Abstract 114: 24/7 Stroke Nurse Team Coverage Reduced Door-to-needle Time and Improved Tissue Plasminogen Activator Utilization Rates in a Stroke Level 1 Community Hospital

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Zohaib Haque ◽  
Marsha Enchelmeier ◽  
Stephanie Bern ◽  
Maheen Malik
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Community Hospital ◽  
Heart Association ◽  
Rapid Response Team ◽  
Complication Rates ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Primary Stroke Center ◽  
Iv Tpa

Background: Although the American Heart Association has placed particular emphasis on the importance of improving door-to-imaging (DTI) and door-to-needle (DTN) times, treatment with intravenous tissue Plasminogen Activator (IV tPA) remains nationally low in Acute Ischemic Stroke (AIS) patients, especially for community hospitals due to a lack of in-house neurovascular physician coverage. We sought to remedy this problem by implementing round-the-clock coverage of the Emergency Department by Stroke-trained nurses for patients presenting with AIS who may be appropriate to receive IV tPA. Methods: AIS patients treated with IV tPA at a Community Hospital and Primary Stroke Center in St. Louis, Missouri were studied between 2013 and 2016. A 24/7 Rapid Response Team of nurses was trained as specialized stroke responders for which the DTI time, DTN time, and IV tPA utilization rates were then compared between pre-implementation (12 months) and post-implementation (30 months). Results: We studied 189 Stroke Code patients who were treated with IV tPA (40 pre-implementation and 149 post). The median DTI time was reduced from 16 minutes (interquartile range [IQR]10-21) to 11 minutes (IQR 6-12) (P < .05), and the median DTN time was reduced from 64 minutes (IQR 44-79) to 51 minutes (IQR 39-65) (P<.05). Compliance within the 60-minute benchmark DTN time improved from 55% (27 of 44 patients) to 76.1% (113 of 149 patients) treated in less than 60 minutes with 53.5% (80 of 149 patients) being treated in less than 45 minutes (P<.05). The tPA treatment rates also increased pre and post-implementation by 77.5% (40 to 71 patients) (P<.05) while IV tPA complication rates decreased from 7.3% to 2.7% (P<.10). Conclusions: Implementation of round-the-clock on-site stroke nurse coverage for Acute Stroke Code significantly reduced the DTI and DTN time while increasing treatment rates and decreasing complications amongst patients with AIS treated with IV tPA.

Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lila E Sheikhi ◽  
Stacey Winners ◽  
Pravin George ◽  
Andrew Russman ◽  
Zeshaun Khawaja ◽  
...  
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Stroke Unit ◽  
Early Experience ◽  
Final Diagnosis ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Mobile Stroke Unit ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

scholarly journals Medicolegal Considerations with Intravenous Tissue Plasminogen Activator in Stroke: A Systematic Review

2013 ◽  
Vol 2013 ◽  
pp. 1-6 ◽  
Author(s):  
Archit Bhatt ◽  
Adnan Safdar ◽  
Dhara Chaudhari ◽  
Diane Clark ◽  
Amber Pollak ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Malpractice Litigation ◽  
Extensive Search ◽  
Intravenous Tissue Plasminogen Activator ◽  
Increased Risk ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background.Intravenous tPA (tissue plasminogen activator) therapy remains underutilized in patients with Acute Ischemic Stroke (AIS). Anecdotal data indicates that physicians are increasingly liable for administering and for failure to administer tPA.Methods.An extensive search of Medline, Embase, Westlaw, LexisNexis Legal, and Google Scholar databases was performed. Case studies that involved malpractice litigation in ischemic stroke and thrombolytic therapy were analyzed systematically.Results.We identified 789 ischemic stroke litigation cases, of which 46 cases were related to intravenous tPA and stroke litigation. Case descriptions of 40 cases were available. Data for verdicts were available for 38 patients. The most frequent plaintiff claim was related to failure to administer intravenous tPA (38, 95%). Only 2 (5.0%) claim involved complications of treatment with tPA. Hospitals were defendants in majority of the 36 cases. Physicians were involved in 33 cases. While ED physicians were involved in 25 (60.52%) cases, neurologists were involved in 8 (20.0%) cases. There were 26 (65%) defendant-favored and 12 (30%) plaintiff-favored verdicts.Conclusion.Physicians and hospitals are at an increased risk of litigation in patients with AIS when in IV-tPA is being considered for treatment. While majority of the cases litigated were cases where tPA was not administered, only about 1 in 20 cases was litigated when complications occurred.

scholarly journals Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of “Drip and Ship” on Effectiveness and Outcomes

2020 ◽  
Vol 11 ◽  
Author(s):  
Adam Chang ◽  
Elham Beheshtian ◽  
Edward J. Llinas ◽  
Oluwatoyin R. Idowu ◽  
Elisabeth B. Marsh
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Hemorrhagic Transformation ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
The Impact ◽  
Iv Tpa

Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital.Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes.Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h.Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.

scholarly journals Imaging Evidence for Cerebral Hyperperfusion Syndrome after Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

2016 ◽  
Vol 2016 ◽  
pp. 1-5
Author(s):  
Yi Zhang ◽  
Abhay Kumar ◽  
John B. Tezel ◽  
Yihua Zhou
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Cerebral Hyperperfusion Syndrome ◽  
Hyperperfusion Syndrome ◽  
Cerebral Hyperperfusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background. Cerebral hyperperfusion syndrome (CHS), a rare complication after cerebral revascularization, is a well-described phenomenon after carotid endarterectomy or carotid artery stenting. However, the imaging evidence of CHS after intravenous tissue plasminogen activator (iv tPA) for acute ischemic stroke (AIS) has not been reported.Case Report. Four patients were determined to have manifestations of CHS with clinical deterioration after treatment with iv tPA, including one patient who developed seizure, one patient who had a deviation of the eyes toward lesion with worsened mental status, and two patients who developed worsened hemiparesis. In all four patients, postthrombolysis head CT examinations were negative for hemorrhage; CT angiogram showed patent cervical and intracranial arterial vasculature; CT perfusion imaging revealed hyperperfusion with increased relative cerebral blood flow and relative cerebral blood volume and decreased mean transit time along with decreased time to peak in the clinically related artery territory. Vascular dilation was also noted in three of these four cases.Conclusions. CHS should be considered in patients with clinical deterioration after iv tPA and imaging negative for hemorrhage. Cerebral angiogram and perfusion studies can be useful in diagnosing CHS thereby helping with further management.

scholarly journals Endovascular therapy for acute stroke: Quo vadis?

2013 ◽  
Vol 02 (02) ◽  
pp. 119-123
Author(s):  
Venkatesh Madhugiri ◽  
Paritosh Pandey
Keyword(s):  
Acute Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Endovascular Therapy ◽  
Stent Retriever ◽  
Current Status ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Quo Vadis ◽  
Iv Tpa

Abstract Endovascular therapy (EVT) has gained vogue in the management of patients with acute stroke. Newer stent-retriever devices have led to better recanalization rates. In many centers, EVT is slowly being used as an add on to or in some instances, even as an alternative to intravenous tissue plasminogen activator (IV tPA). The publication of the results of the SYNTHESIS expansion, Interventional Management of Stroke III and Mechanical Retrieval Recanalization of Stroke Clots Using Embolectomy trials in 2013 has questioned the enthusiastic use of EVT in acute stroke. They demonstrate that EVT (using a variety of devices) is no superior to IV tPA in the management of acute stroke. In the light of these controversial findings, we review the current status of EVT in the management of acute stroke.

scholarly journals Utilization of a Parental Approach to Informed Consent in Intravenous Tissue Plasminogen Activator Administration Decision-Making: Patient Preference and Ethical Considerations

2019 ◽  
Vol 2019 ◽  
pp. 1-4
Author(s):  
Ann M. Murray ◽  
Ashley B. Petrone ◽  
Amelia K. Adcock
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Family Member ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Medical Community ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
To Receive ◽  
Iv Tpa

Objective. While administration of intravenous tissue plasminogen activator (IV-tPA) is the standard of care in acute ischemic stroke and has been shown to have statistically significant benefit, there can also be potentially life-threatening complications; however, there is no standard informed consent approach. The purpose of this study was to present a parental, technical, and general model of informed consent for IV-TPA and to determine which approach was preferred. Methods. Survey respondents were asked to hypothetically decide whether or not to provide consent for their family member to receive IV-tPA. Respondents were presented with 3 informed consent models: one emphasizing parental qualities, one emphasizing statistical data, and one representing a general consent statement. After being presented each model, the respondents had to select their preferred consent model, as well as rate their level of agreeability toward their family member receiving the medication following each approach. Results. The results of 184 surveys showed respondents were equally as likely to give consent for their family member to receive IV-TPA following all three approaches; however, respondents were significantly more likely to prefer the parental approach compared to a technical or general approach. Conclusion. Our results indicate that while paternalism is generally discouraged in the medical community, some degree of parental language may be preferred by patients in tough decision-making situations toward consent to receive medical interventions.

Utilization rates of tissue plasminogen activator and mechanical thrombectomy in patients with acute stroke and underlying malignancy

2019 ◽  
Vol 11 (8) ◽  
pp. 768-771 ◽  
Author(s):  
Lorenzo Rinaldo ◽  
Harry J Cloft ◽  
Leonardo Rangel Castilla ◽  
Alejandro A Rabinstein ◽  
Waleed Brinjikji
Keyword(s):  
Acute Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Population Level ◽  
National Database ◽  
Intravenous Tissue Plasminogen Activator ◽  
Underlying Malignancy ◽  
Tissue Plasminogen ◽  
Iv Tpa

ObjectiveRelatively little is known about the effect of malignancy on patient outcomes after acute ischemic stroke (AIS) or utilization rates of stroke interventions in this population. We aimed to assess the effect of underlying malignancy on outcomes and treatment of AIS at a population level.MethodsOutcomes after AIS between patients with and without malignancy were compared using a national database of hospital reported outcomes.ResultsThere were 351 institutions reporting the outcomes of 3 18 127 admissions for AIS. Of these admissions, 16 141 patients carried a pre-existing diagnosis of malignancy at the time of admission. Administration of intravenous tissue plasminogen activator (IV tPA) was less common in patients with malignancy compared with patients without malignancy (7.3% vs 10.7%; P<0.001) but there was no difference in the rate of mechanical thrombectomy (3.1% vs 3.1%; P=0.967). Mortality rates were higher among patients with malignancy (7.1% vs 3.7%; P<0.001), a relationship which persisted when analysis was restricted to patients receiving IV tPA (10.8% vs 6.1%; P<0.001) or thrombectomy (20.3% vs 13.5%; P<0.001). Rates of both IV tPA administration (2.5% vs 10.5%; P<0.001) and mechanical thrombectomy (2.1% vs 5.4%; P<0.001) were lower in patients with brain malignancy relative to patients with malignancy of non-CNS origin.ConclusionA diagnosis of malignancy on admission for acute stroke was associated with a higher rate of mortality. Malignancy was also associated with a lower rate of IV tPA administration but no difference in mechanical thrombectomy utilization.

Abstract T P14: Multi-modality Treatment of Acute Ischemic Strokes Improves Patient Outcome at Discharge vs Intravenous Tissue Plasminogen Activator

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Haitham Dababneh ◽  
Asif Bashir ◽  
Mohammed Hussain ◽  
Sara Misthal ◽  
Mohammad Moussavi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Group Analysis ◽  
Treatment Modalities ◽  
Poor Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Iv Tpa

Background and Purpose: Since the introduction of Intravenous Tissue Plasminogen Activator (IV tPA) and mechanical thrombectomy, the management of acute ischemic stroke has advanced. The objective of this analysis is to compare treatment modalities and the outcome among stroke patients. Methods: This is a retrospective analysis of all patients (n=142) that presented to our hospital with ischemic stroke and received treatment between January 2009 and July 2012. We divided the patients into two groups based on the treatment they received: A) patients received only IV tPA B) patients received both IV tPA and mechanical thrombectomy. Analysis of variance was used to compare the difference of the means between the two groups. Uni- and multivariate logistic regression models were used to compare the association of different treatment modalities with the modified rankin scale (mRS) at discharge. Discharge status was dichotomized based on an mRS greater than 2 as a poor outcome. Multivariate models were created adjusting for age, gender, NIHSS, hypertension (HTN), diabetes mellitus (DM), and hyperlipidemia (HLD). All measurements were done using the SAS software version 9.2. Results: Group analysis including n, gender, mean age, mean NIHSS and mortality at discharge was as follows: A) 104, 50% female, 73±14, 12±7, 6.73% B) 38, 50% female, 71±14, 18±7, 7.89%. When controlling for age, gender, DM, HTN, and HLD, patients in group B had a better outcome than group A (OR 0.3, 95% CI, 0.09-0.96) despite presenting with a worse NIHSS. There was no difference in mortality between the two groups. There was a significant association between NIHSS at admission and mRS at discharge (OR 1.2, 95% CI, 1.13-1.29). There was also a significant association between having DM and a poor outcome (OR 3.94, 95% CI, 1.37-11.37). Conclusion: In our patient subset, multi-modality treatment of acute stroke is safe and associated with a better clinical outcome than IV tPA alone at discharge. Further prospective studies are needed to corroborate our findings.

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