Abstract TP81: Healthcare Disparities For Thrombolysis In Patients Presenting With Stroke-like Symptoms At A Comprehensive Stroke Center

Background: Stroke is a leading cause of death and disability. Early presentation allows clinicians to use tPA for acute stroke therapy to improve outcomes. However, healthcare disparities among different racial/ethnic and gender groups remain a limitation for uniform access to acute stroke therapy. We investigated if such gender and racial disparity exist in tPA administration at a large community comprehensive stroke center (CSC).

Methods: Retrospective analysis of a prospective cohort of patients was conducted of patient with acute stroke symptoms who presented to a CSC between May 2018 and May 2022. Demographics, time from last known normal (LKN), rate of tPA administration and door to needle time (DTN) was calculated. Univariate analysis between groups was performed using one-way ANOVA for mean, Kruskal-Wallis test for median and p-value <0.05 was considered significant.

Results: Total number of patients presenting to our CSC during the study period with stroke like symptoms was 3901. Of this index cohort, 401 (10.2%) were administered tPA - 207 (51.6%) women and 194 (48.3%) men. Women were significantly older [67.5 ± 15.1 years compared to men, 62.6 ± 13.3 years (p=0.027)]. Average time of LKN to arrival was 124 ± 3.8 min for women and 130 ± 4.9 min for men (p=0.298). Black women’s DTN was longer compared to white women ( 50.9 ± 3.15 min v. 41.5 ± 2.07 min, p=0. 0103). However, proportion of Black women receiving tPA did not differ from white women [87/770 (11.3%) v. 113/1041 (10.9%), p=0.824]. Race disparity was noted among Black men compared to white men for tPA administration [64/798 (8.0%) v 119/1226 (9.7%), p=0.018]. No gender or racial disparity was noted among tPA recipients regarding mRS at discharge [white men v. white women v. Black men v. Black women - 2 (IQR 1,4) v. 3 (IQR 1,4) v. 3 (IQR 1,4) v. 3 (IQR 1,4), p=0.211].

Conclusions: At a large volume, urban, non-academic comprehensive stroke center, overall gender, or racial factors were similar for discharge outcome. However, a delay in tPA administration among Black women and lower incidence of tPA administration in Black men compared to their respective white counterparts need to be validated in larger registries.

Sex differences in endovascular thrombectomy outcomes in large vessel occlusion: a propensity-matched analysis from the SELECT study

BACKGROUND

Sex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women.

OBJECTIVE

To compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women.

METHODS

From the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016-2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measures, mixed-effects regression model.

RESULTS

Of 285 patients, 139 (48.8%) were women. Women were older with median (IQR) age 69 (57-81) years vs 64.5 (56-75), p=0.044, had smaller median perfusion deficits (Tmax >6 s) 109 vs 154 mL (p<0.001), and had better collaterals on CT angiography and CT perfusion but similar ischemic core size (relative cerebral blood flow <30%: 7.6 (0-25.2) vs 11.4 (0-38) mL, p=0.22). In 65 propensity-matched pairs, despite similar discharge functional independence rates (women: 42% vs men: 48%, aOR=0.55, 95% CI 0.18 to 1.69, p=0.30), women exhibited worse 90-day functional independence rates (women: 46% vs men: 60%, aOR=0.41, 95% CI 0.16 to 1.00, p=0.05). The reduction in mRS scores from discharge to 90 days also demonstrated a significantly larger improvement in men (discharge 2.49 and 90 days 1.88, improvement 0.61) than in women (discharge 2.52 and 90 days 2.44, improvement 0.08, p=0.036).

CONCLUSION

In a propensity-matched cohort from the SELECT study, women had similar discharge outcomes as men following EVT, but the improvement from discharge to 90 days was significantly worse in women, suggesting the influence of post-discharge factors. Further exploration of this phenomenon to identify target interventions is warranted.

TRIAL REGISTRATION NUMBER

NCT02446587.

Abstract TP46: Rates Of Symptomatic Intracerebral Hemorrhage After Tpa At Rural Telemedicine Spoke And Hub Sites

Introduction: Symptomatic intracerebral hemorrhage (sICH) is the primary bad outcome monitored post-alteplase (tPA) administration for treatment of acute ischemic stroke (AIS). Risk of sICH ranges from 2-7% based on patient population. However, little is reported on sICH with the use of telestroke, particularly in the rural setting. We evaluated rates of sICH after tPA administration for our telestroke process in a rural Texas spoke-hub system.

Methods: Patient data was prospectively collected from 6/2018 (start of telestroke system) to 5/2021, including age, sex, race/ethnicity, tPA administration, door-to-needle times and sICH. Patients were included if >18 years old and underwent tPA administration at the hub or telemedicine spoke site in a rural Texas healthcare system. Six spokes and one hub were included in this study. Documented sICH was retrospectively abstracted from the database with the primary outcome comparing sICH rate between the hub and spokes. Statistical analysis was conducted by chi-square analysis.

Results: A total of 160 patients received tPA at the hub and 239 at the spokes. Four patients suffered sICH at the hub and five at spokes (2.5% v 2.1%, p=0.793). Rates of tPA administration were not significantly different. Demographic comparison between spoke and hub were significantly different. Notably, there was a higher proportion of male and non-white patients at the hub compared to spoke sites, adding to the variation in populations. Patients were older at spoke sites.

Conclusion: There was no difference in rates of tPA administration and rate of sICH between hub and spokes in a rural Texas telemedicine program. Rate of sICH in this setting was similar to rate reported in the literature. Furthermore, though there was a statistically significant difference between the populations studied, the likelihood of sICH remained similar. These findings further support the safety of telemedicine use for acute stroke care and tPA administration.

Abstract NS9: Two Level Stroke Activation: Fine Tuning Stroke Criteria

Background: The burden of acute stroke alerts on hospital resources and staff have grown with expanding treatment timelines. The purpose of this project is to develop a nurse activated acute stroke process to accurately capture ischemic and hemorrhage stroke amendable for acute treatment with a two level activation model for 0-4 hours (level 1) and 4-24 hours (level 2) from last known well.

Methods: Prospective quality improvement data abstracted on patients in a five-hospital regional telestroke network from October 2020 thru June 2021 with the current single level 24-hour stroke symptom protocol. We retrospectively applied our proposed two level activation model to our data to look for accuracy in stroke diagnosis, proportion of stroke mimics, missed stroke interventions, including intracerebral hemorrhage (ICH), and telestroke provider time spent. We used standard error of mean (SEM) to measure discrepancy of process.

Results: A total of 340 stroke activation were captured. Of those, 54% (183/340) were discharged without a stroke diagnosis, 27% (93/340) ischemic, 14% (48/340) transient ischemic attack, 4% (13/340) ICH, 1% (3/340) subarachnoid hemorrhage, and 34% (117/340) arrived in the level 2 window. We excluded 5 ICH patients due to arriving comatose necessitating emergent imaging outside of stroke alert process. Comparing single activation versus two level activation resulted in a reduction of stroke alerts (117 versus 21), telestroke provider time (2501 minutes versus 713 minutes), increase in accurate stroke diagnosis (46% versus 76%), decrease in stroke mimics (54% versus 29%), with 1 missed ICH and 1 missed thrombectomy (5%). The single activation showed a mean 11.11% and SEM of 0.023 compared to the two level activation mean 1.99% and SEM of 0.006.

Conclusion: Two level stroke activation process was validated to reduce stroke mimics, improve accurate stroke diagnoses, maximize resources utilization, and capture 95% of all ischemic strokes with large vessel occlusions, therefore the new process will be implemented within our large telestroke system following staff education.

Abstract P559: Sex Differences in Clinical Outcomes After Endovascular Thrombectomy for Large Vessel Occlusion Stroke: A Sub-Analysis of the SELECT Study

Background: Women have been shown to have greater disability than men after acute ischemic stroke (AIS) treated by thrombolysis. Whether endovascular thrombectomy (EVT) outcomes differ by sex with AIS from large vessel occlusion (LVO) is controversial. We compared sex differences in EVT outcomes and assessed relationship to post-discharge improvement.

Methods: In SELECT prospective cohort, EVT treated anterior circulation LVOs (ICA, MCA M1/M2) ≤24 hrs from LKW were stratified by sex. Discharge, 90-day mRS were compared in all patients and a propensity matched cohort. We evaluated mRS improvement (discharge to 90-day) using repeated measure mixed regression with linear approximation of mRS.

Results: Of 285 patients, 139 (48.8%) were women, and older (mean IQR 69 years (57,81) vs 65 (56,75), p=0.04) with similar NIHSS (17 (11,22) vs 16 (12,20), p=0.44). Women had smaller perfusion lesion 109 (66,151) vs 154 (104,198) cc, p<0.001) and better collaterals on CTA/CTP but similar ischemic core size 8 (0,25) vs 11 (0,38) cc, p=0.22. Discharge functional independence rates, mean (IQR) mRS were similar (women 39% vs men 46%, p=0.14, and mRS: 3 vs 3, p=0.43). 90-day mRS 0-2 did not differ between women and men (50% vs 55%, aOR 0.77, 95% CI 0.39-1.50, p=0.39) and mean (IQR) mRS: 2 (1,4) vs 2 (0,4). Larger predicted mRS score improvement trend seen in men (2.62 vs 2.21, reduction 0.41) than women (2.65 vs 2.46, reduction: 0.19, p=0.21), Fig 2A. In propensity matched 65 pairs, women exhibited worse 90-day mRS 0-2 (46% vs 60%, aOR 0.41, 95% CI 0.16-1.00, p=0.05). mRS improvement from discharge to 90-day was significantly larger in men (2.49 vs 1.88, reduction 0.61 vs women 2.52 vs 2.44, reduction 0.08, p=0.04), despite similar discharge disposition Fig 2B.

Conclusion: Women had similar discharge outcomes as men following EVT, but improvement at 90 days was significantly worse in women. Further exploration of the influence of post-discharge factors to identify target interventions is warranted.

Abstract P178: Rapid Improvement in Timely tPA Administration With Initiation of Telestroke in a Predominantly Rural Catchment Area

Introduction: In acute ischemic stroke (AIS) treatment, reduction in tPA Door-To-Needle time (DTN) by 15 minutes improves functional outcomes. Telestroke has demonstrated timely tPA administration over several years of implementation. However, telestroke care in the rural setting is less well characterized, and many telestroke studies have only shown improvement in DTN over longer periods. We evaluated reduction in DTN over a 6 month period after implementing an internal telestroke process in a rural spoke-hub model in central Texas.

Methods: Data was abstracted from local databases from 6 months before and 6 months after initiation of telestroke at each center over years 2017-2019. Patients who presented to the emergency room at 1 of 5 spokes in central Texas with AIS symptoms were included, 393 pre-telestroke and 362 post. Patients who did not receive tPA were excluded. Patients with documented delay such as initial tPA refusal, further imaging or management of acute comorbidities were also excluded, leaving 80 cases, 33 pre-telestroke and 47 post. Chi-square analyses for changes in DTN were used. T-test analysis was used for continuous variables. Primary outcome assessed reduction in DTN with secondary outcome of number of tPA administrations.

Results: Total stroke volume did not increase over the study period [average per site pre-telestroke 78.6 (SD 58.1) and post-telestroke 72.4 (SD 45.7)] ( t (4)=0.91, p =0.42). Attainment of <45 minute DTN improved from 18.2% pre- to 48.9% post-telestroke ( p = 0.01), and <60 minute DTN improved from 36.3% to 80.1% ( p <0.0001). Total tPA volume at each site increased over the period, with a moderate effect size though not statistically significant (average per site of 6.6 administrations pre-telestroke to 9.4 post-telestroke, t (4)=-1.72, p =0.16, d=-0 .77)

Conclusions: Telestroke within a rural catchment area in central Texas resulted in significant reduction in DTN within 6 months of implementation. This study showed that successful telestroke processes can be implemented in a relatively short time period even in the rural setting. Further investigation of telestroke at rural stroke centers is needed to improve access and quality of care.

Endovascular Thrombectomy for Acute Ischemic Strokes: Current US Access Paradigms and Optimization Methodology

Background and Purpose- Timely access to endovascular thrombectomy (EVT) centers is vital for best acute ischemic stroke outcomes. Methods- US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. Direct EVT-access, defined as the population with the closest facility being an EVT-center, was calculated from validated trauma-models adapted for stroke. Current 15- and 30-minute access were described nationwide and at state-level with emphasis on 4 states (TX, NY, CA, IL). Two optimization models were utilized. Model-A used a greedy algorithm to capture the largest population with direct access when flipping 10% and 20% non-EVT to EVT-centers to maximize access. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center. Results- Of 1941 stroke-centers, 713 (37%) were EVT. Approximately 61 million (19.8%) Americans have direct EVT access within 15 minutes while 95 million (30.9%) within 30 minutes. There were 65 (43%) EVT centers in TX with 22% of the population currently within 15-minute access. Flipping 10% hospitals with top population density improved access to 30.8%, while bypassing resulted in 45.5% having direct access to EVT centers. Similar results were found in NY (current, 20.9%; flipping, 34.7%; bypassing, 50.4%), CA (current, 25.5%; flipping, 37.3%; bypassing, 53.9%), and IL (current, 15.3%; flipping, 21.9%; bypassing, 34.6%). Nationwide, the current direct access within 15 minutes of 19.8% increased by 7.5% by flipping the top 10% non-EVT to EVT-capable in all states. Bypassing non-EVT centers by 15 minutes resulted in a 16.7% gain in coverage. Conclusions- EVT-access within 15 minutes is limited to less than one-fifth of the US population. Optimization methodologies that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT-access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT-access.

Abstract WMP86: Persistent Gender and Racial Disparities Among Neurology Residents and Vascular Neurology Fellows Over the Past 10 Years

Introduction: Women and minorities are underrepresented in academic medicine. There is little in the literature about gender and racial disparities among neurology or vascular neurology trainees. At the International Stroke Conference, women overall and women physicians have been underrepresented as invited speakers and abstract first authors, and there is recent momentum for improvement.

Methods: Data were collected from the Accreditation Council for Graduate Medical Education public website. Dataset included neurology resident and vascular neurology fellow gender data from 2007 to 2017 and race data from 2011 to 2017. Data were analyzed by chi-square test and one-sample proportion test.

Results: From 2007-2017, women represented 45% of all neurology trainees and only 33% of all vascular neurology fellows, both significantly lower than 50% (p<0.0001). There was no trend in the proportion of gender by year for vascular fellows (p=0.11) or neurology trainees (p=0.39). However, each year, except for 2012-2013 and 2015-2016 for vascular fellows, varied significantly by gender where men represented the largest proportion. Race varied by year for vascular fellows (p=0.03) and neurology trainees (p=0.017). Blacks and Hispanics represented the lowest proportions and Whites represented the highest proportion of both vascular and neurology trainees. When comparing Whites vs Non-Whites for both fellows (43% vs 57%; p=0.76) and residents (50% vs 50%; p=0.14), there was no trend in the proportions by year.

Conclusions: Women, Black and Hispanic physicians remain underrepresented as vascular neurology trainees. The low representation of women and underrepresented minorities has not changed in the last decade. Addressing gender and racial disparities among trainees should be a high national priority for future medical and scientific contributions from these groups.

Abstract 163: Recognizing Sex Disparities Among Invited Speakers at the International Stroke Conference Motivates Change

Introduction: Females were significantly underrepresented as invited speakers at the International Stroke Conference (ISC) from 2014-2018. In 2019, there were increased efforts by the ISC program committee to recruit female speakers. Other efforts to increase female participation at the 2019 ISC included a session for women’s issues in stroke and a women’s luncheon.

Methods: ISC invited speaker data were obtained (years 2014-2019) from the American Heart Association. Variables included sex, degree, race, speaker institution country, session type and category. Data were analyzed by Chi-square test, Fisher’s exact test or logistic regression models.

Results: From 2014-2018, females represented 28% of ISC invited speakers, and in 2019 the proportion of females rose to 47%. Females represented 38% of physician speakers in 2019 as compared to 18% from 2014-2018. For Black speakers, in 2019 females represented the majority (64%), increased from 2014-2018 (17%). For Hispanic speakers, females remained one of the lowest proportions, but with an increase from 12% to 39%. Females represented the highest and lowest proportion of speakers from South America (100%) and Africa (0%) and the largest in invited symposium (48%), similar to 2014-2018. The odds of being invited for debate as a female increased in 2019 (OR 0.67 vs 0.37, p=0.36), but this did not reach significance. Females represented the largest proportion of speakers in recovery and rehabilitation (52%) in 2019, similar to 2014-2018. Females had higher odds of being invited as a speaker in the acute, in-hospital care category (OR 0.83 vs 0.53, p=0.22), but this did not reach significance. Females were more often invited as speakers more than once in 2019 (OR 0.94 vs 0.61, p=0.29).

Conclusions: There is potential to increase female participation at major scientific conferences through initiatives by the program committee. Identifying gender disparities at a major conference like the ISC may help to close the gender gap.

Abstract WP363: Females are Significantly Less Likely to be Invited as Speakers to the International Stroke Conference: Time’s Up to Address Sex Disparity

Introduction: Females are underrepresented as speakers at major scientific conferences. Furthermore, in neurology, males outnumber females in academic positions, rank and number of publications, which may influence this inequality.

Objective: To evaluate trends in invited speakers by sex at the International Stroke Conference (ISC).

Methods: Data were obtained (years 2014-2018) for invited speakers to the ISC from the American Heart Association. Variables included sex, degree, race, speaker institution country, and speaker category. Data were analyzed by chi-square test, Fisher’s exact test, or logistic regression.

Results: Over 5 years, 1086 individuals with 1283 presentations were invited for invited symposia (83%), pre-conference (11%), debate (5%), and case theater (1%). Females represented a mean of 29% of speakers, which did not vary by year (p=0.99), so years were combined. The highest and lowest proportions of females were in invited symposia (30.4%) and case theater (5.6%). All mid-levels and nurses, but only 17.7% of physician speakers were female. Females were 32.7% of Caucasian speakers and only 16.7% and 12.0% of Black and Hispanic speakers, respectively. The highest and lowest proportions of female speakers were from institutions in South America (50%) and Africa (0%). The proportion of female speakers was highest in nursing (86.4%) and pediatric stroke (45.2%) and lowest in neurocritical care and aneurysm (0%). Grouped, the highest proportion of female speakers was in recovery and rehabilitation (33.5%), and the lowest was in acute care (19%). Males were more likely invited as speakers more than once (p=0.01).

Conclusions: Females are less likely invited speakers to the ISC compared to males, especially in fields like critical care, with a smaller female pool. Moreover, females in underrepresented racial groups and female physicians are less often speakers. Increased efforts are warranted to improve sex differences among speakers at the ISC.

Abstract TP349: Submitted and Accepted Abstracts by Sex at the International Stroke Conference: Analysis of Trends From 2014-2018

Introduction: Males have higher numbers of publications than females across many medical specialties. Little is known about female involvement in stroke research, especially conference-related science.

Objective: To evaluate sex differences among authors of abstracts at the International Stroke Conference (ISC).

Methods: Data were obtained (2014-2018) for first authors of submitted and accepted ISC abstracts from the American Heart Association. Variables included sex, career classification, career level, institution country, abstract category and type. Data were analyzed by chi-square test, Fisher’s exact test, or logistic regression.

Results: Authors submitted 8532 abstracts (36.9% female), and 6135 abstracts were accepted (36.5% female). There was no difference in submitted abstracts by sex and year (p=0.3), so years were combined. There was no sex difference in the proportion of accepted abstracts (female vs male: 71.7% vs 73.0%, p=0.2). Nurses with accepted abstracts were most likely female (93.2%), and physicians were least likely (27.4%). By career level, the highest proportion of females with accepted abstracts was students/trainees (40.7%), and by institution continent, the highest and lowest proportions were from South America (56.7%) and Asia (19.9%). Females presented 91.5% of abstracts in nursing, 56.3% in clinical rehabilitation and recovery (next highest), and 18.0% in acute endovascular (lowest). The odds of being a female author was 1.82 (95% CI 1.62-2.05) in rehabilitation and recovery and 1.18 (95% CI 1.01-1.39) in basic science as compared to acute care. There was no sex difference in abstract presentation type (p=0.3).

Conclusions: Females are underrepresented among ISC abstract first authors, especially among physicians and for acute, in-hospital stroke research, fields in which males may be overrepresented. This suggests the need for further efforts to increase the participation of females in stroke research.