Emergency Stroke Research Articles

Centralization of the ST elevation myocardial infarction care network in the Lombardy region during the COVID-19 outbreak

Centralization of the ST elevation myocardial infarction care network in the Lombardy region during the COVID-19 outbreak

Comparison between stroke triage scale and emergency severity Index to triage patients with neurological Complaints: A randomized clinical trial

Comparison between stroke triage scale and emergency severity Index to triage patients with neurological Complaints: A randomized clinical trial

Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care

Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic's randomization status. The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39). An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation. ISRCTN Registry Identifier: ISRCTN12418919.

Tokyo Metropolitan Stroke Emergency Medical Services for Interventional Stroke Treatment: The Tama-REgistry of Acute Thrombectomy (TREAT) Study

ObjectiveIt is not clear how patients with large vessel occlusion (LVO) who have undergone mechanical thrombectomy (MT) were transported to hospitals by emergency medical services. Here, we describe the current status of the stroke delivery system in a large city. MethodsWe investigated data from 328 patients (male, n = 199; average age, 74.8 ± 12.9 years) who underwent MT at 12 facilities in the Tama area of Tokyo, between January 2015 and December 2017. The patients were classified according to the destination institution as Stroke A eligible (group A, n = 266 [8.2%]), Tertiary critical care center (group T; n = 35 [10.7%]), and other destinations such as emergency rooms (group O; n = 27 [8.2%]), and then reasons for using Emergency Medical Service (EMS) services and outcomes were compared among the groups. ResultsRates of milder stroke, and middle cerebral artery occlusion were significantly higher in group A than T, whereas that of vertebral-basilar artery occlusion was significantly lower in group A than in groups T and O. The amount of elapsed time from door to picture (DTP) was significantly lower in group A. The time from onset to recanalization, as well as rates of successful recanalization and favorable outcomes (90-day modified Rankin scale 0-2) did not significantly differ regardless of destination. ConclusionsMost patients with LVO in the Tama area were categorized into group A. DTP was significantly lower in group A.

Proteomic Changes in Intracranial Blood During Human Ischemic Stroke

IntroductionSince 2015, mechanical thrombectomy is the standard treatment for emergent large vessel occlusion stroke. The previously published Blood and Clot Thrombectomy Registry and Collaboration (BACTRAC) protocol (clinicaltrials.gov NCT03153683) utilizes thrombectomy to isolate distal blood within the artery immediately downstream from the clot, peripheral blood proximal to the clot, and the thrombus.MethodsTissue samples were obtained in accordance with the established BACTRAC protocol and immediately frozen at −80°C. For this study, we compared the intracranial intraluminal blood distal to the thrombus, using each subject’s systemic arterial blood as an internal comparative control. 40μl aliquots of plasma were thawed and randomized to 96‐well plates and shipped on dry ice to Olink Proteomics (Olink Proteomics, Boston, MA). Cardiometabolic and inflammatory panels were run on 1μl aliquots using a proximity extension assay (PEA) with proximal blood plasma as an internal control for each subject and distal blood plasma as the injury site sample. Protein data were analyzed as average protein expression levels in distal plasma as compared to average protein expression levels in proximal plasma.Results25 adult subjects (&gt;18yrs) were included in the study, of which 15 (60%) were female. Median age was 64 (24–91). 16 subjects (64%) had hypertension, 15 (60%) had BMI &gt; 25, 10 (40%) were active smokers, 6 (24%) had previous stroke, 4 (16%) had type II diabetes, and 4 (16%) had hyperlipidemia. Mean infarct time was 513 ± 246 minutes and mean infarct volume was 58,172 ± 82,284 mm3. Proteins with the greatest change in expression in the cardiometabolic panel were superoxide dismutase 1 (SOD1), CD59, lipocalin‐2 (LCN2), and defensin alpha 1 (DEFA1). Proteins with greatest change in expression in the inflammatory panel were interleukin 4 (IL‐4), AXIN1, interleukin 1 alpha (IL‐1a), sirtuin 2 (SIRT2), interleukin 5 (IL‐5) and leukemia inhibitory factor (LIF). There was a significant sex difference in expression levels of interleukin 20 receptor subunit alpha (IL‐20RA) (p=0.04) and IL‐4 (p=0.03).ConclusionsThese protein data show a complex set of intraluminal responses occurring distal to the thrombus in acute ischemic stroke. Changes in SOD1, LIF, and SIRT2 demonstrate neuroprotective and anti‐inflammatory activity, LCN2 and DEFA1 suggest a response similar to antimicrobial activity, and proteins such as IL‐4 and IL‐5 suggest eosinophil activation and a Th2 phenotype. Future studies will focus on the relationships of proteins with infarct time, infarct volume, and functional outcomes. Such analyses will provide insight into the initial molecular and cell signaling in response to ischemic stroke in the human condition.Support or Funding InformationThe project described was supported by the National Center for Advancing Translational Sciences, through Grant UL1TR001998 and UKHealthCare. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Grant through Center for Clinical and Translational Science

Detection of emergent large vessel occlusion stroke with CT angiography is high across all levels of radiology training and grayscale viewing methods.

CT angiography (CTA) is essential in acute stroke to detect emergent large vessel occlusions (ELVO) and must be interpreted by radiologists with and without subspecialized training. Additionally, grayscale inversion has been suggested to improve diagnostic accuracy in other radiology applications. This study examines diagnostic performance in ELVO detection between neuroradiologists, non-neuroradiologists, and radiology residents using standard and grayscale inversion viewing methods. A random, counterbalanced experimental design was used, where 18 radiologists with varying experiences interpreted the same patient images with and without grayscale inversion. Confirmed positive and negative ELVO cases were randomly ordered using a balanced design. Sensitivity, specificity, positive and negative predictive values as well as confidence, subjective assessment of image quality, time to ELVO detection, and overall interpretation time were examined between grayscale inversion (on/off) by experience level using generalized mixed modeling assuming a binary, negative binomial, and binomial distributions, respectively. All groups of radiologists had high sensitivity and specificity for ELVO detection (all > .94). Neuroradiologists were faster than non-neuroradiologists and residents in interpretation time, with a mean of 47s to detect ELVO, as compared with 59 and 74s, respectively. Residents were subjectively less confident than attending physicians. With respect to grayscale inversion, no differences were observed between groups with grayscale inversion vs. standard viewing for diagnostic performance (p = 0.30), detection time (p = .45), overall interpretation time (p = .97), and confidence (p = .20). Diagnostic performance in ELVO detection with CTA was high across all levels of radiologist training level. Grayscale inversion offered no significant detection advantage. • Stroke is an acute vascular syndrome that requires acute vascular imaging. • Proximal large vessel occlusions can be identified quickly and accurately by radiologists across all training levels. • Grayscale inversion demonstrated minimal detectable benefit in the detection of proximal large vessel occlusions.

Utstein recommendation for emergency stroke care.

BackgroundRecent advances in treatment for stroke give new possibilities for optimizing outcomes. To deliver these prehospital care needs to become more efficient.AimTo develop a framework to support improved delivery of prehospital care. The recommendations are aimed at clinicians involved in prehospital and emergency health systems who will often not be stroke specialists but need clear guidance as to how to develop and deliver safe and effective care for acute stroke patients.MethodsBuilding on the successful implementation program from the Global Resuscitation Alliance and the Resuscitation Academy, the Utstein methodology was used to define a generic chain of survival for Emergency Stroke Care by assembling international expertise in Stroke and Emergency Medical Services (EMS). Ten programs were identified for Acute Stroke Care to improve survival and outcomes, with recommendations for implementation of best practice.ConclusionsEfficient prehospital systems for acute stroke will be improved through public awareness, optimized prehospital triage and timely diagnostics, and quick and equitable access to acute treatments. Documentation, use of metrics and transparency will help to build a culture of excellence and accountability.

Pediatric Acute Stroke Protocol Implementation and Utilization Over 7 Years

To examine the implementation and utilization of a pediatric acute stroke protocol over a 7-year period, hypothesizing improvements in protocol implementation and increased protocol use over time. Clinical and demographic data for this retrospective observational study from 2011 through 2018 were obtained from a quality improvement database and medical records of children for whom the acute stroke protocol was activated. The initial 43months of the protocol (period 1) were compared with the subsequent 43months (period 2). Over the 7-year period, a total of 385 stroke alerts were activated, in 150 children (39%) in period 1 and 235 (61%) in period 2, representing a 56% increase in protocol activation. Stroke was the final diagnosis in 80 children overall (21%), including 38 (25%) in period 1 and 42 (19%) in period 2 (P=.078). The combined frequency of diagnosed stroke, transient ischemic attack (TIA), and other neurologic emergencies remained stable across the 2 time periods at 39% and 37%, respectively (P=.745). Pediatric National Institutes of Health Stroke Scale (PedNIHSS) documentation increased from 42% in period 1 to 82% in period 2 (P<.001). Magnetic resonance imaging (MRI) was the first neuroimaging study for 68% of the children in period 1 vs 78% in period 2 (P=.038). All children with acute stroke received immediate supportive care. Pediatric stroke protocol implementation improved over time with increased use of the PedNIHSS and use of MRI as the first imaging study. However, with increased utilization, the frequency of confirmed strokes and other neurologic emergencies remained stable. The frequency of stroke and other neurologic emergencies in these children affirms the importance of implementing and maintaining a pediatric acute stroke protocol.

Abstract 93: Trends in Intravenous Alteplase Use and Mortality Among Medicare Beneficiaries With Acute Stroke: A Eight-Year Retrospective Analysis

Timely stroke treatment with intravenous alteplase (IV-tPA) reduces functional dependence and mortality. Therefore, communities have taken tremendous efforts to increase IV t-PA use through better access to emergency services and stroke centers and through efficient processes at stroke centers. Our objective is to examine the cumulative effect of these processes over an 8-year period on IV-tPA use and mortality in a national sample of Medicare beneficiaries. Methods: Within a sample of Medicare claims from 2007-2014, we identified patients aged 66+ and evaluated the first hospitalization per patient with primary diagnosis of ischemic stroke. Outcome measures were emergency department (ED) -administered IV-tPA and 30-day mortality. We excluded patients without continuous prior 1-year enrollment in Parts A+B and those not treated in the ED. IV-tPA was identified using ICD-9 procedure 99.10 and CPT 37195. Mortality was derived from the Medicare Beneficiary Summary File. We calculated Cochran-Armitage trend tests to assess outcomes over time and chi-square tests to compare outcomes by patient and hospital characteristics. Results: Among 240,486 patients, there was a significant increase in IV-tPA use from 2.8% to 7.7% (p&lt;0.001). IV-tPA utilization was higher in urban areas (5.5% vs. rural 3.7%, p&lt;0.001) and for patients arriving by ambulance (6.7% vs. 2.5%, p&lt;0.001), with the highest IV-tPA rates observed among urban ambulance-transport patients (Figure). Patient demographics were associated with IV-tPA (all p&lt;0.001); younger (age 66-75) and Non-Hispanic White patients were most likely to receive IV-tPA. During the study period, 30-day mortality decreased from 15.7% to 14.5% (p&lt;0.001). Conclusions: Although we observed tripling of IV t-PA during this period, rural areas had lower use when compared with the urban areas. In this ongoing multi-year study, we will investigate enablers and barriers to IV t-PA use within pre-hospital and hospital systems of care.

Abstract TP20: Protocol to Isolate Lymphocytes for Flow Cytometry From BACTRAC Samples

Introduction: Since 2015, mechanical thrombectomy is the standard treatment for emergent large vessel occlusion stroke. Using standard techniques during mechanical thrombectomy, the Blood and Clot Thrombectomy Registry and Collaboration (BACTRAC) protocol (clinicaltrials.gov NCT03153683) isolates distal blood within the artery immediately downstream from the clot, peripheral blood proximal to the clot, and the thrombus. BACTRAC is the first protocol utilizing the thrombectomy technique to collect local whole blood samples during brain infarction. We aimed to augment the current collection protocol to reproducibly obtain and study local leukocyte populations during human stroke. Methods: We started with the established BACTRAC protocol previously published (PMID: 30064997). We modified the tissue collection protocol to isolate lymphocytes for flow cytometry and to bank the clot and plasma. We performed a flow cytometry panel that identifies CD3, 4, 8, 11b, 11c, 14, 19, 31, 45, 66b, 161, 183 markers to investigate populations of B-cells, T-cells, dendritic cells, NK cells, macrophages/monocytes, granulocytes, endothelial cells, and progenitors, respectively. Results: The protocol was first established in healthy controls (n=9) by drawing venous blood and simulating a vial of distal blood and a vial of proximal blood. In healthy subjects, we were able to isolate on average 2x10 6 leukocytes/ml with a viability of 97.85%. Banked lymphocytes are also viable upon reconstitution and for flow cytometry. This protocol successfully isolates leukocytes in proximal and distal blood samples in subjects undergoing mechanical thrombectomy, with identification and analysis by flow cytometry currently ongoing. Conclusions: This modification to the existing BACTRAC protocol provides the opportunity, for the first time, to study local leukocyte populations in the arteries undergoing ischemic stroke in the human condition. Efficient processing of these samples will provide insight into the neuroinflammatory microenvironment of the occlusion and accelerate translational stroke research towards new methods of diagnosis and treatment.

Abstract TP356: Post-Acute Stroke Experience Survey- Development and Pilot Testing

Background: Administrative claims data show variability in post-acute stroke care. Stroke survivors without health insurance are not included in claims data statistics. The PASES survey was developed and tested to describe stroke care experience of underserved survivors participating in V-STOP a telehealth self-management program. Methods: Semi-structured interviews were completed to elicit feedback from survivors on experiences during their stroke event, emergency and hospital care, and after discharge. Items on PASES were established based on participants’ responses and survey was piloted in a sample of underserved survivors (N=95). Descriptive statistics and Chi-square analysis were applied to describe stroke survivors’ experiences and differences based on health insurance status. Results: The sample was 45% female, mean age 57, 18% Black and 60% Hispanic. Most (60%) had an annual income of less than $25,000 and 44% had no insurance. Only 25% reported calling 911. However (60%) report presenting to a hospital within 2 hours of stroke symptoms recognition. Nearly half (42%) reported not knowing whether they received a “clot dissolving” medication. Fifty-four percent did not receive rehabilitation after discharge. Eighty-percent reported seeing a healthcare provider after discharge. Most (61%) saw a primary care provider and 22% saw a neurologist. However, only 24% reported seeing a provider within one month of hospital discharge. No significant differences were identified between insured vs. uninsured with respect to race, ethnicity, income, calling 911, receiving inpatient rehab, seeing a provider after discharge and follow up with primary care provider vs. neurologist. Significant differences were identified between insured vs. uninsured with respect to presenting to a hospital within 2 hours of stroke symptoms (35 vs 18 [p=0.023]) and in receiving no rehab after discharge (27 vs 12 [p=0.02]). Conclusion: Results suggest low utilization of EMS, delayed presentation to hospital, limited access to rehabilitation after discharge and limited access to timely follow-up with stroke specialist among underserved stroke survivors. Health insurance status may influence delayed hospital presentation and access to rehabilitation services.

Abstract 99: Mobile Stroke Unit CTA and Direct Notification of Interventional Team Shortens Door-to-Puncture Time by One Hour

Introduction: Endovascular thrombectomy (ET) is an effective but time sensitive treatment of acute ischemic stroke. Time from Emergency Department (ED) arrival to start of ET (door-to-puncture time, DTPT) is a modifiable metric. One of the most time consuming steps in prolonging DTPT is identification of large vessel occlusion (LVO) by CT angiography (CTA). BEST-MSU is a prospective multicenter comparative effectiveness study of tPA-eligible patients managed on a mobile stroke unit (MSU) vs Emergency Medical Services (Standard Management, SM). After discovering that DTPT was greater than 60 minutes in both groups at three BEST-MSU centers in 2018, we began to routinely obtain CTA on the MSU and directly alert the ET team at receiving hospitals if a LVO was identified. We hypothesized this would shorten DTPT by over 30 minutes. Methods: In this single center experience, we compared the median (interquartile range, IQR) DTPT and MSU on-scene time for MSU patients having on-board CTA and then ET from 9/2018 to 7/2019 to corresponding MSU ET patients (excluding any that had on-board CTA) from 8/2014 to 8/2018. All CTAs were completed after tPA bolus and during tPA infusion on a Ceretom 8 slice scanner with OptiStat hand injector. All imaging occurred on-scene with the MSU stationary. Consent was obtained for all patients and strict radiation safety guidelines followed. Results: 13 consecutive patients having CTA on-board the MSU and then ET were compared to 84 patients in the pre-on-board CTA group. Baseline characteristics including median NIHSS score (20 in both groups) and frequency of tPA (85% on-board CTA vs 89% pre-on-board CTA) were comparable. Median DTPT was 60 minutes shorter with on-board CTA and direct notification of the interventional team from the MSU; 34 minutes (IQR 30-57) vs 94.5 minutes (IQR 69.75-117.25) (p &lt; 0.001). Despite the additional time to obtain the CTA on the MSU, on-scene time was only slightly prolonged and did not offset the reduction in DTPT (on-board CTA 30 minutes (IQR 28-33) vs pre-on-board CTA 27 minutes (IQR 23-31) (p = 0.01). Conclusion: Pre-hospital identification and notification of LVO by a MSU allows a one hour reduction of DTPT, and can be utilized to establish a direct to angiosuite protocol.

Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates

Introduction: Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates. Methods: First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”. Results Conclusions: Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.

Abstract WP95: Feasibility of 24/7 Neurohospitalist Presence and Impact on Alteplase DTN Times and Mortality

Introduction: After hours stroke coverage in community hospitals is typically provided on-call from home or through telehealth. Lack of immediate on-site stroke expertise may delay door-to-needle (DTN) times for IV alteplase. A 750-bed community hospital that had evening emergency stroke coverage by a neurologist on-call from home transitioned to 24/7 neurohospitalist coverage in October 2015. Methods: Data were obtained from patients treated with alteplase in the ED for ischemic stroke. We evaluated the DTN times at baseline and after intervention of the new care model dichotomized by daytime (7a-5p) and evening (5p-7a). Mortality (death in hospital and discharge (DC) to hospice) was assessed. Data were compared for statistical correlation using a Mood’s Median Test and 2-sample t-test. Results: There were 579 cases from January 2015 through July 2019 treated with alteplase in the ED for ischemic stroke. Patients available for study pre- and post-intervention were 84 and 495, respectively (Table 1). Daytime arrival was more common. Significant improvements in door-to-neurohospitalist at bedside and DTN time were observed regardless of time of day, but the greatest difference seen was in evening hours. Using an ANOVA model, EMS arrival was the most significant factor predicting DTN times. Despite fewer patients arriving via EMS in the post-intervention group (90% vs 94% baseline), the DTN times improved post intervention. Mortality was significantly improved after the intervention. Despite a 44% increase in code stroke arrivals to the ED, the feasibility of the care model over ~4 years was maintained by no loss of any neurohospitalists and the addition of 1 more. Conclusion: In-hospital 24/7 model of neurohospitalist coverage is a feasible model for large community hospitals and is associated with significantly faster DTN times and reduced mortality. We will explore other aspects of the care model and other changes occurring during the study period.

Abstract TP296: Telestroke Associated With Increased Levels of Acute Stroke Care

Introduction/Hypothesis: Telestroke may be used to augment hospitals’ acute stroke services. The Department of Veterans Affairs launched a National TeleStroke Program (NTSP) in September 2017 that provides emergency stroke consultative services at 30 VA hospitals as of August 2019. NTSP uses a virtual hub/spoke model, with transfer to community hospitals when required. We examined the hypothesis that NTSP sites would be overrepresented among VA medical centers increasing their level of acute stroke care between 2012 and 2019. Methods: All VA hospitals with an emergency department or urgent care center were required to submit their stroke policies in 2012 certifying the level of acute stroke care offered: VA primary stroke centers provide alteplase evaluation and treatment 24/7/365, limited hours stroke facilities provide alteplase evaluation and treatment typically during business hours, or supporting stroke facilities which transfer all stroke patients for acute care. Re-attestation was required in 2019, with an additional category of comprehensive stroke center added, reflecting availability of both alteplase and endovascular thrombectomy 24/7/365. All submitted documents were reviewed by a single stroke neurologist and the level of acute stroke services was tabulated. Results: Of the 115 VA hospitals submitting complete documents, 25 increased their level of acute stroke care, and only 2 decreased their level of acute stroke care between 2012 and 2019. Sixteen of 30 NTSP sites (53%) enhanced acute stroke care in 2019 vs. 2012, compared to 9 of 85 hospitals (11%) not using telestroke. The difference was highly significant (p &lt; 0.0001, Chi-square test). Conclusions: In a large, national health care system less driven by financial incentives than most US medical care, adoption of telestroke services was successful in enhancing local VA hospital stroke care. This difference was especially apparent at smaller, rural VA hospitals with limited access to VA neurology services and (in some cases) non-VA care options.

Mobile Stroke Units: Bringing Treatment to the Patient.

Mobile stroke units (MSUs) have revolutionized emergency stroke care by delivering pre-hospital thrombolysis faster than conventional ambulance transport and in-hospital treatment. This review discusses the history of MSUs technological development, current operations and research, cost-effectiveness, and future directions. Multiple prospective and retrospective studies have shown that MSUs deliver acute ischemic stroke treatment with intravenous recombinant tissue plasminogen activator (IV r-tPA) approximately 30min faster than conventional care. The 90-day modified Rankin Scores for patients who received IV r-tPA on the MSU compared to conventional care were not statistically different in the PHANTOM-S study. Two German studies suggest that the MSU model is cost-effective by reducing disability and improving adjusted quality-life years post-stroke. The ongoing BEST-MSU trial will be the first multicenter, randomized controlled study that will shed light on MSUs' impact on long-term neurologic outcomes and cost-effectiveness. MSUs are effective in reducing treatment times in acute ischemic stroke without increasing adverse events. MSUs could potentially improve treatment times in large vessel occlusion and intracranial hemorrhage. Further studies are needed to assess functional outcomes and cost-effectiveness. Clinical trials are ongoing internationally.

Abstract TP389: Collaborative Approach to Improving Tele Stroke Call Back Times

Background/Purpose: Emergency stroke evaluation requires rapid access to stroke experts for treatment decisions and advice, in many community settings this is facilitated through a hub and spoke telemedicine relationship. Since widespread adoption of the expanded endovascular time window, volume of calls to a single large academic hub stroke center have drastically increased and it was identified that there was a delay in achieving rapid connection to the hub sites which may result in delayed tPA evaluations. We sought to implement a focused process review to improve timely access to the hub stroke team. Methods: Leadership from the hub and spoke hospitals collaboratively reviewed and implemented steps to improve the time from spoke call out to hub call back for acute stroke. Interventions included: 1) Establishing a goal of less than 10 minutes for physician contact on all cases, 2) Revising spoke protocol to call out immediately following CT instead of after CT read, 3) Development of a stroke call out log that is shared between sites, 4) Hub hospital revised protocol to have cases within tPA time window bypass phone call and go directly to camera, 5) Exchange of direct cell phone numbers for follow-up questions on existing patients, 6) Weekly calls to discuss any video case time delays and time flow review, 7) development of a hub hospital call center escalation process for when the primary call physician has multiple calls coming in. Results: Data we analyzed through retrospective review of a prospectively collected database over a five month period. Results are displayed in the table 1. Conclusions: Improved process flow times within tele-stroke networks may be achieved through a focused collaborative relationship between hub and spoke hospitals with transparency of data and open discussion about barriers to achieving desired results.

Abstract WP291: Stochastic Methods Can Resolve the Dilemma of Emergency Stroke Transport

Introduction: Drip and Ship (DNS) and Mothership (MS) are well-known emergency transport strategies in acute stroke care, but the criteria for choosing between the two is widely debated. Existing models define time-dependent outcomes but cannot resolve this debate with statistical significance because the independent variables are deterministic. We propose a novel stochastic framework that quantifies statistical significance between DNS and MS in a network of primary and comprehensive stroke centers. Methods: We represented the physiology of ischemic core growth as a stochastic first-order differential equation, enabling infarct volume at time of reperfusion to be calculated and mapped to 90-day mRS. Using Texas as a case study, we configured the state’s stroke network within 15,811 geographic blocks as defined by census data. For each block, we ran Monte Carlo simulations to generate Beta distributions of large- and small-vessel infarct volumes, which were then translated into cumulative distribution functions of mRS. A two-sample Kolmogorov-Smirnov test for significance, and Cohen’s d effect size statistic for practical significance were computed between each DNS and MS pair. Stable effect sizes were assured by sampling &gt; 5,000 total infarct volumes for each block. All model parameters were established from large cohort studies or trials. Results: Of the 13,113 blocks where the primary stroke center is the closest hospital from origin, DNS produces significantly better stroke outcomes than MS in 79.0% (0.3% SEM; P &lt; 0.05; 0.2 &lt; d &lt; 0.5). For the subset of patients with large-vessel strokes, MS produces significantly better outcomes in 44.6% of blocks (1.3% SEM; P &lt; 0.05; 0.4 &lt; d &lt; 0.85). Conclusion: Stochastic methods enable the use of clinically relevant metrics for comparative significance of DNS and MS in a geographic region. This formalism, which has not been incorporated in previous models, can be further generalized beyond stochastic infarct volumes if sufficiently large datasets become available. For example, the kinetic growth model can integrate the statistical distributions of times (pre-hospital and hospital) leading up to intervention, and patient attributes that affect outcomes, such as the degree of collateral flow and comorbidities.

Evaluation of the impact of ‘Act FAST’ stroke awareness campaign on calls to Emergency Medical Services and ambulance dispatches in Qatar

Background: The ‘Act FAST’ campaign is a major international stroke prevention program aiming to raise knowledge and awareness of stroke signs and symptoms and encouraging calling emergency medical service (EMS) providers as soon as symptoms are recognized.1 We aim to evaluate the impact of the campaign by analyzing EMS stroke calls in Qatar as studies on the impact of such initiative on behavioral response at onset are limited.2Methods: This is a retrospective time series evaluation utilizing monthly Hamad Medical Corporation (HMC) EMS call data for strokes in Qatar. HMC Ambulance Service (HMCAS) uses the Medical Priority Dispatch System (MPDS) and International Academies of Emergency Dispatch (IAED) protocols. Emergency calls are thoroughly analyzed for stroke diagnosis. We will evaluate pre- and post-campaign the relative change in stroke calls volume and classify them into true stroke and stroke mimic calls based on Emergency Department and Stroke Unit data, and make a comparison in total proportion of true stroke calls. We will perform multivariable regression to measure the effect of campaign exposure on the volume of stroke-related calls and also describe any significant association between specific patient characteristics with increased ambulance usage, after controlling for confounders. Anticipated results: Following the signs and symptoms of the stroke awareness campaign and suggested behavioral response at stroke onset, a relative increase in the number of stroke calls to EMS is expected as reported by Bray et al., following a similar campaign in Australia3. Conclusion: The impact of the Act FAST stroke campaign on the population of Qatar will be determined by evaluating a relative change in stroke calls post-campaign and misclassifications. The percentage change in false alarms and calls without stroke specific symptoms in a population group will help identify campaign related contributing factors thereby providing evidence to tailor future campaigns.

The myth and truth of a comprehensive stroke scale

Background and purposeThe National Institutes of Health Stroke Scale (NIHSS) has been found to be biased toward the left hemispheric and motoric functions providing minimal assessment to the right hemispheric language and cognitive functions. The need to complement the role of the NIHSS is necessary in accurate and rapid assessment of AIS patients and better management. We hypothesized that combining the NIHSS with a quantitative analysis of Spoken Picture Description scale of Comprehensive Aphasia Test (SPD-CAT) could provide valuable data regarding side, site, and size of stroke.Subjects and methodsEighty-six AIS patients presented within 48 h of onset of stroke were enrolled from Stroke Units of Ain-Shams University Hospitals (ASUHS). Clinical Assessment with NIHSS and SPD-CAT were correlated with the radiological MRI Brain lesions of stroke regarding (site, side, size/volume and lesion volume percent to the whole brain volume “LV% WBV”).ResultsTotal and subscale scores of NIHSS and SPD-CAT have a highly statistically significant correlation with the ischemic “LV% WBV.” Quantitative analysis (content units) of SPD-CAT may help in prediction of the lobar site of the stroke with higher significance in the tempro-parietal and brainstem regions. Right hemispheric strokes have clinically and statistically significant scores on SPD-CAT in comparison to NIHSS scores. Also, the left to right ratio of content units of information carrying words (ICWs) in SPD-CAT gives a significant difference between right and left hemispheric strokes. Recording and analysis time of SPD-CAT makes it easy and rapidly applicable in emergency room (ER) and stroke units.ConclusionCombining the quantitative analysis of NIHSS and SPD-CAT can better predict the side, size, and site of AIS within reasonable time table and without urgent MRI for AIS assessment and management.