Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

2021 ◽  
pp. neurintsurg-2021-017365
Author(s):  
Mais Al-Kawaz ◽  
Christopher Primiani ◽  
Victor Urrutia ◽  
Ferdinand Hui
Keyword(s):  
Mobile Application ◽  
Secondary Analysis ◽  
Multiple Linear Regression Model ◽  
Stroke Care ◽  
Mobile App ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
2021 ◽  
Author(s):  
Laura C.C. van Meenen ◽  
Maritta N. van Stigt ◽  
Arjen Siegers ◽  
Martin D. Smeekes ◽  
Joffry A.F. van Grondelle ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Stroke Care ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
User Friendliness ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

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.

scholarly journals Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke

2019 ◽  
Vol 8 (12) ◽  
Author(s):  
Ludwig Schlemm ◽  
Matthias Endres ◽  
Jan F. Scheitz ◽  
Marielle Ernst ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Disability Adjusted Life Years ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.

Developing a statewide protocol to ensure patients with suspected emergent large vessel occlusion are directly triaged in the field to a comprehensive stroke center: how we did it

2016 ◽  
Vol 9 (3) ◽  
pp. 330-332 ◽  
Author(s):  
Mahesh V Jayaraman ◽  
Arshad Iqbal ◽  
Brian Silver ◽  
Matthew S Siket ◽  
Caryn Amedee ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

We describe the process by which we developed a statewide field destination protocol to transport patients with suspected emergent large vessel occlusion to a comprehensive stroke center.

scholarly journals Impact of Viz LVO on Time-to-Treatment and Clinical Outcomes in Large Vessel Occlusion Stroke Patients Presenting to Primary Stroke Centers

2020 ◽  
Author(s):  
Jacob R. Morey ◽  
Emily Fiano ◽  
Kurt A. Yaeger ◽  
Xiangnan Zhang ◽  
Johanna T. Fifi
Keyword(s):  
New York ◽  
Clinical Outcomes ◽  
Large Vessel ◽  
Similar Proportion ◽  
Time Interval ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Time To Treatment ◽  
Comprehensive Stroke Center ◽  
Stroke Center

AbstractIntroductionRandomized controlled trials have demonstrated the importance of time-to-treatment on clinical outcomes in large vessel occlusion (LVO) stroke. Delays in interventional radiology (INR) consultation are associated with a significant delay in overall time to endovascular treatment (EVT). Delays in EVT are particularly prevalent in Primary Stroke Centers (PSC), hospitals without thrombectomy capability onsite, where the patient requires transfer to a Thrombectomy Capable or Comprehensive Stroke Center for EVT. A novel computer aided triage system, Viz LVO, assists in early notification of the PSC stroke team and affiliated INR team. This platform includes an image viewer, communication system, and an artificial intelligence algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts.HypothesisViz LVO will decrease time-to-treatment and improve clinical outcomes.MethodsA prospectively maintained database was assessed for all patients who presented to a PSC currently utilizing Viz LVO in the Mount Sinai Health System in New York and underwent EVT following transfer for LVO stroke between October 1, 2018 and March 15, 2020. There were 42 patients who fit the inclusion criteria and divided into pre- and post-Viz ContaCT implementation by comparing the periods of October 1, 2018, to March 15, 2019, “Pre-Viz”, and October 1, 2019, to March 15, 2020, “Post-Viz.” Time intervals and clinical outcomes were collected and compared.ResultsThe Pre- and Post-Viz cohorts were similar in terms of gender, age, proportion receiving IV-tPA, and proportion with revascularization of TICI > 2B. The presenting NIHSS and pre-stroke mRS scores were not statistically different.The median initial door-to-INR notification was significantly faster in the post-Viz cohort (21.5 minutes vs 36 minutes; p=0.02). The median initial door-to-puncture time interval was 20 minutes shorter in the Post-Viz cohort, but this was not statistically significant (p=0.20).The 5-day NIHSS and discharge mRS were both significantly lower in the Post-Viz cohort (p=0.02 and p=0.03, respectively). The median 90-day mRS scores were also significantly lower post-Viz implementation, although a similar proportion received a good outcome (mRS score ≤ 2) (p=0.02 and p=0.42, respectively).ConclusionsEVT is a time-sensitive intervention that is only available at select stroke centers. Significant delays in time-to-treatment are present when patients require transfer from PSCs to a EVT capable stroke center. In a large health care system, we have shown that Viz LVO implementation is associated with improved time to INR notification and clinical outcomes. Viz LVO has the potential for wide-spread improvement in clinical outcomes with implementation across large hub and stroke systems across the country.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kavit Shah ◽  
Shashvat Desai ◽  
Benjamin Morrow ◽  
Pratit Patel ◽  
Habibullah Ziayee ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
To Receive ◽  
Rapid Transfer

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

Abstract TP292: Telestroke vs Phone Consultation in Stroke Patients Eligible for Intra-Arterial Therapy

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Nicholas Osteraas ◽  
James Conners ◽  
Shawna Cutting ◽  
Sarah Song ◽  
Laurel Cherian ◽  
...  
Keyword(s):  
Female Gender ◽  
Large Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Telephone Consultation ◽  
Transfer Programs ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Mean Time

Background and Objective: Intra-arterial therapy (IA) is beneficial for acute ischemic stroke patients with large vessel occlusions who have received intravenous tissue plasminogen activator (IVtPA). Telestroke has not been associated with increased IVtPA utilization rates when compared to phone consultations. We sought to determine whether telestroke improved the process of evaluation and transfer of patients who may be eligible for intra-arterial therapy (IA). Methods: The Rush telestroke program consists of an academic hub (comprehensive stroke center) that serves 10 spoke emergency departments (EDs). For sites outside of the telestroke program, the patient receives telephone consultation from the same pool of telestroke neurologists. IA therapy is considered for patients clinically suspected of having a large vessel occlusion who could potentially be treated with IA within 6 hours of last known normal (LKN). We compared IA eligible stroke patients transferred via the telestroke program to those non-telestroke transfer patients. Results: From July 1, 2013 to July 1, 2015, 126 patients were transferred from outside hospital ERs to our institution for potential IA; 6 patients were excluded for non-stroke diagnosis. Among 119 patients, 79 (66%) were evaluated via telestroke and 40 (34%) via phone consultation. There was no difference between groups for age (63.3 vs 59.3 years, p=0.14) female gender (52% vs 58%, p=0.70), hypertension (66% vs 78%, p 0.21), atrial fibrillation (27% vs 20%, p=0.50), initial arrival NIHSS (17 vs 19, p=0.12), frequency of IA (66% vs 55%, p=0.31), mean time from LKN to IVtPA administration (139 vs 138 minutes, p=0.96), mean time from IVtPA administration to arrival (106 vs 94 minutes, p=0.31), and mean time from arrival to IA start (35 vs 31 minutes, p=0.44). More patients who were evaluated via telestroke received TPA compared to those evaluated via phone (80% vs 63%, p<0.05). Conclusions: Telestroke improves the evaluation of IA eligible stroke transfer patients by increasing the rates of IVtPA compared with telephone consultation alone. Comprehensive stroke centers may benefit patients by incorporating telestroke systems into their IA transfer programs.

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.

Abstract WP70: Reperfusion Therapy in Posterior Circulation Large Vessel Occlusion With Perfusion Deficits May Be Safe and Improve Outcomes Beyond 4.5 Hours

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sujan Teegala Reddy ◽  
Kaushik Parsha ◽  
Deep Pujara ◽  
Clark Sitton ◽  
Sean Savitz ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Reperfusion Therapy ◽  
Functional Independence ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
To Receive ◽  
Perfusion Deficits

Introduction: Whether reperfusion therapy is safe and efficacious in acute ischemic strokes (AIS) due to posterior circulation large vessel occlusions (PCLVO) beyond 4.5 hrs is unknown. Methods: A retrospective analysis of AIS due to PCLVO presenting to a comprehensive stroke center up to 24 hrs from last known well. Patients were stratified based on the treatment received into reperfusion therapy (IV-tPA and/or endovascular thrombectomy) and no reperfusion therapy. All patients received CT/CTA and CT perfusion with RAPID mismatch determination. Functional independence (90 day mRS 0-2) and sICH were primary and secondary outcomes. The two groups were compared in the overall cohort in an ordinal logistic regression and in a propensity matched analyses. Results: Between 8/2017 and 5/2019, 52 patients were included [reperfusion = 23(44%) vs no-reperfusion=29(56%)]. Reperfusion rate beyond 4.5 hours was 26% (6/23). The two groups were similar at baseline except for larger perfusion delays (Tmax>6s) volume [median (IQR), 16 (0, 46) vs. 0 (0, 25) cc, p=0.03], and higher presentation NIHSS [median (IQR), 10 (5, 21) vs. 4 (1, 8), p=0.004] in the reperfusion group. Reperfusion was associated with higher functional independence rates 10 (43%) vs. 8 (28%), p=0.23 (fig 1), and a trend for a shift towards better outcomes adj cOR 1.89, 95% CI=0.59-6.13, p=0.29. There was no difference in sICH rates 9% vs. 0%, P=0.19. In a propensity matched analysis on NIHSS and perfusion deficit of 14 pairs, reperfusion was associated with statistically significant higher mRS 0-2 rates 9 (64%) vs. 1 (7%), p=0.004 (fig 2). Functional independence rates did not differ in the reperfusion group in relation to time (47% <4.5 hrs vs. 33%≥4.5 hrs), p=0.36 for heterogeneity. Conclusion: PCLVOs with more severe strokes and large perfusion deficits were more likely to receive reperfusion which was associated with a shift towards better outcomes both earlier and beyond 4.5 hours without worsening safety outcomes.

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