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Background and Purpose: Reversible cerebral vasoconstriction syndrome (RCVS) is a well-established cause of stroke, but its demographics and outcomes have not been well delineated. Methods: Analysis of the United States Nationwide Inpatient Sample database (2016–2017) to characterize the frequency of hospitalizations for RCVS, demographic features, inpatient mortality, and discharge outcomes. Results: During the 2-year study period, 2020 patients with RCVS were admitted to Nationwide Inpatient Sample hospitals, representing 0.02 cases per 100 000 national hospitalizations. The mean age at admission was 47.6 years, with 85% under 65 years of age, and 75.5% women. Concomitant neurological diagnoses during hospitalization included ischemic stroke (17.1%), intracerebral hemorrhage (11.0%), subarachnoid hemorrhage (32.7%), seizure disorders (6.7%), and reversible brain edema (13.6%). Overall, 70% of patients were discharged home, 29.7% discharged to a rehabilitation facility or nursing home and 0.3% died before discharge. Patient features independently associated with the poor outcome of discharge to another facility or death were advanced age (odds ratio [OR], 1.04 [95% CI, 1.03–1.04]), being a woman (OR, 2.45 [1.82–3.34]), intracerebral hemorrhage (OR, 2.91 [1.96–4.31]), ischemic stroke (OR, 5.72 [4.32–7.58]), seizure disorders (OR, 2.61 [1.70–4.00]), reversible brain edema (OR, 6.26 [4.41–8.89]), atrial fibrillation (OR, 2.97 [1.83–4.81]), and chronic kidney disease (OR, 3.43 [2.19–5.36]). Conclusions: Projected to the entire US population, >1000 patients with RCVS are hospitalized each year, with the majority being middle-aged women, and about 300 required at least some rehabilitation or nursing home care after discharge. RCVS-related inpatient mortality is rare.

Background: Treatment options for acute ischemic stroke (AIS) now include mechanical thrombectomy. As a result, primary stroke centers (PSC) must quickly identify large vessel occlusion (LVO) patients, treat them with alteplase when appropriate and transfer them to a comprehensive stroke center (CSC) for potential mechanical thrombectomy. Given the need for expedited care in the emergency department, collaboration with emergency medical services (EMS) in the pre-hospital setting and timely administration of alteplase prior to transfer to the CSC have been identified as practice gaps. Purpose: To examine the effect of an educational stroke simulation session on the knowledge and confidence level of registered nurses (RN) and EMS providers who care for patients with acute stroke receiving alteplase. Methods: Simulations were 60 min, in groups of 4-5 RNs and 1-2 EMS providers, and focused on neurological assessment, administration of alteplase, and rapid transfer when a LVO is suspected and/or identified. Participants completed a pre and post simulation survey assessing confidence levels of nurse role actions and knowledge of stroke care (Table 1). A paired samples t-test examined differences in confidence levels and total percent of correctly answered questions on the survey, pre versus post simulation. A McNemar test examined differences in the proportion of participants that correctly answered each question on the test pre versus post simulation. Results: Following the stroke simulation, the confidence levels of nurses increased for all nurse role actions (all P sP sP Conclusions: Simulation based education can be an effective training tool for improving the knowledge and confidence of nursing and EMS providers in the management of AIS.

Thrombolytic treatment for patients who wake with acute ischemic stroke based on MRI DWI-FLAIR mismatch was added to AHA’s 2019 stroke guidelines. While changes were implemented to facilitate care in 2019, it was determined that managing each patient on a case-by-case basis would best use system resources. The spring of 2020 brought new challenges in delay to hospital arrival due to COVID-19. Purpose: Evaluate the current process of managing potential wake up treatment eligible patients. Methods: All ischemic stroke discharges during CT’s rise and peak of the pandemic were reviewed, January 1 - May 31, 2020. Records were reviewed to determine time of arrival, onset or last seen well, time found, NIHSS, treatment or hyperacute MRI done, and any contraindication based on wake up criteria. A chi-square of proportions or Fisher’s Exact test was used to examine the association between month of discharge and patient characteristics for categorical variables. A Kruskal-Wallis H test was used for the continuous NIHSS variable. Results: Since the first COVID-19 patients were admitted in early March, results from January and February were combined (Group 1 n=122) and compared to March, April and May (Group 2 n=143). There was a non-significant (p=0.48) increase from group 1 (62.3%) to group 2 (66.4%) in the percentage arriving more than 4.5 hours from onset or LSW. In addition, group 1 had higher NIHSSs than group 2 (median, IQR=6, 9 vs 3, 10, respectively), but this was not significant (p=0.27, H=1.21). This did however translate into fewer meeting wake up criteria for treatment during the rise and peak period (Group 1=6.6%, Group 2=2.8%; p=0.15). Use of hyperacute MRI was significantly higher in group 1 than group 2 (5.7% vs 0%, p=0.004) since no patients received a hyperacute MRI during peak pandemic. Conclusions: While more patients were expected to be eligible for acute thrombolytics using the wake up criteria due to delay in hospital arrival, this was not observed. Instead, patients arriving during the peak of the pandemic were less severe. Although a hyperacute MRI was still possible without confirmation of COVID-19 negative status, none were done. Enhancements to facilitate obtaining a hyperacute MRI are still needed regardless of reason for patient delay to hospital arrival.