Turning Point of Acute Stroke Therapy: Mechanical Thrombectomy as a Standard of Care

2015 ◽  
Vol 83 (6) ◽  
pp. 953-956 ◽  
Author(s):  
Keith G. DeSousa ◽  
Matthew B. Potts ◽  
Eytan Raz ◽  
Erez Nossek ◽  
Howard A. Riina
Keyword(s):  
Acute Stroke ◽  
Turning Point ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Stroke Therapy ◽  
Acute Stroke Therapy

Abstract P284: Coordinating Options for Acute Stroke Therapy (COAST): Demonstrating Patient Autonomy by Examining Preferences for Acute Stroke Treatment From a Stroke Advance Directive

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kunal Agrawal ◽  
Ilana Spokoyny ◽  
Chia-Chun Chiang ◽  
Kevin McGehrin ◽  
Brett C Meyer
Keyword(s):  
Acute Stroke ◽  
Advance Directive ◽  
Patient Autonomy ◽  
Standard Of Care ◽  
Stroke Therapy ◽  
Stroke Treatment ◽  
Fda Approval ◽  
Acute Stroke Treatment ◽  
Current Guidelines ◽  
Acute Stroke Therapy

Introduction: Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke. Methods: In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option. Results: In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences. Conclusion: Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.

Abstract 96: CTP-Mismatch Maps Improve Interobserver Agreement

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Waimei A Tai ◽  
Archana Purushotham ◽  
Matus Straka ◽  
Rebecca M Sugg ◽  
Naveed Akhtar ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion ◽  
Interobserver Reliability ◽  
Observer Agreement ◽  
Absolute Difference ◽  
Stroke Therapy ◽  
Adequate Quality ◽  
Ischemic Core ◽  
Observer Disagreement ◽  
Acute Stroke Therapy

Introduction: The use of mismatch between the ischemic core and penumbra to select patients who are likely to benefit from acute stroke therapy has gained popularity. Interpretation of the ischemic core and penumbra on standard CT-perfusion (CTP) maps is subjective. This may lead to variability among physicians in the decision if a patient is a good candidate for acute stroke therapy. A CTP-Mismatch map with outlines of the ischemic core and penumbra could limit this variability. The goal of this study was to determine if inter-observer agreement regarding a patient’s suitability for acute stroke therapy improves with the use of a CTP-Mismatch map. The figure shows a typical CTP-Mismatch map. Methods: Ninety-six consecutive patients evaluated with CTP prior to intra-arterial therapy at St. Lukes Hospital in 2008-09 were included. 79 patients had adequate quality CTP for this analysis. Standard CTP maps (CBV, CBF, MTT, and Tmax) and a CTP-Mismatch map were generated with a fully automated program for processing of CTP source images (RAPID). RAPID assessed the ischemic core using a CBF threshold <30% of the contralateral hemisphere (rCBF<30%). The ischemic penumbra was defined by a Tmax threshold of >6 sec (Tmax>6s). The standard CTP maps and the CTP-Mismatch map were independently analyzed by two vascular neurologists in a blinded fashion. The raters assessed a patient's suitability for intra-arterial therapy based on the following mismatch criteria: (1) a ratio between (Tmax>6s) and (rCBF<30%) volumes >1.8 and (2) an absolute difference between (Tmax>6s) and (CBF<30%) volumes >15ml. Interobserver reliability was assessed with Cohen’s kappa. Results: When assessment of suitability for intra-arterial therapy was based on interpretation of standard CTP maps, the two raters agreed in 58 of 79 patients (kappa=0.46; 95% CI=0.24-0.60). The agreement between observers improved when suitability was determined using CTP-Mismatch maps (agreement in 76 of 79 cases; kappa=0.92; 95% CI=0.75-0.92; p<0.001 for difference between kappa values). The 3 cases with inter-observer disagreement had artifact on the CTP-Mismatch map. Following concensus adjudication of these 3 cases, 40 of the 79 patients (51%) were deemed suitable candidates for acute stroke therapy. Conclusion: CTP-Mismatch maps with estimates of ischemic core and penumbra volumes markedly improve inter-observer agreement regarding assessment of suitability for acute stroke therapy. Such maps, which can be generated automatically, may help standardize decision making algorithms for evaluation of potential intra-arterial therapy candidates.

Abstract TP24: Trends in Iv r-tpa and Thrombectomy Treatment Rates Before and After the LVO RCT’s in a Regional Tele-stroke Network

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Naregnia Pierre Louis ◽  
Suman Nalluri ◽  
Benny Kim ◽  
Aashish Anand ◽  
Tanzila Shams ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Statistical Test ◽  
Stroke Therapy ◽  
Stroke Patients ◽  
Chi Square ◽  
The Third ◽  
Before And After ◽  
Acute Stroke Therapy

The presentation of endovascular stroke trials at international stroke conference was a land mark event in acute stroke therapy. This study aims to analyze the rates of utilization of IV r-tPA, with or without mechanical thrombectomy before and after the 2015 International Stroke Conference (ISC) in a large regional tele-stroke network. Methods: A systematic review of prospective telestroke and procedure database was performed for 18 months prior and 18 months post conference. There were three groups included in the analysis. The first group consisted ischemic stroke patients presented within 12 hours of onset including inpatient events, transfers from primary centers and rural clinics. The second group consisted of patients who received IV r-tPA, and the third group consisted of patients who received IV r-tPA and/or underwent mechanical thrombectomy for a demonstrated LVO. Results: A total of 2628 consecutive ischemic stroke events presented within 12 hours of onset were evaluated. In the pre-ISC conference group, there were 1135 ischemic stroke patients. IV r-tPA was given 535 times(47.1%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 42 times(3.7%). In the post-ISC conference group, there were 1493 ischemic stroke patients. IV r-tPA was given 642 times(43%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 132 times(8.84%). The Chi Square statistical test was performed comparing these groups. When comparing the rate of IV r-tPA usage, there was a significant decrease from the pre-ISC conference group to the post-ISC conference group (P= 0.04). When comparing the rate of mechanical thrombectomy performed, there was a significant increase of greater than double the percentage of thrombectomy procedures performed in the post conference group compared to the preconference group (p< 0.001). Conclusion: There was a significant decrease in IV r-tPA usage but a greater than double the increase in the thrombectomy rate . This may be secondary to increased awareness of benefit of thrombectomy at referral centers. Slightly lower rates of IV r-tPA usage may be secondary to an increase in transfers of patients outside of the 0-4.5 hr window but were deemed candidates for thrombectomy.

Abstract WP121: Incorporating CT-Perfusion Imaging in Acute Stroke Therapy Workflow Does Not Delay Door to Needle Time for Intravenous t-PA

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Bahareh Sianati ◽  
Russel Cerejo ◽  
David Wright ◽  
Ashish Tayal ◽  
Patty Noah ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Perfusion Imaging ◽  
Ct Perfusion ◽  
Brain Perfusion ◽  
Stroke Therapy ◽  
Brain Perfusion Imaging ◽  
Group 2 ◽  
Acute Stroke Therapy ◽  
Iv Tpa ◽  
Group 1

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 stroke therapy. Incorporating standard and advanced imaging together may reduce time to endovascular therapy but may delay administration of intravenous (IV) tPA. Method: A retrospective analysis of all acute stroke therapy cases between August 2017 and March of 2018 was performed at a single stroke center. Brain perfusion imaging was instituted into the workflow in December of 2017. We included patients who received IV tPA before and after implementation of CT perfusion (CT-P). Demographics, clinical presentation, stroke treatment times and imaging characteristics were collected. Results: During the eight-month period, we identified 117 patients who met inclusion criteria. We divided the cohort into two groups, pre CT-P implementation (Group 1) and post CT-P implementation (Group 2). We identified 66 patients in Group 1 and 51 patients in Group 2. In Group 1, 29 (44%) were females with median age of 63 years. In Group 2, 33 (65%) were females, with median age of 72 years. There was no difference in median times for door to needle in Group 1 (57 minutes, interquartile range [IQR] 42 – 76) compared to Group 2 (53 minutes, [IQR] 40 – 68) ( P = 0.20). Conclusion: Incorporating CT-P in the imaging workflow did not delay door to needle time for IV tPA in acute stroke therapy.

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