Effect of routing paradigm on patient centered outcomes in acute ischemic stroke

2019 ◽  
Vol 11 (8) ◽  
pp. 762-767 ◽  
Author(s):  
Minerva H Zhou ◽  
Akash P Kansagra
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Rhode Island ◽  
Clinical Trial Data ◽  
Urban Setting ◽  
Rural Setting ◽  
Good Clinical Outcome ◽  
Minimal Impact ◽  
Stroke Center

BackgroundTo compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.MethodsWe simulated different routing paradigms in a system comprising one primary stroke center (PSC) and one comprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the nearest center paradigm, patients are initially sent to the nearest center, while in CSC first, patients are sent to the CSC. In the Rhode Island and distributive paradigms, patients with a FAST-ED (Facial palsy, Arm weakness, Speech changes, Time, Eye deviation, and Denial/neglect) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome, determined by type and timing of treatment using clinical trial data, and number needed to bypass (NNB).ResultsGood clinical outcome was achieved in 43.76% of patients in nearest center, 44.48% in CSC first, and 44.44% in Rhode Island and distributive in an urban setting; 43.38% in nearest center, 44.19% in CSC first, and 44.17% in Rhode Island in a suburban setting; and 41.10% in nearest center, 43.20% in CSC first, and 42.73% in Rhode Island in a rural setting. In all settings, NNB was generally higher for CSC first compared with Rhode Island or distributive.ConclusionRouting paradigms that allow bypass of nearer hospitals for thrombectomy capable centers improve population level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, paradigm choice may be most impactful in rural settings. Selective bypass, as implemented in the Rhode Island and distributive paradigms, improves system efficiency with minimal impact on outcomes.

Effect of routing paradigm on patient-centered outcomes in acute ischemic stroke

2018 ◽  
Vol 11 (3) ◽  
pp. 251-256
Author(s):  
Minerva H Zhou ◽  
Akash P Kansagra
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Rhode Island ◽  
Clinical Trial Data ◽  
Population Level ◽  
Urban Setting ◽  
Rural Setting ◽  
Good Clinical Outcome ◽  
Stroke Center

ObjectiveTo compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.MethodsWe simulated different routing paradigms in a system comprising one primary stroke center (PSC) and onecomprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the Nearest Center paradigm, patients are initially sent to the nearest center, while in CSC First, patients are sent to the CSC. In Rhode Island and Distributive paradigms, patients with Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome determined by type and timing of treatment using clinical trial data and number needed to bypass (NNB).ResultsGood clinical outcome was achieved in 43.67% of patients in Nearest Center and 44.62% in CSC First, Rhode Island, and Distributive in an urban setting; 42.79% in Nearest Center and 43.97% in CSC First and Rhode Island in a suburban setting; and 39.76% in Nearest Center, 41.73% in CSC First, and 41.59% in Rhode Island in a rural setting. In all settings, the NNB was considerably higher for CSC First than for Rhode Island or Distributive.ConclusionRouting paradigms that allow bypass of nearer hospitals for thrombectomy-capable centers improve population-level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, the choice of model may have greater effect in rural settings. Selective bypass, as implemented in Rhode Island and Distributive paradigms, improves system efficiency with minimal effect on outcomes.

Abstract WP241: Direct Doctor-to-Doctor Telecommunication Between a Stroke Center and Local Hospitals: a Tool to Enhance Clinical Outcome of Intraarterial Thrombectomy for Acute Ischemic Stroke Patients First Visit Local Hospitals

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Hye Seon Jeong ◽  
Hyon-Jo Kwon ◽  
Hyeon Song Koh ◽  
Hee Sun Yu ◽  
Na Young Yun ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Time Analysis ◽  
Stroke Patients ◽  
Good Clinical Outcome ◽  
Telecommunication System ◽  
Time Intervals ◽  
Direct Communication ◽  
Stroke Center

Background: We have executed a direct doctor-to-doctor telecommunication system (D2D-Call) to perform intraarterial thrombectomy (IAT) for acute ischemic stroke patients, who first visited at local hospitals. We evaluated whether the D2D-Call was effective to perform successful IAT for acute stroke patients visited first at the local hospitals. Methods: We analyzed clinical data of 201 consecutive patients (male:female=126:75, mean age±SD, 68.4±12.5 years), who underwent IAT to recanalize occluded intracranial vessels from January, 2011 to May, 2015. The patients were classified by the arrival manners at our center; 1) Direct-Arrival at our center (n=140), 2) transfer after D2D-Call (n=38), and 3) transfer with No-D2D-Call (n=23) from local hospitals. Differences of the time intervals from arrival at our center to IAT start (Arrival-to-Puncture) and from symptom onset to recanalization (Onset-to-Recanalization) were analyzed between the three groups. The recanalization rates and clinical outcome of the three groups were also compared between them. Results: D2D-Call group showed shorter Arrival-to-Puncture time than the other groups (Direct-Arrival, 107.1±28.1; D2D-Call, 49.6±18.3; No-D2D-Call group, 109.8±28.3 minutes, p<0.001). On Onset-to-Recanalization time analysis, D2D-Call group was late 44 minutes yet, but, faster 90 minutes than No-D2D-Call group (Direct-Arrival, 263.9±120.1; D2D-Call, 307.1±70.7; No-D2D-Call group, 393.6±74.9 minutes, p<0.001). Overall recanalization rate of D2D-Call group (76%) was lower than Direct-arrival (84%), but, higher than Non-D2D-call group (65%, p=0.075). Good clinical outcome (defined as 0-3 of modified Rankin Scale) of D2D-Call group (66%) was similar with Direct-Arrival (68%) at 3 months after IAT, but, significantly higher than Non-D2D-Call group (39%) (p=0.030). Conclusion: Direct communication between doctors of a stroke center and local hospitals could reduce overall onset-to-recanalization time of IAT by shortening of staying in emergency room, and, ultimately could achieve better clinical outcome after IAT for acute ischemic stroke patients visited first at local hospitals.

scholarly journals Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

2021 ◽  
Vol 11 (4) ◽  
pp. 504
Author(s):  
Dalibor Sila ◽  
Markus Lenski ◽  
Maria Vojtková ◽  
Mustafa Elgharbawy ◽  
František Charvát ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Stent Retriever ◽  
Good Clinical Outcome ◽  
Significant Difference ◽  
Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

scholarly journals Acute Ischemic Stroke in Late Pregnancy Treated with Intravenous Thrombolysis and Endovascular Therapy

2019 ◽  
Vol 11 (1) ◽  
pp. 41-46 ◽  
Author(s):  
Eva Szuchy Kristiansen ◽  
Hannah Holm Vestergaard ◽  
Boris Modrau ◽  
Lorenz Martin Oppel
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Intravenous Thrombolysis ◽  
Late Pregnancy ◽  
Exclusion Criterion ◽  
Good Clinical Outcome ◽  
Systemic Thrombolysis ◽  
In Pregnancy

Pregnancy has usually been an exclusion criterion in clinical trials with thrombolysis and endovascular therapy in acute ischemic stroke. For that reason, these therapies are not recommended causing lack of evidence and vice versa. In this case report, we describe a pregnant woman in week 33 + 3 presenting with acute ischemic stroke, which was successfully treated with systemic thrombolysis and endovascular therapy, resulting in a good clinical outcome for both mother and child. The altered fibrinolytic system and the risk factors related to pregnancy constitute a challenge for clinicians when choosing the most suitable treatment modality for treating acute ischemic stroke in pregnancy. It is still uncertain whether thrombolysis in combination with endovascular therapy or endovascular therapy alone is the most appropriate treatment option. However, there is slowly growing evidence that thrombolysis and thrombectomy in pregnancy are feasible and safe with a good clinical outcome for both the mother and the child.

Population health impact of extended window thrombectomy in acute ischemic stroke

2020 ◽  
pp. 159101992097220
Author(s):  
Minerva H Zhou ◽  
Akash P Kansagra
Keyword(s):  
Clinical Outcome ◽  
Clinical Outcomes ◽  
Clinical Trial Data ◽  
Population Level ◽  
Health Impact ◽  
Stroke Severity ◽  
Good Clinical Outcome ◽  
Absolute Increase ◽  
Stroke Center ◽  
The Impact

Background Recent trials support endovascular thrombectomy (EVT) in select patients beyond the conventional 6-hour window. Objective In this work, we estimate the impact of extended window EVT on procedural volumes and population-level clinical outcomes using Monte Carlo simulation. Methods We simulated extending EVT eligibility in a system comprising an EVT-incapable primary stroke center (PSC) and EVT-capable comprehensive stroke center (CSC) using routing paradigms that initially direct patients to (1) the nearest center, (2) the CSC, or (3) either CSC or nearest center based on stroke severity. EVT eligibility and outcomes are based on HERMES, DEFUSE-3, and DAWN studies in the 0-6, 6-16, and 16-24 hour windows, respectively. Probability of good clinical outcome is determined by type and timing of treatment using clinical trial data. Results Relative increase in EVT volume in the three tested routing paradigms was 15.7-15.8%. The absolute increase in the rate of good clinical outcome 0.4% in all routing paradigms. NNT for extended window EVT was 239.9-246.4 among the entire stroke population. Conclusion Extended window EVT with DEFUSE-3 and DAWN criteria increases EVT volume and modestly improves population-level clinical outcomes.

CTA collateral score predicts infarct volume and clinical outcome after endovascular therapy for acute ischemic stroke: a retrospective chart review

2015 ◽  
Vol 8 (6) ◽  
pp. 559-562 ◽  
Author(s):  
Lucas Elijovich ◽  
Nitin Goyal ◽  
Shraddha Mainali ◽  
Dan Hoit ◽  
Adam S Arthur ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Chart Review ◽  
Infarct Volume ◽  
Retrospective Chart Review ◽  
Favorable Outcome ◽  
Good Clinical Outcome

BackgroundAcute ischemic stroke (AIS) due to emergent large-vessel occlusion (ELVO) has a poor prognosis.ObjectiveTo examine the hypothesis that a better collateral score on pretreatment CT angiography (CTA) would correlate with a smaller final infarct volume and a more favorable clinical outcome after endovascular therapy (EVT).MethodsA retrospective chart review of the University of Tennessee AIS database from February 2011 to February 2013 was conducted. All patients with CTA-proven LVO treated with EVT were included. Recanalization after EVT was defined by Thrombolysis in Cerebral Infarction (TICI) score ≥2. Favorable outcome was assessed as a modified Rankin Score ≤3.ResultsFifty patients with ELVO were studied. The mean National Institutes of Health Stroke Scale score was 17 (2–27) and 38 of the patients (76%) received intravenous tissue plasminogen activator. The recanalization rate for EVT was 86.6%. Good clinical outcome was achieved in 32% of patients. Univariate predictors of good outcome included good collateral scores (CS) on presenting CTA (p=0.043) and successful recanalization (p=0.02). Multivariate analysis confirmed both good CS (p=0.024) and successful recanalization (p=0.009) as predictors of favorable outcome. Applying results of the multivariate analysis to our cohort we were able to determine the likelihood of good clinical outcome as well as predictors of smaller final infarct volume after successful recanalization.ConclusionsGood CS predict smaller infarct volumes and better clinical outcome in patients recanalized with EVT. These data support the use of this technique in selecting patients for EVT. Poor CS should be considered as an exclusion criterion for EVT as patients with poor CS have poor clinical outcomes despite recanalization.

P-046 Correlation between recanalization rate and good clinical outcome in acute ischemic stroke, a meta-analysis

2012 ◽  
Vol 4 (Suppl 1) ◽  
pp. A44.1-A44
Author(s):  
E Nourollahzadeh ◽  
O Kass-Hout ◽  
M Mokin ◽  
R Aliotta ◽  
K Synder ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Good Clinical Outcome

Abstract WMP8: Results of Trevo Acute Ischemic Stroke Thrombectomy Registry: Predictors of Clinical Outcome

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
O O Zaidat ◽  
A Castonguay ◽  
D Haussen ◽  
J English ◽  
H Farid ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Real Life ◽  
Good Clinical Outcome ◽  
Full Cohort ◽  
Lower Baseline ◽  
Younger Age ◽  
Multicenter Registry

Background and Purpose: Recent randomized clinical trial (RCTs) demonstrated efficacy of mechanical thrombectomy using stent-retrievers in acute ischemic stroke (AIS) patients. The main purpose of TRevo ACute Ischemic StroKe (TRACK) stent-retriever thrombectomy multicenter registry is to demonstrate safety and efficacy in real life clinical practice. Methods: The investigator-initiated TRACK multicenter registry recruited 24 sites in north America to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive AIS patients treated with Trevo stent-retriever device as the first treatment option. Standard clinical safety (symptomatic intracranial hemorrhage (sICH), and mortality) and efficacy (revascularization and disability) outcomes and predictors of clinical outcome were analyzed. Results: 624 patients were enrolled in the TRACK registry. Median age was 68 years (range 16-94, 118 (18.1%) >80), male gender was 51.4%, and 67.7% were white. The median National Institutes of Health Stroke Severity Scale (NIHSS) was 17 (IQR 13-22). Transfer cases were 50.6% with IV-rtPA use in 318 cases (51.3%). Median onset to groin puncture (OTG) time was 283 min (IQR 198.5-443), and groin puncture to revascularization was 66 min (IQR 37.5-103). Anterior circulation occlusion was 86.2% (MCA/M2 in 55.2% followed by ICA in 15.9% and M2 in 12.7%). Use of GA was in 389 cases (62.3%), number of passes were ≤ 3 in 92% of the cases (1: 45.2%, 2:28%, and 3:18.7%), 291 (46.7%) had BGC use. Rescue use was seen in 21.7%. Revascularization of ≥ TIMI 2 was 81.8% and ≥ TICI 2b was 70%. The primary outcome of mRS of ≥ 2 was 48.3% in the full cohort, and 50.6% in TREVO-2 like group. sICH and mortality were 7.2%, and 20.1% in the full cohort vs 6.9% and 17.5% in the TREVO-2 like group, respectively. The independent predictors of clinical outcome were lower baseline NIHSS, younger age, use of BGC, successful recanalization, and no general anesthesia (GA). Conclusions: The real life clinical practice Trevo registry demonstrated good clinical outcome and high rate of recanalization. Younger age, lower baseline NIHSS, use of balloon guide catheter, successful recanalization, and avoiding endotrachaeal GA independent predictors of good clinical outcome.

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