Abstract P818: Increased Eligibility for Endovascular Therapy Following Intensive Door-To-Transfer Improvement Project

Background and Purpose: Early EVT for large vessel acute ischemic stroke is associated with reduced disability and mortality. Longer transfer times from the sending facility contribute to poorer EVT outcomes, and in some circumstances, patient ineligibility for EVT due to a completed stroke on arrival to the endovascular site. Reducing avoidable delays will result in overall improved EVT outcomes and reduce the frequency of completed stroke upon arrival. Methods: A multidisciplinary group utilized the Lean A3 process and PDCA improvement cycle to reduce transfer times. Avoidable delays and resources to expedite the transfers were identified. A standardized plan with defined roles and responsibilities, communication pathways, early transport team activation, and robust staff education were implemented. The PI team met weekly for 3 months to review each individual transfer, determine what went well and what did not, and to identify additional improvement opportunities. A weekly summary with feedback was provided to front line staff and managers. Staff involved in patient transfers that had a DIDO of 90 min or less were recognized with a “Brain Pin” and staff recognition certificate. Results: Since its implementation, 23 patients were transferred for potential EVT. Compared with 12 months prior to implementation, the DIDO median time was reduced from 119 minutes to 80.5 minutes, transfers were achieved in 90 min or less 61% (n=15) of the time vs. 27.2%, and percentage of EVT eligible patients increased from 58.3 to 78.3%. Conclusion: In conclusion, rapid reduction of DIDO times and increased patient eligibility for thrombectomy is attainable through an intensive multidisciplinary process improvement project. Implementing a standardized workflow that includes rapid identification of potential EVT transfers, early activation of the transport team, development of clear pathways of communication, defined roles and responsibilities within the team, and regular staff feedback are essential.

Preschool children deliver stroke knowledge to their families with the FAST 112 Heroes educational programme

Background: FAST (Face, Arm, Speech, Time) 112 Heroes is an educational programme that delivers information to children and their extended families helping them identify the principal signs of stroke and informing them how to respond appropriately in the event of a stroke. Objectives: To examine the baseline stroke literacy that extended families possess, as well as to assess whether children enrolled in FAST 112 Heroes programme effectively convey stroke knowledge to their extended family. Design: Field trial. Setting: Four schools in Northern Greece – two public and two private. Methods: Parents of preschool aged (5–7 years) children completed stroke knowledge questionnaires, before the programme began and one week after the completion of the FAST 112 Heroes programme. Findings were analysed. Results: In total, 240 parents of kindergarten children (146 women, 94 men; 20–59 years old; mean age: 38.81) completed the pre-programme questionnaire, whereas only 80 of them (33.33%) completed the post-programme questionnaire. Before the programme started, 30 out of 80 parents (37.5%) recognised the three rudimentary stroke symptoms, compared to 68 out of 80 (85%) after the completion of the programme ( p = .00). Parental awareness of the emergency number 112 and of the FAST acronym before programme implementation was relatively poor. Conclusions: Improvement of stroke knowledge post-implementation was observed in the extended family of preschool children enrolled in the FAST 112 Heroes programme which suggests that the latter delivered stroke information to their families effectively.

Endovascular Thrombectomy in Acute-Onset Ischemic Stroke – beyond the Standard Time Windows: A Case Report and a Review of the Literature

Endovascular thrombectomy following an acute ischemic stroke can lead to improved functional outcome when performed early. Current guidelines suggest treatment within 6 h after symptom onset. Recent studies including the DEFUSE-3 and DAWN trials demonstrate that some patients may benefit from thrombectomy up to 16 and 24 h after symptom onset, respectively. We present a case of delayed thrombectomy in a 43-year-old man with acute dysarthria, left-sided weakness, and visual neglect. Initial MRI/A demonstrated a small completed stroke and a thrombus in the right middle cerebral artery. Thirty-seven hours after symptom onset, his weakness acutely worsened. A repeat MRI revealed an unchanged core infarct volume and a cerebral angiogram suggested an abrupt occlusion of the right distal M1. Thrombectomy was performed with complete reperfusion and the patient’s strength recovered following the procedure. We compared our clinical reasoning with the DEFUSE-3 and DAWN study criteria, and conclude that there is a subset of patients that may safely benefit from thrombectomy in later time windows beyond the trial criteria, especially in the setting of clinical examination of imaging mismatch.

Physiotherapy provision to hospitalised stroke patients: Analysis from the UK Sentinel Stroke National Audit Programme

Introduction The purpose of this study is to investigate which factors are associated with physiotherapy provision to hospitalised stroke patients. Methods Data were analysed for stroke patients admitted to hospital in England and Wales between April 2013 and March 2017 recorded on the Sentinel Stroke National Audit Programme (SSNAP) national stroke register. Associations between different patient factors, and applicability for and intensity of physiotherapy were measured using multi-level logistic and regression models. Findings: Data from 306,078 patients were included on the SSNAP register. Median age was 77 years (IQR 67–85) and 84.7% of patients with completed stroke severity data had a mild-moderate stroke. In all, 85.2% of patients recorded on SSNAP were deemed applicable for physiotherapy. Applicability for physiotherapy was 47% higher among thrombolysed patients (aOR 1.47, 95% CI 1.40–1.54), 36% lower in those with severe pre-morbid disability (aOR 0.64, 95% CI 0.58–0.71) and more than 2.5-fold higher among patients admitted to hospitals with greater availability of early supported discharge (aOR 2.62, 95% CI 1.28–5.37). Patients who were younger, male, had less pre-morbid disability, lower stroke severity, sustained an infarction, received thrombolysis, and had fewer medical complications were more likely to receive more intensive physiotherapy post-stroke. Conclusion Several patient and service organisational factors are associated with physiotherapy provision to stroke patients, some of which may not be justifiable. Physiotherapists should be aware of these factors when planning and delivering physiotherapy as well as any possible biases associated with physiotherapy provision to patients post-stroke.

A Study on the Clinical and Angiographic Spectrum of Spontaneous Extracranial Dissections in the Cerebral Vasculature

ABSTRACT Aim: To prospectively study the clinical profile, angiographic features, and functional outcomes, in consecutive cases of extracranial dissection seen at two tertiary stroke care centers in South India. Materials and Methods: In this observational study, spanning 4 years (December 12–December 16), a total of 442 patients presented with an acute ischemic stroke/transient ischemic attack (TIA) at our study centers. 14/546 (3.2%) of these patients had magnetic resonance angiography (MRA)/computed tomography angiography (CTA) evidence of extracranial dissections. All cases underwent detailed clinical evaluation on arrival, and data were recorded on a predesigned stroke pro forma. Contrast MRA was done on arrival in all cases as part of a standard stroke protocol, and CTA was done only if MRA was inconclusive. The pattern of the vessel involved and morphology of vessel dissection was analyzed as per a standard radiology protocol. All the cases were managed with short-term anticoagulation using low-molecular-weight heparin followed by oral anticoagulants for 3–6 months. All cases were followed up for 1–2 years and the functional outcomes were recorded using the modified Rankin Scale (mRS). Results: There were 11 males and 3 females in the study, and the mean age was 45.1 years (range = 27–65 years). Focal neurological symptoms occurred in all these patients (10 patients had a stroke, and 4 had TIA). Nearly 64.2% of these (9/14) were stroke in young (age <45 years). The internal carotid artery was the most common vessel involved in 85.7% (12/14) cases. Of the ten patients with completed stroke, a good functional outcome (mRS 1–2) was seen in 8/10 (80%). Digital subtraction angiography and revascularization procedures were needed only in a minority of cases 3/14 (21%).\ Conclusion: This hospital-based study highlights the importance of suspecting arterial dissections in young strokes of unexplained etiology, and offering optimum anticoagulant therapy in the acute phase, to achieve good long-term outcomes.

Abstract 2592: Weakness of ABCD2 Scoring In Transient Ischemic Attack

Introduction: The ABCD2 score is a screening tool used to determine the risk for stroke within the first two days following a TIA. The ABCD2 score is based on 5 parameters: age, blood pressure, clinical features, symptom duration and the presence of diabetes. Each item is scored and added to form a number ranging between 0 and 7. A score of 0-3 predicts a low risk of completed stroke at 2 days (1.0%), 3-4 predicts moderate risk (4.1%) and a score ≥ 5 carries high risk (8.1%). NICE recommends that patients with a score of 4 and above are seen by a stroke physician and investigated within 24 hours of onset. ‘C’, clinical features, is scored out of a maximum of 2 points. Unilateral weakness = 2, speech disturbance = 1, and other presenting symptom = 0. We hypothesised that while the ABCD2 is sensitive for anterior circulation TIA, posterior events will not score in this area, leading to inappropriate risk stratification. Aim: The study aim was to establish if the ABCD2 score is equally effective in stratifying stroke risk in all categories of TIA. Methods: Data was collected retrospectively from TIA clinic referral documentation for all patients presenting over a 7 month period (N=335). Patients scoring ‘0’ for the ‘C’ arm of the ABCD2 score (N=102) were isolated to establish whether TIA was confirmed as the final diagnosis by a stroke physician, and where patients were treated as TIA, the presenting symptom, and vascular territory involved. Results: A ‘C’ score of 0 was present in 103 cases (30%), of which 38 (37%) were diagnosed and managed as TIA . The most common presenting feature in this group was visual disturbance, 20 cases (54%). The majority of these (50%) received a diagnosis of amaurosis fugax, and 25% posterior circulation TIA. The remainder were treated as TIA, but the vascular territory not specified. Facial paraesthesia was described in 5 cases (13%), attributed to carotid artery territory TIA. Ataxia was the presenting feature in 3 patients (8%), attributed to posterior circulation TIA. The remaining 25% had non specific symptoms and the vascular territory not specified on the clinic notes. Conclusion: Our study demonstrates that a significant proportion of confirmed TIA cases do not present with classical symptoms of unilateral weakness and speech disturbance. Isolated visual disturbance appears to be a common presenting feature of a TIA, and amaurosis fugax, a known high risk predictor of subsequent completed stroke is not recognised in the ABCD2 score. Transient balance disturbance and ataxic symptoms are highly suggestive of a posterior circulation event and are again not accounted for. When used in isolation, application of the ABCD2 score in these patients may give an inappropriately low stroke risk prediction, and result in delayed referral for investigation and treatment.

Secondary Prevention of Overt Strokes in Sickle Cell Disease: Therapeutic Strategies and Efficacy

Overt strokes, previously one of the most common neurological complications in sickle cell disease (SCD), have become far less frequent with routine transcranial Doppler (TCD) assessment followed by regular blood transfusion therapy. Nevertheless, children and adults with SCD continue to have overt strokes, and in the foreseeable future will continue to require secondary prevention of strokes. With the exception of the most recently completed “Stroke With Transfusions Changing to Hydroxyurea” Trial (SWiTCH; NCT00122980), randomized trials providing best evidence for long-term management of overt strokes in SCD is lacking. Instead of randomized clinical trials, a series of observational and single-arm studies have predominated. This review assesses the best available evidence for acute and chronic management of overt stroke and the efficacy of regular blood transfusion therapy, hydroxyurea therapy, and hematopoietic stem cell transplantation (HSCT), including matched sibling donor and unrelated HSCT.

RACE to protect brains

INTRODUCTION Rapid-access carotid endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48 h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE. SUBJECTS AND METHODS A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CEAs) performed. Outcomes were compared between elective (ECE) and rapid-access operations. RESULTS In 1 year, 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. Twenty-three (30%) of ECE were for asymptomatic stenoses; no other significant differences in surgical indication were seen. Of symptomatic ECE, 43% were for completed stroke versus 55% for RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was one death following ECE (1.3%) and one stroke after RACE (5%), all not significant. Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time. CONCLUSIONS The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service, we have treated 50% of suitable patients within 48 h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.