Sturge-Weber syndrome (SWS) is a rare and congenitally acquired neurocutaneous disorder characterized by port wine stain, leptomeningeal angiomas with or without glaucoma. Clinical presentation includes focal motor epilepsy as the first symptom. They may also develop migraines, cognitive impairment, blindness secondary to glaucoma, and transient stroke-like episodes. We report a case of a 60-year-old patient with SWS with known leptomeningeal angiomatosis presenting with aphasia in the setting of left middle cerebral artery narrowing who received intravenous tissue plasminogen activator (IV tPA). Neurocutaneous syndromes associated with intracranial vascular malformations have been considered at a higher risk of intracranial bleeding following IV thrombolytic therapy. We report the first case to our knowledge in which a patient with SWS with known leptomeningeal angiomatosis received IV tPA for acute stroke therapy without intracranial bleeding.

Introduction: Tenecteplase has been demonstrated to be an effective option for thrombolysis in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Thrombolysis decision making is an important component of telestroke consultations. Data is scarce concerning tenecteplase usage in telestroke patients. We aimed to evaluate if tenecteplase was safe and feasible for patients with confirmed LVO in a large telestroke network. Methods: We conducted a retrospective analysis of AIS patients with LVO and treated with thrombolysis from May 2018 to April 2021. We compared outcomes in telestroke patients treated with IV alteplase (May 2018 - April 2020) to patients treated with IV tenecteplase (May 2020 - April 2021). We evaluated our primary efficacy and safety outcomes: 90 day functional outcome as measured by modified Rankin Scale (mRS) and complications related to thrombolysis. Secondary outcomes included door to needle time (DTN) and door in door out time (DIO). Ordinal regression assessed 90 day mRS and binomial logistic regression analysis evaluated complications between the groups. Quantile regression models assessed the median to compared groups for DTN and DIO. Results: There were 3747 telestroke consults during the study period and 537 (14.3%) were found to have an LVO, of which 109 (39 IV tenecteplase; 70 IV alteplase) were eligible, received thrombolysis and were included in this study. Patients treated with IV tenecteplase had significantly less disability at 90 days compared to patients treated with IV alteplase [1 (0 - 4.5) vs. 3 (1 - 6)], adjusted odds ratio (aOR) = 0.31 [95%CI, 0.14 - 0.72], p = 0.006, based on mRS ordinal shift analysis. Similar complication rates were reported between the thrombolysis groups, aOR = 3.73 [95%CI, 0.23 - 59.95], p = 0.35. An adjusted quantile regression model found IV tenecteplase was administered 9.40 minutes quicker, standard error (SE) = 3.67, [95%CI, 2.11 - 16.69] than IV alteplase, p = 0.01. There were no differences reported between thrombolysis groups and DIO, p = 0.63. Conclusion: Telestroke patients presenting with confirmed LVO and treated with IV tenecteplase were found to have better 90 day outcomes compared to patients treated with IV alteplase, without increased complication rates.

Evaluate if Early Infarct Growth Rate (EIGR) can be used to predict outcome in telestroke patients treated with IV thrombolysis.

Introduction: Prior studies have demonstrated the importance of measuring and monitoring telestroke sub-events of door-to-needle time (DTN) such as door-to-telestroke request, but there is limited data on educational efforts to reduce sub-events contributing to DTN. We educated spoke coordinators, nurses and physicians at our telestroke sites on tips to reduce sub-events of DTN, developed a reference pocket card and reviewed sub-event metrics during monthly telestroke quality meetings with spoke sites. We aimed to evaluate if our educational activities and monthly data review affected door-to-telestroke request within 10 minutes of arrival, completion-of-video to needle within 1 minute and DTN within 60 minutes. Methods: Prospectively collected data was analyzed retrospectively from a hub-and-spoke model telestroke network. Education of the spokes was completed between January 2019 and April 2019. We compared data for one year prior to education (January 2018 - December 2018) and one year after education (May 2019 - April 2020). Logistic regression analyses were performed to determine the odds of achieving a door-to-telestroke request within 10 minutes, DTN within 60 minutes and completion-of-video to needle within 1 minute in treated patients. We entered possible confounding variables (EMS arrival; NIHSS; posterior symptoms) in the first block followed by the pre/post education groups in the second block. Results: Overall, telestroke was requested 2574 times during the study (1338 pre-education; 1236 post-education). A Chi square test suggested a trend towards more thrombolytic and thrombectomy treatments occurred after education compared to before education (14.6% vs. 12%), OR = 1.25 (95%CI 0.99 - 1.56), p=0.06. Door-to-telestroke request <10 minutes was more likely after education of the spokes, OR=2.15 (95%CI 1.27 - 3.66), p=0.005. DTN with 60 minutes was also more likely after education on telestroke sub-events OR = 1.83 (95%CI 1.04 - 3.20), p=0.035. Completion-of-video to needle with 1 minute was not significantly different after education, OR=0.76 (95%CI 0.37 - 1.59), p=0.47. Conclusions: Education and regular review of sub-events data reduced door-to-telestroke request and door-to-needle time in our telestroke network.

Objective: To determine the impact of chronic kidney disease (CKD) on stroke outcomes stratified by severity of renal impairment among acute ischemic strokes (AIS) patients treated with endovascular therapy (EVT). Methods: Single center retrospective analysis was conducted from January 2012 to December 2019 involving AIS patients with CKD undergoing EVT. We evaluated following primary safety and efficacy outcomes: inpatient mortality and reperfusion status according to TICI score, respectively. Our secondary safety outcomes were symptomatic intracranial hemorrhage (sICH) per SITS-MOST definition, whereas secondary efficacy outcomes were length of hospitalization and favorable discharge disposition (discharge to home or inpatient rehabilitation). CKD was defined with estimated glomerular filtration rate (eGFR) ranging from mild (eGFR 60-89 mL/ min) to moderate (eGFR 30-59 mL/min) to severe (eGFR 15-29 mL/min). We performed propensity score matching to eliminate confounding variables between CKD and non-CKD patients (1:2). In our subgroup analysis, we compared patients with mild-moderate CKD patients and severe CKD and evaluated their association with various clinical outcomes. Results: From a total of 466 AIS patients undergoing EVT, 84 CKD and 165 patients with normal renal function were selected based on 1:2 propensity score matching. CKD was associated with increased risk of in-hospital mortality (Odds ratio [OR] 2.58, 95% confidence interval [CI] 1.49-4.64, p <0.001), whereas favorable discharge disposition, length of hospitalization, sICH, TICI 2B/3 were comparable between the two groups. Subgroup analysis showed that patients with mild and moderate CKD were observed to have favorable discharge disposition (p=0.002), whereas patients with severe CKD were noted to have a higher risk of sICH ( p = 0.03) and prolonged hospitalization 11.54 ± 11.87 days (OR; 1.10, 95% CI 1.03-1.18, p = 0.006). Conclusion: History of CKD among AIS patients undergoing EVT were associated with a higher rate of inpatient mortality. In comparison to patients with mild and moderate CKD, patients with severe CKD were noted to have an increased risk of sICH, prolonged hospitalization, and poor discharge disposition.

Introduction: Data remains scarce on which telestroke related sub-events (component parts/time intervals) are associated with delays in door-to-needle (DTN) time and goals for each telestroke sub-event. We aimed to assess the telestroke sub-events that contribute to DTN. After establishing set goals for each sub-event, we further evaluated the odds of DTN within 45 minutes if sub-event goals were achieved. Methods: We retrospectively analyzed prospectively collected data from a hub-and-spoke model telestroke network from January 2017 to September 2019. To determine which sub-events significantly contributed to DTN time, a sequential multiple regression analysis was performed. We entered covariates (age, sex, time of telestroke [day or night], NIHSS, average number of telestroke consults at a given site) in the first block followed by sub-events (door-to-telestroke request, door-to-CT, request-to-page, stroke physician response time, telestroke phone-to-video, video duration prior to needle and video completion-to-needle) in the second block. Logistic regression models were performed to estimate the odds of achieving a DTN within 45 minutes if sub-event goals were achieved. Results: During the study, 3361 telestrokes were completed and 306 (9.1%) patients received IV thrombolytics. After exclusions, 253 patients treated with IV thrombolytics were included. Five sub-events contributed to DTN time above and beyond the nuisance variables: door-to-telestroke request, stroke physician response time, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle; each p <0.001. DTN time within 45 minutes was more likely when door-to-telestroke request <10 minutes (OR=12.30, 95%CI 3.47-43.65), video completion to needle <1 minute (OR=4.21, 95%CI 1.45-12.20) and telestroke phone-to-video <7 minutes (OR=5.24, 95%CI 1.41-19.49). Conclusions: Telestroke sub-events involving door-to-telestroke request, stroke physician response, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle significantly contribute to DTN time. Successful achievement of sub-event goals was related to greater likelihood of administration of thrombolytic therapy within 45 minutes.

Background: Rapid arterial occlusion evaluation (RACE) scale is a valid prehospital tool used to predict large vessel occlusion of major cerebral arteries in patients with suspected acute stroke. RACE scale administered by Emergency medicine services (EMS) technicians in the prehospital setting correlates well with NIH Stroke Scale score after patient arrival at a hospital. Despite this, the RACE scale is often charac-terized as too difficult for EMS technicians to accurately utilize. There are no data examining RACE scale accuracy in the prehospital setting comparing EMS techni-cians with neurologists. We sought to examine agreement between RACE scores calculated by EMS technicians and stroke neurologists in the prehospital setting during telestroke consultation. Methods: Data for this observational cohort study were prospectively collected and retrospectively analyzed. EMS technicians in per-son and stroke specialized neurologists via televideo connection independently assessed suspected stroke patients and calculated RACE scores in the prehospital setting. We used a linearly weighted Cohen's kappa (kw) to estimate the extent of agreement for RACE score between EMS technicians and stroke neurologists. Results: Thirty-one patients with stroke symptoms were independently examined and assessed with the RACE scale by EMS technicians and stroke neurologists in the prehospital setting. Exact agreement on the RACE score was found in 24 of 31 (77%) patients. We found very good agreement between EMS technicians and stroke neurologists, kw = .818 (95% CI, .677-.960), P< .001. Conclusions: EMS techni-cians provide reliable RACE assessments in patients with suspected stroke, with agreement similar to stroke specialized neurologists in the prehospital setting.

Monday, April 27April 14, 2020Free AccessFactors Contributing to Door to Telestroke Request Times (4582)Nicholas Fuller, Chris Hackett, Robert Fishman, David Wright, Sandeep Rana, Russell Cerejo, Konark Malhotra, and Ashis TayalAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.4582 Letters to the Editor

Introduction: Brain perfusion imaging has become an integral part of acute stroke therapy, especially for the extended time window. A streamlined workflow is essential to reduce delays in acute str...

Introduction: Perfusion based imaging aids in patient selection for endovascular therapy (EVT). Appropriate selection of patients for EVT is an important component of telestroke programs. Thus, tel...

Objective: We aimed to evaluate the proportion of transfers for endovascular therapy (EVT), door-in-door-out time (DIO) and door-to-needle time (DTN) at telestroke sites before and after CT perfusion (CTP) implementation. Background: Perfusion based imaging aids in patient selection for EVT. Appropriate selection of patients for EVT is an important component in telestroke programs. Despite the advantages of perfusion imaging, there is the concern that advanced imaging may delay DTN time. We implemented CTP using RAPID software at three large primary stroke centers within our telestroke network in December 2017. Design/Methods: Data was prospectively collected and retrospectively analyzed as part of our telestroke quality database. We compared data for one year before and after implementing CTP at the telestroke sites. We hypothesized that: the addition of CTP would not delay DTN; a greater proportion of transfers for possible EVT would receive a stroke thrombectomy; and that DIO would be reduced after utilizing CTP. Results: During the study 1253 patients were evaluated via telestroke and 101 (8.1%) were transferred for a possible EVT. Before CTP, 540 telestroke patients completed CT head and/or CTA head and neck imaging. After CTP, 713 telestroke patients received CT head, CTA and CTP imaging. Patients receiving CTP had a significantly shorter DIO time (median 109 minutes) compared to patients without CTP (median 122 minutes), p=0.04, r =0.26. There was no difference in DTN in patients without CTP (66 minutes) compared to patients who received CTP (63 minutes), p=0.42, r=0.07. There was no significant difference in the proportion of patients transferred for a possible EVT that received a stroke thrombectomy in patients without CTP 28 (74%) compared to patients with CTP 38 (84%), p=0.23. Conclusions: In conclusion, automated perfusion maps and calculated ischemic penumbra size in CTP allowed telestroke physicians to make quicker transfer decisions, without delaying DTN. Disclosure: Dr. Hackett has nothing to disclose. Dr. Cerejo has nothing to disclose. Dr. Fishman has nothing to disclose. Dr. Wright has nothing to disclose. Dr. Rana has nothing to disclose. Dr. Tayal has nothing to disclose.

Introduction: Timeliness of a response to page by telestroke physicians is an important component in a telestroke network. Accrediting organizations such as the Joint Commission require telemedicine to be available within 20 minutes of the request. We implemented a secure messaging system to improve physician communication. We hypothesized that implementation of a secure messaging system would improve communication, reduce telestroke physician response to page and reduce door-to-needle (DTN) times compared to the previous pager-based system. Methods: We reviewed data collected as part of our telestroke quality program. We compared response to page times for one year before and after initiation of the secure messaging system. Additionally, we compared DTN times during the same epochs. Results: Seven hundred and sixty-five telestroke consults were completed in the year prior to implementation of the secure messaging system and 941 telestroke consults were completed in the year following implementation. Telestroke response to page time decreased significantly between pre ( mean rank 1005; median 4 min) and post ( mean rank 731 ; median 2 min) implementation of the secure messaging system ( U = 244,240 , p < .001, r = .28). A significantly greater percentage of telestroke neurologist response times occurred within 20 minutes when using secure messaging 936/941 (99.5%) compared to pagers, 751/765 (98.2%), χ 2 (1, N = 1706) = 6.46, p = .01, φ = .06. DTN was lower when using secure messaging (64 min) compared to the prior paging system (66 min), but this difference was not statistically significant ( p = .74). Conclusions: In conclusion, implementation of a secure messaging system improved communication in our telestroke network and reduced telestroke response to page compared to our prior paging system. Implementation of the secure messaging system did not significantly reduce DTN times.

May 6, 2019April 9, 2019Free AccessExtending Telestroke Call Window to 24 Hours Increases Call Volume and Acute Stroke Treatments (P2.3-024)Chris Hackett, Rebekah Heintz, Rahul Rahangdale, David Wright, Robert Fishman, Sandeep Rana, and Ashis TayalAuthors Info & AffiliationsApril 9, 2019 issue92 (15_supplement)https://doi.org/10.1212/WNL.92.15_supplement.P2.3-024 Letters to the Editor