Abstract TP30: Risks and Benefits of Bypassing the Emergency Department for Ischemic Stroke Transferred in for Acute Endovascular Therapy

Background and Purpose: Minimizing time from symptom onset to recanalization is crucial to maximizing outcome. Approaches to save time in ET cases including processes to reduce door-to-recanalization times need to be explored. Methods: We performed a retrospective review of consecutive ischemic stroke patients transferred to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. We compared adverse events (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia), door-to-recanalization time, and short-term outcomes in patients that were evaluated in the emergency department (ED) prior to ET and patients that were transferred directly to the endovascular suite, bypassing the ED. Results: Among the 776 consecutive ischemic stroke patients admitted to our center during the 14-month period, 7% (n=49) received acute ET. Twenty-six of these patients (53%) were transferred to our CSC for ET. Among transfers, 58% (n=15) bypassed the ED. Patients that bypassed the ED had a higher frequency of adverse events (53% vs. 27%, p=0.246), but shorter arrival to recanalization times when compared to patients that did not skip the ED (median 89 vs. 109 minutes p=0.637). Poor functional outcome, as measured by modified Rankin scale (mRS) score of 4-6, was similar between groups (67% vs. 64%, p=1.000), but in-hospital mortality was more frequent in the ED bypass group (33% vs. 18%, p=0.658). Conclusions: In our sample of acute ischemic patients transferred for acute ET, nearly 60% of patients bypassed the ED, reducing time to recanalization. This time savings was associated with a clinically higher proportion of adverse events. Standardized protocols for patients transferred to acute ET are needed to reduce time to recanalization without increasing adverse event rates.

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Abstract WP378: Use of Code Head Bleed to Promote Hemorrhagic Stroke Awareness in the Emergency Department

Stroke ◽

10.1161/str.48.suppl_1.wp378 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Candace J McAlpine ◽

Rocio Garcia ◽

Pablo Rojas

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Patient Care ◽

Stroke Patient ◽

Hemorrhagic Stroke ◽

Stroke Patients ◽

Care Coordinator ◽

Staff Members ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Purpose: Providers recognize the need for quick recognition and allocation of resources when ischemic stroke patients arrive at the emergency department. Hemorrhagic stroke patients have not been always given the same priority. One Comprehensive Stroke Center noticed a deficiency in timely recognition, documentation and mobilization of resources for hemorrhagic stroke patients. The initiation of “code head bleed” in the emergency department was created to correct this deficiency. The purpose of this study was to bring awareness and education to the team initially caring for the hemorrhagic stroke patient. Methods: Using Lean methodology, to bring about quality patient care while reducing wasted time, the “code head bleed” was born. Education was provided for all emergency department staff members and physicians regarding “code head bleed.” When a code head bleed notification is paged out it mobilizes all required resources to the patient’s bedside (Faculty physician, Medical Resuscitation team, Patient Care Coordinator, Respiratory Therapy, Stroke Coordinators and Emergency Department leadership). Results: Since its inception in May, the “code head bleed” is the most used code notification in the hospital (n=163 ), surpassing ischemic stroke alerts (n= 89 ) in the same period. An increase of traumatic hemorrhages has been noticed since they are also included in the notification; which has led to an increased awareness in this population of patients as well. Code head bleed has improved neuro-check documentation by 21 % and documentation of vasoactive drip titration by 15% in the hemorrhagic stroke population. Conclusions: In conclusion, having all essential staff, services and resources lends to optimizing the hemorrhagic stroke patient’s care. The “code head bleed” initiative has been attributed to an increased awareness of the needs of the hemorrhagic stroke patient in the emergency department and an improvement in the documentation of care provided.

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Abstract 3313: Outcomes of “Drip-and-Ship” Paradigm Among Patients with Acute Ischemic Stroke. Results of a State Wide Study

Stroke ◽

10.1161/str.43.suppl_1.a3313 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Saqib A Chaudhry ◽

Gustavo J Rodriguez ◽

M. Fareed K Suri ◽

Adnan I Qureshi

Keyword(s):

Ischemic Stroke ◽

Recombinant Tissue Plasminogen Activator ◽

Population Based ◽

Primary Diagnosis ◽

Hospital Charges ◽

Stroke Patients ◽

Frequency Distributions ◽

Number Of Patients ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: “Drip-and-ship” denotes patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 hours to a comprehensive stroke center. Although drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population based level. Methods: State-wide estimates of thrombolysis, associated in-hospital outcomes and mortality were obtained from 2008-2009 Minnesota Hospital Association (MHA) data. Patient numbers and frequency distributions were calculated for state-wide sample of patients hospitalized with a primary diagnosis of ischemic stroke. Patients outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. Results: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n=473) or drip-and-ship paradigm (n=129). The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with drip-and-ship paradigm (8.5% versus 3.1, p=0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or drip-and-ship paradigm (5.9% versus 7.0%). The mean hospital charges were $65,669 for primary ED arrival and $47,850 for drip-and-ship treated patients (p<0.001). Conclusions: The results of drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this state-wide study.

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Abstract 83: Etiology of Late Right-to-Left Shunting on Transcranial Doppler in Ischemic Stroke Patients

Stroke ◽

10.1161/str.48.suppl_1.83 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Adam de Havenon ◽

Anne Moore ◽

Nicholas Freeberg ◽

Ali Sultan-Qurraie ◽

David Tirschwell

Keyword(s):

Ischemic Stroke ◽

Transcranial Doppler ◽

Inclusion Criteria ◽

Contrast Injection ◽

Stroke Patients ◽

Stroke Etiology ◽

Standard Component ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Toast Classification

Background: An echocardiogram or transcranial Doppler (TCD) bubble study to test for a right-to-left shunt (RLS) is a standard component of an ischemic stroke workup. Because the pathway for an intracradiac RLS, such as a patent foramen ovale (PFO), is more direct, it has been proposed that the late appearance of a RLS suggests an extracardiac pathway. We sought to characterize a cohort of ischemic stroke patients with late RLS (LRLS) on TCD. Methods: We searched the medical record of a Comprehensive Stroke Center for patients with ischemic stroke who had a TCD and echocardiogram bubble study during 2011-2013. LRLS was defined as TCD bubbles appearing more than 18 cardiac cycles after contrast injection. TOAST stroke etiology classification was performed by a vascular neurologist blinded to TCD results. Results: 124 patients met inclusion criteria, of which 67/124 (54%) had RLS on TCD; and 32/67 (48%) had LRLS. In the 35/67 patients with normal RLS on TCD, 23% did not have RLS on echocardiography, consistent with prior reports of TCD’s superiority for detecting RLS. In the 32/67 patients with LRLS on TCD, 56% were negative for RLS by echocardiography. In the cohort of 124 patients, the percentage of TOAST classification 4 (stroke of other determined cause) was 26%, while in the 32 patients with LRLS the percentage of TOAST 4 was significantly higher at 52%(p=0.005) (Table 1). The increase in TOAST 4 in LRLS patients was created by an even distribution of decreases in the other TOAST categories. The most common TOAST 4 stroke etiology in LRLS patients was PFO with concurrent deep venous thrombosis. Conclusion: This preliminary data supports prior studies that have shown superiority of TCD over echocardiography for detection of RLS, and challenge the prevailing notion that extracardiac shunt, such as pulmonary AVM, is the most common cause of LRLS in ischemic stroke patients. This subgroup of patients warrants further research to clarify mechanisms of ischemic stroke in patients with RLS.

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Mandatory Neuroendovascular Evolution: Meeting the New Demands

Interventional Neurology ◽

10.1159/000495075 ◽

2018 ◽

Vol 8 (1) ◽

pp. 69-82

Author(s):

Mohammad El-Ghanem ◽

Francisco E. Gomez ◽

Prateeka Koul ◽

Rolla Nuoman ◽

Justin G. Santarelli ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Endovascular Intervention ◽

Stroke Patients ◽

Hub And Spoke ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

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Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2016.09.008 ◽

2017 ◽

Vol 26 (1) ◽

pp. 192-195 ◽

Cited By ~ 12

Author(s):

Thomas V. Kodankandath ◽

Paul Wright ◽

Paul M. Power ◽

Marcella De Geronimo ◽

Richard B. Libman ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Transfer Times

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National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010–2016

International Journal of Stroke ◽

10.1177/1747493019884526 ◽

2019 ◽

pp. 174749301988452 ◽

Cited By ~ 1

Author(s):

Akiko Kada ◽

Kuniaki Ogasawara ◽

Takanari Kitazono ◽

Kunihiro Nishimura ◽

Nobuyuki Sakai ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Temporal Trends ◽

Stroke Severity ◽

Stroke Patients ◽

Poor Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. Aims To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. Methods This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1–25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3–6) at discharge were examined using hierarchical logistic regression models. Results Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010–2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95–0.99), 0.97 (0.95–0.998), 1.07 (1.04–1.10), and 1.21 (1.14–1.28), respectively). Conclusions This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

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Association of calprotectin with other inflammatory parameters in the prediction of mortality for ischemic stroke

Journal of Neuroinflammation ◽

10.1186/s12974-020-02047-1 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Juan Marta-Enguita ◽

Manuel Navarro-Oviedo ◽

Idoia Rubio-Baines ◽

Nuria Aymerich ◽

Maria Herrera ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Independence ◽

Hemorrhagic Transformation ◽

Prognostic Information ◽

Logistic Regression Models ◽

Inflammatory Parameters ◽

Prediction Of Mortality ◽

Inflammatory Mechanism ◽

Comprehensive Stroke Center ◽

Stroke Center

Abstract Background Inflammatory response plays an important role in many processes related to acute ischemic stroke (AIS). Calprotectin (S100A8/S100A9), released by monocytes and neutrophils, is a key protein in the regulation of inflammation and thrombosis. The purpose of this study is to evaluate the association of circulating calprotectin with other inflammatory biomarkers and AIS prognosis, as well as the calprotectin content in stroke thrombi. Methods Among the 748 patients treated at a comprehensive stroke center between 2015 and 2017, 413 patients with confirmed acute ischemic injury were prospectively evaluated. Patients with systemic inflammation or infection at onset were excluded. Plasma calprotectin was measured by ELISA in blood samples of AIS patients within the first 24 h. Univariate and multivariate logistic regression models were performed to evaluate its association with mortality and functional independence (FI) at 3 months (defined as modified Rankin Scale < 3) and hemorrhagic transformation (HT) after ischemic stroke. Further, S100A9 was localized by immunostaining in stroke thrombi (n = 44). Results Higher calprotectin levels were associated with 3-month mortality, HT, and lower 3-month FI. After adjusting for potential confounders, plasma calprotectin remained associated with 3-month mortality [OR (95% CI) 2.31 (1.13–4.73)]. Patients with calprotectin ≥ 2.26 μg/mL were 4 times more likely to die [OR 4.34 (1.95–9.67)]. Addition of calprotectin to clinical variables led to significant improvement in the discrimination capacity of the model [0.91 (0.87–0.95) vs 0.89 (0.85–0.93); p < 0.05]. A multimarker approach demonstrated that patients with increased calprotectin, CRP, and NLR had the poorest outcome with a mortality rate of 42.3% during follow-up. S100A9 protein, as part of the heterodimer calprotectin, was present in all thrombi retrieved from AIS patients. Mean S100A9 content was 3.5% and tended to be higher in patients who died (p = 0.09). Moreover, it positively correlated with platelets (Pearson r 0.46, p < 0.002), leukocytes (0.45, p < 0.01), and neutrophil elastase (0.70, p < 0.001) thrombus content. Conclusions Plasma calprotectin is an independent predictor of 3-month mortality and provides complementary prognostic information to identify patients with poor outcome after AIS. The presence of S100A9 in stroke thrombi suggests a possible inflammatory mechanism in clot formation, and further studies are needed to determine its influence in resistance to reperfusion.

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Tenecteplase Improves Door‐to‐Needle Time in Real‐World Acute Stroke Treatment

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.121.000102 ◽

2021 ◽

Author(s):

Jillian Hall ◽

Jesse M. Thon ◽

Mark Heslin ◽

Lauren Thau ◽

Terri Yeager ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Process Improvement ◽

Interquartile Range ◽

Tissue Type ◽

Independent Effect ◽

Stroke Treatment ◽

Comprehensive Stroke Center ◽

Stroke Center

Abstract BACKGROUND We report the interim results of a process improvement initiative at a comprehensive stroke center in which all tPA (tissue‐type plasminogen activator)–eligible patients were given tenecteplase for acute ischemic stroke. METHODS We retrospectively analyzed a prospectively maintained single‐center registry of consecutive patients with acute ischemic stroke treated at our comprehensive stroke center emergency department or transferred for further care. Patients treated with alteplase (tPA) before the process improvement initiative (October 2019–April 2020) were compared with those treated with tenecteplase (May 2020–July 2021). The primary efficacy outcome was the Target: Stroke Phase II recommendation of door‐to‐needle (DTN) time ≤45 minutes. Backward stepwise logistic regression was used to estimate an independent effect of tenecteplase against DTN time ≤45 minutes. Two contemporaneous, negative controls (time to first emergency department antibiotic for patients who presented with infectious symptoms and door‐to‐groin puncture for thrombectomy) were evaluated to confirm DTN time was unrelated to emergency department and other stroke treatment throughput. RESULTS Of the 113 included patients, 53 (47%) received tenecteplase. DTN time was significantly faster in patients treated with tenecteplase (median, 41 [interquartile range, 34–62] minutes versus 58 [interquartile range, 45–70] minutes; P <0.01), with no significant difference in symptomatic intracranial hemorrhage (2% versus 7%; P =0.37). Despite the higher proportion of tPA patients being transferred for care (with slower DTN time), tenecteplase remained independently predictive of DTN time ≤45 minutes (adjusted odds ratio, 3.96; 95% CI, 1.58–9.91). There was no difference in time to first emergency department antibiotic ( P >0.05) or door‐to‐puncture ( P >0.05) when similar periods were compared. CONCLUSIONS Tenecteplase was associated with faster DTN time when compared with tPA in those with acute ischemic stroke. This can likely be attributed to the ease of single bolus administration of tenecteplase.

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Direct Admission versus Secondary Transfer for Acute Stroke Patients Treated with Intravenous Thrombolysis and Thrombectomy: Insights from the Endovascular Treatment in Ischemic Stroke Registry

Cerebrovascular Diseases ◽

10.1159/000499112 ◽

2019 ◽

Vol 47 (3-4) ◽

pp. 112-120 ◽

Cited By ~ 6

Author(s):

David Weisenburger-Lile ◽

Raphaël Blanc ◽

Maeva Kyheng ◽

Jean-Philippe Desilles ◽

Julien Labreuche ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Functional Independence ◽

Adjusted Relative Risk ◽

Stroke Patients ◽

Cerebral Imaging ◽

Excellent Outcome ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: To date, thrombectomy for large vessel occlusion (LVO) strokes can be performed only in comprehensive stroke centers with thrombectomy capacity. We compared the clinical outcome of patients first referred to a primary stroke center to those admitted directly to a comprehensive stroke center and treated on site in the multicentric observational Endovascular Treatment in Ischemic Stroke (ETIS) registry. Methods: From our perspective, multicenter, observational ETIS registry, we analyzed anterior circulation stroke patients, treated within 8 h, who underwent thrombectomy after thrombolysis and were admitted to a comprehensive stroke center either with drip and ship or mothership. Clinical and safety outcomes were compared between 2 groups. Results: A total of 971 patients were analyzed: 298 were treated with the mothership approach and 673 with drip and ship. Significantly more functional independence (90-day modified Rankin Scale [mRS] 0–2) was achieved in mothership (60.1%) than in drip and ship patients (52.6%; adjusted relative risk [RR] 0.87, 95% CI 0.77–0.98, p = 0.018). Excellent outcome (90-day mRS 0–1) was achieved in 45.3% of the mothership group, compared to 37.9% of the drip and ship group (RR 0.84, 95% CI 0.71–0.98; p = 0.026). According to the distance between the primary stroke center and the comprehensive stroke center, greater functional independence was achieved in mothership than in drip and ship >12.5 miles patients (adjusted RR 0.82; 95% CI 0.71–0.94). Results in the drip-ship group stratified according to time between cerebral imaging and groin puncture (categorized according to the median cut-off: 140 min) were similar. Symptomatic intracerebral hemorrhage rate and mortality within 90 days was similar in both groups (7.5 vs. 5.9%, p = 0.40; 17.4 vs. 16.1%, p = 0.63). Conclusions: Our study suggests that LVO stroke patients directly admitted to a comprehensive stroke center present a higher chance of functional independence, especially when the distance between the primary stroke center and comprehensive stroke center is >12.5 miles or when the time between cerebral imaging and groin puncture is ≥140 min.

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