Choice of Initial Brain Imaging in Patients with Suspected Acute Stroke: STROKE69, a Population-Based Study

Background: In patients with suspected stroke, brain imaging is recommended in the acute phase for appropriate management and treatment. Both computed tomography (CT) and magnetic resonance imaging (MRI) are considered reasonable choices for initial brain imaging. When both techniques are available, choosing one or the other might be associated with specific factors related either to patients, stroke symptoms, and severity or management organization. Methods: The study was performed within the STROKE 69 database, a population-based cohort of all adult patients with suspected stroke admitted in one of the emergency departments (ED), primary stroke center, or stroke center of the Rhône County, from November 2015 to December 2016. Patients were included if they were admitted within 24 h following either symptom onset or last known normal. To identify factors potentially associated with the choice of initial brain imaging, a multivariate logistic regression was performed. Results: Among the 3,244 patients with suspected stroke enrolled in the STROKE69 cohort, 3,107 (95.8%) underwent brain imaging within the first 24 h after admission. Among those 74.6% underwent CT as initial imaging while 25.4% had an MRI. In multivariate analyses, several factors were associated with a lower probability of having an MRI as initial brain imaging versus CT. These were either patient characteristics: older age (>80 years old, OR 0.39 [95% CI 0.28–0.54]), preexisting disability (OR 0.55 [95% CI 0.36–0.84]), use of anticoagulants (OR 0.52 [95% CI 0.33–0.81]), stroke characteristics: stroke of unknown onset (OR 0.42 [95% CI 0.31–0.58]) or factors associated with overall management: onset-to-door time (>6 h, OR 0.38 [95% CI 0.23–0.60]), initial admission to ED (OR 0.02 [95% CI 0.02–0.04]) or intensive care unit (OR 0.01 [95% CI 0.001–0.08]), personal transport (OR 0.66 [95% CI 0.45–0.96]), and admission during working hours (OR 0.65 [95% CI 0.51–0.84]). Conclusions: Besides CT or MRI availability, a number of other parameters could influence the choice of first imaging in case of stroke suspicion. These are related to patient characteristics, type of stroke symptoms, and type of organization.

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Field triage for endovascular stroke therapy: a population-based comparison

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015033 ◽

2019 ◽

Vol 12 (3) ◽

pp. 233-239 ◽

Cited By ~ 7

Author(s):

Mahesh V Jayaraman ◽

Morgan L Hemendinger ◽

Grayson L Baird ◽

Shadi Yaghi ◽

Shawna Cutting ◽

...

Keyword(s):

Population Based ◽

Stroke Severity ◽

Matched Pairs ◽

Inclusion Criteria ◽

Stroke Therapy ◽

Transport Time ◽

Field Triage ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center

BackgroundEndovascular therapy (EVT) for stroke improves outcomes but is time sensitive.ObjectiveTo compare times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC).MethodsDuring the study, a portion of our region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. We compared times to treatment and clinical outcomes between those two groups. Additionally, we performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC.ResultsOver 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC; 144 were taken to the closest PSC and 88 to the more distant CSC. The median additional transport time to the CSC was 7 min. Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; p<0.001 for both). Among patients who were independent before the stroke, the OR for less disability in the direct group was 1.47 (95% CI 1.13 to 1.93, p=0.003), and 2.06 (95% CI 1.10 to 3.89, p=0.01) for the matched pairs.ConclusionsIn a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.

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Brain imaging (CT/MRI)

10.1093/med/9780198722366.003.0007 ◽

2018 ◽

Cited By ~ 1

Author(s):

Thomas Gattringer ◽

Christian Enzinger ◽

Stefan Ropele ◽

Franz Fazekas

Keyword(s):

Brain Imaging ◽

Time Window ◽

Patient Treatment ◽

Ischaemic Damage ◽

Direct Demonstration ◽

Ready Availability ◽

Magnetic Resonance Imaging Mri ◽

Suspected Stroke ◽

Stroke Evolution ◽

Diagnostic Step

In the acute phase of a suspected stroke, timely brain imaging with rapid and qualified interpretation is a crucial diagnostic step to inform patient management. While brain computed tomography is usually sufficient to indicate thrombolysis within the approved time window (by rapidly excluding intracranial haemorrhage), it often fails to show the actual site and extent of infarction as well as other pathologies, which may mimic a stroke. Magnetic resonance imaging (MRI) has a much higher sensitivity and specificity for ischaemic vascular brain changes and thus allows direct demonstration of the area(s) of acute ischaemic damage. This helps in the diagnosis of clinically uncertain cases, may give aetiological clues, and can also provide pathophysiologic insights into stroke evolution with respective consequences for patient treatment. The capability to rule out many other disorders that may mimic stroke is also an important asset of MRI. All these advantages make MRI the preferred tool in the workup of young individuals with suspected stroke. However, this needs ready availability and adequately tailored and short imaging protocols in order not to delay treatment.

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Stroke Center Certification Is Associated With Improved Guideline Concordance

American Journal of Medical Quality ◽

10.1177/1062860619835317 ◽

2019 ◽

Vol 34 (6) ◽

pp. 585-589

Author(s):

Adam S. Jasne ◽

Heidi Sucharew ◽

Kathleen Alwell ◽

Charles J. Moomaw ◽

Matthew L. Flaherty ◽

...

Keyword(s):

Ischemic Stroke ◽

Epidemiologic Study ◽

Stroke Care ◽

Population Based ◽

Patient Demographics ◽

Certification Programs ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center

Measurement of quality of stroke care has become increasingly important, but data come mostly from programs in hospitals that choose to participate in certification programs, which may not be representative of the care provided in nonparticipating hospitals. The authors sought to determine differences in quality of care metric concordance for acute ischemic stroke among hospitals designated as a primary stroke center, comprehensive stroke center, and non-stroke center in a population-based epidemiologic study. Significant differences were found in both patient demographics and in concordance with guideline-based quality metrics. These differences may help inform quality improvement efforts across hospitals involved in certification as well as those that are not.

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Abstract WP279: Concordance of Paramedic and Hospital Documented Last Known Well Times for EMS Transported Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.48.suppl_1.wp279 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Lucas Ramirez ◽

Nichole Bosson ◽

Marianne Gausche-Hill ◽

Jeffery L Saver ◽

Sid Starkman ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Patient Characteristics ◽

Final Diagnosis ◽

Multivariate Regression Analysis ◽

Stroke Patients ◽

Hospital Arrival ◽

Median Difference ◽

Suspected Stroke ◽

Stroke Center

Background: Last known well time (LKWT) is increasingly used by EMS systems to identify acute stroke patients appropriate for direct routing to Stroke Centers. However, determining LKWT in the field is challenging, as patients may be aphasic, witnesses may not be available on scene, and rapid departure from the scene is desirable. Objective: To characterize the concordance and degree of discordance between prehospital-determined LKWT and final LKWT documented at the hospital. Methods: This is a retrospective analysis of consecutive patients with positive prehospital stroke screens transported to an approved stroke center in a large metropolitan system from January 2011 to December 2014. Data was abstracted from the regional EMS Agency stroke database. Patients with missing prehospital or hospital documentation of LKWT were excluded. The percent concordance and the median difference were calculated for prehospital versus final hospital documented LKWT. The effect of patient characteristics on discordance was also explored via multivariate regression analysis. Result: Among the 9,810 patients transported for suspected stroke, the median age was 75 (Interquartile range [IQR] 62-85) years, 53% were women, 67% White, 11% Asian, 9% Black and 27% Hispanic. The median NIHSS was 11 (IQR 4 to 20). 83% had a cerebrovascular final diagnosis, ischemic stroke (IS) being the most common (n=5160, 53%), whereas 17% had a non-stroke-related diagnosis. There were 6873 patients missing either prehospital or hospital documentation of LKWT leaving 9810 patients for the analysis. Prehospital and hospital documented LKWTs were exactly equal in 42% of patients (36% for IS), within 15 minutes in 53% (48% for IS), within 1 hour in 66% (63% in IS) and within 2 hours in 70% (68% in IS). The median difference in LKWT between documented prehospital and hospital values was 0 minutes (IQR -6 to 18). The degree of discordance in LKWT did not vary with patient sex, race, or Hispanic ethnicity. Conclusions: Paramedic-documented LKWT was within 15 minutes of the final hospital documented LKWT in just over half of acute stroke EMS transports and within 1 hour in two-thirds.. As accurate LKWT determination in the field is challenging, time of symptom onset should be confirmed after hospital arrival.

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Abstract WP359: Achieving Target: Stroke Honor Roll Status through the Utilization of 9 Best Practice Strategies

Stroke ◽

10.1161/str.44.suppl_1.awp359 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Jennifer Garland

Keyword(s):

Brain Imaging ◽

Best Practice ◽

Rapid Acquisition ◽

Rapid Access ◽

Honor Roll ◽

Stroke Team ◽

Data Feedback ◽

National Quality ◽

Primary Stroke Center ◽

Stroke Center

Background: Target: Stroke is a national quality initiative of the American Heart Association/American Stroke Association with the goal of improving <60 minute door-to-needle times (DTN) for at least 50% of patients receiving IV rt-PA. (AHA/ASA, 2012) Purpose: To improve DTN times <60 minutes at an urban Primary Stroke Center in South California through the utilization of the Target: Stroke national quality initiative. Methods: Retrospective data analysis for 11 IV rt-PA receiving patients in the Get With The Guidelines-Stroke (GWTG-Stroke) database from 11/01/2011 to 01/31/2012. Employment of 9 Target: Stroke Best Practice Strategies: Advance Hospital Notification by EMS (Emergency Medical Services), Rapid Triage Protocol and Stroke Team Notification, Single Call Activation System, Stroke Tools, Rapid Acquisition and Interpretation of Brain Imaging, Rapid Laboratory Testing, Rapid Access to Intravenous IV rt-PA, Team-Based Approach, and Prompt Data Feedback. Results: The hospital received advanced hospital notification by EMS for 10 out of 11 (90.9%) IV rt-PA receiving patients. 100% of the patients were rapidly triaged, the stroke team was notified via single call activation & overhead page (stroke alert), and the appropriate thrombolytic stroke order sets were implemented (Stroke Tools). Rapid acquisition and interpretation of brain imaging were measured. CT Scan order to CT complete turn-around-time (TAT) averaged 12 minutes. CT Complete to CT Read TAT averaged 11.33 minutes.Average PT/INR and PTT TATs were 26.1 minutes. Rapid access to intravenous IV rt-PA was mixed by the Emergency Department pharmacist at the bedside for 100% of patients. The Team-Based Approach and prompt Data Feedback were practiced by holding monthly Stroke Steering Committee meetings that included interdisciplinary team members and disseminating data. Eight out of eleven (72.7%) acute ischemic stroke patients treated with IV rt-PA received the medication <60 minutes. Median door-to-needle (DTN) time for patients treated with IV rt-PA: 42 minutes. Conclusion: By employing 9 Target: Stroke Best Practice Strategies at an urban Primary Stroke Center in South California, the hospital was able to achieve Target: Stroke Honor Roll status from 11/01/2011 to 01/31/2012.

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Abstract WP34: Factors Associated with Reduced use of Stroke MRI: an Analysis of Practice Patterns

Stroke ◽

10.1161/str.44.suppl_1.awp34 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

James F Burke ◽

Lesli E Skolarus ◽

Brian C Callaghan ◽

Lewis B Morgenstern ◽

Kevin A Kerber

Keyword(s):

Perceived Value ◽

Patient Characteristics ◽

Routine Care ◽

Sensitivity Analyses ◽

Lower Probability ◽

Predicted Probability ◽

Clinical Scenarios ◽

Multi Level ◽

Magnetic Resonance Imaging Mri ◽

Procedure Codes

Background: Guidelines support the use of Magnetic Resonance Imaging (MRI) in the evaluation of acute stroke, however the perceived value of MRI information to providers in different clinical scenarios is not known. We aimed to identify patient characteristics associated with lower MRI use as means of identifying possible clinical scenarios where providers may perceive MRI to be less valuable. Methods: Stroke hospitalizations (principal ICD-9-CM 433.x1, 434.x1, 436) were identified from the State Inpatient Databases (SID) from 2003-2009 for 12 states. MRI utilization was identified using revenue codes and ICD-9 procedure codes. Patient characteristics were abstracted from the hospitalization record. Multi-level logistic regression with a random hospital-level intercept was used to estimate the association between patient characteristics (demographics, vascular risk factors, stroke mimics, comorbidities, regional socioeconomic status) and MRI. Effect sizes were estimated using posterior probabilities with all covariates held at their means. Sensitivity analyses accounting for the distribution of MRI contraindications were performed. Results: 670,309 hospitalizations were included in our sample; 51% of the population received MRI. From the model (area under ROC 0.82), age and potential cardioembolic source (atrial fibrillation, congestive heart failure, myocardial infarction) were associated with a lower probability of MRI utilization (table). The predicted probability of MRI in a 50 year old was 63.7% (95% CI 61.5%-65.9%) compared to 41.6% (39.4%-43.9%) in an 80 year-old. In sensitivity analysis, the association between cardioembolic sources and lower MRI use remained significant after accounting for extreme assumptions about the distribution of MRI contraindications. Conclusions: In routine care, MRI may have less perceived value by providers in stroke patients who are older and have a potential cardioembolic source.

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Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset

Stroke ◽

10.1161/strokeaha.120.033676 ◽

2021 ◽

Vol 52 (4) ◽

pp. 1441-1445

Author(s):

Tove Almqvist ◽

Annika Berglund ◽

Christina Sjöstrand ◽

Einar Eriksson ◽

Michael V. Mazya

Keyword(s):

High Specificity ◽

High Likelihood ◽

Vessel Occlusion ◽

Triage System ◽

Hospital Patients ◽

Primary Stroke Center ◽

Prehospital Triage ◽

Suspected Stroke ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Purpose: The Stockholm Stroke Triage System, implemented in 2017, identifies patients with high likelihood of large vessel occlusion (LVO) stroke. A previous report has shown Stockholm Stroke Triage System notably reduced time to endovascular thrombectomy (EVT). As the indication for EVT now includes patients up to 24 hours, we aimed to assess Stockholm Stroke Triage System triage accuracy for LVO stroke and EVT treatment for patients presenting late (within 6-24 hours or with an unknown onset), put in contrast to triage accuracy within 0 to 6 hours. Methods: Between October 2017 and October 2018, we included 2905 patients with suspected stroke, transported by priority 1 ground ambulance to a Stockholm Region hospital. Patients assessed 6 to 24 hours from last known well or with unknown onset were defined as late-presenting; those within <6 hours as early-presenting. Triage positivity was defined as transport to comprehensive stroke center because of suspected stroke, hemiparesis and high likelihood of EVT-eligible LVO per teleconsultation. Results: Overall triage accuracy was high in late-presenting patients (90.9% for LVO, 93.9% for EVT), with high specificity (95.7% for LVO, 94.5% for EVT), and low to moderate sensitivity (34.3% for LVO, 64.7% for EVT), with similar findings in the early-presenting group. Conclusions: Our results may support using the Stockholm Stroke Triage System for primary stroke center bypass in patients assessed by ambulance up to 24 hours from time of last known well.

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Door-in-Door-Out Time of 60 Minutes for Stroke With Emergent Large Vessel Occlusion at a Primary Stroke Center

Stroke ◽

10.1161/strokeaha.119.025838 ◽

2019 ◽

Vol 50 (10) ◽

pp. 2829-2834

Author(s):

Philip M.C. Choi ◽

Andrew H. Tsoi ◽

Alun L. Pope ◽

Shelton Leung ◽

Tanya Frost ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Working Hours ◽

Large Vessel ◽

Improvement Program ◽

Vessel Occlusion ◽

Treatment Delays ◽

Continuous Quality ◽

Primary Stroke Center ◽

Stroke Center ◽

Clinical Records

Background and Purpose— Rapid reperfusion with mechanical thrombectomy in ischemic strokes with emergent large vessel occlusions leads to significant reduction in morbidity and mortality. The door-in-door-out (DIDO) time is an important metric for stroke centers without an on-site mechanical thrombectomy service. We report the outcome of a continuous quality improvement program to improve the DIDO time since 2015. Methods— Retrospective analysis of consecutive patients transferred out from a metropolitan primary stroke center for consideration of mechanical thrombectomy between January 1, 2015, and October 31, 2018. Clinical records were interrogated for eligible patients with DIDO times and reasons for treatment delays extracted. Results— One hundred thirty-three patients were transferred over the 46-month period. Median DIDO time reduced by 14% per year, from 111 minutes interquartile range (IQR, 98– 142) in 2015 to 67 minutes (IQR, 55–94) in 2018. A median DIDO time of 59 minutes (IQR, 51–80) was achieved in 2018 during working hours (0800–1700 hours). Overall, 65 patients had no documented delays (49%) with a median DIDO time of 75 minutes (IQR, 54–93) and 103 minutes (IQR, 75–143) in those with at least one delay factor documented. Conclusions— A median DIDO time of <60 minutes can be achieved in a primary stroke center.

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Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes

JAMA Neurology ◽

10.1001/jamaneurol.2017.0477 ◽

2017 ◽

Vol 74 (7) ◽

pp. 793 ◽

Cited By ~ 51

Author(s):

Ryan A. McTaggart ◽

Shadi Yaghi ◽

Shawna M. Cutting ◽

Morgan Hemendinger ◽

Grayson L. Baird ◽

...

Keyword(s):

Patient Outcomes ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Suspected Stroke ◽

Stroke Center

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The Probability of A1C Goal Attainment in Patients with Uncontrolled Type-2 Diabetes in a Large Integrated Delivery System: A Prediction Model

10.2337/figshare.12200135 ◽

2020 ◽

Author(s):

Kevin M Pantalone ◽

Anita D Misra-Hebert ◽

Todd M Hobbs ◽

Sheldon X Kong ◽

Xinge Ji ◽

...

Keyword(s):

Type 2 Diabetes ◽

Goal Attainment ◽

Index Date ◽

Cleveland Clinic ◽

Patient Characteristics ◽

Psychiatric Disease ◽

Lower Probability ◽

Factors Associated ◽

One Year

Objective: To assess patient characteristics and treatment factors associated with uncontrolled type 2 diabetes (T2D) and the probability of A1C goal attainment. Research Design and Methods: Retrospective cohort study using the electronic health record at Cleveland Clinic. Patients with uncontrolled T2D (A1C>9%) were identified on the index date of 12/31/2016 (n=6,973), grouped by attainment (n=1,653 [24.7%) or non-attainment (n=5,320 [76.3%]) of A1C<8% by 12/31/2017, and subgroups compared on a number of demographic and clinical variables. Based on these variables, a nomogram was created for predicting probability of A1C goal attainment. Results: For the entire population, median age at index date was 57.7 years (53.3% male), and the majority were white (67.2%). Median A1C was 10.2%. Obesity (50.6%), cardiovascular disease (46.9%) and psychiatric disease (61.1%) were the most common comorbidities. Metformin (62.7%) and sulfonylureas (38.7%) were the most common anti-diabetes medications. Only 1,653 (24%) patients achieved an A1C <8%. Predictors of increased probability of A1C goal attainment were older age, white/non-Hispanic race/ethnicity, Medicare health insurance, lower baseline A1C, higher frequency of endocrinology/primary care visits, DPP-4i use, thiazolidinedione use, metformin use, GLP-1RA use, and fewer classes of anti-diabetes drugs. Factors associated with lower probability included insulin use and longer time in the T2D database (both presumed as likely surrogates for duration of T2D). Conclusions: A minority of patients with an A1C>9% achieved an A1C<8% at one year. While most identified predictive factors are non-modifiable by the clinician, pursuit of frequent patient engagement and tailored drug regimens may help improve A1C goal attainment.

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