Implementing the SNIS recommendations for neurointerventional emergent care in the setting of COVID-19: impact on stroke metrics and patient outcomes

BackgroundIt is not clear whether the COVID-19 pandemic and subsequent Society of Neurointerventional Surgery (SNIS) recommendations affected hospital stroke metrics.MethodsThis retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic April 1 2020 to June 30 2020 (COVID-19) to patients admitted April 1 2019 to June 30 2019. We examined stroke admission volume and acute stroke treatment use.ResultsThere were 637 stroke admissions, 52% in 2019 and 48% during COVID-19, with similar median admissions per day (4 vs 3, P=0.21). The proportion of admissions by stroke type was comparable (ischemic, P=0.69; hemorrhagic, P=0.39; transient ischemic stroke, P=0.10). Acute stroke treatment was similar in 2019 to COVID-19: tPA prior to arrival (18% vs, 18%, P=0.89), tPA treatment on arrival (6% vs 7%, P=0.85), and endovascular therapy (endovascular therapy (ET), 22% vs 25%, P=0.54). The door to needle time was also similar, P=0.12, however, the median time from arrival to groin puncture was significantly longer during COVID-19 (38 vs 43 min, P=0.002). A significantly higher proportion of patients receiving ET were intubated during COVID-19 due to SNIS guideline implementation (45% vs 96%, P<0.0001). There were no differences by study period in discharge mRS, P=0.84 or TICI score, P=0.26.ConclusionsThe COVID-19 pandemic did not significantly affect stroke admission volume or acute stroke treatment utilization. Outcomes were not affected by implementing SNIS guidelines. Although there was a statistical increase in time to groin puncture for ET, it was not clinically meaningful. These results suggest hospitals managing patients efficiently can implement practices in response to COVID-19 without impacting outcomes.

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Modeling the Optimal Transportation for Acute Stroke Treatment

Stroke ◽

10.1161/strokeaha.119.027493 ◽

2020 ◽

Vol 51 (1) ◽

pp. 275-281 ◽

Cited By ~ 4

Author(s):

Marielle Ernst ◽

Eckhard Schlemm ◽

Jessalyn K. Holodinsky ◽

Noreen Kamal ◽

Götz Thomalla ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Catchment Area ◽

Treatment Time ◽

Intravenous Thrombolysis ◽

Probability Models ◽

Stroke Treatment ◽

Federal States ◽

Medical Response ◽

Stroke Center

Background and Purpose— Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods— Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km 2 with a population of 12 703 561 in 2017 (198 persons per km 2 ). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results— The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain <40 minutes each. A slowed workflow in the DD paradigm resulted in a decrease of the DD catchment area to 1221 km 2 (2%). Conclusions— Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.

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Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts

International Journal of Stroke ◽

10.1177/1747493018765493 ◽

2018 ◽

Vol 13 (5) ◽

pp. 469-472 ◽

Cited By ~ 4

Author(s):

Carlos Garcia-Esperon ◽

Andrew Bivard ◽

Christopher Levi ◽

Mark Parsons

Keyword(s):

Computed Tomography ◽

Acute Stroke ◽

Treatment Decision ◽

Added Value ◽

Stroke Treatment ◽

Computed Tomography Perfusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Weighted Sequences ◽

Perfusion Maps

Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the “lesions” on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.

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Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2020.160 ◽

2020 ◽

pp. 1-5

Author(s):

Joel Neves Briard ◽

Célina Ducroux ◽

Grégory Jacquin ◽

Walid Alesefir ◽

William Boisseau ◽

...

Keyword(s):

Acute Stroke ◽

Negative Impact ◽

Reperfusion Therapy ◽

Observational Cohort Study ◽

Treatment Delays ◽

Stroke Treatment ◽

Time Period ◽

Observational Cohort ◽

Comprehensive Stroke Center ◽

Stroke Center

ABSTRACT: This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

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Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability

Stroke ◽

10.1161/strokeaha.120.032389 ◽

2021 ◽

Author(s):

Minerva H. Zhou ◽

Akash P. Kansagra

Keyword(s):

Acute Stroke ◽

Modest Improvement ◽

Absolute Increase ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Primary Stroke Center ◽

Treatment Volume ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Patient Referrals

Background and Purpose: With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center. Methods: In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials. Results: Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population. Conclusions: Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.

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