Stroke Services Research Articles

285 ‘To communicate or not, that is not the question!’

Abstract Background Safe patient care necessitates accurate and timely patient communication between acute, community, and primary care services. Given the complexities of care of older adults, including polypharmacy and deprescribing, reliable communication between all services is essential. This has been identified as a requirement prior to discharge. This audit aimed to assess compliance with discharge communication across the Geriatrics Service. Methods This audit was carried out from 10th–17th April 2023. Consecutive patient discharges across Stroke and Acute Geriatrics Services were assessed for data including age, gender, date of admission, date of discharge, discharge summary completion, and date and time of validation of the discharge summary. The Electronic Discharge Summary (EDS) and Inpatient Patient Management Systems (IPMS) systems were used for data collection. Data was analysed descriptively. Standards used were The Integrated Care Guidance: A Practical Guide To Discharge And Transfer From Hospital (HSE), and the National Standard For Patient Discharge Summary Information (HIQA). Results 107 patient records were assessed, median age 72.2 years (IQR 29.1), 48.6% female (n = 52). 91.5% (n = 98) patients had discharge summaries completed, 86.7% (n = 85) of which were validated. When including all validated discharge summaries, the median time to validation was 0.4 hours (IQR 79.43) post discharge. Median time to validation pre-discharge was 1.5 hours (IQR 3.1) and represented 54.2% (n = 58) of patients. Median time to validation post discharge was 21.8 hours (IQR 149.76) and represented 31.7% (n = 27) of patients. Conclusion This audit highlights a high level of compliance with discharge summary completion. Areas for improvement include higher levels of completion prior to discharge, and ensuring that all summaries are validated to allow for printing and distribution. This will help ensure seamless and safe communication between all levels of care of older adults.

341 Auditing the timing of CT-Brain and Angiograms in suspected acute stroke

Abstract Background Timing of neuroimaging play a key role in the management and ultimate outcomes of patients presenting to hospital with a suspected acute stroke. The NICE Guidelines on the initial management of suspected acute stroke and the NHS National Stroke Service Model set a target of less than 20 minutes between arrival to hospital and having a CT-Brain and CT-Angiogram performed, analysed, and reported. A clinical audit was performed looking at the timing of all CT-Brain studies performed in 2022 at a level three hospital in Ireland where acute stroke was the suspected presentation. Methods A total of 206 CT-Brain and CT-Angiogram studies were included in the audit. The time of the patients’ registration in the emergency department was compared to the timestamp on NIMIS of the completion of each CT study and of the time of publication of the radiologist’s report. For patients already admitted on a hospital ward, the time that the CT study was requested was used in lieu of arrival time. Results The average time between arrival in the emergency department and the completion of CT-Brain was 82 minutes. The average time between the completion of the CT and the publication of the radiologist’s report was 26 minutes, however many studies had verbal reports delivered to the requesting physician prior to publication of the report. Altogether, the average time for the performance and reporting of a CT-Brain and Angiogram in patients with suspected acute stroke was 108 minutes. Conclusion The average of 108 minutes from door to scanner to reported CT-Brain and Angiogram is significantly longer than the 20 minutes recommended by the NICE Guidelines. This hospital serves a large, rural catchment which makes late presentations common, adding to the urgency of neuroimaging for these patients. In future, key areas of in-hospital delay in CT performance and reporting should be identified and given close attention.

Stroke Riskometer Application (SRA™) influence on lifestyle changes of home bound familial Malaysian stroke caregivers: a randomised controlled trial in a primary care based longer term stroke care facility

BackgroundIn countries where access to Specialist stroke care services are limited, primary care physicians often manage stroke patients and the caregiving family members. This study aimed to evaluate the impact of Stroke Riskometer Application (SRA™) on promoting healthier lifestyles among familial stroke caregivers for primary prevention.MethodsA parallel, open-label, 2-arm prospective, pilot randomised controlled trial was conducted at a long-term stroke service at a university based primary care clinic. All stroke caregivers aged ≥ 18 years, proficient in English or Malay and smartphone operation were invited. From 147 eligible caregivers, 76 participants were randomised to either SRA™ intervention or conventional care group (CCG) after receiving standard health counselling. The intervention group had additional SRA™ installed on their smartphones, which enabled self-monitoring of modifiable and non-modifiable stroke risk factors. The Stroke Riskometer app (SRATM) and Life's Simple 7 (LS7) questionnaires assessed stroke risk and lifestyle practices. Changes in clinical profile, lifestyle practices and calculated stroke risk were analysed at baseline and 3 months.The trial was registered in the Australia-New Zealand Clinical Trial Registry, ACTRN12618002050235.ResultsThe demographic and clinical characteristics of the intervention and control group study participants were comparable. Better improvement in LS7 scores were noted in the SRA™ arm compared to CCG at 3 months: Median difference (95% CI) = 0.88 (1.68–0.08), p = 0.03. However, both groups did not show significant changes in median stroke risk and relative risk scores at 5-, 10-years (Stroke risk 5-years: Median difference (95% CI) = 0.53 (0.15–1.21), p = 0.13, 10-years: Median difference (95% CI) = 0.81 (0.53–2.15), p = 0.23; Relative risk 5-years: Median difference (95% CI) = 0.84 (0.29–1.97), p = 0.14, Relative risk 10-years: Median difference (95% CI) = 0.58 (0.36–1.52), p = 0.23).ConclusionSRA™ is a useful tool for familial stroke caregivers to make lifestyle changes, although it did not reduce personal or relative stroke risk after 3 months usage.Trial registrationNo: ACTRN12618002050235 (Registration Date: 21st December 2018).

Intervention to reduce sedentary behaviour and improve outcomes after stroke (Get Set Go): a study protocol for the process evaluation of a pilot cluster randomised controlled trial (RECREATE)

IntroductionStroke survivors spend long periods of time engaging in sedentary behaviour (SB) even when their functional recovery is good. In the RECREATE programme, an intervention aimed at reducing SB (‘Get...

Malaysian Stroke Conference (MSC) Report 2022

The fourth Malaysian Stroke Conference was held in Eastern and Oriental Hotel Penang from 12 to 13 August 2022. This conference attracted 254 physical delegates and 378 virtual delegates within Malaysia and internationally from Singapore, Indonesia, Philippines, Brazil, Canada, Egypt, India and Japan. The theme of this conference was “FAST: BRAIN AND HEART ATTACK”, with the take-home message of acting as fast as possible in both acute cerebrovascular and acute coronary disease. The main organiser was the Malaysian Stroke Council, with support from other specialities, namely emergency physicians, geriatricians and advanced acute internal medicine physicians. The event was a great success in gathering various stakeholders in stroke care to share the latest updates on stroke. Issues pertaining to stroke care were discussed to take the stroke service delivery to greater heights. This conference has undoubtedly left a profound impact on all the participants that it is time to embrace the practice of hyperacute stroke treatment which saves lives, and that everyone is responsible for offering the best stroke care to our patients.

Statewide availability of acute stroke treatment, services, and programs: A survey of North Carolina Hospitals

IntroductionWe conducted a statewide assessment of the availability of stroke treatment, services, and programs in North Carolina (NC) hospitals. We also examined differences in stroke care capabilities between urban, suburban, and rural hospitals and trends over the past 2 decades. MethodsAn electronic survey was distributed to all 111 licensed hospitals in NC. Survey questions asked about stroke center certification status (i.e., standardized levels of stroke care capabilities), diagnostic testing, acute treatments and protocols, and post-acute management. Responses were collected from October 2020-April 2021. Select characteristics were compared to those from prior NC surveys in 1998, 2003, and 2008. ResultsAll 111 hospitals responded to the survey (100% response rate). Among 108 hospitals providing acute stroke care, 12 (11%) were Comprehensive Stroke Centers or Thrombectomy-Capable Stroke Centers, which were all located in urban or suburban areas. While 38% of urban/suburban hospitals were non-certified, 48% of rural hospitals were non-certified. Non-contrast computed tomography (CT), CT angiography, and alteplase treatment were widely available (100%, 95%, and 99%, respectively). Endovascular thrombectomy was solely available in urban/suburban hospitals (29%). Of non-tertiary hospitals, 81% were using telestroke for treatment and transfer decisions. Compared to prior survey results, the availability of CT angiography (76% in 2008 to 95% in 2020-2021), alteplase treatment (69% in 2008 to 99% in 2020-2021), and acute stroke clinical pathways (47% in 2008 to 90% in 2020-2021) increased. However, having an in-house neurologist on staff dropped from approximately 55% in prior surveys to 21% in the current survey. ConclusionsRural NC hospitals were less likely to have advanced diagnostic imaging and treatment capabilities for acute stroke. Temporal trends in staffing with an in-house neurologist and use of telestroke services should be further examined.

Characteristics, management and outcome of stroke: Observations from the Sri Lanka Stroke Clinical Registry

BackgroundStroke registries are pivotal to the monitoring and improvement of the quality of stroke care. We report data from the initial phase of a nationally representative hospital-based stroke registry in Sri Lanka. MethodsBased on an observational cohort design, all consecutive patients aged ≥18 years with a diagnosis of stroke or transient ischemic attack (TIA) presenting to six tertiary-care hospitals in the Western, Eastern, Southern, Northern and Central provinces of Sri Lanka within 14 days of onset were recruited. ResultsDuring a period of 14 months, 5893 patients with a stroke/TIA (58.8% men; mean age 65.22 years, SD=13.28) were entered into the database; 69.8% (n=4111) had an ischaemic stroke (IS); 20.9% (n=1233) had a haemorrhagic stroke (HS); 7.2% (424) had a TIA; and 2.1% (125) had a venous stroke. While IS were more common among women (71.7% vs 68.4%; p=0.006), HS were more common among men (22.3% vs 19.0%; p=0.003). Hemiparesis (86.2% vs 83.2%; p=0.011), headache (29% vs 11.6%; p<0.001), seizures (5.9% vs 4.2%; p=0.013), sphincter dysfunction (11.8% vs 7.7%; p<0.001) and hypertension (72% vs 67.3%, p=0.002) were more common in HS while dysphasia (63.2% vs 50.0%; p<0.001), ataxia (9.6% vs 7.3%; p=0.014), sensory disturbances (10.8% vs 6.0%; p<0.001) and diabetes mellitus (37.9% vs 28.1%; p<0.001) were more common in IS. Thrombolysis was administered in only 2.1% while only 14.6% had access to stroke units. The mean door-to-needle time was 100.2 (SD=46.0) minutes. The hospital mortality rate was 8.3%. Recurrent strokes within three months were more common in HS than IS (3.2% vs 1.6%; p=0.007). ConclusionsWhile stroke characteristics in Sri Lanka are similar to that of other populations, the rate of thrombolysis and access to stroke units are inadequate. The stroke registry provides useful data for the appraisal and improvement of stroke services.

The PENINGKATAN KAPASITAS PELAYANAN PENANGANAN STROKE ISKEMIK AKUT MELALUI PELATIHAN CODE STROKE DI RS UNIVERSITAS MATARAM

Stroke is the leading cause of death and disability in the world and Indonesia. The standard therapy for acute ischemic stroke is alteplase but only 10-20% of patients receive this standard therapy. Code stroke is quick response for management acute stroke to get alteplase. The success for code stroke requires good communication and cooperation of code stroke team. This training aims to provide code stroke training needed to increase the capacity of stroke services at Mataram University Hospital. The method of training include lecture, patient simulation, video on the code stroke and also preparation of the thrombolysis also discussion and the target of this training are doctors and staffs in the emergency wards, radiology, laboratorium, pharmacy, ICU and inpatient ward. Evaluation of participants' understanding through pre and post tests was assessed with the Kahoot application. Evaluation of the training was also assessed using the Google form. A total of 25 health workers participated in this activity. The mean pre and post test were 34,38% and 68,42% (an increase of 34%). Participants' satisfaction with the activity was good, namely 4.13 (from a Likert scale of 0 – 5). The aspect of material provided in this training had the highest satisfaction score. This education should be given periodically to all health workers to increase the capacity of stroke services.

Evaluation of extended-length cannula inserted using ultrasound guidance in patients with difficult IV access.

Historically, gaining peripheral intravenous (IV) access for patients with difficult intravenous access (DIVA) has been problematic and associated with increased complications, central venous access device insertion and reduced patient satisfaction. Consequently, extended-length peripheral intravenous catheters (PIVCs) have been developed, but to date no real-world data exploring their effectiveness with NHS patients has been published. This article reports on the results of introducing extended-length PIVCs, inserted using ultrasound guidance in patients with DIVA by a vascular access team. This began in 2019, across an adult tertiary hospital setting in the NHS with about 750 beds. The specialties at this hospital include, but are not limited to, emergency medicine; head and neck; vascular; diabetes and endocrinology; respiratory; care of the older person; stroke services; gastroenterology; and trauma and orthopaedics. The vascular access team recorded 1485 individual insertions between 2019 to 2022, with a mean dwell time of 6 days, a first attempt success rate of 91%, and a therapy completion rate of 75 and 78% for inpatient and outpatients respectively. Indications included administration of IV fluids, medication, blood products and access for investigations or procedures. Obtaining reliable IV access in patients with DIVA prevents treatment delays, cancelled or delayed procedures, both of which benefit patients and the healthcare organisation. The data presented in this study support the use of extended-length PIVCs in patients with DIVA and has led to the development of new referral pathways.

Stroke services in MENA: What is there and what is needed.

Stroke represents a health care challenge to most parts of the world including the Middle East and North Africa (MENA) region. The MENA represents 6% of the world population with an age-standardized stroke rate of 87.7 (78.2-97.6) per 100,000 population. This number is subject to increase given that the cause of morbidity has recently shifted from infectious diseases to non-communicable diseases. Thus, in the coming years, treatment of stroke will pose a major burden on MENA countries which mostly lie in the low to middle income economies. Accordingly, we need to study the state of MENA stroke services in order to recognize and further inform policy makers about any gaps that need to be bridged in this domain. Stroke specialists representing 16 countries filled an online survey that included: screening for risk factors, acute management, diagnostics, medications, post-discharge services, and stroke registries. Results showed that 11 countries screen for risk factors, 16 have neuroimaging studies, 15 provide intravenous thrombolysis (IVT), 13 mechanical thrombectomy (MT) while medications for secondary prevention are available in all countries. However, stroke units are not equally available and even absent in 4 countries, and despite the availability of IVT yet, the rate of administration is still low in 6 countries (<5%), and ranges from 5-20% in 7 countries. Stroke registries and training still need to be implemented in most countries. Although imaging, revascularization therapies and medications for secondary prevention are available in most MENA countries, yet the rate of revascularization is low, so is the number of stroke units insufficient in some countries. Additionally, registries and structured training are still defective. Further field studies are required for more accurate determination of the status of stroke services in the MENA region.

‘Drive the doctor’ for endovascular thrombectomy in a rural area: a simulation study

BackgroundPatients who present in a primary stroke center (PSC) with ischemic stroke are usually transferred to a comprehensive stroke center (CSC) in case of a large vessel occlusion (LVO) for endovascular thrombectomy (EVT) treatment, the so-called ‘drip-and-ship’ (DS) model. The ‘drive-the-doctor’ (DD) model modifies the DS model by allowing mobile interventionalists (MIs) to transfer to an upgraded PSC acting as a thrombectomy capable stroke center (TSC), instead of transferring patients to a CSC. Using simulation we estimated time savings and impact on clinical outcome of DD in a rural region.MethodsData from EVT patients in northern Netherlands was prospectively collected in the MR CLEAN Registry between July 2014 - November 2017. A Monte Carlo simulation model of DS patients served as baseline model. Scenarios included regional spread of TSCs, pre-hospital patient routing to ‘the nearest PSC’ or ‘nearest TSC’, MI’s notification after LVO confirmation or earlier prehospital, and MI’s transport modalities. Primary outcomes are onset to groin puncture (OTG) and predicted probability of favorable outcome (PPFO) (mRS 0–2).ResultsCombining all scenarios OTG would be reduced by 28–58 min and PPFO would be increased by 3.4-7.1%. Best performing and acceptable scenario was a combination of 3 TSCs, prehospital patient routing based on the RACE scale, MI notification after LVO confirmation and MI’s transfer by ambulance. OTG would reduce by 48 min and PPFO would increase by 5.9%.ConclusionsA DD model is a feasible scenario to optimize acute stroke services for EVT eligible patients in rural regions. Key design decisions in implementing the DD model for a specific region are regional spread of TSCs, patient routing strategy, and MI’s notification moment and transport modality.

Stroke in women: experience in a developing country

BackgroundSeveral studies have addressed gender differences in stroke. Yet, results are diverse, and research is still required in different populations. So, this study investigates variation in stroke according to gender in a developing country.MethodsThis is a registry-based, retrospective observational cross-sectional study comparing men and women as regards age, risk factors, stroke severity, quality of services, and stroke outcome.ResultsData analyzed comprised 4620 patients. It was found that men outnumbered women, while women had an older age, more prevalence of hypertension and atrial fibrillation, with severer strokes and worse outcomes. However, there was no gender difference in promptness nor frequency of administration of revascularization therapies.ConclusionDespite the gender difference in risk factors and stroke severity, we could not detect any significant disparity in acute stroke services provided to either gender. Among age categories in women, we identified differences in acute ischemic stroke subtypes, and acute management in favor of older age.

Postacute Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack: The COMprehensive Post-Acute Stroke Services (COMPASS) Trial

ObjectivesThe COMPASS (COMprehensive Post-Acute Stroke Services) pragmatic trial cluster-randomized 40 hospitals in North Carolina to the COMPASS transitional care (TC) postacute care intervention or usual care. We estimated the difference in healthcare expenditures postdischarge for patients enrolled in the COMPASS-TC model of care compared with usual care. MethodsWe linked data for patients with stroke or transient ischemic attack enrolled in the COMPASS trial with administrative claims from Medicare fee-for-service (n = 2262), Medicaid (n = 341), and a large private insurer (n = 234). The primary outcome was 90-day total expenditures, analyzed separately by payer. Secondary outcomes were total expenditures 30- and 365-days postdischarge and, among Medicare beneficiaries, expenditures by point of service. In addition to intent-to-treat analysis, we conducted a per-protocol analysis to compare Medicare patients who received the intervention with those who did not, using randomization status as an instrumental variable. ResultsWe found no statistically significant difference in total 90-day postacute expenditures between intervention and usual care; the results were consistent across payers. Medicare beneficiaries enrolled in the COMPASS intervention arm had higher 90-day hospital readmission expenditures ($682, 95% CI $60-$1305), 30-day emergency department expenditures ($132, 95% CI $13-$252), and 30-day ambulatory care expenditures ($67, 95% CI $38-$96) compared with usual care. The per-protocol analysis did not yield a significant difference in 90-day postacute care expenditures for Medicare COMPASS patients. ConclusionsThe COMPASS-TC model did not significantly change patients’ total healthcare expenditures for up to 1 year postdischarge.

RECREATE: a study protocol for a multicentre pilot cluster randomised controlled trial (cRCT) in UK stroke services evaluating an intervention to reduce sedentary behaviour in stroke survivors (Get Set Go) with embedded process and economic evaluations

IntroductionSedentary behaviour (sitting or lying during waking hours without being otherwise active) is strongly associated with adverse health outcomes, including all-cause, cancer and cardiovascular mortality in adults. Stroke survivors are...

Exploring the Poststroke Experiences and Needs of South Asian Communities Living in High-Income Countries: Findings from a Scoping Review.

Despite the high prevalence of stroke among South Asian communities in high-income countries, a comprehensive understanding of their unique experiences and needs after stroke is lacking. This study aimed to synthesize the literature examining the experiences and needs of South Asian community members impacted by stroke and their family caregivers residing in high-income countries. A scoping review methodology was utilized. Data for this review were identified from seven databases and hand-searching reference lists of included studies. Study characteristics, purpose, methods, participant characteristics, results, limitations, recommendations, and conclusions were extracted. Data were analyzed using descriptive qualitative analysis. In addition, a consultative focus group exercise with six South Asian community members who had experienced a stroke and a program facilitator was conducted to inform the review interpretations. A total of 26 articles met the inclusion criteria and were analyzed. Qualitative analysis identified four descriptive categories: (1) rationale for studying the South Asian stroke population (e.g., increasing South Asian population and stroke prevalence), (2) stroke-related experiences (e.g., managing community support versus stigma and caregiving expectations), (3) stroke service challenges (e.g., language barriers), and (4) stroke service recommendations to address stroke service needs (e.g., continuity of care). Several cultural factors impacted participant experiences, including cultural beliefs about illness and caregiving. Focus group participants from our consultation activity agreed with our review findings. The clinical and research recommendations identified in this review support the need for culturally appropriate services for South Asian communities across the stroke care continuum; however, more research is necessary to inform the design and structure of culturally appropriate stroke service delivery models.

Gender disparity versus equality in acute stroke: a Middle Eastern country hospital-based study

BackgroundAcute stroke management is well-established in developed countries with no gender difference. Yet, in developing countries there are reports on gender disparity in medical services including stroke services. Egypt, a developing low–middle-income country, heavily populated, in the Middle East is a good example to answer whether acute ischemic stroke service is provided equally to males and females or there is disparity in risk factors, onset to door (OTD), door to needle (DTN), and outcome. The current study was prospective observational analytical hospital-based study, on acute ischemic stroke cases admitted to Nasr city insurance hospital stroke unit between September 2020 and September 2022.Results350 cases were included, 257 males and 93 females. Hypertension was the commonest risk factor 66% males and 81% females P = 0.011, atrial fibrillation was predominant in females P < 0.001, smoking was predominant in males P < 0.001. Median OTD in hours was 8.0 among both genders with minimum zero and maximum 96 h in males compared to minimum 1 and maximum 120 h in females, DTN was around 30 min with no significant difference. Median NIHSS on which rtPA was administered was 12.5 (6–13) in females compared to 10 (6–12) in males. Males who did not receive rtPA had a better mRS on discharge and on 90 days P = 0.01, 0.009, respectively, while there was no significant difference on discharge and 90 days between both genders on receiving rtPA.ConclusionsNo gender disparity was found in DTN, discharge outcome, and 90 days among rtPA recipients. Females tended to have higher NIHSS and relatively delayed presentation to ER with less favorable outcome at discharge and 90 days in case of not receiving rtPA. Encouraging earlier arrival and conducting awareness campaigns for risk factors management is warranted.

Twenty years of monitoring acute stroke care in Australia through the national stroke audit programme (1999-2019): A cross-sectional study.

National organisational surveys and clinical audits to monitor and guide improvements to the delivery of evidence-based acute stroke care have been undertaken in Australia since 1999. This study aimed to determine the association between repeated national audit cycles on stroke service provision and care delivery from 1999 to 2019. Cross-sectional study using data from organisational surveys (1999, 2004, 2007-2019) and clinical data from the biennial National Stroke Acute Audit (2007-2019). Age-, sex-, and stroke severity-adjusted proportions were reported for adherence to guideline-recommended care processes. Multivariable, logistic regression models were performed to determine the association between repeated audit cycles and service provision (organisational) and care delivery (clinical). Overall, 197 hospitals provided organisational survey data (1999-2019), with 24,996 clinical cases from 136 hospitals (around 40 cases per audit) (2007-2019). We found significant improvements in service organisation between 1999 and 2019 for access to stroke units (1999: 42%, 2019: 81%), thrombolysis services (1999: 6%, 2019: 85%), and rapid assessment/management for patients with transient ischaemic attack (1999: 11%, 2019: 61%). Analyses of patient-level audits for 2007 to 2019 found the odds of receiving care processes per audit cycle to have significantly increased for thrombolysis (2007: 3%, 2019: 11%; OR 1.15, 95% CI 1.13, 1.17), stroke unit access (2007: 52%, 2019: 69%; OR 1.15, 95% CI 1.14, 1.17), risk factor advice (2007: 40%, 2019: 63%; OR 1.10, 95% CI 1.09, 1.12), and carer training (2007: 24%, 2019: 51%; OR 1.12, 95% CI 1.10, 1.15). Between 1999 and 2019, the quality of acute stroke care in Australia has improved in line with best practice evidence. Standardised monitoring of stroke care can inform targeted efforts to reduce identified gaps in best practice, and illustrate the evolution of the health system for stroke.

Psychosocial care in DHB-based stroke services in Aotearoa: a survey of current practice.

Stroke has significant psychosocial impacts which contribute to burden for the person with stroke and affect stroke outcomes. The Psychosocial Working Group of the National Stroke Network (NSN) sought to survey current practices for assessing and supporting psychosocial needs within district health board (DHB) based stroke services to inform national service delivery initiatives. The survey was conducted in 2021. It was distributed to senior clinicians in all DHBs via the NSN. Thirty-seven responses were received from stroke services, representing 90% of DHBs. Sixty-three percent of services reported some process for screening for psychosocial needs. Of these, only 11% used validated screens. Variability in the type of psychosocial support was evident. Seven percent of services had routine access to psychology, while 53% could access psychology on referral. There was limited evidence of specific screening and support processes for Māori, Pacific peoples, or those with communication impairments. Respondents identified training and resources needs to enable better psychosocial care. Stroke services are not consistently meeting national guidelines which require all services have a process for screening for psychosocial needs. This survey has informed a work programme to support psychosocial care practices in stroke services in Aotearoa New Zealand.

Patient with Recurrent Acute Ischemic Strokes Found to have Cryptococcal Meningitis: A Case Report (P12-5.023)

<h3>Objective:</h3> n/a <h3>Background:</h3> Cryptococcal meningitis is a rare cause of ischemic stroke. Infections most often present in immunocompromised patients, classically AIDS or transplant patients. We present a case of a seemingly immunocompetent patient who presented with recurrent strokes found to have cryptococcal meningitis. <h3>Design/Methods:</h3> n/a <h3>Results:</h3> The patient was a 55-year-old male construction worker with hypertension. A year prior to admission, he was hospitalized for a week with mild SARS-COVID-19 infection. He had received two doses of the mRNA Covid vaccines. One month prior to admission, he developed headaches initially treated as sinus infection with oral antibiotics and steroids. Two weeks later, there was concern for acute-onset aphasia. He was afebrile with mild leukocytosis (13.6 B/L). MRI brain showed multiple, bilateral, scattered lacunar infarcts and left cerebellar infarcts. Transthoracic and transesophageal echocardiography were unremarkable. A loop recorder was placed. He was started on dual antiplatelet and statin therapy. A week later, he was encephalopathic and lethargic. Repeat MRI brain showed new acute lacunar and bilateral cerebellar infarcts. The loop recorder was negative for arrhythmias. A lumbar puncture (LP) was deferred for unclear reasons. Patient was transferred to our stroke service, where he was febrile (102.3°F) with leukocytosis (17.4 B/L). He was encephalopathic and had nuchal rigidity. LP showed elevated opening pressure (55 cm H2O) and tested positive for Cryptococcal antigen. Liposomal amphotericin B and flucytosine were initiated. Diagnostic angiogram was negative for vasculitis. His CD4 count was 332 (normal 410–1,590), however HIV testing was negative and pan-CT scan showed no signs of underlying malignancy. His prolonged hospital course was complicated by elevated intracranial pressure, further strokes, and poor mental status requiring placement of tracheostomy and enteral tube access. <h3>Conclusions:</h3> It is important to keep infection, including cryptococcal meningitis, in the differential for the cause of recurrent strokes even in seemingly immunocompetent patients. <b>Disclosure:</b> Lauren Thaete has nothing to disclose. Dr. Azuma has nothing to disclose.

Risk of acute stroke in young patients with new-onset lupus nephritis: a case series (P9-5.028)

<h3>Objective:</h3> To investigate the relationship between new-onset lupus nephritis and acute stroke. <h3>Background:</h3> Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disease associated with an increased risk for stroke. <h3>Design/Methods:</h3> We reviewed medical records of patients evaluated by the inpatient Stanford Stroke Service from 2020–2022 with confirmed stroke on neuroimaging and diagnosis of SLE based on American College of Rheumatology Classification Criteria. Data regarding the clinical course, laboratory testing, and neuroimaging were extracted from electronic medical records. <h3>Results:</h3> Three patients were identified (two male, one female) with ages ranging from 17–32 years. Two patents had prior diagnosis of SLE without renal involvement. Magnetic resonance imaging obtained for all three patients demonstrated ischemic strokes restricted to a vascular territory. Magnetic resonance angiography demonstrated a proximal left superior cerebellar artery thrombus for one patient and slight enhancement in the proximal left M1-segment for another patient. Initial preliminary labs for all three patients were notable for leukopenia, anemia, hematuria, proteinuria, elevated urine protein/creatine ratio. Serologic testing was notable for positive ANA, positive anti-dsDNA, positive anti-Sm, low C3, and low C4. Anti-phospholipid labs and hypercoagulable work-up was negative. CSF analysis yielded normal protein, glucose, WBC, and RBC. All three patients were diagnosed with new-onset lupus nephritis, with two patients undergoing confirmatory renal biopsy. Patients were initially treated with a combination of prednisone, mycophenolate mofetil, and/or hydroxychloroquine and closely followed as an outpatient. One patient with vessel enhancement on initial imaging continued to have reoccurring strokes and required escalation of immunotherapy to cyclophosphamide with eventual remission and normalization of antibody levels. <h3>Conclusions:</h3> This case series presents several young patients with acute stroke in the setting of new-onset lupus nephritis without other traditional SLE-related stroke risk factors. Further research is needed to guide the stratification of stroke risk among patients with SLE. <b>Disclosure:</b> Dr. Wu has nothing to disclose. Dr. Han has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Roche. Dr. Han has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Arena Pharmaceuticals. Dr. Lee has nothing to disclose.