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Background and objectivesTelemedicine bridges the gap between care needs and provider availability. The value of telemedicine can be eclipsed by long wait times, especially if patients are stuck in virtual waiting rooms. UCSD Tele-Untethered allows patients to join visits without waiting in virtual waiting rooms. Tele-Untethered uses a text-to-video link to improve clinic flow, decrease virtual waiting room reliance, improve throughput, and potentially improve satisfaction.MethodsThis institutional review board (IRB)-approved quality improvement pilot (IRB #210364QI) included patients seen in a single vascular neurology clinic, within the pilot period, if they had a smartphone/cell phone, and agreed to participate in a flexible approach to telehealth visits. Standard work was disseminated (patient instructions, scripting, and workflows). Patients provided a cell phone number to receive a text link when the provider was ready to see them. Metrics included demographics, volumes, visit rates, percentage seen early/late, time savings, and satisfaction surveys.ResultsOver 2.5 months, 22 patients were scheduled. Of those arriving, 76% were "Tele-Untethered" and 24% were "Standard Telemedicine." Text-for-video link was used for 94% of Tele-Untethered. Fifty-five percent were seen early. There was a 55-minute-per-session time savings.ConclusionThis UCSD Tele-Untethered pilot benefitted patients by allowing scheduling flexibility while not being tied to a "virtual waiting room." It benefited providers as it allowed them to see patients in order/not tied to exact times, improved throughput, and saved time. Even modest time savings for busy providers, coupled with Lean workflows, can provide critical value. High Tele-Untethered uptake and use of verbal check-in highlight that patients expect flexibility and ease of use. As our initial UCSD Tele-Untethered successes included patient flexibility and time savings for patients and providers, it can serve as a model as enterprises strive for optimal care and improved satisfaction. Expansion to other clinic settings is underway with a mantra of "UCSD Tele-Untethered: Your provider can see you now."

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 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.

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 (CBF6s), 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=70ml (6.8%,7.8%;p=1.0), and NIR eligibility based on DEFUSE-3 (71.8%,68.9%;p=0.63), with 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.

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 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: 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 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.

Cerebral vessel recanalization therapy, either intravenous thrombolysis or mechanical thrombectomy, is the main treatment that can significantly improve clinical outcomes after acute ischemic stroke. The degree of recanalization and cerebral reperfusion of the ischemic penumbra are dependent on cerebral hemodynamics. Currently, the main imaging modalities to assess reperfusion are MRI and CT perfusion. However, these imaging techniques cannot predict reperfusion-associated complications and are not readily available in many centers. It is also not feasible to repeat them frequently for sequential assessments, which is important because of the changing nature of cerebral hemodynamics following stroke. Transcranial Doppler sonography (TCD) is a valid, safe, and inexpensive technique that can assess recanalized vessels and reperfused tissue in real-time at the bedside. Post thrombectomy reocclusion, hyperperfusion syndrome, distal embolization, and remote infarction result in poor outcomes after mechanical or intravenous reperfusion therapy. Managing blood pressure following these endovascular treatments can also be a dilemma. TCD has an important role, with major clinical implications, in evaluating cerebral hemodynamics and collateral vessel status, guiding clinicians in making individualized decisions based on cerebral blood flow during acute stroke care. This review summarizes the most relevant literature on the role of TCD in evaluating patients after reperfusion therapy. We also discuss the importance of performing TCD in the first few hours following thrombolytic therapy in identifying hyperperfusion syndrome and embolic signals, predicting recurrent stroke, and detecting reocclusions, all of which may help improve patient prognosis. We recommend TCD during the hyperacute phase of stroke in comprehensive stroke centers.

Objective Embolectomy is standard for select occlusions up to 24 hours. Transfer patients may have worse outcomes than those originating in embolectomy centers. We developed the Brain Emergency Management Initiative (BEMI) protocol to streamline this transfer process and mimic the urgency that surrounds ST-elevation myocardial infarction cardiac evaluations. Methods We conducted an exploratory assessment of consecutive acute telestroke patients transferred for potential intervention in pre-BEMI versus BEMI periods. Times included spoke in, spoke out, hub in, and groin puncture. Outcomes included discharge destination and symptomatic intracranial hemorrhage. Results Overall, 68 transfers were assessed. There was a higher National Institute of Neurological Disorders and Stroke in BEMI (11 pre-BEMI vs. 20 B.M., P = .01). There were shorter spoke door in to door out (143 vs. 118 minutes, P = .01) and spoke door out to hub door in times (23 minutes pre-BEMI vs. 21 minutes BEMI, P = .001). For embolectomy patients, there was shorter hub door in to reperfusion (83 minutes pre-BEMI vs. 74 minutes BEMI, P = .04) and recombinant tissue plasminogen decision to groin puncture (155 minutes pre-BEMI vs. 130 minutes BEMI; P = .01). There were no symptomatic intracranial hemorrhage or discharge differences. Conclusion In our hub–helicopter emergency medical services–spoke telestroke network, BEMI led to improved evaluation times. BEMI may serve as a model for future rapid stroke transfer pathways.

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.

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 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: 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 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.

BackgroundWe investigated patterns in the time from recombinant tissue-type plasminogen activator (rt-PA) treatment to symptomatic intracranial hemorrhage (sICH) onset in acute ischemic stroke.MethodsWe retrospectively reviewed all admitted “stroke code” patients from 2003 to 2017 at the University of California San Diego Medical Center from a prospective stroke registry. We selected patients that received IV rt-PA within 4.5 hours after onset/last known well and had sICH prehospital discharge. sICH diagnosis was made by prospective review. Endovascular-treated patients were excluded, given the variability of practice. sICH was prospectively defined as any new radiographic (CT/MRI) hemorrhage after rt-PA treatment and any worsened neurologic examination. Time to sICH was the time from rt-PA administration start to documented STAT head CT order time with the first evidence of new hemorrhage. Charts were reviewed for examination time metrics, demographics, clinical history, and neuroimaging.ResultssICH was identified in 28 rt-PA-only treated patients. The mean time to sICH was 18.28 hours (range 2.4–34 hours). Median time to sICH was 18.25 hours. sICH was correlated with increased age (p = 0.02) and increased NIH Stroke Scale (p = 0.01).ConclusionsOur findings suggest that rt-PA patients have the highest risk of post rt-PA sICH within the first 24 hours after treatment. This supports monitoring of rt-PA-treated patients in specialized settings such as neuro-intensive care units or stroke units. Our findings suggest that the probability of sICH is low 36 hours post rt-PA. Future larger studies are warranted to identify the patterns of bleeding after rt-PA administration.

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 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: 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 (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= 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: 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 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.

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= 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.

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) 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 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.

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.

Domain-specific endpoints are assessments that correspond to the output of individual neural systems and are useful for capturing treatment effects on specific behaviors. By contrast, global endpoints combine several attributes into a single score and are useful for capturing broad treatment effects in a summary way. While global endpoints have become the de facto mechanism required to define benefit in stroke trials, they also have important limitations, some of which might be addressed by simultaneously measuring domain-specific endpoints. Substantial opportunity remains to identify quantifiable patient benefit that would otherwise not be captured by global endpoints. Potential advantages of incorporating domain-specific endpoints in acute stroke trials are discussed, such as increased granularity of measurement, improved understanding of how therapies affect the brain between acute treatment and day 90, and optimized therapeutic translation. Potential disadvantages are also considered, including time and cost of administering domain-specific endpoints, as well as statistical implications. Domain-specific endpoints and global endpoints are not mutually exclusive, and both capture clinical benefits to patients. Incorporating a broader set of outcome assessments in stroke trials, including both global and domain-specific endpoints, is warranted.

Background: The authors draw upon their experience with a successful, enterprise-level, telemedicine program implementation to present a "How To" paradigm for other academic health centers that wish to rapidly deploy such a program in the setting of the COVID-19 pandemic. The advent of social distancing as essential for decreasing viral transmission has made it challenging to provide medical care. Telemedicine has the potential to medically undistance health care providers while maintaining the quality of care delivered and fulfilling the goal of social distancing. Methods: Rather than simply reporting enterprise telemedicine successes, the authors detail key telemedicine elements essential for rapid deployment of both an ambulatory and inpatient telemedicine solution. Such a deployment requires a multifaceted strategy: (1) determining the appropriateness of telemedicine use, (2) understanding the interface with the electronic health record, (3) knowing the equipment and resources needed, (4) developing a rapid rollout plan, (5) establishing a command center for post go-live support, (6) creating and disseminating reference materials and educational guides, (7) training clinicians, patients, and clinic schedulers, (8) considering billing and credentialing implications, (9) building a robust communications strategy, and (10) measuring key outcomes. Results: Initial results are reported, showing a telemedicine rate increase to 45.8% (58.6% video and telephone) in just the first week of rollout. Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period). Conclusion: This article is designed to offer a "How To" potential best practice approach for others wishing to quickly implement a telemedicine program during the COVID-19 pandemic.

Background and purpose The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes. Methods The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE. Aims The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management. Conclusions The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis.

The rapid rise of computational aids for stroke diagnosis have led to important concerns about clinicians developing an over-dependence on technology. Other studies have assessed reliance on clinical decision support systems in fields like diabetes, but no such study exists for stroke diagnosis. In this work, we developed a high-fidelity user interface for a computational aid designed to support acute ischemic stroke diagnosis. Engaging with stroke practitioners at the UCSD Stroke Center, we conducted an experiment to determine how technology for identifying stroke symptoms may affect their diagnostic decision-making processes. By assessing how clinicians changed their video-based diagnosis of stroke when provided with data visualizations and predictions from a machine learning tool, we observed that such computational aids do in fact affect clinicians' decisions but only in cases when the aid directly supports or contradicts their prior beliefs. Future computational aids for stroke diagnosis should focus on helping clinicians solidify their decisions rather than only providing them with overly quantitative information that may impede or confuse their judgement.

Background Isolated mental status changes as a presenting sign (EoSC+), are not uncommon stroke code triggers. As stroke alerts, they still require the same intensive resources be applied. We previously showed that EoSC+ strokes (EoSC+ Stroke+) account for 0.1–0.2% of all codes. Whether these result in thrombolytic treatment (rt-PA), and the characteristics/ risk factor profiles of EoSC+ Stroke+ patients, have not been reported. Methods Retrospective analysis of stroke codes from an IRB approved registry, from 2004 to 2018, was performed. EoSC+ was defined as a NIHSS>0 for Q1a, 1b, or 1c with remaining elements scored 0. Characteristics and risk factors were compared for EoSC+, EoSC−, EoSC+ Stroke+, and rt-PA (EoSC+ Stroke+TPA+) patients. Results EoSC+ occurred in 55/2982 (1.84%) of all stroke codes. EoSC+ Stroke+ occurred in 8/55 (14.5%) of EoSC+ codes and 8/2982 (0.27%) of all stroke codes. 6/8 (75%) of EoSC+ Stroke+ scored NIHSS=1. When comparing EoSC++versus EoSC−, Hispanic ethnicity (p=0.009), hypertension (p=0.02), and history of stroke/TIA (p=0.002) were less common in EoSC+. No demographic/risk factor differences were noted for EoSC+ Stroke+ vs. EoSC+ Stroke−. No cases of rt-PA eligibility/treatment were noted. In EoSC+ Stroke+ analysis, imaging positive stroke/intracranial hemorrhage was noted on only 3 cases (3/2982=0.10% of all stroke codes) and none were posterior stroke. Conclusions EoSC+ rarely results in stroke/TIA (0.27%) or stroke (0.10%), and in our analysis never (0%) resulted in rt-PA. Sub-analysis did not show missed rt-PA or posterior strokes. Understanding characteristics, and knowing that EoSC+ Stroke+ patients are unlikely to receive rt-PA, may help triage stroke resources.

The only known therapy for stroke, a major leading cause of death and disability, has to be administered within 3 hours of the onset of symptoms for it to be effective. Accurately diagnosing a stroke as soon as possible after it occurs is difficult as it requires a subjective evaluation by a clinician in a hospital. With the narrow time window required for diagnosis, stroke evaluation would benefit from being aided by computational approaches that identify and quantify stroke symptoms in an efficient way. Here, we propose the design of a novel interface that provides clinicians with visualizations of the results of a machine learning-based technological aid for stroke diagnosis. To effectively support clinicians in determining stroke type, the proposed approach allows them to compare their own manual stroke evaluation with the results of the diagnostic system. By developing and evaluating our prototypes with neurologists, we explore how to best integrate technological aids into busy hospital workflows without burdening clinicians or biasing their decision making processes. We found that properly balancing the predictions of humans with that of technology is key to promoting the adoption of the latter in hospitals.

Purpose: To assess the demographic and clinical characteristics of patients who refuse intravenous thrombolysis (IV tPA) for acute ischemic stroke from the Stroke Registry population collected by the University of California San Diego (UCSD) Stroke Team and to compare outcomes between those who were treated with IV tPA and those who refused. Methods: We evaluated patients between July 2004 and July 2019 from the prospective Institutional Review Board (IRB) approved Stroke Registry project. Patients who either received IV tPA or refused IV tPA were included. Baseline demographics, NIHSS, treatment times and 90 day mRS were collected. Results: A total of 1056 patients were included in the analysis. Forty-seven patients (4.5%) refused IV tPA. There were no differences in demographics between patients who were treated with IV tPA and those who refused. Patients who refused IV tPA had a significantly lower baseline NIHSS (4 vs 9, p= Conclusions: There is a low rate of IV tPA refusal in our registry population which is similar to what previous studies have shown 1,2 . We found that patients who refuse IV tPA have milder deficits and worse pre-morbid disability. We suspect that the longer “arrival to treatment decision” time in the refuse IV tPA group is due to longer informed consent discussions. This study demonstrates the utility of informed consent in clinical practice and highlights the importance of respecting patient autonomy.

Background: Because acute treatment in stroke is time-based for inclusion, efficacy and safety, obtaining an accurate Last Known Normal (LKN) is of critical importance in stroke codes. We sought to assess with a larger sample if the assessment of 1st documented LKN times has improved since our prior 2013 data. Methods: Data was obtained from an IRB approved stroke registry in a single center from July 2013 to December 2018, for LKN time documented by a neurologist (“LKN2”). Chart review was done to document 1st reported LKN time as documented by EMS (or ED if no runsheets available) (“LKN1”). Inpatient stroke codes and hospital transfers were excluded. Differences in LKN1 and LKN2 were computed and stratified into Groups A (LKN1 is earlier in time than LKN2), B (LKN1 is the same as LKN2), and C (LKN1 is later in time than LKN2). Baseline characteristics, thrombolysis rates, stroke code time interval metrics, 90-day disability and death, discharge disposition, and symptomatic ICH rates, were compared between groups. Results: Of 990 stroke codes, 397 or 40.1% had agreeable LKN1 and LKN2 times (Group B) (increased from a historic 26.4%;p= Conclusion: Though initial LKN times obtained by EMS and ED responders have improved over time, there remains a significant discrepancy with 60% incorrect initial reports. Caution should be used when considering rt-PA treatments based on these LKN1 reports as 56% of cases could have been treated outside of current guidelines and evidence. This study highlights the need for continuous training in obtaining accurate LKN times and caution about using initial estimates of time.

Background: Cardiovascular disease is associated with unfavorable outcomes following acute ischemic stroke (AIS). Left ventricularejection fraction (LVEF) alone has not been reported as a significant predictor of unfavorable outcomes in observational studies of AIS.The purpose of this study was to evaluate the relationship between LVEF and 90 day functional outcome in AIS patients who received acute stroke therapy with IV recombinant tissue plasminogen activator (rt-PA), endovascular therapy (EVT), or combination IV rt-PA+EVT. Methods: This was a retrospective review of prospectively collected data from the University of California San Diego (UCSD) Stroke registry from October 2014-June 2019. Analysis included all patients for whom a stroke code was activated and who had a transthoracic echocardiogram (TTE) during stroke admission or within the previous 30 days prior to AIS. Acute stroke therapy was defined as 1) IV tPA only; 2) EVT only; or 3) IV tPA + EVT. LVEF function was defined as: low 50% on TTE. Primary outcome was modified ranking scale(mRS) at 90 days post stroke. Data was examined for frequencies and distribution. Continuous variables were assessed by Pearson correlation and t test. Kruskal-Wallis or ANOVA were used to evaluate group differences. ANCOVA was used for adjusted analysis. Results: In the 227 patients identified, low EF patients were more likely to have atrial fibrillation (61.9%, p=.004) and lower mean admission systolic blood pressure (132.6, p=0.009). LVEF was not significantly associated with 90 day outcome in all treated patients in both unadjusted (p=0.992) and adjusted (p=0.62). LVEF was not significantly associated with 90 day outcome for individual acute stroke therapy groups both unadjusted and adjusted. mRS at 90 days was significantly associated with baseline NIHSS (p Conclusion: In this study, LVEF was not independently associated with 90 day functional outcome in AIS patients who received acute stroke therapy. Further studies in more heterogenous samples are warranted to assess the relationship between LVEF and outcome in all stroke populations.

Introduction: Treatment of acute ischemic stroke (AIS) with tPA must be rapid for timely cerebral reperfusion. Anti-hypertensive (AHT) medication may be required to lower blood pressures prior to tPA. Optimal AHT use and its impact on tPA times is unclear. We examined treatment with IV bolus only (IVB), IV continuous infusion only (IVCI), or both bolus and infusion (BBI) AHTs on door-to-needle time (DTN) in AIS patients eligible for IV tPA. We hypothesized that 1) DTN would be significantly longer in patients requiring IV AHT before treatment and 2) DTN would be significantly lower in patients treated with IVCI compared to IVB or BBI. Methods: We analyzed all stroke codes who received IV tPA at our comprehensive stroke center from July 1, 2008 to June 30, 2019. Subjects were grouped by those that required IV AHT prior to IV tPA (med+tPA) and those that did not (no-med+tPA). The three medication groups were IVB, IVCI, or BBI. Variables examined were initial and immediate pre-treatment blood pressures, NIHSS, mRS, and initial blood glucose. The primary outcome was DTN between groups. Results: Overall, 288 patients were included in the analysis. Approximately 12% (n=35) of patients required IV AHTs before tPA. There was a significant difference between the med+tPA and no-med+tPA groups in 1) median NIHSS (12.5, 10; p=0.040) and initial mean glucose (142, 122.5; p Conclusions: Fewer patients required AHT than expected suggesting lower rates of baseline hypertension in our region. Type of AHT agent used did not significantly impact DTN. This may be due to the small sample size of patients receiving blood pressure medication prior to tPA in this study. Further prospective studies are needed to examine the optimal AHT treatment modality on DTN.

Background: Prior studies have looked into language and race disparities in receiving IV thrombolysis, however none into its correlation in obtaining accurate Last Known Normal (LKN) times that critically guide decision-making for acute stroke treatment. We sought to assess if non-English language preference was associated with inaccurate initial reporting of LKN time by emergency responders compared to LKN obtained by neurologists. Methods: Data was obtained from an IRB approved stroke registry in a single center from July 2013 to December 2018, for LKN time documented by a neurologist (“LKN2”). Manual chart review was done to document 1st reported LKN time as documented by EMS (or ED if no runsheets available) (“LKN1”). Inpatient stroke codes and hospital transfers were excluded. Differences in LKN1 and LKN2 were computed and stratified into Groups A (LKN1 is earlier in time than LKN2), B (LKN1 is the same as LKN2), and C (LKN1 is later in time than LKN2). Spearman correlation was used to analyze language differences; race between groups were compared using ANOVA. Results: Of total 990 stroke codes, 59.9% had discrepancy in LKN1 and LKN2 (17.9% in Group A, 42% in Group C) whereas 40.1% had agreeable LKN1 and LKN2 (Group B). Data for preferred language and race was available in 985 and 950 stroke codes, respectively. Language preference for English versus non-English is listed in Table 1, where no difference was found when Groups A and C (discrepant LKN1 and LKN2) was compared to Group B (p=0.68). Race of each group is listed in Table 2, where no difference was noted among Groups A, B, C as well (p=0.68). Conclusion: Non-English language preference among patients did not correlate with inaccurate reporting of LKN times by emergency responders. There were no significant racial differences found as well between groups with discrepant and agreeable LKN1 and LKN2 times.

Background: Early activation of the stroke code system allows for rapid treatment and potentially better outcomes. Multiple disparities have been identified in standard time metrics of acute stroke care. The purpose of this study was to determine if hospital arrival to stroke code activation (SCA) time was significantly different based on age, sex, or race/ethnic differences in an academic, Comprehensive Stroke Center. Methods: We retrospectively assessed prospectively collected data from the UCSD Stroke registry from June 2003 to July 2019 for all patients for whom a stroke code was activated. Stroke code time metrics, demographics, initial and final diagnosis, treatment, medical history, baseline vital signs, and baseline NIHSS were assessed. Continuous variables were assessed by Spearman rho, Pearson correlation and t test. ANOVA was used for ordinal variables. A linear regression model was built in a stepwise method. Analysis were done unadjusted and adjusted for baseline NIHSS and baseline blood glucose. Results: Of the 5,881 total subjects, 2,954 had a final diagnosis of stroke. The overall mean age was 66.4 (18-103 years, SD 16.7) and 69.1 (18-103 years, SD 15.4) for subjects with final diagnosis of stroke. The overall mean time to SCA was 5.2 minutes (-20 to 5,746, SD 124.5). Arrival to SCA was not significantly different with respect to age in unadjusted (rs=-0.13, p=0.08) and adjusted (rs=-0.14, p=0.46) analysis. Time was not significantly different with respect to sex in both unadjusted (p=0.30) and adjusted (p=0.24) analyses. Arrival to SCA time was not significantly different with respect to race in both unadjusted (p=0.99) and adjusted (p=0.99) analyses. Arrival to SCA time was not significantly different with respect to Hispanic ethnicity in both unadjusted (p=0.09) and adjusted (p=0.07) analysis. In a linear regression model, arrival by ambulance (t 3.10, p Conclusion: There were no significant differences in time to SCA based on sex, age, or race at our academic, Comprehensive Stroke Center. Arrival by ambulance was the only independent predictor of lower arrival to SCA times. Protocols and education in acute stroke management in this setting have reduced disparities in SCA.

Background: Isolated mental status changes as presenting sign (EoSC+), are not uncommon stroke code triggers. As stroke alerts, they still require the same intensive resources be applied. We previously showed that EoSC+ strokes (EoSC+CVA+) account for 8-9% of EoSC+ codes but only 0.1-0.2% of all codes. Whether these result in thrombolytic treatment (rt-PA), and the characteristics/ risk factor profiles of EoSC+CVA+ patients, have not been reported. Methods: Retrospective analysis of stroke codes from an IRB approved registry, from 2004 to 2018, was performed. EoSC+ definition used was consistent with prior publications (NIHSS>0 for Q1a, 1b, or 1c with remaining elements scored 0). Other definitions were also assessed. Characteristics and risk factors were compared for EoSC+, EoSC+CVA+, and rt-PA (EoSC+ CVA+TPA+) patients. Results: EoSC+ occurred in 59/2982 (1.98%) of all stroke codes. EoSC+CVA+ occurred in 8/59 (13.56%) of EoSC+ codes and 8/2982 (0.27%) of all stroke codes. 6/8 (75%) of EoSC+CVA+ scored NIHSS=1. Hispanic ethnicity (p=0.009), HTN (p=0.02), and history of stroke/TIA (p=0.002) were less common in EoSC+. No demographic/ risk factor differences were noted for [EoSC+CVA+ vs. EoSC+CVA-]. No cases of rt-PA eligibility/ treatment were noted. In EoSC+CVA+ analysis, imaging positive stroke/intracranial hemorrhage was noted on only 3 cases (3/2982=0.10% of all stroke codes) and none were posterior stroke. Conclusions: EoSC+ is not an uncommon reason to activate stroke codes, but rarely results in stroke/TIA (0.27%) or stroke (0.10%), and in our analysis never (0%) resulted in rt-PA. Sub-analysis did not show missed rt-PA or posterior strokes. This adds information for application of limited acute stroke code resources. Though stroke codes must still to be activated, understanding characteristics, and knowing that EoSC+CVA+ patients are unlikely to receive rt-PA, may help triage stroke resources. Further investigation is warranted.

Within the field of neurology, there has been limited discussion of how to best respect patient autonomy in patients presenting with an acute stroke, who often have impairments in language and cognition. In addition to performing a detailed neurologic examination and providing a thorough timeline of their current presentation and medical history, these patients and their families are then asked to quickly make critical medical decisions regarding acute stroke therapies (thrombolysis and endovascular therapy). These discussions are often limited by time constraints and inadequate opportunities for patient education regarding acute stroke care. This article discusses some of the challenges of preserving patient autonomy in patients presenting with acute stroke and the advent of a stroke advance directive (Coordinating Options for Acute Stroke Therapy [COAST]) aimed to overcome these obstacles.

Background and Purpose— The 2015 updated US Food and Drug Administration alteplase package insert altered several contraindications. We thus explored clinical factors influencing alteplase treatment decisions for patients with minor stroke. Methods— An expert panel selected 7 factors to build a series of survey vignettes: National Institutes of Health Stroke Scale (NIHSS), NIHSS area of primary deficit, baseline functional status, previous ischemic stroke, previous intracerebral hemorrhage, recent anticoagulation, and temporal pattern of symptoms in first hour of care. We used a fractional factorial design (150 vignettes) to provide unconfounded estimates of the effect of all 7 main factors, plus first-order interactions for NIHSS. Surveys were emailed to national organizations of neurologists, emergency physicians, and colleagues. Physicians were randomized to 1 of 10 sets of 15 vignettes, presented randomly. Physicians reported the subjective likelihood of giving alteplase on a 0 to 5 scale; scale categories were anchored to 6 probabilities from 0% to 100%. A conjoint statistical analysis was applied. Results— Responses from 194 US physicians yielded 156 with complete vignette data: 74% male, mean age 46, 80% neurologists. Treatment mean probabilities for individual vignettes ranged from 6% to 95%. Treatment probability increased from 24% for NIHSS score =1 to 41% for NIHSS score =5. The conjoint model accounted for 25% of total observed response variance. In contrast, a model accounting for all possible interactions accounted for 30% variance. Four of the 7 factors accounted jointly for 58% of total relative importance within the conjoint model: previous intracerebral hemorrhage (18%), recent anticoagulation (17%), NIHSS (13%), and previous ischemic stroke (10%). Conclusions— Four main variables jointly account for only a small fraction (

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Objective ST2 is a member of the toll-like receptor superfamily that can alter inflammatory signaling of helper T-cells. We investigated whether soluble ST2 (sST2) could independently predict outcome and hemorrhagic transformation (HT) in the setting of stroke. Methods We measured sST2 in patients enrolled in the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) network biomarker study. 646 patients had plasma samples collected at the time of hospital admission and 210 patients had a second sample collected 48 h after stroke onset. Functional outcome was assessed using the modified Rankin Scale (mRS), with good and poor outcomes defined as mRS 0-2 and 3-6, respectively. HT was classified using ECASS criteria. The relationships between sST2, outcome, and HT were evaluated using multivariable logistic regression, Kaplan–Meier survival analysis and receiver operating characteristic curves. Results 646 patients were included in the analysis (mean age 69 years; 44% women), with a median NIHSS of 5 [IQR: 2–12]. The median sST2 level on hospital admission was 35.0 ng/mL [IQR: 25.7–49.8 ng/mL] and at 48 h it was 37.4 ng/mL [IQR 27.9–55.6 ng/mL]. sST2 was independently associated with poor outcome (OR: 2.77, 95% CI: 1.54–5.06; P = 0.003) and mortality (OR: 3.56, 95% CI: 1.58–8.38, P = 0.001) after multivariable adjustment. Plasma sST2 was also associated with hemorrhagic transformation after adjustment for traditional risk factors (OR: 5.58, 95% CI: 1.40–37.44, P = 0.039). Interpretation Soluble ST2 may serve as a prognostic biomarker for outcome and hemorrhagic transformation in patients with acute stroke. ST2 may link neuroinflammation and secondary injury after stroke.

Background Intravenous (IV) tissue plasminogen activator (rt-PA) is a proven therapy for stroke in the acute treatment window. Recent published data has shown efficacy for embolectomy for acute ischemic strokes within up to six, 16 and 24 hours in the anterior circulation but there is no guideline for optimal therapy for patients with posterior circulation stroke, specifically basilar artery occlusion (BAO) outside the standard IV rt-PA treatment window. Aim To evaluate differences in outcomes between maximal medical treatment versus thrombectomy in BAO. Method We retrospectively evaluated prospectively collected acute stroke code patients from our stroke registry from 7/2004 to 7/2016. Patients who received IV rt-PA were excluded. Patients with evidence of posterior circulation ischemia and a hyper dense artery sign on initial non-contrast CT were included as a surrogate for direct vessel data before 2014. Patients after 9/2014 were selected by evidence of BAO on vessel imaging. All patients were categorized either as endovascular therapy or standard medical treatment alone. Demographics, hospital discharge location and Modified Rankin Scale (mRS) at 90 days were compared. Two-sample t-test and Fisher's exact test compared continuous and categorical variables across groups respectively. Results A total of 18 patients were included (three embolectomy and 15 medical therapy only). There were no significant differences in demographic data (age, gender, race, ethnicity, blood pressure, diabetes mellitus, hypertension, atrial fibrillation, tobacco use, alcohol use and initial NIHSS). Results for outcome and efficacies showed no statistical difference between medical management and endovascular intervention for functional outcome mRS (0-3) at 90 days (p = 0.2) and discharge location of home/inpatient rehabilitation vs other locations (p = 0.52). Conclusions Our single-center review showed the expected transition from predominantly medically treated posterior circulation BAOs, to a mixed pattern including embolectomy. Although the sample size was small, this study also illustrates the lack of clear efficacy data for optimal treatment strategies, and the ongoing treatment challenges in posterior circulation stroke population in a population of patients outside the rt-PA window.

BACKGROUND AND PURPOSE Identifying a last known well (LKW) time surrogate for acute stroke is vital to increase stroke treatment. Diffusion-weighted imaging (DWI) signal intensity initially increases from onset of stroke but mapping a reliable time course to the signal intensity has not been demonstrated. METHODS We retrospectively reviewed stroke code patients between 1/2016 and 6/2017 from the prospective; Institutional review board (IRB) approved University of California San Diego Stroke Registry. Patients who had magnetic resonance imaging of brain from onset, with or without intervention, are included. All ischemic strokes were confirmed and timing from onset to imaging was calculated. Raw DWI intensity is measured using IMPAX software and compared to contralateral side for control for a relative DWI intensity (rDWI). LKW and magnetic resonance imaging (MRI) time were collected by chart review. Correlation is assessed using Pearson correlation coefficient between DWI intensity, rDWI, and time to MRI imaging. 1.5T, 3T, and combined modalities were examined. RESULTS Seventy-eight patients were included in this analysis. Overall, there was statistically significant positive correlation (.53, P < .001) between DWI intensity and LKW time irrespective of scanner strength. Using 1.5T analyses, there was good correlation (.46, P < .001). 3T MRI analysis further showed comparatively stronger positive correlation (.66, P < .001). CONCLUSIONS There is good correlation between DWI intensity and minutes from onset to MRI. This suggests a time-dependent DWI intensity response and supports the potential use of DWI intensity measurements to extrapolate an LKW time. Further studies are being pursued to increase both experience and generalizability.

To study the rate of symptomatic intracerebral hemorrhage (SxICH) and major systemic hemorrhage (MSH) after acute stroke treatments among different ethnicities/races.Studies have reported ethnic/racial disparities in intravenous tPA treatment (IV tPA). The adverse outcome of tPA and/or intra-arterial intervention (IA) among different ethnicities/races requires investigation.We retrospectively reviewed all patients from an IRB-approved registry between June 2004 and June 2018. Patients who received IV tPA, IA, or both for acute stroke were identified and classified into 2 ethnic groups: non-Hispanics or Hispanics (NH/H) and 4 racial groups: Asian, Black, Other (Native Americans and Pacific Islanders), and White (A/B/O/W).We identified 916 patients that received acute therapy (A/B/O/W: n = 50/104/16/746, H/NH: n = 184/730). For those received IV tPA only (n = 759), IA only (n = 85), and IV tPA+IA (n = 72), the SxICH rate was 4.3%, 4.7%, and 6.9%; the MSH rate was 1.3%, 0%, and 0%, respectively. No significant difference in the rate of SxICH or MSH among different racial or ethnic groups was found after either therapy. Asian race (OR 14.17, P = .01), in association with age, international normalized value (INR), and Partial thromboplastin time (PTT) (OR 1.06, 46.52, and 1.18, P = .020, 0.037, and 0.042, respectively), was predictive of SxICH after IV tPA. There was a significant correlation between age and National Institute of Health Stroke Scale with SxICH (P.01, P = .02, respectively). Age, INR, and PTT were independent predictors of SxICH after IV tPA (OR 1.06, 46.52, and 1.18, P = .02, 0.04, and 0.04, respectively).There was no significant difference in the rate of SxICH or MSH after IV tPA, IA, or IV tPA+IA among different racial or ethnic groups. Larger studies are needed to elucidate the race specific causes of SxICH and MSH after acute stroke treatment.

Introduction: Studies have reported ethnic/racial disparities in intravenous tPA treatment. The outcome of tPA and/or intra-arterial intervention (IA) among different ethnicities/races requires investigation. The purpose of the study was to examine the symptomatic intracranial hemorrhage (SxICH) and major systemic hemorrhage (MSH) after acute stroke treatment among different ethnicities/races. Methods: We retrospectively reviewed all stroke code patients from an IRB- approved stroke code registry between June 2004 and June 2018. We identified patients who received either IV tPA, IA, or IV tPA+IA. Demographics, clinical presentation, co-morbidities, stroke treatments, and adverse outcomes were collected. Patients were classified into two ethnic groups - Hispanics or non-Hispanics (H/NH) and four racial groups- Asians, Black, Others (includes Native Americans and Pacific Islanders), and White (A/B/O/W). Results: We identified 916 patients that received acute therapy (A/B/O/W: n=50/104/16/746, H/NH: n= 184/730). For those received IV tPA only (n=759), the overall SxICH rate was 4.3% (A/B/O/W: 8.1%/6.6%/8.3%/3.7%, p=0.17; H/NH: 5.7%/4.1%, p=0.42), and the MSH rate was 1.3% (A/B/O/W: 2.7%/1.1%/0%/1.3%, p=0.55; H/NH=1.4%/1.3%, p=1.00). White race was significantly correlated with lower SxICH rate after IV tPA (OR 0.07, p=0.02). There was a significant correlation between age and baseline NIHSS with SxICH (p Conclusions: White race correlated with a significantly lower rate of SxICH after IV tPA. There was no significant difference in the rate of SxICH or MSH after IV tPA, IA, or IV tPA+IA among different racial or ethnic groups in this study. Larger studies are needed to elucidate the race specific causes of these SxICH and MSH after acute stroke treatment.

Introduction: We recently published a risk prediction score for telestroke (TS) encounters to differentiate stroke mimics (SM) from ischemic cerebrovascular disease, derived and validated at multiple telestroke sites across the US and Europe. In this study, we assessed if it could be applied to a comprehensive stroke center, non-telemedicine, stroke code registry. Method: In this IRB approved analysis, we performed ROC curve analysis on retrospectively assessed prospectively collected data from acute stroke code registry database for patients from 10/2004 to 7/2018. We tested only characteristics previously shown to be associated with SM. The TM score = (Age multiplied by 0.2) + 6 (if Hx of atrial fib) + 3 (if Hx of HTN) + 9 (if facial weakness) + 5 (if NIHSS > 14) - 6 (if Hx of seizure)). Result: Based on final diagnosis, SM accounted for 1,978/4,185 (47.2%) of patients. Age, NIHSS > 14, facial weakness, atrial fibrillation, hypertension, and seizure were all significantly associated with diagnosis of SM. The TM Score performed well on ROC curve analysis with AUC of 0.704 (p Conclusion: This non-TS, face to face, validation cohort performed similarly to our validations at prior centers (0.70 vs 0.72). This finding not only continues to validate the TM score as an effective tool in assessing the ability to predict SMs, but also broadens its potential for use in non-TS populations. It is promising that it performed well despite a substantially higher proportion of SMs than in TS encounters where some may have already been screened out. Tools like the TM score may help highlight key clinical differences between mimics and stroke patients during complex, time-critical acute evaluations.

Introduction: There has been extensive education required as part of the Joint Commission (TJC) stroke center certification to rapidly identify acute stroke patients. One study found from 1998 to 2001, 25.3% of stroke codes (SC) were deemed stroke mimics (SM). The purpose of this study was to assess if SC activation in true stroke (TS) patients has improved as part of TJC certification. Methods: This study was a retrospective, observational study of prospectively collected data from an IRB approved Stroke Registry. This includes all SC managed by the stroke team from June 2006-June 2018. Data collected includes initial diagnosis, final diagnosis, demographics, and treatment variables. Analysis included all patients in the registry. Final diagnosis was adjudicated by stroke faculty. Baseline demographics, medical history, treatments, and baseline NIHSS were assessed. Data was examined for frequencies and distribution. Baseline demographics and correlations were compared as appropriate. Results: Of all SC (n=4602), 2100 were SM (45.6%). SM were associated with lower age and blood pressure, history of seizure or dementia, female sex, and black race (Table 1). SM also had a lower median NIHSS (3 vs 6, p Conclusions: In this large retrospective, study, 45.6% of SC activations were SM. This is a significant increase in the number of SM captured in previous studies. These results show healthcare professionals are overly cautious at alerting a stroke code as they do not want to miss an opportunity to provide thrombolytic treatment.

Objective: To evaluate an expedited “Brain Emergency Management Initiative (BEMI)” transfer process within a telestroke network with the goal of decreasing transfer delays and time to stroke embolectomy intervention. Methods: We conducted an exploratory, retrospective assessment of consecutive acute telestroke patients transferred for potential intervention to compare outcomes in pre-BEMI vs. BEMI periods. Baseline characteristics included age, sex, ethnicity, stroke risk factors, and NIHSS. Times included Spoke In, Spoke Out, Hub In, and groin puncture. Outcomes included discharge destination home, and Symptomatic Intracranial Hemorrhage (SxICH). Results: Overall, 68 transfers were assessed. There were no differences for age, sex, diabetes, hypertension, or atrial fibrillation. There was a higher NIHSS in BEMI (11 pre-BEMI vs. 20 BEMI;p=0.01). There was a shorter spoke door in to door out (143 vs 118 minutes; p=0.01) and spoke door out to hub door in (23min pre-BEMI vs. 21min BEMI;p=0.001). For embolectomy patients, there was a shorter hub door in to reperfusion (83min Pre-BEMI vs. 74min BEMI;p=.04), and rt-PA decision to groin puncture (155min Pre-BEMI vs.130min BEMI;p=.01). There were no sxICH or discharge home differences. Though NIHSS was correlated with home discharge destination (r=-0.26;p=0.04), Hispanic ethnicity (r=0.33;p=0.01), hub door in to reperfusion (r=0.11;p=0.04) and spoke out to reperfusion (r=0.28;p=0.04), no relationship was strong. Conclusions: In our Hub-EMS-Spoke telestroke network, BEMI led to improved evaluation times. Rapid transfer protocols are critical for improving outcomes. BEMI can serve as a model for future rapid stroke transfer pathways. Further work assessing generalizability and outcomes is underway.

Background Acute stroke codes may be activated for anisocoria, but how often these codes lead to a final stroke diagnosis or alteplase treatment is unknown. The purpose of this study was to assess the frequency of anisocoria in stroke codes that ultimately resulted in alteplase administration. Methods We retrospectively assessed consecutive alteplase-treated patients from a prospectively-collected stroke registry between February 2015 and July 2018. Based on the stroke code exam, patients were categorized as having isolated anisocoria [A+(only)], anisocoria with other findings [A+(other)], or no anisocoria [A−]. Baseline demographics, stroke severity, alteplase time metrics, and outcomes were also collected. Results Ninety-six patients received alteplase during the study period. Of the 94 who met inclusion criteria, there were 0 cases of A+(only). There were 9 cases of A+(other) (9.6%). A+(other) exhibited higher baseline National Institutes of Health (NIH) Stroke Scale scores compared to A− (17 versus 7; P = .0003), and no additional differences in demographics or alteplase time metrics. Final stroke diagnosis and other outcome measures were no different between A+(other) and A−. Of the A+ patients without pre-existing anisocoria, 5 of 6 (83%) had posterior circulation events or diffuse subarachnoid hemorrhage. Conclusions In this exploratory analysis, zero patients with isolated anisocoria received alteplase treatment. Anisocoria as a part of the neurologic presentation occurred in 10% of alteplase patients, and was strongly associated with a posterior circulation event. Therefore, we conclude that anisocoria has a higher likelihood of leading to alteplase treatment when identified in the presence of other neurologic deficits.