Prehospital Stroke Research Articles

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study

ObjectivesTime is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions...

Establishing an MSU service in a medium-sized German urban area-clinical and economic considerations.

Mobile stroke units (MSU) have been demonstrated to improve prehospital stroke care in metropolitan and rural regions. Due to geographical, social and structural idiosyncrasies of the German city of Mannheim, concepts of established MSU services are not directly applicable to the Mannheim initiative. The aim of the present analysis was to identify major determinants that need to be considered when initially setting up a local MSU service. Local stroke statistics from 2015 to 2021 were analyzed and circadian distribution of strokes and local incidence rates were calculated. MSU patient numbers and total program costs were estimated for varying operating modes, daytime coverage models, staffing configurations which included several resource sharing models with the hospital. Additional case-number simulations for expanded catchment areas were performed. Median time of symptom onset of ischemic stroke patients was 1:00 p.m. 54.3% of all stroke patients were admitted during a 10-h time window on weekdays. Assuming that MSU is able to reach 53% of stroke patients, the average expected number of ischemic stroke patients admitted to MSU would be 0.64 in a 10-h shift each day, which could potentially be increased by expanding the MSU catchment area. Total estimated MSU costs amounted to € 815,087 per annum. Teleneurological assessment reduced overall costs by 11.7%. This analysis provides a framework of determinants and considerations to be addressed during the design process of a novel MSU program in order to balance stroke care improvements with the sustainable use of scarce resources.

Use of the SONAS Ultrasound Device for the Assessment of Cerebral Perfusion in Acute Ischemic Stroke

Background Early recognition of large‐vessel occlusion in acute ischemic stroke is pivotal to ensuring timely and effective treatment. However, current prehospital evaluation strategies largely rely on stroke scales that lack sensitivity and specificity. Recently, a novel, portable, noninvasive brain perfusion ultrasound device (SONAS) was developed as a diagnostic aid and demonstrated robust correlation with magnetic resonance imaging–based brain perfusion imaging. The present study aimed to investigate the feasibility and diagnostic performance of the SONAS device in identifying alterations in cerebral blood flow in patients with acute ischemic stroke with suspected or known perfusion deficits. Methods We performed a phase II, single‐arm, prospective study using SONAS in a close timely relation to computed tomography perfusion imaging in subjects diagnosed with acute ischemic stroke and suspected or known large‐vessel pathology, presenting within 24 hours of symptom onset between April 2019 through December 2019. Performance end points included successful measurement of time‐to‐peak in each hemisphere and comparison of perfusion deficits measured by SONAS to the reference standard computed tomography perfusion imaging. Safety end points included frequency, severity, and outcome of adverse events. Results A total of 20 subjects were enrolled. Eighteen subjects (90%) had microbubble signals successfully detected on initial assessment by SONAS. The diagnostic accuracy of the SONAS device in identifying a perfusion deficit was 88.9%. The sensitivity was 14 of 15 (93.3%), and the specificity was 2 of 3 (66.7%). No adverse events were reported secondary to SONAS or the contrast agent used. Conclusion In this clinical study, we demonstrated that the SONAS system is a safe tool that can aid in identifying cerebral perfusion deficits in this selected population of patients with acute ischemic stroke with suspected or known perfusion deficits. Future studies should assess the efficacy and impact on clinical outcomes of using SONAS in a real‐world “in the field” setting on a large subset of patients with suspected stroke and in addition to prehospital stroke scales.

Experiences from a cluster-randomized trial (ParaNASPP) exploring triage and diagnostic accuracy in paramedic-suspected stroke: a qualitative interview study.

Timely prehospital stroke recognition was explored in the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) by implementation of stroke education for paramedics and use of the National Institutes of Health Stroke Scale (NIHSS) through a mobile application. The study tested triage and facilitated communication between paramedics and stroke physicians. To complement the quantitative results of the clinical trial, a qualitative approach was used to identify factors that influence triage decisions and diagnostic accuracy in prehospital stroke recognition experienced by paramedics and stroke physicians. Semi-structured qualitative individual interviews were performed following an interview guide. Informants were recruited from the enrolled paramedics and stroke physicians who participated in the ParaNASPP trial from Oslo University Hospital. Interviews were audio recorded, transcribed verbatim and approached inductively using the principles of thematic analysis. Fourteen interviews were conducted, with seven paramedics and seven stroke physicians. Across both groups two overarching themes were identified related to triage decisions and diagnostic accuracy in prehospital stroke recognition: prehospital NIHSS reliably improves clinical assessment and communication quality; overtriage is widely accepted whilst undertriage is not. Paramedics and stroke physicians described how prehospital NIHSS improved communication quality and reliably improved prehospital clinical assessment. The qualitative results support a rationale of an application algorithm to decide which NIHSS items should prompt immediate prenotification rather than a complete NIHSS as default.

Are we missing an opportunity? Prehospital delay in patients with acute ischemic stroke and known atrial fibrillation

Introduction and ObjectivesThe follow-up of patients with atrial fibrillation (AF) presents an opportunity to alert patients and their families on how to recognize and act in the event of stroke. Our aim was to compare stroke recognition-to-door time and prehospital stroke code activation in patients with known AF (KAF) and AF detected after stroke (AFDAS). MethodsWe performed a retrospective cohort study of consecutive patients receiving acute recanalization treatment for acute ischemic stroke between January 2016 and August 2022, with AF as a potential stroke cause. Patients were divided into KAF and AFDAS, and stroke recognition-to-door time and prehospital stroke code activation were compared. In the KAF subgroup, we assessed whether the use of preadmission anticoagulation was associated with the studied prehospital parameters. ResultsWe included 438 patients, 290 female (66.2%), mean age 79.3±9.4 years. In total, 238 patients had KAF (54.3%) and 200 (45.7%) had AFDAS. Of those with KAF, 114 (48.1%) were pretreated with anticoagulation. Patients with KAF and AFDAS had no differences in stroke recognition-to-door time (74.0 [55.0–101.0] vs. 78.0 [60.0–112.0] min; p=0.097) or prehospital stroke code activation [148 (64.6%) vs. 128 (65.3%); p=0.965]. In the KAF subgroup, preadmission anticoagulation did not influence stroke recognition-to-door time or mode of hospital admission. ConclusionStroke recognition-to-door time and prehospital stroke code activation were similar between patients with known or newly diagnosed AF. Preadmission anticoagulation treatment also did not affect the studied parameters. Our findings highlight a missed opportunity to promote stroke knowledge in patients followed due to AF.

Optimization of the stroke hospital selection strategy and the distribution of endovascular thrombectomy resources.

Nowadays, emergency medical technicians (EMTs) decide to send a suspected stroke patient to a primary stroke center (PSC) or to an endovascular thrombectomy (EVT)-capable hospital, based on the Cincinnati Prehospital Stroke Scale (CPSS) and the number of symptoms a patient presents at the scene. Based on existing studies, the patient is likely to have a better functional outcome after three months if the time between the onset of symptoms and receiving EVT treatment is shorter. However, if an acute ischemic stroke (AIS) patient with large vessel occlusion (LVO) is first sent to a PSC, and then needs to be transferred to an EVT-capable hospital, the time to get definitive treatment is significantly increased. For this purpose, We formulate an integer programming model to minimize the expected time to receive a definitive treatment for stroke patients. We then use real-world data to verify the validity of the model. Also, we expand our model to find the optimal redistribution and centralization of EVT resources. It will enable therapeutic teams to increase their experience and skills more efficiently within a short period of time.

Abstract WP93: Providing Stroke Reports to Emergency Medical Services (EMS) Agencies Improves Data Quality in Michigan's Statewide EMS Data Repository

Intro: The Michigan Stroke Program (MiSP) monitors statewide EMS stroke care performance and data quality. Starting in 2018, quarterly performance and outcome benchmark data were shared with EMS agency partners to support prehospital quality improvement (QI) for stroke patients. Objective: To improve EMS data quality and prehospital stroke care performance. Methods: This is a retrospective before and after study of the impact of tailored QI interventions to improve EMS compliance with three prehospital stroke quality metrics selected by MiSP EMS partners: (prehospital stroke scale documentation, last known well documentation, and prehospital notification). Five MiSP EMS partners participated in the intervention which consisted of provision of quarterly performance reports generated from linked data from Michigan’s EMS Information System and the Michigan Stroke Registry. The MiSP team reviewed agency performance with EMS leadership to select the target measures for intervention and then assisted in development of a QI plan to improve agency performance. Measure compliance was compared from three months prior to and six months after data quality solutions were implemented. Results: Through data sharing and communication with EMS agencies and EMS software data vendors, common themes were identified related to poor data quality beginning in January 2020. A sample of agencies and resolutions to address these issues are displayed in the Table. Compliance with the targeted metric improved significantly at each agency at three and six months following intervention. Conclusions: Analysis of EMS data and sharing performance data directly with EMS agency partners identified correctable data quality issues negatively impacting EMS quality measures. Correcting these issues led to dramatic and sustained improvement in EMS quality metric compliance. This approach may serve as a model for improving the accuracy of EMS performance data in state-level EMS registries.

Abstract TMP13: Prehospital Stroke Scales Are Non-Inferior to NIHSS in Prediction of Intravenous Thrombolysis Use in a Large Telestroke Network

Introduction: Recent studies report similar outcomes with antiplatelet drugs and intravenous thrombolysis (IVT) in patients with minor nondisabling ischemic stroke. These patients still meet emergent triage criteria and can increase the burden on stroke systems through prehospital stroke activation. Prehospital large vessel occlusion (LVO) scales can improve triage of LVO patients but have not been evaluated as tools to predict IVT administration. We sought to determine if common LVO scales can predict IVT use in a large academic telestroke practice. Methods: This retrospective study included all video telestroke consults performed in a large academic telestroke network from 2019-2020. Patients were excluded if they were on anticoagulation, presented beyond 4.5 hours from last known well, or family declined IVT due to goals of care. We recorded presenting NIHSS and IVT recommendations. NIHSS was used to calculate 7 LVO scales (RACE, G-FAST, FAST-ED, VAN, PASS, 3I-SS, and C-STAT). Scale performance was assessed by calculating area under curve (AUC) and compared to NIHSS total score using the DeLong test. Youden cutpoint was established for each scale and subsequently used to calculate sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. Results: A total of 513 patients were included; 205/513 (40%) were recommended IVT. Median (IQR) NIHSS was 1 (0-3) in non-IVT patients and 6 (4-11) in IVT patients. The RACE and G-FAST scales were noninferior to the NIHSS in predicting IVT recommendation (Table 1). Conclusion: The RACE and G-FAST scales may be useful triage tools to identify patients needing emergent stroke evaluation for consideration of IVT.

Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke.

Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94-0.96] to 0.98 [95% CI, 0.97-0.98] in women versus 0.94 [95% CI, 0.93-0.95] to 0.96 [95% CI, 0.94-0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43-0.63] to 0.76 [95% CI, 0.68-0.84] versus 0.49 [95% CI, 0.40-0.57] to 0.63 [95% CI, 0.55-0.73]), whereas specificity was lower (0.79 [95% CI, 0.76-0.81] to 0.87 [95% CI, 0.84-0.89] versus 0.82 [95% CI, 0.79-0.84] to 0.90 [95% CI, 0.88-0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.

Abstract WP83: Prioritize Rural Routing With Large Vessel Occlusion Stroke Severity Scale

Background: As a growing rural Primary Stroke Center (PSC), we found acute stroke patients bypassing a PSC via air care to receive care at a Comprehensive Stroke Center (CSC) without a Large Vessel Occlusion (LVO) severity scale assessment. In collaboration with our local Emergency Medicine Services (EMS), we aimed to initiate a LVO severity scale assessment with routing algorithm to enhance stroke care. Our goal was to improve pre-hospital acute stroke assessments with a standard LVO severity scale and routing algorithm. Further improving time sensitive care and utilizing resources appropriately during a time of hospital diversion and staff shortage. Method: Utilizing stroke guidelines, a standardized LVO scale and routing algorithm were developed and incorporated into Emergency Department (ED) and EMS education and communication. From March 2022 to March 2023, we reviewed all pre-hospital stroke alerts. We compared LVO assessments competed, appropriate routing, and air care activation; as well as, door-to-needle, and door-to transfer times. Results: There were 31 pre-hospital stroke alerts prior to the initiation of LVO assessment and routing interventions from March through June 2022 (Total LVO assessed 23%, bypass PSC with positive LVO assessed 33%, Door-to-needle median 30 minutes, Door-to-transfer median 64 minutes). After initiation of LVO assessment and routing algorithm from July 2022 to March 2023 there were 84 pre-hospital stroke alerts (Total LVO assessed 95%, bypass PSC with positive LVO assessed 100%, activation of air care to PSC with positive LVO assessed 100%, Door-to-needle median 27 minutes, Door-to-transfer 48 minutes). Conclusion: By identifying an assessment gap and providing education with assessment and routing resources, we experienced an increase in LVO assessments, improved routing of the acute stroke patient, along with improved door-to-needle and door-to-transfer times. Initiating and educating ED and EMS staff on a LVO assessment scale with routing algorithm was an effective intervention within our rural services area.

Abstract WP67: Utilization and Impact of Large Vessel Occlusion Stroke Screening Practices and Selected Target Stroke III Strategies in the Get-with-the-Guidelines Registry Hospitals

Background: The utilization and impact of pre-hospital and in-hospital large vessel occlusion (LVO) stroke screening protocols and Target: Stroke phase III (TS III) best-practice strategies on time metrics for endovascular treatment at a national level, have not been studied. Methods: We sent an online survey in July 2022 to hospital representatives of 2528 hospitals participating in the GWTG registry about their EMS systems, clinical and imaging protocols, and utilization of selected TS III best-practice strategies (multiple choice, 0-100 scale, and yes/no questions). We obtained Individual patient-level data from the GWTG-Stroke Registry from January 2017 to March 2022. Multivariable linear regression models were performed to investigate the associations of these strategies with door-to-puncture (DTP) in endovascular (EVT) patients. Results: Out of 2455 sites that met our inclusion criteria, 1455 sites completed the survey, with a response rate of 59.3%. Hospital-level baseline characteristics, utilization of selected LVO screening practices, and site-reported strategies associated with shorter DTP times are shown (Table 1). Strategies associated with shorter DTP were the performance of simultaneous vascular imaging along with non-contrast CT scan on all stroke patients within 24 hours, and the use of newer technologies for LVO detection in the field leading to a 7.1 min (CI -12.8, -1.5) decrease and a 10 min (CI -18.6, -1.3) decrease in DTP with every 25% increase in the utilization of these strategies, respectively (Table 1). Conclusion: The simultaneous performance of vascular imaging with non-contrast CT scan in all stroke patients presenting within 24 hours and the use of newer technologies for LVO detection in the field could lead to shorter DTP times.

Abstract WP84: The 'When' in Response to BEFAST by EMS

Background: In cases of suspected stroke in prehospital patients, EMS response focuses on rapid assessment and transport. In Arkansas, stroke patients are identified by a unique barcode wristband for tracking and quality assurance. Prehospital stroke screens, such as BEFAST (Balance, Eyes, Face, Speech and Time), may influence destination decisions and transport time. We examined utilization of Stroke as a primary impression, compliance with placing stroke bands, if prehospital BEFAST influenced transport times from First Medical Contact (FMC), and which components were associated with rapid transport. Methods: In a single large urban EMS agency, prehospital care records of suspected stroke from Jan 1 to Dec 31, 2022, were retrospectively evaluated utilizing primary or secondary impression of Stroke or Transient Ischemic Attack (TIA). FMC and BEFAST performance time was noted and time intervals of FMC to BEFAST (FMC2BEFAST) and FMC to Arrival at destination (FMC2Arrival). Protocol compliance was determined by the placement of a stroke band. Time measures and BEFAST normal or abnormal scores were determined by ANOVA and protocol compliance with BEFAST with chi-square analysis. Results: There were 224 EMS transports for Stroke/TIA in 2022. Stroke bands were placed in 54% of patients with Stroke/TIA impressions. Stroke was a primary impression in 13% of transports and a secondary impression in 77% of transports. Patients with abnormal BEFAS(T) were 54, 26, 36, 41 and 60%, respectively. Stroke bands were placed in 61, 65, 69, 27 and 62%, respectively of cases with an abnormal BEFAS(T) (p < 0.018). FMC2Arrival time had a 9 min improvement with stroke band placement (p=0.0021). Patients with abnormal Facial Droop (p=0.043) and Eye Disturbance (p=0.022) had significantly shorter FMC2Arrival times. Abnormal Balance, Arm Drift nor Speech was not associated with shorter FMC2Arrival times (p=NS). Conclusions: Rapid evaluation and transport of suspected stroke patients can be challenging. Identification was low in our single center study, abnormalities in Facial Droop and Eye Disturbances resulted in faster transport time. Improved training on the identification and screening may result in a higher stroke band placement, recognition and rapid transport times.

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.

Effect of Remote Ischemic Conditioning in Ischemic Stroke Subtypes: A Post Hoc Subgroup Analysis From the RESIST Trial.

Remote ischemic conditioning (RIC) is a simple and noninvasive procedure that has proved to be safe and feasible in numerous smaller clinical trials. Mixed results have been found in recent large randomized controlled trials. This is a post hoc subgroup analysis of the RESIST trial (Remote Ischemic Conditioning in Patients With Acute Stroke), investigating the effect of RIC in different acute ischemic stroke etiologies, and whether an effect was modified by treatment adherence. Eligible patients were adults (aged ≥18 years), independent in activities of daily living, who had prehospital stroke symptoms with a duration of less than 4 hours. They were randomized to RIC or sham. The RIC treatment protocol consisted of 5 cycles with 5 minutes of cuff inflation alternating with 5 minutes with a deflated cuff. Acceptable treatment adherence was defined as when at least 80% of planned RIC cycles were received. The analysis was performed using the entire range (shift analysis) of the modified Rankin Scale (ordinal logistic regression). A total of 698 had acute ischemic stroke, 253 (36%) were women, and the median (interquartile range) age was 73 (63-80) years. Median (interquartile range) overall adherence to RIC/sham was 91% (68%-100%). In patients with a stroke due to cerebral small vessel disease, who were adherent to treatment, RIC was associated with improved functional outcome, and the odds ratio for a shift to a lower score on the modified Rankin Scale was 2.54 (1.03-6.25); P=0.042. The association remained significant after adjusting for potential confounders. No significant associations were found with other stroke etiologies, and the overall test for interaction was not statistically significant (χ2, 4.33, P=0.23). In patients with acute ischemic stroke due to cerebral small vessel disease, who maintained good treatment adherence, RIC was associated with improved functional outcomes at 90 days. These results should only serve as a hypothesis-generating for future trials. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03481777.

Abstract TMP82: How Well Do Prehospital Stroke Triage Scores Identify Patients With Intracerebral Hemorrhage?

Background: Prehospital stroke triage scores aim to identify LVO patients who benefit from direct transport to high-level stroke centers for EVT by bypassing primary stroke centers. Patients with ICH may benefit from direct transport to high-level centers for neurologic intensive care and hematoma evacuation. Lobar ICH patients may particularly benefit as randomized clinical trial data suggest hematoma evacuation is more effective in these patients. We determined the ability of prehospital LVO triage scores to identify ICH patients and to discriminate lobar from non-lobar ICH. Methods: We identified ICH cases presenting to the ED in Greater Cincinnati/Northern Kentucky in 2005, 2010, and 2015. Cases were identified by ICD codes (ICD9 430-438, ICD10 G45-46, H34.11-12, I60-69), clinical data was extracted by a research nurse and adjudicated by physicians. The CSTAT and RACE scores were abstracted from the NIHSS. We calculated the proportion of ICH patients with a CSTAT ≥ 2 and a RACE ≥ 5, cut-offs used to bypass primary stroke centers, and the scores’ ability to distinguish lobar from non-lobar ICH. Results: We identified 904 ICH patients (median age 72, 54% female, 25% Black). CSTAT was ≥ 2 in 45% of all ICH patients while 27% had a RACE ≥ 5. These score cut-offs identified patients with more severe deficits (Table). Among patients with lobar ICH (n=391), 44% had a CSTAT ≥ 2 and 27% had a RACE ≥ 5. Results were similar for non-lobar ICH (n=473, 45% CSTAT ≥ 2 and 26% RACE ≥ 5). Both scores performed poorly in differentiating lobar from non-lobar ICH (CSTAT ≥ 2: sensitivity 0.44, specificity 0.55, AUC 0.52; RACE ≥ 5: sensitivity 0.27, specificity 0.74, AUC 0.53). Conclusion: Prehospital LVO triage scores identified fewer than half of all ICH patients and did not discriminate between lobar and non-lobar ICH. New prehospital triage scores are needed to identify all ICH patients, or perhaps ICH subgroups, along with LVO patients who benefit from direct transport to high-level stroke centers.

Abstract WMP41: Neighborhood Social Vulnerability is Associated With Lower Frequency of Stroke Scale Assessment Among Patients With Suspected Stroke

Introduction: High-quality prehospital care during initial assessment by EMS providers can affect downstream care for acute stroke patients. Prehospital guidelines strongly recommend assessing suspected stroke patients with a validated stroke scale and obtaining a blood glucose level, but EMS adherence varies widely. Neighborhood socioeconomic characteristics are associated with stroke incidence and outcomes, but there is little research evaluating their relationship to quality metrics in prehospital stroke care. Hypothesis: Greater neighborhood-level social vulnerability is associated with lower frequency of stroke scale assessment and blood glucose check by EMS for patients with suspected stroke. Methods: We conducted a cross-sectional evaluation of EMS activations for suspected stroke patients in the 2019 ESO Data Collaborative. We included 911 responses where EMS documented a field impression of stroke and excluded activations from an acute health care facility. Neighborhood-level social vulnerability, using CDC’s Social Vulnerability Index (SVI), was assigned to each encounter based on pick-up location. Descriptive statistics were calculated, and mixed effects logistic regression models were fit to assess any relationship between SVI and documentation of stroke scale and blood glucose assessments, controlling for patient and event characteristics and clustering by EMS agency. Results: Among 84,411 patients with suspected stroke, 46% were male, with an average age of 71 years. Stroke scale assessment was documented in 78% of cases, and blood glucose in 88%. Compared to patients in the least vulnerable SVI quartile, those in the most vulnerable SVI quartile had lower odds of documented stroke scale assessment (OR 0.91, 95% CI 0.82, 1.00, p=0.04), but similar odds of documented blood glucose (OR 0.97, 95% CI 0.89, 1.06, p=0.48). High agency-level variation was present for stroke scale (ICC 70%, 95% CI 69, 73). Conclusions: Higher social vulnerability areas may be associated with less frequent stroke scale assessment; however, high agency-level variation indicates that the best targets to improve EMS systems’ compliance with evidence-based guidelines for acute stroke care may be low-performing agencies, regardless of setting.

Abstract WP17: Best Practices for Optimizing Door-to-Needle Times: Road to Target Stroke Phase III

Introduction: The launch of AHA’s Target: Stroke Phase III in 2019 challenged stroke centers to achieve DTN times ≤ 30 min of arrival to ≥ 50% of AIS patients treated with IV thrombolytics. At the time of Phase III launch, we were achieving the DTN ≤ 30 min goal in 43% of patients (median DTN 34 min) at our CSC (> 1300 ischemic stroke discharges/year). Methods: Our stroke team, in collaboration with the ED and other relevant departments, analyzed the stroke alert process and implemented incremental changes (listed below, 1 change per month to allow focus) to improve DTN times. • Vascular neurologist (VN) arriving to ED before EMS for pre-hospital stroke alerts • Assigning specific roles to each stroke team member • Calling out time since arrival every 5 minutes • Minimizing time in ED prior to CT (ie, not changing patient into gown, bypassing EKG) • Premixing alteplase (prior to TNK transition) • Giving IV thrombolytic in CT prior to CTA • Implementing video stroke alerts to allow VN to have virtual presence 24/7 DTN times were collected at launch of Phase III in 2019, and after changes were implemented. Objectives were to improve DTN times from baseline, in order to optimize care and achieve Phase III goals. Results: DTN times improved from a median of 34 min in FY19 to 25 min in FY21, corresponding to an increase in achievement of the Target: Stroke Phase III goal from 43% to 95% (Figure 1). Conclusion: By implementing collaborative and focused interventions, our CSC was able to improve and optimize the workflow of stroke patients receiving IV thrombolytics, allowing us to achieve the rigorous Target: Stroke Phase III goals and optimize patient outcomes.

Abstract WP71: Early Stroke Alert and Telestroke Notification Reduces Door to Needle Time

Background: Door to telestroke request times (DTSR) contribute to door to needle time (DTN) in telestroke networks, however, data is limited on the relationship between DTSR, DTN and other contributing factors. We aimed to evaluate the relationship between processes at the spoke, by EMS and how these contributed to DTN in telestroke spokes. Methods: This is a multi-center retrospective analysis of telestroke patients treated with IV thrombolysis from a hub and spoke telestroke network from June 2018 to March 2023. Patients were excluded from this study due to missing data. The Primary outcome was to examine the relationship between DTSR, DTN and other contributing variables. Multiple regression analyses evaluated which factors contributed to DTSR and DTN. A simple mediation model with covariates NIHSS and average telestroke volume was used to determine if DTSR mediates the relationship between door to stroke alert and DTN. A subgroup analysis examined which variables contributed to DTSR in patients arriving by EMS. A hierarchical multivariable regression analysis entering potential confounding variables as identified in preliminary analyses then variables of interest was used in the subgroup analysis. Results: There were 582 telestroke patients treated with IV thrombolysis and after exclusions, 471 (80.9%) patients were included in the study. The mean age ± SD of the patients was 69.50 ± 15.11 and 238 (50.5%) were female. Door to telestroke request partially mediated the relationship between door to stroke alert and DTN as door to stroke alert was significantly associated with DTN after adjustment for DTSR, B = 0.25 [95% Confidence Interval (CI), 0.10 - 0.41], p < 0.001. In the adjusted model, DTSR explained 29% [95%CI, 22% - 35%] of the variance in DTN. Prehospital stroke alert by EMS reduced DTSR by 6.99 minutes [95%CI, 3.31 - 10.68], p < 0.001, after adjustment of confounding variables. In patients with prehospital stroke alert, earlier ED physician evaluation was associated with quicker DTSR, B = 0.48 [95%CI, 0.01 - 0.95], p = 0.045. Conclusion: Early notification of the local stroke alert team and telestroke physician is associated with quicker DTN. Prehospital stroke alerts by EMS allow for quicker evaluation by ED physician which results in reduced DTSR.

Comparison of Mothership Versus Drip‐and‐Ship Models for Endovascular Treatment of Basilar Artery Occlusion in the London Metropolitan Area

Background To date it is uncertain whether the drip‐and‐ship (DS) model (transport to the nearest primary stroke centers) or the mothership (MS) model (direct transportation to the comprehensive stroke center) is the best prehospital stroke system of care to deliver endovascular thrombectomy in patients with basilar artery occlusion. In the present analysis, we aim to investigate the impact of MS versus DS model in patients with basilar artery occlusion treated with endovascular thrombectomy in the London metropolitan area. Methods This is a multicenter observational, investigator‐initiated, retrospective study comparing outcomes (functional independence, defined as modified Rankin scale scores of 0 through 2, the rate of successful reperfusion, and the rate of complications postprocedure) in DS versus MS stroke patients with basilar artery occlusion admitted in 5 thrombectomy capable centers in London (United Kingdom). Results Of 113 patients, 38 (33.6%) patients were MS and 75 (66.4%) were DS. Between the 2 groups we did not observe statistically significant differences for most of the clinical characteristics. There was a significant difference regarding the rate of functional independence at 3 months between the MS and DS groups, respectively 47.4% versus 36% ( P = 0.047). Rates of complications postprocedure and successful recanalization did not differ between the 2 groups. Multivariable regression analysis demonstrated that MS model was an independent predictor of functional independence at 90 days (odds ratio [OR] 1.17; [95% CI, 1.11–1.26]; P = 0.003 and independent negative predictor of postoperative complications (OR, 0.39; [95% CI, 0.16–0.98]; P = 0.045). Conclusion Our study showed that MS model was a predictor of functional independence at 3 months and reduced risk of postoperative complications post‐endovascular thrombectomy in patients with basilar artery occlusion in a metropolitan area.

Pengaruh Edukasi Pre-Hospital Tentang StrokeTerhadap Pengetahuan Masyarakat Dalam Melakukan Tindakan Pertolongan Pre-Hospital Stroke Di Kelurahan Kombos Timur Lingkungan VKota Manado

Pre-hospital stroke is a service provided when and during the victim is first found, during the transportation process until the patient arrives at the hospital. Pre-hospital stroke treatment can be a determinant of the condition and subsequent treatment. The aim of this research is to determine the effect of pre-hospital education about stroke on community knowledge in carrying out pre-hospital stroke aid measures in Kombos Timur Subdistrict, Environment V, Manado City.This research is an experimental design research with a One Group pretest-posttest design. The sampling technique is purposive sampling. The sample was 15, the instrument used was a questionnaire, then the data collected was tested using the Mac-Nemar test.The research results showed that the largest gender in the study was male, with respondents (53.3%). The highest level of education was junior high school with 8 respondents (53.3%) with the highest age being adults 46-55 years as many as 7 respondents (46.7%) while the highest education was junior high school with 8 respondents (53.3%). The conclusion in this study is that there is an influence of pre-hospital education about stroke on public knowledge in carrying out pre-hospital stroke aid measures. The suggestions in this research are that it is hoped that this research will be used as a source of knowledge for patients regarding knowledge in carrying out pre-hospital stroke procedures, so that it can be applied by families at home so that this education will be more beneficial.