scholarly journals Acute Ischemic Stroke (AIS) Patient Management in French Stroke Units and Impact Estimation of Thrombolysis on Care Pathways and Associated Costs

2015 ◽  
Vol 39 (2) ◽  
pp. 94-101 ◽  
Author(s):  
Aurélie Schmidt ◽  
Chérif Heroum ◽  
Didier Caumette ◽  
Katell Le Lay ◽  
Stève Bénard
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Discharge ◽  
Treated Patient ◽  
Care Pathways ◽  
Post Discharge ◽  
Term Care ◽  
Stroke Units ◽  
Rehabilitative Care ◽  
The Impact

Background: Stroke is the second leading cause of death and a first leading cause of acquired disability in adults worldwide. This study aims to evaluate the current management and associated costs of acute ischemic stroke (AIS) for patients admitted in stroke units in France and over a one-year follow-up period as well as to assess the impact of improved thrombolytic management in terms of increasing the proportion of patients receiving thrombolysis and/or treated within 3 h from the onset of symptoms. Methods: A decision model was developed, which comprises two components: the first corresponding to the acute hospital management phase of patients with AIS up until hospital discharge, extracted from the national hospital discharge database (PMSI 2011), and the second corresponding to the post-acute (post-discharge) phase, based on national treatment guidelines and stroke experts' advice. Five post-acute clinical care pathways were defined. In-hospital mortality and mortality at 3 months post-discharge was taken into account into the model. Patient journeys and costs were determined for both phases. Improved thrombolytic management was modeled by increasing the proportion of patients receiving thrombolysis from the current estimated level of 16.7 to 25% as well as subsequently increasing the proportion of patients treated within 3 h of the onset of symptoms post-stroke from 50 to 100%. The impact on care pathways was derived from clinical data. Results: Among 202,078 hospitalizations for a stroke or a transient ischemic attack (TIA), 90,528 were for confirmed AIS, and 33% (29,999) of them managed within a stroke unit. After hospitalization, 60% of discharges were to home, 25% to rehabilitative care and then home, 2% to rehabilitative care and then a nursing home, 7% to long-term care, and 6% of stays ended with patient death. Of a total cost over 1 year of €610 million (mean cost per patient of €20,326), 70% concern the post-acute phase. By increasing the proportion of patients being thrombolyzed, costs are reduced primarily by a decrease in rehabilitative care, with savings per additional treated patient of €1,462. By adding improved timing, savings are more than doubled (€3,183 per additional treated patient). Conclusions: This study confirms that the burden of AIS in France is heavy. By improving thrombolytic management in stroke units, patient journeys through care pathways can be modified, with increased discharges home, a change in post-acute resource consumption and net savings.

scholarly journals Acute Ischemic Stroke (Ais) Patient Management in French Stroke Units and Impact Estimation of Thrombolysis On Care Pathways and Associated Costs

2014 ◽  
Vol 17 (7) ◽  
pp. A503
Author(s):  
A. Schmidt ◽  
S. Bénard ◽  
C. Heroum ◽  
D. Caumette ◽  
O. Delaitre ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Management ◽  
Care Pathways ◽  
Stroke Units

Abstract WP17: Rates and Outcomes of Neurosurgical Evacuation for Thromboytic Related Intracerebral Hemorrhage in Patients with Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Kiersten E Norby ◽  
Malik M Adil ◽  
Haseeb A Rahman ◽  
Farhan Siddiq ◽  
Adnan I Qureshi
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Medical Management ◽  
Care Facility ◽  
Treated Group ◽  
Term Care ◽  
Management Group ◽  
The Impact

Background: Thrombolytic related intracerebral hemorrhage (ICH) is an infrequent occurrence in patients with acute ischemic stroke. There is controversy surrounding the value of neurosurgical evacuation of hematomas and decompression in these patients and whether such availability is a necessary pre-requisite for administration of thrombolytics. Objective: To report the frequency and outcomes of patients who suffer from thrombolytic related ICH and undergo a craniotomy. Materials/Methods: Using the Nationwide Inpatient Sample (NIS) from 2002 to 2010, acute ischemic stroke patients who suffered from thrombolytic related ICH were identified using ICD-9 codes. Patients were divided into those who received craniotomy and those who received medical management alone. Discharge destination and mortality were primary endpoints. Results: A total of 7359 patients suffered thrombolytic related ICH, 125 (1.7%) of those patients underwent craniotomy and 7234 patients (98.3%) received medical treatment alone. Patients who underwent craniotomy were younger (58±5 versus 72±11 years, p=0.09). Patients in the craniotomy group were frequently in extreme severity APR-DRG category compared with medical management group (92.2% versus 55.5%, p=0.0003). The craniotomy group had greater requirements for gastrostomy (47.8% versus 16.7%, p=0.02) and mechanical ventilation (55% versus 13.8%, p=0.005) compared with the medical management group. The mean length of stay was also longer in the craniotomy group (21.5±7 versus 10±2 days, p<0.0001). The in-hospital mortality and discharge to nursing home/long-term care facility was 24.2% and 72% among those treated with craniotomy, respectively. The corresponding proportions were 30.5% and 57% for medically treated group (p=0.5 and p=0.1, respectively). Conclusion: Emergent craniotomy for thrombolytic related hematoma evacuation or decompression in acute stroke is a salvage treatment offered to a small proportion of patients. There may be evidence that this reduces mortality, however long term disability may be higher in those patients. More detailed analysis may be required to understand the impact of emergent craniotomy on patient disability in thrombolytic related hemorrhage for acute ischemic stroke.

Abstract P24: Assessing Tpa Eligibility Using Mr-Witness and Wake-Up Trial Criteria May Substantially Improve Post-Discharge Outcomes in Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Joseph Conovaloff ◽  
Amit Chaudhari ◽  
Mohammed Shafie
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Neurological Deficits ◽  
Post Discharge ◽  
Acute Setting ◽  
Total Hospital Stay ◽  
Discharge Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Early administration of tissue plasminogen activator (tPA) improves morbidity and mortality in acute ischemic stroke (AIS). However, the strict NINDS exclusion criteria, especially the emphasis on last known well times (LKWT) which are often unreliable in the acute setting, restrits tPA use to only 2-5% of all AIS patients. The MR-Witness and WAKE-UP trials propose using MRI diffusion-to-flair mismatch in these cases to better judge the age of an infarct, but the impact of this on post-discharge outcomes has not yet been reported. We conducted a retrospective analysis of all AIS patients in one comprehensive stroke center to further investigate this question. Of our total 1016 patients, 165 (16.2%) received tPA and 58 (5.7%) underwent mechanical thrombectomy. 380 patients (37.4%) were refused tPA due to an NINDS exclusion other than LKWT, 246 (24.2%) due to minimal or resolving neurological deficits, and 6 (0.6%) due to family preference. The remaining 161 patients (15.8%) were refused tPA only because of an unreliable LKWT. Statistical analyses comparing these 161 patients to the 165 who received tPA revealed no differences in age (p=0.306), gender (p=0.214), race, or even NIHSS score on presentation (p=0.306). However, while the total hospital stay was similar in both groups (p=0.954), patients who received tPA had significantly better post-discharge outcomes, with more patients going to acute rehab or home (p=0.033). In summary, comprehensive stroke centers generally out-perform national tPA administration averages (16.2% in our stroke center compared to 2-5% nationally). However, our study showed that a large percentage of AIS patients are still refused tPA only because of an unreliable LKWT. Obtaining emergent MRIs to assess diffusion-to-flair mismatch in these cases may increase the number of people with AIS eligible for tPA and substantially improve their post-discharge outcomes.

Abstract WP472: Improving Neurologic Follow-Up After Stroke Utilizing a Nurse Practitioner

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Larry Dashefsky ◽  
Carol Hren ◽  
Tiffanie Munici ◽  
Melissa Richardson
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Discharge ◽  
Nurse Practitioner ◽  
Transitions Of Care ◽  
Post Discharge ◽  
Readmission Rates ◽  
Discharge Disposition ◽  
Increased Risk

Background: Patients who experience acute ischemic stroke are at increased risk for a secondary vascular event. Risk factor management as well as review of the medication regimen are important components to secondary prevention. Neurologic follow-up is an essential step during transitions of care to ensure these components are addressed. For a variety of reasons, stroke patients do not always complete follow up appointments. The literature suggests that such patients are at increased risk for readmission. Purpose: The purpose of this project was to improve access to neurologic follow-up for patients diagnosed with acute ischemic stroke after discharge from an acute care or rehabilitation setting. The secondary goal was to decrease readmission rates. Methods: A nurse practitioner (NP) was added to the inpatient stroke neurology service. The model of care was redesigned with the NP performing subsequent assessments after the initial evaluation was completed by the neurologist. The NP also organized the plan of care, including appropriate post discharge follow-up. Over time, due to challenges with access to appointments, the NP started an outpatient stroke clinic. Data were entered into Get With The Guidelines®-Stroke to identify the patients who had a neurology provider appointment scheduled prior to hospital discharge, regardless of discharge disposition. Results: Between the first quarter of 2018 and the second quarter of 2019, the percentage of patients with a neurologic follow-up appointment scheduled prior to hospital discharge improved from 23% to 61%. During this same time period, the readmission rates decreased from 14% to 9%. Conclusions: Adding the NP position to an inpatient stroke neurology service and using this role to lead an outpatient stroke clinic improves the percentage of patients who have appointments scheduled prior to hospital discharge. Improving access to follow-up care influences readmission rates.

Abstract P8: IV Alteplase Prior to Thrombectomy Benefitted Patients With M1 Occlusions but Not Thrombectomy Patients With M2 Occlusions

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jason W Tarpley ◽  
Tamela L Stuchiner ◽  
Joseph T Ho ◽  
Renee Ovando ◽  
George P Teitelbaum ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Race And Ethnicity ◽  
Skilled Nursing Facility ◽  
Inpatient Rehabilitation ◽  
Vessel Occlusion ◽  
Term Care ◽  
Stroke Registry ◽  
The Impact ◽  
Iv Tpa

Introduction: Endovascular Therapy (EVT) has overwhelming efficacy for the treatment of acute ischemic stroke due to large vessel occlusion. There is debate regarding whether the administration of IV-alteplase influences the efficacy of this powerful treatment. Here we examined whether M1 and M2 occlusion patients may have differential benefit from IV tPA prior to their EVT. Methods: Data from the Providence System Stroke Registry for acute ischemic stroke patients receiving EVT between January 2015 and May 2020 and who had an occlusion in M1 or M2 middle cerebral artery were used. Multinomial regressions were used to asses if EVT patients with an M1 or M2 occlusion who received IV tPA compared to those who did not were more likely to be discharged as expired or hospice or other location (acute care or long term care, skilled nursing facility, left against medical advice), compared to home or inpatient rehabilitation (IRF), adjusting for patient age, sex, race and ethnicity, last known well to arrival, and NIHSS at admit. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) are reported. Results: A total of 667 EVT patients with an M1 occlusion were included in the analysis, of which 52.2% (n=348) received IV tPA and 47.8 (n=319) did not, and 273 EVT patients with an M2 were analyzed, of which 53.8% (n=147) received IV tPA and 46.2% (n=126) did not. The M1 MCA patients treated with IV tPA had 36% lower likelihood of being discharged somewhere other than home / IRF (AOR=0.64, 95% CI: 0.43, 0.94) than to home/IRF. Among M2 patients there were no differences found in the likelihood of being discharged expired/hospice or somewhere other home compared to home/IRF between those who did or did not receive IV tPA. Conclusions: Patients with M1 occlusions who received EVT and IV tPA had better discharge dispositions than those who did not receive IV tPA. However, patients with M2 occlusions who received EVT had equivalent discharge dispositions regardless of whether they got IV tPA or not. These results underscore the need for more randomized prospective clinical trials to evaluate the impact of thrombolysis on EVT patient outcomes and highlight the importance of evaluating lesion location as a potential covariate in these trials.

The impact of antihypertensive use in the treatment of acute ischemic stroke in patients receiving alteplase

2021 ◽  
Author(s):  
Megan A. Rech ◽  
Elisabeth Donahey ◽  
Joshua M. DeMott ◽  
Laura L. Coles ◽  
Gary D. Peksa
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
The Impact

scholarly journals Eosinophil-to-monocyte ratio is a potential biomarker in the prediction of functional outcome among patients with acute ischemic stroke

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Shuhong Yu ◽  
Yi Luo ◽  
Tan Zhang ◽  
Chenrong Huang ◽  
Yu Fu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Poor Outcome ◽  
Net Reclassification Improvement ◽  
Potential Biomarker ◽  
The Impact ◽  
The Relationship ◽  
Integrated Discrimination Improvement

Abstract Background It has been shown that eosinophils are decreased and monocytes are elevated in patients with acute ischemic stroke (AIS), but the impact of eosinophil-to-monocyte ratio (EMR) on clinical outcomes among AIS patients remains unclear. We aimed to determine the relationship between EMR on admission and 3-month poor functional outcome in AIS patients. Methods A total of 521 consecutive patients admitted to our hospital within 24 h after onset of AIS were prospectively enrolled and categorized in terms of quartiles of EMR on admission between August 2016 and September 2018. The endpoint was the poor outcome defined as modified Rankin Scale score of 3 to 6 at month 3 after admission. Results As EMR decreased, the risk of poor outcome increased (p < 0.001). Logistic regression analysis revealed that EMR was independently associated with poor outcome after adjusting potential confounders (odds ratio, 0.09; 95% CI 0.03–0.34; p = 0.0003), which is consistent with the result of EMR (quartile) as a categorical variable (odds ratio, 0.23; 95% CI 0.10–0.52; ptrend < 0.0001). A non-linear relationship was detected between EMR and poor outcome, whose point was 0.28. Subgroup analyses further confirmed these associations. The addition of EMR to conventional risk factors improved the predictive power for poor outcome (net reclassification improvement: 2.61%, p = 0.382; integrated discrimination improvement: 2.41%, p < 0.001). Conclusions EMR on admission was independently correlated with poor outcome in AIS patients, suggesting that EMR may be a potential prognostic biomarker for AIS.

scholarly journals Impact of Post-Stroke Recanalization on General and Upper Limb Functioning: A Prospective, Observational Study

2021 ◽  
Vol 13 (1) ◽  
pp. 46-58
Author(s):  
João Paulo Branco ◽  
Filipa Rocha ◽  
João Sargento-Freitas ◽  
Gustavo C. Santo ◽  
António Freire ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Observational Study ◽  
Acute Ischemic Stroke ◽  
Upper Limb ◽  
Functional Recovery ◽  
Prospective Observational Study ◽  
Positive Impact ◽  
Rehabilitation Program ◽  
Patient Functioning ◽  
The Impact

The objective of this study is to assess the impact of recanalization (spontaneous and therapeutic) on upper limb functioning and general patient functioning after stroke. This is a prospective, observational study of patients hospitalized due to acute ischemic stroke in the territory of the middle cerebral artery (n = 98). Patients completed a comprehensive rehabilitation program and were followed-up for 24 weeks. The impact of recanalization on patient functioning was evaluated using the modified Rankin Scale (mRS) and Stroke Upper Limb Capacity Scale (SULCS). General and upper limb functioning improved markedly in the first three weeks after stroke. Age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission were associated with general and upper limb functioning at 12 weeks. Successful recanalization was associated with better functioning. Among patients who underwent therapeutic recanalization, NIHSS scores ≥16.5 indicate lower general functioning at 12 weeks (sensibility = 72.4%; specificity = 78.6%) and NIHSS scores ≥13.5 indicate no hand functioning at 12 weeks (sensibility = 83.8%; specificity = 76.5%). Recanalization, either spontaneous or therapeutic, has a positive impact on patient functioning after acute ischemic stroke. Functional recovery occurs mostly within the first 12 weeks after stroke, with greater functional gains among patients with successful recanalization. Higher NIHSS scores at admission are associated with worse functional recovery.

Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

Abstract 1122‐000034: Systematic CT‐Perfusion acquisition in All Suspected Stroke Patients Increases Vascular Occlusion Detection and Thrombectomy Rates

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Marta Olive‐Gadea ◽  
Manuel Requena ◽  
Facundo Diaz ◽  
Alvaro Garcia‐Tornel ◽  
Marta Rubiera ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Symptoms ◽  
Ct Perfusion ◽  
False Negative ◽  
False Negative Rate ◽  
Vascular Occlusion ◽  
Stroke Patients ◽  
Imaging Protocols ◽  
The Impact

Introduction : In acute ischemic stroke patients, current guidelines recommend noninvasive vascular imaging to identify intracranial vessel occlusions (VO) that may benefit from endovascular treatment (EVT). However, VO can be missed in CT angiography (CTA) readings. We aim to evaluate the impact of consistently including CT perfusion (CTP) in admission stroke imaging protocols on VO diagnosis and EVT rates. Methods : We included patients with a suspected acute ischemic stroke that underwent urgent non‐contrast CT, CTA and CTP from April to October 2020. Hypoperfusion areas defined by Tmax>6s delay (RAPID software), congruent with the clinical symptoms and a vascular territory, were considered due to a VO (CTP‐VO). Cases in which mechanical thrombectomy was performed were defined as therapeutically relevant VO (EVT‐VO). For patients that received EVT, site of VO according to digital subtraction angiography was recorded. Two experienced neuroradiologists blinded to CTP but not to clinical symptoms, retrospectively evaluated NCCT and CTA to identify intracranial VO (CTA‐VO). We analyzed CTA‐VO sensitivity and specificity at detecting CTP‐VO and EVT‐VO respecitvely. We performed a logistic regression to test the association of Tmax>6s volumes with CTA‐VO identification and indication of EVT. Results : Of the 338 patients included in the analysis, 157 (46.5%) presented a CTP‐VO, (median Tmax>6s: 73 [29‐127] ml). CTA‐VO was identified in 83 (24.5%) of the cases. Overall CTA‐VO sensitivity for the detection of CTP‐VO was 50.3% and specificity was 97.8%. Higher hypoperfusion volume was associated with an increased CTA‐VO detection, with an odds ratio of 1.03 (95% confidence interval 1.02‐1.04) (figure). DSA was indicated in 107 patients; in 4 of them no EVT was attempted due to recanalization or a too distal VO in the first angiographic run. EVT was performed in 103 patients (30.5%. Tmax>6s: 102 [63‐160] ml), representing 65.6% of all CTP‐VO. Overall CTA‐VO sensitivity for the detection of EVT‐VO was 69.9%. The CTA‐VO sensitivity for detecting patients with indication of EVT according to clinical guidelines was as follows: 91.7% for ICA occlusions and 84.4% for M1‐MCA occlusions. For all other occlusion sites that received EVT, the CTA‐VO sensitivity was 36.1%. The overall specificity was 95.3%. Among patients who received EVT, CTA‐VO was not detected in 31 cases, resulting in a false negative rate of 30.1%. False negative CTA‐VO cases had lower Tmax>6s volumes (69[46‐99.5] vs 126[84‐169.5]ml, p<0.001) and lower NIHSS (13[8.5‐16] vs 17[14‐21], p<0.001). Conclusions : Systematically including CTP perfusion in the acute stroke admission imaging protocols may increase the diagnosis of VO and rate of EVT.

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