Abstract TMP10: Impact on Mechanical Thrombectomy Time Efficiencies Following Hospital Bypass Protocol Implementation: Northwest Ohio Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sharjeel Panjwani ◽  
Julie Shawver ◽  
Rami Abdelaziz ◽  
Gretchen Tietjen ◽  
Mouhammad Jumaa ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prospective Studies ◽  
Mechanical Thrombectomy ◽  
Arterial Occlusion ◽  
Before And After ◽  
Lucas County ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
Early Stroke

Background: Early stroke identification and treatment with mechanical thrombectomy (MT) increases likelihood of favorable outcome. We compared our MT time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: Our RA protocol mandates emergent comprehensive stroke center transfer for patients with RACE score ≥ 5. We compared MT cases for RA patients (N=37) from Jul 2015-Jun 2016 with procedures performed on Stroke Alerts [(SA) N=56] from preceding 2 years. Transfers from outside LC, private transport and inhospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 call to treatment, and outcomes were compared. Results: Treatment times including 911 call to IV tPA treatment, groin puncture, and recanalization were all significantly faster in the RA cohort (see graphic). Overall RA patients achieved recanalization and favorable outcomes at higher rate, although the latter was not statistically significant. Conclusion: Our experience indicates that RA protocol is highly effective in enhancing overall time efficiency for MT and may contribute to improved clinical outcomes. Further prospective studies are warranted.

Abstract WP68: Impact on ER Arrival & IV TPA Treatment Times Following Hospital Bypass Protocol Implementation: Northwest Ohio Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Julie Sahwver ◽  
Theodore Popa ◽  
Sharjeel Panjwani ◽  
Rami Abdelaziz ◽  
Gretchen Tietjen ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Treatment Time ◽  
Arterial Occlusion ◽  
Significant Delay ◽  
Protocol Implementation ◽  
Before And After ◽  
Lucas County ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: There is concern regarding hospital bypass stroke protocols potentially compromising IVtPA treatment due to transit time delay. We compared our IV thrombolysis time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: RA protocol whereby RACE score ≥5 patients are transferred directly to comprehensive stroke center (CSC) for potential mechanical thrombectomy (MT) was implemented in Jul 2015. All stroke alerts (SA) that required MT from July 2013 through June 2015 were compared to MT cases performed following RA protocol implementation. Transfers from other counties, private transport and in-hospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 activation to treatment time, and outcomes were compared. Results: Between Jul 2015-Jun 2016, 37 RA patients underwent MT of which 21 (56.8%) were given IV tPA at the CSC. Whereas in the preceding 2 years from Jul 2013-Jun 2015, 56 SA patients underwent MT, of which 22 (39%) received IVtPA. Of these SA cases, 11 (50%) were drip and transfer from other LC ERs and the remaining 11 (50%) presented directly to CSC. The 911 activation to 1 st ER arrival remained unchanged (34 vs. 32 mins, p 0.4), whereas tPA administration was significantly faster (64 vs. 88 mins, p <0.05) in the RA cohort (see graphic). Conclusions: Within LC, the RA bypass protocol did not result in a significant delay to ER arrival and it significantly expedited IV tPA delivery to patients undergoing MT. Further prospective studies are warranted.

Abstract 1122‐000091: Predictors of Symptomatic Hemorrhagic Transformation After Mechanical Thrombectomy in Acute Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Anqi Luo ◽  
Agnelio Cardenas ◽  
Lee A Birnbaum
Keyword(s):  
Risk Factors ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Hemorrhagic Transformation ◽  
Current Standard ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Introduction : Mechanical thrombectomy (MT) has become the current standard of care for large vessel occlusion stroke but is associated with an increased risk of intracranial hemorrhage (ICH). Although several studies have investigated the risk factors, there is still limited, not well‐established data. This study aims to evaluate the risk factors of HT after MT. Methods : We retrospectively reviewed all MT patients who were treated at a single comprehensive stroke center from 12/2016 to 7/2019. Variables included initial NIHSS, blood glucose, initial systolic blood pressure, age, gender, IV tPA, time from door to recanalization, and TICI score. Outcome measures were HT on post‐procedure or 24‐hour post‐tPA head CT/MRI as well as modified Rankin scale (mRS) upon discharge. Results : Among 74 patients (68.8 ± 14 years, men 47.3%), 9 (12.2%) experienced hemorrhagic transformation after thrombectomy. Average admitting NIHSS was significantly higher in the HT group (22 vs 16.8, p = 0.041). TICI 3 after MT was protective for HT (OR 0.078, 95% CI 0.009‐0.663). IV tPA (OR 3.86, 95% CI 1.448‐10.326) was associated with good neurological outcome at discharge (mRS < = 2), but HT was not (OR 0.114, 95% CI 0.013‐0.964). Patients with mRS < = 2 upon discharge were younger (65.2±12 vs 71.9±15, p = 0.04) and had lower initial BG (124±45.8 vs 157±69.6, P = 0.02). Conclusions : TICI 3 score, decreased NIHSS, and lower BG were associated with less HT and better outcomes in our MT cohort. Admitting NIHSS > = 20 may be a reasonable threshold to predict HT after MT. Our findings are consistent with the TICI‐ASPECTS‐glucose (TAG) score to predict sICH; however, we used initial NIHSS as a surrogate for ASPECTS. Further studies may utilize additional quantitative measures such as CTP data to predict HT.

scholarly journals How a CT-Direct Protocol at an American Comprehensive Stroke Center Led to Door-to-Needle Times Less Than 30 Minutes

2016 ◽  
Vol 7 (2) ◽  
pp. 70-73 ◽  
Author(s):  
Lisa M. Caputo ◽  
Judd Jensen ◽  
Michelle Whaley ◽  
Mark J. Kozlowski ◽  
Christopher V. Fanale ◽  
...  
Keyword(s):  
Implementation Process ◽  
Evaluation Process ◽  
Protocol Implementation ◽  
Time Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Before And After ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes ( P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

scholarly journals Thrombectomy accessibility after transfer from a primary stroke center: Analysis of a three-year prospective registry

2017 ◽  
Vol 12 (5) ◽  
pp. 519-523 ◽  
Author(s):  
Denis Sablot ◽  
Nicolas Gaillard ◽  
Philippe Smadja ◽  
Jean-Marie Bonnec ◽  
Alain Bonafe
Keyword(s):  
Symptom Onset ◽  
Mechanical Thrombectomy ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Interventional Neuroradiology ◽  
High Volume ◽  
Large Artery ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background No comprehensive study exists about mechanical thrombectomy accessibility for patients admitted to a primary stroke center without onsite interventional neuroradiology service. Aims To evaluate mechanical thrombectomy accessibility within 6 h after transfer from a primary stroke center to a distant (156 km apart; 1.5 h by car) comprehensive stroke center. Methods Analysis of data collected in a three-year prospective registry on patients admitted to a primary stroke center within 4.5 h after symptom onset and selected for transfer to a comprehensive stroke center for mechanical thrombectomy. Eligible patients had confirmed proximal arterial occlusion and no large cerebral infarction on MRI images (DWI-ASPECTS ≥ 5). The rate of transfer, transfer without mechanical thrombectomy, mechanical thrombectomy, reperfusion (TICI score ≥ 2b-3), and the main relevant time measures were determined. Results Among the 385 patients selected for intravenous thrombolysis and/or potential mechanical thrombectomy, 211 were considered as transferrable for mechanical thrombectomy. The rate of transfer was 56.4% (n = 119/211), transfer without mechanical thrombectomy 56.3% (n = 67/119), mechanical thrombectomy 24.6% (n = 52/211), and reperfusion by MT (TICI score 2b/3) 18% (n = 38/211). The relevant median times (interquartile range) were: 130 min (62) for intravenous thrombolysis start to comprehensive stroke center door, 95 minutes (39) for primary stroke center door-out to comprehensive stroke center door-in, 191 min (44) for intravenous thrombolysis start to mechanical thrombectomy puncture, 354 min (107) for symptom onset to mechanical thrombectomy puncture and 417 min (124) for symptom onset to recanalization. Conclusions Our study suggests that transfer to a distant comprehensive stroke center is associated with reduced access to early mechanical thrombectomy in patients with acute ischemic stroke and large artery occlusion. These results could be translated to other high volume distant primary stroke center.

Abstract WP198: Is There a "Smoker's Paradox" in Acute Reperfusion Therapies?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Reza Bavarsad Shahripour ◽  
John P Donnelly ◽  
Harn Shiue ◽  
Alissa Gadpaille ◽  
Kanika Arora ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Ischemic Stroke ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Nihss Score ◽  
Paradoxical Finding ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background & Purpose: Recent studies have suggested a “smoker’s paradox,” referring to higher recanalization rates and better outcomes after IV thrombolytic therapy for ischemic stroke in smokers compared to nonsmokers. Our goal was to evaluate whether this paradox exists for both IV and endovascular therapies (ET) in our population. Methods: We retrospectively evaluated consecutive AIS patients (March 2014-April 2015) admitted to our comprehensive stroke center. Patients were stratified by treatment: IV tPA, ET, or neither. The primary endpoint was the modified Rankin scale (mRS) at discharge (“favorable outcome” score 0- 2) analyzed by logistic regression adjusted for demographic factors and admission NIHSS score. Successful reperfusion after ET was classified as Thrombolysis in Cerebral Infarction (TICI) scores of 2b or greater on immediate angiographic imaging. Results: Of 765 patients, 29 % were smokers (n= 222) including 63 % white (Table). Among smokers, 15% received tPA and 3% of patients received ET. Among nonsmokers 14% received tPA and 6% received ET. There was no difference in favorable outcome between smokers and nonsmokers in patients treated with tPA (60.6% vs. 52.6%; P= 0.43) or ET (26% vs. 40.0%; P= 0.325). There was no difference between smokers and nonsmokers in re-canalization after ET (70.6 % vs. 70.0%; P= 0.62). In patients without tPA or ET treatment, favorable outcome was more frequent in smokers compared to nonsmokers (66.5% vs. 47.8 %; P< 0.001). In a regression model adjusted for admission NIHSS, age, gender, and race, the prevalence of good outcome in smokers was 18% more than nonsmokers. (PR 1.177; 95% CI: 1.021 - 1.409). Conclusions: Our study did not support presence of the “Smoker’s Paradox” in AIS patients who receive IV or ET therapy. A rigorous adjustment for risk factors is likely to eliminate the paradoxical finding of more frequent favorable outcome in smokers who have not received tPA or ET.

scholarly journals Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina

2020 ◽  
Vol 78 (1) ◽  
pp. 39-43
Author(s):  
Matías ALET ◽  
Federico Rodríguez LUCCI ◽  
Sebastián AMERISO
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Demographic Data ◽  
Reperfusion Therapy ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Abstract Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Objective: Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke. Methods: Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed. Results: We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%. Conclusions: With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.

Abstract TP24: Should the Decision for Mechanical Thrombectomy be Based on Pre-procedure CT Head Showing Early Changes in Specific Regions of the Brain?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Daniel Korya ◽  
Mohammad Moussavi ◽  
Siddhart Mehta ◽  
Jaskiran Brar ◽  
Mena Samaan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Mechanical Thrombectomy ◽  
Regions Of Interest ◽  
Paired Samples ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Right ◽  
Iv Tpa

Background: The treatment of acute ischemic stroke has evolved over the past several years to utilize neuroimaging in guiding therapy. With regard to IV tPA and thrombectomy, recent endovascular therapy trials have utilized the ASPECT score in determining if intervention should be attempted. We sought to evaluate different regions of interest on the ASPECT score to determine if specific areas of injury should be weighed more heavily during decision making. Methods: We evaluated the pre-intervention CT scans of the head on all patients who received IV tPA and mechanical thrombectomy during the last two years at a community based, university affiliated comprehensive stroke center. All 20 regions of interest (ROIs) of the ASPECT score were compared with each other with regard to initial NIH stroke score, discharge NIHSS, delta NIHSS and modified Rankin Score to determine if one or more regions were associated with worse outcome. SPSS version 22 was used to determine Spearman rho values and paired samples t-test. Results: A total of 864 patients presented with acute ischemic stroke, of which 70 patients received IV tPA followed by mechanical thrombectomy and were included in the study. The 4 ROIs with the greatest correlation with worse outcome as rated by discharge mRS were the right and left M5-M6 [4.2 (p=.001, 95%CI 3.5-4.8); 4.3 (p=.001, 95%CI 3.4-5.1); 4.3 (p=.001, 95%CI 3.4-5.2); 4.2 (p=.001, 95%CI 3.6-4.8), respectively]. Conclusion: Early changes defined as hypodensity in the M5 and M6 ROIs on either side of the pre-intervention head CT were associated with significantly worse outcomes. A modified ASPECT score should be considered to better prognosticate patients and guide the appropriateness of endovascular therapy in select patients. These findings should be validated in a larger population and a longer follow-up period.

Abstract TP35: Eptifibatide is Safe and May Improve Outcomes in Stroke Patients Undergoing Thrombectomy After Receiving IVtPA

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Siddhart Mehta ◽  
Mohammad Moussavi ◽  
Daniel Korya ◽  
Jaskiran Brar ◽  
Harina Chahal ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Prospective Trial ◽  
Standard Of Care ◽  
Duration Of Treatment ◽  
Paired Samples ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
Continuous Drip

Introduction: Recent trials have shown significant improvement in outcome for patients suffering from acute ischemic stroke (AIS) when mechanical thrombectomy is added to the standard of care of IV tPA. In addition to the acute anti-platelet properties eptifibatide may also reduce acute inflammatory response following neurovascular intervention. Our goal was to evaluate the potential benefit of adding IV eptifibatide to mechanical thrombectomy and IV tPA. Methods: Patients who presented to a community based university affiliated comprehensive stroke center from 2012-2015 with AIS over a 2 year period were included in the study. Only patients who received thrombectomy after IV tPA were included. A subgroup of those patients also received IV eptifibatide as a continuous drip during and after the procedure. Details of bolus dosing and duration of treatment were documented. The initial NIH Stroke Score (NIHSS) and 24-hour NIHSS were compared between the two groups with paired samples t-test using SPSS Version 22. Results: A total of 866 patients were evaluated, and 139 met the study criteria. All patients received mechanical thrombectomy after IV tPA, but 70 also received a bolus dose of 135 mcg/kg of eptifibatide followed by 0.5 mcg/kg/min continuous drip. The mean duration of the drip was 23.8 minutes (SD 14.13). There were no significant differences in complication or hemorrhage rates between groups. The mean initial minus 24-hour NIHSS (Initial-24) for the patients receiving only IV tPA/thrombectomy was 1.6. Patients who also received eptifibatide had a mean Initial-24 of 3.6. The paired mean difference was 2 (95% CI .19-3.8; p=.03), favoring the addition of eptifibatide. Conclusion: The addition of eptifibatide bolus followed by a continuous drip for a mean of 24-hours to IV tPA/thrombectomy was associated with a significantly better 24-hour post-procedure outcome. The mechanism of action may be related to the suppression of inflammation and potential prevention of rethrombosis after treatment. No additional complications were noted with eptifibatide and patients tolerated it well. A larger prospective trial is warranted to corroborate our findings.

Abstract WP435: Post Procedural Monitoring Tool Improves the Joint Commission Comprehensive Stroke Center Standard Compliance

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Denise Gaffney ◽  
Lorina Punsalang ◽  
Alvina Mkrtumyan ◽  
Raeesa Dhanji ◽  
David McCartney ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Electronic Monitoring ◽  
Vital Signs ◽  
Joint Commission ◽  
Monitoring Tool ◽  
Post Intervention ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
The Joint Commission

Background: The Joint Commission (TJC) Comprehensive Stroke Center standard requires monitoring of patients after IV tPA administration, diagnostic angiography, aneurysm coiling, carotid angioplasty and stenting, mechanical endovascular reperfusion (MER) and carotid endarterectomy. Meeting 100% compliance of the standard is challenging. In 2018, monitoring and documentation were among the TJC’s top ten cited survey findings. Purpose: To determine if an electronic tool can improve documentation compliance and reduce delays in monitoring of vital signs, and neurologic, pedal pulse and skin site assessments. Methods: The initiative was implemented in 2018 with the objective for all patients to have 100% of their post procedural monitoring completed. A documentation tool was created and introduced to nursing units via annual stroke education updates. The tool was added to an online nursing resource SharePoint website and application, which was accessible to all nurses within the hospital. The procedure end time was entered in the tool, which automatically calculated the documentation times. Data was compared 12 months pre and post intervention. Analysis and reporting of data were conducted monthly via the program’s quality oversight committee. Data was analyzed using T-Test. Results: In post-IV tPA patients, more patients had 100% complete documentation (79% post vs. 29% pre-implementation; p=0.006). For all post neuro-interventional radiology procedures, more patients had 100% complete documentation (68% post vs. 17% pre-implementation; p<0.001). For post carotid endarterectomy revascularization, there was a trend toward more patients with 100% complete documentation (83% vs 38%; p=0.07). Conclusion: Utilization of an electronic monitoring tool for post procedural documentation adherence can improve the percentage of patients who have 100% completed assessments and help meet the TJC standard.

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