Background and Purpose— Timely access to endovascular thrombectomy (EVT) centers is vital for best acute ischemic stroke outcomes. Methods— US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. Direct EVT-access, defined as the population with the closest facility being an EVT-center, was calculated from validated trauma-models adapted for stroke. Current 15- and 30-minute access were described nationwide and at state-level with emphasis on 4 states (TX, NY, CA, IL). Two optimization models were utilized. Model-A used a greedy algorithm to capture the largest population with direct access when flipping 10% and 20% non-EVT to EVT-centers to maximize access. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center. Results— Of 1941 stroke-centers, 713 (37%) were EVT. Approximately 61 million (19.8%) Americans have direct EVT access within 15 minutes while 95 million (30.9%) within 30 minutes. There were 65 (43%) EVT centers in TX with 22% of the population currently within 15-minute access. Flipping 10% hospitals with top population density improved access to 30.8%, while bypassing resulted in 45.5% having direct access to EVT centers. Similar results were found in NY (current, 20.9%; flipping, 34.7%; bypassing, 50.4%), CA (current, 25.5%; flipping, 37.3%; bypassing, 53.9%), and IL (current, 15.3%; flipping, 21.9%; bypassing, 34.6%). Nationwide, the current direct access within 15 minutes of 19.8% increased by 7.5% by flipping the top 10% non-EVT to EVT-capable in all states. Bypassing non-EVT centers by 15 minutes resulted in a 16.7% gain in coverage. Conclusions— EVT-access within 15 minutes is limited to less than one-fifth of the US population. Optimization methodologies that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT-access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT-access.

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BackgroundSex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women.ObjectiveTo compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women.MethodsFrom the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016–2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measures, mixed-effects regression model.ResultsOf 285 patients, 139 (48.8%) were women. Women were older with median (IQR) age 69 (57–81) years vs 64.5 (56–75), p=0.044, had smaller median perfusion deficits (Tmax >6 s) 109 vs 154 mL (p<0.001), and had better collaterals on CT angiography and CT perfusion but similar ischemic core size (relative cerebral blood flow <30%: 7.6 (0–25.2) vs 11.4 (0–38) mL, p=0.22). In 65 propensity-matched pairs, despite similar discharge functional independence rates (women: 42% vs men: 48%, aOR=0.55, 95% CI 0.18 to 1.69, p=0.30), women exhibited worse 90-day functional independence rates (women: 46% vs men: 60%, aOR=0.41, 95% CI 0.16 to 1.00, p=0.05). The reduction in mRS scores from discharge to 90 days also demonstrated a significantly larger improvement in men (discharge 2.49 and 90 days 1.88, improvement 0.61) than in women (discharge 2.52 and 90 days 2.44, improvement 0.08, p=0.036).ConclusionIn a propensity-matched cohort from the SELECT study, women had similar discharge outcomes as men following EVT, but the improvement from discharge to 90 days was significantly worse in women, suggesting the influence of post-discharge factors. Further exploration of this phenomenon to identify target interventions is warranted.Trial registration numberNCT02446587.

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Introduction: Females are underrepresented as speakers at major scientific conferences. Furthermore, in neurology, males outnumber females in academic positions, rank and number of publications, which may influence this inequality. Objective: To evaluate trends in invited speakers by sex at the International Stroke Conference (ISC). Methods: Data were obtained (years 2014-2018) for invited speakers to the ISC from the American Heart Association. Variables included sex, degree, race, speaker institution country, and speaker category. Data were analyzed by chi-square test, Fisher’s exact test, or logistic regression. Results: Over 5 years, 1086 individuals with 1283 presentations were invited for invited symposia (83%), pre-conference (11%), debate (5%), and case theater (1%). Females represented a mean of 29% of speakers, which did not vary by year (p=0.99), so years were combined. The highest and lowest proportions of females were in invited symposia (30.4%) and case theater (5.6%). All mid-levels and nurses, but only 17.7% of physician speakers were female. Females were 32.7% of Caucasian speakers and only 16.7% and 12.0% of Black and Hispanic speakers, respectively. The highest and lowest proportions of female speakers were from institutions in South America (50%) and Africa (0%). The proportion of female speakers was highest in nursing (86.4%) and pediatric stroke (45.2%) and lowest in neurocritical care and aneurysm (0%). Grouped, the highest proportion of female speakers was in recovery and rehabilitation (33.5%), and the lowest was in acute care (19%). Males were more likely invited as speakers more than once (p=0.01). Conclusions: Females are less likely invited speakers to the ISC compared to males, especially in fields like critical care, with a smaller female pool. Moreover, females in underrepresented racial groups and female physicians are less often speakers. Increased efforts are warranted to improve sex differences among speakers at the ISC.

Background: Stroke is a leading cause of death and disability. Early presentation allows clinicians to use tPA for acute stroke therapy to improve outcomes. However, healthcare disparities among different racial/ethnic and gender groups remain a limitation for uniform access to acute stroke therapy. We investigated if such gender and racial disparity exist in tPA administration at a large community comprehensive stroke center (CSC). Methods: Retrospective analysis of a prospective cohort of patients was conducted of patient with acute stroke symptoms who presented to a CSC between May 2018 and May 2022. Demographics, time from last known normal (LKN), rate of tPA administration and door to needle time (DTN) was calculated. Univariate analysis between groups was performed using one-way ANOVA for mean, Kruskal-Wallis test for median and p-value &lt;0.05 was considered significant. Results: Total number of patients presenting to our CSC during the study period with stroke like symptoms was 3901. Of this index cohort, 401 (10.2%) were administered tPA - 207 (51.6%) women and 194 (48.3%) men. Women were significantly older [67.5 ± 15.1 years compared to men, 62.6 ± 13.3 years (p=0.027)]. Average time of LKN to arrival was 124 ± 3.8 min for women and 130 ± 4.9 min for men (p=0.298). Black women’s DTN was longer compared to white women ( 50.9 ± 3.15 min v. 41.5 ± 2.07 min, p=0. 0103). However, proportion of Black women receiving tPA did not differ from white women [87/770 (11.3%) v. 113/1041 (10.9%), p=0.824]. Race disparity was noted among Black men compared to white men for tPA administration [64/798 (8.0%) v 119/1226 (9.7%), p=0.018]. No gender or racial disparity was noted among tPA recipients regarding mRS at discharge [white men v. white women v. Black men v. Black women - 2 (IQR 1,4) v. 3 (IQR 1,4) v. 3 (IQR 1,4) v. 3 (IQR 1,4), p=0.211]. Conclusions: At a large volume, urban, non-academic comprehensive stroke center, overall gender, or racial factors were similar for discharge outcome. However, a delay in tPA administration among Black women and lower incidence of tPA administration in Black men compared to their respective white counterparts need to be validated in larger registries.

Introduction: Excessive daytime sleepiness (EDS) and post-stroke depression (PSD) are risk factors for stroke morbidity and mortality. EDS is commonly seen after stroke, but is not routinely assessed after stroke. EDS may be related to sleep disordered breathing (SDB) including obstructive and central sleep apneas, but can also occur in the absence of SDB. The relationship between EDS and PSD is not well understood. Hypothesis: We sought to assess the association between EDS and PSD. We hypothesized that patients with EDS are more likely to demonstrate symptoms of moderate to severe depression compared to patients without EDS. Methods: We identified ischemic stroke patients from the outpatient clinic registry (06/2014 - 10/2015). We screened for depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9; range 0-27, higher worse), and for EDS using the Epworth Sleepiness Scale (ESS; range 0-24, higher worse). Univariate and multivariate analyses were used to evaluate association between EDS and PHQ-9 (moderate to severe depression = PHQ-9 > 9). Regression analysis was also used to evaluate association between EDS and symptoms included in the PHQ-9. Results: Among 200 ischemic stroke patients, 166 completed ESS and PHQ-9 within 90 days of stroke occurrence. Mean age was 61.5 and 54.8% were male. EDS (ESS>9) and moderate to severe depression were each present in 28.9% of patients. Patients with EDS had 3.5 times odds of moderate to severe depression compared to patients without EDS (table 1). Moreover, EDS was associated with higher odds of anhedonia, impaired mood, sleep disturbance, low energy, poor appetite, and impaired concentration (table 1). Conclusion: The presence of EDS is associated with moderate to severe depression in stroke survivors. This is not related solely to SDB symptoms. Patients with fatigue and EDS should be screened for depression. Future studies are also needed to explore the role that SDB plays in this relationship.

Background: The burden of acute stroke alerts on hospital resources and staff have grown with expanding treatment timelines. The purpose of this project is to develop a nurse activated acute stroke process to accurately capture ischemic and hemorrhage stroke amendable for acute treatment with a two level activation model for 0-4 hours (level 1) and 4-24 hours (level 2) from last known well. Methods: Prospective quality improvement data abstracted on patients in a five-hospital regional telestroke network from October 2020 thru June 2021 with the current single level 24-hour stroke symptom protocol. We retrospectively applied our proposed two level activation model to our data to look for accuracy in stroke diagnosis, proportion of stroke mimics, missed stroke interventions, including intracerebral hemorrhage (ICH), and telestroke provider time spent. We used standard error of mean (SEM) to measure discrepancy of process. Results: A total of 340 stroke activation were captured. Of those, 54% (183/340) were discharged without a stroke diagnosis, 27% (93/340) ischemic, 14% (48/340) transient ischemic attack, 4% (13/340) ICH, 1% (3/340) subarachnoid hemorrhage, and 34% (117/340) arrived in the level 2 window. We excluded 5 ICH patients due to arriving comatose necessitating emergent imaging outside of stroke alert process. Comparing single activation versus two level activation resulted in a reduction of stroke alerts (117 versus 21), telestroke provider time (2501 minutes versus 713 minutes), increase in accurate stroke diagnosis (46% versus 76%), decrease in stroke mimics (54% versus 29%), with 1 missed ICH and 1 missed thrombectomy (5%). The single activation showed a mean 11.11% and SEM of 0.023 compared to the two level activation mean 1.99% and SEM of 0.006. Conclusion: Two level stroke activation process was validated to reduce stroke mimics, improve accurate stroke diagnoses, maximize resources utilization, and capture 95% of all ischemic strokes with large vessel occlusions, therefore the new process will be implemented within our large telestroke system following staff education.