emulsion (DDFPe) (NuvOx Pharma, Tucson, AZ) given IV within 3h of onset can reduce AIS symptoms and stroke volumes markedly in animal studies and may widen the window significantly for therapy. We conducted a randomized, placebo-controlled, double blinded, dose escalation AIS trial to demonstrate the Maximum Tolerated Dose, characterize adverse events and explore impacts on acute NIHSS values and long-term outcomes.

Methods: AIS patients with NIHSS of 2-20 were randomized to either 3 doses of IV DDFPe or placebo, one every 90 minutes, starting within 12 hours of symptom onset. Doses were given as soon as possible between unmodified standard stroke care elements. Each dose cohort included 8 patients, with 2 receiving placebo and 6 DDFPe. Primary outcomes were SAEs, AEs, NIHSS values, and mRS.

Results: No Dose Limiting Toxicities were encountered and no maximum dose defined. One unrelated delayed death occurred in the DDFPe group and one in the placebo group while SAEs and AEs were similar. Early DDFPe treatment of any dose had better NIHSS values at 4.5h than late doses, p=0.03. In high dose DDFPe mRS outcomes suggested improvement, p=0.01 at 30 days and p=0.03 at 90 days.

Conclusions: IV DDFPe appeared safe at all doses. Early DDFPe treatment showed NIHSS improvements and high dose DDFPe patients suggested improved outcomes. Larger trials are warranted.

Abstract TP355: Rate of Deep Vein Thrombosis in Patients When Pharmacological DVT Prophylaxis is Delayed Due to IV tPA Use

Introduction: Deep vein thrombosis (DVT) is associated with pulmonary embolism and reduced post stroke recovery. After thrombolysis, current US guidelines recommend a delay of 24 hours before initiation of pharmacological DVT prophylaxis. We sought to determine the rate of DVT in post-tPA patients with delayed pharmacological prophylaxis.

Methods: Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 13,420 consecutive stroke admissions from 02/2002 - 06/2018. Rates of DVT were compared between those with delayed prophylaxis due to post-tPA vs. all others. Chi-square was used for categorial data, T-Test for parametric continuous and Wilcoxon for non-parametric continuous variables. Multiple regression analysis (MV) was used to identify associations.

Results: Of the 13,420 patients, 2974 (22.2%) received IV-tPA, 772 (5.8%) underwent EVT, 252 (1.9%) only EVT and 3279 (24.4%) received IV-tPA and/or EVT. There was a total of 536 (4.0%) patients with a documented DVT during the in-hospital stay. The rate of DVT in patients who received IV-tPA was significantly higher than in those who did not (4.6% vs 3.8%, p=0.036). Rates of DVT were 3.8% in patients not receiving tPA or EVT, 4.6% in IV tPA only group, 4.0% in EVT only group and 4.4% in IV tPA and/or EVT group. On univariate analysis Caucasian race, atrial fibrillation, smoking, weakness on presentation and use of IV tPA was significantly associated with DVT. On MV, only age, Caucasian race and a history of smoking was remained significantly associated with DVT.

Conclusion: Although the NINDS tPA trial delayed DVT ppx initiation to 24 hrs, ECASS 3 allowed DVT ppx in post tPA patients without delay. Our analysis shows that post-thrombolysis patients with delayed DVT ppx had higher rates of DVT, although this effect did not remain significant on MV analysis. Larger studies to assess the safety of delaying DVT ppx in post tPA patients are warranted.

Abstract 74: The Role of Race in Comfort Care Determination After Acute Ischemic Stroke

Intro: Death after acute stroke often occurs in the context of transitioning from life-sustaining interventions to comfort measures only (CMO). We sought to evaluate if black race was associated with the decision to transition to CMO care in the setting of substantial post stroke disability.

Methods: Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 9,913 stroke admissions from 01/2009 - 12/2017. Overall rates and temporal trend in the rates of CMO were computed. Factors associated with CMO were evaluated with univariate and multivariable (MV) regression.

Results: Of the 9,913 patients, 996 (10%) transitioned to CMO during the hospitalization: 10.8% (807/7,475) white, 5.7% (92/1,609) black and 11.7% (97/829) other. The figure shows the overall temporal trend in the rates of CMO, stratified by Black versus White race. CMO patients were significantly older, more often female and White, while less often Black, and had higher rates of CAD/MI, atrial fibrillation and heart failure. CMO patients had higher NIHSS and more often presented with weakness, altered level of consciousness and language problems. CMO patient had higher rates of reperfusion therapies and higher rates of in-hospital complications. On MV analysis, Black race was associated with lower odds of CMO use (OR 0.51 (95% CI 0.35, 0.73, p<0.001).

Conclusion: Black patients were less likely to transition to CMO care after stroke. While this difference declined over time, it suggests an influence of race in end of life decision-making. Further research is needed to understand the factors that contribute to differences in utilization of CMO care.

Abstract TP378: Elevated Creatinine at Presentation is Associated With Higher In-Hospital Mortality Among Acute Ischemic Stroke Patients

Introduction: Impaired renal function is an established predictor of survival in the general population, and in patients with myocardial infarction or heart failure. Recent evidence suggests that reduced kidney function may predict mortality after acute ischemic stroke (AIS). We sought to evaluate if elevated creatinine (Cr >1.5mg/dL) at presentation is associated with higher in-hospital mortality in AIS patients.

Methods: Using GWTG stroke registry data from three large comprehensive stroke centers in Northeast, South and West, we analyzed 9,472 consecutive stroke admissions from 02/2002 - 06/2018 with documented Cr. Patient were divided into Group 1: normal renal function (Cr ≤1.5) and Group 2: elevated Creatinine (>1.5). Chi-square was used for categorial data, T-Test for parametric continuous and Wilcoxon for non-parametric continuous variables. Multiple regression analysis was used to identify associations.

Results: Of the 9,472 AIS patients, 977 (10.3%) had baseline Cr > 1.5. Patients with elevated Cr were older, more often male, less often White and had higher frequency of hypertension, diabetes, hyperlipidemia, CAD/MI, heart failure and atrial fibrillation, and had increased pneumonia during the incident admission. They had higher NIHSS at presentation and underwent IV tPA +- endovascular therapy more often than patients with Cr ≤ 1.5. The in-patient mortality was twice as high in Group 2 than Group 1 (OR 1.17 per 1.0 mg/dL increase in Cr (95% CI 1.10, 1.30; p<0.001)). Renal impairment (Cr > 1.5) remained a strong predictor for mortality in multivariable regression (OR 1.91 (95% CI 1.47, 2.48; p<0.001)).

Conclusion: Patients with elevated Cr at presentation were found to have higher in-hospital mortality, suggesting an independent association between renal function and mortality after AIS. Further research is warranted, especially since many of these patients are exposed to nephrotoxic contrast agents.

Abstract TP270: When Telestroke Programs Work, Bed Size Really Doesn’t Matter

Background: Telestroke rural networks are comprised of micro>small>medium>large sized hospitals without specialized neurology support. Many times the micro hospitals are < 25 beds. In an examination of spoke hospitals in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program, we determined program efficacy correlating bed number. Efficacy was determined by the mean Door-to-ED physician (D2MD) time and door-to-needle (D2N) Alteplase time, and numbers of Alteplase administrations (#Alteplase), mock scenario sessions (#Mocks) and consults (#Consults).

Hypothesis: All hospitals would perform equally well with the larger hospitals with slight tendencies to outperform the smaller hospital sites in the #Consults and #Alteplase.

Methods: We retrospectively reviewed 2015-2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The #Mocks and #beds were comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase. Spoke sites were categorized by bed numbers; 0-25, 26-50, 51-100, 101-150, 151-200 and > 200.

Results: Data from 53 spokes encompassing 2,555 consults over three years indicated that sites > 151 beds were significantly higher in #Alteplase (p < 0.01) and #Consults (p < 0.002). Although the #Mocks were not different among the smaller vs. larger hospitals (p > 0.19), nor was the D2MD time (p=0.82). However, the hospitals < 50 beds had significantly shorter D2N mean time (p < 0.03). The micro (0-25 beds) vs the largest hospitals ( > 200 beds) D2N mean times, were significantly less (76.0±2.5 vs 87.5±4.0 min, p=0.01, respectively).

Conclusions: Although the smaller hospitals receive less volume of consults and #Alteplase, with training they perform equally if not better than their larger counterparts.

Abstract 169: Rural Hospitals in Telestroke: How Effective are On-Site Mock Drills and Community Education on Stroke Awareness?

Background: Mock drills of stroke triage care is an essential training component of most telestroke programs. Another potential component for telestroke programs is community stroke awareness education. While stroke-mocks improve the timeliness and care in rural spoke emergency departments (ED), community stroke awareness education may also improve treatment. Mocks and community education information was evaluated in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program. Correlations were made with mean Door to ED physician (D2MD) time and door-to-needle (D2N) Alteplase time and administration numbers (#Alteplase) and consult numbers (#Consults).

Hypothesis: Total number of mocks (#Mocks) and community education events (#Community-events) will independently increase #Consults and #Alteplase, and improve the D2MD and D2N time.

Methods: We retrospectively reviewed 2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The total number of #Mocks, #Community-Events was comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase.

Results: Data from 51 spoke sites and 1,002 consults, indicated #Mocks were positively correlated to the D2MD time (R=0.31; p=0.03) and the #Alteplase (R=0.28; p=0.04); however, increasing the #Mock sessions did not influence the D2N time or the #Consults (p=NS). Community-Events were significantly associated with #Consults (R=0.48; p=0.0004) and #Alteplase (R=0.47; p=0.0006); however not to D2MD time or D2N time (p=NS).

Conclusions: Mocks and Community stroke awareness education played crucial roles in the AR SAVES program improving #Consults and #Alteplase administrations. Both education components are warranted for telestroke programs.

A Pilot Study Validating Video-Based Training on Pre-Hospital Stroke Recognition

INTRODUCTION

Delays in recognizing stroke during pre-hospital emergency medical system (EMS) care may affect triage and transport time to an appropriate stroke ready hospital and may preclude patients from receiving time dependent treatment. All EMS transports in a large urban area in the stroke belt were evaluated for transport destinations, triage and transport time and stroke recognition following distribution ofan educational training video to local EMS services.

HYPOTHESIS

Following video training, local paramedics will improve stroke recognition and shorten triage and transport time to appropriate stroke centers of care.

METHODS

A training module (<10 min) containing a stroke triage scenario, instruction on the Cincinnati Prehospital Stroke Score (CPSS) and the Los Angeles Prehospital Stroke Score (LAPSS) and 'where to transport' stroke patients was distributed and viewed by 96 paramedics. Data was collected from February to October 2016. Stroke recognition was determined from one primary stroke center (PSC) hospital's confirmation of EMS delivered patients (Site A). Yearly stroke recognition percentages of 44% from Site A in 2014 were used as baseline.

RESULTS

A total of 34,833 emergency 911 response transports were made with a total of 502 (1.4%) suspected strokes identified by paramedics. Median [IQR] triage and transport time for stroke transports was 33 [27-41] min. The PSC hospitals received a 5% increase in stroke transports and non-specific care facilities decreased by 7%. From 8,554 transports to site A (PSC) confirmed strokes totalled 107 transports with 139 suspected strokes by paramedics. Of these transports, 60 were correctly identified by paramedics (positive predictive value of 43%, sensitivity of 56%). By the second month following training, recognition percentages increased from baseline to 64%. At five months, percentages of correct stroke identification had dropped to 36%.

CONCLUSION

Video based training improved stroke recognition by an additional 19%, but continual monthly or quarterly training is recommended for maintenance of increased stroke recognition.

Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt

Background

Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time.

Methods

We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN).

Results

The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients.

Conclusions

Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.

Abstract TP233: An Analysis of Thrombolysis in a Large Telestroke Program in the Stroke Belt

Background: Thrombolytic treatment of stroke patients in telestroke can be enhanced by studying critical time interval requirements. We retrospectively examined 12 concurrent months of targeted time interval information from 2016 in a large 48 site telemedicine program. Telemedicine programs with new spoke sites added throughout the year must continually evaluate where improvements can be made to decrease the arrival to treatment time.

Hypothesis: We hypothesized that referral data analysis would highlight areas for improvement to shorten time to treatment.

Methods: We analyzed critical time targeted information during 12 months of 247 consecutive telestroke neurology referrals from AR SAVES spoke sites when tissue plasminogen activator (tPA) was given. Measured time intervals of: emergency department (ED) door to CT (ED2CT), ED door to call center (ED2CC) for initiation of consult and ED door to neurology call (ED2NeuroCall), neurology call to camera (NeuroCall2Cam), total consult (Con), ED door to tPA (ED2tPA) were studied.

Results: Reported median times of door to CT [ED2CT, 8 min, IQR 4-15 min], door to call center [ED2CC, 37 min, IQR 26-53 min], door to neurology call time [ED2NeuroCall, 42 min, IQR 33-57 min], neurology call response time [NeuroCall2Cam, 3 min, IQR 2-5 min], and total time spent in consult [Con, 24 min, IQR 19-32 min] all contributed to a ED2tPA median time of 73 min [IQR 60-90]. Twenty-six percent of referral patients received tPA ≤ 60 min and an overall tPA treatment rate of 33.2% was reported. The largest delay in time were: arrival to neurology call time and in consult time, 27 minutes and 13 minutes respectively. Totaling 40 minutes in variation.

Conclusion: Focus in either ED2NeuroCall or Con of these time areas, may produce the largest improvements and reduce the door to treatment time. A 20 minute reduction in time would dramatically reduce the door to treatment time and increase the percentage of tPA administration to well within the goal of 60 minutes or less.

Abstract WP149: Women on Hrt With Ischemic Stroke, a Positive Effect on Deficits and Recovery?

Background: Hormone replacement therapy (HRT) for post-menopausal women is associated with increased incidence of ischemic stroke risk. Effects of HRT on stroke related deficits and functional outcomes in acute ischemic stroke (AIS) are uncertain. We retrospectively examined female consult data for HRT use and National Institutes of Health Stroke Score (NIHSS) at baseline and recovery for 2015 and 2016 in a large stroke telemedicine program.

Hypothesis: The age of women on HRT will affect stroke severity and outcomes.

Methods: We analyzed consult data from two consecutive years for women HRT use, age, and baseline and 24 hour NIHSS’s. We included all treated with IV Activase.

Results: In two years 235 women received Activase therapy. Women without HRT use numbered 208 and 27 women listed HRT use. All 235 consults regardless of HRT use had significantly improved 24 h NIHSS vs. baseline (7.5 +/- 0.5 vs. 11.2 +/- 0.5, p<0.0001). Women on HRT had significantly improved 24 h NIHSS vs. baseline, (4.9 +/- 1.6 vs. 8.4 +/- 1.2, p=0.0084). Composite NIHSS’s at 24 h for ‘No HRT’ was not different from ‘Yes HRT’ (7.8 +/- 0.6 vs. 4.9 +/- 1.6, p=0.084) when groups included all women regardless of age. The baseline NIHSS’s when divided into specific age ranges showed decreased values when on HRT from 50s through 70s ( figure A ) p=0.028. Women placed in decade age ranges showed that 24 h NIHSS’s (40-80 years) with HRT use were lower vs. women >80 years ( figure B ). p=0.084.

Conclusion: While controversy persists on the use, route and dosage of HRT for risks of ischemic stroke, positive HRT benefits could include moderation of AIS deficits and improved outcomes in women <80 years of age. Further study is needed.

Abstract WP233: A Pilot Study Validating Video-based Training on Pre-hospital Stroke Recognition

Introduction: Delays in recognizing stroke during pre-hospital emergency medical system (EMS) care may affect triage+transport time to appropriate stroke ready hospitals and may preclude patients from receiving time dependent treatment. All EMS transports in a large urban area in the stroke belt were evaluated for transport destinations, triage+transport time and stroke recognition following distribution of an educational training video to local EMS services.

Hypothesis: Following video training local paramedics will improve stroke recognition, shorten triage+transport time, and increase stroke transports to primary stroke centers (PSC) of care.

Methods: A training module (<10 min) containing a stroke scene scenario, instruction on the Cincinnati Prehospital Stroke Score (CPSS) and the Los Angeles Prehospital Stroke Score (LAPSS) and ‘where to transport’ stroke patients was distributed and viewed by 94 paramedics. Data was collected from February to October 2016. Stroke recognition was determined from one PSC hospital’s confirmation of EMS delivered patients (site A). Stroke recognition percentages from site A collected in 2014 were used as baseline.

Results: A total of 35,207 emergency 911 response transports were made with a total of 506 (1.4%) paramedic identified strokes. Average triage+transport time for stroke transports was 33 +/- 0.7 minutes. The PSC hospitals received a 5% increase in stroke transports and the non-specific care facilities decreased by 7%. The PSC stroke confirmation totaled 130 transports with 140 suspected strokes by paramedics and 71 of 130 confirmed strokes correctly identified by paramedics (positive predictive value of 50.7%, sensitivity of 54.6%). By the third month following training, recognition percentages increased from 54% at baseline to 73%. At five months, percentages of correct stroke identification had dropped to pre-training levels.

Conclusion: The training improved stroke recognition by an additional 19% with follow-up training recommended at five months.

Abstract TMP60: Validation of an Education Gauge for Measuring Stroke Outreach Efforts

Background: To improve rural population access to telestroke sites for referral and treatment, hospitals are required to fulfill monthly educational outreach. Telehealth sites that provide stroke outreach through awareness educational campaigns remain unaware of the efficacy of their outreach efforts. This study sought to apply a measurable scale to their outreach efforts and determine if the values correlated to the sites referral and treatment rates.

Hypothesis: Measurable differences of outreach efforts in rural populations positively correlate to referral and treatment rates at telestroke hospital sites.

Methods: A large telestroke network (n=48 spoke sites) had 12 consecutive months during 2016 of community outreach efforts evaluated on an educational gauge scale. Events were categorized as active or passive depending on the type of event. All events were assigned a value based on the type of event, audience size and the crowd’s level of attention/participation. Total monthly values for all spoke sites were calculated and compared by month and category. Regression analysis was used to determine significance of correlative analysis of education vs. number of referrals and vs. number of tissue plasminogen activase (tPA) treatments.

Results: Outreach efforts promoting stroke awareness from all 48 sites totaled 2,625 educational points. There was a temporal trend of active events occurring in the spring (April through June) and in the fall (October). In regression analysis there was a positive correlation in the number of referrals vs. educational gauge (R=0.23; P=0.0013) and in the number of tPA treatments (R=0.20; P=0.0055). One spoke site was evaluated for their community events due to their high referral rate in the first quarter of the year. Outreach efforts during these months included stroke awareness events at local high schools, a sporting race event and to apartment residents.

Conclusion: Targeted outreach efforts can now be measured for efficacy of reaching diverse populations with direct effects on referral and treatment rates.

Abstract 226: Strokes Worse in Women at 24 hours but Severity Reduced in Younger Women With Hormone Therapy

Background: Gender related differences in stroke incidence hallmark the increased observation of women experiencing strokes later in life. Complications of women longevity has accounted for their increased risk of cardiovascular and cerebrovascular diseases. However, the severity of acute ischemic stroke (AIS) outcomes in women remains problematic. Previous studies have reported that women experience more disabilities and have poorer outcomes at three month follow-ups and may be related back to age at the time of stroke. We retrospectively examined 12 months of neurology consults in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telemedicine program.

Objective: To investigate whether gender influenced recovery at 24 hours following therapy for AIS.

Methods: During 12 consecutive months 809 patients received neurology acute stroke consults and 238 (29%) received tissue plasminogen activator (tPA). Outcome data at 24 hours was available on 216 tPA-consults. Patient demographics, age, and gender, were analyzed along with baseline and 24 hour outcome National Institutes of Health Stroke Scale (NIHSS), onset to tPA, smoking, alcoholism, and hormone replacement therapy (HRT). Co-morbidity information collected included previous transient ischemic attacks (TIA), atrial fib (AF), diabetes, chronic obstructive pulmonary disease (COPD), hypertension (HT), hyperglycemia and coronary artery disease (CAD).

Results: A total of 108 men and 108 women tPA treated patients showed no significant differences in age for male vs. female (mean±se 67.5±1.3 vs. 70±1.5, p=0.79). However, the men had twice the number of women in the 70-79 age range and women had twice the number of men at >80 years of age ( χ 2 p=0.0096 for all age ranges for both sexes). While baseline NIHSS was not significant in men vs. women (10.8±0.6 and 11.8±0.7, p=0.32, respectively), the women’s 24 hour NIHSS was significantly greater (5.9±0.7 vs. 9.1±0.9, p=0.0047, respectively). The incidence of HRT use in n=11 women < 80 years of age was associated with lower NIHSS’s at 24 hours vs. women without HRT (2.3±0.8 vs. 8.7±1.4, p=0.03, respectively). Males had a higher incidence of smoking ( χ 2 p=0.007). All other co-morbidities occurred equally between sexes.

Conclusion: Women in this study had more severe 24 hour AIS outcomes than men but this improved with HRT use in women younger than 80 years. This cannot be fully explained by age differences as there could be other underlying factors. Improving 24 hour NIHSS may correctly predict later outcomes following AIS. Further study of HRT use in AIS outcomes is justified.

Abstract WP362: Trends and Outcomes of Intracranial Hemorrhage in HIV Positive Population (2002-2012)

Background: The incidence of Intracranial Hemorrhage (ICrH) in HIV patients is on the rise in the United States, especially after the development of newer antiretroviral drugs. This study determines the trends of ICrH in HIV patients in the United States.

Design/Methods: Data from the Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project (HCUP) were analyzed for years 2002-2012.Hospitalizations with HIV positive status were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 042, V08 and ICrH by 430.xx-432.xx. Cochrane Armitage trend test and multivariate regression were used to analyze temporal trends and the potential reasons for temporal changes over the years.

Results: A total of 2,584,548 hospitalizations with HIV status were made from 2002 to 2012. Of these, 10,292 (0.40%) admissions were due to ICrH or developed ICrH during hospitalization. Concurrent trend of ICrH and HIV increased from 0.34% to 0.45% in 2012 (p trend <0.001). This trend increased annually by 3.5% (OR 1.035; 95% CI 1.01-1.05;p<0.001). The temporal rise was explained by changes in demographics and co-morbidities. Amongst HIV-related hospitalizations, Age (10 year increase) (OR 1.23; 95% CI 1.09-1.43; p<0.001), African-American race (OR 1.25; 95% CI 1.09-1.43; p<0.001), Hispanic race (OR 1.29; 95% CI 1.07-1.55; p<0.001) and history of Hypertension (OR 1.97; 95% CI 1.76-2.22; p<0.001) were significantly associated with the development of ICrH, However females had lower odds of developing ICrH(OR 0.80; 95% CI 0.71-089; p<0.001).

Conclusions: These data suggest that the incidence of ICrH among hospitalized adults with HIV infection continue to increase. This increasing ICrH was explained by an aging HIV population, changing demographics and chronic comorbidities, but questions still remain regarding unexplained factors which merit in-depth study.

Abstract TP241: Concordance of Pre-hospital Stroke Recognition by Medical Dispatchers and Paramedics in an Urban County

Background: Immediately after a stroke, the time it takes to reach a designated stroke center can determine the patient’s chances of recovery or permanent disability. In pre-hospital care, the first level of care occurs when 911 is called, second when the paramedics arrive and triage, and third, transport to the nearest primary stroke center (PSC). When emergency medical dispatchers (EMD) initially recognize stroke they provide critical stroke triage codes guiding the paramedic’s decision in appropriate hospital choice, saving time and improving patient recovery. This study assessed EMD and paramedic stroke recognition and performance in an urban area.

Hypothesis: EMD recognition of stroke would provide paramedics adequate codes for correct recognition and influence transports to area primary stroke centers (PSCs).

Methods: All emergency medical service (EMS) transports in an urban county area (392,664 population) during 2014 were retrospectively analyzed. The transports encompassed True/Negatives, False/Positives, False/Negatives and True/Positives for data on the number and percentages of EMS correctly identified stroke ground transport 911 calls. Dispatch impressions of calls were compared to paramedic decisions and confirmed by hospital ICD-9-CM billing codes 430-438. Transports to area PSC and non-PSC hospitals were determined.

Results: Over 12 months, in N=40,171 total transports, EMDs impression of strokes were n=942 with 51.3% confirmed as strokes by paramedics. The other 47.6% of calls reported as strokes by EMDs were coded by paramedics as syncope/fainting, altered level of consciousness, abdominal pain, diabetic, behavioral, cardiac rhythm disturbance and seizures. Paramedic reported strokes were coded by dispatchers as 52.0% strokes/CVA or as headaches, sick person, unconscious/fainting, fall victim, chest pain, convulsions/seizures and breathing problems. Significantly more stroke-related deliveries were made to PSCs (55%, p<0.001) than other area facilities. Hospital confirmation by discharge data services of paramedic coded strokes provided a true positive predictive value of 44.8% and sensitivity of 25%.

Conclusion: EMS dispatch and paramedic services could benefit from stroke recognition education.