Eligibility for late endovascular treatment using DAWN, DEFUSE-3, and more liberal selection criteria in a stroke center

2019 ◽  
Vol 12 (9) ◽  
pp. 842-847 ◽  
Author(s):  
Stefania Nannoni ◽  
Davide Strambo ◽  
Gaia Sirimarco ◽  
Michael Amiguet ◽  
Peter Vanacker ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Selection Criteria ◽  
Time Window ◽  
Real Life ◽  
Good Health ◽  
Late Time ◽  
Vessel Occlusion ◽  
Stroke Registry ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and purposeThe real-life application of DAWN and DEFUSE-3 trials has been poorly investigated. We aimed to identify the proportion of patients with acute ischemic stroke (AIS) eligible for late endovascular treatment (EVT) in our stroke center based on trial and more liberal selection criteria.MethodsAll consecutive patients in our stroke registry (2003–2017) admitted within 5–23 hours of last proof of good health were selected if they had complete clinical and radiological datasets. We calculated the proportion of patients eligible for late EVT according to trial (DAWN and/or DEFUSE-3) and more liberal clinical/imaging mismatch criteria (including lower admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score for core estimation).ResultsOf 1705 patients with AIS admitted to our comprehensive stroke center in the late time window, we identified 925 patients with complete clinical and radiological data. Among them, the proportions of late EVT eligibility were 2.5% (n=23) with DAWN, 5.1% (n=47) with DEFUSE-3, and 11.1% (n=103) with more liberal criteria. Considering late-arriving patients with large vessel occlusion (n=221), the percentages of eligible patients were 10.4%, 21.3%, and 46.6%, respectively. A favorable outcome was observed at comparable rates in treated patients selected by trial or liberal criteria (67% vs 58%, p=0.49).ConclusionsIn a long-term stroke registry, the proportion of late EVT eligibility varied greatly according to selection criteria and referral pattern. Among late-arriving patients referred to our comprehensive stroke center, we found 5.6% eligible according to trial (DAWN/DEFUSE-3) and 11.1% according to liberal criteria. These data indicate that late EVT could be offered to a larger population of patients if more liberal criteria are applied.

scholarly journals Value of repeated imaging in patients with a stroke who are transferred for endovascular treatment

2021 ◽  
pp. neurintsurg-2020-017050
Author(s):  
Laura C C van Meenen ◽  
Nerea Arrarte Terreros ◽  
Adrien E Groot ◽  
Manon Kappelhof ◽  
Ludo F M Beenen ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Improvement ◽  
Treatment Delay ◽  
Clinical Deterioration ◽  
Large Vessel Occlusion ◽  
Intracranial Hemorrhages ◽  
Vessel Occlusion ◽  
Quality Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center

BackgroundPatients with a stroke who are transferred to a comprehensive stroke center for endovascular treatment (EVT) often undergo repeated neuroimaging prior to EVT.ObjectiveTo evaluate the yield of repeating imaging and its effect on treatment times.MethodsWe included adult patients with a large vessel occlusion (LVO) stroke who were referred to our hospital for EVT by primary stroke centers (2016–2019). We excluded patients who underwent repeated imaging because primary imaging was unavailable, incomplete, or of insufficient quality. Outcomes included treatment times and repeated imaging findings.ResultsOf 677 transferred LVO stroke, 551 were included. Imaging was repeated in 165/551 patients (30%), mostly because of clinical improvement (86/165 (52%)) or deterioration (40/165 (24%)). Patients who underwent repeated imaging had higher door-to-groin-times than patients without repeated imaging (median 43 vs 27 min, adjusted time difference: 20 min, 95% CI 15 to 25). Among patients who underwent repeated imaging because of clinical improvement, the LVO had resolved in 50/86 (58%). In patients with clinical deterioration, repeated imaging led to refrainment from EVT in 3/40 (8%). No symptomatic intracranial hemorrhages (sICH) were identified. Ultimately, 75/165 (45%) of patients with repeated imaging underwent EVT compared with 326/386 (84%) of patients without repeated imaging (p<0.01).ConclusionsNeuroimaging was repeated in 30% of patients with an LVO stroke and resulted in a median treatment delay of 20 minutes. In patients with clinical deterioration, no sICH were detected and repeated imaging rarely changed the indication for EVT. However, in more than half of patients with clinical improvement, the LVO had resolved, resulting in refrainment from EVT.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

Procedural Complications During Early Versus Late Endovascular Treatment in Acute Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Errikos Maslias ◽  
Stefania Nannoni ◽  
Federico Ricciardi ◽  
Bruno Bartolini ◽  
Davide Strambo ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Time Window ◽  
National Institutes Of Health ◽  
Late Time ◽  
Short Term ◽  
Term Outcome ◽  
Stroke Registry ◽  
Short Term Outcome ◽  
Procedural Complications

Background and Purpose: Endovascular treatment (EVT) in acute ischemic stroke is effective in the late time window in selected patients. However, the frequency and clinical impact of procedural complications in the early versus late time window has received little attention. Methods: We retrospectively studied all acute ischemic strokes from 2015 to 2019 receiving EVT in the Acute Stroke Registry and Analysis of Lausanne. We compared the procedural EVT complications in the early (<6 hours) versus late (6–24 hours) window and correlated them with short-term clinical outcome. Results: Among 695 acute ischemic strokes receiving EVT (of which 202 were in the late window), 113 (16.3%) had at least one procedural complication. The frequency of each single, and for overall procedural complications was similar for early versus late EVT (16.2% versus 16.3%, P adj =0.90). Procedural complications lead to a significantly less favorable short-term outcome, reflected by the absence of National Institutes of Health Stroke Scale improvement in late EVT (delta-National Institutes of Health Stroke Scale-24 hours, −2.5 versus 2, P adj =0.01). Conclusions: In this retrospective analysis of consecutive EVT, the frequency of procedural complications was similar for early and late EVT patients but very short-term outcome seemed less favorable in late EVT patients with complications.

Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Raul G Nogueira ◽  
Laurie Preston ◽  
Adnan I Qureshi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method ◽  
Morbid Conditions

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

scholarly journals Thrombectomy 6-24 hours after stroke in trial ineligible patients

2018 ◽  
Vol 10 (11) ◽  
pp. 1033-1037 ◽  
Author(s):  
Shashvat M Desai ◽  
Marcelo Rocha ◽  
Bradley J Molyneaux ◽  
Matthew Starr ◽  
Cynthia L Kenmuir ◽  
...  
Keyword(s):  
Time Window ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Off Label ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

Clinical and neuroimaging criteria to improve the workflow in transfers for endovascular treatment evaluation

2019 ◽  
Vol 15 (9) ◽  
pp. 988-994 ◽  
Author(s):  
Manuel Requena ◽  
Marta Olivé-Gadea ◽  
Sandra Boned ◽  
Anna Ramos ◽  
Pere Cardona ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Treatment Success ◽  
Population Based ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Transfer protocols from primary to comprehensive stroke centers are crucial for endovascular treatment success. Aim To evaluate clinical and neuroimaging data of transferred patients and their likelihood of presenting a large infarct core at comprehensive stroke center arrival. Methods Retrospective analysis of population-based mandatory prospective registry of acute stroke patients evaluated for endovascular treatment. Consecutive patients evaluated at primary stroke center with suspected large vessel occlusion and PSC-ASPECTS ≥ 6 transferred to a comprehensive stroke center were included. PSC and CSC-ASPECTS, time-metrics, and clinical data were analyzed. Results During 28 months, 1185 endovascular treatment candidates were transferred from PC to comprehensive stroke center in our public stroke network, 477 had an anterior circulation syndrome and available neuroimaging information and were included. Median baseline NIHSS was 13 (8–19). On arrival to comprehensive stroke center, large vessel occlusion was confirmed in 60.2% patients, and 41.2% received endovascular treatment. Median interfacility ASPECTS decay was 1 (0–2) after a median of 150.7 (SD 101) min between both CT-acquisitions. A logistic regression analysis adjusted by age, time from symptoms to PC-CT, and time from PC-CT to CSC-CT showed that only a baseline NIHSS and PSC-ASPECTS independently predicted a CSC-ASPECTS < 6. ROC curves identified baseline NIHSS ≥ 16 and PSC-ASPECTS ≤ 7 as the best cut-off points. The rate of CSC-ASPECTS < 6 increased from 7% to 57% among patients with NIHSS ≥ 16 and PSC-ASPECS ≤ 7. Conclusion After a median transfer time >2 h, only 11.9% showed ASPECTS < 6 at the comprehensive stroke center. Activation of endovascular treatment teams should not require confirming neuroimaging on arrival and repeating neuroimaging at comprehensive stroke center should only be performed in selected cases.

Abstract WMP5: Predictors and Outcome of Eligible Patients for Late Endovascular Treatment: Real Life Analysis From a Comprehensive Stroke Center

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Stefania Nannoni ◽  
Davide Strambo ◽  
Gaia Sirimarco ◽  
Michael Amiguet ◽  
Peter Vanacker ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Real Life ◽  
Life Analysis ◽  
Comprehensive Stroke Center ◽  
Stroke Center

scholarly journals The “Flying Intervention Team”: A Novel Stroke Care Concept for Rural Areas

2021 ◽  
pp. 1-8
Author(s):  
Gordian Jan Hubert ◽  
Frank Kraus ◽  
Christian Maegerlein ◽  
Sabine Platen ◽  
Benjamin Friedrich ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Rural Areas ◽  
Stroke Care ◽  
Vessel Occlusion ◽  
Angiography Suite ◽  
Secondary Transfer ◽  
Primary Stroke Center ◽  
Intervention Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center

<b><i>Background:</i></b> Endovascular treatment of large vessel occlusion in acute ischemic stroke patients is difficult to establish in remote areas, and time dependency of treatment effect increases the urge to develop health care concepts for this population. <b><i>Summary:</i></b> Current strategies include direct transportation of patients to a comprehensive stroke center (CSC) (“mothership model”) or transportation to the nearest primary stroke center (PSC) and secondary transfer to the CSC (“drip-and-ship model”). Both have disadvantages. We propose the model “flying intervention team.” Patients will be transported to the nearest PSC; if telemedically identified as eligible for thrombectomy, an intervention team will be acutely transported via helicopter to the PSC and endovascular treatment will be performed on site. Patients stay at the PSC for further stroke unit care. This model was implemented at a telestroke network in Germany. Fifteen remote hospitals participated in the project, covering 14,000 km<sup>2</sup> and a population of 2 million. All have well established telemedically supported stroke units, an angiography suite, and a helicopter pad. Processes were defined individually for each hospital and training sessions were implemented for all stroke teams. An exclusive project helicopter was installed to be available from 8 a.m. to 10 p.m. during 26 weeks per year. <b><i>Key Messages:</i></b> The model of the flying intervention team is likely to reduce time delays since processes will be performed in parallel, rather than consecutively, and since it is quicker to move a medical team rather than a patient. This project is currently under evaluation (clinicaltrials NCT04270513).

Abstract WP244: How Many Potential Mechanical Thrombectomy Patients Are Missed Because of Emergency Medical Systems Transport Windows of 4.5 Hours or Less Since Last Known Normal in the Field?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Evan Allen ◽  
Paul Banerjee ◽  
Donald Richards ◽  
Chut Sombutmai ◽  
Abraham P Thomas ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Time Window ◽  
Transport Protocols ◽  
Medical Systems ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Emergency Medical Systems ◽  
Clinical Deficits ◽  
Prospective Database

Intro: Many EMS transport protocols exclude patients last known normal (LKN) >4.5 or >6 hours from transport to Comprehensive Stroke Center (CSC) as acute stroke codes. Because recent Mechanical Thrombectomy (MET) studies enrolled few patients last known normal (LKN) > 6 hours prior to imaging, the incidence of CTP or ASPECTS suggesting possible benefit from MET in this time window for Large Vessel Occlusion (LVO) ischemic stroke is unclear. Method: Through retrospective review of a prospective database, the percentage of LVO patients with ASPECTS or CTP suggesting possible benefit from MET, defined as ASPECTS score >5 or salvageable penumbra and <70ml ischemic core on CTP, was compared between a group of 42 patients imaged > 6 hours since LKN and 106 patients imaged <6 hours since LKN. Results: 33% (14 of 42) of LVO patients LKN > 6 hours at time of CTP imaging (median 8 hours, range 6-20 hrs) received MET based on favorable CTP imaging and disabling clinical deficits. This was not statistically significantly different than the 40.5% (43 of 106) of LVO patients LKN < 6 hours at time of CTP imaging (median 128 min) that received MET based on same criteria (OR 95% CI, 0.73 0.34 – 1.55; P=0.42). The LKN > 6 hour MET patients (median NIHSS 18) had a trend towards less frequent favorable home or rehab discharge destination than the LKN < 6 hour MET patients (median NIHSS 16) (29% vs 57%, OR 0.3040, 95 % CI: 0.08 to 1.12, P = 0.07). There were no significant differences between the > 6 hour and <6 hour groups in factors associated with poor outcome after intervention or poor collateral circulation: median ASPECTS score (9 for both), percentage of ASPECTS scores >5 (80% vs 90%, p=0.31) median age (74 for both), ED glucose >150 mg/dl (16.6% vs 23.5%, p= 0.51), Atrial fibrillation (38% vs 37%). With a 30 minute door-to-CTP time, a < 4.5 hour LKN EMS transport policy would have excluded 24.5% of patients who received MET at our CSC. 6, 8, 10 and 13 hour LKN EMS transport windows would have excluded 11%, 9%, 2% and 0% MET intervention patients respectively. Conclusion: < 4.5 hour LKN EMS transport protocols may exclude a significant number of LVO patients with CTP and ASPECTS results possibly suitable for MET. These data need to be confirmed with a prospective multicenter study.

Abstract P483: Immediate Feedback to Emergency Medical Services Reduce Door to Angiogram and Transfer Time for Endovascular Treatment of Large Vessel Occlusion Ischemic Strokes

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kimberley Stephania Yescas Garibay ◽  
Nguyen Vo ◽  
Syung Jung ◽  
Sun Lee
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Transfer Time ◽  
Large Vessel Occlusion ◽  
Immediate Feedback ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The morbidity of acute ischemic Stroke (AIS) caused by a large vessel occlusion (LVO) can be significantly reduced with endovascular intervention. However, delay in diagnosis can exclude a patient from therapy.Rapid Arterial Occlusion evaluation (RACE) score of five or more have an 85% chance of being LVO acute ischemic stroke. Pre-arrival notification of potential LVO cases by EMS (Emergency Medical Service) is an important factor to reduce door-to-transfer time from a Primary Stroke Center (PSC) to a Comprehensive Stroke center (CSC). We hypothesize that immediate feedback to EMS teams on their pre-hospital RACE score reporting will improve prehospital recognition of LVO strokes. Therefore, reducing the Door to Needle CTA (CT Angiogram) and/or Door to Transfer Time for endovascular treatment. Methods: Our inclusion criteria included patients with a diagnosis of AIS brought in by EMS with a RACE score of five or more, was given IV thrombolytics, or transferred to a comprehensive stroke center for endovascular treatment. A 5-item feedback form was developed for each case and was reviewed biweekly with our EMS liaison. Feedback included compliance with RACE score reporting, presence of IV access, CTA time, and TPA/Transfer time. Direct feedback was verbally given to the EMS transport team. Results: Comparison of data from a twelve-month preintervention period (n=29) to a four-month postintervention period (n=12) was conducted through direct comparison. This showed a decrease in mean Door-to-CTA time from 212.14 (CI ±83.3) to 97.08 (CI ±54.92) minutes with a p-value of 0.0126 in a one-tailed t-Test, a 54% reduction and a reduction in door to transfer time (305 minutes to 132 minutes, a 56.7 % reduction ). Conclusion: A pilot project focused on providing immediate feedback to EMS regarding accurate prehospital notification of RACE score showed a statistically significant improvement in door to CTA time and door to transfer time. Extension of the post study period is needed to confirm the significance of transfer time. This study demonstrates the importance of collaboration between a PSC and EMS to ensure prompt diagnosis and transfer for endovascular treatment of AIS caused by LVO.

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