Comprehensive Stroke Center Research Articles

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.

Abstract WP29: Early Adopter of Intravenous Tenecteplase: Two Year Clinical Experience in a Non-Academic Suburban Comprehensive Stroke Center for Acute Ischemic Stroke Treatment

Background: The most recent American Heart Association/American Stroke Association acute ischemic stroke guidelines recognize tenecteplase (TNK) as an alternative to alteplase (ALT) for acute ischemic stroke (AIS) treatment. TNK has a longer half-life, and is given as a single intravenous bolus compared to the complex and cumbersome ALT administration. A switch to TNK was implemented at our Comprehensive Stroke center (CSC) after a rigorous training of nurses and providers on May 1, 2021. We sought to evaluate the comparative performance of two thrombolytics over the period of last two years of ALT and first two years on TNK use. Methods: This was a retrospective review of prospectively collected database of consecutive AIS patients treated with ALT between May 2019 to April 2021 and those who received TNK from May 2021 to April 2023 at our CSC. Data samples were analyzed with respect to baseline patient characteristics, stroke severity, Door to Needle (DTN) time, 90 day Modified Rankin Scores (MRS), complications, and cost savings. Statistical analyzes were used for between group comparisons (SPSS). Results: A total of 115 patients were treated with ALT and 134 - with TNK. There were no significant differences in baseline characteristics or stroke severity between the groups (mean NIHSS of 10 for both). The mean DTN was 53.0 minutes for ALT and 41.5 minutes for TNK (p<0.001). There was a strong trend towards improved 90-day clinical outcomes for TNK-treated patients (mRS 2.5 vs 3.1, p=0.06). No significant differences in rates of symptomatic Intracerebral Hemorrhage (SICH) were observed between two groups (2.6% ALT vs 2.9% TNK). Estimated cost savings of TNK use over two year period were $75,102. Conclusion: Our real-world data suggests that intravenous TNK for AIS appears to be safe and may result in improved clinical outcomes and substantial cost savings compared to ALT.

Abstract TMP17: Predicting Neurosurgical Intervention After Intracerebral Hemorrhage (ICH) Transfer

This is a retrospective chart review to ascertain the rates of neurosurgical intervention following transfer of patients with non-traumatic intracerebral hemorrhage (ICH) to a Comprehensive Stroke Center (CSC) and characterize predictors of need for surgical intervention. Introduction: While neurosurgical intervention is required in a minority of cases, it has become standard practice for all ICH patients to be transferred to our tertiary care center, without consideration of additional factors. This creates significant burden and stress to patients and families as well as hospital resources. Hypothesis: We hypothesize that only a minority of ICH patients require neurosurgical intervention and that we will be able to identify predictors that will assist in identifying patients who are at risk for needing neurosurgical intervention. Methods: We retrospectively reviewed the EMR from all ICH patients transferred to a 700-bed CSC from 2020-2023. We collected: age, sex, pre-stroke modified Rankin score, ICH score, BP management, anticoagulant reversal, any neurosurgical intervention performed, length of stay (LOS), and 30-day mortality. The data was stored and analyzed in a secure online database. Results: Of the 420 completed charts, 55% of patients were male with an average age of 67.7 years. Only 14.25% (61/420) of all patients underwent neurosurgical intervention. Predictors for surgery included: age (average age of patients who underwent surgery was 61.2 years); size and location of the hematoma (the majority of patients who underwent surgery (58/61) had ICH volume >30cc, were subtentorial in location, or had IVH extension); higher ICH score (23.96% with ICH ≥2 vs. 6.67% with ICH 0-1); and lower GCS (41.5% GCS <12 vs. 9.8% GCS ≥ 12). Average hospital length of stay was 10.5 days. Mortality rate at 30-days was 24.5% overall and higher in patients who underwent neurosurgical intervention (32.8%). Conclusion: Only a small percentage of patients with ICH transferred to our CSC require neurosurgical intervention. There are many predictive factors allowing for a more thoughtful approach to better utilize health care resources. We recommend further studies to develop better strategies to triage these patients.

Abstract WP264: Identifying Gaps in Discharge Statin Prescription Within a Stroke Clinical Network

Introduction: Statins are recommended in national guidelines for secondary prevention following acute ischemic stroke (AIS). Studies have reported patients not taking statins after AIS have increased mortality. The purpose of this retrospective quality improvement initiative was to determine if there is a difference in prescription of statin medications at discharge for patients with AIS within a Stroke Clinical Network (SCN), consisting of one comprehensive stroke center (CSC) and eight primary stroke centers (PSC). Methods: The Get with The Guidelines registry was queried for AIS patients admitted to the SCN between 2017-2022 to evaluate discharge practices for statins. Information was collected to include age, gender, race, history of CAD, DM, HTN, and if discharging facility was a PSC or a CSC. Patients were excluded if they died, discharged to hospice, or if a reason for no statin at discharge was documented. A Chi-square and a multivariable regression were performed to examine the relationships between demographic and medical variables and if a statin was prescribed at discharge. Results: A total of 15,606 AIS patients were identified. Mean age was 68 years (SD +/- 14.2), 50% male (7798/15606), and 38.8% Black (6061/15606). Of the 15,606, a total of 13,319 (85.3%) were prescribed a statin at discharge. Compared to patients with the following risk factors, there was a significant difference in the odds of being discharged without a statin for patients who did not have HTN (OR 1.52, 95% CI [1.36-1.69]), DM (OR 1.65, 95% CI [1.48-1.83]) or CAD (OR 1.34, 95% [1.18-1.53]). Patients who are < 70, white, female, and discharged from a PSC are also at higher risk for non-statin use. Conclusions: In a large SCN, those without well-known vascular risk factors, those under the age of 70, white patients and women were at higher risk of not being prescribed statins at discharge. Further studies should be done to address these disparities and to optimize secondary stroke prevention.

Abstract WP78: Large Vessel Occlusion Triage and Routing Utilized for Long-Distance Stroke Transports by Emergency Medical Services (LVO TRUST EMS)

Introduction: Endovascular treatment (EVT) is the most effective therapy in acute ischemic stroke (AIS) with large vessel occlusion (LVO) but its practice is limited to comprehensive stroke centers (CSC). Previous studies have suggested that trained Emergency Medical Services (EMS) professionals can successfully detect LVO cases using a validated screening tool. For these cases, direct transfer to CSC bypassing community hospitals could lead to better outcomes. Methods: This is a retrospective cohort study from 01/01/2018-12/31/2022 of patients with suspected stroke transported by EMS providers from 14 community agencies (primarily fire paramedics) in Southeastern Massachusetts (EMS Region V). When stroke was suspected, EMS providers applied the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score to assess severity. Bypass of local community hospitals for direct transport to CSC was generally considered for patients with FAST-ED ≥4 and approval of the Region V EMS Medical Director, with the goal of early intervention for severe strokes. In addition to standard education on the use of the FAST-ED score, the EMS agencies received annual aggregate performance feedback and individual case feedback (when requested) from the CSC. Data were collected from the Electronic Health Record (EHR) on demographics, comorbidities, final diagnoses, FAST-ED scores, NIHSS and acute treatments. Descriptive statistics were performed to describe the accuracy of diagnosis and rates of treatment. Results: Among 166 triaged patients to go directly to CSC, 57.6% (95/166) were diagnosed with AIS, and 61.1% (58/95) of them were found to have LVO. There was a higher proportion of AIS or intracranial hemorrhage (ICH) in cases with higher FAST-ED scores. Only 23.4% (39/166) of the cases were diagnosed with stroke mimics, primarily related to lower FAST-ED scores. In total, 36.9% of patients with AIS received EVT: thrombectomy with standard window tPA (21.1%) or late presenter tPA (LKW ≥ 4.5 h, 1.1%), and without tPA (14.7%). Conclusions: A diverse group of community-based EMS services in Southeastern Massachusetts using a prehospital tool can identify patients with severe stroke, i.e. AIS due to LVO or ICH, with acceptable diagnostic accuracy.

Abstract WP57: Who Needs to Compete When You Can Collaborate? Celebrating 25 Years of Successful Stroke Care

Background: In 2004, Kansas City nurses partnered with the American Stroke Association to provide stroke education to health care providers and the community. Over time, the goal shifted to stroke systems of care. Today this group is known as the Bistate Stroke Consortium, comprised of 34 hospitals and rehab facilities. The group continues to work together to facilitate their mission in a spirit of collegiality and collaboration throughout two states. The communities have also benefited as evidenced by an increase in Primary and Comprehensive Stroke Centers in the region. Methods: In 2021, this Consortium formed a community outreach and stroke leader development sub-committee. Multiple innovative projects were created for both community outreach and stroke leader development to help with educating our region about strokes, celebrating successes, and highlighting best practices from our group. The purpose of this research is to evaluate the effectiveness of these projects. Results: This group placed an emphasis on community and leader education. The group distributed over 10,000 resources in the region and gained substantial community viewership. The group members of the Bistate group provide over 130 hours of education each year including best practices and benchmarked data from GWTG. Notably, during this same period, these two states experienced improvements in stroke related mortality and hospitalizations. The increasing number of patients with stroke symptoms arriving at the hospital via EMS indicates a clear preference for calling 911 and the impact of community education. While the precise factors contributing to these improvements are multifaceted, it is likely that the efforts of this group have played a pivotal role in influencing these positive outcomes. Conclusion: The Bistate Stroke Consortium collaborates to improve patient care, community education, and supports Stroke Coordinators. Stroke mortality and hospitalizations are decreasing in the Consortium's region. Timely stroke recognition by non-healthcare providers and presentation to appropriate healthcare systems are essential to improve outcomes. Continued focus on community outreach and program development is crucial to the Consortium's success.

Abstract WP62: Intracerebral Hemorrhage Score and Glasgow Coma Scale Are Not Accurate Predictors of Subsequent Mechanical Ventilation in Initially Non-Intubated Intracerebral Hemorrhage Patients

Introduction: Intracerebral hemorrhage (ICH) often requires mechanical ventilation (MV), increasing patient risks and hospital costs. Two standard tools were evaluated for their ability to predict patients needing subsequent MV. A predictive tool could reduce costs and complications from unnecessary MV and reduce risks for patients requiring non-elective intubation. Methods: Spontaneous ICH patients were evaluated at a comprehensive stroke center, focusing on those not intubated upon arrival or in the Emergency Department. Retrospective chart review included ICH score (ICHS), Glasgow Coma Scale (GCS), MV rates, and timing of intubation. To assess the ability of ICHS and GCS to predict subsequent MV within two weeks, we used the area under the receiver operating characteristic curve (AUC) and Youden's J statistic (range 0-1), which combines sensitivity and specificity. Higher values indicate better test performance. Results: Over 4 years, 700 consecutive ICH patients were evaluated, with 231 meeting analysis criteria. Of these, 20/231 (8.66%) received subsequent MV within the following two weeks. Neither the ICHS nor GCS accurately predicted subsequent MV, with AUC/Standard Error/Youden's J of 0.630/0.066/0.254 for ICHS and 0.643/0.070/0.235 for GCS. Specificity was >97% (95% Confidence Interval: 94-99%) for both an ICHS > 4 and a GCS < 8; however, corresponding sensitivities were low (5% and 10%, respectively). Conclusions: The ICHS and GCS are not accurate predictors of subsequent MV, as shown by the low AUC and Youden's J. Both scales are >97% specific when the ICHS is > 4 or GCS is < 8, which may identify high-risk patients but would overlook others. Development of an intubation-specific tool, further exploration of alternative existing ICH scores, and evaluation of a larger sample size are needed.

Abstract TMP57: User Engagement is Associated With Clinical Impacts of Automated LVO Detection Software

Introduction: Machine learning (ML)-based acute ischemic stroke (AIS) large vessel occlusion (LVO) detection algorithms can reduce door to groin time (DTG). Here, we examine whether the dependency of these benefits on end user engagement and interaction. Methods: This analysis was conducted as a pre-planned post hoc analysis of our multicenter, prospective randomized clinical trial (NCT05838456). ML-based LVO detection software was implemented at 4 comprehensive stroke centers in the greater Houston area in a stepped fashion between Jan 2021 and March 2022. Patients were included in this analysis if they underwent EVT for LVO AIS. Exclusion criteria included inter-hospital transfers or inpatient stroke alerts. ML-software utilization was quantified as the number of software interactions including imaging viewing and/or HIPAA-compliant text messaging and was trichotomized at the hospital level into low/medium/high. Primary outcome was the reduction in DTG relation to pre-ML implementation by hospital utilization level. Secondary outcomes included CT to groin puncture time, and sensitivity analyses in subsets of patients who did and did not have an LVO alert sent. Results: Among 243 patients that met inclusion criteria, median age was 70 (IQR 58-79), 50% were female and median NIHSS was 17 (IQR 11-22). There were 2 high-utilization centers interacting with the ML software mean 160 times, one medium center that interacted 64 times and one low center interacting 42 times during the study period. We observed a reduction on DTG of 11 minutes in the high-interaction center (p<0.01) but no significant reduction in DTG in the medium or low-interaction centers. Similarly, time from CT scan initiation to groin puncture fell in the high-utilization centers by 32 minutes (p<0.05) but no significant change in others. Without adjusting for hospital-level software utilization, there was no statistically significant reduction in DTG for patients analyzed by the ML software versus those that were not (p=0.35). Conclusion: The benefit of ML-enhanced LVO AIS workflows are dependent on user engagement.

Abstract TP96: Association Between Infarct Volume, Neighborhood-Level Deprivation, and Outcomes in Pediatric Stroke

Introduction: Recent studies in adults have reported an association between neighborhood-level deprivation, infarct volume and outcome. However, this is yet to be investigated in pediatric arterial ischemic stroke (AIS). Our study aimed to assess the relationship between neighborhood-level deprivation, infarct volume, and neurological outcome in children diagnosed with AIS. Methods: We conducted a study of a consecutive cohort of children aged > 28 days-18 years and diagnosed with AIS between 2004 and 2019 at a comprehensive stroke center. Patient demographic, clinical characteristics and neighborhood material deprivation data including household income, parental educational attainment, the proportion of single-parent families, and housing quality were collected. Lesion volumes were determined by conducting semi-automatic segmentation of diffusion-weighted MRI brain scans at stroke presentation. Neurological outcome was assessed using the Pediatric Stroke Outcome Measure Severity Classification System wherein poor outcome was defined as moderate-to-severe deficit at 18 months post-stroke. Wilcoxon rank sum test was conducted. Results: Seventy-two patients were included in the study (62% male, median age of stroke onset 6.1 years [IQR 1.0-12.7]). 39% of patients were White, 72% lived in an urban region, and 64% in highly deprived neighborhoods. 70% of patients arrived within 6 hours from onset of stroke. Cardiac disease and other risk factors including infection and head trauma represented the most common risk factor. 55% presented with moderate stroke severity (as per the PedNIHSS). Median lesion volume was 14 cm 3 (IQR 2-51) and a mean infarct volume of 3% was reported. Race, rurality, and neighborhood-level material deprivation were not significantly associated with either percent infarct volume or neurological outcome; however, percent infarct volume was significantly associated with neurological outcome at 18 months post-stroke (W = 79, p = 0.025). Conclusion: Our study findings confirm the relationship between infarct volume and pediatric AIS outcomes. Future multi-center studies are warranted to further understand the interplay between material deprivation, infarct volume, and post-AIS neurological outcomes in children.

Abstract TMP63: Blood Pressure (BP) Protocol Violations in IV Tenecteplase Treated Ischemic Stroke Patients is Associated With Early Neurologic Deterioration and Symptomatic Intracranial Hemorrhage

Background: The American Heart Association guidelines recommend BP goal of <180/105 mmHg for the first 24 hours in acute ischemic stroke (AIS) patients treated with IV Alteplase and now adopted for IV Tenecteplase (TNK). Studies suggest increased hemorrhage risk in patients with BP ≥170 mmHg and greater BP variability. Methods: We performed a retrospective study with data from the Get with The Guidelines database and electronic medical record of all adult AIS patients treated with TNK at a Comprehensive Stroke Center from 6/2021 to 6/2023. All BP readings from ED arrival to 24 hours post TNK were queried. We analyzed the temporal trends of BP characteristics and their association with early neurological deterioration (END) and symptomatic intracranial hemorrhage (sICH). The BP characteristics included mean and standard deviation of systolic (SBP) and diastolic (DBP) measurements, intra-patient BP variability and frequency of excessive BP (SBP > 180 mmHg and DBP > 105 mmHg) at each time point. Results: There were 132 TNK treated patients: mean age 68 ± 15 years, 54% male, 73% Caucasian, median admission NIHSS 9, IQR 4-15, 42 (32%) underwent mechanical thrombectomy, 72 (54.5%) treated with IV antihypertensive(s). Of these, 6 (4.5%) developed END and another 6 (4.5%) sICH. Of the 5901 BP measurements, 217 (3.7%) and 99 (1.7%) exceeded systolic of >180 mmHg and diastolic of >105 mmHg respectively. All END and sICH patients had excessive BP within 4 hours post TNK (Figure 1) and during this time there was a strong association of END with excessive SBP (14% vs 4.8%; p=0.05) and DBP (14% vs 1.2%; p < 0.001). sICH had a similar but weaker association: excessive SBP (7.7% vs 4.9%; p=0.3) and excessive DBP (3.8% vs 1.4%; p=0.2). Conclusion: Our findings suggest that excessive BPs within 4 hours of TNK may be associated with patients developing END and sICH. Further exploration of moderate BP parameters deserve further study post thrombolysis, like the BEST II study in post thrombectomy patients.

Abstract TP244: Racial and Ethnic Differences in Risk Factors and Outcomes in Young Patients With Intracerebral Hemorrhage

Racial and ethnic disparities in risk factors and outcomes for young patients with ischemic stroke (AIS) are well described. Less is known about disparities in risk and outcomes for young patients presenting with intracerebral hemorrhage (ICH), which is associated with higher short-term and long-term mortality. As such, it is important to review disparities in its evaluation and management. In this study, we aimed to evaluate racial and ethnic differences in risk factors and outcomes for young patients with ICH. Methods: We identified patients aged 18-45 from our inpatient stroke registry who presented to our comprehensive stroke center with non-traumatic ICH from 10/2016 to 11/2019, with exclusion of patients with primary subarachnoid hemorrhage. We abstracted baseline characteristics and compared ICH risk and outcomes amongst different racial groups and ethnicities through examination of sociodemographic and medical risk factors and outcomes using independent samples t-test for continuous outcomes, and chi-squared test for categorical outcomes. All tests were two-tailed and the error rate was set at 5%. Results: Among 430 patients who met inclusion criteria, 22.3% were non-Hispanic White (NHW), 31.6% Non-Hispanic Black(NHB), 28.6% Hispanic (HIS), 4.9% Asian, and 5.1% other. There were significant differences in insured status, with 50.4% of HIS having insurance compared to 67.6% of NHB and 68.8% of NHW patients. NHB and HIS patients were more likely to be single (55.1% and 44.7%), compared to NHW (32.3%) and Asian (38.1%) patients. Black patients had the highest likelihood of living alone (20.6%; p=0.07), while Hispanic patients were more likely not to not have a primary care provider (64.2%; p=0.02). NHB patients were more likely to have prior hypertension (72%), and diastolic dysfunction (27.2%) compared to NHW (53.1%, 13.5%), and HIS (50.4%, 11.4%) patients). No significant differences in overall discharge disposition or mRS was noted when comparing racial and ethnic groups. Conclusion: Although we did not find significant differences in measured outcomes, our study demonstrates underlying sociodemographic and clinical risk factors which may underlie racial and ethnic disparities in long-term outcomes for patients with ICH.

Abstract TMP52: Modern Thin-Slice CT Perfusion Has High Sensitivity for Supratentorial Lacunar Stroke

Background: Lacunar stroke is a common form of ischaemic stroke with mechanisms poorly understood compared to large vessel stroke. Access to gold standard MRI is often limited in the acute setting. Acute diagnosis of lacunar stroke is difficult with conventional CT, as non-contrast CT and CT angiography have poor sensitivity. Previous studies have demonstrated only low to moderate sensitivity of CT perfusion (CTP). Aims: To test the accuracy of thin-slice CTP to detect lacunar stroke and compare the clinical and radiological characteristics to better understand the limitations of CTP for diagnosis of lacunar stroke. Methods: We reviewed thin-slice CTP (slice thickness <=3mm) of cases presenting with an acute lacunar syndrome without large/medium vessel occlusion, or perfusion lesion detected by automated analysis. Cases presented to two comprehensive stroke centres in Sydney and Newcastle, NSW, Australia, between 2019 and 2022. CTP was reviewed by two independent reviewers, blinded to follow-up MRI but not the clinical syndrome. CTP and DWI were registered to a standard template and DWI lesions were manually segmented. CTP was further reviewed adjacent to DWI, and raw CTP values within the lesion was calculated. Results: We reviewed 394 cases of acute lacunar syndrome including 82 stroke mimics, 48 infratentorial and 250 supratentorial infarcts. Overall sensitivity was 76% and varied by infarct location. Sensitivity was lowest for brainstem (46%), moderate for thalamic (69%) and high for infarcts within the lenticulostriate perforator territory (84%). Factors associated with reduced sensitivity include small infarct volume, increased noise, or artefact, and infratentorial location. Conclusion: Thin-slice CTP has high sensitivity for detection of supratentorial lacunar infarcts however is more susceptible to noise and imaging artefact than larger infarcts. Advanced processing techniques show promise to improve overall diagnosis of lacunar stroke.

Abstract TP55: A Statewide Quality Improvement Project: Identifying Disparities in Dysphagia Screening for Stroke Patients

Objectives: One of the principal cornerstones of the Minnesota Department of Health’s Stroke Program is quality improvement. Minnesota Primary (PSC) and Comprehensive Stroke Center (CSC) hospitals have consistently demonstrated performance below the national benchmark (76%) for dysphagia screening. We formed a workgroup comprised of stroke coordinators from across the Minnesota Stroke System to stratify the data by race, ethnicity, and insurance status and collectively identify ways to improve dysphagia screening for stroke patients. Methods: In 2021, MN Stroke Registry data was analyzed for dysphagia screening performance and compliance. Data was stratified by race, ethnicity and insurance status to assess for variance in performance. Disparities by patient race/ethnicity and an overall underperformance on this measure in MN compared to hospitals nationwide was identified. Work group members developed an action plan to improve resources and increase dysphagia screening performance. Results: In Minnesota, Asian (63%) and African American (68%) stroke patients are less likely to be screened for dysphagia than stroke patients overall (76%). Patients on Medicaid were also slightly less likely to receive dysphagia screening. Statewide initiatives included: guidance on stratifying site-specific data; creation of Impaired Swallowing Education for medical providers accessible on YouTube, cultural considerations, and electronic health record best practices; facilitators and barriers were reported and shared. Conclusions: The overall percentage of dysphagia screening compliance has remained steady at 77%. Continuation of the QI project will focus on identifying group participants that are actively engaged and implementing programmatic changes to improve dysphagia screening and identify disparities within their organizations. Education was successfully disseminated to 136 hospitals across the Minnesota Stroke System with over 450 views on YouTube. The work group is exploring further development of data disaggregation standards, specific to the diverse and growing populations of Minnesota. This is a vital step to develop more effective strategies and interventions that directly address health disparities.

Abstract TP261: Cocaine Use on Patients With Acute Ischemic Stroke: Classification of Subtype, Management, and Clinical Outcomes

Introduction: There are several pathogenic mechanisms that have been theorized for cocaine-related ischemic strokes (CRIS). However, there are limited studies to date that have classified them under a subtype of the Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria. This study aims to describe CRIS by the TOAST criteria, treatment, and clinical outcomes. Methods: A retrospective chart review was performed at our comprehensive stroke center from 2020-2022 to identify patients with acute ischemic stroke (AIS) with a cocaine-positive status on admission. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, TOAST criteria, location of stroke, home medications, comorbidities, medical management, and inpatient outcomes including modified Rankin Score (mRS) were reported. Results: A total of 74 patients were identified to have a positive cocaine status on admission with a diagnosis of new AIS from 2020-2022. The mean age was found to be 60.8 years old with a majority male population at 73.0%. Seventy-eight percent were found to be cocaine positive on admission via urine toxicology with the remaining endorsing a history of cocaine use. The most common category under the TOAST criteria was large artery atherosclerosis (39.2%). Among the cocaine-positive cohort, 10.8% of patients received thrombolytics and 18.9% underwent endovascular thrombectomy. The majority of patients had intracranial atherosclerotic disease (62.2%) on imaging and in the area of the stroke (55.4%). Overall mortality was low (97.3% alive) and modified Rankin score (mRS) at discharge was less than 3 for 59.5% of patients. Conclusion: Our data suggests that CRIS may have a higher association with large artery atherosclerosis. This study highlights the importance of future larger studies to investigate atherosclerosis as a contributor to cocaine-induced ischemic strokes.

Risk Factors and Prognosis of Early Neurological Deterioration after Bridging Therapy.

Early neurological deterioration (END) after bridging therapy (BT) of acute ischemic stroke (AIS) patients is associated with poor outcomes. We aimed to study the incidence, risk factors and prognosis of END after BT. From January to December 2021, the clinical data of AIS patients treated by BT (intravenous thrombolysis with alteplase prior to mechanical thrombectomy) from three comprehensive stroke centers were analyzed. Patients were divided into non-END group and END group according to whether they developed END within 72 hours of symptom onset. Modified Rankin scale (mRS) was used to assess the patient's prognosis at 90 days, and favorable outcomes were defined as mRS≤2. The incidence of END was investigated, and binary logistic regression analysis was used to explore its associated factors. The incidence of END after BT was 33.67%. The eligible 90 patients included 29 cases in the END group and 61 cases in the non-END group. Multivariate Logistic regression analysis showed that increase of systolic blood pressure (SBP) (OR=1.026, 95%CI:1.001-1.051, p =0.043), higher level of blood glucose at admission (OR=1.389, 95%CI:1.092-1.176, p =0.007) and large artery atherosclerosis (LAA) subtype (OR=8.009, 95%CI:2.357-27.223, p =0.001) were independent risk factors of END. Compared with the non-END group, the END group had significantly lower rates of good outcomes (6.90% versus 65.57%, p =0.001) while higher rates of mortality (44.83% versus 4.92%, p =0.001). It was found that the incidence of END after BT in AIS patients was 33.67%. An increase in SBP, higher glucose levels at admission, and LAA were independent risk factors of END that predicted a poor prognosis.

Abstract TP280: Monogenetic Stroke Syndrome Testing in Adults: A Single Center Experience

As access and coverage of genetic testing has increased, it is being used more commonly in adults with strokes. However, no clear guidelines exist for who should undergo genetic testing. Our retrospective review aims to provide guidance in this regard and show our experience. Genetic testing was ordered at our comprehensive stroke center between June 2022 and September 2023. Tests were ordered from GeneDx and genetic material was collected by buccal swab after consent was obtained. Most of the testing was done routinely in the outpatient setting, but was rarely performed inpatient when diagnosis would change acute management. Genetic testing was ordered for 41 patients. Tests ordered included whole exome sequencing, mitochondrial genome sequencing, Marfan syndrome and thoracic aortic aneurysm and dissection panel, Disorders of connective tissues panel and expedited whole genome sequencing. Indications for testing included evaluation of carotid and vertebral dissections, recurrent stroke, cryptogenic stroke, and leukoencephalopathy. The average age of tested patients was 47. Of these patients, 6 had not had a stroke and the testing was ordered to evaluate etiology of vertebral or carotid dissections. Of the 35 patients being evaluated for stroke etiology, 60% had at least one stroke or TIA prior to presentation. Of patients tested, 14 had evidence of dissection in the carotid arteries or vertebral arteries. At the time of analysis, 27 patients had results available, of which 15 had negative results. Positive results with pathogenic variant were seen in 4 patients. Pathologic variants detected included mutations in ABCC6, NOTCH3, MT-TL1, HBB, and MCCACHC genes. Variants of unknown significance were seen in 8 patients. These variants included mutations in MYLK, COL5A1, COL5A2, KRIT1, CCM2, XPR1, MT-CYB, MT-ND4, and MT-ATP6 genes. This study highlights that in the right clinical population, like young patients with recurrent stroke, genetic testing can be helpful to elucidate the etiology of cerebrovascular disease when standard stroke work up is inconclusive. With retrospective review, we aim to provide guidance on indications for genetic testing in adults with stroke and dissection.

Abstract WP171: Sex Differences in Risk Factors and Outcomes in Young Patients With Intracerebral Hemorrhages

Introduction: While the attention on racial, ethnic, and gender differences in ischemic stroke has progressed beyond reporting to evaluating corrective activities, less is known about disparities in hemorrhagic stroke evaluation and care, especially amongst young population. Since hemorrhagic stroke is associated with significantly higher short-term and long-term mortality than ischemic stroke and has a rising incidence, it is important to review disparities in its evaluation and management. Methods: We obtained data for our patients (18-45 years) who presented at our comprehensive stroke center with ICH from 10/2016 to 11/2019. We examined the various risk factors and outcomes among males and females and the statistical differences were tested using student’s t-test for continuous outcomes and using chi-squared test for categorical variables. A 5% error rate was assumed and all statistical tests were two-tailed. Results: A total of 430 patients (268 males,162 females) were studied. Overall, men were older than women (41.5±7.7 years vs 39.4 ±8.5 years respectively, p=0.01). More women were insured compared to men (73.5% vs 63.1%, p=0.06). More women had access to primary care compared to men (51.2% vs 38.4%, p<0.01). Men had significantly higher systolic blood pressure compared to women on arrival (181.3 ± 45.9 vs 159.6 ± 43.7 respectively, p <0.01) and similar trend was noted for diastolic blood pressure as well (105.6 ± 28.4 vs 92.9 ± 28.2 respectively, p <0.01). Men with ICH had significantly higher hemoglobin A1c on admission compared to women (14.2 ± 2.5 vs 12.4 ± 7.3 respectively, p <0.01). On baseline echo, men had more evidence of diastolic dysfunction compared to women (20.1% vs 13.0%, p=0.01). Men also had significantly higher history of smoking and alcohol abuse compared to women (p<0.01). There were no statistically significant sex differences noted in the outcomes. In hospital mortality was 20.4% in women and 19.4% in men ( p = 0.45), and discharge outcome among survivors (modified Rankin Scale [mRS] score 3-5) 74.7% in women and 79.9% in men ( p = 0.26). Conclusion: Men had a higher risk of ICH than women. Women had more access to primary care and insurance. Further research is needed to determine whether social factors can drive disparities in ICH risk.

Abstract WMP39: Incorporation of Automated Robotic Transcranial Doppler to Screen for Patent Foramen Ovale and Quantify Right to Left Shunt Severity in the Evaluation of Ischemic Stroke Patients for Stroke Etiology at a Comprehensive Stroke Center

Background: Patent foramen ovale (PFO) as a source of right-left shunting (RLS) is a recognized risk factor for recurrent stroke in young patients. Current standard care for RLS diagnosis includes transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and manual transcranial Doppler (TCD) which have disadvantages. The purpose of this retrospective review is to evaluate incorporation of an automated robotic TCD (rTCD) into the standard evaluation for RLS as cause of stroke, as prior studies have indicated higher sensitivity and quantification of RLS size to direct cardiology referral for potential PFO closure. Methods: Between Dec 2021-Oct 2022, 200 stroke patients age <65 were included in this retrospective review. Average age was 55.7 ± 11.1 yrs. All patients had standard TTE and an rTCD (NovaSignal) with saline bubble injection at rest and Valsalva strain for assessment of RLS performed by echo and ultrasound technicians. Neurologists read results, including RLS shunt severity using the Spencer Shunt Grading scale (0-5), where Grade 3-5 is considered large. Results: The rate of positive RLS shunt using rTCD was 55.5% (n=111), of which 23.5% (n=47) were Spencer grade 3+ or higher. No bone window rate was 8.5% (n=17), which is lower than reported manual TCD rates. There were no rTCD RLS shunt negative patients who had a positive TTE or TEE. Of patients who had positive rTCD (n=14) and TTE with bubble, only 5 TTE’s were positive (35.7% sensitivity). Of rTCD positive patients (n=23) who also had TEE with bubble, only 11 were positive (48% sensitivity). And of 15 rTCD Grade 3+ RLS, only 11 TEE with bubble were positive (73% sensitivity). Conclusion: We successfully replaced rTCD for TTE with bubble to screen for RLS on patients who were admitted with a stroke or TIA, with the following advantages. Non-TCD technicians could be trained to perform the tests with accuracy. rTCD was more sensitive in detecting RLS than TTE with bubble. Quantification of RLS severity identified stroke patients with potentially higher risk of recurrence, prioritized to more aggressive medical management and cardiology referral for TEE and potential PFO closure.

Abstract 44: Portable Optical Blood Flow Monitor for the Detection of Large Vessel Occlusion

Introduction: Early detection of large vessel occlusion (LVO) facilitates triage to appropriate stroke centers and reduces treatment times. Prehospital stroke scales are insensitive, so we investigated the ability of the Openwater Headset, a portable optical blood flow monitor, to detect LVO in patients undergoing acute stroke evaluation. Hypothesis: We hypothesized that the Openwater Headset would detect LVO with greater sensitivity and specificity than prehospital scales. Methods: At two comprehensive stroke centers, eligible patients presented to the emergency department or were transferred from another facility for acute stroke evaluation within 24 hours of symptom onset and NIHSS ≥2. Eligible patients underwent emergent vascular imaging as per routine care. LVO was defined as occlusion of the ICA or the first/second segment of the MCA. Each patient underwent a 70-second bedside optical blood flow evaluation with the Openwater Headset (prior to endovascular therapy, if applicable). The Openwater Headset generated blood flow waveforms based on the relative change in the speckle contrast, acquired at 40 Hz. A deep neural network was trained to identify waveform features that discriminate LVO status ( Figure 1a ), withholding a validation set to test model performance. ROC analysis compared Openwater Headset performance with that of prehospital stroke scales. Results: 135 patients completed the optical evaluation a median of 6 hours after symptom onset (IQR: 3-14). The median NIHSS was 9 (IQR: 4-18). 52 patients (39%) had a LVO. The Openwater LVO stroke alert algorithm had 81% sensitivity and 80% specificity for the presence of LVO (AUC 0.85 by ROC analysis), exceeding that of prehospital stroke scales ( Figure 1b ). Conclusions: The Openwater Headset outperformed prehospital stoke scales for LVO detection in patients who underwent acute stroke evaluation, but further investigation is needed to assess performance in pre-hospital settings.

Abstract TP184: Outcomes and Clinical Features Associated With Emergency Conversion to General Anesthesia During Stroke Thrombectomy

Introduction: Anesthesia options for ischemic stroke patients undergoing endovascular thrombectomy (MT) can include local anesthesia, conscious sedation, or general anesthesia. Recent meta-analyses show that patients requiring emergency conversion (EC) to general anesthesia (GET) have higher mRS post-discharge than non-converters. The aim of this study was to assess the immediate outcomes in EC patients and identify factors associated with EC risk. Methods: This retrospective study included 264 sequential patients undergoing MT for large vessel occlusion at a comprehensive stroke center. EC was defined as intra-procedural induction of GET during MT. Results: Twelve patients (4.5%) required EC to GET. Median times from puncture to first pass (49 vs. 27 mins) and puncture to reperfusion (88 vs. 47 mins) were nearly doubled in EC patients compared to non-converters. Though the median TICI scores were similar, EC patients required double the number of passes and experienced significantly more symptomatic hemorrhagic complications (OR 5.82; 95% CI 1.10-30.688; p=0.018). An increased trend towards in-hospital death was noted (OR 1.46; 95% CI 0.382-5.602; p=0.289). Tobacco use was the only correlated clinical factor reaching statistical significance (RR 2.05; 95% CI 0.878-4.783; p=0.048). Conclusion: Although EC patients have similar reperfusion scores based on radiographic criteria, more complications were observed, and nearly double the time was required for reperfusion. While there is no consensus on anesthesia type during MT, EC introduces unnecessary risk and should be avoided. Given the potential harm from EC, multidisciplinary communication prior to puncture is essential.