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BackgroundPatients with ischemic stroke and concomitant coronavirus 2019 (COVID-19) infection have worse outcomes than those without this infection. However, research on the impact of COVID-19 infection on outcomes following hemorrhagic stroke remains limited. We aim to study whether concomitant COVID-19 infection leads to worse outcomes in spontaneous intracerebral hemorrhage (ICH).DesignWe conducted an observational study using data from Get With The Guidelines® Stroke, an ongoing, multi-center, nationwide quality assurance registry.MethodsWe implemented a two-stage design: first, we compared outcomes of ICH patients with and without COVID-19 infection admitted during the pandemic (from March 2020 to February 2021). Second, we compared the same outcomes between ICH patients admitted before (March 2019 to February 2020) and during (March 2020 and February 2021) the pandemic. Main outcomes were poor functional outcome (defined as a modified Rankin Scale of 4 to 6 [mRS] at discharge), mortality and discharge to skilled nursing facility (SNF) or hospice.ResultsThe first stage included 60,091 COVID-19-negative and 1,326 COVID-19-positive ICH patients. In multivariable analyses, ICH patients with versus without COVID-19 infection had 68% higher odds of poor outcome (OR 1.68, 95%CI 1.41-2.01), 51% higher odds of mortality (OR 1.51, CI 1.33-1.71) and 66% higher odds of being discharged to a SNF/hospice (OR 1.66, 95%CI 1.43-1.93). The second stage included 62,743 pre-pandemic and 64,681 intra-pandemic ICH cases. In multivariable analyses, ICH patients admitted during versus before the COVID-19 pandemic had a 10% higher odds of poor outcome (OR 1.10, 95%CI 1.07-1.14), 5% higher mortality (OR 1.05, 95%CI 1.02-1.08) and no significant difference in the risk of being discharged to SNF/hospice (OR 0.93, 95%CI 0.90-0.95).ConclusionsThe pathophysiology of the COVID-19 infection and changes in healthcare delivery during the pandemic played a role in worsening outcomes in this patient population. Further research is needed to identify these factors and understand their effect on the long-term outcome.

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

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

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

The healthcare system is undergoing a transition from paying for volume to paying for value. Clinicians, as well as public and private payers, are beginning to implement alternative delivery and payment models, such as the patient-centered medical home, accountable care organizations, and bundled payment arrangements. Implementation of these new models will necessitate delivery system transformation and will actively involve all fields of medical care, in particular medicine and surgery. This call to action, on behalf of the American Heart Association’s Expert Panel on Payment and Delivery System Reform, serves to offer support and direction for further involvement by the American Heart Association. In doing so, it (1) provides baseline review and definition of the present models and some of the early results of these delivery models, including outcomes; (2) initiates a conversation within the American Heart Association on the impact of payment and delivery system reform, as well as how the American Heart Association should engage in the interest of patients; (3) issues a call to action to our organization and to cardiovascular and stroke health professionals across the country to become educated about these models so to as to understand their impact on patient care; and (4) asks the government and other funding agencies, including the American Heart Association, to begin supporting and prioritizing meaningful research endeavors to further evaluate these models.

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

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

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

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

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

Background Desmoteplase is a novel, highly fibrin-specific thrombolytic agent in phase III of clinical development. In comparison to alteplase, it has high fibrin selectivity, is associated with minimal or no neurotoxicity, and has no apparent negative effect on the blood–brain barrier. The safety and efficacy of desmoteplase is being studied in the Desmoteplase in Acute Ischemic Stroke clinical trial program. Three studies (Dose Escalation Study of Desmoteplase in Acute Ischemic Stroke, Desmoteplase in Acute Ischemic Stroke, and Desmoteplase in Acute Ischemic Stroke-2) have been completed, two large randomized, double-blind, placebo-controlled, phase III trials are ongoing at >200 sites worldwide (Desmoteplase in Acute Ischemic Stroke-3 and Desmoteplase in Acute Ischemic Stroke-4, n = 800; DIAS-3 and DIAS-4), and a randomized, double-blind, placebo-controlled, dose-escalation phase II trial is ongoing in Japan (Desmoteplase in Acute Ischemic Stroke-Japan, n = 48; DIAS-J). Aims The objective of DIAS-3 and DIAS-4 is to evaluate the safety and efficacy of a single IV bolus injection of 90 μg/kg desmoteplase given three- to nine-hours after onset of ischemic stroke (National Institutes of Health Stroke Scale 4–24, age 18–85 years). The objective of DIAS-J is to evaluate the safety and tolerability of desmoteplase 70 and 90 μg/kg three- to nine-hours after ischemic stroke onset in Japanese patients. Methods Patients are included with occlusion or high-grade stenosis (thrombolysis in myocardial infarction 0–1) in proximal cerebral arteries on magnetic resonance or computed tomography angiography but excluded with extended ischemic edema on computed tomography or diffusion-weighted imaging. Conclusion Desmoteplase is the only thrombolytic agent in late-stage development for acute ischemic stroke that is now tested in patients with proven stroke pathology. The results of the Desmoteplase in Acute Ischemic Stroke clinical trial program will show whether patients with major artery occlusions but not extended ischemic brain damage can be safely and effectively treated up to nine-hours after onset.

Background: Over 17.2% of the U.S. population primarily speaks a language other than English at home. Limited-English proficiency (LEP) may negatively impact patients, yet its influence on stroke patients’ receipt of thrombolysis remains unknown. Objectives: To evaluate the influence of LEP on acute ischemic stroke patients’ receipt of thrombolysis. Methods: We analyzed data from 3,894 acute ischemic stroke patients who participated in “Get With The Guidelines - Stroke” at Massachusetts General Hospital 1/1/2003-4/30/2014. Information included patients’ language in which they preferred to receive medical care; those who identified a language other than English were considered to have LEP. We performed descriptive statistics and stepwise logistic regression models to examine associations between patients’ LEP status and the use of IV tPA, adjusting for relevant covariates. Results: A total of 307/3894 (9.3%) acute ischemic stroke patients met LEP criteria, representing 25 different languages [Table 1]. Multivariable analyses showed that patients with LEP were more likely than English-speaking patients to receive IV tPA when adjusting for socioeconomic factors (OR=1.64, CI=1.09-2.48, p=0.02). Models that also incorporated patients’ age, sex, and initial NIHSS did not find a statistically-significant effect for LEP on patients’ receipt of IV tPA but highlighted that patients’ NIHSS seemed to be the driving force of IV tPA receipt (OR=1.15; CI=1.13-1.16; p Conclusion: Contrary to our hypothesis, acute ischemic stroke patients with LEP were more likely to receive IV tPA than English-speaking patients; this seemed to be driven by their worse stroke severity.

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

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

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

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

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

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

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

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

Background: Catheter ablation for persistent and long standing persistent atrial fibrillation (PersAF) is challenging and associated with less favorable outcomes and higher risk of thromboembolic events. VICTORY AF is a prospective, multi-center, controlled study that rigorously and independently

Intro: IV tPA use has increased since the 2009 US guidelines recommended extending the window to 4.5 hr. The most common reasons for nontreatment are rapid improvement of stroke symptoms (RISS) and stroke “Too Mild”. We evaluated the NIHSS profile and outcomes over time in Massachusetts Coverdell patients receiving IV tPA, or not treated due to RISS and Too Mild. Methods: All adults >18 yr arriving at a MA Coverdell hospital < 4.5 hr from time last known well with a diagnosis of ischemic stroke or TIA (with persistent symptoms) were included (n=10,433). We compared rates of NIHSS documentation, median NIHSS, and discharge home between 11/09-10/10 (Year 1, n=2,573) vs. 11/12-10/13 (Year 4, n=2,658) among All, IV tPA, RISS, and Too Mild patients. Ordinal variables were analyzed by Kruskal-Wallis and proportions by Chi square, and odds ratio of discharge home was adjusted for NIHSS, age, and gender. NIHSS was missing in 20% of cases. Results: The two cohorts were similar by gender and vascular risk factors, except for age, HTN and dyslipidemia. IV tPA use within 4.5 hr of onset increased (19% vs. 25%, p Discussion: IV tPA use in MA Coverdell patients is increasing and now reaches 25% of all early arriving subjects. NIHSS documentation is increasing as well, especially among subjects with lower NIHSS scores. The median NIHSS in RISS or Too Mild patients is reassuringly low, and decreased significantly among Too Mild patients. These data, coupled with the fact that unadjusted rates of discharge home among IV tPA patients are increasing while severity-adjusted rates are not, suggests that more patients previously felt to be Too Mild are now receiving IV tPA. Further efforts are still warranted.

Background: Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. While studies have shown a beneficial effect of hospital participation in GWTG-Stroke upon processes of care, whether there are associated improvements in clinical outcomes has not been previously investigated. Methods: From among all acute care US hospitals, we matched 366 hospitals that joined the GWTG-Stroke program between April 2004 and December 2007, with 366 hospitals that did not. Matching was based on ischemic stroke case volume, calendar year, baseline hospital post-stroke 1-year all-cause mortality rates, teaching status, and geographic region. Outcomes of all acute ischemic stroke (AIS) patients admitted to the study hospitals were abstracted from the CMS administrative claims database (65 years and older). Outcomes at matched hospitals were compared in the PRE-GWTG-Stroke period (-540 to -181 days before program launch), RUN-UP period (-180- to -1 day), EARLY period (0 to 180 days) and SUSTAINED period (181 to 540 days). Additional analysis was performed of the entire BEFORE (-540 to -1 days) and AFTER periods (0 to 540 days). The main analytical approach was stratified Cox proportional hazard modeling, with matched site ID at stratum. We adjusted for patient characteristics (age, gender, race, medical history) and hospital characteristics (rural vs. urban, # beds, annual IS discharges.) Results: The study analyzed 88,584 AIS admissions at the 366 GWTG-Stroke hospitals and 85,401 admissions at the 366 matched non-GWTG-Stroke hospitals. In adjusted analysis comparing BEFORE and AFTER periods, GWTG-Stroke hospitals achieved reduced 30 day mortality (30M - HR 0.911, p Conclusions: Hospitals joining the GWTG-Stroke quality improvement program between 2004-2008 achieved significantly greater improvement in stroke patient outcomes than matched hospitals not joining the program, with lower all-cause mortality at 30 days and 1 year and higher rates of discharge directly to home.

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

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

Background: Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) initiated after myocardial infarction (MI) reduce mortality and are American College of Cardiology / American Heart Association (ACC/AHA) guideline recommended. Yet, contemporary use of ACEI or ARB in acute coronary syndrome (ACS) patients at hospital discharge has not been well studied. Objective: To examine ACEI/ARB prescription based on current Class I guideline criteria, patient and hospital factors associated with use, and temporal trends in patients hospitalized with ACS. Methods: We performed an observational analysis of 80,241 patients admitted with an ACS and discharged home from 311 hospitals participating in the Get With The Guidelines - Coronary Artery Disease Program from January 01 2005 to December 30 2009. Patient and hospital characteristics, measures and other outcomes were summarized descriptively by ACEI/ARB vs. no ACEI/ARB for ACC/AHA Class I indication. Pearson Chi-square test was used for categorical variables and Wilcoxon test was used for continuous variables. A multivariable logistic regression model with GEE method was fitted to identify influencing factors on ACEI/ARB use at discharge. Results: Among the 60,847 patients with an ACC/AHA Class I indication (left ventricular dysfunction or medical history of heart failure, hypertension or diabetes mellitus), 49,682 (81.7%) received ACEI/ARB with modest increase in treatment over the study period (76.7% to 84.6%). Patient and hospital factors independently associated with ACEI/ARB therapy use in patients meeting ACC/AHA Class I indication are shown in Table 1. Conclusion: Results from this large national registry suggest that one in five eligible patients hospitalized for ACS failed to receive ACC/AHA Class I guideline recommended ACEI/ARB therapy and use varies by patient factors. In particular, the low likelihood of ACEI/ARB post coronary artery bypass grafting surgery (CABG) raises concern. Thus, additional quality improvement efforts are warranted.

Background: Prior studies find regional variation in the use of secondary stroke prevention treatments. We determined whether guideline-recommended stroke treatments vary by region for patients treated at Get With The Guideline (GWTG)-Stroke hospitals. Methods: Receipt of guideline-recommended interventions (acute IV-tPA, antihypertensive medications, antithrombotics, diabetes medications, anticoagulants for atrial fibrillation, lipid-lowering medications at discharge and smoking cessation) in addition to weight loss education were compared by region among eligible ischemic stroke and TIA patients. GEE models compared regional differences for each intervention adjusted for patient demographics, medical history and hospital characteristics. Results: There were 991,995 stroke or TIA admissions (South 37%, Northeast 27.6%, Midwest 19.3%, West 15.9%). Receipt varied by region: tPA ranged from 58.2-67.8%; antihypertensives 87.4-91.1%; antithrombotics 95.6-96.8%; diabetes meds 80.9-84.5%; anticoagulants 90.6-92.5%; lipid-lowering meds 72.5-75.7%; smoking cessation 89.8-92.7%; and weight loss education 49.3-54.7%. In adjusted analyses, the largest differences were in tPA and anticoagulant use (lower rates in the South and Midwest vs. the Northeast, Figure). Interventions tended to be less frequently provided in the Midwest vs. the Northeast. Conclusion: Although receipt of many recommended interventions is high, there are regional differences among patients treated at GWTG-stroke hospitals. As the hospitals participated in the same quality improvement program, the reasons for the differences are unclear and require further investigation.

Background Approximately one third of the 780,000 people in the United States who have a stroke each year have recurrent events. Although efficacious secondary prevention measures are available, levels of adherence to these strategies in patients who have had stroke are largely unknown. Understanding medication-taking behavior in this population is an important step to optimizing the appropriate use of proven secondary preventive therapies and reducing the risk of recurrent stroke. Methods The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry is a prospective study of adherence to stroke prevention medications from hospital discharge to 1 year in patients admitted with stroke or transient ischemic attack. The primary outcomes are medication usage as determined by patient interviews after 3 and 12 months. Potential patient-, provider-, and system-level barriers to persistence of medication use are also collected. Secondary outcomes include the rates of recurrent stroke or transient ischemic attack, vascular events, and rehospitalization and functional status as measured by the modified Rankin score. Results The AVAIL enrolled about 2,900 subjects from 106 hospitals from July 2006 through July 2008. The 12-month follow-up will be completed in August 2009. Conclusions The AVAIL registry will document the current state of adherence and persistence to stroke prevention medications among a nationwide sample of patients. These data will be used to design interventions to improve the quality of care post acute hospitalization and reduce the risks of future stroke and cardiovascular events.

This paper summarizes the experiences of the Paul Coverdell National Acute Stroke Registry first four prototype registries in Georgia (GA), Massachusetts (MA), Michigan (MI), and Ohio (OH), and includes information on their sampling design, case ascertainment, and data collection methods, as well as some key findings.Using a combination of different sampling methods, each prototype obtained a representative statewide sample of hospitals. Acute stroke admissions were identified through prospective (MA, MI) or retrospective (GA, OH) methods. A common set of case definitions and data elements were used by each registry. Weighted site-specific frequencies and 95% confidence intervals were generated for each outcome. A summary estimate, representing a weighted average of the four site-specific estimates, was also calculated.Of the total 6867 admissions, 1487 (21.6%) were from the GA registry, 1206 (17.6%) from MA, 2566 (37.4%) from MI, and 1608 (23.4%) from the OH prototype. Just less than 60% of admissions were ischemic strokes (site-specific estimates ranged from 52% to 70%), with transient ischemic attack (18.5%) and intracerebral hemorrhage (8.8%) making up most of the remainder. Twenty-one percent of patients admitted were younger than 60 years of age, and 55.3% were women. The proportion of black subjects varied from 7.1% (MI) to 30.6% (GA). Twenty-three percent of admissions arrived at the emergency department within 3 hours of onset. Overall 4.5% of ischemic stroke admissions were treated with recombinant tissue plasminogen activator; site-specific treatment rates were 3.0% (GA), 3.2% (OH), 3.4% (MI), and 8.5% (MA). Only a small minority of treated patients (range, 10.8% [OH] to 19.6% [MI]) received recombinant tissue plasminogen activator within the recommended 1 hour door-to-needle time. A minority of eligible subjects were screened for dysphagia (45.4%), underwent lipid testing (33.6%), or received smoking-cessation counseling (21.4%). In contrast, compliance with antithrombotic treatments at discharge was high (91.5%).A minority of acute stroke patients are treated according to established guidelines. Quality improvement interventions, targeted primarily at the healthcare systems level, are needed to improve acute stroke care in the United States.

BACKGROUND AND PURPOSE: Lesions revealed by pretreatment diffusion-weighted imaging (DWI) may not progress to infarction, and apparent diffusion coefficient (ADC) or DWI thresholds for tissue viability may exist. We evaluated the evolution of abnormal DWI findings in patients with acute stroke who underwent thrombolysis. METHODS: Sixteen patients with acute occlusion of the anterior circulation underwent DWI followed by intra-arterial thrombolysis; follow-up CT or MR imaging was performed after reperfusion therapy. Lesion volumes were measured on all images. In three patients with abnormal DWI findings that appeared normal at follow-up, ADC values, ADC ratios, and DWI ratios were obtained on a section-by-section basis in the DWI-hyperintense regions that were either abnormal or normal at follow-up. RESULTS: In three patients, part of the DWI-hyperintense tissue appeared normal and part appeared abnormal at follow-up imaging. In one of these patients, the lesion decreased by −35.6%. In the other two, lesion growth appeared in regions that appeared normal at initial DWI: in one, the overall change in size was −2.4%, and in the other, the lesion increased by 89.8%. Respective mean changes at follow-up in normal-appearing and abnormal-appearing regions were: ADC, 731.7 × 10(−6) mm(2)/s and 650.4 × 10(−6) mm (2)/s; ADC ratio, 0.92 and 0.78; and DWI ratio, 1.16 and 1.32 (P < .001 for all measures). CONCLUSION: In patients with acute stroke who undergo intra-arterial thrombolysis, most abnormal, pretreatment DWI findings indicate eventual infarction. In 19% of the patients described herein, DWI-hyperintense regions appeared normal at follow-up. ADC values, ADC ratios, and DWI ratios may be useful in identifying the portion of abnormal tissue that is potentially salvageable after reperfusion therapy.

Objective To measure longitudinal use of stroke prevention medications following stroke hospital discharge. We hypothesized that a combination of patient-, provider-, and system-level factors influence medication-taking behavior. Design Observational cohort design. Setting One hundred six US hospitals participating in the American Heart Association Get With The Guidelines-Stroke program. Patients Two thousand eight hundred eighty-eight patients 18 years or older admitted with ischemic stroke or transient ischemic attack. Main outcome measure Regimen persistence, including use of antiplatelet therapies, warfarin, antihypertensive therapies, lipid-lowering therapies, or diabetes medications, from discharge to 3 months. Reasons for nonpersistence were also ascertained. Results Two thousand five hundred ninety-eight patients (90.0%) were eligible for analysis. At 3 months, 75.5% of subjects continued taking all secondary prevention medications prescribed at discharge. Persistence at 3 months was associated with decreasing number of medication classes prescribed, increasing age, medical history, less severe stroke disability, having insurance, working status, understanding why medications are prescribed and how to refill them, increased quality of life, financial hardship, geographic region, and hospital size. Conclusions One-quarter of stroke patients reported discontinuing 1 or more of their prescribed regimen of secondary prevention medications within 3 months of hospitalization for an acute stroke. Several modifiable factors associated with regimen persistence were identified and could be targets for improving long-term secondary stroke prevention.