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Background and Purpose High-grade carotid artery stenosis may alter hemodynamics in the ipsilateral hemisphere, but consequences of this effect are poorly understood. Cortical thinning is associated with cognitive impairment in dementia, head trauma, demyelination, and stroke. We hypothesized that hemodynamic impairment, as represented by a relative time-to-peak (TTP) delay on MRI in the hemisphere ipsilateral to the stenosis, would be associated with relative cortical thinning in that hemisphere.Methods We used baseline MRI data from the NINDS-funded Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis–Hemodynamics (CREST-H) study. Dynamic contrast susceptibility MR perfusion-weighted images were post-processed with quantitative perfusion maps using deconvolution of tissue and arterial signals. The protocol derived a hemispheric TTP delay, calculated by subtraction of voxel values in the hemisphere ipsilateral minus those contralateral to the stenosis.Results Among 110 consecutive patients enrolled in CREST-H to date, 45 (41%) had TTP delay of at least 0.5 seconds and 9 (8.3%) subjects had TTP delay of at least 2.0 seconds, the maximum delay measured. For every 0.25-second increase in TTP delay above 0.5 seconds, there was a 0.006-mm (6 micron) increase in cortical thickness asymmetry. Across the range of hemodynamic impairment, TTP delay independently predicted relative cortical thinning on the side of stenosis, adjusting for age, sex, hypertension, hemisphere, smoking history, low-density lipoprotein cholesterol, and preexisting infarction (P=0.032).Conclusions Our findings suggest that hemodynamic impairment from high-grade asymptomatic carotid stenosis may structurally alter the cortex supplied by the stenotic carotid artery.

Introduction: The proliferation of literature regarding the COVID-19 pandemic has served to highlight a wide spectrum of disease manifestations and complications, such as thrombotic microangiopathies. Our review with a brief case presentation highlights the increasing recognition of TTP in COVID-19 and describes its salient characteristics. Methods: We screened the available literature in PubMed, EMBASE, and Cochrane databases from inception until April 2022 of articles mentioning COVID-19-associated TTP in English language. Results: From 404 records, we included 8 articles mentioning data of 11 patients in our review. TTP was predominantly reported in females (72%) with a mean age of 48.2 years (SD 15.1). Dyspnea was the most common symptom in one third of patients (36.6%). Neurological symptoms were reported in 27.3% of cases. The time to diagnosis of TTP was 10 days (SD 5.8) from onset of COVID-19. All 11 cases underwent plasma exchange (PLEX), with a mean of 12 sessions per patient, whereas 6 cases received Rituximab (54.5%), and 3 received Caplacizumab (27.3%). One patient died from the illness. Conclusion: This review of available literature highlights the atypical and refractory nature of COVID-19-associated TTP. It required longer sessions of PLEX, with half of the patients receiving at least one immunosuppressant.

Objective: To describe the impact of COVID-19 on acute cerebrovascular disease care across 9 comprehensive stroke centers throughout Los Angeles County (LAC). Methods: Volume of emergency stroke code activations, patient characteristics, stroke severity, reperfusion rates, treatment times, and outcomes from February 1 to April 30, 2020, were compared against the same time period in 2019. Demographic data were provided by each participating institution. Results: There was a 17.3% decrease in stroke code activations across LAC in 2020 compared to 2019 (1,786 vs. 2,159, respectively, χ2 goodness of fit test p < 0.0001) across 9 participating comprehensive stroke centers. Patients who did not receive any reperfusion therapy decreased by 16.6% in 2020 (1,527) compared to 2019 (1,832). Patients who received only intravenous thrombolytic (IVT) therapy decreased by 31.8% (107 vs. 157). Patients who received only mechanical thrombectomy (MT) increased by 3% (102 vs. 99). Patients who received both IVT and MT decreased by 31.8% (45 vs. 66). Recanalization treatment times in 2020 were comparable to 2019. CSCs serving a higher proportion of Latinx populations in the eastern parts of LAC experienced a higher incidence of MT in 2020 compared to 2019. Mild increase in stroke severity was seen in 2020 compared to 2019 (8.95 vs. 8.23, p = 0.046). A higher percentage of patients were discharged home in 2020 compared to 2019 (59.5 vs. 56.1%, p = 0.034), a lower percentage of patients were discharged to skilled nursing facility (16.1 vs. 20.7%, p = 0.0004), and a higher percentage of patients expired (8.6 vs. 6.3%, p = 0.008). Conclusion: LAC saw a decrease in overall stroke code activations in 2020 compared to 2019. Reperfusion treatment times remained comparable to prepandemic metrics. There has been an increase in severe stroke incidence and higher volume of thrombectomy treatments in Latinx communities within LAC during the pandemic of 2020. More patients were discharged home, less patients discharged to skilled nursing facilities, and more patients expired in 2020, compared to the same time frame in 2019.

We thank the Editors of JNIS for alerting us in advance to the concerns about SELECT2 raised by Jadhav1 and colleagues and appreciate the opportunity to explain the rationale for the study design and clarify the benefits of including perfusion imaging-based selection criteria. We are confident that SELECT2 will provide high-level, reliable data regarding the safety and efficacy of endovascular thrombectomy (EVT) for large core patients. The choice of imaging modality for identifying large core in acute ischemic stroke remains an area of considerable debate. Magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI), computed tomography (CT) or MR perfusion imaging and Alberta Stroke Program Early CT Score (ASPECTS) have all been proposed and studied. At present, there is no clear consensus on which imaging modality is best for identifying patients with large core. It is important to recognize that the early window randomized EVT trials used a broad range of imaging selection criteria. The imaging selection criteria for the initial five pivotal trials ranged from allowing patients to be enrolled regardless of the degree of early infarct signs,2 to studies that required a specific ASPECTS score range in addition to other imaging criteria,3–5 to EXTEND IA6 where the ASPECTS score was not considered, and CT perfusion (CTP) mismatch with a maximum estimated core size was required. All five trials were successful but with substantial variability in the treatment effect, leaving uncertainty as to the optimal imaging approach as well as whether there are patient subgroups who do not benefit. In fact, those utilizing perfusion mismatch criteria (EXTEND-IA, SWIFT PRIME) had higher rates of modified Rankin Scale (mRS) scores 0–2 and larger treatment effects, compared with other trials.2–6 Even if a treatment has a clear benefit in most patients, there can be important subgroups that do not …

Background: Limited data are available on endovascular thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) patients presenting >24hr from last known well (LKW). We compared outcomes between patients receiving EVT and best medical management (MM) in a multicenter international cohort. Methods: Consecutive patients with anterior circulation LVO presenting >24h after LKW from 13 centers from 7/2012-4/2021 were analyzed. Multivariable models for 90d mRS distribution and symptomatic ICH were adjusted for age, NIHSS, glucose, IV tPA, transfer status, clot location, time from LKW, CT ASPECTS and ischemic core (rCBF6s volumes. Results: Of 240 patients with a median (IQR) LKW to presentation 28.3h (24.9-38.2), 153 (64%) received EVT. Baseline characteristics were similar except for NIHSS (EVT: 13 (8-20) vs MM: 17 (10-22), p=0.005), CT ASPECTS (EVT: 8(6-9) vs MM: 4(3-6), p Conclusions: EVT may be associated with better functional outcomes, despite numerically increased risk of sICH in patients presenting with anterior circulation LVO beyond 24 hours. Further prospective studies are warranted.

Objective This study was undertaken to evaluate functional and safety outcomes for endovascular thrombectomy (EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits, stratified by perfusion imaging mismatch. Methods The pooled cohort consisted of patients with National Institutes of Health Stroke Scale (NIHSS) < 6 and internal carotid artery (ICA), M1, or M2 occlusions from the Extending the Time for Thrombolysis in Emergecy Neurological Deficits - Intra-Arterial (EXTEND-IA) Trial, Tenecteplase vs Alteplase before Endovascular Thrombectomy in Ischemic Stroke (EXTEND-IA TNK) trials Part I/II and prospective data from 15 EVT centers from October 2010 to April 2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVTpri) were compared to those who received primary MM (MMpri), including those who deteriorated and received rescue EVT, in overall and propensity score (PS)-matched cohorts. Patients were stratified by target mismatch (mismatch ratio >= 1.8 and mismatch volume >= 15ml). Primary outcome was functional independence (90-day modified Rankin Scale = 0-2). Secondary outcomes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality). Results Of 540 patients, 286 (53%) received EVTpri and demonstrated larger critically hypoperfused tissue (Tmax > 6 seconds) volumes (median [IQR]: 64 [26-96] ml vs MMpri: 40 [14-76] ml, p < 0.001) and higher presentation NIHSS (median [IQR]: 4 [2-5] vs MMpri: 3 [2-4], p < 0.001). Functional independence was similar (EVTpri: 77.4% vs MMpri: 75.6%, adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 0.82-2.03, p = 0.27). EVT had worse safety regarding sICH (EVTpri: 16.3% vs MMpri: 1.3%, p < 0.001) and neurological worsening (EVTpri: 19.6% vs MMpri: 6.7%, p < 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence (EVTpri: 77.4% vs MMpri: 72.7%, aOR = 1.68, 95% CI = 1.01-2.81, p = 0.048), whereas there was a trend toward less favorable outcomes with primary EVT (EVTpri: 77.4% vs MMpri: 83.3%, aOR = 0.39, 95% CI = 0.12-1.34, p = 0.13) without target mismatch (p(interaction) = 0.06). Similar findings were observed in a propensity score-matched subpopulation. Interpretation Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. ANN NEUROL 2022

Introduction: In-hospital strokes (IHS) often have delayed recognition time and a delay in physician assessment, playing a role in unfavorable outcomes. Telestroke (TS) participation is linked to lower odds of hospital mortality and is safe and effective in treating acute ischemic stroke. We implemented a TS program for IHS patients at primary stroke centers (PSC) and assessed tPA time metrics, complications and 90-day functional outcomes as compared to a robust in hospital stroke system of care at a comprehensive stroke center (CSC). Methods: Using a network database, data for all in-hospital code strokes were retrospectively abstracted between 2010-2020 at a CSC and 11 PSC’s. The CSC was compared to PSC’s pre and post implementation of a TS program. Data were analyzed using Wilcoxon rank-sum test, chi-square and exact tests. Results: We identified 193 patients, 77 at the CSC, 71 at pre-tele PSC’s, and 45 at post-tele PSC’s. Symptom-recognition-time (SRT) to neurology evaluation (median 15min {IQR 10-27} vs 75min {IQR 45-126, p= Conclusions: Implementation of a TS program for IHS at PSC’s may improve tPA time metrics and 90 functional outcomes to the standards of CSC’s without increasing complication rates. Our study was limited by retrospective design and small sample size.

Background: Poststroke depression (PSD) is under-recognized and affects the recovery and rehabilitation of stroke patients. PSD affects one-third of stroke survivors and there is little known when depressive symptoms manifest. Early identification of PSD may reduce its related functional impairment and mortality. Purpose: The purpose of this study is to demonstrate the feasibility of nursing driven depression identification at 30-45 days post discharge. Methods: All primary stroke patients received a phone call from SCRN to assess depression between 30 to 45 days post discharge using the Patient Health Questionnaire (PHQ9). Three attempts were made per patient. Data were analyzed from August 2019 thru March 2020. Based on the PHQ9 scores, patients were referred to different clinical care pathways. Patients who scored 1-9 received lifestyle modification information, 10-19 were referred to depression care management (DCM), 20 and above were referred to psychiatry. The number of patients evaluated and the percentage of those who were referred to specific pathways were assessed. Results: 427 patients were discharged with a stroke diagnosis. 197 (46.1%) completed the PHQ9 assessment. 14 (7%) were ages 18 to 44 years, 65 (33%) were 45 to 64 years, and 118 (60%) were 65 years and above. 92 (47%) were female. 64% were Caucasian, 19% Asian, 13% Black, and 5% Other. 30% were Hispanic. 72% were ischemic, 19% ICH, and 9% SAH. 230 patients (53.9%) were not able to complete PHQ9. 88 (38%) were unavailable, and 120 patients (52%) were not able to participate due to stroke severity. 20 (10%) were referred to DCM and/or psychiatry. Conclusions: Nurse-driven 30-day PHQ9 assessment is feasible and identifies patients with depressive symptoms. The 30-45-day post-stroke timeframe may be reasonable to diagnose depression after an acute stroke.

Background: According to the American Heart Association, a formal assessment of cognitive dysfunction caused by stroke is a level I recommendation. However, cognitive evaluation is often missed or overlooked in the inpatient setting. When and who performs the assessment is not well-defined. Stroke nurses can corroborate with clinicians in completing the Montreal Cognitive Assessment (MoCA) 8.1, a validated tool for assessing cognitive function in stroke patients. Purpose: The purpose of this study was to evaluate the process of using the bedside nursing swallow screen (NSS) as a trigger for an inpatient cognitive evaluation by the Speech Therapist (ST). This study was also used to determine if post-discharge cognitive therapy referrals were placed based on the MoCA scores. Methods: All STs completed the required MoCA certification. The new process was implemented in October 2019. Data were analyzed from October 2019 through March 2020. NSS was performed on newly admitted stroke patients. If failed, an ST consult was ordered for a dysphagia evaluation. However, if passed, a cognitive evaluation consult was triggered by the RN. MoCA was completed within 24 hours. The total possible score is 30; a score of 26 or above is considered normal. A MoCA score of 25 or less, prompted a post-discharge cognitive therapy referral. Results: 229 patients were assessed, all of whom had an NSS completed. 120 (52.4%) passed the NSS, of which 85 (71%) completed a MoCA evaluation. 42 (49.4%) scored 25 or less, of which 35 (83.3%) were referred for a post-discharge cognitive therapy. 7 (17%) had no referral, of which 4 (57%) were discharged home to self-care; 2 (29%) discharged to other healthcare facility; and 1 (14%) left against medical advice. Conclusions: Repurposing the NSS as a standardized tool to trigger an inpatient MoCA evaluation was innovative, practical and efficient. Timely post-discharge cognitive therapy referrals were also evident on MoCA scores of 25 or less.

Introduction: Central or branch retinal artery occlusion (CRAO/BRAO) results in acute monocular vision loss. Only one prospective study of IV tPA use within 4.5 hours with a recent updated patient-level meta-analysis showed favorable visual outcomes but long-term visual outcomes were not reported. We evaluated the use of IV tPA within 4.5 hours for CRAO/BRAO vs medical management and assessed 90-day visual outcomes. Given the increasing use of telemedicine (TM), we also assessed the diagnostic accuracy of CRAO/BRAO evaluated via TM vs in-person. Methods: Data were retrospectively abstracted for CRAO/BRAO treated with IV tPA vs medical management within a large managed healthcare system. 90-day visual outcomes were reported as Low Vision (no light perception, light perception, hand motion, finger counting) and mean LogMAR, which was converted from Snellen, and classified as normal-mild impairment (LogMAR 0.4-0.5), moderate-severe impairment (LogMAR 0.6-1.3) and blind-low vision (LogMAR >1.3). Visual outcomes were analyzed using the Wilcoxon rank-sum and signed-rank tests. Results: Between 2012-2019, 21 patients received IV tPA within 4.5 hours for presumed CRAO/BRAO vs 34 medically managed. One patient evaluated via TM and one patient evaluated in-person were misdiagnosed and excluded from analysis. Of those accurately diagnosed and treated with IV tPA, 15 were evaluated via TM and 4 in-person. At 90 days, intragroup analysis revealed at least a one-point improvement on the Low Vision scale (68% tPA, p= 0.007 vs 30% non-tPA, p=0.63) and the LogMAR scale (32% tPA, p=0.03 vs 12% non-tPA, p=0.38) with 26% of tPA patients having normal-mild impairment in vision vs 9% in non-tPA patients. Initial to 90-day vison on the Low Vision scale showed visual improvement in the tPA group (p=0.001) and a trend towards improvement on the LogMAR scale (p=0.07). Conclusions: Similar to a recent prospective study with patient level meta-analysis, we found that IV tPA within 4.5 hours for CRAO/BRAO may lead to improved visual outcomes at 90 days compared to medical management. Diagnostic accuracy of CRAO/BRAO was similar irrespective of method of being evaluated via TM or in-person. Our study was limited by small sample size and retrospective design.

Introduction: Many clinical trials have suffered poor enrollment or have been placed on hold due to the COVID-19 pandemic. Limitations on in-person interaction with patients, legally authorized representatives, coordinators, and physician investigators disrupt research processes including screening, consent, randomization, and study interventions. Remote enrollment practices incorporating telemedicine and electronic consent may address these enrollment limitations. Methods: We retrospectively reviewed clinical trial enrollments in two pivotal phase-III acute stroke trials (NCT03735979, NCT03785678) at two high-volume stroke centers that routinely use remote enrollments in clinical research. Individual elements of acute clinical stroke trial enrollment, including: screening, consent, randomization, and intervention were reviewed. For each research phase, we compared the rate of successful completion and research protocol violations for in-person vs remote research via Fisher’s exact test. Results: Forty patients were reviewed (median age 72 [IQR 63-84], 50% female, median NIHSS 13 [IQR 7.5-19.5]; 35 patient were enrolled and 5 were screened and consented, but found ineligible on qualifying imaging. All research phases were completed successfully with the exception of one in-person study intervention. Fisher’s exact test revealed no differences in protocol violations between research elements conducted remotely (predominantly via telemedicine) versus in-person (see Table). Conclusion: Our study revealed no difference in successful completion of acute clinical trial research elements when conducted remotely or in-person. Incorporation of remote research, especially telemedicine, may enable stroke clinical trial enrollments both during the COVID 19 pandemic and beyond.

Background: Identifying and tracking COVID-19 related data has been crucial to the pandemic response. Most hospital systems have created internal tracking databases specific to COVID-19 but separated from other disease specific data pools. Traditional methods for tracking and trending novel and specific data such as COVID-19 related strokes may require personnel with highly technical skills to abstract the data. We aimed to create a COVID-19 stroke dashboard which would easily auto-abstract and update data. Methods: A simple monitoring system was designed using PowerBI™ and Microsoft Suite™ products that model existing data sources without using other IT resources. Existing data queries from various sources were modeled into one report and the resulting data model was used to track and trend incidence of COVID-19 and its relationship to stroke care throughout a 14- hospital stroke system. Results: The report allowed region-wide identification and evaluation of several metrics, including: volume of code strokes, the volume of patients who had a stroke within two weeks before or after testing positive for COVID-19, the initial NIHSS, if alteplase was administered, reason for no alteplase administration, delay in alteplase administration and if related to COVID-19 and the relationship of COVID-19 cases to the volume of code strokes. It was found that the volume of code strokes significantly decreased during the time of the pandemic and was inversely related to the volume of COVID-19 positive cases being reported in a county. The tool also found that COVID-19 positive stroke patients increased as the overall COVID-19 hospital volume increased. Conclusion: Assessing the relationships between a novel disease and other disease states may lead to changes in hospital workflows and practices resulting into improved patient outcomes.

Introduction: The COVID-19 pandemic presents obstacles to time sensitive emergencies, such as stroke care. In acute strokes, knowing the COVID-19 status may help to preserve personal protective equipment (PPE) in patients in whom a thrombectomy may be indicated and helps to decrease unnecessary exposure. This study aims to demonstrate that rapid evaluation of a patient’s COVID-19 status is feasible without delaying treatment times. Methods: An intradisciplinary team was convened to create a workflow for rapid COVID-19 testing. The Abbott Rapid® COVID-19 swab kit and assay were stocked in the ED Pyxis, utilizing the narcotic count feature to ensure all swabs were accounted. Upon activation of Code Stroke, the ED RN donned PPE and swabbed the patient’s naso-oral pharynx. The collected swab was labeled, placed in a bio-hazard bag, sanitized and handed to a second RN outside of the room. The specimen was taken to a pre-alerted lab technician who prepped the assay after hearing the code stroke. After specimen collection, the patient followed the normal code stroke pathway and was taken to the CT scanner. Metrics were analyzed for the pre COVID-19 (January through April) and during active COVID-19 (May through July) periods. Results: There were 136 code strokes from January thru July 2020. 81 were during pre-COVID vs. 55 during active-COVID. 47 of 55 (96%) were swabbed, 2 (4%) of whom were positive. There was no difference between pre-COVID and active-COVID door to CT initiated time (16 mins [IQR 13-24] vs. 22 mins [IQR 13-25] p=0.75), door to CT resulted time (21 mins [IQR 15-26]) vs. 23 mins [IQR 16-29] p=0.63). 18 patients received tPA pre-COVID and 5 during active-COVID with no difference in DTN (pre: 37.5 mins [IQR 30-43] vs. active: 28 mins {IQR 26-41] p=0.37). Door to CT initiated was faster for those who had their COVID swab performed pre-CT (14 mins [IQR 11.5-16.5] p=0.034) vs. post-CT (20 mins [IQR 17-28]). Likewise, door to CT resulted was also faster pre-CT: 24 mins [IQR 19-32] vs. post-CT: 17 mins [IQR 15-23] (p=0.04). Conclusion: The COVID-19 rapid swab code stroke process was feasible and did not delay treatment times.

Background: Performance Improvement (PI) enhances processes, services, and outcomes. The Joint Commission (TJC) standards require a comprehensive approach to PI. This can be challenging due to variability of staffing within a stroke program. The stroke coordinator is often left to manage PI projects, which can be arduous due to the multiple demands of their role. A dedicated Stroke Quality Coordinator RN (SQCRN) manages quality improvement activities solely for the stroke program. It is a unique position that requires clinical knowledge of stroke, neuro-interventional and neurosurgical procedures, as well as, comprehension of regulatory requirements, PI and data analysis. Purpose: To determine if having an SQCRN dedicated to a stroke program results in an increased number of PI Projects implemented. Methods: The SQCRN initiative was implemented in 2020 with the objective of determining the impact of having a dedicated SQCRN on the number of projects completed. A survey was created consisting of 5 questions and sent to 328 individuals via email utilizing an anonymous Microsoft Forms Link. The survey was emailed to the Los Angeles Stroke Coordinator Network and National Stroke Coordinator group. Fifty-eight (17.6%) responded. Survey results were compared for stroke programs with a Dedicated SQCRN to those without. Data were analyzed using T-Test. Results: In stroke programs with a dedicated SQCRN, there were more respondents who reported 6 or greater PI projects than stroke programs who did not have a dedicated SQCRN. This was statistically significant when compared to both 2 or less (p=0.001) or 4 or less projects p=0.035. Conclusion: A dedicated SQCRN improves the number of PI projects that a stroke program can implement. PI initiatives help to improve the safety, treatments, services and quality of care in order to improve patient outcomes.

Context New stroke thrombectomy devices have significantly improved recanalization rates in patients with large vessel occlusion. The first pass effect, or complete or near complete recanalization after a single pass of a device, is associated with better outcome. However, it remains unclear whether one technique is superior to the others at first pass recanalization. Objective The successful recanalization rates of three common techniques: 1) Stent-retriever with the Solitaire or 2) Trevo device, or 3) primary aspiration (PA) with a distal aspiration catheter, were compared across three Kaiser Permanente Southern California Medical Centers over a 5-year period. Design Retrospective review of cases between October 2013 and May 2018. Main outcome measure Successful recanalization after a single pass of a device. Results Forty-five percent of Solitaire thrombectomies resulted in first pass success, compared with 31% of Trevo and 39% of PA, not statistically significant (p = 0.26). Adjusted for age, gender, and National Institutes of Health Stroke Scale score, the odds of successful recanalization were 1.90 ± 0.72 (CI 0.90-3.99, p = 0.09) for Solitaire compared with Trevo, and 1.41 ± 0.50 (CI 0.70-2.84, p = 0.33) for aspiration compared with Trevo. Conclusion In this multi-center cohort, there was no statistical difference in successful first pass recanalization between Solitaire, Trevo, and PA. However, there was a trend towards improved efficacy with the Solitaire device compared to Trevo (OR 1.90, p = 0.09). Additional data are needed to determine the conditions under which design differences may favor one technique over another.

A 53-year-old man was admitted to hospital for elective repair of a descending aortic dissection and type B intramural haematoma. He had a history of stage 3 chronic kidney disease and took aspirin for paroxysmal atrial fibrillation. At 07:00 on the morning of the operation he was awake, alert and moving all limbs. His surgery began at 09:10. He received various anaesthetic medications, including rocuronium 50 mg (0.5 mg/kg); last dose at 17:20. The surgical repair ended at 16:15, and left the operating theatre at around 20:00 after an uneventful surgery. At midnight, he was still unresponsive despite receiving naloxone. His observations were: temperature 37°C, blood pressure 158/100 mmHg, heart rate 80/min, intubated and breathing at set respiratory rate 14/min, and oxygen saturation 100% on pressor support of 8 cmH2O, tidal volume 580 mL (8 mL/kg of his ideal body weight), FiO2 45%, and positive end-expiratory pressure of 5 cmH2O. He was not on sedation. His pupils were …

Background: The Joint Commission (TJC) Comprehensive Stroke Center standard requires monitoring of patients after IV tPA administration, diagnostic angiography, aneurysm coiling, carotid angioplasty and stenting, mechanical endovascular reperfusion (MER) and carotid endarterectomy. Meeting 100% compliance of the standard is challenging. In 2018, monitoring and documentation were among the TJC’s top ten cited survey findings. Purpose: To determine if an electronic tool can improve documentation compliance and reduce delays in monitoring of vital signs, and neurologic, pedal pulse and skin site assessments. Methods: The initiative was implemented in 2018 with the objective for all patients to have 100% of their post procedural monitoring completed. A documentation tool was created and introduced to nursing units via annual stroke education updates. The tool was added to an online nursing resource SharePoint website and application, which was accessible to all nurses within the hospital. The procedure end time was entered in the tool, which automatically calculated the documentation times. Data was compared 12 months pre and post intervention. Analysis and reporting of data were conducted monthly via the program’s quality oversight committee. Data was analyzed using T-Test. Results: In post-IV tPA patients, more patients had 100% complete documentation (79% post vs. 29% pre-implementation; p=0.006). For all post neuro-interventional radiology procedures, more patients had 100% complete documentation (68% post vs. 17% pre-implementation; p Conclusion: Utilization of an electronic monitoring tool for post procedural documentation adherence can improve the percentage of patients who have 100% completed assessments and help meet the TJC standard.

Background: Stroke is life changing for both patients and caregivers. Recovery from stroke affects the physical, social and emotional aspects of life. Transitioning to a new normal should begin immediately after stroke, ideally during hospital admission. Most support groups exist outside of the hospital setting and begin weeks to months after the ictus. The Road to Recovery Stroke Support Group (RRSSG) was created to bridge the gap between the inpatient and outpatient setting. Purpose: RRSSG aims to provide a weekly platform for stroke survivors and caregivers in an in-hospital setting. During sessions, attendees learn about types of challenges after stroke, rehabilitation services available to them and what to expect after leaving the hospital. Patients can return to the same support group once discharged from the hospital. Methods: RRSSG was launched in November 2018. Candidates for the weekly RRSSG meeting were identified by nurses and the stroke case manager. Meetings were facilitated by a stroke survivor volunteer, case management and physical and social medicine. Invitations were extended to patients and their caregivers prior to discharge. Data were collected for 7 months and analyzed for the following: patient demographics, types of stroke and discharge disposition. Results: During the 7-month period, 514 patients were discharged with a stroke diagnosis, 24.3% of which attended the RRSSG. The demographics were 53.7% women with a median age of 66 years; 33.1% White/European, 36% Hispanic/Latino, 18.0% African American, 10.8% Asian, and 2.1% other. 61.6% had an ischemic stroke, 30.4% had an intracerebral hemorrhage, 11.2% had a subarachnoid hemorrhage. More patients who attended RRSSG were discharged to an acute rehabilitation hospital (6.5% RRSG vs. 1.8% non-RRSG, p=0.04). There was no difference in those discharged to: home (54.0% RRSSG vs. 55.5% non-RRSSG) and skilled nursing facility (27.3% RRSSG vs. 20.1% non-RRSSG). Conclusion: Creating and sustaining an inpatient multi-disciplinary stroke support group on a weekly basis is feasible. The future goals are to assess the impact of the in-hospital support group on stroke knowledge retention, medication compliance, post-stroke depression, recurrent stroke and re-admission rates.

Background: IV tPA is established as an effective treatment for acute ischemic stroke. Currently it is endorsed up to 4.5 hours of last known well time by major guidelines. A randomized trial, WAKE-UP, displayed its safety and efficacy in patients who presented within 4.5 hours of waking up with their symptoms. Objective: To establish a practical tPA protocol for patients who wake up or are found with stroke symptoms at a large Comprehensive Stroke Center (CSC) and its 13 telestroke spokes (TS) based on the WAKE-UP trial. Methods: A wake up tPA protocol was created and given to all teleneurologists. Door to needle times (DTN) and reasons for no tPA were collected for 12 months post implementation and evaluated for differences between wake up (WU) and non-wake up (NW) patients. Results: 93 WU patients were identified; 23 at CSC and 70 at TS. 11 (47.8%) vs. 4 (5.7%) patients received tPA at CSC and TS, respectively. Median DTN was not significantly different for WU patients at CSC vs. TS (64 vs. 89 mins, p=0.54). Median DTN at CSC was shorter for NW vs. WU (37 vs. 64 mins; p=0.003). Similarly, median DTN at TS trended toward being shorter for NW vs. WU (44 vs. 89 mins; p=0.062). The reasons for no tPA at CSC were no mismatch found in 6 (50%), and MRI unavailability in 6 (50%); at TS were no mismatch found in 11 (16.6%), MRI unavailability in 54 (81,1%) and MRI was contraindicated in 1 (1.5%). Conclusion: Treating WU patients using a CSC Hub and TS model is feasible. DTN are longer for WU vs. NW. In the United States, MRI availability is the main barrier to WU tPA at both CSC and community hospitals. The difference between median DTN for WU between CSC and TS did not reach statistical significance, likely due to the small sample size.

Introduction: Stroke Champions (SC) are AHA recommended designated inpatient nurses that serve as expert resources for their units to ensure that evidence-based practices for stroke care are implemented. Inpatient Code Strokes (ICS) are difficult to recognize which results in delayed treatment. The purpose of this study is to determine if there was an improvement in inpatient acute stroke metrics with the addition of SC in the hospital. Methods: Over a 12-month period at a Comprehensive Stroke Center (CSC), 12 nurses in the inpatient stroke units were trained as SC. This training consisted of advanced education in CSC metrics, guidelines and required documentation. SC provided peer-to-peer education, served as expert resources, conducted comprehensive chart reviews, shift huddles, and “on the spot” feedback to nurses and physicians. The metrics were examined pre and post intervention and included: Symptom Recognition Time (SRT) to CT interpretation, SRT to tPA bolus time, and SRT to groin puncture. SRT is equivalent to Emergency Department door time for inpatient strokes. Statistical analysis was performed using T-test and the Mann-Whitney test. Results: There were 114 pre-SC and 101 post-SC ICS. There was a trend toward more patients being accurately diagnosed with a TIA or stroke (75.3% post vs. 65.8% pre-SC; p=0.06). The SRT to CT interpretation time for patients who received tPA improved from 43 to 35 mins. The number of patients treated with tPA increased from 10 to 17. SRT to tPA bolus time trended toward improvement from 57 to 42 mins (p=0.07). SRT to groin puncture time in patients who received both tPA and thrombectomy trended toward improvement from 81 vs. 65 mins (p=0.07). There were twice as many inpatient thrombectomy cases in post-SC (n=23) vs. pre-SC (n=12). Conclusion: The knowledge and expertise provided by SC resulted in a higher percentage of ICS having a final diagnosis of stroke. This demonstrates an increased accuracy of stroke specific symptom recognition by the inpatient nursing teams. There was improved SRT to tPA bolus and groin puncture time. This is the only study that shows implementation of the AHA recommended SC program improves inpatient code stroke recognition and treatment metrics.

Background: Post-interventional cerebral hyperdensities (PCHD) are present 31.2 to 87.5% of the time on post-thrombectomy (PT) CT. It can be difficult for radiologists to differentiate if PCHD represents intracerebral hemorrhage (ICH) or contrast staining using conventional CT. The ability to accurately determine the etiology of PCHD may be important for a patient’s outcome. Methods: We retrospectively investigated clinical risk factors, imaging findings, and interventional technique of patients who had a thrombectomy from 2011-2017 (n=238) at a Comprehensive Stroke Center. 112 patients with anterior circulation infarcts and immediate PT CTs as well as either a PT MRI or follow-up CT within 48 hours were included. Two experienced neuroradiologists interpreted all imaging. Baseline demographics and imaging characteristics were collected. The presence of ICH was determined by dephasing on gradient echo or by its persistence > 2 days on repeat CT. Chi-square and Fisher’s exact tests were used for statistical significance, and logistic regression to determine risk estimates. Results: 84% of patients had PCHD, of which 56% had ICH. Patients had similar demographics (ICH: median age 69, 47.5% female; non-ICH: median age 71, 42.5% female). Higher pre-thrombectomy ASPECTS score (OR 0.62, p < 0.05) decreased the risk of ICH, and higher Hounsfield units (HU) of PCHD both on immediate (OR 1.04, p < 0.05) and intermediate (OR 1.1, p < 0.0005) PT CT increased the risk of ICH. PCHDs in the deep grey matter (OR 2.84, p < 0.05) and demonstrating a confluent pattern (OR 3.9 p < 0.05) increased the likelihood of ICH. 10% increase risk of ICH was seen for every HU increase in density on PT CT at 24 or 48 hours. A 50% decrease in ICH was observed for each unit increase of the pre-thrombectomy ASPECTS score. ROC revealed the optimal cut-off for predicted probability as 0.64, sensitivity 70.2% and specificity 69.2%. The AUC for the predicted model was 0.84 (95%CI= (0.75- 0.92, p Conclusion: Several imaging characteristics of PCHDs and ASPECTS score can help differentiate between the PT ICH and contrast staining. Application of these variables to patients in the immediate PT period may change clinical management.

Background: Door-in-door-out time (DIDO) is an established driver of outcome in ischemic stroke patients who initially present to a Primay Stroke Center (PSC) and require transfer for endovascular intervention. In 2019, the Joint Commission required monitoring of DIDO as part of its STK-OP measure. Given the importance of rapidly transferring ischemic stroke patients, we embarked to create a monitoring tool to help assess the areas of delay in a 14 hospital telemedicine supported stroke system. Methods: A monitoring system was designed using PowerBI™ and Microsoft Suite™ products that models various data sources for consumption and action. Separate data queries from various sources were entered into one report using the Office365™ suite and Power Query Editor™ in PowerBI™. The resulting data model was then reorganized and programmed into a PowerBI™ report that can be shared throughout the organization. Results: The report allowed region-wide or hospital specific evaluation of several time based transfer metrics, including: door to initial call to transfer center, transfer center contact to neurointerventional physician accept time, accept time to ambulance arrival, ambulance arrival to ambulance departure and travel time to thrombectomy center. The largest areas of delays identified were door to initial call to transfer center and time of ambulance arrival to spoke to departure from spoke. The tool also allowed the separation of the STK-OP measure into ischemic stroke, intracerebral hemorrhage or sub-arachnoid hemorrhage. The assessment of these time metrics at a regional and individual hospital level permitted us to create a plan to focus on the greatest areas of delay to further decrease our transfer times. Conclusion: Modern data software may be leveraged by stroke programs to help assess the specific time metrics causing delay in DIDO, which could then further assist in focused quality improvement of these metrics.

ObjectiveTo update the 2016 American Academy of Neurology (AAN) practice advisory for patients with stroke and patent foramen ovale (PFO).MethodsThe guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations.Major recommendationsIn patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B). In patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B). Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B). In patients younger than 60 years with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C). In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).

Summary of case A 69‐year‐old man with uncontrolled type 2 diabetes presented to an outside hospital with altered mental status. He progressed from being argumentative to encephalopathic and agitated by the evening with urinary frequency, urinary urgency, nausea, and vomiting. His vital signs were normal, and he had no focal neurological deficits on presentation. He was generally encephalopathic, only groaning with no ability to follow commands. He was found to have diabetic ketoacidosis on initial labs. A left parietal hypodensity on CT Head was found, and he was positive for Sars‐COV‐2.

In patients presenting with acute ischemic stroke, when the clinical presentation cannot be explained by findings seen on imaging, consider the presence of rare anatomical variations.

Background: Patients with deficient stroke knowledge characteristically present to the hospital outside the treatment window. Providing effective inpatient stroke education motivates patients to change their modifiable risk factors, hence reducing the threat of a secondary stroke. Purpose: The purpose of this study is to validate the effectiveness of the American Heart Association’s Get with the Guidelines Stroke Champion (SC) Program. Inpatient Nursing SC (INSC) endeavored to optimize patients’ retention of stroke education. This study is one of the first to provide data supporting the use of INSC to improve stroke education retention post discharge. Methods: The INSC initiative was implemented in 2017. Data was compared 6 months pre and post intervention. INSC conducted chart reviews, provided peer to peer feedback, implemented “1 Learner 1 Topic” education theme per shift, and ensured education throughout the care continuum. The aggregate data was collected from 7day survey calls (n=340) and stroke-specific HCAHPS topbox survey scores completed by the patient at 90 days post discharge (n=155). Statistical analysis was performed using a chi-squared test. Results: At 7 days, more patients were able to recall stroke risk factors and prevention (54% pre vs. 85% post intervention; p Conclusions: Implementation of an INSC can improve patients’ retention of stroke symptoms, risk factors, prevention, and cause at 7 days and 90 days post discharge.

Introduction: Intravenous tissue plasminogen activator (IV tPA), for acute ischemic stroke, has a more robust effect if given early. Improving Door-to-Needle (DTN) times in order to allow quicker administration of IV tPA continues to be the primary aim of TARGET:STROKE. The Stroke Champion (SC) Program, an American Heart Association’s Get with the Guidelines recommendation, was implemented in our emergency department (ED) in 2018. Purpose: The purpose of this study was assess if an ED Nurse SC would help to improve DTN, with a specific goal to increase the percentage of patient’s receiving IV tPA ≤30 minutes. Methods: The SC program was initiated in our ED in January 2018. The ED Nurse SC carries the following responsibilities: respond to all stroke alerts, weekly audit of all stroke alert charts, peer to peer follow up for any fallouts to determine if there was a system error or if there was an educational opportunity, weekly update of ED staff virtual communication board, weekly meeting with ED director for any challenges or expected changes, development of a relevant stroke education topic to be delivered at the biweekly ED nursing huddle, participate at the weekly code stroke huddle to collaborate with the stroke team, and attend relevant stroke conferences or stroke-related educational opportunities. A weekly “Stroke Shout Out” was also initiated by the ED Nurse SC to recognize a high performing member of the ED team. Data was compared 6 months pre and post-intervention, and analyzed using a Wilcoxon Rank Sum Test. Results: More patients received IV tPA after the initiation of the ED Nursing SC program than before (38 vs. 23 p=0.03). The median DTN was 36 (IQR 23-49) mins after implementation vs. 47 (IQR 40-56) mins before implementation (p=0.004). A higher percentage of patients received IV tPA less than 30 minutes post intervention vs. pre-intervention (42.1% vs. 17.4% , p Conclusion: Implementation of an ED Nurse SC can increase the number of patients who receive IV tPA, improve DTN, and increase the percentage of patients who receive IV tPA less than 30 minutes from door time.

Introduction: Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke. Studies have assessed the efficacy of aspiration thrombectomy (AT), but have been limited to smaller populations, and AT was often reserved for patients with worsening neurological deterioration, which itself portends a poor prognosis. Purpose: To compare outcomes of AT vs. medical management (MM) in a large referral population without neurological deterioration at a single Comprehensive Stroke Center. Methods: We retrospectively identified patients using ICD-10 codes within our network between 2007-2017. Baseline demographics and clinical data were abstracted. Mann-Whitney U test and chi-square test were used for continuous and categorical variables, respectively. Results: 383 patients were identified, and 99 were excluded due to age Conclusion: This study shows that MM was more likely to have a favorable outcome at discharge than AT. No difference in outcome measured at 3, 6 and 12 months was seen.

Background and Purpose- Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) ≥6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS,6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods- A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results- Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance ( P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions- Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS,6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS ≥6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.

CONTEXT Tissue plasminogen activator (tPA) is underutilized for treatment of acute ischemic stroke. OBJECTIVE To determine whether the probability of tPA administration for patients with ischemic stroke in an integrated health care system improved from 2009 to 2013, and to identify predictors of tPA administration. DESIGN Retrospective analysis of all ischemic stroke presentations to 14 Emergency Departments between 2009 and 2013. A generalized linear mixed-effects model identified patient and hospital predictors of tPA. MAIN OUTCOME MEASURES Primary outcome was tPA administration; secondary outcomes were door-to-imaging and door-to-needle times and tPA-related bleeding complications. RESULTS Of the 11,630 patients, 3.9% received tPA. The likelihood of tPA administration increased with presentation in 2012 and 2013 (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.26-2.43; and OR = 2.58; 95% CI = 1.90-3.51), female sex (OR = 1.27; 95% CI = 1.04-1.54), and ambulance arrival (OR = 2.17; 95% CI = 1.76-2.67), and decreased with prior stroke (OR = 0.47; 95% CI = 0.25-0.89) and increased age (OR = 0.98; 95% CI = 0.97-0.99). Likelihood varied by Medical Center (pseudo-intraclass correlation coefficient 13.5%). Among tPA-treated patients, median door-to-imaging time was 15 minutes (interquartile range, 9-23 minutes), and door-to-needle time was 73 minutes (interquartile range, 55-103 minutes). The rate of intracranial hemorrhage was 4.2% and 0.9% among tPA- and non-tPA treated patients (p < 0.001). CONCLUSION Acute ischemic stroke care improved over time in this integrated health system. Better understanding of differences in hospital performance will have important quality-improvement and policy implications.

Ischemic stroke in young adults is a devastating condition with many possible causes. A multimodality imaging approach facilitates identification of the etiology and allows for early initiation of definitive treatment. A 28-year old woman presented with acute onset slurred speech and left-sided

In their 2015 report, Improving Diagnosis in Health Care , the National Academy of Medicine asserted that most individuals ‘will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences’1 and ‘improving the diagnostic process is not only possible, but it also represents a moral, professional, and public health imperative.’1 A key barrier to eliminating diagnostic errors is the lack of operational measures to track diagnostic performance.2 3 Novel approaches using ‘big data’ to identify statistically meaningful patterns offer unique opportunities to operationalise measurement of diagnostic errors and misdiagnosis-related harms.4 In a study of ~190 000 US inpatient stroke admissions, the authors found missed opportunities to diagnose stroke early were often linked to clinical presentations with dizziness or vertigo.5 A graphical temporal profile analysis of treat-and-release emergency department (ED) visits showed an exponential increase in visit frequency in the days before stroke admission, establishing these as likely misdiagnoses.5 We operationalised this approach by constructing a diagnostic performance dashboard to monitor diagnostic quality and safety. Kaiser Permanente-Mid Atlantic Permanente Medical Group (KP) and the Johns Hopkins University School of Medicine (JHM) partnered to build a learning ecosystem using visual analytics tools. Visual analytics combines expert knowledge with machine computational power for smart data exploration.6 Visual representations allow users to see the big picture and visually explore relevant data. Interactive data discovery supports ‘slice-and-dice’ operations with data drill-through capabilities, enabling exploratory data mining, hypothesis testing and decision making. Leveraging the exploratory data …

Introduction: TARGET:STROKE (TS) has established metrics for hospitals to measure the timely administration of thrombolytics. However, these time metrics may not apply to patients who suffer a stroke while admitted to the hospital, since the initial time is the emergency department (ED) door time. The aim of this project was to create metrics and an algorithm applicable to an Inpatient Code Stroke (ICS), and assess a hospital wide education series to improve times to intervention. Methods: ICS metrics defined by TS were established with the Symptom Recognition Time (SRT) to equate to the ED door time, and assessed pre and post intervention. The intervention was a hospital wide education of stroke symptoms, as well the ICS process. A badge reference card with this information was given to nurses. Data were recorded for 6 months pre and post implementation. Outcomes included SRT to stroke team notification, CT scan initiation and interpretation, thrombolytic administration and groin puncture. Fisher’s Exact and Wilcoxon Rank Sum Tests were used for data analysis. Results: There were 86 ICS activations (34 pre and 51 post intervention). There was no difference in baseline demographics, and ICS activation based on unit type. Surgical patients were the most common to have an ICS activation (25.8%). There was a strong trend of SRT to stroke team notification being faster post intervention (median: 22 [0-435] mins pre vs. 12 [0-187] mins post, p=0.059). SRT to groin puncture was faster post intervention (median: 131 [0-286] mins pre vs. 67 [38-91] post, p=0.006). There were more patients who had SRT to thrombolytic ≤ 60 mins or SRT to groin puncture ≤ 90 mins post-intervention (4 [33.3%] pre vs. 10 [71.4%] post, p=0.036). Conclusion: This is the first study to demonstrate that implementation of an ICS algorithm and its accompanying education can increase the percentage of patients who receive thrombolytics and groin puncture for thrombectomy ≤ 60 mins and ≤ 90 mins from SRT, respectively.

Introduction: Patients with minor stroke symptoms tend not to call 911. They often come to the Emergency Department (ED) via personal transport, and walk in through the triage area. These patients historically have longer door to needle times. We established the Brain Alert (BA) nurse driven initiative with ED education on an algorithm applicable to patients who walk in with stroke symptoms. This study assesses the difference between time metrics before and after implementation. Methods: BA metrics were based on the TARGET:STROKE guidelines. The intervention was an ED wide education of all ED staff on F.A.S.T symptoms and the BA process. The ED triage nurse was empowered to page a BA and rapidly initiate the bedding of the patient. The BA page triggered the stroke team to rapidly come to the ED and examine the patient simultaneously with the ED physician. Data were recorded for 6 months pre and post implementation. Outcomes included door to initial MD evaluation, stroke team notification, CT scan initiation and interpretation and thrombolytic administration (DTN). Fisher’s Exact and Wilcoxon Rank Sum Tests were used for data analysis. Results: There were 38 walk in patients pre intervention vs. 36 post intervention. Thirteen (35.1%) BA activations occurred post intervention. The most common reason for not calling a BA was the patient did not have F.A.S.T symptoms. No differences in baseline demographics were found. CT scans were ordered and completed quicker post intervention (median ordered: 13.5 [IQR 7-18.5] mins post vs. 17.5 [IQR 12.5-22.5] mins pre, p=0.021), (median completed: 22.5 [IQR 18-27] mins post vs. 25 [IQR 20-30] mins pre, p= 0.024). A higher percentage of patients received thrombolytics ≤60 mins post intervention (84.6% vs. 78.7%), but was not statistically significant, p=0.41). Conclusion: The BA process improved door to CT order and completion times. There was higher percentage of patients who received IVtPA ≤ 60 minutes, which did not reach statistical significance likely due to the small number of patients involved in the study. Institution of a specific algorithm to address patients who walk in with stroke symptoms into a hospital triage area, can result in improved code stroke time metrics.

Background: Aspiration pneumonia is one of the leading causes of post stroke morbidity. It increases length of stay, rehabilitation period, readmission rates and mortality. Retrospective chart review at Kaiser Permanente, Woodland Hills indicated that hospital-acquired infections were the leading cause of harm in patient deaths. Of these deaths, hospital-acquired pneumonia (HAP) was the leading contributor. HAPs account for 5% of our hospital’s total pneumonia admissions. Objective: We aimed to implement a simple, multidisciplinary Hospital-Acquired Pneumonia Prevention (HAPP) program in one of our stroke units, which had the highest incidence of HAPs, thus improving our stroke recovery and outcome. Method: We analyzed data in a 15-month period, from January 2015 - April 2016, and determined our baseline data for HAP incidence. Data were separated based on nursing units. The stroke units had the highest incidences of HAPs, accounting for 50% of cases (53 out of 102 cases) in the hospital. We selected the stroke unit with the highest incidence to implement the HAPP program. Patients who were at risk for HAPs were identified using the following: Age ≥ 65, history of or actual aspiration, malnutrition, parenteral tube presence, chronic obstructive pulmonary disease, smoking, ventilator use and post-surgery. Once the patient had been identified as at risk for HAP, the HAPP bundle was implemented. The HAPP bundle included head of bed > 30 ° at all times, up and out of bed for all meals, oral care using chlorhexidine rinse, ambulate at least twice per day, bedside incentive spirometry use and patient/family education. Results: After 3 months of HAPP program implementation there was a significant reduction of HAPs when compared to the same time period the previous year. In 4thQtr 2015, we had 8 HAPs, in 4thQtr 2016 after HAPP program implementation, we had 0 HAP on our targeted stroke unit. Conclusion: Based on our 3 month data, the HAPP program is effective in preventing HAPs. However, we would need to further look at data over a longer period to determine the success of the bundle in preventing HAPs. We also would be spreading this practice throughout all the nursing units within our hospital and eventually to the rest of our hospital system within the Southern California Region.

Background: Peroxisome proliferator activated receptor-gamma (PPAR-γ) agonists enhanced hematoma resolution and improved functional recovery in our animal model of intracerebral haemorrhage (ICH). We conducted a translational Phase 2 randomized, controlled clinical trial to determine the maximum tolerated dose (MTD) of the PPAR-γ agonist, pioglitazone (PIO), in patients with spontaneous ICH. Methods: Patients with spontaneous ICH within 24 hours of symptom onset were randomly allocated to PIO or placebo. Patients received escalating doses of PIO daily for three days, followed by a 30 mg maintenance dose for the duration of treatment. The primary safety outcome was mortality at Day 14. Secondary measures of safety included mortality at 3 and 6 months, symptomatic cerebral oedema, hypoglycaemia, respiratory, cardiovascular, hematologic, and hepatotoxicity. Secondary measures of clinical outcomes included modified Rankin Scale (mRS) score, National Institute of Health Stroke Scale (NIHSS) score, Barthel index (BI) Stroke Impact Scale (SIS) and EuroQol (EQ) at 3 and 6 months. The MTD was determined using the Continual Reassessment Method (CRM). Findings: From March 2009 to April 2013, 84 patients (42 PIO, 42 control) were enrolled with a dose range from 7·5-135 mg/day. The primary safety outcome of death within 14 days occurred in two (2%) patients. The MTD of PIO based on CRM was 75 mg/day. Secondary measures of safety and clinical outcomes were similar between treatment groups. Interpretation: Short-term, escalating doses of PIO were tolerated in ICH patients without an increase in adverse events compared to placebo. These results provide the foundation for an efficacy trial evaluating PIO as a potential treatment for patients with spontaneous ICH. Clinical Trial Number: SHRINC was registered with ClinicalTrials.gov (NCT00827892). Funding Statement: The SHRINC Trial was funded by the National Institute of Neurological Disorders and Stroke, the American Heart Association Clinical Research Program and the National Institutes of Health/National Center for Research Resources. Declaration of Interests: The authors state: "I/We declare no competing interests." Ethics Approval Statement: IRB NUMBER: HSC-MS-08-0410, Approval to conduct this trial was sought from the Institutional Review Board (IRB) for the University of Texas Health Science Center at Houston (UTHSC-H). IRB APPROVAL DATE: 12/16/2011

Thrombelastography (TEG) measures coagulation in venous blood. We hypothesized that TEG, by reflecting clot subtype and ex vivo fibrinolysis, might predict fibrinolytic response to tPA as reflected by rapid clinical improvement or hemorrhagic transformation of the infarct. 171 acute ischemic stroke patients treated with tPA were prospectively enrolled. Venous blood for TEG was drawn before and 10 min after tPA bolus. We measured rapid clinical improvement (RCI = 8 point improvement on NIHSS or total NIHSS of 0, 1 at 36 h), Hemorrhagic transformation (HT = any blood on imaging within 36 h), and hyperdense middle cerebral artery sign (HDMCA = biomarker for erythrocyte-rich clot). Multivariable regression models compared TEG parameters after adjusting for potential confounders. No differences in pre- or post-tPA TEG were found between patients with or without RCI. Also, there was no correlation between TEG and HDMCA. Clotting was slightly prolonged in patients with HT (p = 0.046). We failed to find a robust association between TEG and clinical response to tPA. It is likely that arterial clot lysis is determined by factors unrelated to coagulation status as measured by TEG in the venous circulation. It is unlikely that TEG will be useful to predict clinical response to tPA, but may help predict bleeding.

Background: The transfer process for patients with large vessel occlusions from a community hospital to an intra-arterial therapy (IAT)-capable center often involves multiple teams of physicians and administrative personnel, leading to delays in care. Objective We compared time metrics for spoke drip-and-ship telemedicine (TM) patients transferred for IAT to comprehensive stroke centers (CSC) in two different health systems: Kaiser Permanente (KP) with an integrated health care system of spokes and a 50 mile range using ambulances for transfer vs UTHealth (UTH), where patients are transferred by helicopter from varying health systems ranging up to 200 miles from the hub. Methods: We retrospectively identified patients in the KP and UTH networks transferred from TM spokes to the CSC (KP—6 spokes and UTH -17 spokes). From 9/15 to 4/16, a total of 79 TM patients (KP-28 patients, UTH-51 patients) were transferred to the respective hubs for evaluation of IAT. Baseline clinical data, transfer, and IAT metrics were abstracted. Results: On average, it takes ~90 minutes for a TM patient to arrive at the CSC hub once accepted by the transfer center. Patients in the KP Network arrive at the hub faster than UTH patients, but IAT metrics/outcomes are comparable. Over 50% of the patients did not undergo IAT on hub arrival mostly due to lack of clot on CTA (20/45) or symptom improvement (9/45). Conclusion: In two large, yet different TM networks, the transfer time from spoke to hub needs to be shortened. Areas for improvement include spoke arrival to transfer acceptance and transfer acceptance to hub arrival. A prospective study is underway to develop best practice time parameters for this complex process of identifying and transferring patients eligible for IAT.

Background: Telestroke (TS) has been used to provide acute stroke care through a variety of different models. Two of these include an external vendor model (EVM), where care is provided by specialists that are not intrinsically related to the hospitals to which the care is being delivered, and another is an internally designed model (IDM) run by neurologists employed by the same hospital system. Our hospital system at Kaiser Permanente employed coverage via an outside vendor at certain sites as well as concurrently used an internally designed telestroke program at other sites. Objective: We aimed to determine if an IDM would provide quicker telestroke services and improve the door to needle time (DTN) to that provided by EVM in the management of acute ischemic stroke. Methods: Charts in which tPA was administered using TS, from 1/1/2015 to 12/31/2015, were retrospectively reviewed from two different medical centers of similar size and patient volume. One center utilized an EVM while the other employed an IDM. Several metrics were compared including DTN, door to telestroke consultation time and call back time from telestroke neurologist. A 2 tailed T-test was used to compare the differences between both groups. Results: Thirty three patients received tPA via IDM, and 37 patients via EVM. The median door to telestroke consultation placement time was 11 minutes (mins) in both hospitals (p=0.10). The median telestroke physician call back was 16 (IQR 13-18) mins in EVM vs. 7 (IQR 10-24) mins in IDM (p=0.024). The overall door to telestroke consultation was 44 (IQR 29-40) mins in the EVM vs. 21 (IQR 14-40) mins in IDM (P=0.006). The median DTN was 86 (IQR 69-107) mins in EVM vs. 51 (IQR 42-70) mins in IDM (p= 0.005). Conclusion: The IDM cohort had quicker call back and consultation times compared to the EVM group. However, there was no difference between door to consult placement time helping to remove local emergency department variability. This suggests that a model that is internally developed with physicians intrinsically related to the hospital system compared to an external vendor may provide quicker telestroke services and improve DTN.

Cerebellar infarction represents 3% of all ischemic strokes in the United States,1-3 resulting in 27,400 new cerebellar infarctions each year.4 An ischemic stroke within the cerebellum presents a clinical and radiological diagnostic challenge. This difficulty may likely be increased in an acute setting where certain components of the neurological examination are often omitted, such as coordination, eye movements and gait.5 The initial radiological study of choice to assist in the diagnosis of an acute neurological deficit is often non-contrast computerized tomography (CT) scan. However, in the early hours after the onset of an acute ischemic stroke the CT scan is often negative,6 and its sensitivity in the posterior fossa is lower than that of supratentorial ischemic strokes.7 Due to the difficulty of rapidly diagnosing a cerebellar stroke, individuals with cerebellar infarction may represent a population of “missed opportunity” for thrombolysis or early preventative interventions to reduce the risk of recurrent stroke. In addition, some cerebellar infarctions progress to pseudotumor edema and brainstem compression, necessitating surgical decompression. A delay in diagnosis may be associated with morbidity and mortality,8 but there are no prior studies that have compared patients correctly diagnosed at initial presentation versus those who have a delay in the diagnosis of cerebellar infarction. This cross-sectional study addresses for the first time the differences in clinical features and outcomes between those individuals with a cerebellar infarct who were diagnosed correctly on initial presentation compared with those who initially were misdiagnosed with another medical condition.

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.