Abstract 26: RACE to Treat Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Andrea M Korsnack ◽  
Andrea Adams
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Arterial Occlusion ◽  
First Responders ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Artery ◽  
Stroke Patients ◽  
Conversion Disorders

Background: Endovascular treatment was shown to drastically improve stroke patient outcomes but earlier identification of eligible patients is crucial. First responders are instrumental to the rapid identification and transportation of stroke patients to the nearest appropriate facility for acute stroke care especially when endovascular intervention is an option. Purpose: To develop and evaluate the effectiveness of an algorithm for first responders to use to differentiate which stroke patients should be transported to the closest Interventional Stroke Center for treatment. Method: We revised the County-Level Emergency Medical Services (EMS) protocol and algorithm to include the Rapid Arterial oCclusion Evaluation (RACE) scale in addition to the Cincinnati Prehospital Stroke Scale (CPPS). Together these simple in-the-field scales assess stroke severity and identify patients with acute stroke and large artery occlusion in a prehospital setting. Lucas County EMS staff received a four hour block of continuing education with credit on acute stroke, the updated protocol and algorithm, and use of the new RACE scale in addition to the CPPS. Effectiveness of the training and use of the RACE alert was measured by the percent of patients accurately identified with and without large artery occlusion. Results: Training was provided to 450 EMS staff in several in-person sessions in June 2015. The RACE protocol went citywide on July first. Of the 18 patients brought in to our hospital by EMS in July using the RACE protocol, 72% were identified correctly using the tool. Of these, 6 were identified correctly as having large vessel occlusions and 7 were correctly identified as not having large vessel occlusions. The remaining 5 patients transported by EMS were identified as large vessel occlusions, but were not found to have strokes (seizures, intoxication, and conversion disorders). Conclusion: Our data suggests that first responders can accurately differentiate between which stroke patients could benefit from endovascular treatment using a simple algorithm. Future evaluation could measure the relationship between accurate pre-hospital identification and treatment rates.

scholarly journals Transfer to the Local Stroke Center versus Direct Transfer to Endovascular Center of Acute Stroke Patients with Suspected Large Vessel Occlusion in the Catalan Territory (RACECAT): Study protocol of a cluster randomized within a cohort trial

2019 ◽  
Vol 14 (7) ◽  
pp. 734-744 ◽  
Author(s):  
Sònia Abilleira ◽  
Natalia Pérez de la Ossa ◽  
Xavier Jiménez ◽  
Pere Cardona ◽  
Dolores Cocho ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Arterial Occlusion ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Center ◽  
Cluster Randomized

Rationale Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion have not been assessed in randomized trials. Aim To establish whether stroke subjects with rapid arterial occlusion evaluation scale based suspicion of large vessel occlusion evaluated by emergency medical services in the field have higher rates of favorable outcome when transferred directly to an endovascular center (endovascular treatment stroke center), as compared to the standard transfer to the closest local stroke center (local-SC). Design Multicenter, superiority, cluster randomized within a cohort trial with blinded endpoint assessment. Procedure Eligible patients must be 18 or older, have acute stroke symptoms and not have an immediate life threatening condition requiring emergent medical intervention. They must be suspected to have intracranial large vessel occlusion based on a pre-hospital rapid arterial occlusion evaluation scale of ≥5, be located in geographical areas where the default health authority assigned referral stroke center is a non-thrombectomy capable hospital, and estimated arrival at a thrombectomy capable stroke hospital in less than 7 h from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with three strata: day/night, distance to the endovascular treatment stroke center, and week/week-end day. Study outcome The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is mortality at 90 days. Analysis The primary endpoint based on the modified intention-to-treat population is the distribution of modified Rankin Scale scores at 90 days analyzed under a sequential triangular design. The maximum sample size is 1754 patients, with two planned interim analyses when 701 (40%) and 1227 patients have completed follow-up. Hypothesized common odds ratio is 1.35.

scholarly journals Prehospital Acute Stroke Severity Scale to Predict Large Artery Occlusion

Stroke ◽  
2016 ◽  
Vol 47 (7) ◽  
pp. 1772-1776 ◽  
Author(s):  
Sidsel Hastrup ◽  
Dorte Damgaard ◽  
Søren Paaske Johnsen ◽  
Grethe Andersen
Keyword(s):  
Acute Stroke ◽  
Artery Occlusion ◽  
Stroke Severity ◽  
Large Artery ◽  
Severity Scale

Abstract WP439: Who Benefits From CT-Angiography Previous Intravenous Thrombolysis?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Pedro Cardona ◽  
Helena Quesada ◽  
Blanca Lara ◽  
Nuria Cayuela ◽  
Paloma Mora ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Clinical Group ◽  
Large Artery ◽  
Characteristic Analysis ◽  
Vessel Occlusion ◽  
Significant Difference ◽  
Distal Migration

Background: Endovascular treatment (EVT) is an effective treatment in strokes with persistent large artery occlusion despite previous intravenous thrombolisis (IVT) as rescue treatment. Performing computer tomography angiography (CTA) before IVT could allow early activation of neurointerventional teams; however routine CTA could delay unnecessary door-to-needle time of IVT and may be infeasible. Methods: We reviewed stroke code activations between May 2011 and June 2015 in our comprehensive stroke center and divided into groups based on NIHSS and patency of arterial occlusion according to non-enhanced CT on admission (dense artery sign or dot sign) and baseline CTA. We assessed patients treated with IVT and selected to EVT according to results in CTA post-IVT. We analyze percentage of recanalization or migration of thrombus after IVT alone and variables associated to successful treatment. Results: Of 2856 stroke codes registered during the study period 1810 were diagnosis of ischemic strokes. We treated 520 patients with IVT, 202 had a radiological evidence of large artery occlusion (55%M1, 32% M2, 5%TICA, 5%ICA, 3% basilar). Thirty-two percent of patients showed changes in CTA carried out after IVT(17% successfully recanalized, 15% distal migration of thrombus) so they were not selected to endovascular treatment. There were significant difference between M1 and M2 occlusion regarding changes in CTA after IVT (23% vs 70%; p<0.001). In multivariate logistic regression a baseline score NIH<10 was associated with higher percentage of recanalization with rtPA despite signs of large vessel occlusion (78% vs 32%; p:0.001). In receiver operating characteristic analysis higher baseline NIH was associated with persistent occlusion after IVT (area under curve=0.79;95% CI, 0.6-0.9; P:0.001) with optima threshold of 10 ( Sensivity 84%, Specificity 74%). Conclusions: We consider defer CTA angiography until after IVT in stroke code patients with moderate clinical impairment (NIH<10) or M2-segment occlusion, because they achieve a high percentage of arterial recanalization. CTA previous IVT could be unnecessary, provide unreliable information and delay IVT in that clinical group but could be useful to plan EVT in patients with higher NIH scores.

DEVT: A randomized, controlled, multicenter trial of direct endovascular treatment versus standard bridging therapy for acute stroke patients with large vessel occlusion in the anterior circulation – Protocol

2020 ◽  
pp. 174749302092534
Author(s):  
Zhongming Qiu ◽  
Hansheng Liu ◽  
Fengli Li ◽  
Weidong Luo ◽  
Deping Wu ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Multicenter Trial ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Randomized Controlled

Background Eight randomized controlled trials have consistently shown that endovascular treatment plus best medical treatment improves outcome after acute anterior proximal intracranial large vessel occlusion strokes. Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation, large vessel occlusion is of any additional benefits remains unclear. Objective This study compares the safety and efficacy of direct endovascular treatment versus intravenous recombinant tissue-type plasminogen activator bridging with endovascular treatment (bridging therapy) in acute stroke patients with intracranial internal carotid artery or middle cerebral artery-M1 occlusion within 4.5 h of symptom onset. Methods and design The DEVT study is a randomized, controlled, multicenter trial with blinded outcome assessment. This trial uses a five-look group-sequential non-inferiority design. Up to 194 patients in each interim analysis will be consecutively randomized to direct endovascular treatment or bridging therapy group in 1:1 ratio over three years from about 30 hospitals in China. Outcomes The primary end-point is the proportion of independent neurological function defined as modified Rankin scale score of 0 to 2 at 90 days. The primary safety measure is symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. Trial registry number ChiCTR-IOR-17013568 ( www.chictr.org.cn ).

Abstract WP441: Association Between Troponin Levels and Embolic Stroke of Undetermined Source

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Alexander E Merkler ◽  
Gino Gialdini ◽  
Santosh Murthy ◽  
Peter M Okin ◽  
Costantino Iadecola ◽  
...  
Keyword(s):  
Risk Factors ◽  
Sensitivity Analysis ◽  
Acute Stroke ◽  
Univariate Analysis ◽  
Vascular Risk Factors ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Artery ◽  
Vascular Risk ◽  
Elevated Troponin

Background: Asymptomatic elevations in serum troponin levels often occur in patients with acute ischemic stroke. We evaluated whether patients with embolic strokes of undetermined source (ESUS) have higher rates of asymptomatic elevated troponin than patients with small- or large-vessel strokes. Methods: The Cornell AcutE Stroke Academic Registry (CAESAR) prospectively enrolled all adults with acute stroke at Weill Cornell Medical Center from 2011 to 2014. The etiology of stroke was retrospectively ascertained by two independent neurologists, with a third resolving any disagreements. We included patients with ESUS and, as controls, those with small- or large-vessel strokes. We defined an asymptomatic troponin elevation as a value exceeding our laboratory’s upper limit (0.04 ng/mL) within 24 hours of presentation, in the absence of a clinically recognized acute myocardial infarction. We used the chi-square test to compare rates of elevated troponin in patients with ESUS versus controls. Multiple logistic regression was used to evaluate the association between ESUS and elevated troponin after adjustment for demographics, NIH Stroke Scale score, insular infarction, and vascular risk factors. In a sensitivity analysis, we excluded patients diagnosed with atrial fibrillation during ambulatory heart-rhythm monitoring. Results: Among 547 patients, 258 (47.3%) had ESUS and 285 (52.7%) had a small- or large-vessel stroke. Patients with ESUS were younger (mean age 65.7 vs. 69.6 years) and more often female, and had equally severe strokes, higher rates of insular infarctions, and fewer vascular risk factors. In univariate analysis, patients with ESUS more often had an elevated troponin than controls (14.7% versus 8.0%; P = 0.01). After adjustment for demographics, stroke severity, insular involvement, and vascular risk factors, ESUS remained associated with elevated troponin (OR, 2.44; 95%, 1.04-5.77). This result was unchanged in our sensitivity analysis. Conclusions: Elevations in serum troponin appear to be more common in patients with ESUS than in those with small- or large-artery strokes. Further research is required to understand the pathogenesis and significance of elevated troponin in patients with ESUS.

Abstract W P8: "Double Trouble": Endovascular Treatment of Tandem Arterial Occlusions in Acute Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Mikayel Grigoryan ◽  
Diogo Haussen ◽  
Andrey Lima ◽  
Jonathan Grossberg ◽  
Shannon Doppelheuer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Imaging Data ◽  
Stroke Patients ◽  
Symptomatic Intracerebral Hemorrhage

Background: Tandem extracranial/intracranial arterial occlusions in acute stroke present treatment challenges both due to suboptimal response to systemic intravenous thrombolysis as well as complex endovascular approach. We report our experience in treating this cohort of acute stroke patients with the analysis of angiographic and clinical outcomes Materials and Methods: We retrospectively reviewed clinical and imaging data of all consecutive acute stroke patients with proximal intracranial arterial occlusion and additional extracranial occlusion/critical stenosis, treated with endovascular techniques between February 2011 and February 2014 at two hospitals. We analyzed patients’ demographics, clinical presentation, treatment strategies, time to recanalization, imaging and clinical outcomes. Results: A total of 66 patients were included. The mean NIHSS on presentation was 19. Extracranial carotid with concomitant intracranial anterior circulation occlusions were present in 95% of the patients (63/66), while 5% (3/66) had tandem vertebrobasilar occlusions. 41% of the patients (27/66) received intravenous rt-PA. With regards to endovascular treatment, in 70% of the cases (46/66), extracranial lesion was treated with a stent placement. Stentrievers were used in 50% (33/66) of the patients for intracranial thrombectomy. Thrombolysis in Cerebral Infarction (TICI) >= 2B reperfusion was achieved in 77% of all the patients (51/66) and in 97% (32/33) of the stentriever patients. Good clinical outcome at 90 days (mRS<=2) was seen in 42% of the patients. Symptomatic intracerebral hemorrhage (PH-2)occurred in 9% (6/66) of the patients. Conclusions: Endovascular treatment of tandem arterial occlusions in acute ischemic stroke is relatively safe, feasible, and may yield excellent angiographic and good clinical outcomes.

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