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Background: Despite the high rates of successful reperfusion in the randomized mechanical thrombectomy (MT) trials, only 27% of large vessel occlusion (LVO) patients treated successfully with MT achieved functional independence at 90 days. One proposed theory is impaired distal reperfusion with persistent small thrombi within the microcirculation despite complete recanalization “the no-Reflow phenomenon”. These distal small thrombi would be more suitable to dissolve by thrombolytics. Methods: This is a retrospective cohort obtained from Get with the guidelines stroke (GWGS) database available at Medical University of South Carolina Comprehensive Stroke Center (CSC) for LVO patients presented within 4.5 hours of last known well (LNW) between January/2018- June/2022. We aim to investigate the influence of intravenous thrombolysis (IVTPA) on the functional independence mRS (0-2) after a successful MT defined as modified thrombolysis score (mTICI2c-3). Results: Of 188 LVO patients who achieved successful reperfusion (TICI2c-3) during the study period, 93 (49%) arrived at our CSC within 4.5 hours of LSW, of them 40 patients (43%) received IVTPA. There was no difference in age, gender, race and initial NIHSS between patients who received IVTPA and those who did not receive IVTPA. Patients received IVTPA arrived at the CSC earlier [median LNW 60 min IQR (51 - 151) vs 165 min (IQR 103- 214), p = Conclusion: Intravenous thrombolysis can still influence LVO stroke patients' outcomes with complete revascularization. This positive effect might be related to distal microthrombi thrombolysis and subsequent improvement of the microcirculation flow beyond the occlusion site

Objective: The purpose of this study is to understand the nature and source of disruptions in an ambulance during the telemedicine-based caregiving process for stroke patients to enhance the ambulance design for supporting telemedicine-based care. Background: Telemedicine is emerging as an efficient approach to provide timely remote assessment of patients experiencing acute stroke in an ambulance. These consults are facilitated by connecting the patient and paramedic with a remotely located neurologist and nurse using cameras, audio systems, and computers. However, ambulances are typically retrofitted to support telemedicine-enabled care, and the placement of these systems inside the ambulance might lead to spatial challenges and disruptions during patient evaluation. Method: Video recordings of 13 simulated telemedicine-based stroke consults were coded and analyzed using an existing systems-based flow disruption (FD) taxonomy. For each observed disruption—the type, severity or impact, location in the ambulance, and equipment involved in the disruption were recorded. Results: Seat size, arrangement of assessment equipment, location of telemedicine equipment (computer workstation), and design of telemedicine camera were among the factors that impacted telemedicine-related disruptions. The left ambulance seat zone and head of the patient bed were more involved in environmental hazard–related disruptions, while the right zone of the ambulance was more prone to interruptions and communication-related disruptions. Conclusion: Adequate evaluation space for the paramedic, proper placement of evaluation equipment, and telemedicine computer location could facilitate the stroke care evaluation process and reduce FDs in the ambulance.

Past research has established that telemedicine improves stroke care through decreased time to treatment and more accurate diagnoses. The goals of this study were to 1) study how clinicians complete stroke assessment using a telemedicine system integrated in ambulances, 2) determine potential errors and usability issues when using the system, and 3) develop recommendations to mitigate these issues. This study investigated use of a telemedicine platform to evaluate a stroke patient in an ambulance with a geographically distributed caregiving team comprised of a paramedic, nurse, and neurologist. It first determined the tasks involved based on 13 observations of a simulated stroke using 39 care providers. Based on these observational studies, a Hierarchical Task Analysis (HTA) was developed, and subsequently, a heuristic evaluation was conducted to determine the usability issues in the interface of the telemedicine system. This was followed by a Systematic Human Error Reduction and Prediction Approach (SHERPA) to determine the possibility of human error while providing care using the telemedicine work system. The results from the HTA included 6 primary subgoals categorizing the 97 tasks to complete the stroke evaluation. The heuristic evaluation found 123 unique violations to heuristics, with an average severity of 2.38. One hundred and thirty-one potential human errors were found with SHERPA, the two most common being miscommunication and selecting an incorrect option. Several recommendations are proposed, including improvement of labeling, consistent formatting, rigid or suggested formatting for data input, automation of task structure and camera movement, and audio/visual improvements to support communication.

Background: Previous studies have shown that primary stroke centers (PSCs) have shorter door to needle (DTN) time than non-PSCs hospitals. We aimed to validate these findings in a high-volume teles...

Introduction Clinical trials have proven the efficacy of mechanical thrombectomy in stroke patients with large-vessel occlusion presenting within 24 hours of symptom onset. Extending the thrombectomy window to 24 hours resulted in a higher number of thrombectomies being performed. However, little is known about the impact of the extended thrombectomy window on the telestroke call burden. Methods We used the prospectively maintained database of a telestroke network covering a large geographic area in the Southeast USA. We included patients presenting between January 2015 and December 2019. We compared the characteristics and outcomes between patients who presented before and after the publication of the extended window thrombectomy trials. Results A total of 9041 patients presented with stroke-like symptoms during the study period. Of these, 4995 presented after February 2018. There was no difference in the patient demographics in both groups. However, patients in the post extended window group had a lower National Institute of Health Stroke Scale on presentation (3 vs. 4; p Discussion The number of telestroke consults nearly doubled after the publication of the extended thrombectomy window trials, with an increase in the number of thrombectomies performed. These findings have important operational implications for hospitals implementing telestroke call coverage.

Background and Purpose: The impact of the coronavirus disease 2019 (COVID-19) pandemic on stroke systems has not been systematically evaluated. Our study aims to investigate trends in telestroke consults during the pandemic. Methods: We did retrospective chart review of consecutive patients seen through a telestroke network in South Carolina from March 2019 to April 2020. We dichotomized patients to preCOVID-19 pandemic (March 2019 to February 2020) and during COVID-19 pandemic (March to April 2020). Results: A total of 5852 patients were evaluated during the study period, 613 (10.5%) were seen during the pandemic. The median number of weekly consults dropped from 112 to 77 during the pandemic, P =0.002. There was no difference in baseline features; however, Black patients were less likely to present with strokes during the pandemic (13.9% versus 29%, P ≤0.002). Conclusions: The COVID-19 pandemic has led to a significant drop in telestroke volume. The impact seems to disproportionately affect Black patients.

Background: The growth of telestroke services expanded the reach of acute stroke treatment. However, ethnic disparities in receiving such treatment have not been fully assessed. Materials and Metho...

Background: Studies show that telestroke (TS) improves rural access to care and outcome for stroke patients receiving TS services, but population health impacts of TS are not known. We examine impacts associated with South Carolina's (SC) statewide TS network on an entire state population of patients suffering acute ischemic stroke (AIS) as TS became available across SC counties. Methods: A population health study using Donabedian's conceptual model and an ecological design to describe the change observed over time in use of thrombolysis and endovascular therapy (EVT) as the SC TeleStroke Network (SCTN) diffused across SC counties. Changes in county rates of stroke mortality and discharge destination are reported. The unit of interest is the population rate for AIS patients living in a SC county. Patients’ county of residence at the time of hospitalization defined county cohorts. Relative risks were estimated using logistic regression adjusted for age >75 years. Results: Overall tissue plasminogen activator (tPA) rate was 6.28%, and EVT rate was 1.10%. Patients living where SCTN was available had a 25% higher likelihood of receiving tPA (adjusted relative risk [ARR] = 1.25, 95% confidence interval [CI] = 1.15–1.36) and lower risks of mortality (ARR = 0.91; 95% CI = 0.84–0.99) or discharge to skilled nursing (ARR = 0.93; 95% CI = 0.89–0.97). Conclusions: TS diffusion affects the structure of the health system serving a county, as well as the processes of care delivered in the emergency department; these changes are associated with measurable population health improvements. Results support a population benefit of TS implementation.

Background: Patients aged ≥80 years are often underrepresented in stroke trials. Observational studies have shown that older patients have worse outcomes compared with younger patients, but outcome...

Background: Over the past decade, tele-stroke networks have been shown to remarkably improve our ability to provide timely treatments for stroke patients. Data on the economic impact of tele-stroke networks are scarce. Our aim is to assess the economic impact associated with the adoption of tele-stroke in local, geographically defined areas in the state of South Carolina (SC). Methods: Data were extracted from SC All-payer hospital discharges database from 2014-1017. Patients included were admitted with primary diagnosis ICD-9 codes for acute ischemic stroke. SC tele-stroke tracking data was used to assign county exposure. Data was analyzed using multivariable logistic, Poisson and gamma regression models with robust error variance in Proc Genmod to estimate effects. Multiple variables were assessed including tPA treatment, mechanical thrombectomy, and cost of in-hospital and follow up care for readmissions or ED visits in patients that had tele-stroke available in-county compared to those that did not. Results: A total of 33,603 patients were included in these analyses. A total of 2,799 patients received tPA and 695 patients received mechanical thrombectomy. Estimated mean hospital payments were $13,715 (SD $15,742) for patients with tele-stroke available compared to $14,065 (SD $15,477) where tele-stroke was not available (P=0.0002). Total mean payments were significantly higher for patients without tele-stroke availability ($34,560 SD $51,049) compared to patients with tele-stroke available ($31,744, SD $45,517) (P Conclusion: Our results indicate that tele-stroke presence in geographic locations improves treatment and outcomes in patients with acute ischemic stroke and may be expected to have an economic benefit. We observed a significant population-level association between availability of tele-stroke and mean hospital payments, follow up payments, and follow up ER visit payments.

IntroductionStroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy.MethodsPatients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed.ResultsA total of seven subjects were identified. The average age was 33.2 years (range 25–38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9–28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0–5).ConclusionEVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population.

Introduction This study evaluated the impact of establishing an inpatient teleneurology consultation service alongside an already established telestroke network on the stroke transfers to the hub. The study also aimed to assess the financial impact of establishing this network. Methods Prospectively collected data on all stroke patients evaluated through our telestroke and teleneurology networks between January 2008 and March 2018 were interrogated. For all spokes (eight sites) that had both teleneurology and telestroke services, we compared the rate of transfers to the hub before and after the establishment of the teleneurology network in August 2014. The cost reduction was estimated using the Medicare 5% standard analytic files. Results A total of 4296 stroke patients were evaluated during the study period. Of these, 2493 were seen before and 1803 were seen after the implementation of the teleneurology network at the included sites. Patients in the pre-teleneurology group were older (66.4 years ( SD = 14.7 years) vs. 67.8 years ( SD = 15.1 years); p = 0.002). Otherwise, there were no differences in baseline characteristics. Patients in the pre-teleneurology group were more likely to be transferred to the telestroke hub (29.4% vs. 20.2%; p Discussion The implementation of an inpatient teleneurology network was associated with a significant reduction in the transfer rate of stroke patients to hospitals with a higher level of care and could lead to a significant cost reduction.

Objective To assess the long-term functional outcome of stroke in patients treated with mechanical thrombectomy (MT) performed during work hours (on-hours) versus after-hours, weekends, and official holidays (off-hours). Methods Data on all patients receiving MT at a comprehensive stroke center was collected between December 2014-December 2016. Our primary outcomes were the discharge and 90-day modified Rankin Scale (mRS). We developed propensity scores for off-hours treatment and used inverse probability of treatment weights to address confounding. We estimated logistic regression to assess the relationship between off-hours treatment and favorable patient outcomes. Independent variables include receiving thrombectomy during the off-hours, admission National Institute of Health Stroke Scale (NIHSS), door to groin time in minutes, age, and race. Results During the study period, 80 (41%) patients underwent thrombectomy during on-hours and 116 (59%) during off-hours. Mean age was 69.1 years for the on-hours group and 64.1 years for the off-hours group (P = .02). There were no statistically significant differences in median admission NIHSS, rate of alteplase administration, mean time from last known well to thrombectomy, rate of revascularization, and rate of hemorrhagic transformation between the 2 groups. Logistic regression analysis showed the probability of a favorable outcome at discharge (mRS ≤ 2) is 12.6 % lower for off-hours patients (P = .038, [95%CI −.25 to −.01]). For patients with a 90-day mRS (n = 117), the probability of a favorable outcome was 18.7% lower for those treated during the off-hours (P = .029, [95%CI −.36 to −.02]). Conclusions There is a higher probability of a good functional outcome in acute ischemic stroke patients who receive MT when performed during regular work hours.

BackgroundInter-hospital transfer is important in the treatment of acute stroke. We sought to assess door in to door out (DIDO) time at spoke sites, and transportation time between spoke sites and thrombectomy-capable stroke center (TSC) in 2 large, rural telestroke networks.MethodsRecords of patients treated with tissue plasminogen activator through 2 telestroke networks between March 2017 and December 2017 were reviewed. Mann–Whitney test was used to compare median times, and a generalized linear regression model was used to predict the total time of care controlling for transportation distance.ResultsEighty-five patients were included with median NIH stroke scale on presentation of 13 (interquartile range [IQR] 7–17), median door to needle time 49 minutes (IQR 40–62), and median DIDO 111 minutes (IQR 92–157). Eighteen patients (21%) underwent computed tomography angiography (CTA) at spoke prior to transportation. Median DIDO was 169 minutes for patients who received CTA before transfer, compared with 107 minutes for patients who did not (p = 0.0004). Median door-to-groin time at TSC was 68 minutes for the CTA group and 85 minutes in the non-CTA group (p = 0.832). Controlling for distance, the predicted time of care from spoke door in time to groin puncture at TSC (sDTG) is 93.68 minutes longer for patients who receive CTA prior to transport (p = 0.034).ConclusionIn the included telestroke networks, the sDTG time is longer when CTA is conducted at spoke site prior to transportation to TSC. New strategies are urgently needed to decrease sDTG when CTA is done prior to transfer to TSC.

Objective The purpose of this study is to understand the communication among care teams during telemedicine-enabled stroke consults in an ambulance. Background Telemedicine can have a significant impact on acute stroke care by enabling timely intervention in an ambulance before a patient reaches the hospital. However, limited research has been conducted on understanding and supporting team communication during the care delivery process for telemedicine-enabled stroke care in an ambulance. Method Video recordings of 13 simulated stroke telemedicine consults conducted in an ambulance were coded to document the tasks, communication events, and flow disruptions during the telemedicine-enabled stroke care delivery process. Results The majority (82%) of all team interactions in telemedicine-enabled stroke care involved verbal interactions among team members. The neurologist, patient, and paramedic were almost equally involved in team interactions during stroke care, though the neurologist initiated 48% of all verbal interactions. Disruptions were observed in 8% of interactions, and communication-related issues contributed to 44%, with interruptions and environmental hazards being other reasons for disruptions in interactions during telemedicine-enabled stroke care. Conclusion Successful telemedicine-enabled stroke care involves supporting both verbal and nonverbal communication among all team members using video and audio systems to provide effective coverage of the patient for the clinicians as well as vice versa. Application This study provides a deeper understanding of team interactions during telemedicine-enabled stroke care that is essential for designing effective systems to support teamwork.

Background and Purpose: The novel coronavirus of 2019 (COVID-19) has been associated with worse outcomes for hospitalized patients across the US and worldwide. Our study investigates the effect of the pandemic on functional outcomes for patients presenting with stroke-like symptoms in two high-volume Tele-Stroke networks. Methods: We performed retrospective chart review of 7689 consecutive patients seen through two Tele-Stroke networks (Medical University of South Carolina and Augusta University) from July 2019 through May 2020. Discharge outcomes were assessed using modified Rankin scale (mRS). We dichotomized patients to preCOVID-19 pandemic (July 2019 to February 2020) and during COVID-19 pandemic (March to May 2020). Results: During COVID, a higher percentage of patients received intravenous tissue plasminogen activator (tPA) (14.2% vs 11.3% before, p=0.001), despite a similar baseline NIHSS. Also, patients during the pandemic had a shorter symptom-onset to hospital door time (288 vs 353, P=0.012). Demographics were similar between groups, other than older age in patients presenting during COVID (66.02 vs 65.15 before, p=0.04) (table 1). During the pandemic, a higher percentage of patients had a poor functional outcome, as defined by mRS 3-6 (35.7% vs 30% before, p=0.012), and a higher percentage died or were discharged to hospice (7.0% vs 5.1%, p=0.000). Conclusions: Despite earlier ED presentation and increased tPA administration, our results demonstrate worse discharge outcomes during the pandemic in two large telestroke networks. Changes in workflow and resulting delays during COVID-19 may explain these findings.

Introduction: It is well established that mechanical thrombectomy (MT) improves functional outcome in stroke patients with a large vessel occlusion and salvageable brain tissue. In this study, we evaluate the impact of transportation mode on outcomes of patients undergoing MT. Methods: The prospectively maintained data from medical charts of consecutive patients transferred to a single comprehensive stroke center (CSC) for thrombectomy from January 2017 to December 2019 was reviewed. Clinical outcome was measured at a 90-day follow up with National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Multivariate logistic regression analysis was used to assess the relationship between helicopter transportation and favorable 90-day outcome in MT patients. Results: A total of 135 MT patients underwent the procedure following interhospital transfer by helicopter or ground ambulance. 60/135 (44%) of the patients were transferred by air. On univariate analysis there was no significant differences in age (median of 66 vs. 68 years; p=0.23), sex (31% vs. 36% men; p=0.605) or race (31% vs. 44% white; p=0.344) between the air vs. ground groups. Also, baseline NIHSS did not differ (95% CI 12.0-15.69 vs. 14.06-17.31; p=0.136). Total of 56 (41.5%) patients received tissue plasminogen activator (tPA) (25 air vs. 31 ground; p=0.97) and the overall door to groin time was similar in both groups (85.17 vs. 83.96 minutes; p=0.86). NIHSS at 90-day follow up was significantly lower in those taken by helicopter compared to ground transit (95% CI 4.60-11.26 vs. 11.50-17.61; p=0.015). Air transportation was independently associated with good long-term functional outcome on multivariable logistic regression after controlling for age, sex, race, tPA and transportation time (OR 3.757 95% CI 1.23-11.4; p=0.02). Conclusions: Air transportation in MT patients was independently associated with better long-term functional outcome. The association between helicopter transit and long-term function is shown to be independent of transit time.

Faster treatment times are associated with improved outcomes in patients with acute ischemic stroke. In this prospective pilot study, we assess the feasibility of initiating telestroke consultation in emergency medical services unit (TEMS).Patients with stroke symptoms were evaluated via TEMS using a video-call with a stroke provider. After TEMS evaluation, patients were transferred to the nearest stroke center (NSC) or thrombectomy capable center (TCS) depending on stroke severity and symptom onset time. We compared time metrics between patients evaluated via TEMS to those via standard telestroke (STS) consultation.49 patients were evaluated via TEMS between May 2017 and March 2020. Median age was 66, 24 (49%) were females, 15 (30.6%) received intravenous alteplase (tPA) after arrival to a local hospital, and 3 (6.1%) underwent mechanical thrombectomy (MT) after bypassing the NSC. Compared to 52 tPA patients treated through STS consultation, TEMS patients had shorter door to needle (DTN) time (21 vs. 38 min, p 0.001). In addition, patients who received MT after bypassing the NSC had shorter onset to groin time compared to those transferred from NSC (216 vs. 293 min, P = 0.04).Prehospital stroke triaging using TEMS is feasible, and could result in shorter DTN and onset to groin times.

Background The safety and efficacy of dual antiplatelet use for symptomatic intracranial atherosclerosis beyond 90 days is unknown. Data from SAMMPRIS was used to determine if dual antiplatelet therapy (DAPT) beyond 90 days impacted the risk of ischemic stroke and hemorrhage. Methods This post hoc exploratory analysis from SAMMPRIS included patients who did not have a primary endpoint within 90 days after enrollment (n = 397). Patients in both the aggressive medical management (AMM) and percutaneous transluminal angioplasty and stenting (PTAS) arms were included. Baseline features and outcomes during follow-up were compared between patients who remained on DAPT beyond 90 days (on clopidogrel) and patients who discontinued clopidogrel and remained on aspirin alone at 90 days (off clopidogrel) using Fisher's exact tests. Results The stroke rate was numerically lower in the group on clopidogrel vs off clopidogrel among both the AMM alone arm (6.0% versus 10.8%, p = 0.31) and the PTAS arm (8.7% versus 9.8%; p = 0.82), but the difference was not significant. The major hemorrhage rates were numerically higher in the group on clopidogrel vs. off clopidogrel group among both the AMM alone arm (4.0% versus 2.5%; p = 0.67) and the PTAS arm (10.9% versus 3.5%; p = 0.08), but were not significant. Conclusion This exploratory analysis suggests that prolonged DAPT use may lower the risk of stroke in medically treated patients with intracranial stenosis but may increase the risk of major hemorrhage.

Introduction: Recently, two randomized controlled trials proved the safety and efficacy of mechanical thrombectomy in patients presenting up to 24 hours from symptom onset. While the number of patients receiving mechanical thrombectomy has increased following the publication of the extended time window trials, the literature on acute stroke calls over telestroke is relatively scant. In this study we evaluate the volume of telestroke calls, rate of transfers to the thrombectomy center and MT receipt before and after the extended window MT trials publication. Methods: We interrogated the prospectively collected data from a major telestroke network in Southeast the United States to include patients who received a telestroke consult between January 2015 and July 2019. We compared the demographical and clinical characteristics and the outcomes between patients who presented before and after the publication of the extended window mechanical thrombectomy trials. Results: Total of 7,438 patients were evaluated during the study period. Of those, 3392 were after February 2018. There was no difference in age, race, or sex between the two groups (table 1). Patients in the post extended window group had lower National Institute of Health stroke scale (NIHSS) on presentation (3 vs. 4, P Conclusion: The number of telestroke consults almost doubled since the publication of the extended thrombectomy trials without increase in the rate of MT receipt. These findings have important operational implications for hospitals implementing telestroke call coverage.

Introduction: Clinical trials have proven the safety and efficacy of mechanical thrombectomy (MT) with intravenous alteplase (tPA) compared to tPA alone in patients presenting with large vessel occlusion (LVO). The impact of tPA prior to MT on procedural metrics, successful revascularization, symptomatic hemorrhage and long-term functional outcome has not been established from large scale real-world studies. In this study we evaluate the impact of tPA prior to MT on procedural times, immediate and long-term outcomes. Methods: The STAR registry combined prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe and Asia. Patients who received mechanical thrombectomy with or without intravenous tPA prior to MT were included in these analyses. Baseline characteristics, procedural time, successful revascularization (TICI ≥ 2B), symptomatic intracranial hemorrhage (PH2), and long-term functional outcomes were compared between the two groups. Results: Total of 1869 patients were included in this analysis. Of those, 907 received tPA prior to MT. Baseline features and outcomes are summarized in table 1. There were more white patients in the non-tPA group, and more patients in this group had atrial fibrillation and hyperlipidemia; otherwise there were no differences in baseline features between the two groups. Median NIHSS on admission was 16 in both groups, median ASPECTS was 9 in the tPA group versus 8 in the non-tPA group, p=0.208. Patients in the tPA group had higher rate of successful revascularization, lower number of revascularizations attempts and were more likely to achieve excellent long-term functional outcome. There was no difference in procedural time, rate of symptomatic hemorrhage or length of hospital stay. Conclusion: Bridging therapy with intravenous tPA prior to mechanical thrombectomy may facilitate MT and yield to better long-term functional outcome.

Background and Purpose: In spite of the increase of thrombolysis treatment rates at remote hospitals (spoke) due to implementation of telestroke systems, only 25% of telestroke patients who received tissue plasminogen activator (tPA) are transferred to a Comprehensive Stroke Center (CSC) in the United States. This leaves 3 out of 4 treated patients to receive their post-stroke care at telestroke spoke sites. As post-stroke rehabilitation is a pivotal component of recovery, we aimed to report outcomes of acute ischemic stroke (AIS) patients who received thrombolytic therapy, yet remained at a spoke hospital with a rehabilitation unit (RU). Methods: This was a retrospective review of the telestroke registry at our institution from January 2016 through July 2019. We included patients who received intravenous tPA at spoke sites and were not candidates to be transported to a CSC for mechanical thrombectomy (Drip-and-Stay paradigm). We compared baseline characteristics, discharge disposition, and excellent outcome [defined as a 90-day Modified Rankin Scale (mRS) of 0-1] of patients who remained at spoke sites with a RU to patients at spoke sites without a RU. A logistic regression model was used to assess the effect of RU on the possibility of having excellent outcomes controlling for confounding factors. Results: Of the 740 eligible AIS patients during the study period, 40% (n=294) received post-stroke care at a spoke with a RU. There were no significant differences in patient age, sex, admission NIHSS, door to needle times, or length of stay between patients in both groups. More patients in the spoke with rehabilitation units were discharged home (62% vs. 52%, P=0.001). Excellent long-term functional outcome was reported in 66% (n=193) of patients remaining at spoke sites with RU versus 58% (n=285) at those without RU (P=0.033). On multivariate analysis, RU was an independent predictor of having excellent outcomes (OR 2.02, 95% CI 1.42-2.87, P Conclusions: Our study indicates a higher likelihood of both favorable discharge outcome and excellent long-term functional outcome in drip-and-stay patients who receive their post-stroke care at spoke sites with RU.

BackgroundIn response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.MethodsA prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.Results458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (PConclusionWe observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

Telemedicine implementation in ambulances can reduce time to treatment for stroke patients, which is important as "time is brain" for these patients. Limited research has explored the demands placed on acute stroke caregivers in a telemedicine-integrated ambulance system. This study investigates the impact of telemedicine on workload, teamwork, workflow, and communication of geographically distributed caregivers delivering stroke care in ambulance-based telemedicine and usability of the system. Simulated stroke sessions were conducted with 27 caregivers, who subsequently completed a survey measuring workload, usability, and teamwork. Follow-up interviews with each caregiver ascertained how telemedicine affected workflow and demands which were analyzed for barriers and facilitators to using telemedicine. Caregivers experienced moderate workload and rated team effectiveness and usability high. Barriers included frustration with equipment and with the training of caregivers increasing demands, the loss of personal connection of the neurologists with the patients, and physical constraints in the ambulance. Facilitators were more common with live visual communication increasing teamwork and efficiency, the ease of access to neurologist, increased flexibility, and high overall satisfaction and usability. Future research should focus on eliminating these barriers and supporting the distributed cognition of caregivers.

Introduction: A significant proportion of acute ischemic stroke (AIS) patients who are evaluated through telestroke consultation are transferred to thrombectomy-capable stroke centers (TSCs) for concern of large vessel occlusion (LVO). Patient triage selection is commonly based on the clinical suspicion of LVO, which lacks specificity and could result in unnecessary transfers. In this study, we aimed to assess the accuracy of the most commonly used LVO recognition scales in telestroke setting. Methods: AIS patients transferred to TSCs for suspicion of an LVO were included in this retrospective study. Patients were evaluated by a stroke neurologist through a telestroke consult before transfer. The National Institute of Health Stroke Scale (NIHSS) score documented by the stroke neurologist was retrieved from medical records and used to calculate five other LVO recognition scales (Rapid Arterial Occlusion Evaluation Scale [RACE], Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Cincinnati Prehospital Stroke Severity Scale [CPSSS], 3-item stroke scale [3I-SS], and Prehospital Acute Stroke Severity Scale [PASS]). We calculated the sensitivity, specificity, accuracy, positive and negative predictive values, false positive rate (FPR), and false negative rate (FNR) of each score using published cutoffs and then examined all possible cutoff values for each of these scales in addition to the NIHSS. Results: A total of 439 patients were included in the final analysis. A total of 48.5% of patients had an LVO confirmed on computed tomography angiogram. RACE score had the highest accuracy (78%). Overall, the five derived LVO recognition scores have at least 10% FNR. When examining all possible cutoff values, the NIHSS (cutoff of 6) had a 3% FNR but 73% FPR (false transfer). Conclusion: The use of the NIHSS and other LVO recognition scores over telestroke may result in unnecessary transfers. Better diagnostic tools that could maximize sensitivity with acceptable specificity are urgently needed.

Background: A “U-shaped” relationship between admission blood pressure (BP) and mortality (wherein patients within a middle range have better outcomes than patients at higher or lower extremes) in ...

ObjectiveTo evaluate the long-term functional outcome of interhospital transfer of patients with stroke with suspected large vessel occlusion (LVO) using Helicopter Emergency Medical Services (HEMS).MethodsRecords of consecutive patients evaluated through 2 telestroke networks and transferred to thrombectomy-capable stroke centers between March 2017 and March 2018 were reviewed. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to address confounding factors. Multivariate logistic regression analysis with IPTW was used to determine whether HEMS were associated with good long-term functional outcome (modified Rankin scale score ≤ 2).ResultsA total of 199 patients were included; median age was 67 years (interquartile range [IQR] 55–79 years), 90 (45.2%) were female, 120 (60.3%) were white, and 100 (50.3%) were transferred by HEMS. No significant differences between the 2 groups were found in mean age, sex, race, IV tissue plasminogen activator (tPA) receipt, and thrombectomy receipt. The median baseline NIH Stroke Scale score was 14 (IQR 9–18) in the helicopter group vs 11 (IQR 6–18) for patients transferred by ground (p = 0.039). The median transportation time was 60 minutes (IQR 49–70 minutes) by HEMS and 84 minutes (IQR 25–102 minutes) by ground (p < 0.001). After weighting baseline characteristics, the use of HEMS was associated with higher odds of good long-term outcome (OR 4.738, 95% CI 2.15–10.444, p < 0.001) controlling for transportation time, door-in-door-out time, and thrombectomy and tPA receipt. The magnitude of the HEMS effect was larger in thrombectomy patients who had successful recanalization (OR 1.758, 95% CI 1.178–2.512, p = 0.027).ConclusionsHEMS use was associated with better long-term functional outcome in patients with suspected LVO, independently of transportation time.

Background: The need for neurologists has been steadily increasing over the past few years. The implementation of teleneurology networks could serve as a potential solution to this need. Methods: A retrospective review of the Medical University of South Carolina (MUSC) Teleneurology records for all consults performed between August 2014 and July 2018 was conducted. Collected data included number of consults, baseline characteristics, final diagnosis, and number of providers and hospitals over the study period. Results: A total of 4,542 Teleneurology consults were performed during the study period. The most common diagnosis was cerebrovascular disease, followed by seizure disorders. The number of consults per month increased throughout the study period from three in August 2014 to 257 in July 2018. The number of community hospitals covered has increased from 3 hospitals in August 2014 to 14 hospitals throughout the state of South Carolina in July 2018. Conclusion: Over 4 years, the MUSC teleneurology program has evolved into a robust partnership with 14 partner hospitals, and is now delivering more than 250 expert neurology consultations monthly to patients throughout the state of South Carolina.

Introduction: While more spokes are now capable of taking care of post-tPA patients, little is known, however, about long term functional outcome of those patients. In this study, we aim to compare long-term outcome for patients who received tPA at a telestroke spoke and remain at the spoke (drip-and-stay) to those patients who received tPA at a spoke and were transferred to the telestroke hub (drip-and-ship). Methods: This is a retrospective review of prospectively collected data on patients who received tPA through the Medical University of South Carolina (MUSC) telestroke program between January 2016 and March 2018. Collected data included age, sex, race, admission NIH stroke scale, door to needle time (DTN), and long-term outcomes measured by modified Rankin Scale (mRS) at 90 days. Patients who were transferred to the telestroke hub because of suspected large vessel occlusion were excluded from the study. Descriptive statistics were used to compare patient demographics and clinical outcomes across the two groups. Generalized linear regression model was used to assess the effect of the drip-and-ship paradigm on 90-day mRS controlling for baseline characteristics. Results: Total of 517 patients were identified (410 drip-and-stay and 107 drip-and-ship). Baseline characteristics are summarized in table 1. Drip-and-stay group had higher percentage of women (60%) as compared to the drip-and-ship group (46.7%) (P=0.013). mRS of 0-2 at 90 days was achieved in 323 patients (78.8%) in the drip-and-stay and in 80 patients (74.8%) in the drip-and-ship group (P=0.372). Regression analysis showed no difference in the adjusted relative risk of having 90-day mRS ≤2 between drip-and-stay and drip-and-ship patients (RR 0.95, p=0.365, 95% CI [0.05-1.1]). Conclusion: In our study, no difference was found in the long-term functional outcome for telestroke patients who were treated under drip-and-stay paradigm when compared to the drip-and-ship paradigm

Background: Faster door to needle (DTN) times has been shown to lead to better functional outcome in patients with acute ischemic stroke. The implementation of telestroke networks has improved access to intravenous alteplase (tPA). In this study, we aim to compare DTN time between of tPA administered through telestroke in primary stroke center (PSC) spokes versus non-PSC spokes. Methods: A retrospective review of prospectively collected data on patients who received tPA through the Medical University of South Carolina telestroke program between July 2016 and March 2018. Collected data included baseline characteristics, baseline NIH stroke scale, door to CT times, door to telestroke consult time, symptom-onset to needle time, time between tPA decision and tPA administration, door to needle time, and 90-day modified Rankin scale (mRS). Wilcoxon Rank-sum (Mann-Whitney) test was used to compare median times between different groups. Results: During the study period, 399 patients received tPA through our telestroke network (314 received tPA at PSC spokes, and 85 received tPA at non-PSC spokes). PSC patients had more females (61.2%) compared to non-PSC patients (48.2%) (P=0.032). Other baseline characteristics including age and race were similar between both groups. Median NIHSS was 6 for both groups (IQR 4-9) (P=0.59). Mean times for all procedure measures were longer in non-PSC spokes; Door to CT: 8 min Vs. 5 min (P=0.029), Door to telestroke consult: 24 min Vs. 20.5 min (P=0.017), Symptom-onset to needle: 150 min Vs. 122 min (P=0.001), tPA decision to tPA administration: 20 min Vs. 10 min (2 ) in the PSC group (79.1% and 75.7% of patients in PSC and non-PSC respectively, P=0.054) Conclusion: In our study, PSC spokes had better performance in the procedural measures for tPA administration than non-PSC spokes. Further research is needed to study the trend of these measures over time and to study the effect on the long-term functional outcome.

Introduction: Improving time to t-PA decision and door to needle times (DTN) is a sought after phenomenon in telestroke workflows. Timely interventions of ischemic stroke patients have shown to significantly improve outcomes and quality of life. With the goal of decreasing door to need times in the state , one academic medical center partnered with a community hospital and an EMS unit to explore the efficacy and feasibility of placing telestroke systems into the pre-hospital setting. Methods: An EMS unit was equipped with telehealth technology and software modalities. Stroke patients were identified in the 9-1-1 setting and a telestroke consultation was initiated by paramedics to connect to local hospital providers and neuro-specialists. An EMS algorithm was developed to capture patient medical history and assessments for expedited decision making. Upon arrival to the local emergency department, paramedics transported patients directly to radiology and t-PA was mixed, prepped, and ready for administration, if applicable. Data, generated from the telehealth platform, was analyzed to compare DTN times and door to t-PA decision times to stroke patients treated under the current protocols at the same facility. Statistical comparison included median time to treatment using the Wilxocon Rank Sum. Results: Between May 2017 and June 2018, 25 patients were eligible for and received tPA. Three patients (12%) were in the EMS intervention group and 22 (88%) received traditional care. Median door-to-decision time for traditional care patients was 33 minutes (IQR 28-42) and 13 minutes for EMS intervention patients (IQR 2-21) (p=0.0151). Median DTN time was 40 minutes (IQR 30-48) for traditional care versus 23 minutes (IQR 20-33) for EMS patients (p=0.12). Conclusion: Initiating telestroke consults in an EMS unit is a promising way to improve t-PA decision times thus reducing door to needle times. Further partnerships with local EMS and community hospitals is warranted to evaluate multiple telestroke consultations and t-PA decisions. An additional focus on cellular data and connectivity in rural areas is also necessary to activate the consult and begin assessing the emergent stroke patients.

Background: The majority of acute stroke patients eveluated through telestroke end up being transferred to the hub for further care; this is largely due to the unavailability of a neurologist on site at spokes. In this study, we investigate the impact of implementing a teleneurology program with an already established telestroke program on the rate of transfers to the hub. Methods: This is a retrospective review of the medical records of patients evaluated through the Medical University of South Carolina telestroke network between January 2008 and March 2018. Only patients presenting to telestroke sites that later joined the MUSC teleneurology consultation program were included. Collected data included age, sex, race, NIHSS on arrival, tPA administration, whether patients were seen in the referring hospital before or after establishing the teleneurology program. Chi-square and t-tests were used to compare differences among categorical and continuous variables, respectively. Multivariable logistic regression was used to examine the relationship between presenting with acute stroke after the establishment of teleneurology program and the odds of being transferred to the hub, controlling for patient baseline characteristics. Results: A total of 4296 patients were included (2493 patients before the establishment of the teleneurology program and 1803 patients after that). Mean age was 66.4 (SD 14.7) years and 67.8 (SD15.1) in both groups respectively (P=0.002). No difference was found in sex distribution or mean admission NIHSS on admission between both groups. Patients who presented after the establishment of the teleneurology network were less likely to be transferred to the hub (transfer rate 20.2% Vs. 29.4% before telestroke, P Conclusion: The implementation of a teleneurology program has allowed stroke patients to receive continuous neurologic care while remaining at spokes. This could reduce the number of unnecessary transfers to a the hub

Introduction: Time of presentation to the emergency department may affect the door to needle time (DTN) and could subsequently affect long-term outcome in acute ischemic stroke (AIS) patients assessed via telestroke. In this study, we evaluate whether DTN times and long-term functional outcome differ among AIS patients treated with IV tPA via telestroke during on-hours versus off-hours. Methods: All patients who received IV tPA through the Medical University of South Carolina telestroke network between January 2016 and December 2017 were analyzed. Primary outcome was 90-day Modified Rankin Scale (mRS), with mRS ≤2 considered a good functional outcome. Independent variables included time of presentation, age, race, sex, admission NIHSS, symptom onset to needle, and door to needle time. On-hours were defined as 8am-5pm Monday-Friday, and off-hours were 5pm-8am Monday-Friday, weekends and holidays. Chi-square and t-tests were used to compare differences among categorical and continuous baseline variables, respectively. Multivariable logistic regression was used to examine the relationship between tPA delivery time and 90-day mRS, adjusting for patient baseline characteristics. Results: During the study period, 223 (39%) AIS patients received IV tPA during on-hours and 349 (61%) during off-hours in our telestroke network. Baseline characteristics were similar, except that the off-hours group had more white patients (P=0.04), and longer tPA decision to administration time (P=0.006). On-hours mean DTN time was 57.3 minutes, as compared to 63.2 minutes during off-hours (P=0.017). Primary outcome was similar between the two groups (OR 1.088, 0.687-1.722). Conclusions: AIS patients who presented during off-hours and received tPA had a longer DTN time, but comparable long-term outcome after IV thrombolysis in our telestroke network. The findings need validation in other telestroke cohorts, with the aim of providing consistent 24-hour telestroke care.

Introduction: Telestroke has expanded access to acute stroke care. Time of presentation to the emergency department affects the door to needle time (DTN) and may subsequently affect long-term outcome in acute ischemic stroke (AIS) patients assessed via telestroke. In this study, we assess whether DTN times and long-term functional outcome differ among AIS patients treated with IV tPA via telestroke during on-hours versus off-hours. Methods: All patients who received IV tPA through the Medical University of South Carolina telestroke network between January 2016 and December 2017 were analyzed. Primary outcome was 90-day Modified Rankin Scale (mRS), with mRS ≤2 considered a good functional outcome. Independent variables included time of presentation, age, race, sex, admission NIHSS, symptom onset to needle, and door to needle time. On-hours were defined as 8am-5pm monday - friday, and off-hours were 5pm-8am Monday-Friday, weekends and holidays. Chi-square and t-tests were used to compare differences among categorical and continuous baseline variables, respectively. Multivariable logistic regression was used to examine the relationship between tPA delivery time and 90-day mRS, adjusting for patient baseline characteristics. Results: During the study period, 223 (39%) AIS patients received IV tPA during on-hours and 349 (61%) during off-hours in our telestroke network. Baseline characteristics were similar, except that the off-hours group had more white patients (P=0.04), and longer tPA decision to administration time (P=0.006). On-hours mean DTN time was 57.3 minutes, as compared to 63.2 minutes during off-hours (P=0.017). Primary outcome was similar between the 2 groups (OR 1.088, 0.687-1.722). Conclusion: AIS patients who presented during off-hours and received tPA had a longer DTN time, but comparable long-term outcome after IV thrombolysis in our telestroke network. The findings need validation in other telestroke cohorts, with the aim of providing consistent 24-hour telestroke care.

Background: Telestroke has significantly improved acute stroke care in intensive care and inpatient settings, but post discharge care has been lacking and fragmented resulting in poor secondary stroke prevention, post-stroke complications, and inadequate patient education. Immediate need for stroke follow up ignited the development of telemedicine outpatient stroke clinics led and managed by nurses and nurse practitioners. Nurses identified these gaps and advocated for telestroke clinics in rural areas. Purpose: The purpose of this program was to develop a nurse led telemedicine outpatient stroke clinic and improve access to expert neuro consults. Methods: Through affiliate relations with healthcare facilities and nurse advocacy, the continuity of stroke care in local communities was expanded to 2 telemedicine outpatient clinics. A specialized nurse practitioner was credentialed, privileged, and trained to conduct telemedicine appointments. Telehealth nurse coordinators trained clinics on the neurological assessment and telepresenter role. Data was analyzed assessing appointment compliance rates, miles saved, and cost of travel. Results: Between October 2017 and August 2018, 48 patients were seen at nursing led telestroke outpatient clinics. Data showed a decrease in no show appointments from fiscal year 2016 (16.29%) to 2018 (15.3%). On average, patients saved 5896 miles round trip (122.8 miles per patient) and saw a cost savings of $655.11 in gas (at $2.50/gallon). Community facilities received downstream revenue from ancillary studies; however, coordinating pre appointment scans initially exhibited interruptions in patient care. Further challenges included training clinicians on technology platforms, while simultaneously assisting remote neuro specialists with hands on patient assessments. Conclusion: Nursing advocacy for the development of telestroke outpatient clinics has shown promising improvements in no show appointment rates, increased access to specialty care, and reduction in travel burdens. Further growth and expansion of telemedicine outpatient clinics by nurses is essential in providing a holistic approach for specialized patient care and empowering nurses to be an advocate in the continuum of stroke care.

Objective: The purpose of this study is to compare long-term functional outcome for patients who receive intravenous alteplase (tPA) at a primary stroke center (spoke) through telestroke c...

Intravenous tissue plasminogen activator (tPA) remains the cornerstone medical treatment for acute ischemic stroke. The establishment of telestroke technology has allowed patients presenting to hospitals that lack expert stroke care to be evaluated and receive tPA. The safety of tPA administered through telestroke has been evaluated only when tPA is given within the 3-h window of last known normal. The purpose of this study is to evaluate the safety of tPA when administered through telestroke within a 4.5-h window.A retrospective analysis on the prospectively collected database for all patients who received tPA at the Medical University of South Carolina Comprehensive Stroke Center (MUSC) (hub), as well as the MUSC telestroke network partner hospitals (spokes), was performed. Collected data included demographics, baseline characteristics, time from last known well to tPA administration, and symptomatic intracerebral hemorrhage (sICH) rates. Logistic regression was used to examine the odds of a sICH in patients at spoke sites compared with the hub controlling for patient stroke severity, gender, age, and race.A total of 830 patients were identified. Median National Institute of Health Stroke Scale was significantly higher among patients treated at the hub (9 vs. 8, p = 0.013), and the hub treated a higher percentage of nonwhite patients (p = 0.039). sICH occurred in 27 (4.8%) in the spoke group and 10 (3.8%) in the hub group (p = 0.523). Logistic regression results found no significant difference in the odds of sICH if tPA is given in a spoke site.Our study shows similar rates of sICH when intravenous tPA is administered at spokes through telestroke network compared with the hub.

Background: Stroke telemedicine has the potential to improve access to intravenous thrombolysis nationwide among acute ischemic stroke (AIS) patients. No formal training or credentialing process has been established nationally for neurologists to provide telestroke care. Our academic Remote Evaluation of Acute Ischemic Stroke (REACH) program has been delivering telestroke care for almost 10 years. Every telestroke provider neurologist undergoes a training curriculum prior to providing telestroke care. Aim: 1. To demonstrate safety of IV tPA in AIS patients treated via telestroke. 2. To assess impact of acute stroke training curriculum by comparing safety outcomes in patients treated by fellowship trained stroke neurologists (FTSN) versus other neurologists (ON). Methods: All REACH consults from May 2008 to July 2017 were included in our analysis. Patients were classified based on whether remote evaluation was performed by FTSN or ON. Symptomatic ICH (sICH), asymptomatic ICH (aICH), and any ICH rates were determined overall, and in the 2 groups. Fisher’s exact test and Wilcoxon rank-sum test were used to compare categorical variables and continuous variables respectively. Results: Total number of telestroke consults performed were 10,904 (7644 by 12 FTSN and 3260 by 13 ON respectively). IV tPA was given to 1446 (18.91%) patients in FTSN and 569 (17.45%) patients in ON group respectively (p=0.07). Symptomatic ICH occurred in 59 (2.92%) patients overall, and was comparable between the two groups [42 (2.90%) vs 17 (2.98%), p-value 0.88]. Asymptomatic ICH occurred in 121 (6%) patients, 77 (5.32%) of whom were in FTSN group and 44 (7.73%) patients in ON group (p-value 0.04). Any ICH occurred in 180 patients, 119 (8.22%) and 61 patients (10.72%), p-value 0.08 respectively. Discussion: Our study demonstrates safety of IV tPA delivery via telestroke in AIS patients. There were no differences in IV tPA administration, sICH and any ICH rates between FTSN and ON providers, but the aICH rate was higher among ON. The comparable safety outcomes between ON and FTSN in our study are likely attributed to an AIS training curriculum at credentialing. National standardized credentialing training curricula for telestroke providers may help improve outcomes in AIS patients.

Background: Intravenous thrombolysis in acute ischemic stroke patients (AIS) via telestroke (TS) is safe and effective, with comparable functional outcomes to patients treated at academic stroke centers. However, the association between demographic, clinical and TS logistic factors and functional outcome at 3 months in TS patients has not been studied. Identification of TS specific predictors of good outcome may guide future strategies of care delivery. Aim: To determine demographic, clinical, and TS logistic variables associated with 90-day functional outcome in AIS patients treated with IV tPA via TS. Methods: We retrospectively analyzed all TS consults treated with IV tPA between January 2016-July 2017 in our state-wide telestroke network. Patients who underwent endovascular intervention were excluded. Fisher exact and χ 2 test for categorical and Student t test for continuous variables with a significance level of Results: tPA was given to 400 AIS patients via TS. Functional outcome at 90 days was obtained in 94.3% patients. Mean age was 66.8 years and 62% patients were Caucasian. Median NIHSS on presentation was 7. Medical history included hypertension (72%), diabetes (36%), hyperlipidemia (25%), atrial fibrillation (AF) (11%), and CHF (5%). Mean “onset to needle” time was 138.4 minutes(min) and mean “door to needle time” was 61.4 min. Mean “door to login” time was 26.2 min, and mean “login to tPA” time was 19.7 min. Symptomatic ICH and asymptomatic ICH occurred in 15 (5.98%) and 28(11.3%) respectively. Younger age, lower NIHSS at presentation, lower door to login time, and absence of AF and CHF were associated with higher odds of good functional outcome at 90 days in univariate analyses. In multivariate logistic regression, age (OR 0.75, 95% CI 0.67-0.84) and NIHSS at presentation (OR 0.85, 95% CI 0.82-0.89) remained independent predictors. Discussion: Younger patients and patients with low NIHSS at presentation are more likely to have good outcome post IV tPA treatment via TS. Larger studies powered to measure the impact of TS delivery variables on functional outcome are needed.

Background: Prompt evaluation and management of patients having a transient ischemic attack (TIA) with the ABCD2 triage score has been shown to decrease the risk of stroke and potentially life-long disability. However, creating an organized, well-coordinated approach that provides rapid access for patients is a challenge at many high-volume stroke centers. Purpose: We sought to determine the feasibility of a nurse practitioner (NP)-led Rapid Access Care Execution for Transient Ischemic Attack (RACE-TIA) Clinic as part of an Outpatient Stroke Nurse Practitioner Clinic. Methods: Our RACE-TIA Clinic Algorithm uses ABCD2 score triaging, and outlines the care process for TIA patients who present either through the Emergency Department (ED), Outpatient Clinic or via telephone triage. Patients with possible TIA are triaged using the ABCD2 tool. Those who present to the ED are evaluated by a member of the Acute Stroke Team and patients with a score ≥ 3 remain in the ED Clinical Decision Unit (CDU) for evaluation. Patients with a score < 3 are scheduled in the RACE-TIA Clinic staffed by two stroke-trained NPs. Referrals to the RACE-TIA clinic from the electronic medical record (EMR) referral or the dedicated phone line are triaged by a registered nurse who was trained to complete the ABCD2 scoring. All appointments are scheduled within 24-48 hours of receiving a referral. Results: Since initiating the RACE-TIA Clinic Algorithm in January 2017 a total of 20 patients were seen as outpatients for TIA evaluation. Six patients were directly referred to the RACE-TIA Clinic for acute TIA evaluation and of those, 5 were referred from the ED and 1 from a primary care office. Another 14 patients were scheduled for follow-up after having an initial TIA evaluation at either an outside hospital (3), the ED (2), ED CDU (3) or after inpatient hospitalization (6). The average time from referral to clinic visit was 34 hours. Conclusion: Our NP-led RACE-TIA Clinic has successfully evaluated patients with low risk TIA in the outpatient setting in a timely way and also provided close follow-up for high risk TIA patients after the acute evaluation without expanding or duplicating existing resources.

Background: Mechanical thrombectomy is the standard of care for patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Recent studies have shown that door to reperfusion time is longer during nighttime and weekends. In this study we examine the long term functional outcome of stroke patient treated with mechanical thrombectomy performed during work hours (on-hours) versus after hours (off-hours). Methods: Data on all patients receiving mechanical thrombectomy at a comprehensive stroke center between Dec/2014 and Dec/2016 was collected. Our primary outcome was the 90-day Modified Rankin Scale (mRS). Independent variables included receiving thrombectomy during on-hours (7am and 4pm) or off-hours 4pm-7am, weekends, and official holidays), admission NIH stroke scale, age, race, and sex. Multivariable logistic regression was used to examine the relationship between off-hours thrombectomy and mRS, controlling for patient baseline characteristics. Chi-square and t-tests were used to compare differences among categorical and continuous variables. Results: During the study period, 92 (41%) patients underwent thrombectomy during on-hours and 133 (59%) during off-hours. On average, the on-hours patients were older (P=0.02), and had a higher percentage of males (P=0.04) compared to the off-hours. Differences in median admission NIHSS, rate of tPA administration, location of occlusion, mean time from last known well to thrombectomy, revascularization rates, and hemorrhagic transformation rates were not statistically significant between the two groups. Median door to groin time was 53 minutes versus 78 minutes for the on-hours and off-hours groups respectively (P= < 0.00). Logistic regression showed that the odds of a favorable mRS ≤2 are 47% lower for off-hours patients compared to patients seen during on hours (OR 0.53, P=0.044, [95%CI 0.28-0.98]). Additional significant predictors included, age (OR 0.97 [CI.95-.99]) and admission NIHSS (OR 0.9 [CI.87-.94]). Conclusion: Our study shows that there is higher likelihood of good functional outcome following mechanical thrombectomy when performed during work hours. This could be due to a prolonged door to groin time.

Background: Intravenous alteplase (rtPA) is a proven treatment for acute ischemic stroke. The implementation of telestroke networks increases access to expert stroke care and rtPA administration. Previous studies showed that faster door to needle time (DTN) leads to a better functional outcome; however DTN has been shown to be longer over telestroke when compared to that at a comprehensive stroke center. The purpose of this study is to compare the long term functional outcome of rtPA when administered at spoke hospitals through telestroke consultations to that at the comprehensive stroke center (hub). Methods: Data on baseline characteristics and long-term outcomes for all patients evaluated at the Medical University of South Carolina (MUSC) and MUSC telestroke network between January 2016 and March 2017 were collected. Eligible patients received rtPA at either the spoke or hub location during the study period. Data sources included registry data collected from telestroke consultations at 22 different spokes in South Carolina and electronic medical record data for patients at one hub. Patients who received mechanical thromectomy were excluded from the study. Functional outcome was assessed with 90 day Modified Rankin Scale (mRS). To predict the odds of a low category mRS for spoke patients compared to hub, adjusting for patient stroke severity (NIHSS), door to needle time, age, sex, and race, we estimated a logit model. T-tests and Chi-squared were used to examine the differences in continuous and categorical patient variables. Results: Total of 426 were identified (60 hub and 366 spoke patients). There were no significant differences in patient age, sex, admission NIHSS, or door to needle times between the two groups. More patients (55%) were white in the hub group compared to (61.8%) in the spoke group (P=0.02). mRS of 0-2 at 90 days was achieved in 37 (61.7%) of the hub and in 255 (69.7%) in the spoke patients (P=0.216). On logistic regression, there was no difference in the adjusted odds of having a lower mRS between spoke and hub patients (OR 1.75, p=0.104, 95% CI [0.89-3.37]). Conclusion: Our study shows no difference in the long-term functional outcome for rtPA when administered at spokes through telestroke compared to that at the hub.

Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. Methods We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). Results The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P

Background and Purpose— In the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times), patients with large vessel occlusions and small infarct cores identified with computed tomography (CT)/CT angiography were randomized to endovascular therapy or standard of care. CT perfusion (CTP) was obtained in some cases but was not used to select patients. We tested the hypothesis that patients with penumbral CTP patterns have higher rates of good clinical outcome. Methods— All CTP data acquired in ESCAPE patients were analyzed centrally using a semiautomated perfusion threshold-based approach. A penumbral pattern was defined as an infarct core 15 mL, and a total hypoperfused volume:core volume ratio of >1.8. The primary outcome was good functional outcome at 90 days (modified Rankin Scale score, 0–2). Results— CTP was acquired in 138 of 316 ESCAPE patients. Penumbral patterns were present in 116 of 128 (90.6%) of patients with interpretable CTP data. The rate of good functional outcome in penumbral pattern patients (53 of 114; 46%) was higher than that in nonpenumbral patients (2 of 12; 17%; P =0.041). In penumbral patients, endovascular therapy increased the likelihood of a good clinical outcome (34 of 58; 57%) compared with those in the control group (19 of 58; 33%; odds ratio, 2.68; 95% confidence interval, 1.25–5.76; P =0.011). Only 3 of 12 nonpenumbral patients were randomized to the endovascular group, preventing an analysis of treatment effect. Conclusions— The majority of patients with CTP imaging in the ESCAPE trial had penumbral patterns, which were associated with better outcomes overall. Patients with penumbra treated with endovascular therapy had the greatest odds of good functional outcome. Nonpenumbral patients were much less likely to achieve good outcomes.

The implementation of telestroke programs has allowed patients living in rural areas suffering from acute ischemic stroke to receive expert acute stroke consultation and intravenous Alteplase (tPA). The purpose of this study is to compare door to needle (DTN) time when tPA is administered at telestroke sites (spokes) through telestroke consultations compared to tPA administration at the comprehensive stroke center (hub).Data on all patients who received intravenous tPA at the hub and spoke hospitals through a large telestroke program between May 2008 and December 2016 were collected. Baseline characteristics were compared between the two groups, and the percentage of patients meeting DTN guidelines was compared between the hub and spoke hospitals during the study period. Comparison of DTN before and after the implementation of a quality improvement project was performed.A total of 1,665 patients received tPA at either the spoke (n = 1,323) or the hub (n = 342) during the study period. Baseline characteristics were comparable in both treatment groups. Before the intervention, DTN time60 min was achieved in 88% of the hub patients versus 38% of the spoke patients. This difference between the two groups decreased by 35 percentage points, controlling for year (p = 0.0018) after the interventions.Overall, DTN is longer at the spoke hospitals compared to the hub hospital. This can be improved by various interventions that target quality, training, education, and improving the comfort level of the staff at partner hospitals when treating acute stroke patients.