Abstract 115: Improving Door-to-Needle Times in Acute Ischemic Stroke: Interim Findings From Target: Stroke Phase II

Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014. Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression. Results: There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure). Conclusions: The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.

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Abstract 86: Progress in Achieving More Rapid Door-to-Needle Times in Acute Ischemic Stroke: Interim Findings From Target: Stroke Phase II

Stroke ◽

10.1161/str.48.suppl_1.86 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Gregg C Fonarow ◽

Margueritte Cox ◽

Eric Smith ◽

Jeffrey Saver ◽

Mat Reeves ◽

...

Keyword(s):

Ischemic Stroke ◽

Phase I ◽

Acute Ischemic Stroke ◽

Phase Ii ◽

Best Practice ◽

Patient Characteristics ◽

Clinical Decision ◽

Absolute Difference ◽

Rate Of Increase ◽

Support Tools

Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent and hospitals participating in Target: Stroke have substantially improved the proportion of patients being treated with door-to-needle (DTN) times of ≤60 minutes. However, very few patients were treated with DTN times of ≤45 or ≤30 minutes during Target: Stroke Phase I (2010-2013). This study aims to assess whether there have been greater achievement of DTN times ≤45 and ≤30 minutes since the launch of Target: Stroke Phase II in Q2 2014. Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤45 and ≤30 minutes were compared prior to Target: Stroke (2003-2009), during Phase I (2010-2013), and during Phase II (Q2 2014-present) by weighted linear regression. Results: There were 131,166 intravenous tPA treated patients from 1397 GWTG-Stroke hospitals. Patient characteristics were similar during the study periods. Median DTN time declined from Phase I to Phase II: 66 minutes (IQR 51-87) to 54 minutes (IQR 41-71) and % of patients with DTN times ≤60 minutes increased from 42.0% to 62.7%, (P<0.0001). The % of patients with DTN times ≤45 minutes increased from Phase I to Phase II: 17.3% to 33.9%, absolute difference +16.6%, (P<0.0001). The % of patients with DTN times ≤30 minutes also increased from Phase I to Phase II: 4.1% to 10.3%, absolute difference +6.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤45 minutes was 0.25% per year pre-Target Stroke, 3.5% per year during Phase I, and 7.7% per year during Phase II (P<0.0001) (Figure). Conclusions: There has been accelerating progress in achieving more rapid DTN times for tPA administration among GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, opportunities remain to further improve the timeliness of care and clinical outcomes.

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Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2

Cerebrovascular Diseases ◽

10.1159/000514369 ◽

2021 ◽

Vol 50 (4) ◽

pp. 397-404

Author(s):

Kotaro Tatebayashi ◽

Kazutaka Uchida ◽

Hiroto Kageyama ◽

Hirotoshi Imamura ◽

Nobuyuki Ohara ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Characteristics ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Tandem Occlusion ◽

The Mean ◽

Patient Prognosis

Introduction: The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. Results: Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1–5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30–0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42). Discussion/Conclusion: The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

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Abstract TP251: Onset-to-Door Times and Means of Transportation for Acute Ischemic Stroke Patients Attending a Public Hospital in Bogota DC, Colombia. Is an Ambulance the Fastest Way to Reach the Hospital?

Stroke ◽

10.1161/str.47.suppl_1.tp251 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Javier Vicini-Parra ◽

Jenny Ospina ◽

Cristian Correa ◽

Natalia Gomez ◽

Stephania Bohorquez ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Public Transportation ◽

Public Hospital ◽

Descriptive Analysis ◽

First Year ◽

Stroke Patients ◽

Health Authorities ◽

Public Health Authorities ◽

Ischemic Attack

Introduction: A prospective stroke database was implemented as part of a still-growing comprehensive stroke centre (CSC). This CSC is located within a referral public hospital (Hospital Occidente de Kennedy) in Bogota DC, Colombia , that serves 2.3 million people of mainly low economic income. In this abstract, we present the data pertaining patients who were thrombolysed in our institution during the first year of data collection, and specify onset-to-door (OTD) times as they relate to the means of transportation used. Hypothesis: Acute stroke patients who arrive in ambulance have the shortest onset-to-door times. Methods: Printed forms were filled for every patient who arrived with diagnosis of acute ischemic stroke (AIS) or transient ischemic attack (TIA). Data was transcribed to an electronic database (Numbers, Apple Inc.) and analyzed with SPSS Statistics version 23 (IBM Corporation). A retrospective descriptive analysis was performed for central tendency and dispersion measures. Results: Since August 1st 2014 until July 31st 2015, 39 patients (17.7% of AIS patients) were thrombolysed. Mean onset-to-door times are shown in table 1. Prenotification was received for only 1 patient. All patients came from their homes. Conclusions: Almost half of our thrombolysed patients arrived in taxi to our institution. Taxi was the fastest means of transportation, ambulance was the slowest and private cars were in the middle of those. This confirmed our suspicion that the state-owned emergency medical services (SEMD) are suboptimal and that stroke patients prefer to use public transportation rather than SEMD. This should warn public health authorities on he urgent need to improve our SEMD. In the meantime, this finding prompts us to include taxi drivers in our periodic stroke campaigns.

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Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention

Stroke ◽

10.1161/strokeaha.121.035853 ◽

2021 ◽

Author(s):

Ying Xian ◽

Haolin Xu ◽

Eric E. Smith ◽

Jeffrey L. Saver ◽

Mathew J. Reeves ◽

...

Keyword(s):

United States ◽

Quality Improvement ◽

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Phase I ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

The United States

Background and Purpose: The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. Methods: We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010–2013) and Target: Stroke Phase II (2014–2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Results: Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60–98) preintervention, to 66 minutes (51–87) during Phase I, and 50 minutes (37–66) during Phase II ( P <0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% ( P <0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% ( P <0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014–2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31–2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64–0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62–0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38–1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. Conclusions: A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

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Outcome of Patients with Acute Ischemic Stroke in the First Year after the Establishment of a Stroke Care Unit

Nihon Ika Daigaku Igakkai Zasshi ◽

10.1272/manms.4.96 ◽

2008 ◽

Vol 4 (2) ◽

pp. 96-105

Author(s):

Yuichi Komaba ◽

Nobuto Nakajima ◽

Kouichi Nomura ◽

Genki Mizukoshi ◽

Eiko Sunami ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Care ◽

First Year

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Intra-Arterial Bone Marrow Mononuclear Cells (BM-MNCS) Transplantation in Acute Ischemic Stroke (IBiS Trial): Protocol of a Phase II, Randomized, Dose-Finding, Controlled Multicenter Trial

International Journal of Stroke ◽

10.1111/ijs.12520 ◽

2015 ◽

Vol 10 (7) ◽

pp. 1149-1152 ◽

Cited By ~ 27

Author(s):

Francisco Moniche ◽

Irene Escudero ◽

Elena Zapata-Arriaza ◽

María Usero-Ruiz ◽

María Prieto-León ◽

...

Keyword(s):

Bone Marrow ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Phase Ii ◽

Mononuclear Cells ◽

Multicenter Trial ◽

Dose Finding ◽

Bone Marrow Mononuclear Cells ◽

Trial Protocol

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Abstract T P260: Confirmation: The Target Stroke Best Practice Strategies Work

Stroke ◽

10.1161/str.46.suppl_1.tp260 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Nojan Valadi ◽

Alexis Thomas

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Process Improvement ◽

Best Practice ◽

Stroke Patients ◽

High Performers ◽

Process Implementation ◽

Honor Roll ◽

Stroke Team ◽

Stroke Center

Background: A recent national push for optimizing stroke center performance led by the efforts of AHA/ASA to recognize high performers with the Target Stroke Honor Roll recognition have focused on achieving expedited treatment for stroke with door-to-needle (DTN) time of ≤60 minutes.Our organization recognized the need to optimize our performance and set an initial goal of achieving DTN time of ≤60 minutes in greater than 50% of our patients. The Target Stroke Initiative by the AHA/ASA identified 10 key strategies for best practice associated with reducing DTN times. Our organization adopted and implemented all of these strategies over a 30-day period. Methods: The Target Stroke best practice strategies were implemented over a 30-day period, and the Stroke Team worked collaboratively to identify other weaknesses needing to be addressed. DTN times ≤60 minutes from the 12 months prior to process improvement implementation were compared with the first 2 months post implementation. Results: There were 345 ischemic stroke patients treated at our facility during the 12 month period prior to the process implementation, with a total of 14 patients (1.12 per month) treated with tPA. The percentage of patients treated with tPA was 4%, and the percentage of patients treated with DTN ≤60 minutes was 0%. Over the two months following process implementation, 68 ischemic stroke patients were treated at our facility, with 11 patients treated with tPA (5.5 per month). The percentage of stroke patients treated with tPA was 16%, with 70% of patients treated with DTN ≤60 minutes. Conclusion: This study serves as confirmation that collaboration and implementation of the 10 key strategies for best practice as outlined by the Target Stroke Initiative, coupled with changes to identified areas of weakness, can improve and expedite the care of patients with acute ischemic stroke. This can substantially improve DTN times, as well as the overall number and percentage of patients that receive thrombolysis with a hopeful impact on their outcome as well as Target Stroke Honor Roll recognition for the facility. In conclusion, we recommend implementation of these best practice strategies to other facilities.

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Abstract T P26: Combining Clinical and Imaging Data to Develop a Highly Predictive Model of Outcomes in the MR RESCUE Trial

Stroke ◽

10.1161/str.46.suppl_1.tp26 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Chelsea S Kidwell ◽

Reza Jahan ◽

Jeffrey Gornbein ◽

Jeffry R Alger ◽

Val Nenov ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Patient Characteristics ◽

Hemorrhagic Transformation ◽

Imaging Data ◽

Vascular Events ◽

Vessel Occlusion ◽

Intermediate Variables ◽

Core Volume

Background: Identifying patient characteristics that predict outcomes in acute ischemic stroke may assist in triaging those who are candidates for endovascular therapies. We sought to identify predictors of outcome in the overall Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) cohort and compare results to the previously validated Totaled Health Risks in Vascular Events (THRIVE) score. Methods: MR RESCUE randomized 118 acute ischemic stroke patients with multimodal imaging to embolectomy or standard care within 8 hours of onset. For this analysis, we investigated 17 baseline variables (e.g. age, predicted core volume, time to enrollment) and 8 intermediate variables (e.g. hemorrhagic transformation, day 7 recanalization, final infarct volume) with the potential to impact outcomes (day 90 mRS). The baseline variables were analyzed employing bivariate and multivariate methods (random forest and logistic regression). Two models were developed, one including only significant baseline variables, and the second also incorporating significant intermediate variables. Results: A multivariate model (Table) employing only baseline covariates achieved an overall accuracy (C statistic) of 85% in predicting poor outcome (day 90 mRS 3-6) compared to 80.5% for the THRIVE score. A second model (Table) adding significant intermediate variables achieved 89% accuracy in predicting day 90 mRS. Conclusions: In the MR RESCUE trial, advanced imaging variables, including predicted core volume and site of vessel occlusion, contributed to a highly accurate multivariable model of outcome. In the development phase, this model achieved higher accuracy than the THRIVE score. Future studies are needed to validate this model in an independent cohort.

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Association between acute ischemic stroke etiology and macroscopic aspect of retrieved clots: is a clot’s color a warning light for underlying pathologies?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-014905 ◽

2019 ◽

Vol 11 (12) ◽

pp. 1197-1200 ◽

Cited By ~ 2

Author(s):

Alessandro Sgreccia ◽

Zoé Duchmann ◽

Jean Philippe Desilles ◽

Bertrand Lapergue ◽

Julien Labreuche ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Infective Endocarditis ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Patient Characteristics ◽

Study Groups ◽

Double Blind ◽

Stroke Etiology

BackgroundFew case reports have considered the chromatic aspect of retrieved clots and the possible association with their underlying etiology.ObjectiveThe aim of our study was to analyze the frequency of the TOAST ischemic stroke typical (atrial fibrillation, dissection, atheroma) and atypical (infective endocarditis, cancer-related, valve-related thrombi) etiologies depending on the chromatic aspect of retrieved clots.MethodsA total of 255 anonymized and standardized clot photos of consecutive patients treated by mechanical thrombectomy for acute ischemic stroke were included. A double-blind evaluation was performed by two senior interventional neuroradiologists, who classified the visual aspects of the clots into two main patterns: red/black or white. Main patient characteristics, distribution of underlying stroke etiologies, and outcomes were compared between the two study groups.ResultsThe inter-reader agreement for clot colors was excellent (k=0.78). Two hundred and thirty-three patients were classified as having red/black clots and 22 as having white clots. A statistically significant association (p=0.001) between atypical etiologies and white clots was observed.ConclusionsWhite clots were significantly associated with atypical etiologies in this cohort,in particular, with infectious endocarditis.

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