Background and purpose: The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes. Methods: The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE. Aims: The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management. Conclusions: The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis.

DeyeCOM(++) had 100% specificity for large vessel occlusion, whereas DeyeCOM(--) had a 100% specificity for absence of large vessel occlusion. Sustained DeyeCOM, whether positive or negative, is a strong predictor of ultimate diagnosis that could lead to quicker endovascular treatment times.

BackgroundWe investigated patterns in the time from recombinant tissue-type plasminogen activator (rt-PA) treatment to symptomatic intracranial hemorrhage (sICH) onset in acute ischemic stroke.MethodsWe retrospectively reviewed all admitted “stroke code” patients from 2003 to 2017 at the University of California San Diego Medical Center from a prospective stroke registry. We selected patients that received IV rt-PA within 4.5 hours after onset/last known well and had sICH prehospital discharge. sICH diagnosis was made by prospective review. Endovascular-treated patients were excluded, given the variability of practice. sICH was prospectively defined as any new radiographic (CT/MRI) hemorrhage after rt-PA treatment and any worsened neurologic examination. Time to sICH was the time from rt-PA administration start to documented STAT head CT order time with the first evidence of new hemorrhage. Charts were reviewed for examination time metrics, demographics, clinical history, and neuroimaging.ResultssICH was identified in 28 rt-PA-only treated patients. The mean time to sICH was 18.28 hours (range 2.4–34 hours). Median time to sICH was 18.25 hours. sICH was correlated with increased age (p = 0.02) and increased NIH Stroke Scale (p = 0.01).ConclusionsOur findings suggest that rt-PA patients have the highest risk of post rt-PA sICH within the first 24 hours after treatment. This supports monitoring of rt-PA-treated patients in specialized settings such as neuro-intensive care units or stroke units. Our findings suggest that the probability of sICH is low 36 hours post rt-PA. Future larger studies are warranted to identify the patterns of bleeding after rt-PA administration.

Background: Early activation of the stroke code system allows for rapid treatment and potentially better outcomes. Multiple disparities have been identified in standard time metrics of acute stroke care. The purpose of this study was to determine if hospital arrival to stroke code activation (SCA) time was significantly different based on age, sex, or race/ethnic differences in an academic, Comprehensive Stroke Center. Methods: We retrospectively assessed prospectively collected data from the UCSD Stroke registry from June 2003 to July 2019 for all patients for whom a stroke code was activated. Stroke code time metrics, demographics, initial and final diagnosis, treatment, medical history, baseline vital signs, and baseline NIHSS were assessed. Continuous variables were assessed by Spearman rho, Pearson correlation and t test. ANOVA was used for ordinal variables. A linear regression model was built in a stepwise method. Analysis were done unadjusted and adjusted for baseline NIHSS and baseline blood glucose. Results: Of the 5,881 total subjects, 2,954 had a final diagnosis of stroke. The overall mean age was 66.4 (18-103 years, SD 16.7) and 69.1 (18-103 years, SD 15.4) for subjects with final diagnosis of stroke. The overall mean time to SCA was 5.2 minutes (-20 to 5,746, SD 124.5). Arrival to SCA was not significantly different with respect to age in unadjusted (rs=-0.13, p=0.08) and adjusted (rs=-0.14, p=0.46) analysis. Time was not significantly different with respect to sex in both unadjusted (p=0.30) and adjusted (p=0.24) analyses. Arrival to SCA time was not significantly different with respect to race in both unadjusted (p=0.99) and adjusted (p=0.99) analyses. Arrival to SCA time was not significantly different with respect to Hispanic ethnicity in both unadjusted (p=0.09) and adjusted (p=0.07) analysis. In a linear regression model, arrival by ambulance (t 3.10, p<0.001) was the only independent predictor of arrival to SCA time. Conclusion: There were no significant differences in time to SCA based on sex, age, or race at our academic, Comprehensive Stroke Center. Arrival by ambulance was the only independent predictor of lower arrival to SCA times. Protocols and education in acute stroke management in this setting have reduced disparities in SCA.

A B S T R A C TBACKGROUND AND PURPOSE: Identifying a last known well (LKW) time surrogate for acute stroke is vital to increase stroke treatment. Diffusion-weighted imaging (DWI) signal intensity initially increases from onset of stroke but mapping a reliable time course to the signal intensity has not been demonstrated. METHODS: We retrospectively reviewed stroke code patients between 1/2016 and 6/2017 from the prospective; Institutional review board (IRB) approved University of California San Diego Stroke Registry. Patients who had magnetic resonance imaging of brain from onset, with or without intervention, are included. All ischemic strokes were confirmed and timing from onset to imaging was calculated. Raw DWI intensity is measured using IMPAX software and compared to contralateral side for control for a relative DWI intensity (rDWI). LKW and magnetic resonance imaging (MRI) time were collected by chart review. Correlation is assessed using Pearson correlation coefficient between DWI intensity, rDWI, and time to MRI imaging. 1.5T, 3T, and combined modalities were examined. RESULTS: Seventy-eight patients were included in this analysis. Overall, there was statistically significant positive correlation (.53, P < .001) between DWI intensity and LKW time irrespective of scanner strength. Using 1.5T analyses, there was good correlation (.46, P < .001). 3T MRI analysis further showed comparatively stronger positive correlation (.66, P < .001). CONCLUSIONS:There is good correlation between DWI intensity and minutes from onset to MRI. This suggests a timedependent DWI intensity response and supports the potential use of DWI intensity measurements to extrapolate an LKW time. Further studies are being pursued to increase both experience and generalizability.