Abstract W P211: Clinical Characteristics of Pseudo Negative Cases in Prehospital Triage for Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Shuichi Tonomura
Keyword(s):  
Acute Stroke ◽  
Clinical Characteristics ◽  
Stroke Onset ◽  
The Other ◽  
Small Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Subtypes ◽  
Prehospital Triage ◽  
Prehospital Diagnosis

Objective: The accuracy of prehospital diagnosis for stroke by emergency medical services (EMS) is improved using instruments for symptom recognition. On the other hand, prehospital misdiagnosis for stroke and subsequent delay in presentation to a hospital with stroke expertise play a critical role in the exclusion of potential therapeutic candidates. Our study aims to investigate the clinical characteristics of pseudo-negative cases in prehospital triage for stroke/TIA by EMS. Methods: From April 2013 to April 2014, consecutive 644 acute stroke patients were transferred by EMS to our hospital. We investigated prehospital diagnosis, Cincinnati prehospital stroke scale (CPSS) by EMS, neurological symptoms and complaints of patients themselves at stroke onset. We also examined activity of daily life (ADL) and cognitive impairments before stroke onset, and stroke subtypes in final diagnoses. Results: Among 644 acute stroke patients, 36 patients (22 men, mean 72.5±4.4 years old) were pseudo-negative cases in prehospital triage for stroke and had no abnormalities in CPSS by EMS. When EMS arrived at emergency site, 12 patients (33%) had loss of consciousness. Before stroke onset, 6 patients (17%) had impaired ADL (modified Rankin Scale >2), and 5 (14%) cognitive impairment. Among the stroke subtypes, the proportion of small vessel occlusion (22.4%, p=0.0025) and transient ischemic attack (TIA) (25%, p=0.0021) was significant higher in pseudo negative cases in prehospital triage; on the other hand, intracranial hemorrage (11%, p=0.0028) was lower. In complaint of patients themselves at stroke onset, weakness in one or two extremities was reported in 20 patients (56%), abnormal speech/language in 13 (36%), however all of them were not clarified by EMS. Conclusion: This study showed that small vessel occlusion and TIA tend to be misdiagnosed in a prehospital triage by EMS. The complaint of patients themselves at stroke onset is important to prehospital diagnoses by EMS.

Abstract TP414: Cerebral Infarction After Antithrombotics Withdrawal and Its Impact on Clinical Outcome

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Keonjoo Lee ◽  
Jeong Min Kim ◽  
Keun-Hwa Jung ◽  
Jee-young Han ◽  
Jae-Kyu Roh
Keyword(s):  
Cerebral Infarction ◽  
Acute Stroke ◽  
Clinical Characteristics ◽  
Antiplatelet Agent ◽  
Stroke Onset ◽  
Poor Compliance ◽  
Stroke Outcome ◽  
Stroke Patients ◽  
Common Cause ◽  
Regular Medication

Background: The cessation of antithrombotic agent is related with increased thromboembolic events. However, the clinical characteristics of stroke after antithrombotics withdrawal and its impact on stroke outcome have not been studied. In this study we tried to evaluate clinical significance of antithrombotics withdrawal in stroke occurrence and outcome. Methods: Between January 1 st 2009, and March 1 st 2012, the acute stroke patients who admitted in Seoul National University Hospital within seven days after symptom onset were eligible in the study. We defined stroke after antithrombotics withdrawal (SAW) as those stroke patients who had maintained antiplatelet agent or anticoagulant regularly but ceased their medication before stroke onset. We reviewed their clinical characteristics as well as the reason of medication cessation, type of medication, and duration between medication hold and stroke onset. To evaluate the effect of antithrombotics withdrawal in stroke outcome, we compared SAW with stroke patients which occurred on regular medication. Results: Among 1635 acute stroke patients, 84 patients (5.2%) were identified as SAW during the inclusion period, with a mean age of 68.0±13.2 years including 49 male patients. The most common cause of medication cessation is poor compliance in 32 patients (37.7%), followed by pre-operation/procedure hold in 24, antithrombotics complication in 16, and doctor’s decision in 13. The 42 patients with SAW who had stroke within one month after medication cessation were compared with 261 patients who experienced cerebral infarction during regular medication. Stroke progression defined as 3 or more NIHSS worsening during admission was more prevalent in SAW patients than in patients with regular medication (14.3% vs. 5.0%, p=0.042). The patients with poor functional outcome defined as mRS of 5 and 6 at discharge were more common in SAW than in patients with regular medication (16.7% vs. 6.5%, p=0.043). Conclusion: This study shows that 5.2% of total stroke is due to medication withdrawal, and poor compliance is the most common cause of antithrombotics hold. Stroke after antithrombotics hold is associated with higher rate of stroke progression and poor outcome, implying exacerbated thromboembolic state.

Abstract P186: New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michal Bar ◽  
Martin Cabal ◽  
Ondrej Volny ◽  
Petr Jaššo ◽  
David Holeš ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT, and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes. Methods: In a prospective interventional multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion, and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database. Results: For EVT patients, the median OGT was 213 min in 2015, and 142 min in 2018; and median TT was 118 min in 2015, and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015, and 109 min in 2018; and median TT was 41 min in 2015, and 48 min in 2018. Clinical outcome did not significantly change. The median mRS at 3 months after stroke onset in both 2015 and 2018 was 2 among tPA patients, and 3 among EVT patients. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60% vs 59% in tPA patients, and 40% vs 44% in EVT patients. Conclusions: The new prehospital triage has yielded shorter onset-to-groin times for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

scholarly journals New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

2021 ◽  
Vol 12 ◽  
Author(s):  
Martin Cabal ◽  
Linda Machova ◽  
Daniel Vaclavik ◽  
Petr Jasso ◽  
David Holes ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here, we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes.Methods: In a before/after multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian–Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database.Results: For EVT patients, the median OGT was 213 min in 2015 and 142 min in 2018, and the median TT was 142 min in 2015 and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015 and 109 min in 2018, and the median TT was 41 min in 2015 and 48 min in 2018. Clinical outcome did not significantly change. The percentages of patients with favorable clinical outcome (mRS 0–2) were comparable between 2015 and 2018: 60 vs. 59% in tPA patients and 40 vs. 44% in EVT patients.Conclusions: The new prehospital triage has yielded shorter OGTs for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

Association of CT-Based Hypoperfusion Index With Ischemic Core Enlargement in Patients With Medium and Large Vessel Stroke

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012855
Author(s):  
Ali Z Nomani ◽  
Joseph Kamtchum Tatuene ◽  
Jeremy L Rempel ◽  
Thomas Jeerakathil ◽  
Ian Winship ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Reperfusion Therapy ◽  
Stroke Onset ◽  
Progression Rate ◽  
Stroke Patients ◽  
Infarct Core ◽  
Vessel Occlusion ◽  
Slow Progressors

Objective:The rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium-vessel-occlusion (MeVO) compared to large-vessel-occlusion (LVO) stroke and within a larger time frame since stroke onset.Methods:Core progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core-time criteria, fast progressors had core>70-mL within 6-hours of stroke onset and slow progressors had core ≤70mL, mismatch ≥15mL and mismatch-to-core-ratio ≥1.8 within 6-24-hours. The relationship between HI and infarct core progression (core/time) was examined using receiver-operating-characteristics to determine optimal HI cut-off. The HI cut-off was then tested in overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24-hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 acute ischemic stroke patients.Results:In 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core-time criteria. HI>0.5 was associated with fast progression and able to distinguish fast from slow progressors (AUC=0.94;95%CI=0.80-0.99). In MeVO patients (n=26) HI>0.5 had a core progression of 0.30-mL/min compared to 0.03-mL/min with HI≤0.5 (p<0.001). In LVO patients (n=80), HI>0.5 had a core progression of 0.26-mL/min compared to 0.02-mL/min with HI≤0.5 (p<0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI>0.5 had progression rate of 0.21-mL/min compared to 0.03-mL/min with HI≤0.5 (p<0.001). Validation in a second cohort of patients with acute ischemic stroke (n=110; MeVO n=42, LVO n=68) yielded similar results for HI>0.5 to distinguish fast and slow core progression with an AUC of 0.84(95%CI=0.72-0.97).Conclusions:HI can differentiate fast from slow core progression in MeVO and LVO patients within the first 24-hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of MeVO and LVO stroke patients for reperfusion therapy that warrant further study.

scholarly journals Prehospital triage for endovascular clot removal in acute stroke patients

2016 ◽  
Vol 4 (1) ◽  
pp. 68-74 ◽  
Author(s):  
Yu Suzuki ◽  
Yasuhiro Hasegawa ◽  
Kohtaro Tsumura ◽  
Toshihiro Ueda ◽  
Kazunari Suzuki ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Patients ◽  
Clot Removal ◽  
Prehospital Triage

scholarly journals Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Stefanie Behnke ◽  
Thomas Schlechtriemen ◽  
Andreas Binder ◽  
Monika Bachhuber ◽  
Mark Becker ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Unsolved Problem ◽  
Standard Operating Procedure ◽  
Stroke Management ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Standard Operating ◽  
Los Angeles Motor Scale ◽  
Triage Decisions

Abstract Background The prehospital identification of stroke patients with large-vessel occlusion (LVO), that should be immediately transported to a thrombectomy capable centre is an unsolved problem. Our aim was to determine whether implementation of a state-wide standard operating procedure (SOP) using the Los Angeles Motor Scale (LAMS) is feasible and enables correct triage of stroke patients to hospitals offering (comprehensive stroke centres, CSCs) or not offering (primary stroke centres, PSCs) thrombectomy. Methods Prospective study involving all patients with suspected acute stroke treated in a 4-month period in a state-wide network of all stroke-treating hospitals (eight PSCs and two CSCs). Primary endpoint was accuracy of the triage SOP in correctly transferring patients to CSCs or PSCs. Additional endpoints included the number of secondary transfers, the accuracy of the LAMS for detection of LVO, apart from stroke management metrics. Results In 1123 patients, use of a triage SOP based on the LAMS allowed triage decisions according to LVO status with a sensitivity of 69.2% (95% confidence interval (95%-CI): 59.0–79.5%) and a specificity of 84.9% (95%-CI: 82.6–87.3%). This was more favourable than the conventional approach of transferring every patient to the nearest stroke-treating hospital, as determined by geocoding for each patient (sensitivity, 17.9% (95%-CI: 9.4–26.5%); specificity, 100% (95%-CI: 100–100%)). Secondary transfers were required for 14 of the 78 (17.9%) LVO patients. Regarding the score itself, LAMS detected LVO with a sensitivity of 67.5% (95%-CI: 57.1–78.0%) and a specificity of 83.5% (95%-CI: 81.0–86.0%). Conclusions State-wide implementation of a triage SOP requesting use of the LAMS tool is feasible and improves triage decision-making in acute stroke regarding the most appropriate target hospital.

scholarly journals In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

2020 ◽  
Author(s):  
Juha-Pekka Pienimäki ◽  
Jyrki Ollikainen ◽  
Niko Sillanpää ◽  
Sara Protto
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ordinal Logistic Regression Analysis ◽  
Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Abstract P184: Effect of Acute Stroke Care Hospital Networks in Korea

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jihoon Kang ◽  
Seong Eun Kim ◽  
Hyunjoo Song ◽  
Hee-joon Bae
Keyword(s):  
Network Analysis ◽  
Acute Stroke ◽  
Stroke Care ◽  
The Other ◽  
Care Hospital ◽  
Initial Visit ◽  
Analysis Method ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Hospital Networks

Purpose: Stroke patients generally transport stroke patients either to nearest stroke hospital with secondary transfers or to hub hospitals in selective cases. This study aimed to determine the stroke community of close networks and to evaluate their role for the access the endovascular treatment (EVT). Methods: Using the nationwide acute stroke hospital (ASH) surveillance data assessed the major quality indicators of all stroke patients of South Korea, triage information both initial visit and secondary interhospital transfers were extracted according to the hospitals. Based on them, stroke community with dense linkages were partitioned using the network-based Louvain algorithm. The hierarchical model estimated the function of stroke community for the EVT. Results: For 6-month surveying period, 19113 subjects admitted to the 246 ASHs. Of them, 1831 (9.6%) were transferred from 763 adjacent facilities not ASH, while 1283 (6.7%) from the other ASHs. The algorithm determined the 113 stroke communities where composed median 7 hospitals (2 ASHs and 5 adjacent facilities) and treated about 30 subjects per month. Most of communities formed the spindle shape with higher centralization index and located within 150 Km (Figure). Stroke communities significantly affected 11% of EVT after adjustments. Conclusions: Network analysis method effectively contoured the high centralizing stroke communities and helped the functions on the EVT accessibility.

Abstract TP380: Significant Factors of Early Independent Gait in Acute Ischemic Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Yuna Hosaka ◽  
Takahisa Mori ◽  
Yuki Sawada
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Mmse Score ◽  
Lower Limbs ◽  
Upper Limbs ◽  
Stroke Patients ◽  
Trunk Control ◽  
Stroke Subtypes ◽  
Significant Factors

Introduction: Acute stroke patients have problems with gait disturbance. Independent gait in hospitalized patients is important for early discharge to home. Therefore, we must find factors of disturbing independent gait following acute stroke and intensively treat them. Hypothesis: Impaired trunk control and cognitive function are factors of disturbing early independent gait. Methods: We included acute ischemic stroke patients who were admitted in our hospital from June 2017 to May 2018 and excluded patients with disturbed level of consciousness. We defined a score of 6 (modified Independence) or 7 (complete independence) in the Functional Independence Measure (FIM) as gait independence. We evaluated association of stroke subtypes, Brunnstrom recovery stage (BRS) of upper limbs, fingers and lower limbs, trunk control test (TCT) score and Mini-Mental State Examination (MMSE) score with early gait independence on the 7th day of a stroke onset. Results: One hundred twenty- six patients met our inclusive criteria and we analyzed them. Stroke subtypes had no relation to early gait independence. In gait independent and dependent patients on the 7th day, median BRS score of upper limbs was 5 and 5 (ns), median BRS score of fingers was 5 and5 (ns), median BRS score of lower limbs was 6 and 5 (p<0.01), TCT score was 100and 75 (p<0.01) and MMSE score was 28.5 and 24.5 (p<0.01), respectively. Multiple logistic regression analysis that TCT (p<0.01) and BRS lower limbs (p<0.01) were independent factors for early independent gat. Receiver operating characteristic curve (ROC) for early gait independence demonstrated that cut-off values of TCT score and BRS of lower limbs and were 100 and 5. Conclusions: Impaired trunk control and muscle weakness of lower limbs were significant factors of disturbing early gait independence.

Abstract TP205: Clinical Aspects Of First-ever Stroke In Patients With Permanent Pacemaker

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Jiro Kitayama ◽  
Hiroshi Nakane ◽  
Hiromi Ishikawa ◽  
Masahiro Shijo ◽  
Masahiro Kamouchi ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Pacemaker Implantation ◽  
The United States ◽  
Permanent Pacemaker ◽  
Stroke Onset ◽  
Clinical Aspects ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Stroke Registry ◽  
History Of

OBJECTIVES: Recently, increasing numbers of patients take pacemaker implantation: almost sixty thousands in Japan, and no less than two hundreds of thousands in the United States per year. Previous reports have indicated that prevalence of atrial fibrillation (Af) is high, and several coagulation markers are elevated in those with pacemaker. However, the precise features of stroke with implanted device are not clear. We, thus, examined the clinical aspects of stroke in pacemaker patients. METHODS: For the present study, we analyzed data from the Fukuoka Stroke Registry that is a multicenter epidemiological study database on acute stroke. From June 1999 to May 2011, 11376 ischemic stroke patients (72±12 years of age, female/male=4613/6763) who admitted to the hospital within seven days after onset were enrolled in the registry. Stroke subtypes were classified according to the diagnostic criteria of TOAST (Trial of Org 10172 in Acute Stroke Treatment). RESULTS: A total of 207 patients (1.8% of registered stroke patients) were with pacemaker. Among them, 130 patients had no history of any stroke. They appeared to be a mean age of 81±9 (range 42 to 97) years, and female/male ratio of 77/53. Mean duration from pacemaker implantation to stroke onset was 8±7 (median 6, quartile 3-11) years. 32 patients (25%) were given oral anticoagulant prior to stroke onset; 60 (46%) were on antiplatelet. Prevalence of Af in pacemaker patients was 48% (n=63). In those with Af, 48 patients (76%) were diagnosed as cardioembolic stroke, but only 22 (35%) were on anticoagulation before onset. Even in those without Af, 33 cases (49%) were also diagnosed as cardioembolic. The percentage of subjects with increased plasma D-dimer (≥1.5 μg/ml) was significantly higher in pacemaker group than no-pacemaker group, regardless of the presence or absence of Af (75% vs. 45% with Af; p<0.0001, 74% vs. 25% without Af; p<0.0001). CONCLUSIONS: In our current study, stroke in pacemaker patients revealed to have higher incidence of cardiogenic embolism, with or without Af. In addition, the majority was elderly, and failed to receive anticoagulant prior to stroke. It is needed to re-consider therapeutic strategy, including anticoagulation, for prevention of stroke in those with permanent pacemaker.

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