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

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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Abstract 3313: Outcomes of “Drip-and-Ship” Paradigm Among Patients with Acute Ischemic Stroke. Results of a State Wide Study

Stroke ◽

10.1161/str.43.suppl_1.a3313 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Saqib A Chaudhry ◽

Gustavo J Rodriguez ◽

M. Fareed K Suri ◽

Adnan I Qureshi

Keyword(s):

Ischemic Stroke ◽

Recombinant Tissue Plasminogen Activator ◽

Population Based ◽

Primary Diagnosis ◽

Hospital Charges ◽

Stroke Patients ◽

Frequency Distributions ◽

Number Of Patients ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: “Drip-and-ship” denotes patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 hours to a comprehensive stroke center. Although drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population based level. Methods: State-wide estimates of thrombolysis, associated in-hospital outcomes and mortality were obtained from 2008-2009 Minnesota Hospital Association (MHA) data. Patient numbers and frequency distributions were calculated for state-wide sample of patients hospitalized with a primary diagnosis of ischemic stroke. Patients outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. Results: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n=473) or drip-and-ship paradigm (n=129). The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with drip-and-ship paradigm (8.5% versus 3.1, p=0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or drip-and-ship paradigm (5.9% versus 7.0%). The mean hospital charges were $65,669 for primary ED arrival and $47,850 for drip-and-ship treated patients (p<0.001). Conclusions: The results of drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this state-wide study.

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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)

Interventional Neurology ◽

10.1159/000442715 ◽

2015 ◽

Vol 4 (3-4) ◽

pp. 138-150 ◽

Cited By ~ 26

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.

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In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

The Neurohospitalist ◽

10.1177/19418744211007001 ◽

2021 ◽

pp. 194187442110070

Author(s):

Felix Ejike Chukwudelunzu ◽

Bart M Demaerschalk ◽

Leonardo Fugoso ◽

Emeka Amadi ◽

Donn Dexter ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Statistical Significance ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Community Based ◽

Chi Square ◽

Stroke Team ◽

Primary Stroke Center ◽

Stroke Center

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

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Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

Acta Radiologica ◽

10.1177/02841851211006897 ◽

2021 ◽

pp. 028418512110068

Author(s):

Yu Hang ◽

Zhen Yu Jia ◽

Lin Bo Zhao ◽

Yue Zhou Cao ◽

Huang Huang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Secondary Endpoints ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

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Association of Carotid Artery Endothelial Signal Intensity Gradient with Unilateral Large Artery Ischemic Stroke

Cerebrovascular Diseases ◽

10.1159/000514141 ◽

2021 ◽

Vol 50 (3) ◽

pp. 270-278

Author(s):

Chan-Hyuk Lee ◽

Sang Hyuk Lee ◽

Young I. Cho ◽

Seul-Ki Jeong

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Signal Intensity ◽

Internal Carotid ◽

University Hospital ◽

Large Artery ◽

Intensity Gradient ◽

National University ◽

Endothelial Shear Stress ◽

Stroke Center

Background: Common carotid artery (CCA) and internal carotid artery (ICA) are aligned linearly, but their hemodynamic role in ischemic stroke has not been studied in depth. Objectives: We aimed to investigate whether CCA and ICA endothelial shear stress (ESS) could be associated with the ischemic stroke of large artery atherosclerosis (LAA). Methods: We enrolled consecutive patients with unilateral ischemic stroke of LAA and healthy controls aged >60 years in the stroke center of Jeonbuk National University Hospital. All patients and controls were examined with carotid artery time-of-flight magnetic resonance angiography, and their endothelial signal intensity gradients (SIGs) were determined, as a measure of ESS. The effect of right or left unilateral stroke on the association between carotid artery endothelial SIG and ischemic stroke of LAA was assessed. Results: In total, the results from 132 patients with ischemic stroke of LAA and 121 controls were analyzed. ICA endothelial SIG showed significant and independent associations with the same-sided unilateral ischemic stroke of LAA, even after adjusting for the potential confounders including carotid stenosis, whereas CCA endothelial SIG showed a significant association with the presence of the ischemic stroke of LAA. Conclusion: Although CCA and ICA are located with continuity, the hemodynamics and their roles in large artery ischemic stroke should be considered separately. Further studies are needed to delineate the pathophysiologic roles of ESS in CCA and ICA for large artery ischemic stroke.

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Abstract 83: Etiology of Late Right-to-Left Shunting on Transcranial Doppler in Ischemic Stroke Patients

Stroke ◽

10.1161/str.48.suppl_1.83 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Adam de Havenon ◽

Anne Moore ◽

Nicholas Freeberg ◽

Ali Sultan-Qurraie ◽

David Tirschwell

Keyword(s):

Ischemic Stroke ◽

Transcranial Doppler ◽

Inclusion Criteria ◽

Contrast Injection ◽

Stroke Patients ◽

Stroke Etiology ◽

Standard Component ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Toast Classification

Background: An echocardiogram or transcranial Doppler (TCD) bubble study to test for a right-to-left shunt (RLS) is a standard component of an ischemic stroke workup. Because the pathway for an intracradiac RLS, such as a patent foramen ovale (PFO), is more direct, it has been proposed that the late appearance of a RLS suggests an extracardiac pathway. We sought to characterize a cohort of ischemic stroke patients with late RLS (LRLS) on TCD. Methods: We searched the medical record of a Comprehensive Stroke Center for patients with ischemic stroke who had a TCD and echocardiogram bubble study during 2011-2013. LRLS was defined as TCD bubbles appearing more than 18 cardiac cycles after contrast injection. TOAST stroke etiology classification was performed by a vascular neurologist blinded to TCD results. Results: 124 patients met inclusion criteria, of which 67/124 (54%) had RLS on TCD; and 32/67 (48%) had LRLS. In the 35/67 patients with normal RLS on TCD, 23% did not have RLS on echocardiography, consistent with prior reports of TCD’s superiority for detecting RLS. In the 32/67 patients with LRLS on TCD, 56% were negative for RLS by echocardiography. In the cohort of 124 patients, the percentage of TOAST classification 4 (stroke of other determined cause) was 26%, while in the 32 patients with LRLS the percentage of TOAST 4 was significantly higher at 52%(p=0.005) (Table 1). The increase in TOAST 4 in LRLS patients was created by an even distribution of decreases in the other TOAST categories. The most common TOAST 4 stroke etiology in LRLS patients was PFO with concurrent deep venous thrombosis. Conclusion: This preliminary data supports prior studies that have shown superiority of TCD over echocardiography for detection of RLS, and challenge the prevailing notion that extracardiac shunt, such as pulmonary AVM, is the most common cause of LRLS in ischemic stroke patients. This subgroup of patients warrants further research to clarify mechanisms of ischemic stroke in patients with RLS.

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Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates

Stroke ◽

10.1161/str.51.suppl_1.wp429 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Daniel D'Amour ◽

Jayme Strauss ◽

Amy K Starosciak

Keyword(s):

Treatment Time ◽

Treatment Decision ◽

Treatment Rate ◽

Treatment Decision Making ◽

National Rate ◽

Number Of Patients ◽

Stroke Team ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Positive Effect

Introduction: Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates. Methods: First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”. Results Conclusions: Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.

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Etiology of ischemic stroke among young adults of Serbia

Vojnosanitetski pregled ◽

10.2298/vsp0811803j ◽

2008 ◽

Vol 65 (11) ◽

pp. 803-809 ◽

Cited By ~ 8

Author(s):

Dejana Jovanovic ◽

Ljiljana Beslac-Bumbasirevic ◽

Ranko Raicevic ◽

Jasna Zidverc-Trajkovic ◽

Marko Ercegovac

Keyword(s):

Risk Factors ◽

Young Adults ◽

Ischemic Stroke ◽

Heart Diseases ◽

Developed Countries ◽

Large Artery ◽

Stroke Treatment ◽

Prosthetic Valves ◽

Number Of Patients ◽

Coagulation Inhibitors

Background/Aim. Etiology of ischemic stroke (IS) among young adults varies among countries. The aim of the study was to investigate the causes and risk factors of IS in the young adults of Serbia. Methods. A total of 865 patients with IS, aged 15 to 45 years, were treated throughout the period 1989-2005. Etiologic diagnostic tests were performed on the patient by the patient basis and according to their availability at the time of investigation. The most likely cause of stroke was categorized according to the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. Results. There were 486 men and 379 women, with 19% of the patients ? 30 years old. Large artery arteriosclerosis and small artery disease were confirmed in 14% of the patients, and embolism and other determined causes in 20%. Undetermined causes made up 32% of the patients, mostly those (26%) with incomplete investigations. Smoking (37%), hypertension (35%) and hyperlipidemia (35%) were the most common risk factors. Rheumatic heart diseases and prosthetic valves were the most common causes of IS. Arterial dissections and coagulation inhibitors deficiency were detected in a small number of patients. Conclusion. Etiology of IS among Serbian young adults shares characteristics of those in both western and less developed countries.

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Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

Stroke Research and Treatment ◽

10.1155/2021/6624231 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Cesar Velasco ◽

Brandon Wattai ◽

Scott Buchle ◽

Alicia Richardson ◽

Varun Padmanaban ◽

...

Keyword(s):

Urban Areas ◽

Stroke Care ◽

Final Diagnosis ◽

Medical Attention ◽

Presenting Symptoms ◽

Number Of Patients ◽

Community Transmission ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7 min ) compared to the same time period in 2019 ( 42 ± 8.2 min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

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Abstract TP317: Utility and Cost of Inpatient Thrombophilia Testing in Ischemic Stroke Patients Aged 18-60

Stroke ◽

10.1161/str.51.suppl_1.tp317 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Effrosyni Apostolidou ◽

Priya Khatri ◽

Eric Thomas ◽

Sean Savitz ◽

Alicia Zha

Keyword(s):

Ischemic Stroke ◽

Cryptogenic Stroke ◽

Inpatient Setting ◽

Initial Hospital ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

One Year ◽

Care Costs ◽

Fvl Mutation

Introduction: Patients (pts) <60 years with ischemic stroke (IS) are commonly tested for thrombophilias (TP) due to the perception that there could be underlying hypercoagulable states. However, inherited TPs are largely not a risk factor for IS; and testing for acquired TPs in an acute inpatient setting may yield erroneous results that increase health care costs. We reviewed the frequency and cost of TP testing at our institution as part of a plan-do-study act cycle for improving the utilization of inpatient TP testing in young pts after IS. Methods: We performed a retrospective review of 18-60 year old pts admitted for IS to our comprehensive stroke center between 11/2016 and 7/2018. Pts discharged with a stroke etiology not attributed to large vessel (LV), small vessel (SV), or cardioembolic (CE) origin and the initial hospital TP testing monitored. Pts seen subsequently in clinic or later admissions in our system were monitored. Results: Of 1,162 pts, 104 without diagnosed LV/SV/CE etiologies were identified. At least one TP test was performed in 82 (79%) pts (Table 1). In 70 pts testing was done in the initial 24 hrs of hospitalization. One test abnormality was seen in 42 (51%) pts but anticoagulation was initiated in only one 1 patient at discharge. Forty-seven (45%) pts were followed in our outpatient clinic, with a mean follow up of 5 (0.2 – 24) months. TP was confirmed in 3 pts in clinic – two with heterozygous FVL mutation and one with known homozygous FVL mutation. The total charges of the initial inpatient testing is estimated to be as high as $222,150 for 82 patients. Conclusion: Frequent inpatient TP testing in young pts with cryptogenic stroke does not change management and can be costly to the hospital. Based on these results, we created a practice guideline to improve utilization of TP testing starting January 2019. A one year analysis of the effectiveness, safety, and cost for these changes is ongoing.

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