Comprehensive Stroke Center Research Articles

Impact of Sex on Thrombectomy Outcomes in Ischemic Stroke: A Propensity Score‐Matched Study, Systematic Review, and Meta‐Analysis

Background Women are underrepresented in stroke thrombectomy trials, and the impact of sex differences in outcomes after stroke thrombectomy is unclear. We performed a multicenter propensity matching study to define sex‐related differences in outcome after endovascular thrombectomy and integrated results in a meta‐analysis. Methods We included patients with anterior circulation large vessel occlusion consecutively treated with thrombectomy at 2 Comprehensive Stroke Centres (2016–2023). Selection criteria reflected international guidelines. Through systematic review we selected all studies reporting endovascular thrombectomy outcomes in anterior circulation large vessel occlusion stroke, applying propensity score matching. MEDLINE, EMBASE, and Cochrane CENTRAL were searched up to August 15, 2023 according to predefined protocol (OSF.io/je3da). Data were extracted by 2 independent raters, pooled estimates calculated according to random‐effect modeling meta‐analysis and reported as odds ratio (OR) and standard 95% CI. Outcomes were good functional outcome, defined as modified Rankin Scale score 0–2 at 90 days after stroke, and symptomatic intracranial hemorrhage, adjudicated according to European Cooperative Acute Stroke Study II criteria. Results After matching, 698 patients (349 women versus 349 men) had similar cardiovascular risk factors, baseline features, and treatment approach. No significant differences were found for good functional outcome (OR = 0.89, 95% CI = 0.66–1.2) and symptomatic intracranial hemorrhage (OR = 1.00, 95% CI = 0.44–2.26) in the cohort study by sex. Systematic review identified 3 studies (n = 3706), all of high quality. No differences emerged in rates of good functional outcome (OR = 1.00, 95% CI = 0.79–1.21) or symptomatic intracranial hemorrhage (OR = 0.85, 95% CI = 0.60–1.19) depending on sex. Conclusion Women receiving endovascular thrombectomy for anterior circulation large vessel occlusion related stroke have similar rates of good functional outcome and symptomatic intracranial hemorrhage compared to men.

Modafinil Therapy and Mental Status Following Aneurysmal Subarachnoid Hemorrhage: Comprehensive Stroke Center Analysis

Disorders of consciousness impair early recovery after aneurysmal subarachnoid hemorrhage (aSAH). Modafinil, a wakefulness-promoting agent, is efficacious for treating fatigue in stroke survivors, but data pertaining to its use in the acute setting are scarce. This study sought to assess the effects of modafinil use on mental status after aSAH. Modafinil timing and dosage, neurological examination, intubation status, and physical and occupational therapy participation were documented. Repeated-measures paired tests were used for a before-after analysis of modafinil recipients. Propensity score matching (1:1 nearest neighbor) for modafinil and no-modafinil cohorts was used to compare outcomes. Modafinil (100-200mg/day) was administered to 21% (88/422) of aSAH patients for a median (IQR) duration of 10.5 (4-16) days and initiated 14 (7-17) days after aSAH. Improvement in mentation (alertness, orientation, or Glasgow Coma Scale score) was documented in 87.5% (77/88) of modafinil recipients within 72hours and 86.4% (76/88) at discharge. Of 37 intubated patients, 10 (27%) were extubated within 72hours after modafinil initiation. Physical and occupational therapy teams noted increased alertness or participation in 47 of 56 modafinil patients (83.9%). After propensity score matching for baseline covariates, the modafinil cohort had a greater mean (SD) change in Glasgow Coma Scale score than the no-modafinil cohort at discharge (2.2 [4.0] vs.-0.2 [6.32], P= 0.003). A temporal relationship with improvement in mental status was noted for most patients administered modafinil after aSAH. These findings, a favorable adverse-effect profile, and implications for goals-of-care decisions favor a low threshold for modafinil initiation in aSAH patients in the acute-care setting.

Identification of Anterior Large Vessel Occlusion Stroke During the Emergency Call: Protocol for a Controlled, Nonrandomized Trial.

Endovascular thrombectomy (ET), combined with intravenous thrombolysis if possible, is an effective treatment option for patients with stroke who have confirmed anterior large vessel occlusion (aLVO). However, ET is mainly limited to comprehensive stroke centers (CSCs), resulting in a lack of ET capacity in remote, sparsely populated areas. Most stroke networks use the "Drip and Ship" or "Mothership" strategy, resulting in either delayed ET or intravenous thrombolysis, respectively. This study protocol introduces the Leitstellen-Basierte Erkennung von Schlaganfall-Patienten für eine Thrombektomie und daraufhin abgestimmte Optimierung der Rettungskette (LESTOR) strategy, developed to optimize the preclinical part of the stroke chain of survival to improve the clinical outcome of patients with suspected aLVO stroke. This involves refining the dispatch strategy for identifying patients with acute aLVO stroke using a phone-based aLVO query. This includes dispatching emergency physicians and emergency medical services (EMS) to urban emergency sites, as well as dispatching helicopter EMS to remote areas. If a highly suspected aLVO is identified after a standardized aLVO score evaluation during a structured examination at the emergency scene, prompt transport to a CSC should be prioritized. The LESTOR study is a controlled, nonrandomized study implementing the LESTOR strategy, with a stepped-wedge, cluster trial design in 6 districts in southwest Germany. In an interprofessional, iterative approach, an aLVO query or dispatch protocol intended for use by dispatchers, followed by a coordinated aLVO examination score for use by EMS, is being developed, evaluated, and pretested in a simulation study. After the training of all participating health care professionals with the corresponding final aLVO query, the LESTOR strategy is being implemented stepwise. Patients otherwise receive usual stroke care in both the control and intervention groups. The primary outcome is the modified Rankin Scale at 90 days in patients with stroke receiving endovascular treatment. We will use a generalized linear mixed model for data analysis. This study is accompanied by a cost-effectiveness analysis and a qualitative process evaluation. This paper describes and discusses the protocol for this controlled, nonrandomized LESTOR study. Enrollment was completed in June 2023. Data analysis is ongoing and the first results are expected to be submitted for publication in 2024. The project started in April 2020 and will end in February 2024. We expect that the intervention will improve the clinical outcome of patients with aLVO stroke, especially outside the catchment areas of CSCs. The results of the accompanying process evaluation and the cost-effectiveness analysis will provide further insights into the implementation process and allow for a better interpretation of the results. German Clinical Trials Register DRKS00022152; https://drks.de/search/de/trial/DRKS00022152. DERR1-10.2196/51683.

Postprocedural delirium following mechanical thrombectomy for acute ischemic stroke: a retrospective study

IntroductionNational representative estimates on in-hospital delirium after acute ischemic stroke are not well established and there is limited data on the impact of delirium on clinical outcomes following mechanical thrombectomy. We evaluated risk factors for delirium and the impact on outcomes following mechanical thrombectomy for acute ischemic stroke.MethodsThis is a retrospective study of patients who underwent mechanical thrombectomy for acute ischemic stroke at a single tertiary comprehensive stroke center between April 2011 and December 2019. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit. Patient characteristics, comorbidities, laboratory data, elapsed times, tissue plasminogen activator use, duration of the procedure, type of anesthesia, National Institute of Health stroke scores (NIHSS), sedation scores, reperfusion grades, complications, length of hospital stay, discharge disposition, and 90-day mortality were evaluated.ResultsFive hundred and two patients were evaluated, and post-procedural delirium was identified in 24/467 (5.1%) patients. Thirty-five patients could not be assessed for delirium due to excessive sedation. The incidence of delirium in white vs. non-white patients <65 years was 5/137 (3.6%) compared to 0/91 (0%), and 7/176 (4.0%) compared to 12/63 (19%) in patients ≥65 years, P = 0.006. Bias reduction multi-variable analysis identified low postprocedural hemoglobin level odds ratio of 0.76 (95% CI 0.61–0.92, P = 0.006), greater age (odds ratio 1.04, 95% CI 1.01–1.009, P = 0.024), and non-white race odds ratio of 2.52 (95% CI 1.06–6.38, P = 0.030) as factors associated with delirium [Brier score = 0.045, C-index = 0.800, and Akaike Information Criterion (AIC) = 174]. General anesthesia was not associated with an increased delirium risk. NIHSS at 24 and 48 h and discharge, length of stay, and 90-day mortality were not different between delirium and no-delirium groups. Delirium patients had a reduced odds ratio of 0.13 (05% CI 0.01–1.00, P = 0.02) for home discharge.DiscussionDelirium following mechanical thrombectomy for acute ischemic stroke primarily affected older patients and was associated with reduced odds of home discharge following hospitalization. Changes in NIHSS during hospitalization and 90-day mortality were not adversely affected by the presence of delirium. General anesthesia was not associated with an increased delirium risk following mechanical thrombectomy.

Neurological Improvement by One-Thirds Is Associated With Early Recanalization in Stroke With Large Vessel Occlusion.

A proportion of large vessel occlusion strokes demonstrate early recanalization, obviating the initial intention to proceed to endovascular thrombectomy. Neurological improvement is a possible surrogate marker for reperfusion. We aimed to determine the optimal threshold of neurological improvement, as defined by the National Institutes of Health Stroke Scale (NIHSS), which best associates with early recanalization. We retrospectively analyzed consecutive patients with large vessel occlusion transferred from primary stroke centers to a tertiary comprehensive stroke center in Melbourne, Australia, for possible endovascular thrombectomy from January 2018 to December 2022. Absolute and percentage changes in NIHSS between transfer, as well as other definitions of neurological improvement, were compared using receiver operating characteristic curve analysis for association with recanalization as defined by the absence of occlusion in the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on repeat vascular imaging. Six hundred and fifty-four transferred patients with large vessel occlusion were included in the analysis: mean age was 68.8±14.0 years, 301 (46.0%) were women, and 338 (52%) received intravenous thrombolytics. The proportion of extracranial internal carotid artery, intracranial internal carotid artery, M1, proximal M2, and basilar artery occlusion was 18.8%, 13.6%, 48.3%, 15.0%, and 4.3%, respectively, on initial computed tomography angiogram. Median NIHSSprimary stroke center and NIHSScomprehensive stroke center scores were 15 (interquartile range, 9-18) and 13 (interquartile range, 8-19), respectively. Early recanalization occurred in 82 (13%) patients. NIHSS reduction of ≥33% was the best tradeoff between sensitivity (64%) and specificity (83%) for identifying recanalization. NIHSS reduction of ≥33% had the highest discriminative ability to predict recanalization (area under the curve, 0.735) in comparison with other definitions of neurological improvement. One-third neurological improvement between the primary hospital and tertiary center was the best predictor of early recanalization.

Abstract TP44: Door In-Door Out Times: A Comprehensive Stroke Center Review

Expeditious transfer of patients with acute ischemic stroke (AIS) and LVO presenting to a primary stroke center (PSC) and within the window for mechanical thrombectomy (MT) is vital to optimize their functional outcome. Door-in-door-out (DIDO) represents the time of patient arrival to the PSC to the time of discharge from the PSC for transfer to a comprehensive stroke center (CSC). The goal for this metric is 90 minutes. At a large urban academic and CSC with a high volume of patient transfers, we examined our DIDO metrics to identify trends and opportunities for improvement. Methods: The CSC MT database was queried to analyze DIDO times. Inclusion criteria included AIS cases with LVO transferred to the CSC for MT from fiscal year 2022-2023. Hospitals transferring less than 5 cases during that timeframe, inpatient cases, and unavailable times were excluded. Hospital DIDO times and their components (i.e. each step in the process) were grouped into quartiles and analyzed. A survey to PSC stakeholders was sent to identify themes for possible barriers. Results: Among 8 hospitals, the top quartile with the fastest DIDO times had a mean of 132 minutes and median of 122 (N = 22 patients). The hospitals with the longest DIDO had a mean of 205 and a median of 193 (N=17). The components of DIDO times that separated the fastest from the slowest were PSC arrival to 1 st call to CSC and 1 st call of PSC to acceptance at CSC . The PSCs with the highest DIDOs took double the time in these components (40 vs 81, 22 vs 53 minutes). Distance from the CSC does not appear to be a factor in DIDO times, with the fastest being 13 to 68 miles away vs. 11 to 30 miles for the slowest. In the survey results, 81% of participants had CSC bed availability as the top barrier, whereas 69% reported delays in transport time to PSC. Conclusion: DIDO times from PSCs continues to be an opportunity for process improvement. Only 5% in our sample met the DIDO metric goal of 90 minutes. Two areas of potential improvement include decreasing PSC time to 1 st call and improving time of CSC acceptance. PSCs believe that a “ready” bed at the CSC would decrease DIDO times, but there are additional opportunities among the components.

Abstract TP108: Clinical Utility of the Alberta Stroke Program Early CT Score: A Survey Comparing Comprehensive Stroke Centers

Introduction: The Alberta Stroke Program Early CT Score (ASPECTS) is often used in considering whether patients are appropriate for thrombolysis and/or thrombectomy after acute ischemic stroke (AIS). We hypothesized that while clinical guidelines recommend ASPECTS evaluations in AIS, ASPECTS use is low in practice. We also explored differences in ASPECTS use between high and low volume comprehensive stroke centers (CSC). Methods: We surveyed United States CSC from 2021-2022 regarding ASPECTS utilization in evaluating eligibility for thrombolysis and/or thrombectomy in patients with suspected or confirmed large vessel occlusion. We asked whether ASPECTS was routinely used, if it was the preferred primary modality for final decision making, and whether an ASPECTS < 6 excluded a patient from thrombectomy consideration. Survey responses were divided between large (Annual volumes of ischemic strokes >600) and small CSC ( < 600). Chi square analysis was performed on this data. Results: Thirty-nine CSC completed the survey. Of these, 21 were large CSC and 18 were small CSC. Of all CSC, 31% did not use ASPECTS at all. Seventy-four percent preferred automated mismatch software over ASPECTS as the primary modality in final decision making. Thirty six percent of CSC noted that an ASPECTS < 6 would exclude a patient from consideration for thrombectomy. There was no relationship between CSC size and ASPECTS use [X 2 (1, N = 39) = 0.71, p < .05]. There was also no relationship between CSC size and whether ASPECTS was the preferred primary final decision making modality [X 2 (1, N = 39) = 0.23, p < .05]. Additionally, there was no relationship between CSC size and whether ASPECTS < 6 excluded patients from thrombectomy consideration [X 2 (1, N = 39) = 0.73, p < .05]. Conclusion: In practice, the clinical utility of ASPECTS for AIS evaluation is low. Case volume experience also has no apparent impact on ASPECTS utilization. Our preliminary survey reveals low use of ASPECTS, and a preference for mismatch software in choosing AIS candidates for intervention. This discrepancy suggests significant differences between clinical guidelines and actual practice.

Abstract WP117: Improvement of Collateral Status in Thrombectomy-Eligible Stroke Patients During Inter-Hospital Transfer: Association With Clinical Factors and Outcome

Background: Ischemic stroke patients who are eligible for endovascular therapy (EVT), can be transferred from a primary stroke center (PSC) to an EVT-capable comprehensive stroke center (CSC). Little is known about the dynamics of the collateral circulation in this time-window. We aimed to explore changes in collateral status during inter-hospital transfer among patients with poor collaterals on presentation to the PSC. Methods: Data from patients with an anterior circulation large vessel occlusion (LVO), transferred to two CSCs were prospectively collected. A CT perfusion was obtained at the PSC followed by an MRI immediately on arrival at the CSC. The hypoperfusion intensity ratio (HIR), a measure of collateral blood flow, was calculated as the ratio of the Tmax volumes of >10s and >6s. Only patients with stable LVO at the CSC and poor collateral status at the PSC (HIR ≥ 0.40) were included. An HIR < 0.40 in the CSC and a difference ≥ 0.10 was considered as HIR improvement. Results: Data from 104 patients with perfusion imaging at both PSC and CSC, were analyzed. Of them, we included 59 patients with an HIR ≥ 0.40 at the PSC. Sixteen (27%) patients experienced HIR improvement during transfer (Figure 1) . A smaller baseline core volume was independently associated with HIR improvement (OR for every 10 ml increase = 0.46 {95%CI 0.21-0.81}; p=0.03). Collateral improvement was associated with slower infarct growth during transfer (2.45 {95%CI 1.03-3.62} vs 7.77 {95%CI 4.56-17.86} ml/h; p<0.01) and a better functional outcome at 90 days post stroke (median mRS 3 {IQR 1-5} vs 4 {IQR 4-6}; p=0.01). Conclusion: During inter-hospital transfer spontaneous improvement in collateral status, as measured by HIR, is commonly seen, and associated with a smaller infarct core at the PSC, slower infarct growth during transfer, and better functional outcomes. Future neuroprotective trials targeted at collateral improvement, might consider the use of the HIR change as a surrogate outcome marker.

Abstract TP131: Computed Tomography Perfusion Imaging Patterns Are Similar Before and After Interfacility Transfer of Ischemic Stroke Patients

Background: Large vessel occlusion (LVO) stroke patients are often transferred from regional hospitals to comprehensive stroke centers (CSC) for thrombectomy. The need for repeat imaging at CSCs prior to intervention is unclear. We compared regional hospital and CSC perfusion imaging results for interfacility transfers in a single health system. Methods: We analyzed a cohort of patients in western Michigan who received CT perfusion imaging before and after transfer to a CSC. Perfusion mismatch (MM), core infarct volume (CIV), and favorability of imaging for mechanical thrombectomy (MT) candidacy were compared between the regional and CSC studies. A favorable imaging profile was defined as the presence of LVO, MM volume >10 mL, and MM/CIV ratio of >1.2. Linear regression was used to examine predictors of infarct growth during transfer. Results: Over a 10-month period, 25 patients met inclusion criteria. The median age was 76 (IQR 66-81), 60% were male, median NIHSS was 11 (IQR 2-18), and most patients had occlusion of the internal carotid or middle cerebral arteries (72%). The median time from last known well to initial CT was 250 minutes (IQR 85-620). Regional median MM volume was 52 mL (IQR 8-97), CIV was 0 mL (IQR 0-13), and hypoperfusion intensity ratio (HIR) was 0.25 (IQR 0-0.34). The median time between CTs was 152 minutes (IQR 139-226). The median change in MM volume was -3 mL (IQR -27-3) and median CIV growth rate was 0 mL/hr (IQR 0-2.0). In a multivariable regression model, higher HIR (β=23.2, p=0.012) and minutes between imaging studies (β=0.10, p=0.021) were associated with CIV growth. Sixteen patients (64%) had favorable imaging profiles for MT at the regional hospital. Of these, 15 (93.8%) continued to have a favorable CSC imaging profiles and 9 (56.2%) underwent MT. Of the 9 patients without favorable regional imaging profiles, 1 (11.1%) had a favorable CSC imaging profile and 2 (22.2%) underwent MT. Conclusion: In our sample, regional and CSC perfusion imaging patterns were similar and patients infrequently crossed thresholds for MT candidacy between studies. Initial HIR and longer delays between were independently associated with infarct growth during transfers, however overall infarct growth was very small.

Abstract WMP93: Door-to-Thrombolysis Time Between Primary Stroke Centers and Comprehensive Stroke Centers: Is There an Added Benefit?

Introduction: Comprehensive Stroke Centers are skilled, highly trained facilities that provide advanced care to an array of stroke patients. If stroke patients are not able to reach a Comprehensive Stroke Center, Primary Stroke Centers provide convenient and rapid care to patients presenting with acute ischemic stroke. Ideally, these Primary Centers save time to intervention. Whether there are differences in time to intervention, and resultant patient outcomes, between such centers has not been thoroughly studied. To this end, we examined door-to-needle and door-to-stroke alert time between one Comprehensive Stroke Center and three Primary Stroke Centers in Northwest Ohio. Hypothesis: Primary Stroke Centers will have longer time to intervention (i.e., door-to-needle times) than that of Comprehensive Stroke Centers. Methods: From 2018-2023, we examined door-to-needle and door-to-stroke alert times in patients presenting to the ProMedica Health System with ischemic stroke in a retrospective chart review. All patients presented with Large Vessel Occlusion (LVO) ischemic stroke. Results: 293 patients and 255 patients presented to either the Primary Centers or the Comprehensive Stroke Center, respectively. Door-to-needle time was significantly longer in patients presenting to the Primary Centers (Median: 59.00 minutes), compared to the Comprehensive Stroke Centers (Median: 39.50) (Mann Whitney U-Test: p <0.0001). However, door-to-stroke alert was not different between the two centers (Primary, Median: 2; Comprehensive, Median: 1, Mann Whitney U-Test: p = 0.099). Conclusions: We report a longer latency to needle in Primary Stroke Centers compared to Comprehensive Stroke Centers, with no change in door-to-stroke alert time. It is forthcoming whether this difference impacts patient outcome measures. Such findings suggest that stopping at Primary Stroke Centers may not provide either a time- or outcome-benefit in lieu of immediate arrival to a Comprehensive Stroke Center.

Abstract WMP40: A Geospatial Information Services Assessment of Prehospital Bypass on Overtriage for Large Vessel Occlusion and Hemorrhagic Stroke

Introduction: To increase the number of patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) transported directly to Comprehensive Stroke Centers (CSCs), on December 1, 2021, the threshold score for our county EMS agency’s quantitative stroke severity scale (FAST-ED) for bypassing a non-CSC decreased from 7 to 6. The goal of this work was to evaluate the impact of and adherence to this change, and its effect on overtriage. Methods: Two large regional health systems and the county EMS agency collaborated on this study. Using latitude and longitude coordinates from our EMS agency’s database, we geocoded the pick-up location of all patients who had a FAST-ED score of ≥6 from September 2019 to December 2022. We used ArcGIS to calculate drive times to the closest facility among 2 CSCs and 7 non-CSCs, and linked EMS records to hospital records to determine LVO AIS involving the intracranial ICA, M1, M2 or basilar artery. For patients without a CSC as the closest destination facility, we defined overtriage as routing to a CSC for a non-LVO or non-hemorrhagic stroke patient. Results: Over our 40-month study period, among patients with a FAST-ED score performed (n=13,913), 824 had a score ≥6. Actual versus ArcGIS drive times in minutes [mean(SD)] compared favorably [14.8(8.5) vs 14.4(6.4), with an ICC of 0.68 (95% CI 0.64-0.72). For 799/824 patients (97%), one of the county’s two CSCs was not the closest destination facility, and among this group 99% (n=787/799) of EMS records were successfully linked to the hospital record. Among these patients, prior to December 1, 2021, 67% (n=219/326) patients with FAST-ED score ≥7 were bypassed to a CSC, with an overtriage rate of 49% (n=107/219), while after that date 88% (n=230/262) patients with a FAST-ED score ≥6 were bypassed to a CSC, with an overtriage rate of 55% (n=126/230). Conclusion: It is feasible to use drive times calculated from ArcGIS to evaluate the performance of EMS stroke triage and destination plans. Lowering our county’s FAST-ED score threshold for bypass increased adherence to the bypass protocol with a modest increase in overtriage. Future work will incorporate undertriage rates with the ultimate goal of optimizing our regional stroke and triage destination plan.

Abstract 23: Results of CRISP2: CTP and CTA Assessment of Collaterals Predicts Inter-Hospital Infarct Growth

Background: Acute ischemic stroke patients with a large vessel occlusion (LVO) who present in a primary stroke center (PSC) without endovascular treatment capability, are often transferred to a comprehensive stroke center (CSC) for thrombectomy. CRISP2 was a prospective NIH funded multi-center study that aimed to determine characteristics associated with infarct growth during inter-hospital transfer. Methods: Data from patients with an anterior circulation LVO transferred to two CSCs were collected. A CT perfusion (CTP) was obtained at the PSC followed by an MRI at the CSC, before consideration of thrombectomy. The inter-hospital infarct growth rate was defined as the difference between the co-registered infarct volumes on MRI and CTP, divided by the time between the two scans. Multivariable logistic regression was used to determine characteristics associated with fast inter-hospital progression, defined as a growth rate ≥ 5ml/h. The hypoperfusion intensity ratio (HIR) was calculated automatically from the CTP, while the Tan collateral score was visually rated on baseline CT angiography. Results: A total of 183 patients, of whom 45% were fast progressors, were included. Baseline characteristics are presented in Table 1 . An HIR ≥0.40 identified fast infarct growth with a sensitivity of 0.76 (95%CI 0.65-0.84) and a specificity of 0.55 (95%CI 0.44-0.65), whereas for Tan 0-1 sensitivity was 0.37 (95%CI 0.27-0.48) and specificity 0.93 (95%CI 0.86-0.97). In multivariable models, baseline core volume and poor collaterals defined as either an HIR ≥ 0.40 (aOR = 2.18 (95%CI 1.10-4.42); p = 0.03) or a Tan score of 0-1 (aOR = 4.74 (95%CI 1.90-13.07); p=0.001), remained independently associated with fast infarct growth. Conclusion: An HIR ≥ 0.40 is a predictor of fast inter-hospital infarct growth with high sensitivity and a Tan score of 0-1 predicts fast growth with high specificity. These are promising imaging markers for patient selection in future neuroprotective trials.

Abstract WP47: Creation of a Pediatric Stroke Alert Protocol

Background: In 2021, our Comprehensive Stroke Center (CSC) in San Antonio (SA), Texas received 7 pediatric patients suffering from signs and symptoms of stroke. These patients ranged in age from 4-17 and approximately 57% were positive for an acute ischemic stroke (AIS). During the month of March, 2 patients were brought in via EMS and both MRIs were positive for AIS, prompting our stroke team to evaluate our adult processes. We concluded that an Emergency Department (ED) Pediatric Stroke Alert Protocol was needed in order for our hospital to have the capability to care for this patient population, and also appropriately triage and offer acute therapies to give these patients the best chance possible. Purpose: Develop an ED Pediatric Stroke Alert Protocol in order to provide rapid triage and advanced therapies if warranted. The ED Pediatric Stroke Alert protocol was developed with our same stroke alert time frame in mind, 0-6 hours, and with the age range of 2-17 years. Methods: An interdisciplinary team consisting of Vascular neurology, Pediatric Neurology, Pediatric Hematology/Oncology, Pediatric Critical Care nursing, Pediatric / Adult ED nursing & Faculty, Neuro Critical Care, Pharmacy, and our Stroke Team met to discuss how to implement a pediatric protocol. It was decided that modeling it after the Adult ED Stroke Alert Protocol would be best to limit confusion and triage errors. The Cincinnati Stroke Scale was used as the tool of choice in order for our ED team to identify stroke symptoms, also a time frame of less than 6 hours from onset of symptoms AND a blood glucose between 60 and 600. This would then prompt the activation of the Pedi ED Stroke Alert Protocol. Triage on the protocol includes inclusion and exclusion criteria for IV tPA, which was also tailored to the pediatric population with the help of Pediatric Hematology/Oncology. Results: The ED Pedi SA Protocol has since been revised to meet the needs of our changing pediatric stroke population. The CSC continues to treat pediatric patients and continues to develop other tools to meet the needs of this population. Conclusion: Our CSC has been categorized by EMS as one of the only CSCs in SA, Texas that is capable of providing complete stroke care to the pediatric population.

Abstract TP282: Impact of Interhospital Transfer on Patients Undergoing Endovascular Thrombectomy for Acute Ischemic Stroke From a Comprehensive Stroke Center

Objective: This study aims to evaluate how interhospital transfers impact the correlation between functional outcomes, mortality, reperfusion rates, and workflow time metrics in patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion (LVO). Background: This analysis is based on a prospective database encompassing consecutive patients who underwent EVT for LVO between January 2021 and June 2023 at a comprehensive stroke center (CSC). Main Outcome Measures: The primary outcome measures assessed include the rate of favorable 90-day functional outcomes (modified Rankin Scale 0-2), successful reperfusion (Thrombolysis in Cerebral Infarction scale grade 2b or 3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Additionally, essential workflow time metric milestones were analyzed. Results: Out of 363 patients, 172 (47.4%) were transferred from other hospitals. The transferred patients were relatively younger than those who presented directly (66.5 ± 15.6 vs. 70.6 ± 14.5). No significant differences were observed in baseline characteristics, including gender, National Institutes of Health Stroke Scale score, and the rate of intravenous thrombolysis, between the transferred and direct presentation groups (all p > 0.05). The time of symptom onset to groin puncture time was significantly higher for the transfer group (703.6 min vs. 394.5 min, p < 0.0001), while comparable figures were noted for groin puncture to reperfusion time (43.9 min vs. 45.1 min, p = 0.7071) and ICU length of stay (70.8 hours vs. 59.3 hours, p = 0.7071) between the two cohorts. Similar rates were also seen for successful reperfusion (p = 0.2348), sICH (p = 0.4933), favorable 90-day functional outcomes (p = 0.9457), mortality (p = 0.8534), and composite complications during hospitalization (p = 0.5779). Conclusion: Although we observed significantly longer time intervals from symptom onset to initiation of mechanical thrombectomy in patients transferred from outside facilities, there were no adverse consequences on patient outcomes.

Abstract TMP37: Improved Outcomes for Acute Ischemic Stroke Patients After Implementation of the RapidAI Platform in a Comprehensive Stroke Center in Santiago, Chile

Introduction: In Latin America (LATAM), the prevalence of stroke is alarmingly high. The advancement of artificial intelligence (AI) technologies has potential to dramatically improve healthcare outcomes. RapidAI is a software solution that utilizes AI to quickly analyze imaging data to identify vascular occlusions and salvageable tissue. Physicians receive notifications and can review source images on the Rapid mobile app (RMA). Methods: This was a retrospective analysis of 1,672 consecutive acute stroke patients (AIS) treated at Clinica Alemana de Santiago between 2014-2023. Primary outcomes were the number of AIS patients treated with thrombolysis (IV tPA), mechanical thrombectomy (MT), or decompressive craniectomies as well as time to treatment. Secondary outcomes included discharge Modified Rankin score (mRS) and hospital length of stay (LOS). Results: This analysis included 824 patients pre-RapidAI installation and 848 after installation of Rapid CTP with hypodensity, CTA, ASPECTS, LVO and RMA communication. The baseline NIHSS and last know well to hospital arrival was balanced between the 2 study cohorts. Median time to IV tPA improved by 42 minutes (80 to 38 minutes, p < 0.0001). IV tPA utilization increased from 23% to 30% post-Rapid (p = 0.0033). MT procedure utilization increased from 5% pre-Rapid to 10% (p < 0.0001). Decompressive craniectomies were reduced from 13 to 4, LOS was unchanged. There was a favorable shift in the distribution of mRS scores at discharge in post-Rapid patients (p = 0.031) and a significant increase in mRS 0-1 outcomes (61% vs 45%). Discussion: Following implementation of the AI software platform in a comprehensive stroke center like Clinica Alemana, there was a significant increase in patients treated with IV tPA, faster door to tPA and/or MT times, a decrease in the number of DCTs, and improved discharge mRS scores. This work supports future studies expanding the use of AI technology for improving stroke outcomes in LATAM.

Abstract TMP42: Reducing 30-day Stroke Readmissions Using a Multi-Step Quality Improvement Approach

Background: Thirty-day all-cause readmissions occur in about 12% of acute ischemic stroke (AIS) patients, are associated with a 4-fold increase in mortality, and are associated with increased cost utilization. Therefore, reducing 30-day readmissions in AIS patients is of paramount importance. In this study, we aimed to test the effect of a multi-step quality improvement (QI) initiative on readmission rates in hospitalized AIS patients. Methods: We included all patients discharged from a Comprehensive Stroke Center with a diagnosis of AIS or TIA over a 3-year period. The pre-intervention period was 1/1/2020 - 9/30/2021. The approach was instituted on 10/1/2021. After a 3-month washout, the post-intervention period was 1/1/2022 - 6/30/2023. Intervention measures are below.1. An inpatient checklist was instituted to help providers identify and address common problems before AIS/TIA patients were discharged.2. Complex patients discharged home would receive a call shortly after discharge to ensure good understanding of their care and next steps. Such patients were also scheduled to follow up in a rapid access clinic within 2 weeks of discharge.3. Complex patients discharged to a facility required a handoff call to the facility’s accepting provider.4. All readmissions were reviewed in our monthly QI meeting, with efforts to identify preventable causes.We used t-tests to compare mean observed to expected (O:E) length of stay and mortality metrics between the pre- and post-intervention periods. We used Chi Square tests to compare overall readmission rates. Results: Over the study period, 2532 patients were discharged with a principal diagnosis of AIS or TIA, and the all-cause 30-day readmission rate was 8.8% (223/2532). Compared to pre-intervention, the post-intervention period had a lower 30-day readmission rate (7.6% vs. 10.2%, p = 0.023), a non-significantly lower mean O:E mortality rate (0.71 vs. 0.82, p = 0.252), and a non-significantly lower mean O:E hospital length of stay (0.92 vs. 0.88, p = 0.13). Conclusion: At a Comprehensive Stroke Center, a multi-step approach for transitions of care was associated with reduced all-cause readmission rates without increasing hospital length of stay or mortality. Our findings require external validation.

Abstract 129: An Automated Perfusion Collateral Score as a Tool to Predict Inter-Hospital Infarct Growth and Functional Outcome

Background: The accuracy of infarct growth prediction based on collateral scores, assessed on CT perfusion (CTP) and CT angiography, has been modest. We aimed to investigate the accuracy of infarct growth prediction using a novel collateral score based on two CTP parameters. Methods: Patients were included from CRISP2, a multi-center prospective cohort study of stroke patients with an anterior circulation large vessel occlusion who are transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC). CTP was performed at the PSC, and MRI was performed immediately after arrival at the CSC. The inter-hospital infarct growth rate was calculated as the difference between the co-registered infarct volumes on MRI and CTP divided by the time interval between the scans, with fast inter-hospital growth ≥ 5ml/h. The hypoperfusion intensity ratio (HIR) was defined as the ratio of the volumes of Tmax >6s and Tmax >10s, and the CBV index as the ratio of mean CBV values within the Tmax >6s volume and the mean CBV in normal brain regions. An automated collateral score, based on the HIR and CBV index, was calculated from the CTP images at the PSC ( Fig 1A ). Results: Of 183 patients who were included, 111 (61%) were classified as having good collaterals and 72 (39%) as poor. Patients with poor collaterals experienced more rapid early infarct growth (median 2.19 ml/h IQR [0.32, 5.46] vs 7.92 [4.23, 16.23]; p-value <0.001) and had worse 90-day functional outcomes (p=0.01). The combined collateral score, based on both HIR and CBVindex, showed a trend towards better prediction of fast infarct growth compared to HIR alone (HIR ≥ 0.40 = poor collaterals) and CBV alone (CBVindex < 0.85 = poor collaterals) ( Fig 1B ). Conclusion: A perfusion collateral score, based on HIR and CBV index, is strongly associated with inter-hospital infarct growth rate and functional outcome. This automated tool can aid in patient selection for (neuroprotective) treatment strategies and transfer decisions.

Abstract WP60: On vs. Off-Hours Arrival to Groin Time: Identifying Gaps in a Comprehensive Stroke Center

Introduction: Timeliness of treatment for patients with acute ischemic stroke (AIS) directly correlates with outcomes. The most current AHA guidelines standard of care for patients having a large vessel occlusion (LVO) stroke is endovascular mechanical thrombectomy (MT). Earlier treatment is associated with better outcomes at 90 days. Parallel processing is paramount when executing an expedited transition from the emergency department (ED) to the MT suite. At a large academic comprehensive stroke center (CSC), as we receive a high volume of direct ED cases, we examined whether there was a difference in daytime vs. off-hour LVO cases. Methods: The MT database maintained by the CSC was queried for all cases from July 2022- July 2023. Inclusion criteria included all AIS with LVO and receiving MT that were transported by EMS directly to the CSC ED. Data was further stratified by time of day and day of the week. Cases were designated as day if they arrived Monday through Friday between 7am-5pm. Cases were considered night/weekend if they arrived 5pm-7am or anytime Saturday or Sunday. Times between groups were compared with t-test. Results: There were a total of 37 cases in the day group and 43 cases in the night/weekend group. Patients arriving during the day had a median arrival-to-groin time of 89 minutes and a mean of 93 minutes. The night/weekend group had a median of 116 minutes and a mean of 125 minutes, and the difference was statistically significant (p=0.0009). Upon further analysis, mean ED arrival to suite time was significantly longer for night/weekends, 105 vs. 76 minutes, p=0.008, but mean suite to groin puncture time was not significantly different, 18 vs. 16 minutes, p=0.24. Conclusion: There is a statistically significant difference in arrival to suite/groin times between the day and night/weekend groups, therefore putting patients with LVO arriving off hours at higher risk for poor outcomes. Historically some cardiac cath labs have utilized nursing bridge teams to help with parallel processing, and we theorize that using such a team to facilitate preparation of the patient and suite, we can reduce treatment times for off-hour’s ED MT cases and potentially improve outcomes.

Abstract 33: An Innovative Digital Health Approach to Enhance Patient Engagement in Stroke Care

Introduction: Patient engagement (PE) is a crucial aspect of health management shown to improve adherence and outcomes. For patients with ischemic stroke (IS) and transient ischemic attack (TIA) PE holds significant value. Novel ways to engage IS/TIA patients and deliver personalized education may enhance knowledge, satisfaction, and adherence while potentially reducing recurrent stroke. Purpose: Develop and implement a stroke-specific 90-day digital health PE platform for IS/TIA patients discharged (DC) home from a Comprehensive Stroke Center (CSC). Utilizing the Twistle TM digital platform the initiative focuses on patient education and adherence. Methods: An expert panel (digital health operations, vascular neurologist, stroke-certified nurse practitioner) designed a 90-day program with 21 modules emphasizing education, adherence, communication, and 90-day mRS self-assessment. A pre-implementation survey assessed confidence to prevent stroke and knowledge of personalized risk factors, lifestyle modification, and medication in 14 IS/TIA patients (Mdn 21 days from DC), with 11 responses (73.3%). After pilot testing with 2 patients and feedback incorporation, 10 more patients were enrolled. A patient engagement and satisfaction survey was administered on day 20. Results: Assessment determined the program was feasible and compared pre-implementation and 20-day survey responses from participants (response rate 6/9). Post-implementation outcomes showed improved patient knowledge and confidence. Patients agreeing/strongly agreeing to having lifestyle modification knowledge increased from 64.6% (n=11) to 83.4% (n=6). Confidence in preventing another stroke/TIA rose from 27.3% (n=11) to 66.7% (n=6). Participants reported heightened engagement through digital messages (83.3%, 5/6), while one respondent (16.7%) remained neutral. Conclusions: Initial findings underscore the potential of digital health, delivered through platforms like Twistle TM , to enhance patient engagement and confidence post-IS/TIA. The program's successful launch suggests promise for expansion at the CSC and potentially across additional health system hospitals. The initiative holds potential for enhancing patient outcomes and well-being.

Abstract NS2: An Expedited Transfer Process Improves Door In Door Out Times

Background: Rapid reperfusion with mechanical thrombectomy for ischemic stroke secondary to large vessel occlusion leads to significant reduction in morbidity and mortality. DIDO time is an important metric for stroke centers without on-site mechanical thrombectomy. Delays in treatment can occur when patients present at a Primary Stroke Center (PSC) then require transfer to the CSC for MT. Our system Comprehensive Stroke Center (CSC) receives patients from 2 of our system’s PSCs. In order to expedite care an expedited transfer protocol was implemented. Purpose: The goal of this work is to decrease the time at the PSC, known as door-in-door-out (DIDO), and decrease overall time from patient presentation to treatment with thrombectomy. Methods: Patients are screened at triage by a PSC emergency department provider for the following: aphasia, gaze preference, or neglect with unilateral weakness within 24 hours of last known normal. If these criteria are present, the emergency department provider contacts the CSC transfer center to initiate the expedited transfer process, which begins mobilizing resources to the PSC while clinical work-up continues. This expedited early transfer process was implemented in January 2021. Transfers for MT during the 12-month period before and after the implementation of the expedited transfer process were analyzed. Results: A sustained reduction in overall DIDO was observed during the time period following implementation of the expedited transfer process (Fig 1) Mean DIDO was lower when the transfer call was placed before CT vs after CT (81 min vs. 132 min respectively) (p=.0031). Conclusions: Use of the Expedited Transfer Process allows transfer resources to begin moving to the patient with a suspected LVO in parallel with ongoing evaluation, resulting in faster DIDO times leading to faster treatment aimed at reducing stroke morbidity and mortality. Further analysis of the effect of the expedited transfer process on DIDO times is planned.