Abstract TP59: Rapid MR in Suspected Acute Stroke: Identifying Mimics That Can Avoid Admission

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Julie Bykowski ◽  
Nathan Gaines ◽  
Brett Meyer ◽  
Dawn Meyer ◽  
Thomas Hemmen ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Acute Stroke ◽  
Median Time ◽  
Accurate Method ◽  
First Year ◽  
Imaging Data ◽  
Head Ct ◽  
Stroke Mimics ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Diffusion weighted MR imaging (DWI) is the most accurate method to confirm or exclude acute ischemic stroke, however due to logistics is not widely used in the emergent setting. While many patients with stroke symptoms will get an MRI during their hospitalization, it may occur only after hours of care in the ER or after admission. Hypothesis: Providing emergent MR imaging in Stroke Code patients avoids unnecessary admission and associated costs for work-up of stroke mimics which otherwise would not be rapidly identified. Methods: IRB-approved retrospective review of the first year of expedited acute stroke MR imaging availability at a TJC Comprehensive Stroke Center. Imaging included immediate non-contrast head CT on arrival with CT Angiography at discretion of Stroke Code Leader. Emergent MR was then performed in patients without MRI contraindications who had unclear diagnosis, or to clarify extent of infarct. Demographic, clinical and imaging data were analyzed with time from triage to imaging, tPA decision, and discharge. Results: MRI was performed prospectively in 68/456 patients presenting with possible acute stroke symptoms from 7/1/2014-7/1/2015 (44 male, 26 female, age 60+/-15 years). Symptom onset was within 3 hours in 34 (49%), 3-6 hours in 12 (17%) and >6 hours or awoke with symptoms in 22 (31%); NIHSS of 4 or less in 40 (59%). Median time from arrival to completion of non-contrast head CT was 16 minutes; median time from CT imaging to completion of DWI was 39 minutes. Twenty-nine patients were discharged directly from the ER after MRI, with median ER stay of 5 hours, 15 minutes. Conclusions: Through multi-departmental collaboration, expediting MR imaging in the setting of acute stroke evaluation can avoid unnecessarily prolonged ER observation and admission in patients with stroke mimics.

Abstract W P212: The Effect Of Pre-hospital Notification On Time To Head Ct, Stroke Specialist Arrival, And Tpa Administration For Hispanic Patients With Acute Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jonathan McCoy ◽  
Ralph Fader ◽  
Colleen Donovan ◽  
Robert Eisenstein ◽  
Pamela Ohman-Strickland ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Care ◽  
Independent Effect ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Head Ct ◽  
Logistic Regression Models ◽  
Hispanic Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Hispanics have an increased incidence of ischemic stroke but may be less likely to use Emergency Medical Services (EMS) for stroke care. Objective: To examine disparities in pre-hospital triage and emergent evaluation of Hispanic stroke patients. We hypothesized that Hispanic stroke patients with pre-hospital notification experience less delay in emergent evaluation but the reduction may not be as pronounced as general stroke patients. Methods: Retrospective cohort study of all emergency department patients alerted as Brain Attack (BAT) between January 1, 2009 and August 31, 2012, at an urban comprehensive stroke center. We collected demographics, co-morbidities, and stroke severity from a quality assurance database. Outcome variables included EMS utilization, pre-hospital BAT activation, head CT timing & tissue plasminogen activator (TPA) timing. Effects of ethnicity and pre-hospital notification on evaluation and treatment times were measured using multivariate logistic regression models. The study was IRB approved. Results: During the study period, 832(64 Hispanic) patients were alerted as Brain Attacks. Hispanic patients were younger 56±17 vs. 68±16 years (p<0.0001), had trends for less EMS utilization (walk-in 35% vs. 22%) and lower NIHSS 9.3±4.3 vs. 12.8±8.3 (p=0.06), but did not differ in comorbidities. Patients with pre-hospital notification had significantly shorter times to stroke specialist arrival, door to head CT, and door to TPA irrespective of ethnicity. However, ethnicity did have independent effect on time to TPA administration. Please see Table 1. Conclusion: Pre-hospital notification is associated with faster stroke evaluation and treatment, including among Hispanic patients with acute stroke. Further study is needed to examine if outreach to increase EMS utilization will decrease disparities in this population.

Abstract WP240: Ultra-acute Diagnostics for Stroke: Large-scale Implementation of Prehospital Biomarker Sampling

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Olli S Mattila ◽  
Heini Harve ◽  
Saana Pihlasviita ◽  
Juhani Ritvonen ◽  
Gerli Sibolt ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Large Scale ◽  
Biomarker Discovery ◽  
Cost Effective ◽  
Blood Sampling ◽  
Blood Samples ◽  
And Performance ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Acute Diagnostics

Background and purpose: Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. However, large prehospital sample sets required for biomarker discovery and validation are missing, and the feasibility of large-scale blood sampling by emergency medical services (EMS) has not been determined. We set out to establish extensive prehospital blood sampling of thrombolysis candidates in the catchment area of our comprehensive stroke center, with a 1.5 million population base. Methods: EMS personnel were trained to collect prehospital blood samples using a cannula-adapter technique. Time delays, sample quality and performance bottlenecks were investigated between May 20, 2013 and May 19, 2014. Results: Prehospital blood sampling and study recruitment were successfully performed in 430 thrombolysis candidates, of which 55.3% were admitted outside office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than admission blood sampling, and 37 minutes (30-47) earlier than admission neuroimaging. Quality control data from 25 participating EMS units indicated a 4-minute increase in median transport time (from arrival on-scene to hospital door) for study patients compared to patients of the preceding year. The hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples collected with venipuncture. Conclusions: Prehospital biomarker sampling is feasible in standard EMS units and provides a median timesaving of over 30 minutes to obtain first blood samples. Large biobanks of prehospital blood samples will facilitate development of ultra-acute stroke biomarkers.

scholarly journals Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

2018 ◽  
Vol 10 (1) ◽  
pp. 57-62 ◽  
Author(s):  
Tapan Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Gilbert Fortunato ◽  
Ilene Staff ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Acute Stroke ◽  
Simulation Training ◽  
Stroke Registry ◽  
Practice Experience ◽  
Intravenous Tissue Plasminogen Activator ◽  
Simulation Based ◽  
Comprehensive Stroke Center ◽  
Stroke Center

ABSTRACT Background  Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective  To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods  Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results  We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] –15.28 to –4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (&gt; 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36–25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions  Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

scholarly journals Prehospital Stroke Triage

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S25-S33
Author(s):  
Anna Ramos ◽  
Waldo R. Guerrero ◽  
Natalia Pérez de la Ossa
Keyword(s):  
Acute Stroke ◽  
Randomized Clinical Trials ◽  
Vessel Occlusion ◽  
Novel Technologies ◽  
Maximum Benefit ◽  
Prehospital Management ◽  
Prehospital Triage ◽  
Clinical Tools ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

scholarly journals Impact of COVID-19 on Acute Stroke Presentation at a Comprehensive Stroke Center

2020 ◽  
Vol 11 ◽  
Author(s):  
Masaki Nagamine ◽  
Daniel S. Chow ◽  
Peter D. Chang ◽  
Bernadette Boden-Albala ◽  
Wengui Yu ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Abstract WP238: Thrombolytic Use in Stroke Mimics via Telestroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ganesh Asaithambi ◽  
Amy L Castle ◽  
Michael A Sperl ◽  
Aditi Gupta ◽  
Jayashree Ravichandran ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Rehabilitation Unit ◽  
Stroke Mimics ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Mimic ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Acute Rehabilitation

Background: It has been established that safety and outcomes of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) is similar to those presenting to stroke centers. Little is known on the accuracy of TS diagnosis among those receiving IVT. We sought to compare the rate of stroke mimic (SM) patients receiving IVT in our TS network to those who present to our comprehensive stroke center (CSC). Methods: Consecutive patients receiving IVT between August 2014 and June 2015 were identified at our CSC and TS network. The rates of SM patients in each cohort were calculated. Outcomes measured included rates of symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU). Results: During the study period, 132 patients (mean age 71±15 years, 49% women) receiving IVT were included in the analysis (75 CSC, 57 TS). Rates of SM patients receiving IVT were similar (CSC 12% vs TS 7%, p=0.39). One stroke patient developed sICH, and three other stroke patients experienced in-hospital mortality; neither outcome was found in the SM cohort. Discharge to home or ARU was similar between stroke (76.5%) and SM (76.9%) patients (p=1). Patients with SMs had significantly higher diagnoses of migraine (p=0.045) and psychiatric disorders (p=0.0002) compared to stroke patients. Conclusion: The rate of IVT among SM patients via TS is low and similar to those who present directly to a stroke center. Continued efforts should be made to further minimize IVT in SM patients despite the low rate of complications.

Abstract TP391: Working Within a Stroke System of Care to Decrease Door to Transfer Times From Spoke to Hub

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Michelle Whaley ◽  
Alissa Dell ◽  
Melissa Chase ◽  
Melissa Mooney ◽  
Jill Hulbert ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Best Practice ◽  
Retrospective Chart Review ◽  
Nurse Leaders ◽  
Study Objective ◽  
Team Members ◽  
Imaging Results ◽  
Number Of Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Best practice recommends that hospitals treating acute stroke patients have protocols in place to ensure rapid transfer to an advanced facility for a higher level of care, if needed. Our system of hospitals consists of five primary stroke centers (PSC) and one comprehensive stroke center (CSC) in a major metropolitan area. PSCs utilize telemedicine for acute stroke decision-making and patients are transferred to the CSC for consideration of advanced treatments when deemed appropriate by the care team. Purpose: Our study objective was to streamline processes at our PSCs to decrease the door to transport time (DTT) to the CSC. Methods: Stroke coordinators from the six sister hospitals meet quarterly to collaborate and share best practices in patient care. Our team of nurse leaders determined potential strategies to eliminate wasted time in the transfer process. Team members went back to their home facilities with the goal of generating buy-in from individual caregivers to decrease the time to transport out to the CSC. An overall attitude of urgency was encouraged during meetings with stroke councils and providers. Preliminary imaging results were used to guide decision to transfer, rather than waiting for final results. Some hospitals chose to notify the flight team of potential transport earlier in the emergency department stay, while others are still in the process of affecting change. We collected data on transferred patients with a diagnosis of acute stroke between the dates of 2/1/15-7/31/15 (n=23) and compared against the same time period in 2014 (n=11). Results: A total of 34 patients were included in our retrospective chart review. The number of patients transferred for consideration of additional acute treatment increased from 11 in 2014 to 23 during the study period in 2015. When examining patients who transferred and actually received endovascular treatment for acute stroke (n=8 in 2014 versus n=11 in 2015), the mean DTT decreased from 84 minutes in 2014, to 77 minutes in 2015. We also noted that patient transfers were faster during day time hours when compared to night. Conclusions: A system-wide, collaborative approach between PSCs and CSCs can decrease DTT when nurse leaders and providers streamline processes.

Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts

2018 ◽  
Vol 13 (5) ◽  
pp. 469-472 ◽  
Author(s):  
Carlos Garcia-Esperon ◽  
Andrew Bivard ◽  
Christopher Levi ◽  
Mark Parsons
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Treatment Decision ◽  
Added Value ◽  
Stroke Treatment ◽  
Computed Tomography Perfusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Weighted Sequences ◽  
Perfusion Maps

Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the “lesions” on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.

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