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Background and Purpose: During the coronavirus disease 2019 (COVID-19) pandemic, the various emergency measures implemented to contain the spread of the virus and to overcome the volume of affected patients presenting to hospitals may have had unintended consequences. Several studies reported a decrease in the number of stroke admissions. There are no data on the impact of the COVID-19 pandemic on stroke admissions and stroke care in Maryland. Methods: A retrospective analysis of quality improvement data reported by stroke centers in the State of Maryland. The number of admissions for stroke, overall and by stroke subtype, between March 1 and September 30, 2020 (pandemic) were compared with the same time period in 2019 (prepandemic). Median last known well to hospital arrival time, the number of intravenous thrombolysis and thrombectomy were also compared. Results: During the initial 7 months of the pandemic, there were 6529 total admissions for stroke and transient ischemic attack, monthly mean 938 (95% CI, 837.1–1038.9) versus prepandemic 8003, monthly mean 1156.3 (CI, 1121.3–1191.2), P P P =0.507. Conclusions: Our findings suggest that the COVID-19 pandemic adversely affected the acute care of unrelated cerebrovascular emergencies.

Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, “Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient,” with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.

Background: The transition period from hospital to home is a highly vulnerable time for patients after stroke. COVID-19 restrictions have exacerbated safety concerns, stressed the health care system, and put patients at high risk after discharge. Here we describe pilot results from the Joint Stroke Transitional Technology-Enhanced Program (JSTTEP) designed to reduce post-stroke complications, avoid hospital readmission, and enhance recovery. Methods: JSTTEP is a novel, interprofessional program for patients discharged from the Johns Hopkins Comprehensive Stroke Center. In the first weeks after hospital discharge, stroke patients complete a series of multidisciplinary telemedicine visits to (1) reduce the risks of adverse events in the transition from hospital to home, and (2) develop a plan to facilitate a full recovery. The first joint visit is with stroke neurology and physical therapy for risk mitigation, and the second is with physiatry and occupational therapy for a recovery plan. Patients and caregivers participate in an interactive, online group education session covering topics about vascular risk factor modification, nutrition, exercise, fall prevention, and self-management skills. Results: In the first 4 months of the program, 50 patients were enrolled. Average age was 61 years; 26/50 (52%) were women, 23/50 (46%) were African American, and mean baseline NIHSS was 5.4. Of those 45/50 (90%) completed their visit, with 4/50 (8%) requiring conversion from video to phone visit. Unexpected 30-day hospital readmission rate was 3/50 (6%), one of whom was readmitted due to neurological issues identified during the JSTTEP appointment. Interpreter services were utilized for 5 completed video visits (Arabic, Mandarin, Spanish, Twi, Urdu). Patients reported the ability to include family members remotely in the visit as an advantage. Conclusions: The data demonstrate the feasibility and potential benefit of an interprofessional stroke telemedicine program designed to enhance post-stroke recovery. JSTTEP increased access to post-hospital care and reduced risks for adverse outcomes. The ongoing benefits and scaling of such a clinic will rely on permanent legislative and insurance changes to support such a care model.

Introduction: During the Coronavirus Disease-2019 (COVID-19) pandemic the “stay-home” public campaign implemented to contain the spread of the virus and the reorganization of hospitals to manage the overwhelming volume of affected patients, may have had unintended consequences. Prior studies reported a decrease in the number of stroke and TIAs admissions. Most reports have been from single hospitals, there is no data available on the impact on a statewide level. Methods: A retrospective analysis of stroke quality improvement data reported to the State of Maryland. These data are from Primary, Thrombectomy-Capable, and Comprehensive Stroke Centers. The number of admissions for stroke overall and by stroke subtype are reported and compared for March-June 2020 vs. March-June 2019. Last known well (LKW) to hospital arrival, intravenous tPA (IV tPA) and thrombectomy rates were analyzed. Results: The overall number of stroke admissions from March-June 2020 compared to March-June 2019 was 1,001 vs. 1,203 in March, 809 vs. 1,112 in April, 950 vs. 1206 in May, and 937 vs. 1,261 in June. There was an average 21% decrease for the 4-month period in 2020 compared to 2019. For ischemic stroke, there was a decrease in hospital admission for each month in 2020 vs. 2019: 740 vs. 922 in March, 606 vs. 866 in April, 721 vs. 906 in May, and 698 vs. 880 in June. TIAs admission rates were similarly decreased in 2020 vs. 2019: 116 vs. 136, 74 vs. 97, 111 vs. 137, and 107 vs. 111. The number of ICH admissions in 2020 vs. 2019 was 100 vs. 107 in March, 90 vs. 112 in April, 96 vs. 116 in May, and 103 vs. 121 in June. Median LKW well to hospital arrival was 292 vs. 254 min in March, 383 vs. 293 min in April, 291.5 vs. 247 min in May, and 320 vs. 292 min in June. There was about 1% decrease in thrombectomy rates in the 4-month period in 2020 compared to 2019. Conclusions: During the COVID-19 pandemic in the State of Maryland there was a consistent decrease in the volume of stroke admissions. Median LKW to hospital arrival was also increased, supporting evidence for of a delay in stroke care. While reasons for these changes need to be further explored, our findings suggest that public health campaigns for the pandemic should take into account and not adversely affect the acute care of unrelated medical emergencies.

Background: Stroke registries are established with the primary goal of improving health care quality and performance improvement through increased adherence to evidenced based guideline recommendations. As a Joint Commission certified organization, the Comprehensive Stroke Center uses the American Heart Association’s Get With The Guidelines® (GWTG) stroke patient management tool to collect performance improvement data on patients admitted with a principle diagnosis of stroke. Data abstraction is laborious and time consuming which requires manual entry by multiple clinicians. Therefore, we developed an automated internal stroke database to improve efficiency and augment accuracy. Methods: We collaborated with software engineers and EPIC report writers to create an innovative stroke database with the capability to extract data from an Electronic Health Record (EHR) for upload to GWTG. The clinicians identified data elements for automation in the EHR. Based on final ICD-10 coding the report writer retrieved end-user data, which were organized into tables and sent to the software engineer. These variables were processed to match GWTG specifications and then presented to clinicians in the user interface for validation. Next, a CSV file was generated and uploaded to GWTG, where the remaining data was entered. Results: The case completion time was reduced from 45 minutes to one hour to an average of 25 minutes (median 23 minutes), thus achieving our primary goal. Due to the variance in the number of required data elements based on diagnosis and patient specific variables, we aggregated the data elements, automated versus required, and calculated an automation rate of 54%. Approximately half of the 414 fields required in GWTG have the potential for automation, and we continue to strive toward this goal. Due to the complexity of GWTG questions and the way data is captured in the EHR, some data elements require manual entry. Conclusions: An automated stroke registry has the potential to enhance efficiency and limit the opportunity for human error. By minimizing the clinicians’ data entry tasks to those of higher-level data abstraction, there is more time for performance improvement.

Objective: To assess feasibility and replicability of a multidisciplinary, specialized clinic in optimization of secondary stroke prevention and stroke related complications. Background: Recommendations exist for secondary stroke prevention, but it is unclear which outpatient model of care optimizes vascular risk factor control and decreases post-stroke complications most effectively. Designed after the Stroke Transitions, Education, and Prevention clinic in Houston, TX, the Follow up After Stroke, Screening and Treatment (FASST) clinic is an integrated, multidisciplinary, specialized clinic designed to optimize secondary stroke prevention. It provides post discharge stroke education and medication adherence counseling by Pharmacists, as well risk factor and complications management by Vascular Neurologists. Validated patient reported surveys screen for complications: depression, anxiety, sleep disorders, cognitive impairment, disability, social support, quality of life and functional status. Our approach and the characteristics of patients enrolled in the clinic is described. Methods: Patients attending one FASST clinic visit are included. Institutional Board Review approved consent is obtained. Demographic and clinical data are recorded including risk factors, surveys and outcome scores. Data is entered in Redcap and analyzed through the Statistical Analysis Software (SAS) program. Results: Of the 25 patients enrolled in the clinic, 83.3% are African American. A high prevalence of hyperlipidemia (100%) and hypertension (100%) exists, with 44% of patients having concomitant diabetes mellitus. Overall 26.7% screened positive for depression with PHQ-9, and 20% screened positive for anxiety with GAD-7. These patients were started on medications and referred for psychotherapy. Abnormal ESS scores were noted in 31.3% and directed for sleep apnea evaluation. Eighteen medical and pharmacy trainees rotated through the clinic. Conclusion: The FASST clinic represents a reproducible model for an integrated approach to post-stroke care. Adapted to academic centers across the country, a collaborative network would provide best practices, and measure patient reported outcomes to optimize stroke care.

Background: Intracranial atherosclerotic stenosis (ICAS), one of most common stroke subtypes worldwide, carries high risk of stroke recurrence despite maximal medical treatment. ICAS more commonly affects non-white populations including Asian, African-American and Hispanic individuals. It is plausible that non-white stroke patients with ICAS might also have more active disease, and thus higher risks of stroke recurrence. We aim to compare the rate of stroke recurrence in stroke patients with ICAS in white and non-white population. Method: We retrospectively reviewed a consecutive series of patients with ischemic stroke due to ICAS in major vessels (MCA, ACA, PCA, intracranial segment of ICA and VA, BA) with >50% stenosis identified on MRA or CTA. The clinical characteristics, risk factors and rate of stroke recurrence were compared in white and non-white patients, using Chi-square (for categorical variables) test and t-test (for continuous variables). Results: A total of 183 patients [66.3% non-white, mean (SD) age, 63 (±14) years] who were hospitalized between January 2005 and December 2010 and satisfied the inclusion criteria were included in the analysis. Compared with white patients, non-white patients had a higher rate of HTN, DM and drug abuse (Table 1), as well a nonsignificantly higher stroke recurrence rate (3 months: OR 1.29, 95% CI 0.59-2.82; long term: OR 1.63, 95% CI 0.84 - 3.18). History of CKD was the only factor associated with 3-month stroke recurrence (OR 3.73, 965 CI 1.13-12.31). Conclusion: White and non-white ischemic stroke patients with ICAS have distinct risk factor profiles and possibly distinct stroke recurrence rates. Analysis with a larger sample size is ongoing to verify this finding.

Introduction: New EMS routing protocols are being proposed to divert acute stroke patients, based on the likelihood of having a large vessel occlusion (LVO), directly to Comprehensive Stroke Centers (CSC), in order to reduce the inherent delay of a secondary transfer from a Primary Stroke Center (PSC) to a CSC. Within Baltimore City, transfer from a PSC to a CSC for mechanical thrombectomy (MT) adds, on average, an additional 90-minute delay in achieving reperfusion. Aim: To determine the feasibility and safety of an EMS routing protocol in which, patients determined to have an LVO-related acute stroke, based on use of a stroke severity score in the field, are directed to the nearest CSC bypassing closer PSCs within Baltimore City. Methods: A prospective observational study was conducted over a six-month period, from September 2017 to March 2018. Acute stroke patients with a LAMS of ≥4 were taken by EMS to the nearest CSC, bypassing closer PSCs, as long as the travel time did not exceed an additional 30 minutes. Data collected at the three CSCs included transport times, IV-tPA and MT use in the diverted patients, time from onset to treatment and 90-day functional outcomes. Descriptive statistics were used to analyze the data. Results: Forty-five patients with LAMS of ≥4 were diverted to a CSC. Approximately 50% (20/45) had a final diagnosis of acute ischemic stroke and 35% of those were eligible for an intervention, either IV-tPA or MT or both. Average onset to IV-tPA bolus time was 114 minutes (93-163 minutes). Average onset to groin puncture was 197 minutes (192-202 minutes). There were 4 in-hospital deaths. Among survivors, the 90 day modified Rankin Scale (mRS) ranged from 0-3. Mean field transport time was 17 minutes (range: 4-63 minutes). None of the re-routed patients were ineligible for IV-tPA due to additional time to CSC. There were no reported adverse outcomes due to increased travel time associated with diversion. Conclusion: Implementation of EMS routing protocols to divert acute stroke patients suspected of having an LVO past PSCs to CSC within cities is feasible and appears safe. The limitations of this study include small size, short duration and small region of implementation. Further study is warranted on a larger scale both in population and geographic area.

Introduction: Intracranial atherosclerotic stenosis (ICAS), the most common cause of stroke worldwide, is more prevalent in non-white populations including Asian, African-American and Hispanic individuals. We studied the racial difference (white vs non-white) in the plaque features of stroke patients with ICAS using vessel wall MRI (VWMRI). Methods: We retrospectively included stroke patients with etiology being intracranial atherosclerosis who received VWMRI. VWMRI was read by experienced neuroradiologists blinded to other clinic information. Culprit plaque was defined as a plaque in a relevant vessel responsible for the downstream ischemic lesion. In addition to plaque number and degree of the stenosis, other plaques features were analyzed, including degree of plaque enhancement(minimal, moderate and strong), plaque calcification and eccentricity. The association between race, cardiovascular risk factors and plaque features was tested in multivariable models. Results: In 64 stroke patients (mean age 55.6±13.4 y, 62.5% male, 43.8% non-whites), the median number of plaque was 3 (range 0-11). Compared with whites, non-whites have a higher number of plaques (median, 4 vs 3, p=0.029). Smoking was associated with presence of extensive plaque (defined as ≥3 plaques) and remained significant after adjustment for other risks factors (non-white race, hypertension, age≥55 and HbA1C≥6.5; adjusted OR 6.9, 95% CI 1.27-37.66). For culprit plaques, presence of ≥50% stenosis, strong plaque enhancement, eccentric pattern and calcification did not differ by race. LDL >100 mg/dl, history of hyperlipidemia and eGFR2 were each associated with presence of strong plaque enhancement, eccentric pattern and calcification respectively (OR 1.5, 95% CI 1.5-19.6; OR 9.9, 95% CI 1.1-85.6; OR 24, 95% CI 2.3-247.4; respectively). Conclusion: A higher number of intracranial atherosclerotic plaques was revealed by VWMRI in non-white stroke patients with stroke etiology being intracranial atherosclerosis, while the features of their culprit plaque were similar compared with white patients. History of smoking was significantly associated with presence of ≥3 plaques. Studies with larger sample size are needed to validate the above findings.

Background: Despite delivery of hospital-required stroke education, retention by patients/families is poor. We examined knowledge retention using a test-enhanced learning strategy for provision of stroke education. Methods: An experimental study was conducted, enrolling consecutive consenting English-speaking, literate patients/family members from a comprehensive stroke center to two groups: Control group (routine individual teaching, time for questions, and provision of written materials); or, a Test-Enhanced Stroke education Target (TEST) group (informed on enrollment about a discharge written test requirement, along with provision of the same routine education). Prior to discharge both groups completed a written stroke knowledge test to gauge content retention. Demographic data and correct test items were analyzed using descriptive statistics, Fisher’s Exact test, and Mann-Whitney U. Results: We enrolled and prospectively randomized 30 patients to either the control or TEST group. Patient characteristics were similar between groups: 80% and 93% ischemic strokes, 53% and 47% females, 67% and 53% African Americans, with a median LOS of 3 days in the control and TEST groups respectively. However, patients in the TEST group were significantly older at 64 (range 35-84; p=0.03) vs. 52 (range 24-70) years in controls. Overall median scores for all test items were significantly higher in the TEST group compared to controls (p=0.02), with TEST patients understanding their personal risk factors for stroke (p=0.02) and medication for secondary prevention (p=0.04) significantly better than controls patients (Table). Conclusions: Stroke knowledge retention is improved when patients are alerted to a formal testing requirement. Test-enhanced learning may play an important role in preparing stroke patients and family members for assumption of self-care post-hospitalization.