Abstract 252: Implementation and Ongoing Evaluation of a Novel Method for Stroke Severity Assessment and Routing: NYC S-LAMS

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Michael Redlener ◽  
David Ben-Eli ◽  
Pamela Lai ◽  
Elizabeth Lancet ◽  
David Prezant ◽  
...  
Keyword(s):  
New York ◽  
Los Angeles ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Stroke Population ◽  
Improved Outcomes ◽  
First Pass ◽  
Minimum Score ◽  
On Line ◽  
Suspected Stroke

Introduction: For the New York City 911 system stroke population, we sought to create and monitor a system for identifying stroke and large vessel occlusion (LVO) and to route LVO patients to thrombectomy capable centers which would reduce delays in the provision of endovascular care. Methods: We trained all emergency medical technicians and paramedics in the NYC 911 system to perform the Los Angeles Motor Score and to evaluate speech in cases of suspected stroke. We used a minimum score of 4/6 on a combined scale to screen positive for a possible LVO. An on-line medical control (OLMC) contact was required for every case that screened positive. Patients were eligible for transport specifically to thrombectomy capable centers if they screened positive, symptoms were present for less than 5 hours, symptoms were not due to trauma or seizure and the patient was previously ambulatory. Results: In the first six months of activity, there were 907 OLMC contacts, consistent with our prediction of approximately 5 patients per day that was derived from our 911 system’s historical database. After excluding ineligible patients, of these, 328 were transported to primary stroke centers and 579 were transported to thrombectomy capable centers. Of the 579 transported to thrombectomy capable centers, 447 (77.2%) had a confirmed stroke diagnosis. There were 189 (32.6%) LVO cases and 76 (13.1%) intracranial hemorrhages. Median time from EMS arrival to endovascular intervention first pass was 182.6 minutes and from hospital arrival to first pass was 141.5 minutes. Discussion: Overall, the process behaved as expected. We believe that our system can be further refined to reduce time to intervention. Further investigation is required to determine whether or not the system improved outcomes for patients and whether or not any cases of LVO or ICH were missed.

scholarly journals Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings

2018 ◽  
Vol 7 (3-4) ◽  
pp. 196-203 ◽  
Author(s):  
Kessarin Panichpisal ◽  
Kenneth Nugent ◽  
Maharaj Singh ◽  
Richard Rovin ◽  
Reji Babygirija ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Predictive Value ◽  
Area Under The Curve ◽  
Predictive Performance ◽  
Large Vessel ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Comparable Accuracy ◽  
Score Model

Background: Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO. Method: The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS). Results: LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO. Conclusion: The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

Abstract P488: The Impact of First Pass Effect on Acute Ischemic Stroke Clinical Outcomes: Why We Need to Continue to Improve Mechanical Thrombectomy?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Mahmoud Dibas ◽  
Amr Ehab El-Qushayri ◽  
Sherief Ghozy ◽  
Adam A Dmytriw ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Improved Outcomes ◽  
First Pass ◽  
The Impact

Background: Mechanical thrombectomy (MT) has significantly improved outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). The first-pass effect (FPE), defined as achieving complete reperfusion (mTICI3/2c) with a single pass, was reported to be associated with higher functional independence rates following EVT and has been emphasized as an important procedural target. We compared MT outcomes in patients who achieved FPE to those who did not in a real world large database. Method: A retrospective analysis of LVO pts who underwent MT from a single center prospectively collected database. Patients were stratified into those who achieved FPE and non-FPE. The primary outcome (discharge and 90 day mRS 0-2) and safety (sICH, mortality and neuro-worsening) were compared between the two groups. Results: Of 580 pts, 261 (45%) achieved FPE and 319 (55%) were non-FPE. Mean age was (70 vs 71, p=0.051) and mean initial NIHSS (16 vs 17, p=0.23) and IV tPA rates (37% bs 36%, p=0.9) were similar between the two groups. Other baseline characteristics were similar. Non-FPE pts required more stenting (15% vs 25%, p=0.003), and angioplasty (19% vs 29%, p=0.01). The FPE group had significantly more instances of discharge (33% vs 17%, p<0.001), and 90-day mRS score 0-2 (29% vs 20%, p<0.001), respectively. Additionally, the FPE group had a significant lower mean discharge NIHSS score (12 vs 17, p<0.001). FPE group had better safety outcomes with lower mortality (14.2% vs 21.6%, p=0.03), sICH (5.7% vs 13.5, p=0.004), and neurological worsening (71.3% vs 78.4%, p=0.02), compared to the non-FPE group. Conclusion: Patients with first pass complete or near complete reperfusion with MT had higher functional independence rates, reduced mortality, symptomatic hemorrhage and neurological worsening. Improvement in MT devices and techniques is vital to increase first pass effect and improve clinical outcomes.

Emergency medical systems education may improve knowledge of pre-hospital stroke triage protocols

2018 ◽  
Vol 12 (4) ◽  
pp. 370-373 ◽  
Author(s):  
Eleanor L DiBiasio ◽  
Mahesh V Jayaraman ◽  
Lori Oliver ◽  
Gino Paolucci ◽  
Michael Clark ◽  
...  
Keyword(s):  
Los Angeles ◽  
Test Score ◽  
Randomized Clinical Trials ◽  
Task Force ◽  
Real Life ◽  
Stroke Severity ◽  
Training Curriculum ◽  
Vessel Occlusion ◽  
Emergency Medical ◽  
Field Triage

BackgroundFollowing the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs.PurposeWe developed a single-session training curriculum for EMS personnel focused on the Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate in the field, and our state-wide EMS stroke protocol. We assessed the effect of our training on EMS knowledge.MethodsWe assembled a focus group to develop a training curriculum and assessment questions that would mimic real-life conditions under which EMS personnel operate. Ten questions were formulated to assess content knowledge before and after training, and scores were compared using generalized mixed models.ResultsTraining was provided for 179 EMS providers throughout the state.Average pre-test score was 52.4% (95% CI 49% to 56%). Average post-test score was 85.6% (83%–88%, P<0.0001). Each of the 10 questions was individually assessed and all showed significant gains in EMS knowledge after training (P<0.0001).ConclusionsA brief educational intervention results in substantial improvements in EMS knowledge of prehospital stroke severity scales and severity-based field triage protocols. Further study is needed to establish whether these gains in knowledge result in improved real-world performance.

scholarly journals Large Vessel Occlusion Stroke Detection in the Prehospital Environment

2021 ◽  
Author(s):  
Lauren Patrick ◽  
Wade Smith ◽  
Kevin J. Keenan
Keyword(s):  
Endovascular Therapy ◽  
Ease Of Use ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Published Data ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Suspected Stroke

Abstract Purpose of Review Endovascular therapy for acute ischemic stroke secondary to large vessel occlusion (LVO) is time-dependent. Prehospital patients with suspected LVO stroke should be triaged directly to specialized stroke centers for endovascular therapy. This review describes advances in LVO detection among prehospital suspected stroke patients. Recent Findings Clinical prehospital stroke severity tools have been validated in the prehospital setting. Devices including EEG, SSEPs, TCD, cranial accelerometry, and volumetric impedance phase-shift-spectroscopy have recently published data regarding LVO detection in hospital settings. Mobile stroke units bring thrombolysis and vessel imaging to patients. Summary The use of a prehospital stroke severity tool for LVO triage is now widely supported. Ease of use should be prioritized as there are no meaningful differences in diagnostic performance amongst tools. LVO diagnostic devices are promising, but none have been validated in the prehospital setting. Mobile stroke units improve patient outcomes and cost-effectiveness analyses are underway.

scholarly journals A Novel Combination of Blood Biomarkers and Clinical Stroke Scales Facilitates Detection of Large Vessel Occlusion Ischemic Strokes

Diagnostics ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. 1137
Author(s):  
Edoardo Gaude ◽  
Barbara Nogueira ◽  
Marcos Ladreda Mochales ◽  
Sheila Graham ◽  
Sarah Smith ◽  
...  
Keyword(s):  
Multivariable Analysis ◽  
Large Vessel ◽  
P Value ◽  
Stroke Severity ◽  
Blood Biomarkers ◽  
Protein Biomarkers ◽  
Vessel Occlusion ◽  
Suspected Stroke ◽  
D Dimer ◽  
Independent Cohort

Acute ischemic stroke caused by large vessel occlusions (LVOs) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. We recruited two separate cohorts of suspected stroke patients and screened a panel of blood-derived protein biomarkers for LVO detection. Diagnostic performance was estimated by using blood biomarkers in combination with NIHSS-derived stroke severity scales. Multivariable analysis demonstrated that D-dimer (OR 16, 95% CI 5–60; p-value < 0.001) and GFAP (OR 0.002, 95% CI 0–0.68; p-value < 0.05) comprised the optimal panel for LVO detection. Combinations of D-dimer and GFAP with a number of stroke severity scales increased the number of true positives, while reducing false positives due to hemorrhage, as compared to stroke scales alone (p-value < 0.001). A combination of the biomarkers with FAST-ED resulted in the highest accuracy at 95% (95% CI: 87–99%), with sensitivity of 91% (95% CI: 72–99%), and specificity of 96% (95% CI: 90–99%). Diagnostic accuracy was confirmed in an independent cohort, in which accuracy was again shown to be 95% (95% CI: 87–99%), with a sensitivity of 82% (95% CI: 57–96%), and specificity of 98% (95% CI: 92–100%). Accordingly, the combination of D-dimer and GFAP with stroke scales may provide a simple and highly accurate tool for identifying LVO patients, with a potential impact on time to treatment.

Abstract 1122‐000105: Does Persistence in Reperfusion Pay Off?

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Ameer E Hassan ◽  
Johanna T Fifi ◽  
Osama O Zaidat
Keyword(s):  
Subgroup Analysis ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Complete Revascularization ◽  
Vessel Occlusion ◽  
Serious Adverse Events ◽  
Improved Outcomes ◽  
First Pass ◽  
Using Data ◽  
Vessel Dissection

Introduction : Reperfusion with mechanical thrombectomy improves outcomes in patients with Large Vessel Occlusion Acute Ischemic Stroke (LVO‐AIS). The technical goal of thrombectomy is reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b. Here we investigate if procedures requiring multiple passes to achieve complete reperfusion (MP mTICI 3) result in better outcomes compared to procedures stopped after achieving mTICI 2b‐2c on the first pass (FP mTICI 2b‐2c). Methods : Using data from the COMPLETE registry (a global prospective study of LVO‐AIS patients who underwent mechanical thrombectomy using the Penumbra System), we grouped patients into MP mTICI 3 and FP mTICI 2b‐2c. Functional independence (mRS 0–2) at 90 days, all‐cause mortality at 90 days, device‐related serious adverse events (SAE) ≤ 24 hours, procedure‐related SAEs ≤ 24 hours, embolization to new or previously uninvolved territories (ENT), symptomatic intracranial hemorrhage (sICH) ≤ 24 hours, vessel perforation, vessel dissection, and length of stay were compared. Results : Of the 650 patients in the COMPLETE registry, 215 were included in this subgroup analysis; 111 were categorized as MP mTICI 3, and 104 as FP mTICI 2b‐2c. The MP mTICI 3 group has fewer M1 occlusions (48% vs 67%, p = 0.004) and more ICA‐T occlusions (19% vs. 9%, p = 0.032). The groups were otherwise well matched with respect to age, sex, medical history, pre‐procedure ASPECTS, NIHSS, IV tPA use, onset‐to‐puncture time, and occlusion etiology. Outcomes are shown in table 1. Conclusions : In this exploratory subgroup analysis, we found that procedures requiring multiple passes to achieve complete revascularization were not associated with improved outcomes compared to procedures stopping after achieving mTICI 2b‐2c on the first pass.

scholarly journals Portable Neuromonitoring Device Detects Large Vessel Occlusion in Suspected Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Paulina B. Sergot ◽  
Andrew J. Maza ◽  
Bruce J. Derrick ◽  
Lane M. Smith ◽  
Liam T. Berti ◽  
...  
Keyword(s):  
National Institutes Of Health ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Convenience Sample ◽  
Future Studies ◽  
High Discrimination ◽  
Suspected Stroke ◽  
Higher Sensitivity

Background and Purpose: Early detection of large vessel occlusion (LVO) stroke optimizes endovascular therapy and improves outcomes. Clinical stroke severity scales used for LVO identification have variable accuracy. We investigated a portable LVO-detection device (PLD), using electroencephalography and somatosensory-evoked potentials, to identify LVO stroke. Methods: We obtained PLD data in suspected patients with stroke enrolled prospectively via a convenience sample in 8 emergency departments within 24 hours of symptom onset. LVO discriminative signals were integrated into a binary classifier. The National Institutes of Health Stroke Scale was documented, and 4 prehospital stroke scales were retrospectively calculated. We compared PLD and scale performance to diagnostic neuroimaging. Results: Of 109 patients, there were 25 LVO (23%), 38 non-LVO ischemic (35%), 14 hemorrhages (13%), and 32 stroke mimics (29%). The PLD had higher sensitivity (80% [95% CI, 74–85]) and similar specificity (80% [95% CI, 77–83]) to all prehospital scales at their predetermined high probability LVO thresholds. The PLD had high discrimination for LVO ( C -statistic=0.88). Conclusions: The PLD identifies LVO with superior accuracy compared with prehospital stroke scales in emergency department suspected stroke. Future studies need to validate the PLD’s potential as an LVO triage aid in prehospital undifferentiated stroke populations.

Mary Bucholtz, A. C. Laing, & Laurel A. Sutton (eds.), Reinventing identities: The gendered self in discourse. New York and Oxford: Oxford University Press, 1999. Pp. xiii, 431. Pb $35.00.

2001 ◽  
Vol 30 (2) ◽  
pp. 275-278
Author(s):  
Mary M. Talbot
Keyword(s):  
New York ◽  
Los Angeles ◽  
Language Use ◽  
The United States ◽  
Language Community ◽  
Teenage Girls ◽  
Oxford University ◽  
Language And Gender ◽  
On Line ◽  
And Gender

This is the inaugural volume of a new series, Studies in Language and Gender. This substantial book is an edited collection of recent research in the field of language and gender, predominantly but not exclusively focused on language use in the United States. The research represented in its 20 chapters is wide-ranging, both in terms of the genres and media explored in them and in terms of analytic approaches. The genres, media, and locations investigated include, among others, American shopping channel talk (Mary Bucholtz), self-revelatory on-line journals (Laurel Sutton), office interaction (Deborah Tannen), Latina hopscotch in Los Angeles (Marjorie Goodwin), Irish-language community radio (Colleen Cotter), British teenage girls' conversations (Jennifer Coates), and a Tunisian sociolinguistic interview (Keith Walters).

Abstract WMP11: Joint Commission Certified Stroke Centers Treat More Severe Strokes with Faster Procedure Times Compared to Non-joint Commission Certified Stroke Centers in the Trevo Registry

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Rishi Gupta ◽  
Erol Veznedaroglu ◽  
Ronald F Budzik ◽  
Joey D English ◽  
Blaise W Baxter ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Joint Commission ◽  
Stroke Severity ◽  
Stroke Therapy ◽  
Demographic Information ◽  
Centers Of Excellence ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
First Pass ◽  
The Joint Commission

Introduction: Endovascular stroke therapy has become the gold standard treatment for large vessel occlusion. The Joint Commission has certified hospitals as Comprehensive stroke centers (JCCSC) based on rigorous standards in the hopes of identifying centers of excellence. We sought to determine if JCCSC have faster door to reperfusion times compared to non-JCCSC. Methods: The TREVO registry is a multicenter international real world registry assessing angiographic and clinical outcomes with the Trevo device being used in the first pass. We defined a CSC as certified by the Joint Commission as of July 1, 2016. Demographic information, times within the hospital, angiographic results and clinical outcomes were analyzed between the JCCSC and non-JCCSC institutions. Results: A total of 507 patients (329 JCCSC, 178 non-JCCSC) have completed data in the Trevo registry to date. There are a higher proportion of patients with ASPECTS < 7 being treated at JCCSC vs. non-JCCSC (8.8% vs. 0.0%, p<0.02). There were no differences in outcomes, reperfusion rates or symptomatic hemorrhage rates between the two groups. Demographics were similar except patients treated at a JCCSC had a higher median NIHSS [17 vs. 15, p<0.003] compared to the non-JCCSC group. Median (IQR) door to puncture times did not differ between the two groups [85(57-132) vs. 91(59-137), p<0.96], but patients treated at a JCCSC had lower mean angiographic procedure times [59 ± 34 minutes vs. 66±44 minutes, p<0.05]. The analysis did not change when we looked at the subset of patients who were not transferred with anterior circulation strokes less than 8 hours from onset. Conclusions: Patients treated at a JCCSC had faster procedural times, without faster door to procedure times when compared to non-JCCSC centers. Outcomes were no different, due to imbalances in stroke severity at baseline and a higher proportion of patients with ASPECTS < 7 being treated.

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