Back Ground: Rapid Arterial Occlusion Evaluation Scale (RACE) was first instituted in Barcelona and described in 2014 to successfully assess stroke severity and identify patients with acute stroke with large vessel occlusion (LVO) at pre-hospital setting by medical emergency technicians. Objective: We instituted Rapid Arterial Occlusion Evaluation Scale (RACE) hospital bypass protocol (RA) in Lucas county, Ohio since July 2015. Our aim in this study is to evaluate the sensitivity of our RACE protocol in identifying cerebro-vascular accidents and furthermore to identify ischemic CVAs from the cohort. Method: All county EMS personnel (N=464) underwent training in the Rapid Arterial Occlusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke symptoms, who were last seen normal less than 12 hours and had a RACE score ≥5 were taken to a facility that has neuro-interventional capacity, was implemented in July 2015. An IRB approved prospective DB was maintained during that period. Patient’s stroke characteristics, type of acute treatment and final diagnosis on discharge were reviewed for the purpose of this abstract. Our results were comparable to the Spanish study done in Barcelona in 2014. Results: Between Jul 2016-Jun 2016 186 RAs were activated. The discharge diagnoses included ischemic stroke N=91 (49%), ICH N=26 (14%) and TIA N=17(9%). The rate of stroke mimic was N=52 (28%) of the total RACE alerts. These included seizures (12%), metabolic encephalotpathy (12%) and others including sepsis and migraines. Of the patients presenting as RA, 33% underwent IV tPA treatment ± mechanical thrombectomy. Conclusion: Results from our prospective county wide data is comparable to prior studies. RACE score may be scalable to other EMS systems to triage potential LVOs for direct transfer to centers with interventional capabilities.

Background: There is concern regarding hospital bypass stroke protocols potentially compromising IVtPA treatment due to transit time delay. We compared our IV thrombolysis time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: RA protocol whereby RACE score ≥5 patients are transferred directly to comprehensive stroke center (CSC) for potential mechanical thrombectomy (MT) was implemented in Jul 2015. All stroke alerts (SA) that required MT from July 2013 through June 2015 were compared to MT cases performed following RA protocol implementation. Transfers from other counties, private transport and in-hospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 activation to treatment time, and outcomes were compared. Results: Between Jul 2015-Jun 2016, 37 RA patients underwent MT of which 21 (56.8%) were given IV tPA at the CSC. Whereas in the preceding 2 years from Jul 2013-Jun 2015, 56 SA patients underwent MT, of which 22 (39%) received IVtPA. Of these SA cases, 11 (50%) were drip and transfer from other LC ERs and the remaining 11 (50%) presented directly to CSC. The 911 activation to 1 st ER arrival remained unchanged (34 vs. 32 mins, p 0.4), whereas tPA administration was significantly faster (64 vs. 88 mins, p <0.05) in the RA cohort (see graphic). Conclusions: Within LC, the RA bypass protocol did not result in a significant delay to ER arrival and it significantly expedited IV tPA delivery to patients undergoing MT. Further prospective studies are warranted.

Background: Early stroke identification and treatment with mechanical thrombectomy (MT) increases likelihood of favorable outcome. We compared our MT time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: Our RA protocol mandates emergent comprehensive stroke center transfer for patients with RACE score ≥ 5. We compared MT cases for RA patients (N=37) from Jul 2015-Jun 2016 with procedures performed on Stroke Alerts [(SA) N=56] from preceding 2 years. Transfers from outside LC, private transport and inhospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 call to treatment, and outcomes were compared. Results: Treatment times including 911 call to IV tPA treatment, groin puncture, and recanalization were all significantly faster in the RA cohort (see graphic). Overall RA patients achieved recanalization and favorable outcomes at higher rate, although the latter was not statistically significant. Conclusion: Our experience indicates that RA protocol is highly effective in enhancing overall time efficiency for MT and may contribute to improved clinical outcomes. Further prospective studies are warranted.

Objective: Computed Tomography Angiography ( CTA) is the standard of care test for ischemic stroke patients with suspected large vessel occlusion. When establishing emergency room stroke pathways, concerns for contrast induced nephropathy (CIN), which occurs in 11% of the general population could influence the time efficiency for CTA. Our aim is to report the incidence of CIN in our suspected severe stroke population. Method: With Institutional Review board approval, we maintained a prospective database on patients who were identified to have a high pre-hospital Rapid Arterial occlusion Evaluation ( RACE) between July 2015 and June of 2016. Per protocol, RACE alert patients go directly to the CT scanner to obtain a CT head and a CTA unless the test is cancelled by the stroke team. Labs are typically not available when CTA is performed. Our data included patient demographics, pre-morbid risk factors, baseline serum Creatinine level (Cr), peak Cr level during admission and at discharge. Incidence of renal consults and need for Hemodialysis was also monitored. Results: A total of 150 RACE alert patients were included in the analysis. Median age of patients was 73 and 12 patients had pre-morbid chronic renal failure. CTA was not performed in 21 of patients, due to low probabability of stroke determined by stroke team onsite.. Transient CIN occurred in 9(6%) of patients, renal consult was obtained in 4(3%) patients and 2(1) patients had a diagnosis of acute kidney injury on discharge. Conclusion: Emergent CTA resulted in a low number of transient CIN in our RACE alert patients. No cases of chronic renal Failure or need for HD were reported in our prospective cohort. A larger prospective registry may be needed to confirm the safety of this approach.

Background: Concomitant acute cervical ICA and intracranial large vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. We report our institutional outcomes with the 2 approaches, emergent carotid endartectomy (CEA) vs. stenting (CAS). Methods: Between July 2012 to April 2016, 34 patients with concomitant complete ICA origin occlusion and occlusion of either intracranial ICA, MCA M1 or M2 segments underwent thrombectomy at our center. Demographics, risk factors, treatment modalities, imaging and clinical outcomes were reviewed from a prospectively maintained database. Recanalization, hemorrhagic transformation (HT) with clinical decline of >4 points on the NIHSS and favorable outcome rates mRs of < 2 at 90 days were compared. Results: Of the 34 identified subjects, in 6 patients the proximal lesion was not treated either due to failed MT (N=3), ICA re-occlusion prior to CEA (N=2) or MCA recanalization via trans-circulation access with symptomatic resolution (N=1). Of the remaining 28 patients, 10 (35.7%) underwent emergent CEA within 12 hours following MT, while the remainder 18 (64.3%) had carotid stenting performed during the MT. Rate of IV tPA treatment was higher in CAS (61% vs 10%, p<0.01). Successful TICI 2B/3 recanalization was achieved in 90% of the CEA and 94.1% of stenting patients (p=0.6). Following CAS, 3 patients developed HT while none were noted in the CEA arm. At 90 days, 80% (8/10) of the CEA patients were functionally independent compared to 58.8% (10/18) in the stenting group, although this difference was not statistically different (p=0.3). No deaths in the CEA group were noted as compared to 4 (23.5%) in the stenting arm (p=0.09). Conclusions: Our study indicates that for concomitant cervical ICA and ILVO, MT followed by emergent CEA is feasible and may be accompanied with less risk for HT and improved rate of favorable outcome. Further prospective studies are warranted.