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Background and Purpose: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective of this study 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 transient ischemic attack, a baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 5, presenting within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale score of 0 to 1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-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-Stroke participating hospitals (age, 65±14; 42% women; final diagnosis of ischemic stroke, 90%; transient ischemic attack, 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 recipients, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, and extremity weakness. Similar outcomes were noted for the alteplase-treated and untreated groups. Alteplase-treated patients were younger (64±13 versus 67±1.4) with higher NIHSS (2.9±1.4 versus 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 association with Stroke Impact Scale-16 in the restricted sample of baseline NIHSS score 3–5. Few symptomatic intracerebral hemorrhages were recorded ( Conclusions: A large proportion of stroke patients presenting with 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 a suggestion of efficacy was noted in the NIHSS 3–5 subgroup. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02072681.

Background and Purpose: Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. Methods: A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0–5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines–Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. Results: Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. Conclusions: Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT 02072681.

Stroke readmissions within 30 days have been identified by the Centers for Medicare & Medicaid Services (CMS) as a measure of hospital quality. Readmitted stroke patients experience greater mortality, longer lengths of stay, and higher cost per stay. This Comprehensive Stroke Center has had a follow up program since 2010 which includes a 48 hour phone nurse call, a 7 day clinical pharmacist phone call, and stroke clinic visit/phone call at 30 days and 90 days. This process produced a 50% readmission reduction between 2013 and 2018, however opportunities to further reduce stroke readmissions remain. Methods: In 2018, a process was launched where specially-trained Community Paramedicine professionals visit stroke patients at home @ 7-10 days post discharge. This visit includes education reinforcement, social evaluation and support, medical examination, and interventions. The model was previously found to demonstrably reduce heart failure readmissions. Referrals are made to this team by coordinators for ischemic and hemorrhagic patients discharged to home or rehab. Findings and needs are communicated directly to relevant health system elements. Results: From July 2018 through June 2019, CP visited 156 (23%) of the 669 patients discharged to home and acute rehab. Only 1 patient (0.6%) of those visited was readmitted, while 52 (10%) of the 513 not visited were readmitted within 30 days. During the visits, they identified key barriers such as medication errors, absence of help in the home (despite having previously reported they would have help), lack of transportation, and overwhelmed caregivers. They ensured that pill organizers were utilized, reviewed upcoming appointments, assisted with arranging transportation, and provided education and helping strategies to caregivers. Feedback from the patients has been overwhelmingly positive. Conclusion: Stroke Centers are accountable to improve stroke patients’ transitions of care at discharge to reduce readmissions and ensure optimal recovery. Community Paramedicine personnel are well-suited to positively impact readmission rates in stroke patients.

Objective: Reporting a novel mutation in the HTRA1 gene in a CARASIL patient from Americas. Methods: Clinical presentation and neuroimaging were consistent with CARASIL. HTRA1 DNA sequencing was performed using advanced (“next generation”) sequencing technology. The results revealed a homozygous missense mutation as c.616G>A (p.Gly206Arg) in the HTRA1 gene. Results: A 24-year-old man with a history of chronic back pain presented with recurrent ischemic strokes. A diagnosis of CARASIL was made with the finding of a novel homozygous missense mutation c.616G>A in HTRA1 gene, resulting in change from Glycine to Arginine in the Serine Protease HTRA1. Brain imaging showed multiple lacunar infarcts with extensive abnormalities of the white matter that spared the external capsules. He also had unilateral decreased hearing with craniofacial asymmetry. None of the above features have been previously described in known CARASIL patients. Both parents of the proband were heterozygous for the same missense mutation. Conclusion: We discovered a novel missense mutation (c.616G>A) associated with a phenotype of CARASIL. This is the first genetically backed case of CARASIL in the new world. The patient's craniofacial abnormalities, including asymmetry of the head, may be related to impaired modulation of transforming growth factor-β1, the result of loss of proteolytic activity of HTRA1. External capsules remained unaffected, despite findings of advanced changes in the rest of the cerebral white matter. Literature is briefly reviewed. The patient's history, neurological exam, neuroimaging, and genetic testing are included.

Introduction: In 2014, the Centers for Medicare and Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) program. Our institution is contracted for a 90 day stroke bundle, making us responsible for all Medicare stroke patient costs. Quarterly review of 2015 financial data (DRG 64 & 65) revealed a significant spend occurs in the post-acute care phase. Methods: Detailed analysis and sequencing revealed that of the 40% of patients discharged to an Inpatient Rehab Facility (IRF) 31% were unsuccessful in rehabilitation and instead transitioned to a Skilled Nursing Facility (SNF). Had SNF been initially selected, a cost avoidance of $292,650 would have been appreciated. Conclusion: Involvement in the BPCI program has provided insight into the post-acute care of stroke patients. With the advent of BPCI, institutions will be increasingly held fiscally responsible for post-acute care delivery. Ongoing retrospective chart review and collaboration with Physical Medicine and Rehabilitation colleagues is underway to identify key indicators that would project successful rehabilitation. Analysis will include comparison between those who were successfully discharged home after an IRF stay to those that needed a SNF after an IRF stay. This would provide inpatient teams with strategies for predicting the optimal discharge location for stroke patients.

Background: Stroke patients are at a significant risk of inconsistent care and adverse events after discharge from the hospital. Follow-up contact has been thought to facilitate continuity and compliance with the discharge plan of care, but evidence is lacking as to optimal timing and intensity of follow-up. Our organization established a stroke clinic in 2009 with a schedule for follow up at 30 days, 90 days, and 1 year. In 2014, in effort to increase follow-up volume, the process was amended to ensure that appointments were made prior to discharge. Method: Analysis of 2014 follow-up appointments was conducted by the Stroke Clinic Process Improvement Group. The appointment order was added to the stroke admission order sets so that appointments would display on discharge paperwork. Discussion: There was a 55% increase in patients who followed-up from 2013 to 2014. This improvement continued through 2015. However, despite the successful increase in appointments, the clinic reported an atypical no-show rate of 29% for 2014 and 40% for 2015, a loss of $51,165, in addition to the cost of provider down-time. A deeper analysis of appointment type revealed a significant drop in 1-year visits. Since the data also revealed that most patient visits are at either 30-days, or 30 and 90-days, our process was amended once again to exclude 1-year visits. In addition, the follow-up appointments are now ordered 48 hours prior to discharge, ensuring appointments continue to display on discharge paperwork. Conclusion: Process improvements sometimes result in unexpected downstream effects. We determined that the increase in follow-up appointments did not justify the financial and productivity loss to the clinic. Monitoring of no-show data and stroke clinic volume will be essential as this stroke clinic process evolves. Until we find a way to make patients come for stroke clinic follow-up visits, we will continue to be challenged to find a way to support them through their post-stroke recovery.

Introduction: The Bundled Payments for Care improvement (BPCI) initiative was launched by the Centers for Medicare and Medicaid Services (CMS) in 2014. Our organization contracted for Model 2, making us responsible for all costs associated with index hospital stay plus 90 days post discharge for straight Medicare patients. It was anticipated that we would find opportunity for reduction in readmission rates, which would lead to reduced cost of care. Analysis of Q1 & Q2 2014 data revealed other opportunities. First, cases coded as non-traumatic Subdural Hematoma (SDH) - regardless of readmission - accounted for significant financial deficit. Second, 67% of patients utilized Post-Acute Care (PAC - SNF, acute rehab, home health) at least once and 54% utilized a second PAC. All patients discharged to acute rehab who then transitioned to SNF exceeded the target price for the bundle. Methods: A case review of SDH episodes revealed that many were traumatic but not documented as such. A summary of these cases was presented to providers with recommendations for appropriate wording to ensure appropriate coding. Education was also provided to coders related to BPCI regarding the impact of clarifying traumatic cause of SDH. Protocols for post-acute management were developed with partners in acute rehab & SNF’s in the region and gain-sharing agreements were developed. Partner facilities reviewed each bundled stroke patient for opportunities to reduce post-acute care LOS. Results: Analysis of Q3 2015 demonstrated that the number of SDH cases in the bundle dropped significantly, improving the financial picture six-fold. A reduction in SNF LOS of 25% was appreciated. Conclusion: Stroke is a leading cause of disability in the United States and post-acute care for a 90 day episode carries a prohibitive cost. Accurate documentation and partnering with post-acute facilities does improve the financial position. Ultimately though, post-acute care - not readmissions - is the major driving force for dollars spent in Stroke BPCI.

Background: Selection of patients for endovascular stroke treatment has traditionally been based on time since symptom onset. CT perfusion (CTP) imaging has raised the possibility of patient selection on objective measures other than time from stroke onset. However, previous studies have failed to show significant outcome improvement in patients selected for endovascular stroke treatment based on CTP, but have been limited by small sample size, lack of outcomes past time of discharge, or lack of control group. Objective: To determine if endovascular stroke treatment selection with the aid of CTP is associated with improved clinical outcomes at 90 days as compared to patients undergoing endovascular stroke treatment without the aid of CTP. Methods: This study retrospectively reviewed a prospectively collected database of all patients who underwent endovascular stroke treatment at Penn State Hershey Medical Center between 1/1/2009 and 12/31/2011. Patients with posterior circulation strokes and those enrolled in other treatment trials were excluded. Patients were divided into two groups based on whether they had undergone a CTP study prior to endovascular stroke treatment or not. The variables measured included age, sex, and NIHSS on admission. Outcome data measured from the patients 90 day post stroke follow up appointments included an NIHSS improvement by 4 or more, a modified Rankin Score (mRS) of 2 or less, and mortality. Results: Of 41 patients included in the study, there was no significant difference in outcomes at 90 days as measured by an improvement of NIHSS of 4 or more (p=0.106) or modified Rankin score of 0-2 (p=0.475). Table 1 summarizes the results. Conclusion: Endovascular stroke treatment selection with the use of CTP was not associated with improved clinical outcomes at 90 days as measured by NIHSS improvement of 4 or more or a mRS of 0-2.