Abstract 1122‐000128: Imaging Follow‐Up in Carotid Webs: Is There Vascular Remodeling?

Introduction : Carotid web (CaW) is a shelf‐like fibrotic projection at the carotid bulb and constitutes an underrecognized cause of ischemic stroke. Atherosclerotic lesions are known to have dynamic remodeling with time however, little is known regarding the evolution of CaW over time. We aimed to better understand if CaW is a static or dynamic entity on delayed vascular imaging. Methods : This was a retrospective analysis of the CaW database at our comprehensive stroke center, including patients diagnosed with CaW between September 2014 through June 2021. Patients who had at least two good quality CT angiograms (CTAs) that were at least 6 months apart were included (CTAs with CaW and superimposed thrombus were excluded). CaW were quantified with 3‐D measurements using Horos software. This was done via volumetric analysis of free‐hand delineated CaW borders on thin cuts of axial CTA (Figure 1 Panel A). NASCET criteria was used to evaluate the degree of stenosis. Results : Sixteen CaW in 13 patients were identified and included. The median imaging follow‐up window was 16 months (IQR 12–22, range 6–29). Median patient age was 45.5 years‐old, 69% were women, 25% had hypertension, 38% hyperlipidemia, 25% diabetes mellitus, 0% atrial fibrillation, and 13% active smokers. 75% of the included CaW were symptomatic while 25% were asymptomatic. Median volume of CaW on initial CTA (8.52 mm3 [IQR 3.7‐13], range 2.2‐30.4) was comparable to median volume of CaW on most recent CTA (8.47 mm3 [IQR 4.0‐12.8], range 2.3‐29.4; p = <0.001 (Figure 1 Panel B). The CaW volumetric measurement correlation between the initial and most recent CTA was near perfect (rs = ‐0.99, p = <0.001). The median change in measured volume of CaW between first and last CTA was ‐0.19 mm3 [IQR ‐0.6‐0.4], range ‐1‐0.8. Median degree of stenosis was 8.1% [IQR 4.5‐17.1], range 0.4‐31.2. The duration of follow‐up imaging was not correlated with the change in CaW volume (Kendall tau‐b[τb] = ‐0.17, p = 0.93). The initial CaW volume was not found to be correlated to the degree of stenosis (τb = ‐0.08, p = 0.65). Conclusions : The volume of the CaW was not found to change over time, reinforcing the idea that this is a relatively static lesion. The CaW volume was not found to correlate with the degree of stenosis caused by it. Further longitudinal studies with longer follow‐up intervals are warranted.

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Abstract TP317: Utility and Cost of Inpatient Thrombophilia Testing in Ischemic Stroke Patients Aged 18-60

Stroke ◽

10.1161/str.51.suppl_1.tp317 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Effrosyni Apostolidou ◽

Priya Khatri ◽

Eric Thomas ◽

Sean Savitz ◽

Alicia Zha

Keyword(s):

Ischemic Stroke ◽

Cryptogenic Stroke ◽

Inpatient Setting ◽

Initial Hospital ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

One Year ◽

Care Costs ◽

Fvl Mutation

Introduction: Patients (pts) <60 years with ischemic stroke (IS) are commonly tested for thrombophilias (TP) due to the perception that there could be underlying hypercoagulable states. However, inherited TPs are largely not a risk factor for IS; and testing for acquired TPs in an acute inpatient setting may yield erroneous results that increase health care costs. We reviewed the frequency and cost of TP testing at our institution as part of a plan-do-study act cycle for improving the utilization of inpatient TP testing in young pts after IS. Methods: We performed a retrospective review of 18-60 year old pts admitted for IS to our comprehensive stroke center between 11/2016 and 7/2018. Pts discharged with a stroke etiology not attributed to large vessel (LV), small vessel (SV), or cardioembolic (CE) origin and the initial hospital TP testing monitored. Pts seen subsequently in clinic or later admissions in our system were monitored. Results: Of 1,162 pts, 104 without diagnosed LV/SV/CE etiologies were identified. At least one TP test was performed in 82 (79%) pts (Table 1). In 70 pts testing was done in the initial 24 hrs of hospitalization. One test abnormality was seen in 42 (51%) pts but anticoagulation was initiated in only one 1 patient at discharge. Forty-seven (45%) pts were followed in our outpatient clinic, with a mean follow up of 5 (0.2 – 24) months. TP was confirmed in 3 pts in clinic – two with heterozygous FVL mutation and one with known homozygous FVL mutation. The total charges of the initial inpatient testing is estimated to be as high as $222,150 for 82 patients. Conclusion: Frequent inpatient TP testing in young pts with cryptogenic stroke does not change management and can be costly to the hospital. Based on these results, we created a practice guideline to improve utilization of TP testing starting January 2019. A one year analysis of the effectiveness, safety, and cost for these changes is ongoing.

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Abstract W P32: CSF Volumetric Analysis Reliably Quantifies Cerebral Edema And Correlates With Clinical Deterioration In Large Hemispheric Infarcts

Stroke ◽

10.1161/str.46.suppl_1.wp32 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Kristy Yuan ◽

Rajat Dhar ◽

Tobias Kulik ◽

Yasheng Chen ◽

Laura Heitsch ◽

...

Keyword(s):

Cerebral Edema ◽

Infarct Volume ◽

Intraclass Correlation ◽

Volumetric Analysis ◽

Midline Shift ◽

Stroke Patients ◽

Novel Method ◽

Kinetics Of ◽

Over Time

Background: Large hemispheric infarcts (LHI) may be complicated by cerebral edema. Midline shift (MLS), a standard radiographic measure, only crudely estimates extent of edema. Volumetric analysis of CSF compartments over time may provide a reliable and accurate means of quantifying severity and kinetics of edema after LHI. Methods: We retrospectively identified stroke patients with NIHSS≥8 and baseline CT within 6 hours who developed cerebral edema (without hemorrhage) on follow-up (FU) CTs. Two raters outlined the sulci and lateral ventricles ipsilateral (IL) and contralateral (CL) to the infarct on baseline and serial FU CTs (both within 48 hours and at peak edema, 2-5 days post-stroke) and quantified CSF and infarct volumes. Changes in compartment volumes from baseline to peak edema CT were correlated with MLS and edema-related neurologic worsening (need for hemicraniectomy, osmotic therapy, or decline in GCS, associated with MLS≥5mm). Results: Ten patients were analyzed (median NIHSS 14, time to early FU CT 30 hours, IQR 15-37 and to peak edema CT 75 hours, IQR 64-95). Inter-rater reliability for volume measures was excellent (intraclass correlation >0.97). CSF volume diminished by 37±20% (49 ml) from baseline to peak edema, over half occurring within 48 hours; net decline in CSF volume correlated with infarct volume (r=-0.63,p=0.05). Greatest reductions in CSF were seen in IL sulci and IL ventricles (Figure, top), but it was % reduction in CL sulci that correlated best with MLS (Fig, bottom), even adjusting for infarct volume (p=0.02). Decline in volumes of IL and CL sulci were greater in the 5 subjects with neurological worsening (89% vs. 56% and 40% vs. 3%, p<0.05), while infarct volume was not. Conclusions: CSF volumetrics is a reliable tool for quantifying cerebral edema after LHI and a novel method of studying edema kinetics. Loss of sulcal volume correlates with MLS and is more strongly associated with edema-related deterioration than infarct volume alone.

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Abstract WP56: The Hypoperfusion Intensity Ratio is a Poor Discriminator of Infarct Growth in Fully Reperfused Patients

Stroke ◽

10.1161/str.51.suppl_1.wp56 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Krishnan Ravindran ◽

Mehdi Bouslama ◽

Gabriel Rodrigues ◽

Diogo Haussen ◽

Leonardo Pisani ◽

...

Keyword(s):

Intensity Ratio ◽

Infarct Volume ◽

Treatment Decision ◽

Lesion Volume ◽

Treatment Decision Making ◽

Fast Progression ◽

The Difference ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Purpose: The hypoperfusion intensity ratio (HIR) is a perfusion-weighted imaging parameter defined as the ratio of Tmax>10 seconds : Tmax>6 seconds volume and is believed to be reflective of collateral strength and consequently influence infarct growth. We sought to assess the utility of the HIR in predicting infarct growth in patients undergoing thrombectomy at a comprehensive stroke center (CSC). Methods: Consecutive acute ischemic stroke patients transferred to our CSC from 09/2010-11/2018 were identified and included if the following criteria were met: 1)computed tomography perfusion (CTP) imaging enabling assessment of baseline ischemic core volume and HIR 2) follow-up neuroimaging for assessment of final infarct volumes and 3)modified Thrombolysis In Cerebral Infarction scale (mTICI) 2c status or greater post-thrombectomy. Infarct growth rate (IGR) was calculated as the difference between infarct volume on follow-up imaging and the acute DWI lesion volume, divided by time from CTP to reperfusion in hours. Results: 461 patients (median age, 64 [55-75] years, median baseline NIHSS, 16 [12-21]) were eligible for this analysis. HIR poorly correlated with IGR (Spearman’s rho=0.001, p=0.89). An HIR cut-off of 0.5 was not able to discriminate ‘fast progressors’ (IGR>5 mL/hr) (AUC 0.42, sensitivity 40%, specificity 51%), or IGR at thresholds of either 2.5 or 10 mL/hr (AUC 0.44 and 0.49 respectively, with 95% confidence intervals [0.35-0.52] and [0.41-0.57], respectively). Similarly, an HIR of 0.5 only weakly distinguished ‘fast progression’ in patients reperfused beyond 120 min from imaging and patients with early CTP (last known well to CTP<6 hrs) (AUC 0.59, sensitivity 43%, specificity 68% and AUC 0.50, sensitivity 45%, specificity 55%). On multiple regression analysis, HIR was not predictive of infarct growth (regression equation=18.09+8.48x, F=2.46, p=0.11, R 2 =0.13) but was predictive of ‘fast progression’ (OR 0.22, 95% CI [0.09-0.60], p=0.003, pseudo-R 2 =0.16). Conclusions: Though predictive of fast progression, the HIR is a poor discriminator of infarct growth in successfully reperfused thrombectomy patients who undergo perfusion imaging at a CSC, and thus should not be factored into treatment decision-making.

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Abstract WMP89: Outcomes No Different in Real World Including Direct vs Drip-and-Ship Patients: Power of Reperfusion From Mechanical Thrombectomy

Stroke ◽

10.1161/str.51.suppl_1.wmp89 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Darshan G Shah ◽

Aravi Loganathan ◽

Dan Truong ◽

Fiona Chan ◽

Bruce Campbell ◽

...

Keyword(s):

Functional Outcome ◽

Real World ◽

Functional Outcomes ◽

Mechanical Thrombectomy ◽

Vessel Occlusion ◽

Excellent Functional Outcome ◽

The Mean ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Mechanical thrombectomy (MT) became standard care in 2015 after positive trials in patients presenting with acute ischemic stroke and large vessel occlusion (LVO) 0-6h and in 2018 for selected patients up to 24h from symptom onset. Objective: To evaluate whether patients receiving MT at our center would have comparable outcomes in patients presenting to our comprehensive stroke center (direct) vs transfer patients (drip-and-ship) Methods: This is a retrospective observational study utilising prospectively collected stroke database for patients receiving MT for LVO in anterior and posterior circulation in South Brisbane network of 7 hospitals (6 drip-and-ship centers and 1 MT-capable center), Australia which serves 1.6 million. Day 90 modified Rankin scale (mRS) was used to assess functional outcomes via outpatient follow up at direct or referral center. The association of drip and ship versus mothership treatment with day 90 mRS was tested in ordinal logistic regression adjusted for age, baseline NIHSS and IV thrombolysis. Results: Of 191 patients who underwent Mechanical Thrombectomy from 2015 to June 2018 at our center, 22 patients were excluded from analysis as either their baseline mRS was >1 (13) or follow up data was missing (9). The mean age was 64.4 years. Median (inter-quartile range, IQR) NIHSS was 16 (9-21) on admission and 7 (2-18) on day 1. Thrombolysis in Cerebral Infarction (TICI) ≥2b was achieved in 88.9%. At 90 days, 50.9% achieved excellent functional outcome (mRS 0-1), 61.4% achieved good functional outcome (mRS 0-2) and 69% achieved favorable outcome (mRS 0-3). Median mRS was 1 (IQR 0-5) in 96 patients presenting directly to the endovascular center and 1 (IQR 1-4) in 73 drip-and-ship patients (common odds ratio 1.07 (95%CI 0.62-1.83), p=0.82) Conclusion: Our 7-center network experience confirms real world reproducibility of trial results, interestingly with no difference in functional outcomes for direct vs drip-and-ship patients.

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Abstract TP280: Factors Associated With Outpatient Follow-up in Stroke Clinic After Discharge From a Comprehensive Stroke Center

Stroke ◽

10.1161/str.49.suppl_1.tp280 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Reema T Butt ◽

Daniel Miller ◽

Shaneela Malik ◽

Mohammed Ismail ◽

Lonni Schultz ◽

...

Keyword(s):

Factors Associated ◽

Comprehensive Stroke Center ◽

Stroke Center

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Abstract TP368: The Impact of Hospital Based Specialist Physicians Conducting Post-Discharge Follow-Up Phone Calls at a Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tp368 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Cynthia Sinogui ◽

Yogesh Nandan ◽

Amber Jennings ◽

Pat Zrelak

Keyword(s):

Acute Care ◽

Nursing Facilities ◽

Post Discharge ◽

Skilled Nursing ◽

Secure Messaging ◽

Phone Calls ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Background: As a Comprehensive Stroke Center (CSC), The Joint Commission requires post-discharge follow-up phone calls to be conducted within 7 days of discharge for all complex stroke patients. Purpose: To develop and sustain a feasible approach for Hospital Based Specialist (HBS) physicians to conduct follow-up phone calls within 7 days. Methods: A baseline evaluation of all post-discharge phone calls was conducted. It was determined that patients were receiving several phone calls already, therefore the team did not want to add an additional call to meet compliance. HBS calls were realigned to include a stroke-specific focus, reinforcing stroke education and secondary prevention. Calls were made within 7 days by the discharging physician. All stroke patient types discharged with a stroke diagnosis were contacted regardless of severity. Patients discharged to skilled nursing facilities, board and care, acute rehabilitation or other acute care hospitals were excluded. A templated note was developed to ensure all stroke-specific components were covered. All HBS physicians were trained. Telephone interactions occurred between the patient, family member, and/or caregiver. Those unable to be reached but had messages left or secure messaging sent were counted as compliant. Reminders were sent out to physicians to improve call compliance. Tracking occurred weekly for call compliance and note template utilization. Results: Between January 2018 and May 2019, 612 patients discharged home from the acute care setting. Of those, 55% (334) were contacted. Of those, 73% had the templated note documented. Several hurdles were encountered along the way, but utilization of the templated note and physician reminders improved compliance. Conclusion: Post-discharge follow-up phone calls initiated by HBS physicians and utilization of a templated note are a feasible means of meeting and sustaining the CSC requirement.

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Abstract TP365: Stroke Nurse Navigator Improves Post-Acute Transition of Care

Stroke ◽

10.1161/str.51.suppl_1.tp365 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Karen Sher ◽

Armani Edgar ◽

Sarah Clark ◽

Ilene Staff ◽

Amre Nouh

Keyword(s):

Positive Impact ◽

Statistical Significance ◽

Stroke Care ◽

Primary Diagnosis ◽

Transition Of Care ◽

Chi Square ◽

Nurse Navigator ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Post stroke care is multifaceted and should not end at hospital discharge. Patients often lack understanding of the importance of outpatient care to prevent secondary stroke. Objective: To demonstrate the positive impact of a stroke nurse navigator in improving the post-acute transition of care by promoting outpatient follow up after hospitalization. Methods: We retrospectively reviewed all patients discharged from our comprehensive stroke center (excluding hospice) with a primary diagnosis of ischemic or hemorrhagic stroke from January -December 2018, yielding 685 patients. We evaluated whether or not our nurse navigator influenced three aspects of follow up: if stroke clinic appointment was made before discharge, if patient attended the appointment and if patient called the clinic after discharge. Four categories were used based on level of navigator contact with the patient: (SC) Seen in-house and called within 30 days after discharge, (S) Seen only, (C) Called only or (N) No navigator contact. Chi-square test of proportions was used to evaluate the statistical significance among all four groups. Results: Out of the 685 patients, 77.5% (n=531) were scheduled for clinic follow-up before discharge, 60.7% (n=416) attended the appointment and 20% called after discharge (n=137). The distribution of navigator contact level was (SC) 26.7%, (S) 17.5%, (C) 19.3% and (N) 36.5%. Both seeing and calling the patient was proven to be the most effective in all three areas: appointment made prior to discharge (SC) 89.6%, (S) 82.5%, (C) 74.2%, (N) 68% ( p=<0.001 ); patient attended the appointment (SC) 68.9%, (S) 60%, (C ) 65.9%, (N) 52.4% ( p=0.001 ) and patient called the clinic after discharge (SC) 26.2%, (S) 15.8%, (C ) 23.5%, (N) 15.6% ( p=0.02 ). Of interest, patients who were only called but not seen were more likely to attend the appointment or call the clinic as compared to being seen alone. Conclusion: Contact with our nurse navigator increased post-acute follow up in our stroke clinic. An increased number of patient calls associated with navigator interaction showed these patients had a better understanding of the need for continued care. The nurse navigator improves continuity of post-acute care.

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Abstract TMP107: Impact of a Stroke Transitional Care Navigator at a Comprehensive Stroke Center

Stroke ◽

10.1161/str.51.suppl_1.tmp107 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Darren T Larsen ◽

Alexandra Lesko ◽

Elizabeth Baraban

Keyword(s):

Transitional Care ◽

Positive Impact ◽

Outpatient Setting ◽

Unplanned Readmission ◽

Post Discharge ◽

Individualized Care ◽

Ed Visits ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: The Stroke Transitional Care Navigator (STCN), was implemented at our Comprehensive Stroke Center (CSC) in January 2017 in order to bridge care from the inpatient to outpatient setting. The STCN nurse meets with patients prior to discharge to address secondary stroke risk factors and discuss the follow up plan in an effort to improve patient outcomes. The purpose of this study was to determine whether implementation of a STCN improved compliance with follow up stroke neurology care and reduced unplanned readmissions and Emergency Department (ED) visits. Methods: Retrospective data review, included ischemic stroke or ICH patients, 18 or over, discharged from February 2017 through February 2018. Subarachnoid hemorrhages and hospice discharges were excluded. Patients were grouped into a “Followed’ cohort if they had documented contact with the STCN prior to discharge or within 30 days; otherwise they were categorized as “Not Followed”. Outcomes of interest were percentage of patients compliant with attending an outpatient visit with a stroke provider within 45 or 120 days post-discharge and percentage of unplanned readmission and ED visits 30 days post-discharge. Analyses comparing those with and without STCN contact were performed using Fisher’s Exact test and Pearson’s chi square test. Results: There were 689 patients that met inclusion criteria with 47.2% (n=325) in the Followed and 52.8% (n=364) in the Not-Followed cohorts. The Followed cohort was more likely to comply with attending a follow-up visit within 45-days (67.2% vs. 32.8%, p<.001) as well as 120 days of discharge (61.0% vs 39.0%, p<.001). No differences were found between the Followed and Not Followed cohorts for readmissions (9.5% vs. 11.5%, p=.394) or ED visits (9.5% vs. 10.2%, p=.783). Conclusion: The STCN had a significant positive impact on patients returning to clinic for follow up stroke neurology care. Though follow up care has been shown to reduce readmission rates in some studies, in this study there was no impact on 30-day readmissions or ED visits. Given the unique, individualized care and coordination provided by the STCN, which is very well received by patients and providers, qualitative measures may be more useful in the future to determine the effectiveness of the STCN.

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Abstract P254: Decompressive Hemicraniectomy and Functional Outcomes After Malignant Cerebral Infarction: Real World Experience From a Comprehensive Stroke Center

Stroke ◽

10.1161/str.52.suppl_1.p254 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Christine Park ◽

Martin Weiss ◽

Scott Le ◽

Shreyansh Shah ◽

Mary Guhwe ◽

...

Keyword(s):

Clinical Care ◽

Decompressive Hemicraniectomy ◽

Pooled Data ◽

Conflicting Evidence ◽

Malignant Infarction ◽

Observational Cohort ◽

Prospective Trials ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Decompressive hemicraniectomy (DHC), performed in select patients with malignant infarction (MCI), reduces mortality. However, there is conflicting evidence surrounding the use of DHC in improving disability outcomes in this patient population. This is in part due to differing definitions of functional recovery in prior studies. The purpose of this study is to characterize a cohort of patients with ischemic stroke who underwent DHC and compare the outcomes data with pooled data from three major trials published for DHC (DECIMAL, DESTINY, and HAMLET). Methods: This was a retrospective, observational cohort study of consecutive patients who underwent DHC as part of best clinical care during 2015-2020. We report our cohort using descriptive statistics. Results: Of the 44 patients underwent DHC at our institution, 33 were included for analysis after applying the inclusion and exclusion criteria based on the three major trials. Our DHC cohort tended to have higher rates of comorbidities including hypertension and diabetes (Table 1). A greater number of our DHC patients had unfavorable modified Rankin Scale (mRS) scores of 4 or 5 at 6-month follow-up compared to those who underwent DHC or received conservative therapy at 12-month follow-up in the three prospective trials (Figure 1). Conclusion: DHC in patient cohorts with significant comorbid data is associated with reduced mortality but a worsened functional outcome in survivors. The treating practitioner should consider this procedure only in the context of a lengthy discussion regarding the patient’s baseline functional and health status as well as competing benefits and risks associated with this procedure.

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