Abstract 201: Effect of Endovascular Reperfusion in Relation to Site of Arterial Occlusion: A Pooled Analysis of Individual Patient Data

Background: Previous studies have shown an association between reperfusion and good clinical outcome, but it is unknown if this association differs depending on the site of the arterial occlusive lesion (AOL). We pooled individual patient data from prospective endovascular stroke studies to assess this.

Methods: We included data from the endovascular arm of IMS III, a trial of intravenous (IV) thrombolysis alone versus IV thrombolysis and endovascular treatment; SWIFT, a trial comparing the Solitaire with the Merci device; STAR, a cohort study of patients treated with the Solitaire device; and DEFUSE 2, a cohort study of patients who received endovascular therapy. We compared the strength of the associations between reperfusion and clinical outcomes in patients with ICA, M1 and M2/3/4 (M2+) occlusions. The primary outcome was good functional outcome at day 90 defined as a modified Rankin Scale 0-2. Secondary outcomes included 90-day mortality and symptomatic intracranial hemorrhage (sICH).

Results: 710 Patients were included in the analysis. The site of the AOL was ICA in 161, M1 in 389, and M2+ in 160 patients (M2=131, M3=23 and M4=6). The association between reperfusion and good functional outcome was stronger for patients with ICA occlusions (45% vs 19%; OR 3.5, 95%CI 1.7-7.2) and M1 occlusions (58% vs 18%; OR 6.2, 95%CI 3.8-10.2) than for patients with M2+ occlusions (53% vs 45%; OR 1.4, 95%CI 0.8-2.6) (p for difference in ORs=0.003). Mortality was reduced with reperfusion in patients with ICA (39% vs 18%; OR 0.4, 95%CI 0.2-0.7) and M1 occlusions (30% vs 10%; OR 0.3, 95%CI 0.2-0.5), but not in patients with M2+ occlusions (15% vs 15%; OR 1.0, 95%CI 0.4-2.3). Reperfusion was associated with fewer incidences of sICH without evidence of an interaction with AOL (OR 0.3, 95%CI 0.2-0.6).

Conclusion: The association between endovascular reperfusion and improved clinical outcomes is more profound in patients with ICA and M1 occlusions than in patients with M2+ occlusions. This differential response to reperfusion has important implications for the design and power calculations of endovascular stroke trials.

Sun CH, Coleman Martin C, Holloway W, Mueller-Kronast N, English J, Linfante I, Dabus G, Malisch T, Marden F, Bozorgchami H, Xavier A, Rai A, Froehler M, Badruddin A, Abraham M, Janardhan V, Shaltoni H, Yoo A, Abou-Chebl A, Chen P, Britz G, Kaushal R, Nanda A, Nogueira R, Nguyen T, Zaidat OO. Abstract 197: Time Dependency and Relationship to Reperfusion Grade in Acute Ischemic Stroke

Background: Time to reperfusion following endovascular treatment (ET) strongly predicts outcomes after acute ischemic stroke (AIS). However, the impact of time may vary depending on the grade of reperfusion. We sought to assess time-outcome relationship within grades of reperfusion in the North American Solitaire Acute Stroke (NASA) registry.

Methods: The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. We identified patients treated with anterior circulation ischemic stroke treated within 8 hours. The modified Thrombolysis in Cerebral Ischemia (TICI) was used wherein TICI 2 was divided in TICI 2a (< 50% reperfusion) and TICI 2b (> 50% reperfusion). We assessed the impact of time to reperfusion (onset to procedure completion time) on good outcome (modified Rankin Scale 0-2 at 3 months) in those who achieved at least TICI 2a reperfusion, independent of other relevant covariates using logistic regression analysis. We further assessed this relationship within strata of reperfusion grade.

Results: Among 265 eligible patients, 209 (78.9%) had complete data (mean age 68.4 years, median NIHSS score 18). Reperfusion grade was as follows: TICI 3: 35.4%; TICI 2b: 39.7%, TICI 2a: 14.8%; TICI 0-1: 10.0%. Independent predictors of outcome at 3 months among those achieving TICI 2-3 reperfusion were: initial NIHSS score, intravenous tissue plasminogen activator use, symptomatic hemorrhage, and time to reperfusion. For each 30 minutes, the adjusted OR for time to reperfusion was 0.874 (95% CI 0.797-958). There was a significant interaction between final TICI grade and 30-minute time to reperfusion intervals (P=0.001) such that the effect of time was strongest in TICI 2a patients.

Conclusions: Time to reperfusion is a strong predictor of outcome following ET for AIS with 13% decreased odds of good outcome per 30-minute delay in achieving TICI 2-3 reperfusion. However, the effect varied by TICI grade such that its greatest effect was in those achieving TICI 2a reperfusion.

Abstract W P358: Rate of “Non-Go Activation” of a High Volume Stroke Center Neuroendovascular Team during the “After Hours”/On-Call Period: Exploring the Financial Impact to an Acute Stroke Program

Background and Purpose: Timely reperfusion in large vessel occlusion strokes (LVOS) is crucial to achieving optimal functional outcomes. Acute neurointerventional therapy requires a team of individuals be assembled and ready as soon as the workup is completed and the patient is deemed an eligible and appropriate thrombectomy candidate. On occasion, the endovascular on call team is activated but the patient is subsequently determined ineligible for interventional therapy. We aimed to explore the frequency and financial impact of on-call neuroendovascular team activation when the procedure is a “Non-Go” situation and to determine its impact on the operating budget of an acute endovascular stroke program.

Methods: From February-July 2014, information was collected on all instances of the neuroendovascular team being activated during the “After Hours”/On-Call period (defined as: weekdays 7PM-7AM and weekends e.g. Fri 7PM-Mon7AM) but a procedure not done due to patient ineligibility. The information collected included patient demographics, date and time of the activation, and reason why the procedure was not performed.

Results: During the five month data collection period, there were 12 occasions of “Non-Go Activation” of the Neuroendovascular Team during “After Hours”. Three patients (25%) were randomized to IV tPA only in a clinical trial, four patients (33%) had marked improved symptoms and/or no-occlusion on CT angiography, and five patients (42%) had large core on initial imaging. During this same period, a total of 70 thrombectomies were performed for a ratio 5.8 overall thrombectomies for every “Non-Go After Hours” activation which seems to be a financially viable model.

Conclusions: The “stand-by strategy” for the neuroendovascular team for selected stroke transfers and emergency room cases is justifiable based on the need for rapid reperfusion in LVOS. The extra burden on the “on-call” personnel is acceptable and the extra costs represent a relatively small fraction of the treatment expenses.

Door-to-puncture: a practical metric for capturing and enhancing system processes associated with endovascular stroke care, preliminary results from the rapid reperfusion registry

Background

In 2011, the Brain Attack Coalition proposed door‐to‐treatment times of 2 hours as a benchmark for patients undergoing intra‐arterial therapy (IAT). We designed the Rapid Reperfusion Registry to capture the percentage of stroke patients who meet the target and its impact on outcomes.

Methods and Results

This is a retrospective analysis of anterior circulation patients treated with IAT within 9 hours of symptom onset. Data was collected from December 31, 2011 to December 31, 2012 at 2 centers and from July 1, 2012 to December 31, 2012 at 7 centers. Short “Door‐to‐Puncture” (D2P) time was hypothesized to be associated with good patient outcomes. A total of 478 patients with a mean age of 68±14 years and median National Institutes of Health Stroke Scale (NIHSS) of 18 (IQR 14 to 21) were analyzed. The median times for IAT delivery were 234 minutes (IQR 163 to 304) for “last known normal‐to‐groin puncture” time (LKN‐to‐GP) and 112 minutes (IQR 68 to 176) for D2P time. The overall good outcome rate was 39.7% for the entire cohort. In a multivariable model adjusting for age, NIHSS, hypertension, diabetes, reperfusion status, and symptomatic hemorrhage, both short LKN‐to‐GP (OR 0.996; 95% CI [0.993 to 0.998]; P<0.001) and short D2P times (OR 0.993, 95% CI [0.990 to 0.996]; P<0.001) were associated with good outcomes. Only 52% of all patients in the registry achieved the targeted D2P time of 2 hours.

Conclusions

The time interval of D2P presents a clinically relevant time frame by which system processes can be targeted to streamline the delivery of IAT care nationally. At present, there is much opportunity to enhance outcomes through reducing D2P.

A novel approach to diagnose reversible cerebral vasoconstriction syndrome: a case series

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) is classically diagnosed based on the presence of severe thunderclap headache, focal neurologic symptoms, and the radiographic findings of reversible diffuse segmental cerebral vasoconstriction. We present a diagnostic test that may assist in the clinical diagnosis and facilitate treatment.

METHODS

From October 1, 2010, to August 1, 2013, we identified consecutive patients who presented with a presumptive diagnosis of RCVS and underwent cerebral diagnostic angiography with intra-arterial (IA) vasodilator therapy. Medical records including clinical presentation, radiographic, and angiographic images were all reviewed.

RESULTS

We identified a total of 7 patients (4 females; age range, 22-56; mean, 45 years) who met our inclusion criteria. Four patients received a combination of milrinone and nicardipine infusion either in the internal carotid arteries or in the left vertebral artery; the remaining patients received IA therapy solely with either nicardipine or milrinone. Five patients had a positive angiographic response, defined as significant improvement or resolution of the blood vessels irregularities. All 5 patients had a definite discharge diagnosis of RCVS. The remaining 2 patients had a negative angiographic response and based on their clinical and radiographic course had a final diagnosis of intracranial atherosclerotic disease.

CONCLUSIONS

Our small case series suggest that IA administration of vasodilators is safe and may aid in distinguishing vasodilator responsive syndromes such as RCVS from other causes. Further study is required with long-term clinical outcome to determine the utility of this diagnostic test.

Mineral cycling and pH gradient related with biological activity under transient anoxic-oxic conditions: effect on P mobility in volcanic lake sediments

Phosphorus (P) mobility from the sediments to the water column is a complex phenomenon that is generally assumed to be mainly redox sensitive and promoted by anoxic conditions. Thus, artificial aeration of the hypolimnium has been used as a remediation technique in eutrophic water bodies but several times with unexpected disappointing results. To optimize lake restoration strategies, the aim of the present study is to assess the P flux from the sediments under transient anoxic-conditions and to identify the relevant drivers. P sequential extraction, microprofiling (of pH, O2 and H2S), and bacterial community identification were performed on a sediment microcosm approach. The results demonstrated that the overall P release from sediments to the water column during transient phase was higher during the oxic phase, mainly from pH sensitive matrixes. The microprofiles signature suggests that the observed pH gradient during the oxic phase can be a result of H2S oxidation in suboxic layers spatially separated and pared to O2 reduction in top layers, through an electroactive bacterial network. These findings point to an additional driver to be considered when assessing P mobility under transient anoxic-oxic conditions, which would derive from pH gradients, built on the microbial electrical activity in sediments from freshwaters volcanic lakes.

Clinical, angiographic and radiographic outcome differences among mechanical thrombectomy devices: initial experience of a large-volume center

BACKGROUND AND PURPOSE

Higher reperfusion rates have been established with endovascular treatment of acute ischemic stroke (AIS). There are limited data on the comparative performance of mechanical thrombectomy devices.

METHODS

A retrospective single-center analysis was undertaken of all consecutive patients who underwent thrombectomy using Merci, Penumbra or stent retrievers (SR) from September 2010 to November 2012. Baseline characteristics, rates of successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) score 2b-3), symptomatic intracerebral hemorrhage (sICH), final infarct volume, 90-day mortality and independent functional outcomes at 90 days were compared across the three devices.

RESULTS

Our cohort included 287 patients. There were mild imbalances in baseline characteristics with trends towards higher National Institutes of Health Stroke Scale (NIHSS) score in patients in the Merci group (SR=18 vs Merci=21 vs Penumbra=19, p=0.06) and lower Alberta Stroke Program Early CT Score (ASPECTS) in patients in the SR group (>7: SR=51% vs Merci=61% vs Penumbra=62%, p=0.12). On univariate analysis there were no differences in the rate of sICH (SR=7% vs Merci=7% vs Penumbra=6%, p=0.921) and infarct volume (SR=61.5 mL vs Merci=69.5 mL vs Penumbra=59.2 mL, p=0.621). Trends towards better functional outcomes were found with Penumbra and SR vs Merci (41% vs 36% vs 25%, respectively, p=0.079). Complete or near complete reperfusion (mTICI 2b-3) was higher in the SR and Penumbra groups than in the Merci group (86% vs 78% vs 70%, respectively, p=0.027). Binary logistic regression showed that SR was an independent predictor of good functional outcome (OR 2.27, 95% CI 1.018 to 5.048; p=0.045).

CONCLUSIONS

Although our initial data confirm the superiority of SR technology over the Merci device, there was no significant difference in near complete/complete reperfusion, final infarct volumes or clinical outcomes between SR and Penumbra thromboaspiration.

Abstract 144: The Pittsburgh Outcomes After Stroke Thrombectomy (POST) Score Predicts Good Outcomes After Endovascular Therapy for Anterior Circulation Large Vessel Occlusions

Background: Independent predictors of good outcome following large vessel occlusions (LVO) include age, infarct volume, NIHSS at presentation and revascularization status. The aim of this study was to develop an easy-to-use tool to predict good outcome following endovascular treatment for LVO.

Methods: In a derivation cohort of patients with anterior circulation LVO treated with endovascular therapy at Grady Memorial Hospital (GMH, n=247), we performed logistic regression to identify independent predictors of good outcome (mRS 0-2 at 90 days). Factors were weighted based on B-coefficients to generate a score (POST) that predicts good outcome. The derivation cohort was divided in risk group quartiles and correlation analysis between predicted and observed rates of good outcomes was performed. POST was also validated in two cohorts derived from the University of Pittsburgh Medical Center (UPMC, n=380) and the DEFUSE 2 database (n=105).

Results: In the derivation cohort (mean age 66±1 yrs, median NIHSS 18), independent predictors (p<0.2) of good outcome included final infarct volume (FIV; OR 0.97, 0.96-0.98), age (OR 0.96, 0.94-0.98), NIHSS at presentation (OR 0.93, 0.88-0.98) and PH1/PH2 hemorrhage (H; OR 0.3, 0.06-1.6, p=0.15). POST was defined as Age + 0.5 X FIV + 15 X H. Patients in the lowest POST quartile (<60) had a 91% chance of good outcome as compared to 3% in the highest POST quartile (≥120). There was a strong correlation between predicted and observed rates of good outcomes in the 4 groups (R=0.99, p<.001). POST performed well in predicting good outcomes in the derivation (AUC=0.85), as well as the UPMC (AUC=0.81) and DEFUSE 2 (AUC=0.86) validation cohorts.

Discussion: The POST score is a validated tool to predict good clinical outcomes following endovascular therapy in patients with acute large vessel occlusions. This tool can guide families and physicians in clinical decision making following endovascular therapy.

Abstract T P26: Predictors of Clinical and Angiographic Outcomes in Acute Stroke Treatment: Subgroup Analysis From the Star Study

Endovascular acute stroke treatment (AIS) has changed dramatically last years. Stent retrievers are progressively substituting other devices and old practices like intra-arterial thrombolysis. We present the subgroup analysis of the largest prospective multicentre study using stent retrievers on the treatment of AIS. The study was realized in 14 high volume and experienced stroke centres in Europe, Canada and Australia. 202 patients harbouring anterior circulation occlusions were included within 8 hours after onset. All procedures were performed with balloon guiding catheter. We observed that the occlusion location did not change the successful (TICI 2b or 3) recanalization rates (ICA - 76.5% and MCA - 86.4%: p=0.187) or good clinical outcomes (mRS 0-2) (ICA - 47.2% and MCA - 61.3%: p=0.137). However, it was significant when we considered excellent (mRS 0-1) outcomes only (ICA - 25% and MCA - 47.5%: p=0.016). There were no differences concerning the previous use of rtPA on the angiographic (TICI scores) (p=1.0) or clinical (mRS) (p=0.564) outcomes. The anaesthetic management also did not influence the revascularization (p=0.7) or patient’s status (p=0.343). Angiographic collateral status determined using the ASITN/SIR grading system was significantly correlated to good clinical outcomes (Grades 0-2 and Grades3-4, p=0.034). Also the time from the stroke onset to groin puncture influence clinical progress (0-3h, 3-4.5h, over 4.5h: p=0.002). Multivariate regression analysis on prediction of good outcomes was significant for age (OR-0.93 (0.89, 0.97)), baseline NIHSS (OR-0.87(0.79, 0.96)), absence of haemorrhage (OR-5.01 (1.65, 15.16)), time to treatment (OR-0.62(0.45-0.83)) procedure performed under conscious sedation (OR4.83(1.78,13.11)) and successful recanalization (OR-3.37(1.12,10.14)). Early and efficient revascularization is ideal situation for AIS. Conscious sedation can save time for endovascular procedure using a stent retriever in experienced centers.

Abstract T MP10: Pittsburgh Response to Endovascular Therapy (PRE) Score Predicts Likelihood of Benefit From Endovascular Therapy in Anterior Circulation Large Vessel Occlusions

Background: Endovascular therapy seems to benefit a subset of patients with acute large vessel occlusions (LVO). The aim of this study was to develop a clinically useful tool to identify patients with anterior circulation large vessel occlusions who are likely to benefit from endovascular therapy.

Methods: Adults with anterior circulation LVOs were included. In the derivation cohort (2008-2012) from Grady Memorial hospital (GMH), independent predictors (p<0.2) of good outcome (mRS 0-2 at 90 days) were determined using logistic regression. Highly weighted factors were used to derive the PRE score as a predictor of good outcome. Four risk-quartiles were created based on observed rates of good outcomes. The PRE score was validated in the UPMC database (n=322, 2007-2013) and in a database from Unitat d'Ictus Vall d'Hebron (UIVH), Barcelona (n=203, 2009-2012). Performance of PRE was compared with HIAT-2, THRIVE and ASPECTS in predicting good outcome.

Results: In the derivation cohort (N=247, mean age 66±1, median NIHSS 18), independent predictors of good outcome included age (OR 0.96, 0.94-0.98), NIHSS (OR 0.92, 0.87-0.98) and ASPECTS (OR 1.96, 1.6-2.5). The PRE score was calculated as follows: PRE Score = Age + 2 x NIHSS - 10 x ASPECTS. PRE predicted good outcomes in the derivation cohort (AUC 0.79) as well as in the validation cohorts (UPMC: AUC 0.79 and UIVH: AUC 0.72) and comparative rates of good outcome were observed in the four PRE quartiles. PRE < 25 was associated with good outcome (OR 6.0, 3.5-10.5), and controlling for TICI 2B/3 reperfusion status further strengthened this association (OR 12.8, 4.5-36.2). PRE (AUC 0.79) performed better than HIAT2 (AUC 0.75), THRIVE (AUC 0.73) and ASPECTS (AUC 0.57) in predicting good outcomes after endovascular therapy.

Conclusions: The PRE score is a validated tool to predict benefit from endovascular therapy in patients with anterior circulation LVO. PRE can aid in the selection of patients for endovascular reperfusion therapy.

Abstract T MP51: Concordance of Emergency Medical Services and Neurology Times Last Seen Normal in Acute Ischemic Stroke Patients

Background and Purpose: The establishment of a patient’s time last seen normal (TLSN) is an important step for medical decision making in the current treatment paradigm of acute ischemic stroke patients. While both emergency medical services (EMS) and neurologists evaluate stroke patients, there is limited data on the concordance of TLSN as determined by the two groups. The purpose of our study was to identify the frequency of clinically significant differences between reported TLSN by EMS and neurology providers.

Methods: We performed a retrospective chart review of acute ischemic stroke patients brought in to Emory University Hospital by EMS who were treated with IV thrombolysis from January 2010 to April 2013 to obtain the TLSN. For this analysis, we included only those patients who had documentation of TLSN by both EMS and neurology providers. A clinically significant difference between reported TLSN by EMS and neurology providers was defined as a discrepancy >30 minutes.

Results: Of 131 patients who were brought in by EMS and received IV thrombolysis during the study period, 109 (83%) had documentation of TLSN by both EMS and neurology providers (mean age 69.6 ± 16.5 years; 51% female). EMS and neurology providers reported the same TLSN in only 44% of cases. However, a difference of >30 minutes between the 2 groups was found in only 15% of cases. In a multivariable logistic regression analysis, the only variable found to be a predictor of discrepancy >30 minutes between EMS and neurology providers was first medical contact in the morning (midnight to 10 AM)(p=0.02); race, sex, EMS provider company, and baseline NIHSS score were not predictors.

Conclusion: While TLSN obtained by EMS and neurology providers varied in more than half of patients, only 15% of cases had a >30 minute discrepancy. Acute ischemic stroke patients presenting in the morning were more likely to have a clinically significant difference in TLSN reported by EMS and neurology providers.

Abstract 142: ASPECTS Decay During Inter-Facility Transfer Predicts Patient Outcomes in Endovascular Reperfusion for Ischemic Stroke: A Unique Assessment of Dynamic Physiologic Change Over Time

Background: In acute ischemic stroke, delays in reperfusion lead to a reduced probability of good clinical outcomes. Pre-treatment Alberta Stroke Program Early CT Scores (ASPECTS) are also associated with clinical outcomes, but the rate of change between subsequent CT images in transferred patients may be more predictive as it incorporates time. We hypothesized that patients with significant change in ASPECT scores would have worse clinical outcomes despite having a favorable pre-treatment baseline ASPECTS.

Methods: A cohort of patients transferred from seven Primary Stroke Centers and treated with endovascular reperfusion (December 15, 2010 to March 15, 2013) were retrospectively studied. All patients were analyzed with respect to radiographic, demographic, and time-related variables. Absolute ASPECTS decay was defined as [(ASPECTS First CT - ASPECTS Second CT)/time elapsed between CTs in hours]. A binary logistic regression model was performed to determine if the rate of ASPECTS decay was predictive of good 90 day outcomes (mRS 0-2).

Results: A total of 106 patients with a mean age of 66±14 years and median NIHSS of 19 [IQR 15-23] were analyzed. The median time between initial imaging at the outside hospital to repeat imaging at our treatment facility was 2.7 hours (IQR 2.0-3.6). Patients with good outcomes had lower rates of absolute ASPECTS decay compared to those who did not (0.14±0.23 score/hr vs. 0.49±0.39 score/hr; p<0.001). In multivariable modeling, the absolute rate of ASPECTS decay (OR 0.043; 95%CI 0.004-0.457; p=0.01) was a stronger predictor of good patient outcome than the static pre-treatment ASPECTS obtained immediately before intervention (OR 0.653; 95%CI 0.39-1.05; p=0.076). Practically, patients with a decay of two ASPECTS points per hour compared to those who decay at one point per hour had a 23 fold lower probability of a good outcome.

Conclusions: Our analysis demonstrates that patients with faster rates of ASPECTS decay are associated with worse clinical outcomes, reflecting the rate of physiological infarct expansion. This metric may be valuable in selecting patients for IAT, as patients with rapid ASPECTS decay are less likely to derive treatment benefit, particularly with delays in inter-facility transfers and procedure times.

Abstract T MP8: The Thrive Score Strongly Predicts Outcomes in Patients Treated With the Solitaire Device in the Swift and Star Trials

Introduction: The THRIVE score strongly predicts clinical outcome, mortality, and risk of thrombolytic hemorrhage in ischemic stroke patients, and performs similarly well in patients receiving IV tPA, endovascular stroke treatment (EST), or no acute treatment. We recently validated the performance of the THRIVE score in the TREVO-2 trial of a third generation EST device, the Trevo device

Methods: We examined the relationship between THRIVE and clinical outcomes (good outcome [mRS 0-2] or death at 90 days) among patients in SWIFT and STAR. Receiver-Operator Characteristics (ROC) curve analysis was used to compare THRIVE score performance to other stroke prediction scores. Multivariable logistic regression was used to confirm the independence of THRIVE score from procedure-specific predictors (target vessel recanalization or device used in SWIFT) of outcome.

Results: THRIVE score strongly predicted good outcome (Figure, A) and death (Figure, B) among patients treated with the Solitaire device in SWIFT and STAR (Mantel-Haenztel Chi-square test for trend P<0.001 for good outcome, P=0.01 for death). In ROC curve comparisons, THRIVE was superior to SPAN-100 (P<0.001) and performed similarly to HIAT (P=0.98) and HIAT-2 (P=0.54). In logistic regression, THRIVE’s prediction of good outcome was not altered after controlling for recanalization (in all Solitaire patients) or after controlling for device used (in the SWIFT RCT).

Conclusions: The THRIVE score strongly predicts clinical outcome and mortality in patients treated with the Solitaire device in the SWIFT and STAR trials. The lack of interaction between THRIVE and procedure-specific elements such as vessel recanalization or device choice supports the use of the THRIVE score as an a priori selection criterion in stroke clinical trials.

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center.

Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high.

Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers.

Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol.

Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.