Abstract 3097: Acute In-hospital Stroke: How Do We Do Compared To Strokes In The Emergency Department?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Dolora Wisco ◽  
Christopher Newey ◽  
Pravin George ◽  
James Gebel
Keyword(s):  
Emergency Department ◽  
Time Window ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tertiary Center ◽  
Neuro Imaging ◽  
One Year ◽  
To Receive ◽  
Iv Tpa ◽  
Arterial Thrombolysis

Introduction: Intravenous tissue plasminogen activator (IV tPA) has been approved for treating strokes up to 3 hours after onset of symptoms and may be beneficial up to 4.5 hours in patients who qualify. Additionally, neuro-intervention, i.e., intra-arterial thrombolysis or thrombectomy, is also an approved treatment option. Population studies show that 6% receive IV tPA within 3 hours of stroke onset. However, in-hospital strokes present challenges to treating within an adequate time. We present here our experience with in-hospital strokes, treatments, and identifiable delays in treatments. Methods: Single, tertiary center retrospective study of 55 in-hospital strokes over a one-year period from January 2009 to January 2010, and strokes in the Emergency Department over 6 month period from January 2010 to June 2010. Results: Twenty-nine in-hospital strokes were evaluated within 3 hours of symptoms onset. Two (6.9%) received IV tPA, and four (13.8%) received neuro-intervention (either intra-arterial thrombolysis or thrombectomy). None of the patients who presented greater than 3 hours after symptom onset was treated with any treatment (n=28). When compared to patients who present to the ED within 3 hours, in-hospital strokes were less likely to get IV tPA (6.9% vs. 20.8%), and they were more likely to receive neuro-intervention (13.8% vs. 10.3%). Neuro-intervention was performed on 9.09% of all in-hospital strokes (1 of 5 presented beyond the 3 hour time window). For in-hospital strokes that receive any treatment within 3 hours, the average time to neurology evaluation, to CT, and to treatment are 35 min, 68 min, and 237 min, respectively. For strokes in the Ed, the average time to evaluation, to CT, and to treatment are 90 min, 28 min, and 66 min respectively. The delay for in-hospital strokes is in obtaining the CT and initiating the treatment. Discussion: In-hospital stroke patients wait longer than their ED counterparts to be taken to CT and to receive stroke treatment. They are also less likely to receive IV tPA, and more likely to receive neuro-intervention. The longer time to neuro-imaging and thrombolytic treatment may reflect the fact that patients suffering in-hospital strokes have more complex medical co-morbidities that must be taken account during the evaluation and administration of thrombolytic therapy.

Abstract P201: Octogenarian and Nonagenarian Outcomes Among Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
RAJAN R GADHIA ◽  
Farhaan S Vahidy ◽  
Tariq Nisar ◽  
Destiny Hooper ◽  
David Chiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Combined Treatment ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Acute Stroke Treatment ◽  
Iv Tpa

Objective: Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80. Methods: We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation. Results: A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively). Conclusion: Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.

Abstract W P340: Emergency Department Nurses Collaborate With Long Term Care Facilities for Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jamie L Strom
Keyword(s):  
Emergency Department ◽  
Long Term Care ◽  
Stroke Patients ◽  
Term Care ◽  
Stroke Treatment ◽  
Emergency Department Nurses ◽  
Senior Services ◽  
To Receive ◽  
Education Initiative

Background and Purpose: Stroke treatment is often delayed before patients reach the emergency department (ED). Some patients arrive in time to receive medication that can reverse new stroke symptoms. Some are not as fortunate. They are either admitted to the palliative unit, or discharged only to live with their new disabilities possibly for the rest of their lives. In 2013, nurses observed many long term care (LTC) patients were not getting to the ED in time to receive tPA (tissue plasminogen activator), a medication used to reverse stroke symptoms. The purpose of this process improvement was to increase the number of LTC patients with stroke symptoms arriving in the ED within the tPA window. Methods: To determine how many patients from nursing homes were missing the tPA window, data from the ED’s records was abstracted from the month of June 2013. The sample size was all patients who presented with possible stroke symptoms, and who were also from LTC facilities. Surprisingly, 100% of LTC patients presenting with stroke symptoms missed the tPA window. With the support of ED leadership, we decided to raise awareness about the tPA window in the LTC facilities. No evidence existed from ED’s related to LTC patients and the tPA window. Approximately 1,000 unused stroke pamphlets were collected. A PowerPoint presentation based on AHA guidelines was used. A lecture occurred at the community’s senior services meeting, and many LTC administrators were willing to adopt this education initiative at their facilities. ED staff became involved and helped conduct the in-services. In exchange for their volunteering, they received credit to help with career ladders at their hospital. Results: The number of possible stroke patients from LTC facilities getting to the ED within eight hours of the last time seen normal (LTSN) has increased from 0% in June 2013, to 25% in March 2014. Conclusions: Stroke education teams of ED nurses showed improvement in LTC patients arriving in the ED within the tPA window. In conclusion, it is encouraged that other ED staff volunteer to teach in LTC facilities in their own communities, in assisting their stroke patients as well.

scholarly journals Lessons from Recent Advances in Ischemic Stroke Management and Targeting Kv2.1 for Neuroprotection

2020 ◽  
Vol 21 (17) ◽  
pp. 6107 ◽  
Author(s):  
Chung-Yang Yeh ◽  
Anthony J. Schulien ◽  
Bradley J. Molyneaux ◽  
Elias Aizenman
Keyword(s):  
Ischemic Stroke ◽  
Time Window ◽  
Stroke Therapy ◽  
Stroke Management ◽  
Preclinical Research ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Cell Death Pathway ◽  
To Receive ◽  
Neuroprotective Therapies

Achieving neuroprotection in ischemic stroke patients has been a multidecade medical challenge. Numerous clinical trials were discontinued in futility and many were terminated in response to deleterious treatment effects. Recently, however, several positive reports have generated the much-needed excitement surrounding stroke therapy. In this review, we describe the clinical studies that significantly expanded the time window of eligibility for patients to receive mechanical endovascular thrombectomy. We further summarize the results available thus far for nerinetide, a promising neuroprotective agent for stroke treatment. Lastly, we reflect upon aspects of these impactful trials in our own studies targeting the Kv2.1-mediated cell death pathway in neurons for neuroprotection. We argue that recent changes in the clinical landscape should be adapted by preclinical research in order to continue progressing toward the development of efficacious neuroprotective therapies for ischemic stroke.

Abstract 40: Xenon-Loaded Liposomes in Combination with IV tPA Extends the Time Window for Treatment of Thrombotic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Tao Peng ◽  
Yifeng Miao ◽  
George L Britton ◽  
Melvin E Klegerman ◽  
Susan T Laing ◽  
...  
Keyword(s):  
Infarct Size ◽  
Continuous Wave ◽  
Time Window ◽  
Infarct Volume ◽  
Neuroprotective Effect ◽  
Neuronal Cell ◽  
Great Promise ◽  
Tunel Staining ◽  
Stroke Treatment ◽  
Iv Tpa

BACKGROUND: Xenon (Xe) provides great promise for stroke treatment due to its unique neuroprotective effect. Building on previous work for Xe-loaded liposomes (Xe-ELIP) to effectively deliver Xe into the brain, this study investigates the effect of Xe-ELIP in combination with intravenously (IV) administered tissue plasminogen activator (tPA) to extend the time window of treatment for embolic stroke. METHODS: Thrombotic strokes were induced in rats by injecting a standardized blood clot into the middle cerebral artery. In the treatment groups, Xe-ELIP (20mg/kg) and tPA (10mg/kg) were administrated IV at 2 and 4 hours, respectively, after the stroke onset. Continuous wave ultrasound (1 MHz, 50% duty cycle, 1 W/cm 2 ) was applied over the common carotid artery during Xe-ELIP administration to trigger Xe release. Behavioral tests were conducted three days after stroke. Following sacrifice, brain sections were evaluated with triphenyltetrazolium chloride (TTC) and Tunel staining. Infarct size was presented as normalized infarct volume (%). RESULTS: Thrombotic stroke without treatment exhibited the largest infarct size (18.98±2%); tPA treatment reduced the infarct size to 6.1±1% (p<0.001 vs. no treatment). Xe-ELIP in combination with tPA treatment further reduced the infarct size to 1.8±0.4% (p=0.032 vs. tPA treatment; Fig 1a) with lower hemorrhagic adverse effects, improved neurological function and reduced apoptosis (Fig 1b). CONCLUSIONS: This study demonstrates that Xe-ELIP in combination with IV tPA provides improved therapeutic efficacy with reduced neuronal cell death and tPA-associated hemorrhagic side effects. These results have important implications for extending the time window of treatment of thrombotic stroke.

scholarly journals Simultaneous cardio-cerebral embolization due to atrial fibrillation: a case report

2019 ◽  
Author(s):  
Soichiro Abe ◽  
Kanta Tanaka ◽  
Hiroshi Yamagami ◽  
Kazutaka Sonoda ◽  
Hiroya Hayashi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Coronary Intervention ◽  
Limb Weakness ◽  
Intravenous Tissue Plasminogen Activator ◽  
Percutaneous Coronary ◽  
Iv Tpa

Abstract Background Simultaneous cerebral and myocardial infarction is called cardiocerebral infarction (CCI), and is rarely encountered. Because of the narrow time window and complex pathophysiology, CCI is challenging to immediately diagnose and treat. Case presentation A 73-year-old woman suddenly developed right hemiplegia and severe aphasia. Twelve-lead electrocardiography showed tachycardic atrial fibrillation without any significant ST-T change. Magnetic resonance imaging revealed a proximal middle cerebral artery occlusion. She was immediately treated with alteplase at the dosage approved for ischemic stroke followed by mechanical thrombectomy, and complete recanalization was achieved. Aphasia improved and she began to complain of chest pain, and reported that she had experienced chest discomfort just prior to right limb weakness. Coronary angiography showed a partial filling defect in the right coronary artery with rapid and adequate distal flow, for which percutaneous coronary intervention was not required. Alteplase was suggested to have effectively resolved the coronary emboli. The occlusions of the cerebral and coronary arteries were assumed to have occurred nearly simultaneously and cardiogenic embolism due to atrial fibrillation was considered as the most likely etiology. Conclusions As seen in the present case, CCI may benefit from immediate treatment with intravenous tissue plasminogen activator (IV-tPA). Although which of percutaneous coronary intervention or cerebral thrombectomy should be performed first remains unclear, we must decide to rescue the brain or heart first in each patient within a limited window of time. In this era with both IV-tPA and mechanical thrombectomy robustly established as effective intervention for acute ischemic stroke, close cooperation between stroke physicians and cardiologists is becoming more important.

Abstract T P20: Rate of Endovascular Ischemic Stroke Treatment Increases with Onsite Rather than Regional Capabilities

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Nazli Janjua ◽  
Karen Tse-Chang ◽  
Kessarin Panichpisal ◽  
Kimberly Jones ◽  
Debbie Keasler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Gap Analysis ◽  
Target Lesion ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Systemic Thrombolysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Us ◽  
Acute Care Facilities ◽  
Iv Tpa

Introduction: Currently in the US, hospitals with Neuro-Interventional capabilities represent a small proportion of all acute care facilities, and most hospitals rely on regional transfers for these services. At the same time, it is known, that having to transfer patients for Neuro-interventional stroke therapy (NIST) decreases the rate of offering this therapy, because of the time lost in the transfer process. Objective: We sought to compare the rates of NIST being offered to patients after the inception of these services on-site, compared with the prior calendar year. Methods: All patients presenting with neurological disturbance within 4.5 hours with a National Institutes of Health Stroke score (NIHSSS) >/= 4 undergo emergent non contrast head computed tomography (CT) and CT angiography (CTA). All patients who have no contra-indications to systemic thrombolysis receive intravenous tissue plasminogen activator (IV tPA) and in addition, those with large vessel occlusion on CTA are offered NIST. Results: A total of 333 patients were admitted with the diagnosis of ischemic stroke (IS) in 2013. Of these 15 (4.3%) patients were transferred for NIST of which 9 received IV tPA and 6 did not. In addition, 2 patients were declined for NIST by regional centers and 2 who were transferred were unable to undergo NIST due to CT changes upon transfer. In the calendar year 2014 to date (8.5 months), among 225 IS patients, 21 (9.3%) were offered NIST, including 1 patient who was transferred from a neighboring facility. All patients offered treatment, underwent treatment. Among the 21 patients, 1 had spontaneous recanalization, another had a distal stenosis but no occlusion, and in 3, the target lesion could not be reached for intervention due to proximal carotid occlusion. Among these patients the mean initial NIHSSS was 20 and mean NIHSSS at discharge was 10. No patients experienced symptomatic hemorrhage, and one patient expired due to malignant ischemic swelling. Conclusion: Having on-site NI capabilities doubled our rate of offering NIST. Such data may factor into a hospital’s gap analysis as to its need for NIST. Further analysis is needed to assess whether our experience of significant decline in discharge NIHSSS corresponds to long-term good functional outcome.

scholarly journals Utilization of a Parental Approach to Informed Consent in Intravenous Tissue Plasminogen Activator Administration Decision-Making: Patient Preference and Ethical Considerations

2019 ◽  
Vol 2019 ◽  
pp. 1-4
Author(s):  
Ann M. Murray ◽  
Ashley B. Petrone ◽  
Amelia K. Adcock
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Family Member ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Medical Community ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
To Receive ◽  
Iv Tpa

Objective. While administration of intravenous tissue plasminogen activator (IV-tPA) is the standard of care in acute ischemic stroke and has been shown to have statistically significant benefit, there can also be potentially life-threatening complications; however, there is no standard informed consent approach. The purpose of this study was to present a parental, technical, and general model of informed consent for IV-TPA and to determine which approach was preferred. Methods. Survey respondents were asked to hypothetically decide whether or not to provide consent for their family member to receive IV-tPA. Respondents were presented with 3 informed consent models: one emphasizing parental qualities, one emphasizing statistical data, and one representing a general consent statement. After being presented each model, the respondents had to select their preferred consent model, as well as rate their level of agreeability toward their family member receiving the medication following each approach. Results. The results of 184 surveys showed respondents were equally as likely to give consent for their family member to receive IV-TPA following all three approaches; however, respondents were significantly more likely to prefer the parental approach compared to a technical or general approach. Conclusion. Our results indicate that while paternalism is generally discouraged in the medical community, some degree of parental language may be preferred by patients in tough decision-making situations toward consent to receive medical interventions.

scholarly journals Lessons from Recent Advances in Ischemic Stroke Management and Targeting Kv2.1 for Neuroprotection

2020 ◽  
Author(s):  
Chung-Yang Yeh ◽  
Anthony Schulien ◽  
Bradley Molyneaux ◽  
Elias Aizenman
Keyword(s):  
Ischemic Stroke ◽  
Time Window ◽  
Stroke Therapy ◽  
Stroke Management ◽  
Preclinical Research ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Cell Death Pathway ◽  
To Receive ◽  
Neuroprotective Therapies

Achieving neuroprotection in ischemic stroke patients has been a multi-decade medical challenge. Numerous clinical trials were discontinued in futility and many were terminated in response to deleterious treatment effects. Recently however, several positive reports have generated the much-needed excitement surrounding stroke therapy. In this review, we describe the clinical studies that significantly expanded the time window of eligibility for patients to receive mechanical endovascular thrombectomy. We summarize the results available thus far for nerinetide, which can be considered the most promising neuroprotective agent yet for stroke treatment. Lastly, we reflect upon aspects of these successful trials in our own studies targeting the Kv2.1-mediated cell death pathway in neurons for neuroprotection. We propose that recent changes in the clinical landscape must be adapted by preclinical research in order to continue progressing toward the development of efficacious neuroprotective therapies for ischemic stroke.

Abstract TP51: Comparison of Recanalization Rate Between Intravenous Actilyse and Intravenous Actilyse With Mechanical Thrombectomy in Larger Artery Occlusion Ischemic Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sanghyuk Im ◽  
Do-Sung Yoo ◽  
MinHyung Lee ◽  
Byung-Rae Cho ◽  
Jin Eun ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Imaging Study ◽  
Additional Treatment ◽  
Complication Rates ◽  
Large Artery ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Iv Tpa

Background and Purpose: According to the guidelines for acute ischemic stroke treatment, intravenous tissue plasminogen activator (IV-tPA) administration is the first line treatment and intraarterial thrombolysis (IA-Tx) with retrieval stent is regarded as additional treatment. But recanalization rate of large artery intracranial occlusion disease (LAICOD) after IV-tPA is very low and inconsistent according to the reports. Authors tried to find out the early recanalization rate of IV-tPA in patients with LAICOD. Methods: 278 with anterior circulation occlusion patients were included in this analysis. Brain CT-angiography (CTA) was an initial imaging study and acute stroke MRI was following after the IV-tPA. Recanalization rate was studied with initial CTA and followed MRA image. And other clinical outcomes were compared with IV-tPA, IA-Tx or perfusion/diffusion-mismatching (P/D-mismatching) or not. Results: The overall recanalization rate of LAICOD after IV-tPA was 15.5% (43/278), 86.0% (86/100) in patients treated with IA-Tx after IV-tPA, and 78.7% (48/61) in IA-Tx without IV-tPA. In patients who underwent IA-Tx after IV-tPA, P/D-mismatching patients showed higher recanalization rate (88.2% = 67/76 vs. 66.7% = 16/27, p = 0.020), and higher incidence of favorable outcomes (63.2% = 48/76 vs. 12.5% = 3/27, p = 0.000) compared to P/D-matching patients. Conclusion: This study suggests that recanalization rate after IV-tPA for the patients with acute ischemic stroke due to LAICOD is very low and IV-tPA before IA-Tx does not significantly influence on the neurologic outcomes and complication rates. Bridging treatment is effective, for stroke patient management, but authors would like to propose that IA-Tx might be applied as the first therapy option, just like in the management of acute myocardial infarction patients.

Abstract TMP82: Community Education-Impact of Knowing Your Sign

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Kristin Peterson ◽  
Victoria Steinkoenig
Keyword(s):  
Emergency Department ◽  
Symptom Onset ◽  
Arrival Time ◽  
Community Education ◽  
Treatment Options ◽  
The United States ◽  
Medical Attention ◽  
Post Intervention ◽  
Stroke Treatment ◽  
To Receive

Stroke remains one of the leading causes of death and disability in the United States. Even with increased community education on stroke, the most common reason for delay in seeking medical attention is lack of recognition of the signs, symptoms and time sensitivity of stroke treatment. It is compelling to see the amount of patients that do not present for emergency treatment within three hours of symptom onset. This lack of awareness and delay in arrival was found to contribute to decreased candidacy for stroke treatment and leads to increased chances of disability. The critical need for community partnerships specifically aimed at educating on recognition of stroke signs, symptoms and treatment options was identified. The goal of this project was to demonstrate the correlation between community education and decreasing symptom onset to door time. Method: This retrospective study performed at a Central Illinois hospital reviewed data including symptom onset to door times from January 2014 to March 2015 as one method of determining the effectiveness of community education. Intervention time frames were held between April 2014 to December 2014 with a 3 month pre and post intervention phase. Inclusion criteria: any stroke code that presented through triage or via EMS. Exclusion criteria: in house stroke codes and symptom onset that was unknown. Results: In the first quarter of 2014, the average time it took patients to present to the Emergency Department from symptom onset was 233 minutes. Post-implementation data revealed the average symptom onset to door time was 63 minutes which accounts for a nearly 73% decrease in arrival time. Conclusion: Over 20 Community Education sessions on stroke signs, symptoms and the importance of seeking prompt medical attention were held over a nine month period. This community education on stroke was effective because there was a decrease in stroke symptom onset to the Emergency Department which created more eligible patients to receive emergency stroke treatment. This study validated that by providing intense community education aimed at the recognition of stroke signs, symptoms and treatment options, more patients were eligible to receive emergent stroke treatment because the arrival time was drastically shortened.

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