Proportion Of Stroke Patients Research Articles

Abstract WP32: Addressing Disparate Clinical Stroke Resources With A Telestroke Taskforce

Introduction: Telestroke can enhance the timeliness and overall quality of stroke care for rural populations geographically separated from higher level stroke centers. To help hospitals utilize this resource, the Wisconsin (WI) Coverdell Stroke Program (Coverdell) and American Heart Association® (AHA) partnered with 15 hospital systems for a Telestroke Taskforce (TF) which met monthly June 2021-February 2022. Methods: A TF Charter and Framework guided the work. Framework items included: decision to call, telestroke consult, treatment and transfer decision, feedback, and patent satisfaction. Challenges, successes, WI consensus criteria, WI document development, Get With The Guidelines® (GWTG), resource needs and availability were addressed for these items. A manual and two videos were developed. The first video is a four clinician panel across four hospital systems sharing perspectives on telestroke implementation. Second, a demonstration video of conducting the National Institutes of Health Stroke Scale (NIHSS) via telestroke was produced to assist those unfamiliar with the process. The WI Telestroke Toolkit, which includes the charter, framework and established resources, will be published to the Coverdell website in Fall 2022. Results: Five measures were assessed quarterly Q1 2021-Q1 2022 among WI hospitals entering into GWTG® • Proportion of stroke patients w/ telestroke consult - 16.9ppt increase • Thrombolytic administration rate - 0.2ppt increase • Mechanical endovascular rate - 0.6ppt increase • Median time to consult - 2 minute reduction • Door-in-door-out times - 1 minute reduction Conclusions: Measure improvement, given the timeframe, is likely due to an increased focus on telestroke associated with the TF. As the Toolkit is shared and utilized by hospitals, we are hopeful for continued improvement. The Toolkit will be updated annually. Future considerations are to formally evaluate TS recipient satisfaction.

Temporal changes in anticoagulant prescribing and atrial fibrillation: results of interrupted time-series analysis of openly available routine data in England

Abstract Introduction The use of anticoagulants for stroke prevention in patients with atrial fibrillation (AF) has been increasing in England in the recent years (1, 2). The changes in practice coincided with several developments in the area of anticoagulants and AF, including: the emergence of evidence supporting anticoagulant use for stroke prevention in AF, changes in guideline recommendations, and the licensing of direct oral anticoagulants (DOACs) as an alternative to warfarin, which was the mainstay of stroke prevention in AF. Currently, there are four DOACs available for use: dabigatran, rivaroxaban, apixaban, and edoxaban. Recent analyses of time trends of anticoagulant prescribing in England showed an increase in DOACs prescribing and a decrease in warfarin prescribing (1, 2). However, more recent exploration of recent anticoagulant prescribing trends is needed. Aim To explore the changes in anticoagulant prescribing for AF in England. Methods Interrupted time-series analysis (ITSA) of openly available data on anticoagulant prescribing and AF. Separate analyses were conducted for data from Sentinel Stroke National Audit Programme (SSNAP) and Quality and Outcomes Framework (QOF). The timeframe of the analysis and the length of time intervals depended on the characteristics of each dataset. Results Analysis of data from SSNAP showed that the proportion of stroke patients who have a diagnosis of AF who were taking an anticoagulant alone prior to admission increased from 32.51% in the third quarter of 2013 to 62.63% in the third quarter of 2020; this coincided with a decreased proportion of stroke patients who have a diagnosis of AF taking antiplatelets alone from 37.10% to 8.31% during the same period. Analysed QOF data on anticoagulants and AF included information about AF prevalence in QOF datasets, the eligibility of patients with AF for anticoagulant based on stroke risk assessment, and the use of anticoagulants among eligible patients. Prevalence of AF in England in QOF datasets increased from 1.52% in 2012/2013 to 2.05% in 2019/2020 (ITSA gradient=0.08, p-value<.001, 95% confidence interval: 0.07- 0.09). The proportion of patients with AF who are considered eligible for anticoagulation per all patients with AF in QOF datasets increased from 44.95% in 2012/2013 to 80.87% in 2019/2020; there was an increase by 25.24% between 2014/2015 and 2015/2016 which corresponds to modifying risk assessment scores to include additional criteria. The proportion of eligible patients with AF being prescribed anticoagulants also increased in the period between 2012/2013 and 2019/2020 (ITSA gradient = 1.98, p-value<.001, 95% confidence interval: 1.52- 2.44). Conclusion The analysis of data from different sources identified an increase in anticoagulant prescribing for patients with AF in England, which is likely to translate into health gains. However, the use of aggregate data in the analysis did not allow for detailed inspection of patient characteristics, and individual anticoagulants were not specified in the datasets. Therefore, quantitative analyses of primary care data of individual anticoagulant prescribing for different patient groups with AF are needed to further understand whether additional improvements are possible in the prevention of complications from atrial fibrillation. References (1) Adderley NJ, Ryan R, Nirantharakumar K, Marshall T. Prevalence and treatment of atrial fibrillation in UK general practice from 2000 to 2016. Heart. 2019;105(1):27-33. (2) Loo SY, Dell’Aniello S, Huiart L, Renoux C. Trends in the prescription of novel oral anticoagulants in UK primary care. British Journal of Clinical Pharmacology. 2017;83(9):2096-106.

Abstract TMP35: Prehospital Bypass Policies Increase The Proportion Of Stroke Patients Transported To Primary Stroke Centers - A Quasi-experimental Study In A National Sample Of Medicare Beneficiaries.

Objective: Prehospital bypass policies were designed to encourage transport of eligible stroke patients to stroke centers in order to receive rapid assessment and treatment. In a national dataset we examined the relationship between implementation of bypass policies and the proportion of patients transported to stroke centers. Methods: We included EMS transported ischemic stroke patients aged 66+ from a 20% sample of Medicare claims (2007 - 2014). We excluded patients not admitted through the ED, and those not continuously enrolled in parts A/B in the prior year. The outcome measure was transport to PSC. Stroke certification status was validated by multiple stroke certification databases; policy implementation details were obtained from review of statutes and regulations. We employed difference-in-differences (DID) analyses with a state-level random intercept. Results: A total of 20,345 patients were included in the study with 7,239 from policy states and counties and 13,106 from non-policy states and counties. The proportion of patients arriving at PSCs increased from 28% to 43% in non-policy areas and 33% to 57% in policy areas. The DID analysis revealed a net effect of 11% (p<.001): policy areashad 17% higher probability of transporting stroke patients to PSCs after policy implementation (p<.001) while non-policy areas demonstrated a 6% increase (p<.001). Patients from rural areas had 49% lower odds of transport to PSC (OR 0.51, p<.001). Discussion: In pre-thrombectomy era, statewide prehospital bypass policies were related to significant increases in proportion of stroke patients transported to stroke centers. Future analyses will assess if these effects occur in the thrombectomy era, and if these policies influence delivery of stroke treatments.

POSA72 Cost-Effectiveness Analysis of the Helicopter Emergency Medical Services for Stroke Patients in Austria

Many patients suffer from acute stroke at a significant distance from dedicated stroke centers. Since onset of advanced stroke care is time critical, the impact of rapid transport provided by helicopter emergency medical services (HEMS) on patient outcome merits further evaluation. Accordingly, the aim of this study was to evaluate the cost-effectiveness of a HEMS compared with ground-based ambulance-transport for patients with acute stroke to a stroke unit (SU). A Markov-model was developed based on the modified Ranking Scale (mRS) states 90 days after stroke to simulate consequences over a 10-year time-horizon. Consequences include recurrent stroke, deteriorated mRS, death due to recurrent stroke or other reasons. Health benefits were measured in quality-adjusted life-years (QALYs) and life-years (LYs). Probabilities were derived from the literature mainly the stroke registry. According to data derived from the OEAMTC Air Rescue, 4.9% of all SU admissions are carried out by HEMS. The target value for an appropriate use of HEMS was assumed to be 20%. The assumption was because 18% of all patients admitted to a SU suffer a severe stroke (NIH-SS<13). Direct-costs (2020€) were derived from published sources from the payer’s perspective. QALYs, LYs and costs were discounted. Monte-Carlo-simulation accounted for uncertainty. A >20% proportion of stroke patients who were transported by HEMS to a SU is associated with savings over a 10-year time-horizon (3,500.- € to 10,191.- € per patient). Savings are due to a better neurological status (mRS after 90 days), because of the faster onset of stroke interventions. Patients also achieved a higher life expectancy (0.7 to 1.39 LYs) and quality of life [0.23 to 0.86 QALYs). In the entire cohort of stroke patients in 2020 (n=12,953), savings of 45.3 million euros could be achieved. 1€ spend in HEMS results in savings of 15.9.- € in the health-care and social system.

Predictors of unfavorable outcomes despite substantial reperfusion: Insights from Analysis of Revascularization in Ischemic Stroke With EmboTrap II Study.

A considerable proportion of stroke patients have unfavorable outcomes despite substantial reperfusion during mechanical thrombectomy for large vessel occlusion. This study aimed to determine predictors of unfavorable outcomes despite substantial reperfusion (modified thrombolysis in cerebral infarction score of ≥2b). We conducted a post hoc analysis of Analysis of Revascularization in Ischemic Stroke With EmboTrap, a prospective, multicenter study on the efficacy of the EmboTrap revascularization device. We included patients with anterior large vessel occlusion, substantial reperfusion within three passes, and 3-month follow-up. Univariate and multivariate logistic regression analyses were performed to determine independent predictors of dependency or death (modified Rankin Score 3-6) at 90 days. Of the 176 patients included in the study, 124 (70.45%) achieved modified Rankin Score of 0-2 at 90 days and 52 (29.6%) had modified Rankin Score of 3-6. On univariate analysis, patient age and initial National Institutes of Health Stroke Scale score were significantly higher in the modified Rankin Score of 3-6 groups (71.4 ± 11.3 years vs. 66.0 ± 13.1 years, 0.01; 18.9 ± 4.13 vs. 14.6 ± 4.36, p < 0.01, respectively). Mean number of passes and symptomatic intracranial hemorrhage were also higher in patients with modified Rankin Score of 3-6 (2.46 ± 1.42 vs. 1.65 ± 0.9, p < 0.01; 13.5% vs. 2.4%, p = 0.008). On multivariate analysis, initial National Institutes of Health Stroke Scale score and mean number of passes and were independent predictors of modified Rankin Score of 3-6 at 90 days. More severe initial neurologic deficit and higher number of passes in patients with substantial reperfusion were independent predictors of dependency or death. These findings highlight a reduction in the number of passes required to achieve reperfusion as a therapeutic target to improve the outcome after thrombectomy.

Effect of the Interaction between Depression and Sleep Disorders on the Stroke Occurrence: An Analysis Based on National Health and Nutritional Examination Survey.

Objective. To investigate the effect of the interaction between depression and sleep disorders on the stroke occurrence based on the data from the National Health and Nutritional Examination Survey (NHANES). Methods. Seven cycles of 2-year NHANES data (2005-2018) were analyzed in this study. Univariate analysis was first performed between the stroke and nonstroke patients, and then, multivariate logistic regression models were conducted to analyze the association of depression, sleep disorders, and their interactions with stroke occurrence. Results. A total of 30473 eligible participants were included in this study, including 1138 (3.73%) with stroke and 29335 (96.27%) with nonstroke. Except sex, the differences were all significant between the stroke and nonstroke patients in baseline information (all P < 0.001). Depression (odds ratio (OR): 2.494, 95% confidence interval (CI): 2.098-2.964), depression severity (moderate, OR: 2.013, 95% CI: 1.612-2.514; moderately severe, OR: 2.598, 95% CI: 1.930-3.496; severe, OR: 5.588, 95% CI: 3.883-8.043), and sleep disorders (OR: 1.677, 95% CI: 1.472-1.910) were presented to be associated with an increased risk of stroke after correcting all the confounders. The logistic regression analysis showed that there was a synergic, additive interaction between depression and sleep disorders on the stroke occurrence, and the proportion of stroke patients caused by this interaction accounted for 27.1% of all the stroke patients. Conclusion. Depression, depression severity, and sleep disorders are all independently associated with a high risk of stroke. The interaction between depression and sleep disorders can synergistically increase the stroke occurrence.

Implication of problematic substance use in poststroke depression: an hospital-based study

The prevalence of clinically defined problematic substance use among stroke patients is overlooked and its association with post-stroke depression (PSD) is unknown. Our aims were to: (1) estimate the proportion of stroke patients with a problematic substance use as defined by clinical screening scales; (2) determine the proportion of PSD at three months of follow-up; (3) explore if the baseline severity in substance use and its evolution are independent predictors of PSD. A cohort of first-ever non-severe stroke adult patients was screened at baseline and three months post-stroke using recommended cut-off scores of standardized scales for tobacco, alcohol and cannabis abuse. PSD was defined using the Center of Epidemiological Studies Depression scale score. Out of the 244 eligible patients, 74 (30.3%) presented a problematic substance use, including 21 (8.6%) polydrug abusers. Among these patients, the prevalence of PSD was 50.8%, including 29.5% of severe depression. The severity of tobacco dependence at baseline was found to double the risk (OR 1.59, 95% CI 1.05–2.43) of presenting a PSD, independently of previously reported risk factors. We found no significant evidence for an effect of the evolution in substance use at follow-up. Addictive disorders are part of the critical unmet needs that should be addressed in the management of PSD.

Abstract P35: The Trend of Stroke Rehabilitation Utilization Between 2014- 2019 in a Community Based Study

Introduction: Stroke is the leading cause of long-term disability in adults, resulting in significant impairments in motor, sensory, and/ or cognitive that often requires continued rehabilitation services, which vary from intensive acute inpatient rehabilitation to outpatient rehabilitation services. Efforts to reduce disability have advanced rapidly over the past several years. Our data analysis was undertaken to assess whether recent changes in clinical practice have impacted the proportion of stroke patients receiving inpatient versus outpatient rehabilitation over time between 2014-2019 at our institution, which serves a diverse mix of rural, suburban, and urban populations. Methods: Our Institutional Review Board approved retrospective stroke database, including adult patients discharged to receive rehabilitation services data from 2014-2019, was used for analysis. Cochran-Armitage trend analysis was used to assess for differences type of rehabilitation services used over time and regression analysis was used to identify clinical factors associated with discharge type over time. Results: A total of 3467 patients were included in the analysis, 50% woman, 1% Asian, 20% Black, 75% White, 4% undetermined race, 17% intracerebral hemorrhage, 65% ischemic stroke, 11% subarachnoid hemorrhage, 3% transient ischemic attack, 3% other cerebrovascular disease. In this community population, 65% were discharged to inpatient rehab. Trend analysis demonstrated a significant increase in the proportion of patients being discharged home with rehab services, p&lt;.0001. In comparison to those discharged home, patients discharged to rehab were older (odds ratio (OR) 1.02, confidence interval (CI) 1.02-1.03), with a higher NIHSS (OR 1.16, CI 1.14-1.18), discharged in 2014 (OR 1.72, CI 1.23-2.39) or 2016 (OR 1.46, CI 1.05-2.05) versus 2019. There was no association with race, gender, or discharge in 2015, 2017, or 2018. Discussion: Our findings demonstrate the community impact of recent changes in clinical practice guidelines for stroke. The increasing trend of home discharges is encouraging, but the significant proportion of those still not discharged home suggests there is still more work to be done to reduce stroke associated disability in adults.

Abstract P4: Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: Results From the Mild and Rapidly Improving Stroke Study (mariss)

Background: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective is to describe multidimensional outcomes, identify predictors of worse outcomes and explore the effect of thrombolysis in this population. Methods: This prospective observational study included patients with ischemic stroke or TIA presenting with stroke symptoms and a baseline NIHSS 0-5 within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale (mRS) 0-1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16 (SIS-16) and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase. Results: A total of 1765 participants were included from 100 Get With The Guidelines (GWTG)-Stroke participating hospitals (age 65 + 14, 42% women, final diagnosis ischemic stroke 90%, TIA 10%, 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, arm and leg weakness. Similar outcomes were noted for the alteplase-treated and the untreated groups. Alteplase treated patients were younger (64 + 13 vs. 67 + 1.4) with a higher NIHSS (2.9 + 1.4 vs. 1.7 + 1.4). After adjusting for age, sex, race-ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an effect on SIS-16 in the restricted sample of baseline NIHSS 3-5. Very few symptomatic hemorrhages were recorded (3/999). Conclusions: A large proportion of stroke patients presenting with a low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort but an indication of efficacy was noted in the NIHSS 3-5 subgroup.

Abstract WP274: No Improvement in Emergency Medical Services Use by Stroke Patients From 1999-2015: A Population-Based Study

Objective: We sought to assess whether the proportion of stroke patients who utilized Emergency Medical Services (EMS) has changed over time in a population-based epidemiological study. Methods: Stroke and transient ischemic attack (TIA) patients were identified in a population of 1.3 million in the Cincinnati area from data in 1999, 2005, 2010, and 2015. Patient charts and EMS records were analyzed by research nurses and reviewed by study physicians. This analysis excluded strokes/TIAs that occurred while in a hospital, out of town, during EMS transport, or at unknown location. Patients with unknown EMS utilization, stroke severity, baseline pre-stroke disability, race, stroke type, or under age 18 were excluded. Proportion of EMS utilization by stroke patients was calculated and Cochran-Armitage Trend Test was used to analyze trends in EMS utilization over time. Multivariable logistic regression was used to determine the association between age, race, sex, prior stroke, stroke type, where the stroke occurred, stroke severity, and pre-stroke disability with EMS use. Results: In 1999, 2005, 2010 and 2015, 2968 of 3860, 2900 of 3643, 3010 of 3503, and 3327 of 3767 stroke cases were included, respectively. EMS use by stroke patients did not change significantly over time (52%, 51%, 52%, 53%, p=0.12 for trend). In 1999 and 2015, age, pre-stroke disability, stroke severity, hemorrhagic stroke and stroke occurring at work were significantly associated with EMS use. Race, sex, and prior stroke were not. Slight variation in associations occurred in 2005 and 2010, with stroke at work not reaching significance in 2005 and 2010, and pre-stroke disability not reaching significance in 2005. Conclusion: EMS use by stroke patients in our population did not change from 1999 to 2015. With the recent advances in treatment options for stroke, novel and effective approaches to increase EMS use are warranted.

Abstract TMP40: Pharyngeal Electrical Stimulation for Early Decannulation in Tracheotomised Stroke Patients With Dysphagia: A Meta-analysis of Individual Patient Data From Randomised Controlled Trials

Background: Dysphagia is common after stroke and associated with a poor outcome. Pharyngeal electrical stimulation (PES) increased decannulation rates in tracheotomised stroke patients with dysphagia following ventilation in two trials. We report the results of an individual patient data meta-analysis assessing PES in severely dysphagic tracheotomised stroke patients. Methods: We searched for randomised controlled trials of PES in dysphagic tracheotomised stroke patients and obtained individual patient data for demographic and clinical (stroke severity, NIHSS; functional oral intake scale, FOIS; decannulation) variables from trialists. Data are number (%), median [interquartile range], mean (standard deviation) and mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CI). Results: Two completed trials were identified (n=30, PHAST-TRAC n=69 [funded by Phagenesis Ltd]), with data for 99 participants (PES 55, 56%; sham 44, 44%). Mean age 64 (13) years, female 40 (40%), NIHSS 18 [14-21], time from onset to randomisation 27 days [20-38], and FOIS=1 (nil by mouth). As compared with sham, PES was associated with an increased proportion of patients who were ready for early decannulation, 59% versus 11% (OR 11.4, 95% CI 3.86-33.33; p&lt;0.001) and improved FOIS score at discharge (MD 1.13, 95% CI 0.25-2.00; p=0.011). Treated participants who were ready for decannulation tended to have a shorter hospital length of stay: 23 vs 41 days (p=0.070) than those who were not ready. No device-related serious adverse events were reported. Conclusions: PES was associated with an increased proportion of stroke patients who were ready for decannulation and less dysphagia, in two randomised trials.

Stroke Ready: a multi-level program that combines implementation science and community-based participatory research approaches to increase acute stroke treatment: protocol for a stepped wedge trial

BackgroundPost-stroke disability is common, costly, and projected to increase. Acute stroke treatments can substantially reduce post-stroke disability, but few patients take advantage of these cost-effective treatments. Practical, cost-efficient, and sustainable interventions to address underutilized acute stroke treatments are currently lacking. In this context, we present the Stroke Ready project, a stepped wedge design, multi-level intervention that combines implementation science and community-based participatory research approaches to increase acute stroke treatments in the predominately African American community of Flint, Michigan, USA.MethodsGuided by the Tailored Implementation of Chronic Disease (TICD) framework, we begin with optimization of acute stroke care in emergency departments, with particular attention given to our safety-net hospital partners. Then, we move to a community-wide, multi-faceted, stroke preparedness intervention, with workshops led by peer educators, over 2 years. Measures of engagement of the safety-net hospital and the feasibility and sustainability of the implementation strategy as well as community intervention reach, dose delivered, and satisfaction will be collected. The primary outcome is acute stroke treatment rates, which includes both intravenous tissue plasminogen activator, and endovascular treatment. The co-secondary outcomes are intravenous tissue plasminogen activator treatment rates and the proportion of stroke patients who arrive by ambulance.DiscussionIf successful, Stroke Ready will increase acute stroke treatment rates through emergency department and community level interventions. The stepped wedge design and process evaluation will provide insight into how Stroke Ready works and where it might work best. By exploring the relative effectiveness of the emergency department optimization and the community intervention, we will inform hospitals and communities as they determine how best to use their resources to optimize acute stroke care.Trial registrationClinicalTrials.gov Trial Identifier NCT03645590.

Association between diuretic use and the risk of vertebral fracture after stroke: a population-based retrospective cohort study

BackgroundStroke is a major risk factor for osteoporosis and fractures. No study has evaluated the association between diuretic use and risk of vertebral fracture in stroke patients, although a considerable proportion of stroke patients are prescribed diuretics for hypertension. Our study aimed to investigate whether treatment with thiazides or loop diuretics affects the risk of vertebral fracture after stroke.MethodsA population-based propensity score-matched retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. Patients with a new diagnosis of stroke between 2000 and 2011 were included. After propensity score matching, 9468 patients were included in the analysis of the effect of thiazides, of who 4734 received thiazides within 2 years after stroke. To analyze the loop diuretic effect, 4728 patients were included, of who 2364 received loop diuretics. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) of vertebral fractures among patients according to thiazide or loop diuretic use within 2 years following stroke. Sensitivity analyses based on the duration of thiazide or loop diuretic use were further conducted.ResultsThere was no significant difference in vertebral fracture risk between thiazide users and non-users (adjusted HR [aHR] = 1.14, 95% confidence interval [CI] = 0.88–1.47, p = 0.316). Loop diuretic users had a significantly higher vertebral fracture risk than non-users (aHR = 1.45, 95% CI = 1.06–1.98, p = 0.019). However, the sensitivity analysis revealed that short-term thiazide use (exposure duration < 90 days within 2 years after stroke) significantly increased the risk of vertebral fracture versus non-use (aHR = 1.38, 95% CI = 1.02–1.88, p = 0.039). Only short-term loop diuretic users had significantly higher risk of vertebral fracture (aHR = 1.56, 95% CI = 1.11–2.20, p = 0.011). The other two subgroups with longer exposure duration in analyses for both thiazides and loop diuretics revealed no significant effect.ConclusionsShort-term thiazide or loop diuretic use was associated with an increased risk of vertebral fracture after stroke. Further prospective clinical trials are required to confirm this finding.

Abstract WMP2: The Path from Research to Successful Implementation in Clinical Practice: Endovascular Treatment in the Netherlands

Introduction: In the Netherlands, acute endovascular treatment (EVT) for ischemic stroke was not reimbursed andonly allowed as rescue treatment according to national guidelines until 2016. We describe the trend in use of EVT before, during and after the pivotal thrombectomy trials. Methods: Our study used data from all patients who were treated with EVT in the Netherlands from Jan 2002 until Jun 2016 in the Pretrial Registry, MR CLEAN trial and the ongoing MR CLEAN registry. We undertook a time-series analysis to examine trends in the use of EVT using a mixed-effects Poisson regression analysis and several observation plots. Rate ratios (RR) per quarter and 95% confidence intervals (95% CI) were obtained to demonstrate the impact and implementation after the publication of the trial. Regional plots were adjusted for exposure time and population density. Results: Between 2004 and 2010, 491 patients were treated with EVT in the Netherlands. In 2010, the MR CLEAN trial started. All hospitals providing EVT in the Netherlands included patients and reimbursement was conditional on participation in MR CLEAN. At first, a non-significant increase in EVT-treated patients was observed (RR: 4.6 [95%CI 0.1-9.1]). In 2015, an immediate steep increase in EVT-treated patients (RR: 20.9 [95%CI 5.5-30.1]) (Fig. 1) and a more even spread over the country was observed (Fig. 2). In the first years after the trial, 33% of the patients who were considered to be eligible for EVT were treated with EVT. Conclusion: A strict national policy regarding evidence based treatments can be successful. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT.

Abstract 115: Assessing the Concordance Between Stroke Rehabilitation Research Participants &amp; ‘Real World’ Stoke Patients

Stroke rehabilitation programs have been transformed to better align with stroke Clinical Practice Guidelines (CPGs), which prioritize randomized control trials as evidence-based best practices. However, a recent review of stroke rehabilitation randomized control trials (RCTs) found that the RCTS tended to include younger participants, excluded participants based on age related criteria, and often excluded individuals with comorbidities. The objective of this study was to determine the proportion of stroke patients that would meet the enrolment criteria of stroke rehabilitation randomized controlled trials. A retrospective chart audit was conducted for all patients discharged from a high intensity stroke rehabilitation unit for a one-year period (n=110). RCT exclusion criteria were extracted from a recent review that analyzed the study inclusion and exclusions of 428 RCTs (age, cognitive impairment, previous stroke, and comorbidities). These study exclusions were applied to the 110 patients to determine how many patients would have been eligible to participate in the RCTs. Patients admitted to the stroke rehab unit had a mean age of 67.4 years and an average of 6.2 co-morbidities. 60.1% of these patients would have been excluded from participating in the RCTs by one or more exclusion criteria. 5.5% of patients would have been excluded based on age, 84.5% of patients would have been ineligible for 54% of RCTs based on cognitive impairment, 28% of patients would have been ineligible for 36% of RCTs based on a previous stroke, and 4.2% of patients would have been excluded based on the presence of a CCI condition or stroke risk factor. Results highlight the difference between trial subjects and ‘real world’ patients. Based on our understanding of how people accumulate chronic conditions with age, it can be inferred that the high quality evidence may not reflect the clinical reality of stroke rehabilitation. Given the high prevalence of increased age and comorbidities among stroke rehabilitation patients, this study emphasizes the importance of including ‘typical stroke patients’ in research studies or supporting the use of alternative methodologies that addresses application of study results to older patients with comorbidities.

Abstract WP180: Association Between Medicare Reform and Access to Rehabilitation in Ischemic Stroke Patients

Introduction: In 2010, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Rule, requiring IRF patients to tolerate 3 hours of daily therapy (PT &amp;OT/SLP). If unable, rehab at a skilled nursing facility (SNF) is recommended, contrasting the 2016 AHA Stroke Rehabilitation Guidelines for optimal recovery. Hypothesis: Stroke patients are more likely to receive rehab at a SNF compared to an IRF after implementation of the CMS 2010 IRF PPS Rule. Methods: We calculated the proportion of stroke patients discharged to IRF vs home and SNF vs home using prospectively collected registry data from Get with the Guidelines - Stroke, for a cohort of ischemic (85.7%) and hemorrhagic (14.3%) stroke patients between 2008 and 2015 (n=1,962,933). Univariate analyses compared stroke severity by NIHSS, sociodemographic/clinical characteristics and in hospital rehabilitation assessments. Multivariable regression modeling assessed the association between CMS 2010 IRF PPS Rule and age, teaching versus non-teaching hospital and US geographic region. Results: Post CMS 2010 IRF PPS Rule, 1 out of 15 ischemic stroke patients had lower IRF rehab odds (OR 0.94; 95%CI 0.92-0.95; P&lt;0.0001); 1 out of 9 ischemic stroke patients had higher SNF rehab odds (OR 1.12, 95% CI 1.10-1.14; P&lt;0.0001). Multivariable regression - ischemic stroke: Across all ages, in the South, Northeast and at teaching hospitals, the odds of IRF rehab decreased and the odds of SNF rehab increased after implementation of CMS 2010 IRF PPS Rule (Fig 1 &amp; 2). Conclusions: Ischemic stroke patients, with similar clinical histories &amp; stroke severity, had decreased odds of inpatient rehabilitation facility rehab and increased odds of skilled nursing facility rehab after implementation of the CMS 2010 IRF PPS Rule. Additional studies analyzing the effects of low intensity SNF rehab versus IRF rehab on return home and long-term disability are needed.

Abstract WMP85: Frequency of Neurological Consultation in Medicare Patients With Ischemic Stroke

Introduction: Given recent advances in diagnostic and therapeutic tools, delivery of stroke care has become more complex. We sought to investigate what proportion of patients with stroke are evaluated by neurologists, and specifically by vascular neurologists. Methods: Using 2008-2015 claims data from a 5% nationally representative sample of Medicare beneficiaries, we identified all patients &gt;65 years of age who were hospitalized for ischemic stroke, as defined by previously validated ICD-9-CM codes. Our primary outcome was the proportion of patients evaluated during the stroke hospitalization or within 90 days of discharge by a neurologist, as determined from evaluation and management CPT codes and Medicare provider specialty codes. To ascertain which of these neurologists were vascular neurologists, we used a Python script and National Provider Identifier numbers to merge in publicly available data from the American Board of Psychiatry and Neurology on all board-certified vascular neurologists in the U.S. As a comparison, we used previously validated diagnosis codes to identify patients hospitalized with acute myocardial infarction (MI) and determined the proportion seen by a cardiologist during the hospitalization or within 90 days of discharge. Statistical analysis involved descriptive statistics with exact confidence intervals (CI)s and the chi-square test. Results: Among 66,989 patients with ischemic stroke, 49,335 (73.7%; 95% CI, 73.1-74.0%) were evaluated by a neurologist. A board-certified vascular neurologist evaluated 11,001 patients, equating to 16.4% (95% CI, 16.1-16.7%) of all stroke patients and 22.3% (95% CI, 21.9-22.7%) of stroke patients seen by a neurologist. In comparison, a cardiologist evaluated 53,481 of 61,232 patients with acute MI (87.3%; 95% CI, 87.1-87.6%), a proportion significantly higher than the proportion of stroke patients seen by a neurologist ( P &lt;0.001). Conclusions: In a nationally representative cohort of Medicare beneficiaries, we found that approximately 75% of patients with ischemic stroke were evaluated by a neurologist, a proportion significantly lower than the comparable metric for acute MI. Furthermore, about one of every six stroke patients was evaluated by a vascular neurologist.

Immunological and non-immunological effects of stem cell-derived extracellular vesicles on the ischaemic brain

Following the implementation of thrombolysis and endovascular recanalization strategies, stroke therapy has profoundly changed in recent years. In spite of these advancements, a considerable proportion of stroke patients still exhibit functional impairment in the long run, increasing the need for adjuvant therapies that promote neurological recovery. Stem cell therapies have initially attracted great interest in the stroke field, since there were hopes that transplanted cells may allow for the replacement of lost cells. After the recognition that transplanted cells integrate poorly into existing neural networks and that they induce brain remodelling in a paracrine way by secreting a heterogeneous group of nanovesicles, these extracellular vesicles (EVs) have been identified as key players that mediate restorative effects of stem and progenitor cells in ischaemic brain tissue. We herein review restorative effects of EVs in stroke models and discuss immunological and non-immunological mechanisms that may underlie recovery of function.

BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic.

The FAST algorithm (Face, Arm, Speech, Time) helps identify persons having an acute stroke. We determined the proportion of patients with acute ischemic stroke not captured by FAST and evaluated a revised mnemonic. Records of all patients admitted to the University of Kentucky Stroke Center between January and December 2014 with a discharge International Classification of Diseases, Ninth Revision, Clinical Modification code for acute ischemic stroke were reviewed. Those misclassified, having missing National Institutes of Health Stroke Scale data, or were comatose or intubated were excluded. Presenting symptoms, demographics, and examination findings based on the National Institutes of Health Stroke Scale data were abstracted. Of 858 consecutive records identified, 736 met inclusion criteria; 14.1% did not have any FAST symptoms at presentation. Of these, 42% had gait imbalance or leg weakness, 40% visual symptoms, and 70% either symptom. With their addition, the proportion of stroke patients not identified was reduced to 4.4% (P<0.0001). In a sensitivity analysis, if face weakness, arm weakness, or speech impairment on admission examination were considered in addition to a history of FAST symptoms, the proportion missed was reduced to 9.9% (P=0.0010). The proportion of stroke patients not identified was also reduced (2.6%) with the addition of a history of gait imbalance/leg weakness or visual symptoms (P<0.0001). Of patients with ischemic stroke with deficits potentially amenable to acute intervention, 14% are not identified using FAST. The inclusion of gait/leg and visual symptoms leads to a reduction in missed strokes. If validated in a prospective study, a revision of public educational programs may be warranted.

Design and implementation of Pharyngeal electrical Stimulation for early de-cannulation in TRACheotomized (PHAST-TRAC) stroke patients with neurogenic dysphagia: a prospective randomized single-blinded interventional study.

Rationale Ongoing dysphagia in stroke patients weaned from mechanical ventilation often requires long-term tracheotomy to protect the airway from aspiration. In a recently reported single-centre pilot study, a significantly larger proportion (75%) of tracheotomized dysphagic stroke patients regained sufficient control of airway management allowing tracheotomy tube removal (decannulation) 24-72 h after pharyngeal electrical stimulation (PES) compared to controls who received standard therapy over the same time period (20%). Aim To assess the safety and efficacy of PES in accelerating dysphagia rehabilitation and enabling decannulation of tracheotomized stroke patients. Design International multi-centre prospective randomized controlled single-blind trial in approximately 126 ICU patients (the 90th percentile of the calculated maximum sample size). Study outcomes Primary outcome: proportion of stroke patients considered safe for decannulation 24-72 h after PES compared to control patients who do not receive PES. Key secondary outcomes focus on: dysphagia severity, decannulation rates, decannulation rate after a repeat PES treatment in patients persistently dysphagic after an initial PES treatment, stroke severity, duration of ICU-stay, occurrence of adverse events including pneumonia and need for recannulation over 30 days or until hospital discharge (if earlier). Discussion Dysphagia and related airway complications are reported as one of the main reasons for stroke patients remaining tracheotomized once successfully weaned from ventilation. This study will evaluate if PES can improve airway safety sufficiently enough to allow earlier tracheotomy tube removal.