Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays

ABSTRACT: This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

Download Full-text

Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts

International Journal of Stroke ◽

10.1177/1747493018765493 ◽

2018 ◽

Vol 13 (5) ◽

pp. 469-472 ◽

Cited By ~ 4

Author(s):

Carlos Garcia-Esperon ◽

Andrew Bivard ◽

Christopher Levi ◽

Mark Parsons

Keyword(s):

Computed Tomography ◽

Acute Stroke ◽

Treatment Decision ◽

Added Value ◽

Stroke Treatment ◽

Computed Tomography Perfusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Weighted Sequences ◽

Perfusion Maps

Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the “lesions” on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.

Download Full-text

Abstract P32: Advanced Practice Provider-Based Acute Stroke Protocol Performs Well Compared to a Resident-Based Protocol

Stroke ◽

10.1161/str.52.suppl_1.p32 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Noah Grose ◽

Cassandra Forrest ◽

Sharon Heaton ◽

Vivien Lee

Keyword(s):

Acute Stroke ◽

Nurse Practitioners ◽

Final Diagnosis ◽

Reperfusion Therapy ◽

National Institutes Of Health ◽

Advanced Practice ◽

Intravenous Tissue Plasminogen Activator ◽

The Hours ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: The administration of intravenous tissue plasminogen activator (IVtPA) for acute ischemic stroke (AIS) is typically done by neurology resident physicians at academic stroke centers. We sought to compare the performance of an advanced practice provider (APP)-based IVtPA protocol to a resident-based protocol. Methods: We performed a retrospective review of Emergency Room (ER) acute stroke codes from January 1, 2018 to January 1, 2019 that received AIS reperfusion therapy, including IVtPA or mechanical thrombectomy (MT). Inpatient AIS were excluded. During this timeframe, 5 acute stroke-trained nurse practitioners covered the daytime shifts for acute stroke codes on a rotating basis (during the hours of 7:00 am -4:00 pm, Monday through Friday). The neurology residents continued to cover all other stroke code shifts. We collected data on baseline demographics, initial National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and door to groin puncture (DTG) time. Statistical analyses were performed using JMP software package (version 14). All tests were 2-sided, and a P value was considered significant at <0.05. Results: Among 322 AIS case who received acute reperfusion therapy, 133 (41.4%) received IVtPA, 200 (62.3%) received MT, and 11 (3.4%) received both. Among the 133 IVtPA patients, there was no difference in age (62.2 vs 59.9, p 0.56) or mean initial NIHSS (7.7 vs 8.2, p 0.75) when comparing the APP-based protocol to the resident-based protocol group, but patients seen by the APP were more likely to be male (78.3 vs 42.7%, p 0.0015). Compared to the resident-based protocol, the APP-based protocol had faster mean DTN times (38.9 vs 54.7 minutes, p 0.0374) and were more likely to have final diagnosis of stroke (95.7% vs 70%, p 0.0034). Among the 200 MT patients, the DTG time showed a trend for faster times for the APP-based protocol, although this was not significant (60.5 vs 76.5, p 0.0083). Conclusion: At our academic comprehensive stroke center, APP driven acute stroke code protocols perform as well as resident-based protocols in terms of time to reperfusion therapy.

Download Full-text

Implementing the SNIS recommendations for neurointerventional emergent care in the setting of COVID-19: impact on stroke metrics and patient outcomes

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017415 ◽

2021 ◽

pp. neurintsurg-2021-017415

Author(s):

Benjamin Atchie ◽

Stephanie Jarvis ◽

Erica Stoddard ◽

Kristin Salotollo ◽

Amy Nieberlein ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Guideline Implementation ◽

Treatment Utilization ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Stroke Type ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Treatment Use

BackgroundIt is not clear whether the COVID-19 pandemic and subsequent Society of Neurointerventional Surgery (SNIS) recommendations affected hospital stroke metrics.MethodsThis retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic April 1 2020 to June 30 2020 (COVID-19) to patients admitted April 1 2019 to June 30 2019. We examined stroke admission volume and acute stroke treatment use.ResultsThere were 637 stroke admissions, 52% in 2019 and 48% during COVID-19, with similar median admissions per day (4 vs 3, P=0.21). The proportion of admissions by stroke type was comparable (ischemic, P=0.69; hemorrhagic, P=0.39; transient ischemic stroke, P=0.10). Acute stroke treatment was similar in 2019 to COVID-19: tPA prior to arrival (18% vs, 18%, P=0.89), tPA treatment on arrival (6% vs 7%, P=0.85), and endovascular therapy (endovascular therapy (ET), 22% vs 25%, P=0.54). The door to needle time was also similar, P=0.12, however, the median time from arrival to groin puncture was significantly longer during COVID-19 (38 vs 43 min, P=0.002). A significantly higher proportion of patients receiving ET were intubated during COVID-19 due to SNIS guideline implementation (45% vs 96%, P<0.0001). There were no differences by study period in discharge mRS, P=0.84 or TICI score, P=0.26.ConclusionsThe COVID-19 pandemic did not significantly affect stroke admission volume or acute stroke treatment utilization. Outcomes were not affected by implementing SNIS guidelines. Although there was a statistical increase in time to groin puncture for ET, it was not clinically meaningful. These results suggest hospitals managing patients efficiently can implement practices in response to COVID-19 without impacting outcomes.

Download Full-text

Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability

Stroke ◽

10.1161/strokeaha.120.032389 ◽

2021 ◽

Author(s):

Minerva H. Zhou ◽

Akash P. Kansagra

Keyword(s):

Acute Stroke ◽

Modest Improvement ◽

Absolute Increase ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Primary Stroke Center ◽

Treatment Volume ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Patient Referrals

Background and Purpose: With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center. Methods: In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials. Results: Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population. Conclusions: Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.

Download Full-text

Effect of the COVID-19 pandemic on acute stroke reperfusion therapy: data from the Lyon Stroke Center Network

10.21203/rs.3.rs-56553/v1 ◽

2020 ◽

Author(s):

Cécile PLUMEREAU ◽

Tae-Hee CHO ◽

Marielle BUISSON ◽

Camille AMAZ ◽

Matteo CAPPUCCI ◽

...

Keyword(s):

Acute Stroke ◽

Control Period ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Reperfusion Therapy ◽

Acute Stroke Care ◽

Emergency Medical Dispatch ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Abstract BackgroundThe coronavirus disease 2019 (COVID-19) pandemic would have particularly affected acute stroke care. However, its impact is clearly inherent to the local stroke network conditions. We aimed to assess the impact of COVID-19 pandemic on acute stroke care in the Lyon comprehensive stroke center during this period.MethodsWe conducted a prospective data collection of patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) during the COVID-19 period (from 29/02/2020 to 10/05/2020) and a control period (from 29/02/2019 to 10/05/2019). The volume of reperfusion therapies and pre and intra-hospital delays were compared during both periods.ResultsA total of 208 patients were included. The volume of IVT significantly decreased during the COVID-period (55 (54.5%) vs 74 (69.2%); p=0.03) and was mainly due to time delay among patients treated with MT. The volume of MT remains stable over the two periods (72 (71.3%) vs 65 (60.8%); p=0.14) but the door-to-groin puncture time increased in patients transferred for MT (237 [187-339] vs 210 [163-260]; p<0.01). The daily number of Emergency Medical Dispatch calls considerably increased (1502 [1133-2238] vs 1023 [960-1410]; p<0.01).ConclusionsOur study showed a decrease of the volume of IVT, whereas the volume of MT remained stable although intra-hospital delays increased for transferred patients during the COVID-19 pandemic. These results contrast in part with the national surveys and suggest that the impact of the pandemic may depend on local stroke care networks.

Download Full-text

Abstract TP373: Classification of sICH in Stroke Center Hospitals: Reliability in Question

Stroke ◽

10.1161/str.44.suppl_1.atp373 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Victoria Swatzell ◽

Fern Cudlip ◽

Andrei V Alexandrov ◽

Anne W Alexandrov

Keyword(s):

Pay For Performance ◽

Reperfusion Therapy ◽

Hemorrhagic Transformation ◽

Quality Data ◽

Treatment Rate ◽

Team Members ◽

Common Definition ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Contrast Ct

Background: Measuring sICH is an important accountability of Stroke Centers. Since the NINDS rt-PA Study, the sICH definition has changed as knowledge of reperfusion-associated hemorrhagic transformation has grown. We aimed to determine what sICH definition was used by Stroke Centers and how this impacts sICH rates. Methods: Stroke Centers were invited to participate in a survey with the option to complete it via SurveyMonkey TM or by mail. Instructions to adhere to the sICH definition adopted in policies/procedures were provided, and to ask for clarification from Stroke Team members if needed. Data were assembled in SPSS, and analyzed using descriptive statistics and Student t-tests. Results: 229 responses were received representing 84% of U.S. states and the District of Columbia; 31% represented academic medical centers and 69% community hospitals. 64% of respondees were responsible for collecting the stroke quality data that supports certification. Overall tPA treatment rate for the sample was 8.7% + 6.4 (median 7%), with an overall reported sICH rate of 9.5% + 16.4 (median 5%). Official definitions supported sICH for 86% of responding hospitals, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.” Only 17% identified the definition for sICH adopted by TJC for Comprehensive Stroke Center reporting. Among those that adhered to the TJC definition, sICH rates were significantly lower at 3%+2.3 (median 3%; t=4.7; mean difference = 7.7%; p<.0001, 95% CI 4.4-10.95), compared to 10.6%+17.5 (median 6%). Conclusions: Our study documents a significant need for education and inter-rater reliability monitoring of the use of sICH classification after intravenous tPA to ensure accuracy in local quality improvement processes, as well as the validity of data submitted to national stroke registries. Additionally, because sICH associated with reperfusion therapy is a new measure undergoing testing by TJC that could ultimately be tied to future pay-for-performance and public reporting, consensus on its definition as well as reliable sICH classification will be essential to future Stroke Center evaluation.

Download Full-text

Abstract WP240: Ultra-acute Diagnostics for Stroke: Large-scale Implementation of Prehospital Biomarker Sampling

Stroke ◽

10.1161/str.47.suppl_1.wp240 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Olli S Mattila ◽

Heini Harve ◽

Saana Pihlasviita ◽

Juhani Ritvonen ◽

Gerli Sibolt ◽

...

Keyword(s):

Acute Stroke ◽

Large Scale ◽

Biomarker Discovery ◽

Cost Effective ◽

Blood Sampling ◽

Blood Samples ◽

And Performance ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Acute Diagnostics

Background and purpose: Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. However, large prehospital sample sets required for biomarker discovery and validation are missing, and the feasibility of large-scale blood sampling by emergency medical services (EMS) has not been determined. We set out to establish extensive prehospital blood sampling of thrombolysis candidates in the catchment area of our comprehensive stroke center, with a 1.5 million population base. Methods: EMS personnel were trained to collect prehospital blood samples using a cannula-adapter technique. Time delays, sample quality and performance bottlenecks were investigated between May 20, 2013 and May 19, 2014. Results: Prehospital blood sampling and study recruitment were successfully performed in 430 thrombolysis candidates, of which 55.3% were admitted outside office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than admission blood sampling, and 37 minutes (30-47) earlier than admission neuroimaging. Quality control data from 25 participating EMS units indicated a 4-minute increase in median transport time (from arrival on-scene to hospital door) for study patients compared to patients of the preceding year. The hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples collected with venipuncture. Conclusions: Prehospital biomarker sampling is feasible in standard EMS units and provides a median timesaving of over 30 minutes to obtain first blood samples. Large biobanks of prehospital blood samples will facilitate development of ultra-acute stroke biomarkers.

Download Full-text

Abstract TP289: Code Neuro-Intervention a New Necessity: Reality of Shifting Stroke Care Paradigm

Stroke ◽

10.1161/str.48.suppl_1.tp289 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Laura Suhan ◽

Spozhmy Panezai ◽

Jaskiran Brar ◽

Audrey Z Arango ◽

Anna Pullicino ◽

...

Keyword(s):

Stroke Care ◽

Work Hours ◽

Stroke Treatment ◽

Angiography Suite ◽

Stroke Team ◽

Cross Training ◽

Code Process ◽

Time Parameters ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Various strategies have been implemented to reduce acute stroke treatment times. A unique code process pathway was designed at our hospital specifically to be activated by the stroke team for the purpose of rapidly assembling the Neurointerventional team. Methods: Code Neurointervention (NI), was designed and tested from January 2014 to April 2014 for all the patients who presented with ischemic strokes to our community based, university affiliated comprehensive stroke center. We retrospectively analyzed all patients who had Code NI called from May 1, 2014 to April 30, 2015 and compared them to patients who underwent acute endovascular treatment the prior year (Non Code NI). The following parameters were compared: decision to recanalization and door to recanalization times. Further analysis was done to compare patients presenting during business hours (Monday-Friday 8am-5pm) and off hours using GraphPad QuickCalcs Web site. Results: There were 28 Code NI; 14 were called during work hours and 14 during off hours. The previous year 25 patients underwent acute endovascular intervention; 12 during work hours and 13 during off hours. Mean decision to recanalization time was 106 (Code NI) vs 115 minutes (Non Code NI) (p<0.0.6) during work hours and 154 (Code NI) vs 139 minutes (Non Code NI) (p<0.37) during off hours. Mean door to recanalization time was 169 (Code NI) vs 173 minutes (Non Code NI) (p<0.85) during work hours and 252 (Code NI) vs 243minutes (Non Code NI) (p< 0.75) during off hours. Subset analysis of time parameters for patients in Code NI group showed mean decision to recanalization times of 106 minutes during work hours vs 154 minutes off work hours (p<0.004). Mean door to recanalization times were 169 minutes vs 251 minutes (p<0.0003), respectively. Conclusion: Institution of Code NI significantly improved intervention time parameters during work hours as compared to off hours. Rapid assembly of the neurointervention team, rapid availability of imaging and angiography suite likely contribute to these differences. Further initiatives, such as improving neurointervention staff availability during off hours or cross training other staff can further improve acute intervention time parameters.

Download Full-text

Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

Journal of Graduate Medical Education ◽

10.4300/jgme-d-17-00167.1 ◽

2018 ◽

Vol 10 (1) ◽

pp. 57-62 ◽

Cited By ~ 9

Author(s):

Tapan Mehta ◽

Sara Strauss ◽

Dawn Beland ◽

Gilbert Fortunato ◽

Ilene Staff ◽

...

Keyword(s):

Blood Pressure ◽

Medical Education ◽

Acute Stroke ◽

Simulation Training ◽

Stroke Registry ◽

Practice Experience ◽

Intravenous Tissue Plasminogen Activator ◽

Simulation Based ◽

Comprehensive Stroke Center ◽

Stroke Center

ABSTRACT Background Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] –15.28 to –4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (> 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36–25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

Download Full-text

Modeling the Optimal Transportation for Acute Stroke Treatment

Stroke ◽

10.1161/strokeaha.119.027493 ◽

2020 ◽

Vol 51 (1) ◽

pp. 275-281 ◽

Cited By ~ 4

Author(s):

Marielle Ernst ◽

Eckhard Schlemm ◽

Jessalyn K. Holodinsky ◽

Noreen Kamal ◽

Götz Thomalla ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Catchment Area ◽

Treatment Time ◽

Intravenous Thrombolysis ◽

Probability Models ◽

Stroke Treatment ◽

Federal States ◽

Medical Response ◽

Stroke Center

Background and Purpose— Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods— Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km 2 with a population of 12 703 561 in 2017 (198 persons per km 2 ). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results— The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain <40 minutes each. A slowed workflow in the DD paradigm resulted in a decrease of the DD catchment area to 1221 km 2 (2%). Conclusions— Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.

Download Full-text