MR Imaging Helps Predict Time from Symptom Onset in Patients with Acute Stroke: Implications for Patients with Unknown Onset Time

Introduction: It is unclear how the interventions designed to restrict community and in-hospital exposure to the SARS-CoV-2 virus affected the care for stroke patients seeking acute treatment. The objective of the following study was to determine the impact COVID-19 has had on the treatment times for patients evaluated as acute stroke alerts at Baptist Hospital of Miami (BHM). A co-primary objective of the study was to assess the risk of contracting SARS-CoV-2 within 2 weeks from hospital discharge. Methods: This retrospective, two phase study was conducted between December 2019 and April 2020. In phase one, we assessed time from symptom onset to hospital arrival, number of strokes with witnessed onset, and in-hospital treatment times pre & post implementation of Covid-19 preventive exposure measures. In phase two of the study, a telephone survey was conducted on the post implementation group to assess the risk of patients developing symptoms or testing positive for SARS-CoV-2 from hospital admission up to two weeks post discharge. Results: Phase I demonstrated there was a 40% decline in stroke volume, but no significant delay to seek medical attention post implementation of the SARS prevention strategies. On average individuals in the pre-group (n=155) waited approximately 260 minutes (SE=24) to seek medical attention vs. 203 minutes (SE=27) minutes for the post-group (n=87). However, there was nearly a six-fold increase in the percentage of cases with unknown symptom onset post implementation of COVID-19 safety precautions. There was significant delay in administering IV alteplase, increasing from 24 mins (n=16) to 33 mins (n=21) post implementation; delays observed for endovascular treatment were not significant (pre, n=13 mean= 73 mins, post n=12 mean= 82 mins). The volume of patients treated with either IV alteplase and/or endovascular treatment remained similar. Phase II of the study is on-going, results will be available for the ISC. Discussion: The COVID-19 crisis in our community was associated with a six-fold increase in the percentage of cases with unknown stroke onset time. Besides a marked decrease in stroke volume, we did not evidence significant delays to either seek or provide acute stroke care outside a modest increase in door to needle time.

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Quantitative Measurements of Relative Fluid-Attenuated Inversion Recovery (FLAIR) Signal Intensities in Acute Stroke for the Prediction of Time from Symptom Onset

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.2012.129 ◽

2012 ◽

Vol 33 (1) ◽

pp. 76-84 ◽

Cited By ~ 29

Author(s):

Bastian Cheng ◽

Mathias Brinkmann ◽

Nils D Forkert ◽

Andras Treszl ◽

Martin Ebinger ◽

...

Keyword(s):

Acute Stroke ◽

Symptom Onset ◽

Visual Analysis ◽

Onset Time ◽

Inversion Recovery ◽

Classification And Regression Tree ◽

Lesion Volume ◽

Ischemic Lesion ◽

Quantitative Measurements ◽

Fluid Attenuated Inversion Recovery

In acute stroke magnetic resonance imaging, a ‘mismatch’ between visibility of an ischemic lesion on diffusion-weighted imaging (DWI) and missing corresponding parenchymal hyperintensities on fluid-attenuated inversion recovery (FLAIR) data sets was shown to identify patients with time from symptom onset ≤4.5 hours with high specificity. However, moderate sensitivity and suboptimal interpreter agreement are limitations of a visual rating of FLAIR lesion visibility. We tested refined image analysis methods in patients included in the previously published PREFLAIR study using refined visual analysis and quantitative measurements of relative FLAIR signal intensity (rSI) from a three-dimensional, segmented stroke lesion volume. A total of 399 patients were included. The rSI of FLAIR lesions showed a moderate correlation with time from symptom onset ( r = 0.382, P < 0.001). A FLAIR rSI threshold of <1.0721 predicted symptom onset ≤4.5 hours with slightly increased specificity (0.85 versus 0.78) but also slightly decreased sensitivity (0.47 versus 0.58) as compared with visual analysis. Refined visual analysis differentiating between ‘subtle’ and ‘obvious’ FLAIR hyperintensities and classification and regression tree algorithms combining information from visual and quantitative analysis also did not improve diagnostic accuracy. Our results raise doubts whether the prediction of stroke onset time by visual image judgment can be improved by quantitative rSI measurements.

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PROGNOSTIC VALUE OF INFARCT DEMARCATION ON BASELINE T2 AND FLAIR WEIGHTED MR IMAGING IN ACUTE STROKE TREATMENT

10.26226/morressier.58e389acd462b802923853a3 ◽

2017 ◽

Author(s):

Simon Jung

Keyword(s):

Mr Imaging ◽

Acute Stroke ◽

Prognostic Value ◽

Stroke Treatment ◽

Acute Stroke Treatment

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Abstract P138: Improving Emergency Medical Services Documentation of Time Last Known Well

Stroke ◽

10.1161/str.52.suppl_1.p138 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Dot Bluma ◽

Jessica Link Reeve ◽

Susan M Godersky

Keyword(s):

Emergency Medical Services ◽

Symptom Onset ◽

Systems Of Care ◽

Onset Time ◽

Reperfusion Therapy ◽

Report Card ◽

Medical Services ◽

Emergency Department Physician ◽

Measure Data ◽

Emergency Medical

Background and Purpose: In a systems of care model, Emergency Medical Services (EMS) reporting a patient’s last known well (LKW) time to the receiving hospital is crucial for activation of the hospitals Acute Stroke Team. There is evidence that LKW is critical information for determining an acute ischemic stroke patient’s eligibility for advanced stroke therapy which includes intravenous Alteplase and/or mechanical endovascular reperfusion therapy. The 70 Wisconsin (WI) Coverdell Stroke Program (Coverdell) hospitals represent 80% of stroke admissions in WI. Coverdell developed a pre-arrival report card in Q3 2018 in which LKW was a tracked measure. Data entered into Get With The Guidelines®- Special Initiatives (SI) tab was collated to create the report card. After analysis of the data it was determined our performance improvement (PI) project would be to improve EMS’s documentation and reporting of time LKW. In Q3 2018, of those cases entered into the SI tab, EMS reporting a LKW time was 50%. Since LKW is not always obtainable, the project goal was set at 60%. Methods: We recognized implementation of this PI initiative would require a multi-prong approach. To assist EMS agencies in understanding the difference between LKW and symptom onset, we developed a document entitled, The Importance of an Accurate Last Known Well and Symptom Onset Time . A Coverdell team member attended WI’s EMS Physician Advisory Committee meetings where LKW data was discussed. In addition, an Emergency Department Physician hosted a webinar where the presentation highlighted the importance of documenting LKW. This webinar was recorded and sent to EMS agencies and hospitals. For loop closure and with the support of the WI’s EMS Director, LKW became a validated field for EMS in the WI Ambulance Run Data System. Findings: In Q2 2019 there was an improvement in documented LKW as evidenced by an increase to 59.2% The data has remained consistent even as more hospitals have begun to enter the data as demonstrated by the increasing N. Conclusion: The actions taken by the Coverdell program in educating EMS providers on the rationale and importance of LKW documentation was successful. However, additional efforts are required to reach and maintain the project goal of 60% with an additional stretch goal to 70%.

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Abstract 202: Door-to-needle-time at 20 Minutes is Feasible and Safe

Stroke ◽

10.1161/str.45.suppl_1.202 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Sille M Henriksen ◽

Lise L Jeppesen ◽

Anders Christensen ◽

Hanne K Christensen

Keyword(s):

Acute Stroke ◽

Median Time ◽

Onset Time ◽

Trauma Team ◽

Bleeding Complications ◽

Time Of Arrival ◽

Standard Work ◽

Registration Period ◽

Significant Difference ◽

Set Up

Background: Effect size of intravenous fibrinolysis in acute stroke depends on time to treatment, while safety depends on a systematic identification of risk factors for bleeding complications. Fibrinolysis is in Denmark the treatment with most potential of modifying outcome in acute stroke patients both in a quantitative and qualitative perspective. We initiated a quality project aiming at reducing our median door-to-needle-time (DTN). The aim of this study was to obtain median DTN below 20 minutes accepting no increase in bleeding complications. Method: A team including neurologist, radiologist, stroke nurse and radiographer set up a structured patient admission process based on trauma team principles and experience with fibrinolysis. The team has immediate access to both CT and MRI; standard work up is CT + CTA. EMS informs of patients with likely symptoms of acute stroke and the patient is received by the team in a dedicated room. During a 3-month registration period from March to June 2013 an external person registered all cases of acute stroke evaluation. The registration covered time of symptom onset, time of arrival, needle time or decision of no thrombolysis and the distribution of the time used e.g. for blood sampling or CT. For comparison, data from our institution in 2012 was used. Results: A total of 157 patients were evaluated and 148 patients were registered; nine patients (5,7%) missed time registration, however no significant difference in thrombolysis ratio was found between the missing and registered group (p=0,473). Patients had a median age of 67 years and 53,4% was male. Forty-seven patients (31,8%) received fibrinolysis. The overall median time is 16 minutes 58 seconds. For patients receiving fibrinolysis, the DNT was 20 minutes 58 seconds and for patients not receiving treatment the median time to desiscion was 15 minutes 50 seconds. No symptomatic intracranial hemorrhages or other significant bleeding complications occured during the study period. Median DTN in 2012 was 49 minutes. Costs were neutral. Conclusion: DTN time can be reduced to 20 minutes by organizational interventions with no apparent effect on safety. NNT is reduced by 1 with every 20 minutes reduction in DTN so this intervention is likely to be highly clinically significant.

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Abstract 180: The Growth Rate of Early DWI Lesions is Highly Variable and Associated with Penumbral Salvage and Clinical Outcomes Following Endovascular Reperfusion

Stroke ◽

10.1161/str.44.suppl_1.a180 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Hayley M Wheeler ◽

Michael Mlynash ◽

Manabu Inoue ◽

Aaryani Tipirneni ◽

John Liggins ◽

...

Keyword(s):

Growth Rate ◽

Acute Stroke ◽

Clinical Outcomes ◽

Endovascular Therapy ◽

Symptom Onset ◽

Growth Rates ◽

Initial Growth ◽

Stroke Patients ◽

Final Volume ◽

Favorable Clinical Response

Background: The degree of variability in the rate of early DWI expansion has not been well characterized. We hypothesized that Target Mismatch patients with slowly expanding DWI lesions have more penumbral salvage and better clinical outcomes following endovascular reperfusion than Target Mismatch patients with rapidly expanding DWI lesions. Methods: This substudy of DEFUSE 2 included all patients with a clearly established time of symptom onset. The initial DWI growth rate was determined from the baseline scan by assuming a volume 0 ml just prior to symptom onset. Target Mismatch patients who achieved reperfusion (>50% reduction in PWI after endovascular therapy), were categorized into tertiles according to their initial DWI growth rates. For each tertile, penumbral salvage (comparison of final volume to the volume of PWI (Tmax > 6 sec)/ DWI mismatch prior to endovascular therapy), favorable clinical response, and good functional outcome (see figure for definitions) were calculated. We also compared the growth rate in patients with the Target mismatch vs. Malignant Profile. Results: 64 patients were eligible for this study. Target mismatch patients (n=44) had initial growth rates (range 0 to 43 ml/hr, median of 3 ml/hr) that were significantly less than the growth rates in Malignant profile (n=7) patients (12 to 92 ml/hr, median 39 ml/hr; p < 0.001). In Target mismatch patients who achieved reperfusion (n=30), slower early DWI growth rates were associated with better clinical outcomes (p<0.05) and a trend toward more penumbral salvage (n=27, p=0.137). Conclusions: The growth rate of early DWI lesions in acute stroke patients is highly variable; Malignant profile patients have higher growth rates than other MRI profiles. Among Target Mismatch patients, a slower rate of DWI growth is associated with a greater degree of penumbral salvage and improved clinical outcomes following endovascular reperfusion.

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Abstract WP178: Acute Stroke Ischemic Symptom Onset-to-Arrival Time in Michigan Hospitals

Stroke ◽

10.1161/str.47.suppl_1.wp178 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Muhammad U Farooq ◽

Kathie Thomas

Keyword(s):

African American ◽

Ischemic Stroke ◽

Acute Stroke ◽

Patient Outcomes ◽

Symptom Onset ◽

Arrival Time ◽

Heart Association ◽

The United States ◽

Stroke Patients ◽

White Patients

Objectives: Stroke is the fifth-leading cause of death and the leading cause of disability in the United States. One of the primary goals of the American Heart Association/American Stroke Association is to increase the number of acute stroke patients arriving at emergency departments (EDs) within 1-hour of symptom onset. Earlier treatment with thrombolysis in patients with acute ischemic stroke translates into improved patient outcomes. The objective of this abstract is to examine the association between the use of emergency medical services (EMS) and symptom onset-to-arrival time in patients with ischemic stroke. Methods: A retrospective review of ischemic stroke patients (n = 8873) from 25 Michigan hospitals from January 2012-December 2014 using Get With the Guidelines databases was conducted. Symptom onset-to-ED arrival time and arrival mode were examined. Results: It was found that 17.4% of ischemic stroke patients arrived at the hospitals within 1-hour of symptom onset. EMS transported 69.1% of patients who arrived within 1-hour of symptom onset. During this 1-hour period African American patients (22%) were less likely to use EMS transportation as compared to White patients (72%). The majority of patients, 41.8%, arrived after 6-hours of symptom onset. EMS transported only 40% of patients who arrived after 6-hours of symptom onset. As before, during this 6-hour period African American patients (20%) were also less likely to use EMS transportation as compared to White patients (75%). Symptom onset-to-ED arrival time was shorter for those patients who used EMS. The median pre-hospital delay time was 2.6 hours for those who used EMS versus 6.2 hours for those who did not use EMS. Conclusions: The use of EMS is associated with a decreased pre-hospital delay, early treatment with thrombolysis and improved patient outcomes in ischemic stroke patients. Community interventions should focus on creating awareness especially in minority populations about stroke as a neurological emergency and encourage EMS use amongst stroke patients.

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MR Imaging in Acute Stroke

Imaging Decisions MRI ◽

10.1046/j.1617-0830.2001.50101.x ◽

2001 ◽

Vol 5 (1) ◽

pp. 2-10 ◽

Cited By ~ 1

Author(s):

N. Dugar ◽

N. Hoggard ◽

I.D. Wilkinson ◽

P.D. Griffiths

Keyword(s):

Mr Imaging ◽

Acute Stroke

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Interpreting CT perfusion in stroke

Practical Neurology ◽

10.1136/practneurol-2018-001917 ◽

2018 ◽

Vol 19 (2) ◽

pp. 136-142 ◽

Cited By ~ 7

Author(s):

Stevan Christopher Wing ◽

Hugh S Markus

Keyword(s):

Acute Stroke ◽

Perfusion Imaging ◽

Treatment Time ◽

Ct Perfusion ◽

Time Windows ◽

Onset Time ◽

Brain Perfusion ◽

Reperfusion Therapy ◽

Imaging Protocol ◽

Stroke Imaging

CT perfusion images can be rapidly obtained on all modern CT scanners and easily incorporated into an acute stroke imaging protocol. Here we discuss the technique of CT perfusion imaging, how to interpret the data and how it can contribute to the diagnosis of acute stroke and selection of patients for treatment. Many patients with acute stroke are excluded from reperfusion therapy if the onset time is not known or if they present outside of traditional treatment time windows. There is a growing body of evidence supporting the use of perfusion imaging in these patients to identify patterns of brain perfusion that are favourable for recanalisation therapy.

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Analytical and diagnostic performances of a high-throughput immunoassay for SARS-CoV-2 IgM and IgG

10.1101/2020.11.20.20235267 ◽

2020 ◽

Author(s):

Andrea Padoan ◽

Chiara Cosma ◽

Paolo Zaupa ◽

Mario Plebani

Keyword(s):

Sensitivity And Specificity ◽

Symptom Onset ◽

Severe Disease ◽

Onset Time ◽

Time Frame ◽

Serum Samples ◽

Time Period ◽

Analytical Imprecision ◽

Range Of Values

BackgroundAbstractReliable SARS-CoV-2 serological assays are required for diagnosing infections, for the serosurveillance of past exposures and for assessing the response to future vaccines. In this study, the analytical and clinical performances of a chemiluminescent immunoassays for SARS-CoV-2 IgM and IgG detection (Mindray CL-1200i), targeting Nucleocapsid (N) and receptor binding domain (RBD) portion of the Spike protein, were evaluated.MethodsPrecision and linearity were evaluated using standardized procedures. A total of 157 leftover serum samples from 81 hospitalized confirmed COVID-19 patients (38 with moderate and 43 with severe disease) and 76 SARS-CoV-2 negative subjects (44 healthcare workers, 20 individuals with rheumatic disorders, 12 pregnant women) were included in the study. In an additional series of 44 SARS-CoV-2 positive, IgM and IgG time kinetics were also evaluated in a time-period of 38 days.ResultsPrecision was below or equal to 4% for both IgM and IgG, in all the studied levels, whilst a slightly significant deviation from linearity was observed for both assays in the range of values covering the manufacturer’s cut-off. Considering a time frame ≥ 12 days post symptom onset, sensitivity and specificity for IgM were 92.3% (95%CI:79.1%-98.4%) and 92.1% (95%CI:83.6%-97.0%). In the same time frame, sensitivity and specificity for IgG were 100% (95%CI:91.0%-100%) and 93.4% (95%CI:85.3%-97.8%). The assays agreement was 73.9% (Cohen’s kappa of 0.373). Time kinetics showed a substantial overlapping of IgM and IgG response, the latter values being elevated up to 38 days from symptoms onset.ConclusionsAnalytical imprecision is satisfactory as well as the linearity, particularly when taking into account the fact that both assays are claimed to be qualitative. Diagnostic sensitivity of IgG was excellent, especially considering specimens collected ≥12 days post symptom onset. Time kinetics suggest that IgM and IgG are detectable early in the course of infection, but the role of SARS-CoV-2 antibodies in clinical practice still requires further evaluations.

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