scholarly journals Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN)

2015 ◽  
Vol 4 (3-4) ◽  
pp. 138-150 ◽  
Author(s):  
Joey D. English ◽  
Dileep R. Yavagal ◽  
Rishi Gupta ◽  
Vallabh Janardhan ◽  
Osama O. Zaidat ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Endovascular Therapy ◽  
Mechanical Thrombectomy ◽  
Systems Of Care ◽  
Open Label ◽  
Comprehensive Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
New Evidence

Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients.

Abstract TP24: Should the Decision for Mechanical Thrombectomy be Based on Pre-procedure CT Head Showing Early Changes in Specific Regions of the Brain?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Daniel Korya ◽  
Mohammad Moussavi ◽  
Siddhart Mehta ◽  
Jaskiran Brar ◽  
Mena Samaan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Mechanical Thrombectomy ◽  
Regions Of Interest ◽  
Paired Samples ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Right ◽  
Iv Tpa

Background: The treatment of acute ischemic stroke has evolved over the past several years to utilize neuroimaging in guiding therapy. With regard to IV tPA and thrombectomy, recent endovascular therapy trials have utilized the ASPECT score in determining if intervention should be attempted. We sought to evaluate different regions of interest on the ASPECT score to determine if specific areas of injury should be weighed more heavily during decision making. Methods: We evaluated the pre-intervention CT scans of the head on all patients who received IV tPA and mechanical thrombectomy during the last two years at a community based, university affiliated comprehensive stroke center. All 20 regions of interest (ROIs) of the ASPECT score were compared with each other with regard to initial NIH stroke score, discharge NIHSS, delta NIHSS and modified Rankin Score to determine if one or more regions were associated with worse outcome. SPSS version 22 was used to determine Spearman rho values and paired samples t-test. Results: A total of 864 patients presented with acute ischemic stroke, of which 70 patients received IV tPA followed by mechanical thrombectomy and were included in the study. The 4 ROIs with the greatest correlation with worse outcome as rated by discharge mRS were the right and left M5-M6 [4.2 (p=.001, 95%CI 3.5-4.8); 4.3 (p=.001, 95%CI 3.4-5.1); 4.3 (p=.001, 95%CI 3.4-5.2); 4.2 (p=.001, 95%CI 3.6-4.8), respectively]. Conclusion: Early changes defined as hypodensity in the M5 and M6 ROIs on either side of the pre-intervention head CT were associated with significantly worse outcomes. A modified ASPECT score should be considered to better prognosticate patients and guide the appropriateness of endovascular therapy in select patients. These findings should be validated in a larger population and a longer follow-up period.

Abstract 145: Transferred Ischemic Stroke Patients Have Worse Outcomes After Endovascular Therapy

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Malik M Adil ◽  
Shyam Prabhakaran
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Endovascular Treatment ◽  
Endovascular Therapy ◽  
Systems Of Care ◽  
Inpatient Rehabilitation ◽  
Patient Characteristics ◽  
Transferred Patients ◽  
Stroke Systems Of Care

Background and Objective: Ischemic stroke (IS) patients may require inter-facility transfer for higher level of care. Endovascular treatment is the main indication for transfer. We aimed to compare patient characteristics and clinical outcomes amongst transferred vs. non-transferred IS patients who undergo endovascular therapy. Methods: Patients admitted to US hospitals between 2008 and 2011 with a primary discharge diagnosis of IS were identified by ICD-9 codes (433, 434, 436 and 437.1). Mechanical embolectomy (ME) was identified using the ICD-9 procedure code 39.74 or DRG 543 and cerebral angiography (CA) day 0-1 by 88.41. Using logistic regression, we estimated the odds ratio (OR) and 95% confidence intervals (CI) for intracerebral hemorrhage (ICH), in-hospital mortality, and good outcomes (discharge home or inpatient rehabilitation) among transfer vs. non-transfers, adjusting for potential confounders. Results: Of 116,382 patients with IS treated with ME or CA (7.0% of all patients with IS), 10.1% were performed in transferred patients. Atrial fibrillation and hyperlipidemia was significantly higher in IS transfers. In-hospital mortality was higher among IS transfers (9.0% vs. 3.7%; p<0.001) and discharge to home or inpatient rehabilitation was less likely among transferred IS patients (70.2% vs. 80.6%; p<0.001). ICH was higher among IS transfers (4.6% vs. 1.7%; p<0.001). After adjusting for age, gender, race, presence of hypertension, dyslipidemia, atrial fibrillation, renal failure, alcohol abuse, insurance status, and hospital teaching status, transferred patients had higher odds of ICH (OR 2.0, 95% CI 1.5-2.8, p<0.001)] and death (OR 2.0, 95% CI 1.6-2.4, p<0.001) and lower odds of discharge to home/rehabilitation (OR 0.5, 95% CI 0.4-0.7, p<0.001) . Conclusion: Endovascular treatment for acute ischemic stroke may be associated with worse outcomes among inter-hospital transfer patients compared to non-transfers. Organized stroke systems of care may need to consider pre-hospital strategies to increase direct referrals to comprehensive stroke centers and inter-hospital strategies to reduce delays to treatment.

scholarly journals Mandatory Neuroendovascular Evolution: Meeting the New Demands

2018 ◽  
Vol 8 (1) ◽  
pp. 69-82
Author(s):  
Mohammad El-Ghanem ◽  
Francisco E. Gomez ◽  
Prateeka Koul ◽  
Rolla Nuoman ◽  
Justin G. Santarelli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Endovascular Intervention ◽  
Stroke Patients ◽  
Hub And Spoke ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

Abstract WP340: Impact of Increasing Primary Stroke Center Transfers on Comprehensive Stroke Center Capacity

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jane Holl ◽  
Andy Cai ◽  
Lauren Ha ◽  
Alin Hulli ◽  
Melina Paan ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Vessel Occlusion ◽  
Capacity Limits ◽  
Transfer Rates ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Occupancy Rates ◽  
Bed Occupancy Rates

Introduction: Given the time-sensitive benefits of acute stroke (AS) treatments, stroke systems of care must balance reducing door-in-door-out (DIDO) time at primary stroke centers (PSCs) with capacity limits at comprehensive stroke centers (CSCs). For example transferring more AS patients earlier in the process (e.g., prior vascular imaging for large vessel occlusion) from PSCs would result in more inappropriate transfers to CSCs that could overburden these centers.We conducted a simulation to estimate the balance between increased AS transfers from PSCs to CSCs and the percent of CSC time on “bypass” (inability to accept transfers to neuro-ICU). Methods: Clinicians from 3 Chicago-area CSCs and 3 affiliated PSCs and the Chicago Emergency Medical Services (EMS) created a PSC DIDO process map. We assumed CSC time on bypass is affected by AS and non-AS admissions from the CSC and from the affiliated PSCs. Input data were obtained fromtheChicago region registry (e.g., # PSC to CSC transfers), peer reviewed literature (US average transfer rate of AS patients to CSCs), EMS (PSC-CSC affiliations), and CSCs (e.g., average bed occupancy rates). CSC size was estimated by #neuro-ICU beds: small (12 beds), medium (23 beds), and large (28 beds). The simulation output was % time of CSC on “bypass”. Results: Table shows % time of CSC on bypass by varying PSC AS transfer rates for each category of CSC size. Larger increases in PSC transfer rates resulted in modest increases in CSC bypass rates, particularly for medium and large CSCs. Validation with data from one CSC showed < 4% overestimate of CSC % time on bypass. Conclusion: CSCs with more beds have efficiencies of scale leading to lower % time on bypass, even with increases in PSC AS transfer rates proportionate to CSC size. This model allows stroke systems of care to compute regional CSCs’ % time on bypass based on actual PSCs’ transfer rates and CSC size.

National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010–2016

2019 ◽  
pp. 174749301988452 ◽  
Author(s):  
Akiko Kada ◽  
Kuniaki Ogasawara ◽  
Takanari Kitazono ◽  
Kunihiro Nishimura ◽  
Nobuyuki Sakai ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Temporal Trends ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. Aims To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. Methods This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1–25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3–6) at discharge were examined using hierarchical logistic regression models. Results Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010–2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95–0.99), 0.97 (0.95–0.998), 1.07 (1.04–1.10), and 1.21 (1.14–1.28), respectively). Conclusions This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

scholarly journals Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy

2022 ◽  
Vol 12 ◽  
Author(s):  
Lars-Peder Pallesen ◽  
Simon Winzer ◽  
Christian Hartmann ◽  
Matthias Kuhn ◽  
Johannes C. Gerber ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Vessel Occlusion ◽  
Team Members ◽  
Interventional Neuroradiologist ◽  
Patient Arrival ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Prospective Database

Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT.Methods: We analyzed data from our prospective database (01/2016–02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (–EVT-Call) and after (+EVT-Call) implementation of the EVT-Call.Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65–81], NIHSS score 17 [12–22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call). Median (IQR) door-to-image time (18 min [14–22] vs. 10 min [7–13]; p &lt; 0.001), image-to-groin time (54 min [43.5–69.25] vs. 47 min [38.3–58.75]; p = 0.042) and door-to-groin time (74 min [58–86.5] vs. 60 min [49.3–71]; p &lt; 0.001) were reduced after implementation of the EVT-Call.Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined.

Abstract T MP11: Acute Endovascular Reperfusion Therapy Has Inconsistent Results Across Randomized Clinical Trials -A Systematic Review and Meta-Analysis

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Toshiya Osanai ◽  
Vinary Pasupuleti ◽  
Abhishek Deshpande ◽  
Priyaleela Thota ◽  
Yuani Roman ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Trials ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Primary Outcome ◽  
Randomized Clinical Trials ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Good Outcome

Introduction: Endovascular (intra-arterial, IA) therapy for acute ischemic stroke has become part of acute therapy , but limited randomized clinical trials have had inconsistent results. We sought to evaluate efficacy and safety of endovascular therapy in - randomized clinical trials . Methods: We performed a systematic review of literature for randomized clinical trials of endovascular therapy with thrombolytic or mechanical reperfusion compared with comparator groups without IA therapy. Use of systemic thrombolysis was not excluded. Primary outcome was modified Rankin scale of disability of 0-2 at 90 days and secondary outcomes of mortality at 90 days and symptomatic intracranial hemorrhage was noted. Two groups of independent reviewers searched and identified studies and abstracted data. Random-effects meta-analysis was performed. Subgroups were analyzed by study design characteristics. Results: Systematic search identified 10 studies with 1572 subjects, of which 9 studies reported the primary outcome. IA therapy was associated with good outcome at 90 days (Odds ratio (OR) =1.28; 95% CI, 1.01 to 1.62; p=0.04), but there was significant heterogeneity with p of 0.03. Among 3 trials (n=1136) comparing mechanical thrombectomy with control, mechanical thrombectomy was not superior to control with good outcome (OR=0.98; 95 % CI, 0.85 to 1.14; p=0.83). Patients with IA therapy significantly have good outcome in studies without systematic thrombolysis in the comparator (OR=1.55; 95 % CI, 1.05 to 2.29; p=0.03) and required vessel occlusion for randomization (OR=1.54; 95 % CI, 1.10 to 2.14; p=0.01). Mortality was unchanged with IA therapy (OR=0.92; 95 % CI, 0.75 to 1.13; p=0.45) and there was no difference in symptomatic hemorrhage (OR=1.13; 95 % CI, 0.74 to 1.74; p=0.56). Conclusion: IA therapy has a small but significant increase in good outcomes for patients with acute ischemic stroke without increasing mortality and symptomatic hemorrhages.

Abstract 194: Impact of Primary Stroke Centers On a Comprehensive Stroke Center

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Karen C Albright ◽  
Amelia Boehme ◽  
William Hicks ◽  
Woody Bursaw ◽  
Michael Mullen ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Clinical Information ◽  
Patient Characteristics ◽  
Large Artery ◽  
Chi Square ◽  
Number Of Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Houston Area

Introduction: The creation of primary stroke centers (PSCs) accredited by The Joint Commission (TJC) has increased access of care to a higher number of patients with acute ischemic stroke (AIS) in greater metropolitan areas. However, PSCs in many regions of the US do not conduct clinical trials in acute stroke. We hypothesized that creation of PSCs in the greater Houston area has led to changes in the demographics of our stroke admissions. Methods: Consecutive patients admitted to the UT Houston stroke team from 1/1/2005-12/30/2010 were screened. Records were reviewed for demographic and clinical information. Patient characteristics were compared among years using Chi-square and Kruskal-Wallis. Results: Over the 5 year period, 6,036 patients were admitted to our stroke service. The number of admissions increased from 674 in 2005 to 1,234 in 2010. Transfers from outside hospitals trended up from 24.6% (n=166) of all admissions in 2005 to 41.8% (n=516) in 2010. With the increase in transfers, the number of ICH transfer cases has increased over the past 5 years ( Fig ). Among all ischemic strokes, the percent of large artery occlusions (LAOs) presenting within 6-hrs from symptom onset fell from 34.3% (69/201) in 2005 to 16.4% (45/274) in 2010. Minor strokes (NIHSS 0-5) have increased from 37.4% (141/377) in 2005 to 42.5% (239/562). Overall, IV t-PA treatment rates remained unchanged, ranging from 29.7% to 37.0% from 2005 to 2010 (p=.490). Among AIS patients presenting within 6-hrs, study enrollment fell from 41.8% (84/201) in 2005 to 26.3% (72/274) in 2010. Figure 1 shows the changing demographics of our admissions plotted against the number of hospitals that have attained TJC PSC accreditation. Conclusion: As PSCs have arisen in the greater Houston area, we have seen a shift in the demographics of our stroke admissions including an escalating number of transfer patients. Among ischemic stroke patients, the number of LAOs has been decreasing overtime and the number of mild strokes has been increasing. These results are likely due, in part, to the transport of patients by EMS to the nearest PSCs who then preferentially request transfer of ICH cases to comprehensive stroke centers (CSCs). Consequently, the number of patients enrolled into clinical trials (the majority of which have been based on ischemic stroke and LAOs) has substantially decreased at our center. PSCs should be encouraged by accreditation committees to work with CSCs and participate in clinical research. To that end, PSCs may need investments in staff and resources to conduct clinical trials testing new stroke therapies.

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