CNS Francis McNaughton Memorial Prize

Background: This study examines whether abnormal blood hemoglobin concentration (bHB) is associated with worse clinical outcomes and poorer prognosis after acute ischemic stroke. Methods: We included data from the Registry of the Canadian Stroke Network on consecutive patients with ischemic stroke who were admitted between July/2003 and March/2008. Patients were divided into groups as follows: low bHB, normal bHB, and high bHB. Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale: <8), greater degree of disability at discharge (modified Rankin score: 3-6), and 30-day and 90-day mortality. Results: Higher bHB than the superior normal limit is associated with greater degree of impairment (OR=1.45, 95%CI: 1.06-1.95, p=0.0195) and disability (OR=1.49, 95%CI: 1.03-2.15, p=0.0331), and higher 30-day mortality (HR=1.98, 95%CI: 1.44-2.74, p<0.0001) after adjustment for major potential confounders. The Kaplan-Meier curves indicate that abnormal bHB is associated with higher mortality after acute ischemic stroke (p<0.0001). Lower bHB than the inferior normal limit is associated with longer stay in the acute stroke care center (OR=1.11, 95%CI: 1.02-1.22, p=0.017). Conclusions: Polycythemia on the initial admission is associated with poorer prognosis regarding the degree of impairment and disability, and 30-day mortality after an acute ischemic stroke. Anemia on admission is associated with longer stay in the acute stroke center.

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CNS / CSCN Platform Presentations

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2015.92 ◽

2015 ◽

Vol 42 (S1) ◽

pp. S15-S16

Author(s):

JC Furlan ◽

J Fang ◽

FL Silver

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Primary Outcome ◽

Care Center ◽

Blood Platelet ◽

Stroke Care ◽

Acute Stroke Care ◽

Kaplan Meier ◽

Degree Of Disability ◽

Blood Platelet Count

Background: We hypothesized that abnormal blood platelet count (BPC) is associated with poorer outcomes after acute ischemic stroke. Methods: We included data from the Registry of the Canadian Stroke Network on consecutive patients with acute ischemic stroke admitted between July/2003 and March/2008. Patients were divided into groups as follows: low BPC (<150,000/mm3), normal BPC (150,000 to 450,000/mm3) and high BPC (>450,000/mm3). Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale: <8), greater degree of disability at discharge (modified Rankin score: 3-6), and 30-day and 90-day mortality. Results: We included 9,230 patients. Both low and high BPC were associated with higher 30-day mortality (p=0.0103) and 90-day mortality (p=0.0189) following acute ischemic stroke. The Kaplan-Meier curves indicate that abnormal BPC is associated with greater mortality after acute ischemic stroke (p=0.0002). Nonetheless, abnormal BPC was not associated with degree of impairment (p=0.3734), degree of disability (p=0.684), or length of stay (LOS) in the acute stroke care center (p=0.9541) after adjustment for major potential confounders. Conclusions: In patients with acute ischemic stroke, thrombocytopenia and thrombocytosis on the initial admission is associated with higher mortality after stroke. Abnormal BPC does not adversely affect the degree of impairment and disability, or LOS in the acute care center after acute ischemic stroke.

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Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions

Neurology ◽

10.1212/wnl.0000000000012781 ◽

2021 ◽

Vol 97 (20 Supplement 2) ◽

pp. S6-S16

Author(s):

Vasu Saini ◽

Luis Guada ◽

Dileep R. Yavagal

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Randomized Clinical Trials ◽

Time Window ◽

Systems Of Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Global Epidemiology

Purpose of the ReviewTo provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide.Recent FindingsRandomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients.SummaryStroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%–20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.

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A cross-sectional study of awareness regarding dog bite and its management in rural community of Maharashtra, India

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20203593 ◽

2020 ◽

Vol 7 (9) ◽

pp. 1307

Author(s):

Mohammed Alqwaifly

Keyword(s):

Saudi Arabia ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

Cross Sectional Study ◽

Sectional Study ◽

Acute Stroke Care ◽

Cross Sectional ◽

Stroke Treatment

Background: Stroke is a major cause of morbidity and disability worldwide. However, its outcomes have improved in the last few years with advancement in acute stroke treatment, including the use of tissue plasminogen activator (t-PA) within 4.5 hours of onset, which led several international guidelines to adopt it as the standard of care. In this study, authors sought to assess the knowledge, practices, and attitudes of emergency and medicine staff in Qassim, Saudi Arabia toward acute ischemic stroke care.Methods: A quantitative observational cross-sectional study involving 148 physicians from emergency and medicine departments (only three neurologists) was conducted in three main hospitals of the Qassim region, Saudi Arabia. Information was obtained from a self-administered questionnaire. A logistic regression model was used to control for potential confounding factors.Results: Ninety-two percent of participants were aware of t-PA. Eighty-seven percent of participants thought that t-PA was an effective treatment for acute ischemic stroke. Only 20% of participants had given t-PA or participated in the use of t-PA in acute ischemic stroke. Moreover, 64% of participants believed that allowing blood pressure to remain high was the most appropriate action in the first 24 hours in acute ischemic stroke patients who presented outside the t-PA window.Conclusion: Most of the emergency and medicine staff are well informed about t-PA, but the majority of these physicians have never given t-PA or participated in the administration of t-PA to a stroke patient. The main finding here is the positive outlook among emergency and medicine physicians in Qassim toward training in acute stroke care and administering t-PA for stroke, which will positively impact patient outcomes.

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Ongoing Improvement in Acute Ischemic Stroke Therapy Per Concurrent Guidelines and Easily Implementable Quality Improvement Protocol

Neuroscience and Neurological Surgery ◽

10.31579/2578-8868/184 ◽

2021 ◽

Vol 8 (6) ◽

pp. 01-09

Author(s):

Wengui Yu

Keyword(s):

Quality Improvement ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

Linear Regression Models ◽

Stroke Therapy ◽

Acute Stroke Care ◽

Stroke Registry ◽

Intravenous Tissue Plasminogen Activator

Background: Despite proven efficacy of intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in acute ischemic stroke, there has been slow administration of these therapies in the real world practice. We examined the ongoing quality improvement in acute stroke care at our comprehensive stroke center. Methods: Consecutive patients with acute ischemic stroke from 2013 to 2018 were studied. Patients were managed using Code Stroke algorithm per concurrent AHA guidelines and a simple quality improvement protocol implemented in 2015. Demographics and clinical data were collected from Get-With-The-Guideline-Stroke registry and electronic medical records. Patients were divided into 3 groups per admission and implementation date of quality improvement initiatives. Quality measures, including rates of intravenous tPA and EVT, door-to-needle (DTN) time, and door-to-puncture (DTP) time, were analyzed with general mean linear regression models and Jonckheere-Terpstra test. Results: Of the 1,369 eligible patients presenting within 24 hours of symptom onset or wakeup stroke, the rate of intravenous tPA was 20%, 30% and 22%, respectively, in 2013-2014, 2015-2016, and 2017-2018. In contrast, EVT rate was 9%, 14% and 15%, respectively. Based on Jonckheere-Terpstra test, there was significant ongoing improvement in the median DTN time (57, 45, 39 minutes; p < 0.001) and DTP time (172, 130, 114 minutes; p =0.009) during the 3 time periods, with DTN time ≤ 60 and ≤45 minutes in 80% and 63% patients, respectively, in 2017-2018. Conclusions: Getting with the guidelines and simple quality improvement initiatives are associated with satisfactory rates of acute stroke therapy and ongoing improvement in door to treatment times.

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Abstract T P37: Routine CT Angiography in Acute Stroke Does Not Delay Acute Stroke Care

Stroke ◽

10.1161/str.46.suppl_1.tp37 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Gisele S Silva ◽

Renata C Miranda ◽

Rodrigo M Massaud ◽

Andreia M Vacari ◽

Miguel Cendoroglo Neto

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Tertiary Hospital ◽

Acute Stroke Care ◽

Time Intervals ◽

Radiology Report ◽

Group 2

Introduction: Vascular imaging is increasingly used for diagnosis of arterial occlusions in acute ischemic stroke. Hypothesis:We hypothesized that time intervals using a CTA based acute ischemic stroke protocol are not increased when compared to an earlier non-CTA based protocol. Methods: We evaluated a database of consecutive patients admitted to a Brazilian tertiary hospital with acute ischemic stroke from February 2009 to March 2014 and reviewed our stroke quality measures data to determine if the time required to obtain CTA prolonged door-to-neuroimaging, door to radiology report and door-to-needle times. Patients were categorized into: Group 1 (February 2009 to October 2013) (Non-contrast CT Scan based acute stroke protocol) and Group 2 (November 2013 to August 2014) (CTA based acute stroke protocol). Time intervals were compared between the two groups.Results: We evaluated 415 consecutive patients, 20 of whom (4.8%) had a CTA in the acute phase (Group 2). Patients in groups 1 and 2 had similar onset-to-door times (1.86 [0.75-3.58] versus 2.75 hours [1.0-8.49], p=0.09); door to neuroimaging times (27.6 [18.6-46.8] versus 37.8 minutes [23.4-46.2], p=0.28 ) and door to radiology report intervals (39 [27-60.6] versus 53.4 minutes[35.4-61.2], p=0.09). The frequency of treatment with recanalization therapies ( either intravenous thrombolysis or endovascular procedures) was similar between groups 1 (30%) and 2 (21%), p=0.33, as well as door to needle times (p=0.09). Conclusions: CTA based acute stroke care does not significantly delay time to neuroimaging or thrombolysis in routine clinical practice.

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Acute Ischemic Stroke in COVID-19: Putative Mechanisms, Clinical Characteristics, and Management

Neurology Research International ◽

10.1155/2020/7397480 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Ademola S. Ojo ◽

Simon A. Balogun ◽

Ahmed O. Idowu

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Disease Transmission ◽

Clinical Characteristics ◽

Severe Disease ◽

Stroke Care ◽

Current Evidence ◽

Future Research ◽

Acute Stroke Care

The emergence and spread of the highly contagious novel coronavirus disease (COVID-19) have triggered the greatest public health challenge of the last century. Aside from being a primary respiratory disease, acute ischemic stroke has emerged as a complication of the disease. While current evidence shows COVID-19 could cause ischemic stroke especially in severe disease, there are similarities in the risk factors for severe COVID-19 as well as ischemic stroke, underscoring the complex relationship between these two conditions. The pandemic has created challenges for acute stroke care. Rapid assessment and time-sensitive interventions required for optimum outcomes in acute stroke care have been complicated by COVID-19 due to the need for disease transmission preventive measures. The purpose of this article is to explore the putative mechanisms of ischemic stroke in COVID-19 and the clinical characteristics of COVID-19 patients who develop ischemic stroke. In addition, we discuss the challenges of managing acute ischemic stroke in the setting of COVID-19 and review current management guidelines. We also highlighted potential areas for future research.

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Impact of SARS-CoV-2 on reperfusion therapies for acute ischemic stroke in Lombardy, Italy. The STROKOVID network

10.21203/rs.3.rs-105649/v1 ◽

2020 ◽

Author(s):

Alessandro Pezzini ◽

Mario Grassi ◽

Giorgio Silvestrelli ◽

Martina Locatelli ◽

Nicola Rifino ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

Hospital Death ◽

Acute Stroke Care ◽

Process Measures ◽

Endovascular Thrombectomy ◽

Collaborative Project ◽

Occlusive Lesion

Abstract Whether and how SARS-CoV-2 outbreak affected in-hospital acute stroke care system is still matter of debate. In the setting of the STROKOVID network, a collaborative project between the 10 centers designed as hubs for the treatment of acute stroke during SARS-CoV-2 outbreak in Lombardy, Italy, we retrospectively compared clinical features and process measures of patients with confirmed infection (COVID-19) and non-infected patients (non-COVID-19) who underwent reperfusion therapies for acute ischemic stroke. Between March 8 and April 30, 2020, 296 consecutive patients (median age, 74 [interquartile range (IQR), 62–80.75] years; males, 154 [52.0%]; 34 [11.5%] COVID-19) qualified for the analysis. Time from symptoms onset to treatment was longer in the COVID-19 group (230 [IQR, 200.5–270] minutes vs 190 [IQR, 150–245] minutes; p=0.007), especially in the first half of the study period. Patients with COVID-19 who underwent endovascular thrombectomy had more frequently absent collaterals or collaterals filling ≤50% of the occluded territory (50.0% vs 16.6%; OR, 5.05; 95% CI, 1.82–13.80) and a lower rate of good/complete recanalization of the primary arterial occlusive lesion (55.6% vs 81.0%; OR, 0.29; 95% CI, 0.10–0.80). Post-procedural intracranial hemorrhages were more frequent (35.3% vs 19.5%; OR, 2.24; 95% CI, 1.04-4.83) and outcome was worse among COVID-19 patients (in-hospital death, 38.2% vs 8.8%; OR, 6.43; 95% CI, 2.85-14.50). Our findings showed longer delays in the intra-hospital management of acute ischemic stroke in COVID-19 patients, especially in the early phase of the outbreak, that likely impacted patients outcome and should be the target of future interventions.

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Abstract WP399: Reduced Cost and Decreased Length of Stay Associated with Acute Ischemic Stroke Care Provided by Nurse Practitioners: A Single Primary Stroke Center Experience

Stroke ◽

10.1161/str.48.suppl_1.wp399 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Leah Roering ◽

Michelle Peterson ◽

Muhammad Shah Miran ◽

Melissa Freese ◽

Kenneth Shea ◽

...

Keyword(s):

Ischemic Stroke ◽

Length Of Stay ◽

Acute Ischemic Stroke ◽

Nurse Practitioners ◽

Acute Care Hospital ◽

Stroke Care ◽

Care Hospital ◽

Medical Provider ◽

The Mean ◽

Stroke Center

Background: Nurse practitioner (NP) have a wider role in modern stroke centers providing quality evidence based care to patients in both in and outpatient settings for acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients. We studied the outcome measures, length of stay (LOS) and cost before and after implementation of nurse practitioners as the primary medical provider in a community based stroke center. Methods: St Cloud hospital is acute care hospital with dedicated stroke service responsible for workup and management of all patients admitted with AIS and TIA. From March 2014-March 2015, all patients were primarily managed by stroke neurologists with or without support of NP, representing physician driven arm. From June 2015-March 2016 all non-critical patients were managed primarily by NP, representing the NP driven arm of care. For this analysis, we excluded all patients with subarachnoid hemorrhage or intracerebral hemorrhage. Using ICD codes, we abstracted LOS and hospitalization cost for all patients, and compared between two arms. Results: A total of 822 patients were included in physician arm and 336 in NP arm. The mean age was 72±14 years for both arms, and 54.4% were male in physician arm and 57.4% were male in NP arm. The mean total LOS for the physician arm was 3.1 ±3.3 days while 2.9±3.6 for NP arm (p=0.6). The total cost for physician arm was $11,286.70 ±$10,920.90 while the NP arm was $10,277.30± $10,142.30 (p=0.1). Conclusion: There is a trend towards lower cost and length of stay with implementation of NP as primary stroke provider for patients admitted with acute ischemic stroke.

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Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽

10.1161/str.52.suppl_1.p119 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Nicolle W Davis ◽

Meghan Bailey ◽

Natalie Buchwald ◽

Amreen Farooqui ◽

Anna Khanna

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Patient Outcomes ◽

Time Of Day ◽

Stroke Patients ◽

Acute Stroke Care ◽

The Impact ◽

Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

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Abstract W P334: VA Healthcare System Responses to National Stroke Care Reorganization

Stroke ◽

10.1161/str.45.suppl_1.wp334 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Teresa M Damush ◽

Kristine K Miller ◽

Laurie Plue ◽

Arlene A Schmid ◽

Laura Myers ◽

...

Keyword(s):

Acute Stroke ◽

Nurse Managers ◽

Stroke Care ◽

Structured Interviews ◽

Acute Stroke Care ◽

Major Barrier ◽

Ongoing Work ◽

Final Sample ◽

Cross Training ◽

Stroke Center

Aims: In 2011, the VA released the Acute Ischemic Stroke (AIS) Directive which mandated reorganization of acute stroke care, including self-designation as Primary (P), Limited Hours (LH), or Supporting (S) stroke center. We conducted interviews across stroke centers to understand barriers and facilitators faced in response. Methods: The final sample included 38 (84% invited) facilities: 9 P, 24 LH, and 5 S facilities. In total, 107 persons were interviewed including ED Chiefs, Chiefs of Neurology, ED Nurse Managers/Nurses and other staff. Semi-structured interviews were based on the AIS Directive. Completed interviews were transcribed and analyzed using Nvivo 10. Results: Barriers reported were a lack of personnel assigned to coordinate the facility response to the directive. Data collection and lack of staff were likewise commonly reported as barriers. For thrombolysis measures, the low number of eligible Veterans was another major barrier. LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competency, and a lack of stroke clinical champions. Some solutions applied included cross training X-ray technicians to provide head CT coverage, developing stroke order sets and templates, and staff training. Larger facilities added a stroke code pager system and improved upon its use, and established ED nurses to become first alerts for an acute stroke patient. LH and S facilities also responded by attempting to secure additional services and by establishing formal transfer agreements to improve Veteran tPA access. Conclusions: The AIS Directive brought focused attention to reorganizing and improving stroke care across a range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique LH designation presented challenges to consistently organize systems. Since Veterans have financial interest in presenting to a VA facility, ongoing work to organize VA care and to improve access to thrombolysis at smaller VA facilities is needed. This protocol was supported by Genentech Inc. Protocol ML 28238, VA HSRD QUERI Rapid Response Project 11-374, and the VA Stroke QUERI Center.

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