Severe hemiparesis as a prehospital tool to triage stroke severity: a pilot study to assess diagnostic accuracy and treatment times

2015 ◽  
Vol 8 (8) ◽  
pp. 775-777 ◽  
Author(s):  
Rishi Gupta ◽  
Marissa Manuel ◽  
Kumiko Owada ◽  
Samish Dhungana ◽  
Leslie Busby ◽  
...  
Keyword(s):  
Pilot Study ◽  
Endovascular Therapy ◽  
Acute Treatment ◽  
Mechanical Thrombectomy ◽  
Stroke Severity ◽  
Intravenous Tissue Plasminogen Activator ◽  
Number Of Patients ◽  
Tissue Plasminogen ◽  
The Times ◽  
The Impact

IntroductionWith the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes.Materials and methodsWe retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy.Results45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101 min, with 8 of the 12 patients (66.7%) being discharged to home.ConclusionsWe have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.

scholarly journals Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of “Drip and Ship” on Effectiveness and Outcomes

2020 ◽  
Vol 11 ◽  
Author(s):  
Adam Chang ◽  
Elham Beheshtian ◽  
Edward J. Llinas ◽  
Oluwatoyin R. Idowu ◽  
Elisabeth B. Marsh
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Hemorrhagic Transformation ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
The Impact ◽  
Iv Tpa

Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital.Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes.Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h.Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.

scholarly journals A System-Based Intervention to Improve Access to Hyperacute Stroke Care

2017 ◽  
Vol 44 (5) ◽  
pp. 475-482 ◽  
Author(s):  
Richard H. Swartz ◽  
Elizabeth Linkewich ◽  
Shelley Sharp ◽  
Jacqueline Willems ◽  
Chris Olynyk ◽  
...  
Keyword(s):  
Patient Flow ◽  
Stroke Care ◽  
Hyperacute Stroke ◽  
Greater Toronto Area ◽  
Number Of Patients ◽  
Tissue Plasminogen ◽  
Incident Reports ◽  
The Impact ◽  
Mean Time ◽  
Improve Access

AbstractBackground:Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move “walk-in” patients from non-hyperacute hospitals to regional stroke centres (RSCs).Methods and Results:Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes,p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%.Conclusions:A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.

Republished: A novel route of revascularization in basilar artery occlusion and review of the literature

2015 ◽  
Vol 8 (7) ◽  
pp. e25-e25 ◽  
Author(s):  
Alejandro Morales ◽  
Phillip Vaughan Parry ◽  
Ashutosh Jadhav ◽  
Tudor Jovin
Keyword(s):  
Basilar Artery ◽  
Mechanical Thrombectomy ◽  
Antiplatelet Agents ◽  
Artery Occlusion ◽  
Direct Access ◽  
Basilar Artery Occlusion ◽  
Review Of The Literature ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Angioplasty And Stenting

Ischemia of the basilar artery is one of the most devastating types of arterial occlusive disease. Despite treatment of basilar artery occlusions (BAO) with intravenous tissue plasminogen activator, antiplatelet agents, intra-arterial therapy or a combination, fatality rates remain high. Aggressive recanalization with mechanical thrombectomy is therefore often necessary to preserve life. When direct access to the basilar trunk is not possible, exploration of chronically occluded vessels through collaterals with angioplasty and stenting creates access for manual aspiration. We describe the first report of retrograde vertebral artery (VA) revascularization using thyrocervical collaterals for anterograde mechanical aspiration of a BAO followed by stenting of the chronically occluded VA origin. Our novel retrograde–anterograde approach resulted in resolution of the patient's clinical stroke syndrome.

scholarly journals Impact of the COVID-19 pandemic on emergency admission for patients with stroke: a time series study in Japan

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Takuaki Tani ◽  
Shinobu Imai ◽  
Kiyohide Fushimi
Keyword(s):  
Time Series ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Infection Prevalence ◽  
State Of Emergency ◽  
Hospitalised Patients ◽  
Number Of Patients ◽  
Significant Difference ◽  
Baseline Characteristics ◽  
The Impact

Abstract Background Appropriate treatment of stroke immediately after its onset contributes to the improved chances, while delay in hospitalisation affects stroke severity and fatality. This study aimed to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on emergency hospitalisation of patients with stroke in Japan. Methods This was an observational study that used nationwide administrative data of hospitalised patients diagnosed with stroke. We cross-sectionally observed patients’ background factors during April and May 2020, when the COVID-19 pandemic-related state of emergency was declared; we also observed these factors in the same period in 2019. We also modelled monthly trends in emergency stroke admissions, stroke admissions at each level of the Japan Coma Scale (JCS), fatalities within 24 h, stroke care unit use, intravenous thrombolysis administration, and mechanical thrombectomy implementation using interrupted time series (ITS) regression. Results There was no difference in patients’ pre-hospital baseline characteristics between the pre-pandemic and pandemic periods. However, ITS regression revealed a significant change in the number of emergency stroke admissions after the beginning of the pandemic (slope: risk ratio [RR] = 0.97, 95% confidence interval [CI]: 0.95–0.99, P = 0.027). There was a significant difference in the JCS score for impaired consciousness in emergency stroke, which was more severe during the pandemic than the pre-pandemic (JCS3 in level: RR = 1.75, 95% CI: 1.29–2.33, P < 0.001). There was no change in the total number of fatalities with COVID-19, compared with those without COVID-19, but there were significantly more fatalities within 24 h of admission (fatalities within 24 h: RR = 1.75, 95% CI: 1.29–2.33, P < 0.001). Conclusions The infection prevalence of COVID-19 increased the number of fatalities within 24 h as well as the severity of illness in Japan. However, there was no difference in baseline characteristics, intravenous thrombolysis administration, and mechanical thrombectomy implementation during the COVID-19 pandemic. A decrease in the number of patients and fatalities was observed from the time the state of emergency was declared until August, the period of this study.

Abstract T P338: Time is of the Essence: A Nurse-Based Intervention to Improve Door to Needle Times

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Erin Lawrence ◽  
Dawn Merbach ◽  
Sherry Thorpe ◽  
Rafael H Llinas ◽  
Elisabeth B Marsh
Keyword(s):  
Acute Stroke ◽  
Stroke Severity ◽  
Flow Sheet ◽  
Post Intervention ◽  
Time To Treatment ◽  
Patient Demographics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Number Of Patients ◽  
Additional Imaging ◽  
Student’S T

Background: For acute ischemic stroke, the chance of improved recovery is directly impacted by the length of time from symptom onset to administration of intravenous tissue plasminogen activator (IV t-PA). Despite the importance of rapid treatment, stroke centers struggle with achieving consistent door to needle times of less than 60 minutes. In an effort to improve efficiency, we implemented a change in our response to the acute stroke patient by adding a dedicated stroke nurse and Nursing Flow Sheet that focuses on critical benchmarks (e.g., door to CT time) prior to treatment. We collected data on patients treated with IV t-PA pre- and post-intervention to determine if our process increased the number of patients receiving t-PA in less than 60 minutes. Methods: 137 patients (n=77 pre, 60 post) who were treated with IV t-PA between 2009-2013 were included in analysis. Student’s t-tests and Fisher’s exact tests were used to compare door to needle times pre- and post-intervention. Additional data were collected regarding: patient demographics, admission characteristics (e.g., day of the week), stroke severity, medical comorbidities, and other barriers to t-PA administration (e.g., need for antihypertensives or additional imaging). Results: With implementation, the mean time to treatment only decreased from 82 to 78 minutes (p=0.58); however, the percentage of patients successfully treated within 60 minutes of arrival improved from 26% to 58% (p=0.003). NIH Stroke Scale severity and need for additional imaging (i.e., CTA of the chest) were associated with increased time to treatment. Conclusion: The use of a dedicated stroke nurse and Nursing Flow Sheet as part of the acute stroke assessment reduces door to needle times and significantly increases the proportion of patients treated with IV tPA within 60 minutes from hospital arrival.

Abstract P480: Impact of Intravenous Thrombolysis on Reperfusion Status in Stroke Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Helio P Carvalho ◽  
Aaron Wessell ◽  
Gregory Cannarsa ◽  
Timothy R Miller ◽  
Dheeraj Gandhi ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Intracranial Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Procedure Time ◽  
Multivariate Logistic Regression ◽  
Poor Outcome ◽  
Number Of Patients ◽  
The Impact ◽  
Number Of Passes

Introduction: It remains unclear whether use of intravenous thrombolysis (IVT) with intravenous tissue plasminogen activator (tPA) provides additional benefit to patients with emergent large vessel occlusion (ELVO) stroke undergoing mechanical thrombectomy (MT). We sought to determine the impact of IVT on procedure time, number of passes, and successful reperfusion (SR) during MT. Method: We retrospectively analyzed all patients who underwent anterior circulation mechanical thrombectomy for treatment of ELVO stroke at our institution from April 2012 to November 2019. Univariate and multivariate logistic regression analyzes were used to determine independent predictors of poor functional outcome at 90 days,and independent predictors of >2 thrombectomy passes in patients with successful revascularization (SR: TICI 2B, 2C and 3). Results: A total of 400 patients were eligible for analysis. 189 patients received IVT before thrombectomy. Last known well time-to-endovascular therapy was shorter in the IVT group (290.0 min vs 452.75 min; P=<0.001). The IVT group had a trend towards better outcomes at 90 days (mRS 0—2: 44% vs 35%; P=0.076). The number of passes and revascularization status did not significantly differ between IVT and non-IVT patients. The number of patients with any intracranial hemorrhage was higher in the IVT group than non- IVT group [10% vs 4%; p=0.038].Multivariate logistic regression demonstrated ICA occlusion site was an independent predictors of >2 passes relative to M1 occlusion in patients with successful revascularization. Multivariate logistic regression revealed that age (OR 1.05, 95% CI 1.03-1.07; p<0.001), NIHSS (OR 1.11, 95% CI 1.06-1.17; p<0.001), ≥3 thrombectomy passes (OR 2.47, 95% CI 1.23-5.00; p=0.011) and intracranial hemorrhage (OR 5.50, 95% CI 1.45-20.84; p=0.012)were independently associated with an increased odds of poor outcome. TICI 2C/3 was associated with reduced odds of poor outcome (OR 0.16, 95% CI 0.07-0.35; p<0,001). Conclusion: IVT pretreatment did not increase rates of SR and did not shorten MT procedure time nor number of passes needed to achieve SR during MT in our patient population. Randomized controlled trials are required for further evaluation of the impact of IVT on reperfusion status during MT.

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