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Background: In 2015, endovascular therapy (EVT) for large vessel occlusions became standard of care for acute ischemic stroke. Lower utilization of IV alteplase has been reported in women, but whether sex differences in EVT use in the United States exists has not been established. Methods: We identified all acute ischemic stroke discharges from Get With The Guidelines–Stroke hospitals between 2012 and 2019 who were potentially eligible for EVT, based on National Institutes of Health Stroke Scale score ≥6 and arrival Results: Of 302 965 patients potentially eligible for EVT, 42 422 (14%) received EVT. Before 2015, EVT treatment rates were 5.3% in women and 6.6% in men. From 2015 to 2019, treatment rates increased in both sexes to 16.7% in women and 18.5% in men. The adjusted odds ratio for EVT in women compared with men was 0.93 (95% CI, 0.87–0.99) before 2015, and 0.98 (95% CI, 0.96–1.01) after 2015. There were no significant sex differences in outcomes except that after 2015, women were less able to ambulate at discharge (adjusted odds ratio, 0.95 [95% CI, 0.95–0.99]) and had lower in-hospital mortality (adjusted odds ratio, 0.93 [95% CI, 0.88–0.99]). Conclusions: EVT utilization has increased dramatically in both women and men since EVT approval in 2015. Following statistical adjustment, women were less likely to receive EVT initially, but after 2015, women were as likely as men to receive EVT. After EVT, women were more likely to be disabled at discharge but less likely to experience in-hospital death compared with men.

The year 2020 has undoubtedly made Digital Health a necessity and no longer an exception. Many technological advances that seemed futuristic became a reality in a few months due to the pandemic’s needs. Stroke was one of the diseases that most benefited from the digital health revolution. Due to the need for immediate care and a shortage of neurologists worldwide, telestroke has revolutionized the acute care of cerebrovascular diseases in many areas based on strong scientific evidence. In this brief article, we have tried to summarize all we have experienced in 2020, the year which irreversibly transformed the practice of medicine.

Introduction: Injury to the corticospinal tract (CST) has been shown to have a major effect on upper extremity motor recovery after stroke. This study aimed to examine how well CST injury, measured from neuroimaging acquired during the acute stroke workup, predicts upper extremity motor recovery. Methods: Patients (N = 48) with upper extremity weakness after ischemic stroke were assessed using the upper extremity Fugl-Meyer (FM) during the acute stroke hospitalization and again at 3-month follow-up. CST injury was quantified and compared, using four different methods, from images obtained as part of the stroke standard-of-care workup. Logistic and linear regression were performed using CST injury to predict delta FM. Injury to primary motor and premotor cortices were included as potential modifiers of the effect of CST injury on recovery. Results: 48 patients were enrolled 4.2 ± 2.7 days post-stroke and completed this study. CST injury distinguished patients who reached their recovery potential (as predicted from initial impairment) from those who did not, with AUC values ranging from 0.75 to 0.8. In addition, CST injury explained ~20% of the variance in the magnitude of upper extremity recovery, even after controlling for the severity of initial impairment. Results were consistent when comparing four different methods of measuring CST injury. Extent of injury to primary motor and premotor cortices did not significantly influence the predictive value that CST injury had for recovery. Conclusions: Structural injury to the CST, as estimated from standard-of-care imaging available during the acute stroke hospitalization, is a robust way to distinguish patients who achieve their predicted recovery potential and explains a significant amount of the variance in post-stroke upper extremity motor recovery.

Introduction: Stroke patients are the second highest post-acute rehabilitation users but there are few comparisons of inpatient rehabilitation (IRF) and skilled nursing facility (SNF) care on patient-reported outcomes. Methods: We compared 3 and 12 month dependence (modified Rankin Scale score=3-6), quality of life (QOL) (Euro-qol-5D continuous variable max=1; death=0), and institutionalization (residence recorded as nursing home, hospice or dead) for acute ischemic stroke (AIS) patients in GWTG-Stroke and the AVAIL (Adherence eValuation After Ischemic Stroke Longitudinal) study living at home pre-stroke and discharged to an IRF or SNF immediately after hospital discharge. Binary and continuous outcomes were modeled by logistic and linear regression, respectively. Inverse propensity weighting (IPW) was used to adjust for measured differences in demographic, clinical and hospital characteristics. Results: Of 473 AIS patients, 72% were discharged to IRFs vs 27% to SNFs. IRF compared with SNF patients were 73 vs. 77 years, with 23% vs. 18% ambulating independently at hospital discharge. After IPW adjustment patients who received IRF care reported better QOL and were less likely to be institutionalized at 3- and 12-months than those who received SNF care but the difference in dependence was not statistically significant (Table). In sensitivity analyses among patients with a NIHSS score, QOL at 3-months was significantly better for IRF compared with SNF patients with no other differences between groups. Conclusions: AIS patients referred to IRFs had higher QOL at 3-months and lower odds of institutionalization at 3 and 12 months post stroke compared with patients referred to SNFs. Further research is needed to discern the mechanisms for potential differences in patient reported outcomes between settings.

Introduction: Trials have demonstrated that antithrombotic medications can prevent ischemic stroke, but it is unclear if prior therapy can also improve outcomes from those still having an acute ischemic stroke. Hypothesis: Antithombotics are the mainstay of treatment in primary and secondary prevention of stroke and thus their use prior to an acute event may be associated with better outcomes. Methods: We studied 540,993 patients with acute ischemic strokes between Oct 2011 and Mar 2014 from 1661 hospitals participating in Get With The Guidelines-Stroke. The associations between prior antithrombotic use and hospital discharge outcomes were examined, controlling for patient and hospital characteristics. Results: There were 250,104 (46%) stroke patients not receiving any antithrombotic prior to stroke; of whom 31.4% had a documented prior vascular indication. Patients taking antithrombotics prior to stroke were older and had more vascular risk factors. After adjustment for baseline prognostic factors, patients on chronic antithrombotics had better outcomes compared with those who did not (Table 1), regardless of whether a prior vascular indication was present or not. Similar results were observed in a subset of patients in whom NIHSS was available (n=415,034). Conclusions: Prior antithrombotic therapy was independently associated with improved clinical outcomes after acute ischemic stroke. Ensuring use of antithrombotics in appropriate patient populations may be associated with benefits beyond stroke prevention. Table 1

Introduction: Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score, derived from the Partners TeleStroke Network, for use during telestroke encounters to differentiate stroke mimics (SM) from ischemic cerebrovascular disease (iCVD). Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TM score in a broader population. Methods: We evaluated the TM score in 1,985 telestroke consults from the University of Utah Telestroke Program (n=190), Georgia Regents University Telestroke Network (n=719) and the Bavarian TeleMedical Project for integrative Stroke Care (TEMPiS) in Germany (n=1076). We report the AUC in ROC curve analysis with 95% CI. The TM score = 0.2*(Age in years) + 6*(Hx of atrial fib) + 3*(Hx of HTN) + 9*(facial weakness) + 5*(NIHSS > 14) - 6*(Hx of seizure). Lower TM scores correspond with a higher likelihood of being a stroke mimic. Results: Based on final diagnosis at the end of the telestroke consultation, there were 691/1985 (34.8%) SM in the external validation cohort. We tested the association between the TM score and the diagnosis of stroke mimic (Table). The TM score performed well at the external centers on ROC curve analysis with an AUC of 0.70 (0.67 - 0.73; p Conclusion: As telestroke consultation expands, increasing numbers of SM patients are being evaluated. The TM score correctly predicted the presence of a SM in these diverse cohorts just as well as in our original cohort. Decision-support tools based on predictive models, like the TM score, may help highlight key clinical differences during complex, time-critical telestroke evaluations.

Introduction: Several studies have reported poor outcomes in patients “too good to treat” with tPA (TGTT) due to mild or rapidly improving symptoms. We sought to evaluate clinical and imaging factors associated with poor outcomes in these patients Methods: Using our institutional GWTG stroke registry, we analyzed 4,745 consecutive stroke admissions (2009-2015). Univariate and multivariable analysis determined factors associated with poor outcome (i.e., not being discharged home). Results: Of the total 4,745 patients, there were 380 TGTT patients’ symptoms. Of these, 67.8% were discharged home, 25.1% to inpatient rehabilitation, 4.2% to a skilled nursing facility and 2.9% expired/hospice. Patients with poor outcome were older, more often Hispanic had more vascular risk factors and higher median NIHSS. Imaging characteristics associated with poor outcomes included large, multifocal or insular infarcts and proximal occlusion or poor collaterals. In multivariable analysis, age, Hispanic ethnicity, diabetes, NIHSS, and infarct distribution (posterior/anterior+posterior) remained significant. Conclusion: A substantial percentage of patients deemed “too good” for IV tPA were unable to be discharged home. Factors such as advanced age, stroke risk factors, higher NIHSS and infarct location independently predicted poor outcome in patients who are considered TGTT and could be considered in tPA decision-making to optimize outcomes.

Intro: Many patients are transferred to stroke centers for advanced stroke care, especially after IV tPA. We sought to determine differences in the baseline characteristics and outcomes between AIS cases presenting directly to stroke centers’ front doors vs. transfers-in from another regional acute care hospital. Methods: Using data from the national GWTG-Stroke registry, we analyzed 970,390 AIS cases (01/2010 - 03/14). Patients at hospitals with high transfer-in rates (>15%) were selected (284 hospitals, 303,739 patients). Due to large sample size, instead of p-values, standardized differences were reported. Multivariable model (MV) examined the association of transfer-in vs. front door with the primary and secondary outcomes, adjusting for patient and hospital characteristics including NIHSS. Results: High volume transfer-in hospitals admitted 31% of their patients via transfer. Transfer-in patients were younger, more often white and non-Hispanic. They had similar stroke risk factors except for hypertension and previous stroke/TIA which were less common. Transfer-in had worse initial NIHSS, more often had altered consciousness and language disturbance. Transfer-in patients had longer length of hospital stay, higher mRS at discharge, and were less often discharged home. In-hospital mortality was ∼ 3% higher in transfer-in as compared with front-door. Among tPA treated patients, sICH < 36hr was more common in transfer-in patients. On MV, transfer-in patients had overall worse outcomes as shown by the higher odds of in-hospital mortality, longer length of stay, and not able to ambulate independently at discharge (Table). Conclusion: Many hospitals receive high volumes of stroke patients via transfer. Because transfer-in patients have worse outcomes, these patients have the potential to negatively influence institutional outcomes rates. Transfer-in patients should be carefully accounted for in risk adjusted models of hospital outcomes.

Background: Mortality rates as high as 20% have been reported for pregnant patients with intracerebral hemorrhage (ICH). The aim of this study is to describe the risk factors, management and outcomes of pregnant compared to non-pregnant patients with ICH in the Get With The Guidelines (GWTG) Stroke Registry. Methods: Using medical history or ICD-9 codes, we identified 178 pregnant and 4817 non-pregnant female patients aged 18-44 with ICH in GWTG from 2008-2013. Differences in patient and care characteristics were compared by Chi-square tests for categorical variables and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: Pregnant ICH patients were younger, had fewer preexisting stroke risk factors and used fewer associated medications. Median initial blood pressures, initial neurologic exam findings and measures of guideline-based care were similar between groups (Table). Stroke onset did not occur in a healthcare setting for >85% of all patients, but pregnant patients took longer to arrive (median 268 vs. 186 min), used EMS less often (29% vs. 39%) and went to larger hospitals with higher annual ICH admissions than non-pregnant patients. Risk adjusted odds of in-hospital death in pregnant women were about half that of non-pregnant women (aOR 0.57, 95% CI 0.34-0.94), but length of stay >6 days (aOR 1.39, 95% CI 0.86-2.27), independent ambulation at discharge (aOR 1.12, 95% CI 0.81-1.54) and discharge to home (aOR 1.10, 95% CI 0.81-1.51) outcomes were similar. Conclusions: Pregnant women with ICH are younger and healthier than their non-pregnant counterparts but have similar presenting symptoms. Despite later arrival times, in-hospital mortality is lower, suggesting differences in underlying disease pathophysiology.

Background: Subarachnoid hemorrhage (SAH) accounts for up to 4.1% of all pregnancy-related in-hospital deaths, but is less often aneurysmal and is associated with better short term outcomes than in non-pregnant patients. We sought to describe the risk factors, management and outcomes of pregnant vs. non-pregnant patients with SAH in the Get With The Guidelines (GWTG) Stroke Registry. Methods: Using medical history or ICD-9 codes, we identified 152 pregnant and 5745 non-pregnant SAH female patients aged 18-44 with SAH in GWTG from 2008-2013. Differences in characteristics were compared by Chi-square tests for categorical and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: Pregnant SAH patients were younger, more often black and insured with Medicaid. They had higher initial blood pressure (BP) and were less likely to report prior hypertension. Arrival delays from stroke onset were common in both groups (median 340 vs. 277 min), but pregnant SAH patients were more often already hospitalized at stroke onset (16% vs. 10%). Fewer pregnant vs. non-pregnant SAH patients had initial neurologic exam findings recorded (Table). Pregnant SAH patients had lower in-hospital death than non-pregnant patients (aOR 0.17, 95% CI 0.06-0.45) and were more likely at discharge to ambulate independently (aOR 2.40, 95% CI 1.56-3.69) and return home (aOR 2.60, 95% CI 1.67-4.06). Conclusions: Several differences exist between pregnant and non-pregnant women with SAH. Many present with BP well below the threshold for hypertensive disorders of pregnancy, making prompt recognition and prevention of brain hemorrhage challenging. Overall, pregnancy-related SAH is associated with less morbidity and mortality than non-pregnancy related disease.

Purpose: To determine hospital and patient level characteristics associated with use of endovascular therapy for acute ischemic stroke and to analyze trends in clinical outcome. Methods: Data were from Get With The Guidelines-Stroke hospitals from 4/1/2003 to 6/30/2013. We looked at secular trends in number of hospitals providing endovascular therapy, use of endovascular therapy in these hospitals, and clinical outcomes. We also analyzed hospital and patient characteristics associated with endovascular therapy utilization. Results: Of 1087 hospitals, 454 provided endovascular therapy to at least one patient in the study period. From 2003 to 2012, the proportion of hospitals providing endovascular therapy increased by 1.6%/year (from 12.9% to 28.9%), with a modest drop in 2013 to 23.4%. Use in these hospitals increased from 0.7% to 2% of all ischemic stroke patients (p Conclusion: Use of endovascular therapy increased modestly in this national registry from 2003 to 2012 and decreased in 2013. Clinical outcomes improved notably from 2010 to 2013, coincident with the introduction of newer thrombectomy devices.

Background: Ischemic Stroke (IS) is a rare but serious event during pregnancy or the postpartum period. We compared the characteristics and outcomes of pregnant vs. non-pregnant women diagnosed with IS in the Get With The Guidelines Stroke Registry. Methods: We identified 24641 female patients aged 18-44 with IS, based on medical history or ICD-9 codes, from 2008-2013. Patient and hospital categorical variables were compared by Chi-square and continuous variables by Wilcoxon Rank-Sum. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics. Results: There were 338 (1.4%) pregnant IS patients. Compared to non-pregnant patients, pregnant patients had fewer traditional stroke risk factors, were less often black, and were more likely to be insured by Medicaid, in a healthcare setting at stroke onset, and admitted to a stroke center. Both groups had similar initial mild stroke severity and exam findings most notable for weakness (Table). Discharge outcomes of in-hospital death (aOR 0.70, 95% CI 0.33-1.50), discharge to home (aOR 1.04, 95% CI 0.81-1.34), independent ambulation (aOR 1.03, 95% CI 0.79-1.34) or length of stay >4 days (aOR 1.27, 95% CI 0.96-1.68) did not differ between groups. Of the 145 cases where pregnancy stage was coded, 76 (52.4%) occurred postpartum and 65 (44.8%) antepartum, with no difference in discharge outcomes. Women with postpartum compared with antepartum IS were more likely to have hypertension, use antihypertensives pre-stroke, and have higher median initial post-stroke blood pressure. Conclusions: Pregnancy-related IS is uncommon and occurs in women with few traditional stroke risk factors, often within 6 weeks postpartum. Despite these differences, short term outcomes after stroke are similar to non-pregnant women. Further research is needed to determine if pregnancy, itself, independently contributes to stroke risk.

INTRODUCTION: Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality after intracerebral hemorrhage (ICH). Guidelines encourage the early use of mechanical and chemo prophylaxis (CP; i.e., low-dose heparin or low-molecular weight heparin) after ICH. We sought to determine the type and timing, temporal trends, and patient and hospital characteristics associated with VTE prophylaxis after ICH in the Get With the Guidelines-Stroke registry. METHODS: We identified patients with ICH between January 1, 2009 and September 30, 2013 who: 1) were not ambulatory and/or comfort care measures only by hospital day 2; 2) were not transferred to another acute care facility; and 3) had known VTE prophylaxis status at end of hospital day 2. Categories for VTE prophylaxis were 1) no prophylaxis, 2) mechanical prophylaxis alone or unknown/other prophylaxis, or 3) CP with or without mechanical prophylaxis. Early VTE prophylaxis was defined as occurring by hospital day 2. Using multivariable logistic regression, we assessed patient, hospital, and geographic factors associated with early CP use. RESULTS: Among 81,828 patients with ICH from 1,450 hospitals, 5929 (7.2%) received early CP; 68,205 (83.4%) received early mechanical prophylaxis only or other/unknown type; and 7,694 (9.4%) had no early prophylaxis. There was no increase in CP use over the study period. In multivariable analysis, several patient, hospital, and geographic factors were independently associated with early versus no early CP use (Table). CONCLUSIONS: Nationwide, the large majority of ICH patients receive early VTE prophylaxis with mechanical devices only, without prophylactic anticoagulants. Hospital characteristics such as size and geographic location are strong determinants of increased early prophylactic anticoagulant use. Further study of practice variation is needed.

Background: Randomized trials demonstrated benefit of IV tissue plasminogen activator (tPA) is strongly time-dependent, but were underpowered to specify the shape of the time - benefit curve. Large registries can provide insight into how quickly benefits of tPA decay with time. Methods: We analyzed the relationship between onset to treatment (OTT) and 4 outcomes, discharge to home, discharge free of disability (mRS 0-1), discharge ambulatory status, and mortality, in acute ischemic stroke patients treated with tPA within 4.5h in 1456 GWTG-Stroke hospitals from Jan 2009 to Sept 2013. Results: Among the 65,384 tPA-treated patients, median age was 72, 50.5% were female, median OTT was 141 mins (IQR 110-173), and 11.3% (7368) had OTT 0-90m, 71.1% (46,457) had OTT 91-180m, and 17.6% (11,559) had OTT 181-270m. A slight curvilinear relationship was observed between OTT and discharge to home and discharge free of disability, with inflection at 150 minutes (Figure). Discharge free of disability showed rapid decline between 15-150m (11 fewer patients per 1000 treated per 15m delay) and slower decline from 151-270m (5 fewer per 1000 treated per 15m delay). In contrast, a linear relationship with OTT throughout the 15-270 minute window was observed for independent ambulation at discharge (8 fewer per 1000 treated per 15m delay) and in-hospital mortality (2 fewer per 1000 treated per 15m delay). Considering all mRS disability scale transitions, benefit declined more rapidly in the first and second hours (25 and 33 worse outcomes per 1000 treated per 15m delay) compared to 3-4.5 hours (11 worse outcomes per 1000 treated per 15m delay). Conclusions: Rates of excellent, disability-free outcome and of discharge to home after IV tPA decay more rapidly in the first 2.5 hours after stroke onset, while independent ambulation and mortality decline in a linear fashion throughout the 4.5 hour window. Speedier start of tPA treatment within the first 2.5 hours after onset maximizes treatment benefit.

Background: The most feared complication from thrombolysis is symptomatic intracerebral hemorrhage (sICH). Current treatments for sICH are based on limited data. We aim to the efficacy of treatments utilized. Methods: We conducted a collaborative study from 5 academic stroke centers (Columbia University, Massachusetts General Hospital, University of Arkansas, Washington University, and UCLA) on acute post-thrombolysis sICH treatment. The definition of sICH was based on the Safe Implementation of Thrombolysis in Stroke criteria. The primary outcome was in-hospital mortality. Analysis was performed using Fisher’s test and independent t-test, followed by multivariable regression; p Results: We identified 87 patients with sICH from 1/09 to 4/14. Mean time from rtPA infusion to sICH diagnosis was 12±10 hours and mean time to treatment after diagnosis 2.5 ± 2.3 hours. 91% were diagnosed more than 2 hours from initiation of rtPA. The median NIHSS was lower in patients diagnosed in the first 3 hours versus after 3 hours (10 vs. 18, p=0.01). We found no association between receiving any treatment versus none with in-hospital mortality (37% vs 52%, p = 0.1). Factors associated with higher mortality were code status change within 24 hours (56% vs. 13%, p Conclusion: The treatment of post-thrombolysis sICH did not reduce mortality. Possible explanations include perception of futility, prolonged time to diagnosis, and endovascular treatment. More aggressive neurological monitoring beyond two hours from rtPA and screening high risk patients, especially those with high NIHSS score may potentially reduce time to diagnosis/treatment. Innovative treatment with high efficacy and short onset of action should be studied to improve the outcome of sICH.

Background: Pregnancy and recent cesarean delivery are thought to pose unacceptable complication risks from IV thrombolysis (tPA), and most pregnant or recently postpartum women with ischemic stroke (IS) do not receive IV tPA. We sought to determine the frequency of IV tPA use and short term outcomes among pregnant vs. non-pregnant women with IS in the Get With the Guidelines Stroke Registry. Methods: Pregnant or recently postpartum ( Results: Pregnant patients were less likely to receive IV tPA than non-pregnant patients (15/338 (4.4%) vs. 1913/24303 (7.9%), p = 0.03). The primary reasons documented for non-treatment in the 0-3 hour timeframe were pregnancy itself (58% vs. 0%) and recent surgery (47% vs. 12%). Other less commonly noted reasons were stroke symptoms too mild (16% vs. 31%) or rapid improvement (13% vs. 32%). There were no differences in major complications between groups (Table). Discharge outcomes between groups were comparable, with low rates of in-hospital mortality (0-2%) and high rates of home discharge (60-72%). Only the proportion with length of stay > 4 days differed, and was more frequent among pregnant patients (Table). Conclusions: Pregnant patients with IS undergo IV thrombolysis infrequently; less often than non-pregnant patients of childbearing age. Despite the rare use, the short term outcomes and complication rates in these pregnant patients generally appear to be favorable and similar to non-pregnant women. As the data are underpowered to show true differences between the groups, larger studies are warranted to study the efficacy and safety of thrombolysis in pregnancy.

Introduction: Nationally, fewer than 30% of IV tPA-treated patients are imaged within 25 minutes, or receive IV tPA within 60 minutes of ED arrival. In 2007, we implemented a new institutional acute stroke care model to include 10 best practices, all of which were later included in AHA’s Target Stroke program. We evaluated the effect of this strategy on timeliness of acute ischemic stroke (AIS) care. Methods: We analyzed median ED door-to-CT (DTCT) and door-to-needle (DTN) times in 4,477 AIS patients enrolled in our Get with the Guidelines Stroke registry from 2003-2011. Predictors of DTN ≤ 60 min (DTN60) were assessed using Chi-square for categorical variables and t-test for continuous variables. Results: An initial CT scan was performed in our ED in 58% of AIS patients, 289 of whom received IV tPA. Median DTCT times and DTN60 dropped significantly among tPA-treated patients after the intervention (Table 1, Chart 1). The percentage of patients with DTCT ≤ 25 min and DTN60 doubled post-intervention [12.6% vs. 28.1% and 35.0% vs. 70.0%, respectively, p 60 min. Conclusion: Implementing the AHA Target Stroke best practices improved DTCT and DTN60 times for AIS patients, doubling the percent of patients meeting recommended targets. Only calendar year was independently associated with achieving DTN60, demonstrating a step function improvement after the guidelines were systematically applied. Therefore, changes in hospital-level, rather than patient-related factors are driving improvement.

Introduction: Many large stroke centers provide remote acute stroke consultation to partner hospitals via telephone or video, followed by transfer of the patient to the central hospital (“drip and ship” (DS)). We used data from a large, quality-oriented database to describe the characteristics and outcomes of drip and ship patients compared to patients that received rt-PA and were admitted at the same institution (“front door” (FD) cases). Methods: We analyzed acute ischemic stroke cases treated with rt-PA in Get With The Guidelines-Stroke (GWTG-Stroke) between April 2003 and October, 2010. Data were included from fully participating GWTG-Stroke hospitals with discharge information available. Categorical data were analyzed by Pearson chi-square test and continuous data by Wilcoxon test. Results: A total of 44,667 rt-PA treated ischemic stroke pts from 1440 hospitals were included in this analysis, of which 34,192 were front door cases, and 10,475 were drip and ship. DS cases were slightly younger (69yo vs. 72yo), and were more likely male (46% vs. 50%), white (81% vs. 75%), and had lower NIHSSS (11 vs. 12), p Discussion: Within the GWTG-Stroke database, 23% of rt-PA-treated ischemic stroke are “drip and ship” patients, and have similar demographics and co-morbidities to “front-door” treated patients. Clinical outcomes, including in-hospital mortality and symptomatic hemorrhage are also similar. These data demonstrate that the current national paradigm of remote consultation for acute ischemic stroke thrombolysis is as safe as in-person consultation.