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Background and Purpose: Neurohospitalist neurology is a fast-growing subspecialty with a variety of practice settings featuring neurohospitalist models of care. Since inception, the subspecialty has responded to new challenges in resident training, hospital reimbursement, practice, and burnout. Methods: To characterize neurohospitalists’ current practice and perspectives, we surveyed the neurohospitalists and trainees affiliated with the Neurohospitalist Society using an electronic survey distributed through the society listserv. Results: Of 501 individuals surveyed by e-mail, 119 began the survey (23.8% response rate), with 88.2% self-identifying as neurohospitalists. Most neurohospitalists (63%) are 10 years or less out of training, devoting 70% of their professional time to inpatient clinical activities while also performing administrative or teaching activities. Only 38% are employed by an academic department. Call schedules are common, with 75% of neurohospitalists participating in a hospital or emergency call schedule, while 55% provide telemedicine services. The majority (97%) of neurohospitalists primarily care for adults, most commonly treating patients with cerebrovascular disease, seizures, and delirium/encephalopathy. The majority (87%) are overall pleased with their work, but 36% report having experienced burnout. Conclusions: Neurohospitalists are a diverse group of neurologists primarily practicing in the inpatient setting while performing a variety of additional activities. They provide a wide array of clinical expertise for acute neurological diseases and neurological emergencies that require hospitalization, including stroke, seizure, and encephalopathy. Neurohospitalists in general are very pleased with their work, while burnout, as in neurology and other areas of medicine, remains a concern.

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes ( P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

ObjectiveThe safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT.DesignDemographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ2 tests and multivariate logistic regression.ResultsThere were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34).ConclusionsIAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

Introduction: We constantly strive to improve outcomes for stroke patients. Current ASA Guidelines recommend a door to needle (DTN) time of 60 minutes or less, with a secondary goal DTN time of 45 minutes or less. Our goal was to decrease IV Alteplase (tPA) DTN times to 30 minutes or less using primarily Telemedicine. Methods: In February of 2017, significant changes were made to our stroke alert process:Solidified process for direct neurology beam into the Telemedicine camera (rather than phoning first)Pharmacy responds to stroke alerts in person, and pre-mixes (if the neurologist deems appropriate) tPA at the bedsideThe Teleneurologist remains on the camera, which accompanies the patient to CAT Scan (CT). Through the camera, the neurologist reads the head CT in real timeIf no hemorrhage is confirmed on the CT scan, a verbal order to administer tPA is given while in the CT suite Challenges: Staff concern for patient safety, staff matrices, time constraints to implement these changes, our stroke committee collaborated with all affected departments. Resources were created including checklists and a Stroke Kit that contains tPA mixing guidelines, dosing charts, and blood pressure medications. The staff and physicians were educated on the new process via multiple venues including mock stroke alerts Summary: From 2016 to 2017, there was a significant increase in the percentage of stroke patients who received tPA within 45 minutes or less, and within 30 minutes or less. There were no symptomatic hemorrhages post tPA administration in either 2016 or 2017.Our median DTN time decreased by 11 minutes 8 months after the implementations discussed (from 41 minutes in 2016 to 30 minutes in 2017). Many individual DTN times were under 30 minutes.Because of our success, these process changes were adapted by sister facilities within our division.Our stroke alert process is an excellent example of staff interdisciplinary collaboration, open mindedness, flexibility, enthusiasm and knowledge.

Vasoactive substances, including marijuana, are known precipitating factors of reversible cerebral vasoconstriction syndrome (RCVS). Our objective was to describe the demographics, suspected etiology, and outcomes of RCVS patients, with specific interest in examining the subset of patients who used marijuana prior to the onset of RCVS.We identified and described consecutive RCVS cases treated at a regional, high-volume Comprehensive Stroke Center in Colorado (2012-2015). Univariate analyses were performed to examine the associations between the characteristics and outcomes (stroke and discharge disposition) of the RCVS patients by precipitating factors. We compared patients who used marijuana to those who did not and patients who used marijuana to patients who used vasoactive substances aside from marijuana.Forty patients had RCVS. Sixteen (40%) cases were deemed idiopathic and 24 (60%) were secondary to a suspected trigger. Vasoactive substances were the most common suspected trigger (This study suggests there are demographic differences between patients with RCVS triggered by marijuana compared to the typical RCVS patient. As more states legalize marijuana, medical conditions such as RCVS and their association with marijuana warrants further study and awareness.

Background Cerebral venous thrombosis is a rare cause of stroke that poses diagnostic, therapeutic, and prognostic challenges. Mainstay treatment is systemic anticoagulation, but endovascular treatment is increasingly advocated. Our objectives were to describe the epidemiology, treatment, and prognosis of 152 patients with cerebral venous thrombosis. Methods and Results This was a retrospective study of consecutive cerebral venous thrombosis cases from 2006 to 2013 at a comprehensive stroke center through hospital discharge. Predictors of full recovery (modified Rankin Scale scores 0–1) were analyzed with multiple logistic regression and presented as adjusted odds ratios ( AORs ) with 95% confidence intervals ( CIs ). The population was young (average age: 42 years), majority female (69%), and commonly presenting with cerebral edema (63%), and 72% were transferred in. All patients received systemic anticoagulation; 49% (n=73) required endovascular treatment. Reasons for requiring endovascular treatment included cerebral edema, herniation, or hemorrhagic infarct (n=38); neurologic decline (n=17); rethrombosis, persistent occlusion, or clot propagation (n=10); extensive clot burden (n=7); and persistent headache despite anticoagulation (n=1). There were 7 (10%) procedural complications. Recanalization was successful (61%), partial (30%), and unsuccessful (9%). Overall, 60% fully recovered. Positive predictors of full recovery included hormonal etiology, particularly for patients who were transferred in ( AOR : 7.06 [95% CI, 2.27–21.96], interaction P =0.03) and who had migraine history ( AOR : 4.87 [95% CI, 1.01–23.50], P =0.05), whereas negative predictors of full recovery were cerebral edema ( AOR : 0.11 [95% CI, 0.04–0.34], P AOR : 0.28 [95% CI, 0.09–0.96], P =0.04). Conclusions As one of the largest cohort studies, our findings suggest that cerebral edema, history of migraine, and hormonal etiology were prognostic and that endovascular treatment might be a safe and effective treatment for cerebral venous thrombosis when conventional management is inadequate.

Introduction: Patients with mild acute ischemic strokes (NIHSS ≤7, AISs) have been excluded from intra-arterial therapy (IAT) trials, limiting our understanding of their outcomes after IAT. Mild AIS with large vessel occlusions (LVOs) represent a fragile subset of mild AISs. Despite a low NIHSS, these patients can have a sudden failure of collateral circulation and deteriorate rapidly, resulting in significant disability. The objective of this study was to compare patient outcomes between those with mild AIS and LVO who did and did not received IAT. Methods: We included all adults (≥18) with a mild AIS due to an LVO admitted over 6.5 years to a high-volume comprehensive stroke center. Patients were excluded for any contraindication to IAT (n=240). Comparison groups were IAT vs. no therapy. Outcomes were sICH, in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (>2 vs ≤2). Fisher’s, chi-squared, and logistic regression compared outcomes between groups. Results: There were 75 patients included in the study (Table 1). Overall 21% received treatment, and a majority of patients were 55-79 years, presented with hypertension and hyperlipidemia, and arrived within 4.5h from symptom onset. 7 patients also received IV-tPA. The IAT group had a significantly larger proportion of males, and hypo-mild strokes (NIHSS 4-7). There was one sICH in the no therapy group, and overall few deaths (Table 1). There was no significant difference between groups in improvement in NIHSS, and after adjusting for admission NIHSS, there was no significant difference in favorable discharge mRS. There were no IAT procedure complications. Conclusions: It remains to be seen whether IAT is beneficial in patients with mild AIS and LVO. Future, interventional, multi-center studies are needed to definitively determine the efficacy of IAT. Though these data come from a small patient population, they offer an insight into the potential safety of IAT in a fragile stroke population.

Introduction: Telemedicine is widely used for remote evaluation and treatment of acute stroke patients (telestroke). Because time equals brain, the NINDS and ACLS recommend a benchmark of 15 minutes from arrival to neurologic expertise. Our goal was to examine key time metrics and outcomes in an active telestroke network after implementing system-wide improvements. Methods: Our comprehensive stroke center (CSC) serves as the Rocky Mountain Region’s referral center for comprehensive stroke care. The telestroke program launched in 2006; stroke program leaders recently initiated several changes to improve time metrics, including a) a streamlined process for the centralized call center including centralized paging; b) a dedicated, on-call telestroke neurologist; c) outreach and education to the spoke hospitals for accessing the call center; d) back-up systems in place for technical issues and for times of high consult volumes. We examined the following metrics for all telestroke consults compared to patients admitted through the ED of the CSC over the past 18 months: median (interquartile range [IQR]) neurologist response time, transfer rate to the CSC, and IV t-PA rate. Median telestroke consult times (time to initiation of video consultation) were also reported, beginning April 2016. Results: Ten neurologists at the hub CSC responded to 4,283 pages from 45 spoke hospitals, averaging 8 pages/day. Overall, 14.4% of patients were transferred to the CSC for definitive care. The time to telestroke page response was 2 [1-3] minutes, which was comparable to neurologist response at the CSC of 0 [0-5] minutes for 686 patients. The median telestroke consult time was 2 [1-4] minutes for 70 patients. The IV tPA rate for treating acute ischemic stroke was comparable for telestroke vs. bedside consults (17.3% vs. 18.9%). Conclusions: Based on our mature telestroke network, it is possible to be as responsive with telestroke consults as with in-hospital consults. Several new, scalable processes resulted in improved time metrics. These time metrics should help define what should be expected from a Telestroke provider.

Background: Upon hospital arrival, patients with mild or rapidly improving acute ischemic strokes (AIS) are frequently not treated with IV-tPA. Recent guidelines from the American Heart Association report that diagnosis on imaging of large vessel occlusion (LVO) despite mild stroke severity leads to increased risk of poorer outcomes. The objective of our study was to examine outcomes following tPA in this AIS population. Methods: The study included all AIS patients with an admission NIHSS ≤7 and diagnosis of a LVO on imaging from a single comprehensive stroke center between 2010-2016. Patients were excluded due to missing contraindications to tPA or with a symptom to arrival time of >4.5 hours (n=234). We compared patients who received tPA to those who received no treatment because of mild or rapidly improving symptoms. Outcomes were sICH, improvement in NIHSS score, discharge mRS ≤2, and in-hospital mortality. Patient characteristics were compared univariately, and step-wise logistic regression was used to adjust for confounding variables. Entry criterion was P=0.2 and exit criterion was P=0.07. Results: There were 76 patients with an AIS diagnosis of LVO. Of these patients, 39 (51%) were treated with tPA and 37 (49%) were not treated. Overall, the median (IQR) age was 72 (61-82.5). Patients treated with tPA had a median admission NIHSS of 5 (3-6), and a larger proportion were male (77%) and smokers (4%). Patients without tPA treatment had a median NIHSS of 2 (1-3), and a larger proportion had hypertension (49%). All outcomes were not significantly different between groups after adjustment (Table 1). There were no patients with sICH. Conclusions: Our study suggests that tPA in mild LVO patients does not introduce additional risk in terms of sICH, in-hospital mortality, change in NIHSS, or discharge mRS. Further justification for withholding tPA in this group should be based on 90-day mRS scores, in order to better understand long-term functional outcomes.

Introduction: Despite suffering mild acute ischemic strokes (AIS, NIHSS≤7), patients have a non-zero risk of significant morbidity and mortality. Intra-arterial therapy (IAT) is clearly effective in non-mild AIS, but mild AISs have been excluded from IAT trials, limiting our understanding of their outcomes after IAT. The objective of this study was to report on patient outcomes in a mild AIS population who received IAT. Methods: We included all adults (≥18) with a mild AIS admitted over 6.5 years to a high-volume comprehensive stroke center and who received IAT. Patients were excluded for any contraindication to IAT (n=240). Outcomes were symptomatic ICH (sICH), in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (>2 vs ≤2). Results: There were 55 patients included in the study (Table 1). Overall, patients were predominately aged 55-79 years, admitted with an NIHSS 4-7, or had hypertension. 72% of patients either had a cardioembolic or large vessel occlusion (LVO), and 73% arrived either 0h to 4.5h, or >6h to Conclusions: These data highlight the safety of IAT in patients with mild AIS, mirroring the results seen in recent large randomized clinical trials showing efficacy of IAT in the non-mild AIS population. Patients in our study had a non-existent risk of sICH, and a mortality rate similar to literature examining IV-tPA administration in patients with mild AIS. Furthermore, a large proportion of patients showed a clinically meaningful improvement in NIHSS, or were discharged with a favorable mRS.

Introduction: Cervical artery dissection is a recognized cause of acute ischemic stroke (AIS). Intra-arterial treatment (IAT) may be a complementary option to IV tPA and antithrombotic therapy. Hypothesis/Purpose: To describe a large series of patients with dissection treated with IAT. Methods: Demographics, clinical characteristics, treatment, and outcomes were summarized for all dissection patients treated with IAT from 1/2010 - 5/2015. Outcomes included functional independence (modified Rankin score ≤ 2 at 90 days or discharge, or discharge home), recanalization, procedural complications, sICH, and mortality. Data are presented as median (interquartile range) or (n). Results: Of 161 patients with dissection, 24 (15%) were managed with IAT and comprise our population, which was primarily male (75%) aged 52 (42-59.5) and NIHSS of 13 (12 -16). Internal carotid artery dissections (ICAD, 18) were more common than vertebral artery dissections (VAD, 6); three patients had bilateral dissections (1 ICAD, 2 VAD). In all but two patients there was associated intracranial embolus. Dissections were idiopathic (17), traumatic (5) or cough-related (2). Eleven patients were treated with IV tPA. IAT techniques included thrombectomy (19), IA thrombolysis (17), stent (13), and angioplasty (7). The majority of patients had multiple techniques: 2 (2 -3). Functional independence was achieved in 63% (12/19). There were four deaths, none were attributable to IAT. There was one sICH and three procedural complications (2 groin pseudoaneurysm, one catheter induced acute dissection). Among the 6 VADs, 2 were left untreated and the remaining 4 were successfully recanalized (100%). All 6 VADs had a basilar artery occlusion; recanalization was successful in 2 and partial in 4 cases. Among the 18 ICADs, 6 were left untreated and the remaining 12 were successfully recanalized (100%). Sixteen of 18 ICADs had middle cerebral artery occlusion; recanalization was successful in 4, partial in 10, and unsuccessful in 2 cases. Conclusions: Despite the additional intravascular risk, outcomes appear to be similar to those presented in large RCTs with stroke from all causes, suggesting utility of IAT when performed in patients with dissection.

Introduction: There are no data to support the hypothesis of an increased risk of symptomatic ICH (sICH) with the later 3-4.5h IV-tPA treatment window, compared to the Hypothesis: There is a significant difference in the odds of suffering a sICH if treated with IV-tPA Methods: This was a 6-year retrospective observational cohort study. All adult (≥18 yrs) patients admitted with an ischemic stroke between 1/2010-6/2015 and treated with IV-tPA were included in the study. Patients receiving IA treatment were excluded (n=244). Outcomes for this study were sICH (4-point increase in NIHSS within 36h with new ICH seen on CT), in-hospital mortality and favorable discharge mRS (≤2). Chi-squared, Fisher’s exact and Wilcoxon rank-sum tests were used to compare proportions and medians between groups. Multivariate, stepwise logistic regression was used to assess differences in the odds of outcomes; entry and exit criteria for covariates were p=0.20 and p=0.10. Results: 561 (90%) were treated Conclusions: tPA treatment windows impact sICH, mortality and favorable mRS rates. Ensuring thrombolytic therapy is received

Introduction: The safety and efficacy of intraarterial treatment (IAT) for acute ischemic stroke (AIS) due to cervical artery dissection (CAD, carotid and vertebral) has not been studied in a controlled trial. Hypothesis: There will be no differences in safety and efficacy of IAT for AIS due to CAD compared to non-CAD mechanism. Methods: We studied consecutive admissions with AIS who received IAT between 1/2010 - 4/2015 and compared outcomes for AIS patients who presented with CAD mechanism vs. other causes. Outcomes included in-hospital mortality, symptomatic intracerebral hemorrhage (sICH), procedural complications, and functional independence (Modified Rankin Score ≤ 2 at 90-days or discharge, or discharge home). Outcomes were univariately analyzed with Chi-square tests. Co-primary outcomes of functional independence and sICH were analyzed with multivariate logistic regression. Results: Of 3,671 patients with AIS, 445 patients received IAT and comprise our study population: 24 with CAD (5%: 18 carotid, 6 vertebral) and 421 with another cause. Patients with CAD were younger (median age: 52 vs. 70, p < 0.001) with less severe stroke (median NIHSS: 13 vs. 18, p=0.03) than those with another cause of AIS. Unadjusted outcomes were similar by AIS cause (Table 1). After adjustment for NIHSS and age, the odds of achieving functional independence (OR: 0.58 [0.19-1.78], p=0.34) and sICH (OR: 0.57 [0.07-4.66], p=0.60) were not significantly different in patients with CAD vs. other mechanism. Conclusions: Intraarterial treatment appears to be as safe and effective when used in patients with ischemic stroke due to CAD as in AIS patients with other causes. Following the major advances in IAT for AIS in the general population, IAT should be considered in patients with AIS due to a CAD.

Introduction: Clinical trials confirmed the benefits of intra-arterial therapy (IAT) for managing acute ischemic stroke (AIS). Yet not all hospitals are able to perform IAT, requiring rapid transfer of potential IAT candidates. Hypothesis: AIS patients receiving IAT who were admitted directly to a Comprehensive Stroke Center (CSC) would have similar outcomes to those transferred to the CSC from a less specialized hospital. Methods: Data were retrospectively abstracted for AIS patients treated with IAT at a CSC (1/2014 – 5/2015). Clinical characteristics and the following outcomes were compared in patients directly admitted to the CSC and those transferred: recanalization to TICI ≥2b, discharge and 90-day mRS (favorable, ≤2), sICH, and in-hospital mortality. Univariate and multiple logistic regression analyses were conducted. Results: IAT was performed in 133 patients; 34 (25.6%) directly admitted and 99 (74.4%) transferred to the CSC. Transferred patients were significantly younger, more often male, with fewer comorbidities, a longer time from symptom onset to arrival, but shorter time from arrival to groin puncture (table 1). Unadjusted outcomes were similar between groups (table 1). After adjusting for significant covariates (p0.4 for all). Discharge mRS remained worse in transferred patients (p=0.01) after limiting the data to those arriving to the CSC Conclusion: Even after limiting the analysis to patients arriving to the CSC

Objective: Admission measures of stroke severity are often used to assess 30-90 day outcomes. Since some patients have a poor outcome by discharge, we sought to identify a biomarker that distinguishes severities as well as acute outcomes. Disruptions in the equilibrium of the redox system were used as an indicator of stroke severity and acute outcome. Methods: Oxidation reduction potential (ORP), a measure of the redox system, was assessed in plasma at admission and 24 h later in patients admitted with stroke symptoms (n=76). Overall differences in ORP between stroke patients and healthy controls were determined. Within stroke patients, changes in ORP as a function of hospital discharge status, modified Rankin scale and NIHSS were assessed using ANOVA and the ability to predict acute outcome in ischemic stroke patients based on ORP was compared to NIHSS using Receiver Operator Characteristics. Results: Stroke patients had higher ORP levels than healthy controls (p 146.6 mV at admission was associated with a 46 fold increased odds of a good acute outcome. Conclusion: ORP measured at admission identified patients which died or were discharged to hospice based on their lower ORP values. The lower ORP and subsequent increase 24 h later in the most severely affected patients may reflect a failure or a delay in engaging the redox system, a response that may, during acute stages, be beneficial.