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Telemedicine for stroke (Telestroke) has been a key component to efficient, widespread acute stroke care for many years. The expansion of reimbursement through the Furthering Access to Stroke Telemedicine Act and rapid deployment of telemedicine resources during the COVID-19 public health emergency have further expanded remote care, with practitioners of varying educational backgrounds, and experience providing acute stroke care via telemedicine (Telestroke). Some Telestroke practitioners have not had fellowship-level vascular neurology training and many are without training specific to virtual modalities. While many vascular neurology fellowship programs incorporate Telestroke training into the curriculum, components of this curriculum are not consistent, extent of involvement is variable, and not all fellows receive hands-on training in remote care. Furthermore, the extent of training and evaluation of Telestroke in American Board of Psychiatry and Neurology training requirements and Accreditation Council for Graduate Medical Education assessments for vascular neurology fellowship are not standardized. We suggest that Telestroke be formally incorporated into vascular neurology fellowship curricula and provide considerations for key components of this training and metrics for evaluation.

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Background:As Comprehensive Stroke Centers (CSCs) strive to improve neurointerventional (NIR) times, process improvements have been put in place to streamline workflows. Our prior publication (VISIION) demonstrated an improvement in key performance indicators (KPIs) in our CSC. The purpose of this study is to analyze whether the positive results demonstrated were sustainable.Methods:Sequential stroke NIR patients being Direct Arriving LVO (DALVO) and telemedicine transfer LVO (BEMI) cases were assessed, including subgroups of DALVO-OnHours, DALVO-OffHours, BEMI-OnHours, and BEMI-OffHours. We analyzed times for the original 6 months pre (6/10/20-1/15/21) and compared them to a 17 months post-implementation (1/16/21- 6/25/22) to evaluate for sustainability. Mann-Whitney U was utilized.Results:150 NIR cases were analyzed pre (n=47) v. post (n=103) Viz.ai implementation (DALVO-OnHours 7 v. 20, DALVO-OffHours 10 v. 25, BEMI-OnHours 13 v. 20, BEMI-OffHours 17 v. 38). For Door-to-groin (DTG) assessments, improvement was noted for DALVO-OffHours 39% (157min,96min;p<0.001), DALVO-ALL 25% (127min,95min;p=0.006), BEMI-OffHours 46% (45min,25min;p=0.023), and BEMI-ALL 40% (42min,25min;p=0.005). Activation-to-groin (ATG), door-to-device (DTD), and door-to-recanalization (DTR) showed similar improvements. For DALVO-OffHours, there were significant reductions in door to CT (DTC) 81% (26min,5min;p<0.001), ATG 32% (90min,61min;p=0.036), DTG 39% (157min,96min;p<0.001), DTD 31% (178min,123min;p=0.002), and DTR 32% (197min,135min;p=0.003).Conclusions:Consistent with our initial 6 month post-implementation pilot, we noted sustainability over a 17 month period with sustained reduction in KPIs for numerous key NIR subgroups. In the greatest opportunity subgroup (DALVO-OffHours), requiring team mobilization off hours without benefit of telemedicine transfer lead time, we noted a significant reduction in all 5 time metrics. Our sustainability finding is important to show that process improvements continued even after the immediate period, making a Hawthorne effect less likely and adding credibility to the results. Models such as this, could be useful for other centers striving to optimize workflow and improve NIR times.

Introduction:“Stroke AI” platforms discriminate potentially salvageable tissue from infarcted core, to determine embolectomy eligibility. Numerous platforms are in clinical use, but studies comparing their results are limited. Our institution has access to both viz.AI and RAPID for CT perfusion analysis; as such, we assessed whether core and penumbra estimates were statistically different between the two software.Methods:We performed a retrospective review of images from 2/18-1/21 of acute stroke patients with symptoms 6-24 hours from onset who had CTP in the setting of large vessel occlusion (IRB#804221). Studies initially processed through RAPID were re-analyzed by Viz.ai; core volume (CBF<30%), penumbra+core (TMax>6s), and mismatch ratio were compared using paired t-test, and for infinite mismatch McNemar statistics.Results:A total of 157 cases were identified. 48 were excluded for processing failure or deleted raw data, and 6 research participants were excluded. Viz.ai had larger TMax>6s volumes relative to RAPID (160.13ml,108ml;p=<0.001), but less infinite mismatch (30.1%,40.8%;p=0.04). No significant difference was found for: core volume (16.7ml,18ml;p=0.47), percentage of infarcts >70ml (6.8%,7.8%;p=1.0), and NIR eligibility based on DEFUSE-3 (71.8%,68.9%;p=0.63), with <70ml core(93.1%,92.2%;p=1.0), ≥15ml penumbra (78.6%,76.7%;p=0.79), and mismatch >1.8 (83.1%,81.9%;p=1.0).Conclusions:Both Viz.AI and RAPID provided similar core volumes and NIR eligibility, which gives assurance that both algorithms provide similar actionable results. Reasons why Viz.ai showed larger TMax>6s volumes but less infinite mismatch are unclear, though the latter implies that viz.ai identifies a potential core that may or may not be there in more cases. Penumbra estimation is multifactorial and variance may be due to algorithm alterations in voxel selection to account for artifact, scanner and AI protocols as both have different standards for contrast, radiation exposure, and slice #. Understanding if Viz.ai overestimates or RAPID underestimates TMax>6s will require further assessments of imaging and functional outcome variables. Further analysis to assess if results are accounted for by the above factors is ongoing.

Introduction:Sex differences exist in thrombolytic stroke treatment and outcome and likely in endovascular thrombectomy (EVT). Previous analysis has shown a significant correlation of blood pressure variability (BPV) and sex. The purpose of this study was to assess sex differences in a sample of patients with good recanalization post-with EVT and examine the impact of BPV.Methods:We conducted a retrospective analysis of prospectively collected data from an IRB approved Stroke Registry of two academic Comprehensive Stroke Centers in Southern California between 2017 and 2022. Patients were included if they had 1) anterior circulation ischemic stroke due to large vessel occlusions (LVO) and 2) underwent successful EVT defined as a TICI 2b or 3 result. Male and female subjects were compared for age, sex, Hispanic ethnicity, initial NIHSS, history of HTN, current antihypertensive use, symptom onset to groin puncture time, door to groin puncture time, and symptomatic ICH (sICH), BPV, onset to groin, and door to groin . Good outcome was defined as mRS 0-2. Chi squared a t-test were used as appropriate.Results:We included 131 females and 124 males. There was a significant difference between males and females in: 1) history of a fib (76% v 64%, p=0.42); 2) atrial fibrillation during admission (36% v 50%, p=0.01); 3) age (male 67 v female 73 years, p<0.001); 4) post-EVT SBP (137mmHg v 144mmHg, p-0.02). There was a significant difference in onset to groin (p=0.41), but no significant difference in door to groin (p=0.59). When adjusting for time of onset, there was no significant difference in thrombolysis prior to EVT between groups. There was no significant difference in sICH (6 male v 4% female, p=0.50), 90 day mRS (p=0.81); or discharge disposition (p=0.56). BPV was significantly correlated with sex but not significant for any interaction effect with the variables assessed.Conclusion:This study found no significant sex differences in outcome in this sample. The systems of care provided by an academic, CSC ensure that all patients’ care is expedited and provides the best opportunity for a good outcome in both sexes. Studies of sex differences in EVT treatment and outcome in multiple stroke care settings are vital to reduce disparities in care.

Introduction:There is limited data on ethnic disparities in endovascular therapy (EVT) Thrombolysis In Cerebral Infarction (TICI) revascularization scores and EVT complications. The goal of this study was to compare disparities in TICI scores and complications in Hispanic versus Non-Hispanic ethnicities.Methods:We retrospectively examined prospectively collected data from an IRB-approved stroke registry at two academic Comprehensive Stroke Centers (CSC). We included acute ischemic stroke (AIS) patients with large vessel occlusion within 24 hours of last known well that underwent EVT between 1/1/2013-6/30/2022. Favorable outcome was defined as TICI 2b-3. Complications of symptomatic intracranial hemorrhage (sICH), life-threatening or serious systemic hemorrhage, or other serious complication were collected within 36 hours of EVT and compared between Hispanic or Non-Hispanic subjects. Data was analyzed using Chi-squared and was adjusted for baseline NIHSS, blood glucose, and age. A p-value of <0.05 was significant.Results:A total of 411 patients who met study criteria were identified. In Hispanics versus Non-Hispanics, the mean age was 69 vs 70 years, 44.6% vs 48.3% patients were female, and median initial NIHSS was 17 vs 16. The rate of Hispanics in this sample was 29.4% (n=121). There were no differences in baseline characteristics or in patients receiving IV rt-PA prior to EVT between Hispanic and Non-Hispanics (72.6% vs 65.5%; p=0.17). The overall rate of favorable TICI outcome was 93.7% (n=385/411). There was no difference in favorable TICI scores in Hispanic versus Non-Hispanics (96.7% vs 92.4%; p=0.12). Complication rates were also not significantly different in Hispanics versus Non-Hispanics for: sICH (5.8% vs 2.4%; p=0.09), other serious complications (1.7% vs 2.1%; p=0.78), and life-threatening systemic hemorrhage (0.8% vs 0.7%; p=0.88).Conclusion:There were no differences in TICI outcome or complication rates in Hispanic versus Non-Hispanic patients in these 2 academic CSCs. The use of consistent protocols and pathways at a CSC likely contribute to consistent EVT treatment between ethnicities. Further studies must examine EVT outcomes within various ethnicities and races in multiple stroke centers around the country.

Inflammatory biomarkers predict incident and recurrent cardiac events, but their relationship to stroke prognosis is uncertain. We hypothesized that high-sensitivity C-reactive protein (hsCRP) predicts recurrent ischemic stroke after recent lacunar stroke.

Since Food and Drug Administration approval of intravenous tissue-type plasminogen activator (tPA) for treatment of acute ischemic stroke in 1996, it has become clear that several criteria used for exclusion from therapy were not based on actual data or operationally defined for use in clinical practice. All eligibility criteria from the National Institute of Neurological Disorders and Stroke (NINDS) recombinant tPA Stroke Study were adopted within the alteplase package insert as contraindicationswarnings. Many clinicians have expressed the need for clarification and better definition of these treatment criteria.

In a previous study, 0.3 and 0.45 mgkg of intravenous recombinant tissue plasminogen activator (rt-PA) were safe when combined with eptifibatide 75 mcgkg bolus and a 2-hour infusion (0.75 mcgkg per minute). The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke–Enhanced Regimen (CLEAR-ER) trial sought to determine the safety of a higher-dose regimen and to establish evidence for a phase III trial.

Few studies have addressed outcomes among patients ≥80 years treated with acute stroke therapy. In this study, we outline in-hospital outcomes in (1) patients ≥80 years compared with their younger counterparts; and (2) those over >80 years receiving intra-arterial therapy (IAT) compared with those treated with intravenous recombinant tissue-type plasminogen activator (IV rtPA).

Induced hypothermia is a promising neuroprotective therapy. We studied the feasibility and safety of hypothermia and thrombolysis after acute ischemic stroke.

Telemedicine techniques can be used to address the rural–metropolitan disparity in acute stroke care. The Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use, improved data collection, low risk of complications, low technical complications, and favorable assessment times. The main objective of the STRokE DOC Arizona TIME (The Initial Mayo Clinic Experience) trial was to determine the feasibility of establishing, de novo, a single-hub, multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol.

The aim of this new statement is to provide a comprehensive and evidence-based review of the scientific data evaluating the use of telemedicine for stroke care delivery and to provide consensus recommendations based on the available evidence. The evidence is organized and presented within the context of the American Heart Association’s Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for the use of telemedicine in general neurological assessment and primary prevention of stroke; notification and response of emergency medical services; acute stroke treatment, including the hyperacute and emergency department phases; hospital-based subacute stroke treatment and secondary prevention; and rehabilitation.

Introduction:Acute ischemic stroke (AIS) patients requiring interpreter services during an acute stroke code can experience care delays. Prior research has shown no differences in door-to-needle times in non-English fluent patients. The purpose of this study was to examine the influence of interpreter service needs (IS) on time metrics of tPA administration.Methods:We retrospectively reviewed prospectively collected data from our Comprehensive Stroke Center database (1/2011-4/1/2021) and EMR. Subjects with a discharge diagnosis of AIS for whom a “stroke code” was activated were included; in-house strokes were excluded. Baseline characteristics, frequency of tPA, tPA exclusions, NIHSS, and tPA time metrics were compared between patients who did or did not require IS. Analyses utilized ANOVA, t Test, or Pearson’s Chi-squared test as appropriate.Results:Of 1,043 patients with AIS, 41 had a documented need for IS. tPA was administered in 9 IS and 322 non-IS patients. In IS patients, there were no differences in baseline characteristics between those who received tPA and those who did not. In patients who received tPA, there was a larger amount of Hispanic ethnicity (p<0.01) and hyperlipidemia (p=0.02) in patients requiring IS. There were no tPA rate differences between those that did not and did require IS (22% vs 32%; p=0.22). Patients excluded from tPA due to being out of the window were more likely to have required IS (35% vs 59%; p = 0.003). Onset to arrival (p = 0.89), arrival to treatment decision (p = 0.85), door to needle (p=0.41), and onset to treatment (0.41) were not different in IS patients. Median NIHSS was not different overall (p=0.70) or in tPA patients (p=0.36).Conclusions:This study found no significant difference in frequency or time metrics of tPA administration in AIS patients requiring interpreter services during an acute stroke code. If a patient required an interpreter, they were more likely to be excluded from tPA on the basis of time. We hypothesize this is due to increased time required to obtain relevant history or exam data or small sample size. Further work is planned in larger data sets to ensure resource availability to patients who are in need of interpreter services.

Background:Comprehensive Stroke Centers (CSCs) strive to narrow rt-PA and “Door To Groin” (DTG) neurointerventional (NIR) times. Process improvement workflows have been put in place for rt-PA. While similar processes have been implemented to streamline workflows for hyperacute NIR cases, complex pathways, disparate imaging locations, and fragmented communications all highlight a need for continued improvements.Methods:This quality improvement initiative (IRB #210525) was implemented to assess our transition to the Viz.ai platform for immediate image review and centralized communication and its effect on key performance indicators (KPIs) in an already robust CSC. We compared 6 month periods prior to and following deployment. Sequential stroke NIR patients were included. Both Direct Arriving LVO (DALVO) and telemedicine transfer LVO (BEMI) cases were assessed. We assessed subgroups of DALVO-OnHours, DALVO-OffHours, BEMI-OnHours, and BEMI-OffHours. Mann-Whitney U was utilized.Results:Eighty-two NIR cases were analyzed pre v. post Viz.ai implementation (DALVO-OnHours 7 v. 7, DALVO-OffHours 10 v. 5, BEMI-OnHours 13 v. 6, BEMI-OffHours 17 v. 17). DALVO-OnHours improved 19% (97min, 79min; p=0.201) in median DTG times. DALVO-OffHours had a significant 39% reduction (157min, 95min; p=0.009). DALVO-“All” showed a significant 32% reduction (127min, 86 min; p=0.006). BEMI-OnHours improved 18% (37min, 31min; p=0.337). BEMI-OffHours improved 38% (45min, 28min; p=0.077). BEMI-“All” significantly improved 33% (42min, 28min; p=0.036). Overall, there was a 22% reduction (50min, 39min; p=0.066) after Viz.ai implementation.Conclusions:There was an immediate KPI improvement following Viz.ai implementation for both direct arrival and telemedicine transfer NIR cases (32% and 33% respectively). In the greatest opportunity subset (direct arriving cases requiring team mobilization off hours without benefit of telemedicine transfer lead time) we noted a 39% improvement. With Viz.ai, we noted immediate access to images and streamlined group communications, even in an already well-functioning CSC. These results have implications for future care processes and can be a model for centers striving to optimize workflow and improve NIR timeliness.

Background:Recent advances in endovascular therapy (EVT) have led to a significant improvement in functional outcomes of patients with stroke. However, early neurological deterioration (END) after EVT has still remained a concerning issue. Reasons for END include reocclusion, hyperperfusion after recanalization, and hemorrhagic transformation. The current study was designed to assess the feasibility of early transcranial Doppler (TCD) after EVT, to identify association between TCD findings and END.Methods:This is a pilot study to assess the feasibility of TCD prior and early (within 60 minutes) after EVT. For all selected arteries, we measured peak systolic velocity, end diastolic velocity, mean flow velocity and pulsatility index. Patients were followed for three months after the intervention and disability was measured using modified Rankin scale (mRS). We examined the possible association between active leptomeningeal collateral flow after EVT and END.Results:Between October 16, 2020, and March 28, 2021, we recruited 20 acute ischemic stroke patients with large vessel occlusion who underwent EVT. Five patients were excluded because of a poor temporal window; two had an unsuccessful intervention. Four patients had END and all of them had active leptomeningeal flow with elevated blood pressure after EVT. In cases without END, we did not observe any flow diversion or active leptomeningeal collateral after EVT.In those without significant post-stroke disability (mRS<2), we did not observe any active leptomeningeal flow or flow diversion with blood pressure of ≤ 155/85. Most patients with post-stroke disability (mRS ≥ 2) had either flow diversion or active leptomeningeal flow in the presence of blood pressure ≥ 170/93. Hyperemia was associated with hemorrhagic transformation, particularly in the presence of elevated blood pressure. All cases with symptomatic hemorrhagic transformation had hyperemia.Conclusion:TCD is a feasible approach early after EVT. It has clinical implications in identifying those with END and risk for sICH. Early TCD after EVT may provide personalized BP management based on individualized cerebral flow and the presence of active collateral flow after EVT. Studies with larger sample size are warranted.

Introduction:Acute ischemic stroke (AIS) patients require post-acute care (PAC) rehabilitation that is consistent with degree of stroke deficit. Appropriate PAC disposition for AIS patients varies widely. We examine the relationship between initial National Institutes of Health Stroke Scale (NIHSS) and discharge disposition to determine if stroke severity is associated with disposition.Methods:In our IRB-approved database, consecutive Emergency Department stroke code activations with confirmed diagnosis of AIS were retrospectively analyzed from January 2004-May 2021 at UC San Diego. Patients were grouped into mild (NIHSS 0-5), moderate (NIHSS 6-14), and severe (NIHSS >14) stroke. Outcome variables were PAC disposition: Home, Inpatient Rehab Facility (IRF), Skilled Nursing Facility (SNF), Expired, and Other. Chi-squared and Kruskal-Wallis followed by pairwise proportion tests were used for analysis. Analyses were adjusted for age, sex, baseline modified Rankin score (mRS), and acute stroke treatment.Results:Total 2316 patients were included for analysis. There was a difference between initial stroke severity and discharge disposition overall (p<0.001). (Table 1). Mild stroke patients had less discharges to IRF, SNF, Expired, or Other compared to moderate (p<0.001) and severe (p<0.001) strokes. There was no difference between moderate and severe stroke patients discharged to IRF (p=0.44) or SNF (p=0.48). Age, baseline mRS, and receiving acute stroke treatment were independent predictors for discharge to home, IRF, and SNF. Baseline mRS was an independent predictor for Expired patients.Conclusion:Patients with mild strokes are discharged home more than moderate and severe strokes, but there was no difference between moderate and severe stroke patients discharged to either IRF or SNF. This suggests PAC disposition is not consistent with stroke severity and further studies are needed to investigate other factors related to final disposition.

Background:Prior studies have assessed the effect of time of day and day of week on stroke code frequency. Observations that early evening times might result in more treatable stroke cases have been noted. Experiential data raise the question as to whether 7pm codes are often “real” and “intervenable”. Understanding treatment patterns can help allocate resources. We assessed whether 7am early morning stroke code activation resulted in higher yield of acute treatment compared to 7pm evening stroke codes.Methods:A retrospective analysis of prospectively collected data from an IRB approved stroke registry, from 7/2004-7/2020, was performed. All patients presenting as a stroke code to our comprehensive stroke center (CSC) or covered hospitals were included. Subjects were divided into 2 groups: (7ASC): Stroke code called 06:00-08:00 and (7PSC) Stroke code called 18:00-20:00. Treatment was defined as receiving any thrombolytic or endovascular intervention. Chi-squared was used for categorical and 2-proportion Z-Test was used for proportional data.Results:A total of 988 subjects were identified with stroke codes in these time epochs. Total number of code activations (including mimics) was higher in 7PSC group [277(28.0%) 7ASC, 711(72.0%) 7PSC; p<0.0001] compared to 7ASC group. For patient with final diagnosis of stroke, number of code activations remained higher in 7PSC group [134(28.3%) 7ASC, 340(71.7%) 7PSC; p<0.0001]. Acute treatment rates did not differ between groups [22.7% 7ASC, 22.5% 7PSC; p=0.62].Conclusions:We noted more 7PSC stroke codes even when not adjusting for the extended stroke code time windows in later years of the database. We hypothesize that this may be due to more witnesses being available in the early evening. In spite of this finding, acute treatment rates did not differ between times. This data does not support provider perception that early morning codes are unlikely to be “true or treatable” and early evening codes are often “true and treatable”. Irrespective of perception, stroke providers in a CSC must be immediately and equally available in both early morning and evening. This also has ramifications for interventional procedure staffing and clinical trial enrollments. Further analyses in a larger dataset are warranted.

Introduction:Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke.Methods:In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option.Results:In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences.Conclusion:Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.

Background:Patients with acute ischemic stroke (AIS) due to atrial fibrillation (afib) may have increased complications from intravenous thrombolysis or endovascular treatment (ET) compared to other stroke subtypes. The purpose of this study was to compare the rates of symptomatic intracranial hemorrhage (sICH) in patients with and without a history of a fib treated with IV rt-PA and/or ET.Methods:Consecutive stroke code activations were retrospectively analyzed from January 2004-June 2020 at an academic comprehensive stroke center. Patients were included if they were treated with IV rt-PA and/or ET within 24 hours of stroke onset. Patients were stratified into the six groups:1-No hx of a fib with ET only, 2-Hx of a fib with ET only, 3-No hx of a fib with IV rt-PA plus ET, 4-Hx of a fib with IV rt-PA plus ET, 5-No hx of a fib with IV rt-PA only, 6-Hx of a fib with IV rt-PA only. Primary outcome was defined as any sICH within 72 hours of treatment using the NINDS definition. Baseline demographics were compared. Chi squared was used to assess differences in sICH rates and logistic regression to compare individual groups. Analyses were both unadjusted and adjusted for baseline NIHSS, age, sex, baseline blood pressure, pre-stroke mRS, smoking status, and baseline glucose.Results:We identified 720 AIS patients who received acute treatment (IV rt-PA: n=578; ET: n=100; IV rt-PA+ET:n=18). There was a significant difference in sex (p=0.005); Hispanic ethnicity (p=0.002); current smoking (p=<0.001); current alcohol use (p=0.03), CHF (p=0.01); and age (p<0.0001) between groups. Baseline NIHSS was significantly higher in Group 4 (23, SD 8, p=<0.001).In adjusted analysis, there was no significant difference in sICH in patients with a fib after receiving IVtPA (OR 1.53, CI 0.47-4.99, p=0.48), ET (OR 0.93 , CI 0-∞, p=1.00), or both (OR 0.25,CI 0.00-9.07, p=0.45) compared to those without afib. There was no significant difference in sICH in adjusted analyses in patients with and without a fib overall (OR 0.93, CI 0-∞, p=1.00).Conclusion:In this study, atrial fibrillation did not have a significant impact on rates of sICH in AIS patients treated with IV rt-PA, ET, or both. This study supports the safety of IV rt-PA, ET, and combination therapy in the atrial fibrillation population.

Background:Any clinical feature that may improve the early recognition of, or increase pretest probability of, acute stroke could shorten treatment times. We evaluated the sensitivity and specificity of the "Arm and Leg Positioning and self-Help Assessment” (ALPHA) sign in a predominantly stroke population. This sign was developed from the observation that some stroke patients guard the affected limb. Even mild deficits seem to have minimally supportive micro-gestures of one hand touching or lightly supporting the affected limb.Methods:IRB approval was obtained to review available videos of 63 stroke and non-stroke patients. Observers were instructed to only watch the initial 30 seconds of each video and focus on the limbs. The remaining video, and all the audio, were withheld. Videos were independently scored for the ALPHA sign. A composite score, defined as positive if >/= 50% of examiners reported its presence, was assigned. Scores were compared to true diagnosis (stroke/ CNS lesion was positive if there was a scorable deficit and imaging positive CNS lesion). Sensitivity analyses were performed.Results:Of the original 69 videos, 37 were from the outpatient setting (21 with stroke or other CNS lesions; 16 neurologically intact) and 26 were from the inpatient setting (20 with stroke or other CNS lesions; 6 neurologically intact). The ALPHA sign had a specificity of 86.4% and positive predictive value of 89.7%. Sensitivity was 63.4% and negative predictive value was 55.9%.Conclusions:High specificity and positive predictive value of the ALPHA sign were found suggesting that the recognition of subtle supportive gestures may help in early identification of CNS lesions during a stroke code. As expected, the sign had a lower sensitivity as the cohort was not limited to motor-only deficits. Further assessments in other stroke types, assessing a larger cohort and more examiners of various training level, are planned.

Background:Patients with acute ischemic stroke (AIS) due to atrial fibrillation (a fib) may not have as favourable of a response to intravenous thrombolysis or endovascular treatment (ET) compared to other stroke subtypes. The purpose of this study was to compare the 90-day outcome in patients with and without a history of a fib treated with IV rt-PA and/or ET.Method:Consecutive stroke code activations were retrospectively analyzed from January 2004-June 2020 at an academic comprehensive stroke center. Patients were included if they were treated with IV rt-PA and/or ET within 24 hours of stroke onset. Patients were stratified into the six groups: 1- No history of a fib with ET only, 2- History of a fib with ET only, 3- No history of a fib with IV rt-PA plus ET, 4- History of a fib with IV rt-PA plus ET, 5- No history of a fib with IV rt-PA only, 6- History of a fib with IV rt-PA only. Primary outcome was 90 day modified Rankin Scale (mRS) with favourable outcome defined as mRS 0-2. Baseline demographics were compared and pairwise Wilcoxon Rank was used to assess group differences followed by multinomial regression. Analyses were both unadjusted and adjusted for baseline NIHSS, age, sex, baseline blood pressure, pre-stroke mRS, smoking status, and baseline glucose.Results:We identified 720 AIS patients who received acute treatment (IV rt-PA: n=578; ET: n=100; IV rt-PA+ET:n=18). There was a significant difference in sex (p=0.005); Hispanic ethnicity (p=0.002); current smoking (p=<0.001); current alcohol use (p=0.03), CHF (p=0.01); and age (p<0.0001) between groups. Baseline NIHSS was significantly higher in Group 4 (23, SD 8, p=<0.001). In adjusted analysis, there were significantly more patients with mRS 1 (p=0.03) and mRS 2 (p=0.01) in Group 5 compared to group 6. There was no significant difference in “favourable outcome” in adjusted analyses both between groups and in patients with and without afib overall (OR: 3.10, 95% CI: 0.19-50.97, p=0.43).Conclusion:In this study, afib did not have a significant impact on 90-day outcome in AIS patients treated with IV rt-PA, ET, or both. This study supports the acute use of IV rt-PA in the atrial fibrillation population despite anecdotal comments that cardioembolic strokes do not improve with thrombolysis.

Introduction:The COVID-19 pandemic forced immediate changes to stroke code protocols to maintain safety of patients and providers. We hypothesize that stroke code time metrics were significantly longer in the peri-COVID stroke code activations compared to pre-COVID activations.Methods:We analyzed data from an IRB-approved, prospectively collected stroke registry at a large academic, comprehensive stroke center (CSC). We included all patients that presented as stroke code activations from June 2009-August 2020, excluding spoke telestroke and in-house codes. Pre-COVID was defined as June 1, 2009-March 11, 2020 and peri-COVID March 12, 2020 to August 11, 2020. The pre-pandemic stroke code protocol began June 2009. We assessed The Joint Commission stroke code time metrics between groups. Demographic variables of baseline NIHSS, sex, race/ethnicity, age, smoking, pertinent past medical history, arrival mode, and baseline glucose were assessed. A t-test was used to compare stroke code time metrics in minutes. All analyses were done unadjusted.Results:We assessed 813 pre and 328 peri-COVID stroke code activations. Baseline demographics were significant only for an increased number of Hispanics in the pre-COVID group (22.9% vs 11.1%, p<0.001). Onset to hospital arrival time was significantly longer in the peri-COVID compared to pre-COVID group (244 vs 110 min, p<0.001). Onset to stroke code activation was significantly longer in the peri-COVID compared to pre-COVID group (243.8 vs 116.8 min, p<0.009). Time from arrival to treatment decision was significantly decreased in the peri-COVID group (29.9 vs 39.6 min, p=0.04). Time from arrival to CT scan completed (p=0.37), arrival to treatment administration (p=0.06), and onset to treatment administration (p=0.48) were not significantly different between groups.Conclusion:The COVID-19 pandemic significantly impacted the volume and demographic of stroke patients seeking emergency care. This data supports the trend of patients delaying emergent stroke care. This academic, CSC developed and implemented a COVID-19 stroke code protocol within days of a statewide lockdown. The use of telestroke in this peri-pandemic protocol may have accounted for the significant decrease in time to treatment decision.

Background:The effects of circadian rhythm on stroke can include increases in morning heart rate, blood pressure, catecholamines, platelet aggregation, and hypercoagulability and might correlate with higher numbers of morning strokes. We assessed time of day and frequency of stroke code activation for a potential role of circadian rhythm in stroke risk.Methods:A retrospective analysis of prospectively collected data from an IRB approved stroke registry, from July 2004 to July 2020, was performed. Codes were included where stroke codes were activated with last known well (LKW) <6 hours to limit the effect of wake-up strokes and equalize changing practice patterns over time. Subjects were divided into four epochs based on code activation: Night (00:00-05:59), Morning (06:00-11:59), Afternoon (12:00-17:59), and Evening (18:00-23:59). Confirmed diagnosis of stroke, baseline blood pressure (SBP & DBP), heart rate (HR), and PTT were compared. Chi squared was used to compare categorical data and t test for continuous.Results:A total of 5,366 subjects were identified. Stroke code activations differed across epochs (Night n=312, 5.81%; Morning n=1439, 26.82%; Afternoon n=2207, 41.13%; Evening n=1408, 26.24%: p<0.0001). In the subset analysis of true strokes, activations also differed across epochs (Night n=125, 5.26%; Morning n= 831, 34.95%; Afternoon n=934, 39.28%; Evening n=488, 20.52%: p<0.0001). Overall, SBP was different with Evening highest and Morning lowest (x 151.6, x 148.2;p=0.01). Overall DBP showed Night highest and Afternoon lowest (x 83.9, x 81;p=0.002). Heart rate showed Night highest and Morning lowest (x 84.9, x 81.6;p=0.002).Conclusions:This study found that most stroke code activations occur in Afternoons at this CSC. This may be due to patient level characteristics, bystander availability, or other factors. Future studies should assess multi-center data and include other circadian rhythm biomarkers.

The American Stroke Association guidelines emphasized the need for further high-quality studies that assess agreement by radiologists and nonradiologists engaged in emergency telestroke assessments and decision-making. Therefore, the objective of this study was to determine the level of agreement of baseline brain CT scan interpretations of patients with acute stroke presenting to telestroke spoke hospitals between central reading committee neuroradiologists and each of 2 groups, spoke hospital radiologists and hub hospital vascular neurologists (telestrokologists).

To assess the gender differences in patients with acute ischemic stroke treated with and without tissue plasminogen activator. The primary purpose is to evaluate for differences in baseline risk factors, treatment times, and 90-day outcomes. Data regarding gender differences in acute stroke treatment shows a delayed treatment and evaluation in women with stroke, associated with poorer outcome.