scholarly journals Current trends in the acute treatment of ischemic stroke: analysis from the Paul Coverdell National Acute Stroke Program

2019 ◽  
Vol 12 (6) ◽  
pp. 574-578 ◽  
Author(s):  
Ganesh Asaithambi ◽  
Xin Tong ◽  
Kamakshi Lakshminarayan ◽  
Sallyann M Coleman King ◽  
Mary G George
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Intravenous Thrombolysis ◽  
Evidence Based ◽  
Stroke Registry ◽  
Treatment Groups ◽  
Current Trends ◽  
Trends Over Time ◽  
Using Data ◽  
Over Time

BackgroundThe intra-arterial treatment (IAT) of acute ischemic stroke (AIS) is now evidence-based and given the highest level of recommendation among eligible patients. Using a multi-state stroke registry, we studied the trend in IAT among patients with AIS over 11 years and its impact on the utilization of intravenous thrombolysis (IVT) within the same 11 years.MethodsUsing data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT and IAT for patients with AIS between 2008 and 2018. Trends over time were examined for rates of IVT only, IAT only, or a combination of IVT and IAT (IVT+IAT). Favorable outcome was defined as discharge to home.ResultsDuring the study period there were 595 677 patients (mean age 70.4 years, 50.4% women) from 646 participating hospitals with a clinical diagnosis of AIS in the PCNASP. Trends for IVT only, IAT only, and IVT+IAT all significantly increased over time (P<0.001). Total use of IVT and IAT increased from 7% in 2008 to 19.1% in 2018. The rate of patients discharged to home increased significantly over time among all treatment groups (P<0.001).ConclusionIn our large registry-based analysis, we observed a significant increase in the use of IAT for the treatment of AIS, with continued increases in the use of IVT. Concurrently, the percent of patients with favorable outcomes continued to increase.

Abstract 3268: Ct Perfusion As A Tool To Predict The Risk Of Hemorrhagic Transformation In Ischemic Stroke Treated With Tissue Plasminogen Activator: A Single Center Experience.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tareq Kass-Hout ◽  
Maxim Mokin ◽  
Omar Kass-Hout ◽  
Emad Nourollahzadeh ◽  
David Wack ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Brain Tissue ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Stroke Therapy ◽  
Two Phase ◽  
The Mean

Objective: To use the Computed Tomography Perfusion (CTP) parameters at the time of hospital admission, including Cerebral Blood Volume (CBV) and Permeability Surface area product (PS), to identify patients with higher risk to develop hemorrhagic transformation in the setting of acute stroke therapy with intravenous thrombolysis. Methods: Retrospective study that compared admission CTP variables between patients with Hemorrhagic Transformation (HT) acute stroke and those with no hemorrhagic transformation. Both groups received standard of care intravenous thrombolysis with tPA. Twenty patients presented to our stroke center between the years 2007 - 2011 within 3 hours after stroke symptoms onset. All patients underwent two-phase 320 slice CTP which creates CBV and PS measurements. Patients were divided into two groups according to whether or not they had HT on a follow up CT head without contrast, done within 36 hours of the thrombolysis therapy. Clinical, demographic and CTP variables were compared between the HT and non-HT groups using logistic regression analyses. Results: HT developed in 8 (40%) patients. Patients with HT had lower ASPECT score ( P =.03), higher NIHSS on admission ( P= .01) and worse outcome ( P= .04) compared to patients who did not develop HT. Baseline blood flow defects were comparable between the two groups. The mean PS for the HT group was 0.53 mL/min/100g brain tissue, which was significantly higher than that for the non-HT group of 0.04 mL/min/100g brain tissue ( P <.0001). The mean area under the curve was 0.92 (95% CI). The PS threshold of 0.26 mL/min/100g brain tissue had a sensitivity of 80% and a specificity of 92% for detecting patients with high risk of hemorrhagic transformation after intravenous thrombolysis. Conclusions: Admission CTP measurements might be useful to predict patients who are at higher risk to develop hemorrhagic transformation after acute ischemic stroke therapy.

Dysphagia screening after intracerebral hemorrhage

2017 ◽  
Vol 13 (5) ◽  
pp. 503-510 ◽  
Author(s):  
Raed A Joundi ◽  
Rosemary Martino ◽  
Gustavo Saposnik ◽  
Vasily Giannakeas ◽  
Jiming Fang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Clinical Severity ◽  
Stroke Severity ◽  
Stroke Registry ◽  
Patients At Risk ◽  
Poor Outcomes ◽  
Risk Of Aspiration ◽  
To Receive

Background Dysphagia screening is recommended after acute stroke to identify patients at risk of aspiration and implement appropriate care. However, little is known about the frequency and outcomes of patients undergoing dysphagia screening after intracerebral hemorrhage (ICH). Methods We used the Ontario Stroke Registry from 1 April 2010 to 31 March 2013 to identify patients hospitalized with acute stroke and to compare dysphagia screening rates in those with ICH and ischemic stroke. In patients with ICH we assessed predictors of receiving dysphagia screening, predictors of failing screening, and outcomes after failing screening. Results Among 1091 eligible patients with ICH, 354 (32.4%) patients did not have documented dysphagia screening. Patients with mild ICH were less likely to receive screening (40.4% of patients were omitted, adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI) 0.26–0.63). Older age, greater stroke severity, speech deficits, lower initial level of consciousness, and admission to intensive care unit were predictive of failing the screening test. Failing screening was associated with poor outcomes, including pneumonia (aOR 5.3, 95% CI 2.36–11.88), severe disability (aOR 4.78, 95% CI 3.08–7.41), and 1-year mortality (adjusted hazard ratio 2.1, 95% CI 1.38–3.17). When compared to patients with ischemic stroke, patients with ICH were less likely to receive dysphagia screening (aOR 0.64, 95% CI 0.54–0.76) and more likely to fail screening (aOR 1.98, 95% 1.62–2.42). Conclusion One-third of patients with ICH did not have documented dysphagia screening, increasing to 40% in patients with mild clinical severity. Failing screening was associated with poor outcomes. Patients with ICH were less like to receive screening and twice as likely to fail compared to patients with ischemic stroke, and thus efforts should be made to include ICH patients in dysphagia screening protocols whenever possible.

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kerrin Connelly ◽  
Rishi Gupta ◽  
Raul Nogueira ◽  
Arthur Yancey ◽  
Alexander Isakov ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Transport Protocol ◽  
Stroke Patients ◽  
Stroke Registry ◽  
The Public ◽  
State Office ◽  
Stroke Center ◽  
Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Abstract T P47: Response to Thrombolysis in Ischemic Stroke Depends on the Presence of Initial Arterial Occlusion

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Freidrich Medlin ◽  
Michael Amiguet ◽  
Peter Vanacker ◽  
Patrik Michel
Keyword(s):  
Ischemic Stroke ◽  
Randomized Trials ◽  
Primary Outcome ◽  
Interaction Analysis ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Class Iii ◽  
Unfavourable Outcome ◽  
Stroke Registry

Objective: We aimed to assess effectiveness of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) depending on the presence or absence of cervical or intracranial arterial occlusion on acute CT angiography (CTA). Methods: Patients from the Acute STroke Registry and Analysis of Lausanne (ASTRAL) were included in the analysis if they had an onset-to-door-time ≤ 4hours, CTA within 24 hours of onset, premorbid modified Rankin scale (mRS) ≤ 2, and a National Institute of Health Stroke Scale score (NIHSS) >4. Patients having significant intracranial stenosis (50-99%) or receiving endovascular treatment were excluded. The primary outcome was a 3 month handicap of mRS >2. We used an interaction analysis of IVT and initial arterial occlusion after adjusting for potential confounders for the primary outcome. Results: Of 655 included patients, 382 patients (58%) showed arterial occlusion, of whom 263 (69%) received IVT. Of the 273 patients without arterial occlusion, 139 (51%) received IVT. In patients with initial arterial occlusion and after multiple adjustments, IVT was associated with lower likelihood of unfavourable outcome (adjusted OR 0.33, 95% CI 0.12-0.91, p=0.03) whereas it had no significant effect in non-occluded patients (OR 1.32, 95% CI 0.36-4.76, p=0.67). Similarly, the presence of arterial occlusion did not significantly worsen the outcome in thrombolysed patients (OR 1.99, 95% CI 0.68-5.81, p=0.21), whereas it did so in non-thrombolysed patients (OR 7.89, 95% CI 2.29-27.25, p<0.01). Conclusions: IVT for AIS is more effective in the setting of visible arterial occlusions on acute imaging. If confirmed in other studies, this information may influence thrombolysis decisions and planning of further randomized trials. Classification of evidence: This retrospective analysis provides class III evidence that IVT has less benefit in patients without visible occlusion on acute CTA.

scholarly journals Low-dose versus standard-dose alteplase in acute ischemic stroke in Asian stroke registries: an individual patient data pooling study

2019 ◽  
Vol 14 (7) ◽  
pp. 670-677
Author(s):  
Xia Wang ◽  
Jingwei Li ◽  
Tom J Moullaali ◽  
Keon-Joo Lee ◽  
Beom Joon Kim ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Low Dose ◽  
Standard Dose ◽  
Stroke Registry ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Intravenous Alteplase

Objective To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. Methods Individual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the individual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. Results Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85–1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63–1.19), except for lower death with borderline significance, 0.77 (0.59–1.01). Conclusions The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.

scholarly journals B.01 Predictors of dysphagia screening after acute ischemic stroke: Who gets tested?

2016 ◽  
Vol 43 (S2) ◽  
pp. S9-S9
Author(s):  
RA Joundi ◽  
R Martino ◽  
G Saposnik ◽  
J Fang ◽  
V Giannakeas ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Stroke Unit ◽  
Adjusted Odds Ratio ◽  
Process Of Care ◽  
Stroke Registry ◽  
Multivariable Regression ◽  
Mild Stroke

Background: Dysphagia is a devastating complication of stroke and can lead to malnutrition, immobility, aspiration pneumonia, and death. Guidelines advocate screening all patients with acute stroke for swallowing impairment. However, previous research suggests only 60% are screened, and it is unclear what factors contribute to receiving dysphagia screening. Methods: We used the Ontario Stroke Registry to identify patients who were admitted to Regional Stroke Centres from 2010-2013. We used multivariable regression to identify predictors of receiving a dysphagia screen within 72 hours. Results: Among 7172 patients with acute ischemic stroke, 1705 patients (23.8%) did not undergo screening. Factors increasing the odds of being tested were: Stroke unit admission (adjusted odds ratio aOR 6.5), presenting with speech deficits (aOR 1.9) or weakness (aOR 1.5), or receiving thrombolysis (aOR 1.9). Seizure (aOR 0.49) and mild stroke (aOR 0.59 vs moderate stroke) decreased the odds of being tested. Among those with mild strokes who received a swallowing screen, 33% failed. *All p<0.0001. Conclusions: Patients with mild stroke are at risk of not being screened for dysphagia, despite a significant fail rate among those tested. This may expose untested patients to a higher risk of complications from dysphagia, and suggests a gap in process of care that should be addressed.

scholarly journals Endovascular treatment of acute ischemic stroke: the end or just the beginning?

2014 ◽  
Vol 36 (1) ◽  
pp. E5 ◽  
Author(s):  
Maxim Mokin ◽  
Alexander A. Khalessi ◽  
J Mocco ◽  
Giuseppe Lanzino ◽  
Travis M. Dumont ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Randomized Trials ◽  
Intravenous Thrombolysis ◽  
Lessons Learned ◽  
Neurological Deficits ◽  
Medical Community ◽  
Current Status

Various endovascular intraarterial approaches are available for treating patients with acute ischemic stroke who present with severe neurological deficits. Three recent randomized trials—Interventional Management of Stroke (IMS) III, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and Synthesis Expansion: A Randomized Controlled Trial on Intra-Arterial Versus Intravenous Thrombolysis in Acute Ischemic Stroke (SYNTHESIS Expansion)—evaluated the efficacy of endovascular treatment of acute ischemic stroke and, after failing to demonstrate any significant clinical benefit of endovascular therapies, raised concerns and questions in the medical community regarding the future of endovascular treatment for acute ischemic stroke. In this paper, the authors review the evolution of endovascular treatment strategies for the treatment of acute stroke and provide their interpretation of findings and potential limitations of the three recently published randomized trials. The authors discuss the advantage of stent-retriever technology over earlier endovascular approaches and review the current status and future directions of endovascular acute stroke studies based on lessons learned from previous trials.

scholarly journals Accuracy of Administrative Data for the Coding of Acute Stroke and TIAs

2016 ◽  
Vol 43 (6) ◽  
pp. 765-773 ◽  
Author(s):  
Ruth Hall ◽  
Luke Mondor ◽  
Joan Porter ◽  
Jiming Fang ◽  
Moira K. Kapral
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Administrative Data ◽  
Data Validation ◽  
Reference Standard ◽  
Stroke Registry ◽  
Diagnostic Codes ◽  
Icd 10 ◽  
Stroke Type ◽  
Ischemic Attack

AbstractObjective: Administrative data validation is essential for identifying biases and misclassification in research. The objective of this study was to determine the accuracy of diagnostic codes for acute stroke and transient ischemic attack (TIA) using the Ontario Stroke Registry (OSR) as the reference standard. Methods: We identified stroke and TIA events in inpatient and emergency department (ED) administrative data from eight regional stroke centres in Ontario, Canada, from April of 2006 through March of 2008 using ICD–10–CA codes for subarachnoid haemorrhage (I60, excluding I60.8), intracerebral haemorrhage (I61), ischemic (H34.1 and I63, excluding I63.6), unable to determine stroke (I64), and TIA (H34.0 and G45, excluding G45.4). We linked administrative data to the Ontario Stroke Registry and calculated sensitivity and positive predictive value (PPV). Results:: We identified 5,270 inpatient and 4,411 ED events from the administrative data. Inpatient administrative data had an overall sensitivity of 82.2% (95% confidence interval [CI95%]=81.0, 83.3) and a PPV of 68.8% (CI95%=67.5, 70.0) for the diagnosis of stroke, with notable differences observed by stroke type. Sensitivity for ischemic stroke increased from 66.5 to 79.6% with inclusion of I64. The sensitivity and PPV of ED administrative data for diagnosis of stroke were 56.8% (CI95%=54.8, 58.7) and 59.1% (CI95%=57.1, 61.1), respectively. For all stroke types, accuracy was greater in the inpatient data than in the ED data. Conclusion: The accuracy of stroke identification based on administrative data from stroke centres may be improved by including I64 in ischemic stroke type, and by considering only inpatient data.

Genetic parameters and phenotypic trends in the mean and variability of number of stillborn piglets and changes in their relationships with litter size and gestation length

2013 ◽  
Vol 53 (5) ◽  
pp. 395 ◽  
Author(s):  
Craig R. G. Lewis ◽  
Susanne Hermesch
Keyword(s):  
Genetic Parameters ◽  
Gestation Length ◽  
Genetic Associations ◽  
Large White ◽  
Factors Affecting ◽  
Breed Differences ◽  
Trends Over Time ◽  
The Mean ◽  
Using Data ◽  
Over Time

This study examined changes in genetic and phenotypic factors affecting stillborn piglets (SB). Over 15 years, 76 851 litter records were available from Large White (LW), Landrace (LR) and Duroc (DU) sows to investigate SB. The analyses focussed on trends over time in SB and the changes in the number of SB per litter, in factors associated with SB and in genetic parameters for SB. Breed differences were identified with DU producing more SB than the white breeds (mean of 1.46 ± 0.02 vs 1.11 ± 0.01 and 1.07 ± 0.01). However, maximum differences between levels of each factor were 0.73 and 0.65 SB for parity and herd, respectively. Over the 15 years studied, SB had increased by 0.2 piglets accompanied by an increase in the total numbers of piglets born per litter (TB) of ~0.5 piglets. This increase in SB was driven by higher occurrence of more than two SB within a single litter. The effect of TB on SB changed over time with solutions of 0.127 ± 0.002 and 0.150 ± 0.002 SB/TB in 1996 and 2010, respectively. Heritability estimates for SB ranged from 0.06 ± 0.01 to 0.09 ± 0.01 for alternative models and time periods. The unfavourable genetic correlation between SB and TB of 0.46 ± 0.03 based on all data available was slightly lower using only data from the first 5 years (0.38 ± 0.07) versus using data from the last 5 years (0.46 ± 0.06). However, this increase in phenotypic and genetic associations between SB and TB over time may be larger in populations that have observed a larger increase in TB.

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