Acute Stroke Care Research Articles

Assessment of stroke knowledge and awareness among primary healthcare providers: A cross-sectional survey from the Kezhou quality improvement in acute stroke care project.

Acute stroke care is a highly complex type of emergency medical service (EMS) involving patient-centered care in a highly unpredictable and stressful environment with the help of several busy providers. The ability of primary healthcare providers (PHPs) to identify stroke onset early and further manage referrals to higher-level hospitals becomes critical. We conducted a cross-sectional survey about stroke knowledge and awareness among PHPs in China from September 2021 to December 2021. A total of 289 PHPs were divided into two groups, the stroke treatment window (STW) Aware group vs. the STW Unaware group according to their knowledge on the time window for acute ischemic stroke (AIS) management. Logistic regression analysis was performed to explore the predictors associated with knowledge of the time window for acute stroke management. Of 289 PHPs surveyed during the study period, 115 (39.7%) participants were aware of the time window for stroke management and were in the STW Aware group, while 174 (60.2%) were in the STW Unaware group. Forty percent of PHPs in the STW Aware group were familiar with the secondary stroke prevention goal of <140/90 mmHg, compared with 27.01% in the Unaware group (P < 0.05). PHPs were not sufficiently aware of loss of consciousness also a symptom of stroke in two groups (75.7 vs. 62.6%, P < 0.05). A higher proportion of PHPs in the STW Aware group believed that thrombolysis was an effective treatment for AIS (96.5 vs. 79.9%, P < 0.01). Endovascular therapy is indicated for AIS was perceived by a higher proportion of PHPs in the STW Aware group than that in the Unaware group (62.6 vs. 6.9%, P < 0.01). Eighty percent of PHPs in the STW Aware group reported attending training on stroke management compared with 58.1% in the Unaware group (P < 0.01). Logistic regression results showed that the predictors of stroke knowledge and awareness among PHPs included sex (OR: 2.3, 95% CI, 1.2-4.6), received training (OR: 2.9, 95% CI, 1.60-5.1), and times of training per year (OR: 0.70, 95% CI, 0.6-0.9). PHPs present with a mild to moderate level of stroke management knowledge in northwest China. Strategies to help increase stroke knowledge and awareness among PHPs should be considered in order to help improve the stroke related health service system.

Comparison of acute stroke care pathways-Aqualitative multicenter study in three referring hospitals of astroke network

In stroke networks, hospitals that do not provide thrombectomy (referring hospitals) refer patients to specialized hospitals (receiving hospitals) for this specific intervention. In order to improve the access and management of thrombectomy, the focus of research needs to be not only on the receiving hospitals but also on the prior stroke care pathways in referring hospitals. The purpose of this study was to investigate the stroke care pathways in different referring hospitals as well as the advantages and disadvantages associated with these pathways. Aqualitative multicenter study was carried out in three referring hospitals of astroke network. Stroke care was assessed and analyzed by using non-participant observations and 15semi-structured interviews with employees in various health professions. The following aspects were reported as advantageous within the stroke care pathways: (1)astructured and personal prenotification of the patient by the emergency medical service (EMS) members; (2)amore efficiently organized teleneurology workflow; (3)the provision of the secondary referral to thrombectomy by the same EMS members of the primary referral and (4)the integration of external neurologists into in-house structures. The study provides insights into different stroke care pathways of three different referring hospitals of astroke network. The results can be used to derive potentials for improvement of other referring hospitals; however, this study is too small to provide reliable information about their potential effectiveness. Future studies should investigate whether implementation of these recommendations actually leads to improvements and under which conditions they are successful. To ensure patient-centeredness, the perspectives of patients and relatives should also be included.

Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners.

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.

Sex and gender differences in acute stroke care: metrics, access to treatment and outcome. A territorial analysis of the Stroke Code System of Catalonia.

Previous studies have reported differences in the management and outcome of women stroke patients in comparison with men. We aim to analyze sex and gender differences in the medical assistance, access to treatment and outcome of acute stroke patients in Catalonia. Data were obtained from a prospective population-based registry of stroke code activations in Catalonia (CICAT) from January/2016 to December/2019. The registry includes demographic data, stroke severity, stroke subtype, reperfusion therapy, and time workflow. Centralized clinical outcome at 90 days was assessed in patients receiving reperfusion therapy. A total of 23,371 stroke code activations were registered (54% men, 46% women). No differences in prehospital time metrics were observed. Women more frequently had a final diagnosis of stroke mimic, were older and had a previous worse functional situation. Among ischemic stroke patients, women had higher stroke severity and more frequently presented proximal large vessel occlusion. Women received more frequently reperfusion therapy (48.2% vs 43.1%, p < 0.001). Women tended to present a worse outcome at 90 days, especially for the group receiving only IVT (good outcome 56.7% vs 63.8%; p < 0.001), but not for the group of patients treated with IVT + MT or MT alone, although sex was not independently associated with clinical outcome in logistic regression analysis (OR 1.07; 95% CI, 0.94-1.23; p = 0.27) nor in the analysis after matching using the propensity score (OR 1.09; 95% CI, 0.97-1.22). We found some differences by sex in that acute stroke was more frequent in older women and the stroke severity was higher. We found no differences in medical assistance times, access to reperfusion treatment and early complications. Worse clinical outcome at 90 days in women was conditioned by stroke severity and older age, but not by sex itself.

Correction to: Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years.

HomeStrokeVol. 54, No. 3Correction to: Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years Originally published27 Feb 2023https://doi.org/10.1161/STR.0000000000000427Stroke. 2023;54:e123This article corrects the followingRacial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 YearsIn the article by Hammond et al, “Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years,” which published online February 17, 2022, and appeared in the May 2022 issue of the journal (Stroke. 2022;53:1711–1719. doi: 10.1161/STROKEAHA.121.035006), a correction is needed.On page 9 of the Supplemental Material PDF, corrections are needed to Supplemental Table V. In row “2014,” column “Black/Rural,” the value should be suppressed because it is less than 11, in accordance with the Healthcare Cost and Utilization Project National Inpatient Sample data use agreement policy. The value has been replaced by asterisks, and a footnote has been added to the table: “**= value suppressed because less than 11.”This correction has been made to the current online version of the article, which is available at https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.035006. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesRacial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 YearsGmerice Hammond, et al. Stroke. 2022;53:1711-1719 March 2023Vol 54, Issue 3 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/STR.0000000000000427PMID: 36848434 Originally publishedFebruary 27, 2023 PDF download Advertisement

Comparison of acute ischemic stroke care quality before and during the COVID-19 pandemic in a private tertiary hospital in metro Manila, Philippines

Background: The Coronavirus Disease 2019 (COVID-19) pandemic had disrupted established medical care systems worldwide, especially for highly time-sensitive acute conditions such as stroke. Strategies to maintain the quality of stroke care during the COVID-19 outbreak are crucial to prevent indirect mortality and disability due to suboptimal care. Objective: We conducted a single center analysis to compare the time-based measures for acute ischemic stroke care quality before and during the COVID-19 pandemic. Methods: A retrospective study was done utilizing the Registry of Stroke Care Quality (RES-Q) database. All acute ischemic stroke patients who presented within 4.5 hours of symptom onset in Makati Medical Center were included. Patient characteristics, treatment received, in-hospital time-based measures of stroke care quality and clinical outcomes were compared between the two periods- pre-COVID-19 and COVID-19. Results: There were 151 patients during the pre-COVID-19 period and 108 patients during the COVID-19 period who presented to the hospital with acute ischemic strokes within 4.5 hours of symptom onset. There was significantly higher NIHSS scores on admission and MRS scores on discharge during the COVID-19 period. There was no significant difference in the door-to-scan time, door-to-needle time and door-to-groin time between the two periods. Conclusion: There is no significant change in the acute ischemic stroke care quality on the basis of in-hospital time-based measures: door-to-scan time, door-to-needle time, and door-to-groin time, between the pre-COVID-19 and COVID-19 periods. Further studies on pre-hospital challenges are recommended to identify specific targets for improvements in stroke care during pandemics.

Abstract Number ‐ 65: US Comprehensive Stroke Center Utilization of FAST and BEFAST Mnemonics for Public Education

Introduction Symptom recognition and timely access to treatment are critical components of acute stroke care systems. Two mnemonics widely used in public educational campaigns for recognizing stroke symptoms include FAST (Face‐Arm‐Speech‐Time) and BEFAST (Balance‐Eyes‐Face‐Arm Speech‐Time). The FAST mnemonic, endorsed by the AHA/ASA can miss up to 14% of strokes. BEFAST includes common posterior circulation stroke symptoms and has been implemented by several Comprehensive Stroke Centers (CSCs). Methods We sought to analyze the pattern of public educational materials available on the websites US CSCs. The Joint Commission (JC) quality check website compiles a list containing the names and locations of the country’s 217 JC‐certified CSCs, which was downloaded in August, 2022. Each CSC’s website was searched for educational material containing FAST and BEFAST mnemonics for stroke symptom recognition. Results The FAST mnemonic was listed by 35%of CSCs, the BEFAST by 58%, with 7% listing no specific mnemonic. The highest portion of CSCs using BEFAST was in western (65%) and southeastern (63%) states. The highest percentage of CSCs with no listed mnemonic were in the northeastern (14%) and southeastern (13%) states. Conclusions Consistency is critical in shaping public health education related to stroke symptoms. Our study suggests further effort is needed to unify the public messaging on stroke recognition.

Delivering acute stroke care in a middle-income country. The Mexican model: "ResISSSTE Cerebro".

Founded in 2019, the "ResISSSTE Cerebro" program is the first and only stroke network within the Mexican public health system. One advanced stroke center (ASC) and seven essential stroke centers (ESC) provide acute stroke (AS) care through a modified hub-and-spoke model. This study describes the workflow, metrics, and outcomes in AS obtained during the program's third year of operation. Participants were adult beneficiaries of the ISSSTE health system in Mexico City with acute focal neurological deficit within 24 h of symptom onset. Initial evaluation could occur at any facility, but the stroke team at the ASC took all decisions regarding treatment and transfers of patients. Registered variables included demographics, stroke risk factors, AS treatment workflow time points, and clinical outcome measures. We analyzed data from 236 patients, 104 (44.3%) men with a median age of 71 years. Sixty percent of the patients were initially evaluated at the ESC, and 122 (85.9%) were transferred to the ASC. The median transfer time was 123 min. The most common risk factor was hypertension (73.6%). Stroke subtypes were ischemic (86.0%) and hemorrhagic (14.0%). Median times for onset-to-door, door-to-imaging, door-to-needle, and door-to-groin were: 135.5, 37.0, 76.0, and 151.5 min, respectively. The rate of intravenous thrombolysis was 35%. Large vessel occlusion was present in 63 patients, from whom 44% received endovascular therapy; 71.4% achieved early clinical improvement (median NIHSS reduction of 11 points). Treatment-associated morbimortality was 3.4%. With the implementation of a modified hub-and-spoke model, this study shows that delivery of AS care in low- and middle-income countries is feasible and achieves good clinical outcomes.

Sustaining a New Model of Acute Stroke Care: A Mixed-Method Process Evaluation of the Melbourne Mobile Stroke Unit.

Internationally, Mobile Stroke Unit (MSU) ambulances have changed pre-hospital acute stroke care delivery. MSU clinical and cost-effectiveness studies are emerging, but little is known about important factors for achieving sustainability of this innovative model of care. Mixed-methods study from the Melbourne MSU (operational since November 2017) process evaluation. Participant purposive sampling included clinical, operational and executive/management representatives from Ambulance Victoria (AV) (emergency medical service provider), the MSU clinical team, and receiving hospitals. Sustainability was defined as ongoing MSU operations, including MSU workforce and future model considerations. Theoretically-based on-line survey with Unified Theory of Acceptance and Use of Technology (UTAUT), Self Determination Theory (SDT, Intrinsic Motivation), and open-text questions targeting barriers and benefits was administered (June-September 2019). Individual/group interviews were conducted, eliciting improvement suggestions and requirements for ongoing use. Descriptive and regression analyses (quantitative data) and directed content and thematic analysis (open text and interview data) were conducted. There were 135 surveys completed. Identifying that the MSU was beneficial to daily work (β=0.61), not experiencing pressure/tension about working on the MSU (β=0.17) and thinking they did well working within the team model (β=0.17) were significantly associated with wanting to continue working within the MSU model [R2=0.76; F(15, 60)=12.76, P<.001]. Experiences varied between those on the MSU team and those working with the MSU. Advantages were identified for patients (better, faster care) and clinicians (interdisciplinary learning). Disadvantages included challenges integrating into established systems, and establishing working relationships. Themes identified from 35 interviews were MSU team composition, MSU vehicle design and layout, personnel recruitment and rostering, communication improvements between organisations, telemedicine options, MSU operations and dispatch specificity. Important factors affecting the sustainability of the MSU model of stroke care emerged. A cohesive team approach, with identifiable benefits and good communication between participating organisations is important for clinical and operational sustainability.

Are we improving? Temporal trends in outcomes for mechanical thrombectomy for stroke: A systematic review and meta-analysis of randomized trials.

In 2015, mechanical thrombectomy (MT) was deemed the standard of care for acute ischemic stroke (AIS) in the anterior circulation due to large vessel occlusion (LVO). To determine if outcomes in patients treated with MT have changed, we conducted a systematic review and meta-analysis of published randomized controlled trials (RCTs). A systematic literature review of the English language literature was conducted using PubMed. We included RCTs that focused on patients with AIS treated with MT. The primary outcome of interest was good functional outcome defined as modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes included rates of symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Using Joinpoint Regression Analysis Program, we calculated the average annual percent change (AAPC) for the outcomes of interest. We included 23 RCTs with 5784 patients. The years of mid-enrollment among the included RCTs ranged from 2012-2020. There was an AAPC of +3.82% between 2012 and 2020 (95% CI 0.4 to 7.3; P-value = 0.033) in rates of good functional outcome. There was an AAPC of +6.98% between 2012 and 2020 (95% CI 0.5 to 13.9; P-value = 0.039) in rates of sICH. There was an AAPC of -0.49% between 2012 and 2020 (95% CI -4.4 to 3.5; P-value = 0.77) in rates of mortality. Between 2012 and 2020, rates of good functional outcome and sICH increased, while rates of mortality remained consistent in RCTs investigating MT for AIS. Multiple factors likely influenced our results, including increased use of MT and utilization of adjunctive therapies alongside MT.

Dementia and acute care of ischemic stroke in Japan: A retrospective observational study using the Japanese Diagnosis Procedure Combination database.

This study aimed to determine the impact of dementia on the implementation of intravenous thrombolysis and early rehabilitation as acute care for patients with acute ischemic stroke in Japan. This retrospective observational study used the Japanese Diagnosis Procedure Combination database. Patients aged ≥75 years with acute ischemic stroke (ICD-10 code: I63) were enrolled (n=464 710). In this study, dementia was identified using the ICD-10 codes (F00, F01, F02, F03, G30, and G31) for comorbidity. A mixed-effects logistic regression analysis nested at the hospital level was conducted to examine the impact of dementia on the implementation of intravenous thrombolysis and early rehabilitation. Overall, 57 905 patients with ischemic stroke had dementia. The group with dementia was less likely to receive intravenous thrombolysis (5.2% vs. 6.9%) and more likely to undergo early rehabilitation than the group without dementia (76.1% vs. 73.0%). In the mixed-effects logistic regression analysis, dementia was significantly associated with a lower probability of undergoing intravenous thrombolysis (adjusted odds ratio: 0.79, 95% confidence interval: 0.76-0.82, P < 0.001) and a higher probability of early rehabilitation (adjusted odds ratio: 1.06, 95% confidence interval: 1.04-1.09, P < 0.001). We found that while dementia was associated with fewer opportunities for aggressive treatment, such as intravenous thrombolysis, it was also associated with increased opportunities to receive rehabilitation. It is necessary to examine the reasons why patients with dementia do not receive aggressive treatment and to establish a system that allows older adults with and without dementia to receive equal access to medical care. Geriatr Gerontol Int 2023; 23: 270-274.

Less is more - The Finnish Prehospital Stroke Scale prospective validation

The current bifurcation of the acute stroke care pathway requires prehospital separation of strokes caused by large vessel occlusion. The first four binary items of the Finnish Prehospital Stroke Scale (FPSS) identify stroke in general, while the fifth binary item alone identifies stroke due to large vessel occlusion. The straightforward design is both easy for paramedics and statistically beneficial. We implemented FPSS based Western Finland Stroke Triage Plan, including medical districts of a comprehensive stroke center and four primary stroke centers. The prospective study population was consecutive recanalization candidates transported to the comprehensive stroke center within the first six months of implementing the stroke triage plan. Cohort 1 consisted of n=302 thrombolysis- or endovascular treatment candidates transported from the comprehensive stroke center hospital district. Cohort 2 comprised ten endovascular treatment candidates transferred directly to the comprehensive stroke center from the medical districts of four primary stroke centers. In Cohort 1, FPSS sensitivity for large vessel occlusion was 0.66, specificity 0.94, positive predictive value 0.70, and negative predictive value 0.93. Of the ten Cohort 2 patients, nine had large vessel occlusion, and one had an intracerebral hemorrhage. FPSS is straightforward enough to be implemented in primary care services to identify candidates for endovascular treatment and thrombolysis. When used by paramedics, it predicted two-thirds of large vessel occlusions with the highest specificity and positive predictive value reported to date.

Experience in Mechanical Thrombectomy for Acute Stroke Treatment during Pandemic: A Single Center Report

Objective: The COVID-19 disease affected most hospitals with its rapid spread and increased number of severe cases. Thus, delays in acute ischemic stroke care and a decline in hospitalization and interventions, such as endovascular thrombectomy, have been reported. With the present study, we aimed to evaluate baseline patient characteristics and determine the impact of pandemics on MT-related outcomes. Materials and methods: The hospital database was scanned for the patients diagnosed with acute ischemic stroke and treated via mechanical thrombectomy. The patients enrolled in the study were evaluated for their demographic features, infarct characteristics, clinical neurological scores (NIHSS and mRS) on admission and discharge, the TICI results, and the clinical course of the disease. Results: 250 patients were diagnosed with acute ischemic stroke during the Sep.2020-Oct.2021 period. Of the 158 patients were eligible for mechanical thrombectomy. Among the patients who underwent MT, 8 (5.06%) were diagnosed with COVID-19. While the median NIHSS score on admission was 12 (±4.16), the final post-procedural NIHSS score on discharge was 6 (±5.00). The most commonly occluded artery was MCA in 128 (81.01%) patients. While 76 (%48.10) of the patients resulted in procedural success with a TICI 3 score, a post-procedural intracranial hemorrhage was observed in 35 (22%) patients. A total of 90 (%56.96) patients were discharged with a good neurological outcome, while 32 (%20.25) had a lethal result. The outcome data of some patients (32 (%20.25) in particular) could not be obtained. Those patients needed to be referred to another ICU after the MT procedure because of the present hospital's lack of ICU beds. Conclusion: The rate of COVID-19 infection was low among stroke patients who underwent MT. Moreover, all patients who underwent intervention due to a lack of intensive care beds could not be followed up in our hospital and had to be referred to an external center.

Advancing Stroke Research on Cerebral Thrombi with Omic Technologies.

Cerebrovascular diseases represent a leading cause of disability, morbidity, and death worldwide. In the last decade, the advances in endovascular procedures have not only improved acute ischemic stroke care but also conceded a thorough analysis of patients' thrombi. Although early anatomopathological and immunohistochemical analyses have provided valuable insights into thrombus composition and its correlation with radiological features, response to reperfusion therapies, and stroke etiology, these results have been inconclusive so far. Recent studies applied single- or multi-omic approaches-such as proteomics, metabolomics, transcriptomics, or a combination of these-to investigate clot composition and stroke mechanisms, showing high predictive power. Particularly, one pilot studies showed that combined deep phenotyping of stroke thrombi may be superior to classic clinical predictors in defining stroke mechanisms. Small sample sizes, varying methodologies, and lack of adjustments for potential confounders still represent roadblocks to generalizing these findings. However, these techniques hold the potential to better investigate stroke-related thrombogenesis and select secondary prevention strategies, and to prompt the discovery of novel biomarkers and therapeutic targets. In this review, we summarize the most recent findings, overview current strengths and limitations, and present future perspectives in the field.

The Excess Costs of Hospitalization for Acute Stroke in People With Communication Impairment: A Stroke123 Data Linkage Substudy

ObjectiveTo describe the costs of hospital care for acute stroke for patients with aphasia or dysarthria. DesignObservational study from the Stroke123 project. SettingData from patients admitted with stroke (2009-2013) from 22 hospitals in Queensland participating in the Australian Stroke Clinical Registry (AuSCR) were linked to administrative datasets. ParticipantsCommunication impairments were identified using International Classification of Diseases, 10th Revision, Australian Modification codes. Overall, 1043 of 4195 (25%) patients were identified with aphasia (49% were women; median age 78 years; 83% with ischemic stroke), and 1005 (24%) with dysarthria (42% were women; median age 76 years; 85% with ischemic stroke). InterventionsNot applicable. Main Outcome MeasuresLinked patient-level, hospital clinical costing related to the stroke, were adjusted to 2013/2014 Australian dollars (AU$, US$ conversion x 0.691) using recommended national price indices and multivariable regression analysis with clustering by hospital performed. ResultsCompared with patients without aphasia, the median hospital costs/patient were greater for those with aphasia for medical (aphasia AU$2273 vs AU$1727, P<.001), nursing (aphasia AU$3829 vs AU$2748, P<.001) and allied health services (aphasia AU$1138 vs AU$720, P<.001). Similarly, costs were greater for patients with dysarthria compared with those without dysarthria. Adjusted median total costs were AU$2882 greater for patients with aphasia compared with patients without aphasia (95% confidence interval, AU$1880-3884), and AU$843 greater for patients with dysarthria compared with those without dysarthria (95% confidence interval, AU$–301 to 1987). ConclusionsPeople with communication impairment after stroke incur greater hospital costs, in particular for medical, allied health, and nursing resources.

Abstract HUP15: Investigating Racial Disparities In Acute Stroke Management At An Academic Comprehensive Stroke Center

Introduction: In the U.S. racial disparities in age of diagnosis and outcome of ischemic stroke remain despite advances in preventive, acute and chronic management. Social determinants of health, implicit bias and lack of diversity in healthcare which are resultant of systems of oppression have been identified as root causes. It is currently understood that primordial factors such as relatively higher risk of vascular disease, limited access and low stroke literacy contribute to these discrepancies. The role of delivery of care in the acute stroke setting has, however, not yet been investigated. Objectives: In this retrospective study we sought to elucidate if significant delays in acute stroke care exist in non-white (NW) compared to white (W) patients at Wake Forest Baptist. Methods: Data from EPIC of patients hospitalized from January 2018 to December 2019 were pulled via the Comprehensive Stroke Center and Get with the Guidelines databases. Standard descriptive statistical analyses were used. Results: We found that time to activation of acute stroke protocol, time to IV thrombolytic administration (NW 42.5 min, W 44.0 min, p= 0.82) and proportion of Individuals with a 90-day modified Rankin Scale score of 0 to 3 (NW 71.4%, W 60.0%, p= 0.24) were comparable. Interestingly and though not statistically significant, we did find that white patients underwent EVT sooner (NW 98 min, W 88 min, p= 0.54) and were more likely to achieve near-complete reperfusion when compared to their non-white counterparts (NW 80.0%, W 92.3%, p= 0.30). Discussion: Within our institution there are no differences in outcome between races of the patients who receive standard acute stroke care, suggesting that the protocolization of this emergent clinical practice may potentially play a role in mitigating racial disparities.

Imaging of Central Nervous System Ischemia

This article describes imaging modalities used in the evaluation of patients presenting with symptoms of acute ischemic stroke. The year 2015 marked the beginning of a new era in acute stroke care with the widespread adoption of mechanical thrombectomy. Subsequent randomized controlled trials in 2017 and 2018 brought the stroke community even further into this new territory with the expansion of the eligibility window for thrombectomy using imaging-based patient selection, which led to an increase in the use of perfusion imaging. Now, after several years of routine use, the debate is ongoing as to when this additional imaging is truly required and when it results in unnecessary delays in time-sensitive stroke care. At this time, more than ever, a robust understanding of neuroimaging techniques, applications, and interpretation is essential for the practicing neurologist. CT-based imaging is the first step in most centers for the evaluation of patients presenting with symptoms of acute stroke because of its wide availability, speed, and safety. Noncontrast head CT alone is sufficient for IV thrombolysis decision making. CT angiography is very sensitive for the detection of large-vessel occlusion and can be used reliably to make this determination. Advanced imaging including multiphase CT angiography, CT perfusion, MRI, and MR perfusion can provide additional information useful for therapeutic decision making in specific clinical scenarios. In all cases, it is essential that neuroimaging be performed and interpreted rapidly to allow for timely reperfusion therapy.

Abstract WP38: Variation In Performance On Stroke Care Delivery Measures Among Us Community Emergency Departments

Introduction: Many stroke patients initially present to non-stroke center hospitals. However, the delivery of Emergency Department (ED)-based acute stroke care at smaller, non-academic (i.e., community) EDs is less well-described than for larger, academic hospitals. Hypothesis: There is wide variation in community EDs’ performance on acute stroke care delivery measures. Methods: This is a retrospective analysis of a cohort of stroke patients from EDs participating in the Emergency Quality Network (E-QUAL) stroke collaborative, a national stroke quality improvement project targeted to community EDs. Sites used ICD10 codes to identify ischemic stroke patients and submitted data using a web-based submission portal. EDs with data from at least 20 patients were included. For each site, we calculated median door-to-imaging (DTI), door-to-needle (DTN), and door-in-door-out (DIDO) times among transferred patients and ED length of stay (LOS) among admitted patients. We also determined the proportions of eligible patients arriving with 3.5 hours of last known well who received thrombolysis within 4.5 hours, of patients with documentation of severity assessment performance and of dysphagia screening. We used descriptive statistics to illustrate variation. Results: Of the 54 participating EDs, data were available for 45, and 28 included ≥ 20 patients. Of included EDs, median annual ED volume was 34,648 (IQR 21,250-47,120) and 40% were rural. Performance varied on DTI, DIDO among transferred patients, and LOS among admitted patients (Table). Performance was more consistent on documentation of severity assessment and dysphagia screening. Conclusions: Performance on stroke care delivery measures varied between these community EDs and data in the literature from larger hospitals that typically participate in national registries. Future efforts to improve emergency stroke care delivery should consider unique factors impacting care at smaller, community EDs.

Abstract WP190: Central Retinal Artery Occlusion: Do Patient Presentation Patterns Complicate Use Of Potential Treatments?

Introduction: For patients diagnosed with central retinal artery occlusion (CRAO), timely screening for underlying risk factors to prevent secondary stroke and other cardiovascular events is required. Given the profound impact on vision, there is also great interest in the potential to treat CRAO. Thrombolytic therapy is the current standard of care in acute ischemic cerebral stroke, but the window for administration is short. As part of a larger pilot to investigate the prospect of intravenous thrombolysis for patients presenting with acute CRAO in our institution, we set out to evaluate the specific presentation patterns of this population within our system. Methods: Retrospective study performed on 804 patients correctly diagnosed with CRAO from 2011-2020. From this cohort of patients, we identified 484 for whom we could accurately determine the time of first symptoms, the time of first contact with the healthcare system, and the time of evaluation by an ophthalmologist. Results: While 18.0% (87/484) of patients waited over 24 hours from time of vision loss to contact the health care system, 50.2% of patients did connect in under 4.5 hours (243/484). However, only 16.7% (81/484) of patients saw an ophthalmologist within that window, and 35.5% (172/484) did not have any ophthalmologic evaluation within 24 hours of vision loss. Conclusion: Half of CRAO patients within our institution connect with the health care system within a potential window for intravenous thrombolytic treatment, but the majority do not receive ophthalmic diagnosis within that time frame. In conclusion, public health education efforts to speed up presentation times and system-based strategies to decrease the time to ophthalmic diagnosis are needed if thrombolytic treatment either via compassionate use or within a clinical trial setting is to be more widely offered.

Abstract TP55: Racial And Gender Disparities In Patients Undergoing Mechanical Thrombectomy At A Comprehensive Stroke Center

Introduction: Mechanical thrombectomy is the standard of care for acute ischemic stroke for select patients with large vessel occlusion (LVO). Racial and gender disparities exist in the incidence, morbidity, and mortality related to stroke. Furthermore, racial disparities in the utilization of thrombectomy have been previously identified. However, disparities in the utilization of thrombectomy in a single center with a standardized patient selection protocol have not been described. Methods: Using the American Heart Association Quality Improvement Programs Registry, we retrospectively reviewed the records of 1,143 patients with LVO between December 1, 2014, and May 31, 2021. Patient records were assessed for demographic data, stroke risk factors, process metrics, and success of thrombectomy. A Pearson’s Chi-Squared and an Independent two-sample T-test were used to determine significance. Results: Of the 1,143 LVO patients, 50.4% were female, 49.6% were male, 84.3% were white, 15.7% were nonwhite. Males were more likely to have diabetes compared to females (22.8% versus 17.9%; p=0.044). There were no significant differences based on race for stroke risk factors including diabetes and atrial fibrillation. Patient selection for thrombectomy was determined by a protocol agnostic to gender and race. Female patients were more likely to undergo thrombectomy compared to males (62.4% versus 48.9%; p&lt;0.001). White patients were more likely to undergo thrombectomy compared to nonwhites (58.7% versus 39.7%; p&lt;0.001). White patients were more likely to have a shorter interval between their last known well (LKW) to arrival (454 minutes versus 533 minutes; p=0.008) despite the fact our nonwhite patients were more likely to originate from our local county (58.1% versus 8.3%; p&lt;0.001). Conclusions: In our analysis of LVO patients, female patients and white patients were more likely to undergo mechanical thrombectomy. The higher incidence of diabetes in males may have resulted in the patients presenting with a larger core infarct, making them ineligible for thrombectomy. Further investigation with data from multiple centers will be necessary to validate these findings and identify strategies for improving utilization of thrombectomy.