Abstract 3967: Interdisciplinary Emergency Department (ED) Acute Stroke Case Review Decreases Door to Needle (DTN) Times

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Melissa T Fritz ◽  
Sandy Fritzlar
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Case Review ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stroke Team ◽  
Process Oriented ◽  
Stroke Case ◽  
Iv Tpa

Background: Stroke is one of the leading causes of death and the leading cause of disability in the United States. Previous studies suggest that the quicker that intravenous tissue plasminogen activator (IV tPA) is administered, the safer and more effective it is, thus lowering the odds of in hospital mortality and symptomatic intracranial hemorrhage. Objective: To investigate whether implementing a process oriented, interdisciplinary bimonthly review of acute ischemic stroke cases would decrease DTN times and ultimately lead to the consistent administration of IV tPA within 60 minutes of arrival to the ED. Methods: To decrease the IV tPA DTN times, the stroke team at United Hospital in St. Paul, Minnesota developed a new ED stroke review process in July 2010 to analyze each acute ischemic stroke case. The cases were compiled into a document that contained time specific goals for each step of the acute stroke code process. Members of the stroke team would review the data prior to the meeting and if there was a delay (ie outside of the timed goal for lab result) in their department they would investigate the cause. At the meeting, the team would identify best practice efficiencies and barriers, leading to changes in the process. Formal follow up with each department and key learnings were sent to staff on a monthly basis. Results: In 2010, there were 82 patients admitted with an acute ischemic stroke, within 3.5 hours from time last known well, and 28 patients received IV tPA 34% (28/82). From January to June, 2011 there have been 46 acute ischemic stroke patients and 18 patients received IV tPA (18/46) 39%. The mean DTN time was 88 minutes in 2010 vs. 70 minutes in 2011; mean age was 64 vs. 66.5; % female was 46% (13/28) vs. 67% (12/18); median NIH Stroke Scale was 6 vs. 6. The percentage of patients treated with IV tPA within 60 minutes of hospital arrival increased from 21.4% (6/28) in 2010 to 50% (9/18) from January to June 2011 (p=0.022). Conclusions: The DTN times significantly decreased after the implementation of a process oriented, interdisciplinary ED acute stroke case review. The percentage of patients receiving IV tPA within 60 minutes increased from 21.4% to 50% over a 18 month period.

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 WMP32: Variation in the Rates of Acute Ischemic Stroke Transfers Between Hospitals in the United States

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Syed F Ali ◽  
Gregg Fonarow ◽  
Eric Smith ◽  
Li Liang ◽  
Robert Sutter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
High Volume ◽  
The United States ◽  
Teaching Hospitals ◽  
Large Sample Size ◽  
Stroke Registry ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Us ◽  
Iv Tpa

Background: Many patients are transferred from emergency departments or inpatient units to stroke centers for advanced acute ischemic stroke (AIS) care, especially after intravenous tissue plasminogen activator (tPA). We sought to determine variation in the rates of AIS patient transfer in the US. Methods: Using data from the national Get With The Guidelines-Stroke registry, we analyzed AIS cases from 01/2010 to 03/14. Transfer-in was defined as transfer of AIS patients from other hospitals. Due to large sample size, instead of p-values, standardized differences were reported and a map of transfer-in rates across the US constructed. Results: Of the 970,390 patients discharged from 1,646 hospitals in the US, 87% were admitted via the ER or direct admission (front door) vs. 13% transferred-in. While most hospitals (61%) had transfer-in rates of < 5% of all AIS patients, a minority (17%) had high (>15%) transfer-in rates. High transfer-in hospitals were more often in the Midwest, were larger, and had higher annual AIS and IV tPA case volumes, and were also more often teaching hospitals and stroke centers (primary or comprehensive) (Table and Figure).. IV tPA was used more frequently in eligible patients in high-volume transfer-in hospitals (Table); otherwise, stroke quality of care was similar. Conclusions: There is significant regional- and state-level variability in the transfer of AIS patients. This may reflect differences in resource availability and the distribution of smaller, under-resourced hospitals that frequently transfer patients for advanced care after stabilization. Additional research is warranted to understand this variation.

scholarly journals Endovascular therapy in acute ischemic stroke: The way forward after results from the IMS 3, SYNTHESIS and MR Rescue trials

2013 ◽  
Vol 02 (02) ◽  
pp. 115-118 ◽  
Author(s):  
Bijoy Menon ◽  
Mayank Goyal
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Endovascular Therapy ◽  
Current Status ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

AbstractEndovascular therapy (EVT) has gained vogue in the management of patients with acute stroke. Newer stent-retriever devices have led to better recanalization rates. In many centers, EVT is slowly being used as an add on to or in some instances, even as an alternative to intravenous tissue plasminogen activator (IV tPA). The publication of the results of the SYNTHESIS expansion, Interventional Management of Stroke III and Mechanical Retrieval Recanalization of Stroke Clots Using Embolectomy trials in 2013 has questioned the enthusiastic use of EVT in acute stroke. They demonstrate that EVT (using a variety of devices) is no superior to IV tPA in the management of acute stroke. In the light of these controversial findings, we review the current status of EVT in the management of acute stroke.

Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kerrin Connelly ◽  
Rishi Gupta ◽  
Raul Nogueira ◽  
Arthur Yancey ◽  
Alexander Isakov ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Transport Protocol ◽  
Stroke Patients ◽  
Stroke Registry ◽  
The Public ◽  
State Office ◽  
Stroke Center ◽  
Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Nancy Edwards ◽  
Hooman Kamel ◽  
S. Andrew Josephson
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Aneurysms ◽  
Intravenous Thrombolysis ◽  
Aneurysm Rupture ◽  
Exact Test ◽  
Intravenous Tissue Plasminogen Activator ◽  
Unruptured Cerebral Aneurysms ◽  
Risk Of Hemorrhage ◽  
Iv Tpa

Background and Purpose: Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms. Methods: We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms. Results: We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%). Conclusion: Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.

A Pregnant Woman with Aphasia and Right-Sided Weakness

2017 ◽  
Author(s):  
M. Angela O’Neal
Keyword(s):  
Ischemic Stroke ◽  
Pregnant Woman ◽  
Acute Ischemic Stroke ◽  
Case Series ◽  
Intravenous Tissue Plasminogen Activator ◽  
Common Causes ◽  
Tissue Plasminogen ◽  
Multiple Trials ◽  
Iv Tpa ◽  
In Pregnancy

This chapter discusses the evaluation and management of acute ischemic stroke in pregnancy. Stroke in pregnancy is rare, but is a significant cause of morbidity. The etiologies of stroke in pregnancy are diverse. The most common causes in hospital-based studies are cardioembolic or related to eclampsia. The use of intravenous tissue plasminogen activator (IV tPA) as well as intra-arterial clot retrieval in stroke have been validated by multiple trials. Small case series support the safety of both therapies in pregnancy. Therefore, the management of stroke in pregnancy should be based on the mechanism and severity of the stroke, not on obstetrical issues.

scholarly journals tPA for Acute Ischemic Stroke and Its Controversies: A Review

2019 ◽  
Vol 10 (1) ◽  
pp. 5-10 ◽  
Author(s):  
Brian Dewar ◽  
Michel Shamy
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Historical Context ◽  
Building Blocks ◽  
Medical Community ◽  
Emergency Physicians ◽  
Historical Sources ◽  
Historical Building ◽  
Intravenous Tissue Plasminogen Activator

Background and Purpose:Although neurologists consider intravenous tissue plasminogen activator (tPA) to be standard of care in the treatment of patients with acute ischemic stroke, its use remains contentious within the broader medical community, and particularly among emergency physicians. Why might this be? We provide a historical context to this ongoing controversy by reviewing how neurologists have conceptualized the acute stroke and its treatment, with the aim of bridging this gap.Methods:Based on historical sources in the Mackie Family History of Neuroscience Collection at the University of Calgary, as well as online resources, we trace the evolution of the concept of the “acute stroke,” which has come to mean a stroke that is potentially treatable with tPA. We frame this conceptualization in relation to historical “building blocks” in anatomy, pathology, and physiology. We then use these building blocks to explain why neurologists understand tPA to be effective and why emergency physicians often do not.Results and Conclusions:Arguments against the use of tPA reiterate 20-year-old concerns about its efficacy and safety. We believe these persistent concerns can be framed as a lack of understanding of the “building blocks” upon which neurologists’ conception of tPA is built. Our view suggests that the way forward to bridge the gap between neurology and other disciplines is not to conduct more trials but to offer a shared conceptualization of the trials already completed and of the intellectual tradition from which they emerged.

scholarly journals Graduating neurology residents’ experience with use of intravenous tPA for acute ischemic stroke

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 324-324
Author(s):  
Brett L Cucchiara ◽  
Scott E Kasner
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Patient ◽  
Current Treatment ◽  
Acute Stroke Patient ◽  
Career Plans ◽  
Stroke Team ◽  
Faculty Supervision

45 Background: Intravenous tPA was approved as a treatment for acute ischemic stroke in 1996. One potential barrier to increased use of tPA has been lack of experience and training among neurologists. To date, there has been no formal assessment of neurology residents’ experience with tPA during their training. Methods: A 12 item survey was sent in March 2000 to all graduating neurology residents as identified by AMA-GME files. Follow-up surveys were sent in April and May to non-responders. Survey items established residents’ experience and confidence with assessment of the acute stroke patient and use of tPA. Responses were assessed using a 5 point Likert scale. Presence of a dedicated stroke team, ongoing stroke clinical trials, and post-residency career plans were also assessed. Results: Of 398 graduating residents for whom addresses were available, 287 (72%) responded. 80% of respondents had personally treated a patient with tPA; 33% had done so without direct faculty supervision. 12% had neither treated nor observed a patient being treated with tPA. 89% had cared for an acute stroke patient in the first hours after administration of tPA. 73% felt comfortable independently treating acute stroke patients with tPA. 65% of residents had formal NIHSS training. Nearly all residents felt confident in their ability to identify hemorrhage (99%) and early infarct signs (94%) on CT. Residents whose institutions had a stroke team were more likely to have provided post-tPA care (93% vs 71%, p<0.001), to have had formal NIHSS training (69% vs 44%, p<0.001), and to feel comfortable independently treating patients with tPA (75% vs 62%, p=0.08). There was no association between career plans (academics vs private practice) and any survey items. Conclusion: One fifth of graduating neurology residents had never personally treated an acute stroke patient with tPA; one in ten had never seen tPA administered. One quarter did not feel comfortable independently treating with tPA. Experience with current treatment for acute stroke should be considered an essential part of neurology residency training. Stroke teams may be helpful in accomplishing this goal.

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