Abstract WMP87: Simulation Based Medical Education Improves Door to Needle Times in Acute Ischemic Stroke Management

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Tapan V Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Ilene Staff ◽  
Gilbert Fortunato ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Simulation Training ◽  
Linear Regression Analysis ◽  
Univariate Analysis ◽  
Multivariate Linear Regression Analysis ◽  
Simulation Based ◽  
Iv Tpa

Introduction: Literature on the effectiveness of simulation based medical education programs used in acute ischemic stroke (AIS) care is scant. In an effort to improve coordination and door to needle time (DNT) for AIS care, a stroke simulation education training program for neurology nursing staff and neurology residents was implemented in a comprehensive stroke center. Methods: Hospital stroke registry was used for retrospective analysis. The study population was defined as all patients treated with IV-tPA for AIS in the emergency room from October 2008 to September 2014. Simulation training was implemented yearly, for a three month period starting from July 2011. All neurology residents and a group of nurses trained to respond to all AIS cases participated. Simulations were standardized, using deliberate practice with a trained live actor portraying stroke vignettes in the presence of a board certified vascular neurologist. During the period of study, there were no changes in Emergency Department stroke triage protocol, or changes in first provider response to AIS. The data was analyzed using IBM SPSS24 software. Results: We identified 448 patients admitted with AIS who were treated with IV-tPA. The average DNT on univariate analysis before and after intervention was 67.9 and 58.3 minutes [p <0.001]. A multivariate linear regression analysis was performed controlling for age, night/day shift, weekday/weekend, and blood pressure at presentation (>185/110). After controlling for confounders we found that simulation training independently reduced the DNT by 9.64 minutes [95% confidence interval (CI) 4.01 - 15.28, p=0.001]. Amongst other co-variates, only the systolic blood pressure >185 was associated with 14.27 minutes of delay in DNT [95% CI 3.36 - 25.191, p=0.011]. Conclusion: Time to thrombolysis from symptom onset is a critical factor in AIS management and evidence shows improving the DNT could improve patient outcomes. In our six year study, integration of simulation based medical education for AIS reduced the average DNT by 9.64 minutes in multivariate analysis. Simulation based medical education therefore should be considered as a standard process for providers involved in the care of AIS patients receiving thrombolytic treatment.

Abstract WP336: Impact of Anti-Hypertensive Interventions for Treatment of Acute Ischemic Stroke in Patients Receiving Tissue Plasminogen Activator

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jeffrey Leya ◽  
Elisabeth Donahey ◽  
Megan Rech
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Primary Endpoint ◽  
Univariate Analysis ◽  
Control Group ◽  
Poor Outcome ◽  
Tissue Plasminogen

Introduction: Early treatment of acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset is associated with neurologic improvement. A risk of rtPA is hemorrhagic conversion, which has a higher incidence in patients with elevated blood pressure at presentation. Current literature supports the use of blood pressure goals (<185/110 mm Hg) in patients qualifying for rtPA, but the effects of anti-hypertensive (anti-HTN) medications within the first 24 hours of AIS on outcomes has not been evaluated. Hypothesis: AIS patients requiring anti-HTN medications (anti-HTN group) before rtPA have a poorer outcome at 90 days compared to those that do not need anti-HTN medications (control group). Methods: This was a retrospective cohort study of patients >18 years diagnosed with AIS from January 2011 through December 2015 who received one or multiple anti-HTN medication(s) prior to rtPA administration, compared to control patients who did not. Primary endpoint was poor outcome at 90 days, defined as a modified Rankin Scale (mRS) of ≥3. Univariate analysis with Chi-square, Fisher’s exact test or t-test was performed. Multivariate analysis was conducted. Results: Of 235 patients evaluated for AIS, 145 (61.7%) were included. Baseline demographics were well matched, though more patients in the anti-HTN group had a history of HTN (86.7% vs. 62.5%, p<0.01), diabetes (33.3% vs. 17.5%, p=0.04) and chronic kidney disease (20% vs. 7.5%, p=0.04). There was no difference in the primary endpoint of poor outcome (mRS ≥3) between groups who received blood pressure medication versus those who did not (37% anti-HTN group vs. 30% control, p=.374). There was no difference in hemorrhagic conversion (13.3% anti-HTN group vs. 6.3% control, p=.187). Mortality at 90 days did not differ between groups (11% who received anti-HTN vs. 7.5%, p=.508). Conclusion: No difference was observed in poor outcomes, hemorrhagic conversion, or 90-day mortality in patients receiving anti-HTN medications prior to rtPA compared to those that did not. These results suggest that aggressive blood pressure management should be used to control hypertension in AIS who may qualify for rtPA, though larger, randomized trials are needed to confirm this finding.

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.

Abstract TP30: Is IV tPA Use Associated With Acute Carotid Stent Closure in Patients Presenting With Acute Ischemic Stroke With Tandem Lesions Treated With Endovascular Therapy?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sushrut Dharmadhikari ◽  
Vikram Jadhav ◽  
Abhishek Fnu ◽  
Andrew Xavier
Keyword(s):  
Endovascular Therapy ◽  
Linear Regression Analysis ◽  
Univariate Analysis ◽  
Tertiary Care ◽  
Multivariate Model ◽  
Large Vessel ◽  
Multivariate Linear Regression Analysis ◽  
Carotid Stent ◽  
Tandem Lesions ◽  
Iv Tpa

Introduction: Carotid occlusions are responsible for 10-25% of large vessel acute ischemic strokes (AIS). While endovascular therapy (ET) is now standard of care for large vessel AIS, tandem lesions remain a therapeutic challenge. Outcomes of patients with tandem lesions undergoing ET with carotid revascularization remain unknown. We aimed to determine the prevalence, risk factors and outcomes of acute carotid stent closure (ACSC) in AIS patients with tandem lesions undergoing ET. Methods: Retrospective review of endovascular database of AIS patients treated in a single tertiary care center from 2010-2016. Patients with tandem lesions identified. Baseline demographics, home medications, IV tPA use, procedural characteristics and outcomes collected. Patients grouped according to carotid stent patency. Data analyzed using SPSS. Factors with p < 0.20 included in multivariate model. Results: Out of 280 AIS patients undergoing ET, a total of 32 patients with tandem lesions identified. ACSC seen in 25% of patients. Baseline demographics similar in two groups. IV tPA use associated with 3 times greater risk of ACSC (12.5% vs 37.5%; p = 0.10). Number of stents (No ACSC 1.13 ± 0.33 vs ACSC 1.75 ± 1.04; p = 0.013) significant in univariate analysis. Baseline mRS, IV tPA use, Number of Stents, Post Stent Angioplasty, Residual ICA stenosis and Poor TICI recanalization grade included in the multivariate model. Number of stents (p = 0.028) and Poor TICI recanalization grade (p = 0.031) reached significance on multivariate linear regression analysis. Patients with ACSC had significantly greater hospitalization days (7.08 ± 3.73 vs 13.5 ± 6.86; p = 0.002), worse discharge mRS (2.17 ± 2.09 vs 4.5 ± 0.75; p = 0.005), worse discharge NIHSS (4.33 ± 4.53 vs 14.71 ± 4.85; p = 0.001), unfavorable disposition (16.67% vs 62.5%; p = 0.023) and worse 90 days mRS (2.0 ± 2.25 vs 4.67 ± 0.82; p = 0.01). Conclusions: ACSC seen in 25% of AIS with tandem lesions treated with ET. IV tPA use associated with 3 times greater risk of ACSC (37.5% vs 12.5%) presumably due to an inability for antiplatelet loading. Number of stents and poor TICI recanalization grade reached significance on multivariate analysis. ACSC associated with significantly worse outcomes. Larger studies are required to confirm these findings

Abstract WP344: Vascular Unloading Technique for Continuous Non-invasive Blood Pressure Monitoring After Intravenous Thrombolysis in Acute Ischemic Stroke: Interim Analysis of a Prospective Method Comparison Study

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Timo Siepmann ◽  
Anne Koehler ◽  
Kristian Barlinn ◽  
Jessica Kepplinger ◽  
Alexandra Prakapenia ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Interim Analysis ◽  
Method Comparison ◽  
Comparison Study ◽  
Non Invasive ◽  
Method Comparison Study ◽  
Iv Tpa ◽  
Vascular Unloading Technique

Introduction: Elevated arterial blood pressure (BP) increases the risk of intracerebral hemorrhage after intravenous (IV) thrombolysis with tPA in acute ischemic stroke (AIS). While arterial BP is usually monitored using intermittent oscillometric measurements with an upper arm cuff, the vascular unloading technique (VUT) provides non-invasive continuous BP monitoring with a finger cuff. Hypothesis: We hypothesized that VUT monitoring is feasible in AIS patients receiving IV tPA, is comparable to the standard technique, and allows detection of BP peaks that might be missed in oscillometric BP monitoring. Methods: We performed an interim analysis of an ongoing prospective method comparison study. AIS patients were simultaneously monitored over 24 h following IV tPA bolus using VUT and contralateral oscillometric BP assessment every 30 min. Results: We present interim data from 15 out of 24 AIS (4 m, 11 f; aged 72.5±14.9 y, mean±SD) receiving IV tPA. Nominal significance level was set to 0.029 in accordance with Pocock’s rule. Missing data were less than 5% for both techniques. There was a positive correlation between VUT and oscillometric BP assessment (Pearson’s correlation coefficient r=0.91, p<0.001 for systolic BP; and r=0.88, p<0.001 for diastolic BP). Bland-Altman analysis confirmed this agreement (figure 1). The mean difference between VUT and oscillometric BP measurements was 9.4±6.1 mmHg for systolic, and 4.5±3.0 mmHg for diastolic BP (p=n.s.). Peaks (systolic BP>180 or diastolic BP>110 mmHg) were detected by VUT monitoring (at least one episode≥5 min) in 12 patients, and by oscillometric BP assessment (≥one time point of measurement) in 7 patients (p<0.01). Conclusions: Our interim data suggest that VUT-based BP monitoring is feasible in AIS patients receiving IV tPA, and might be more sensitive than intermittent oscillometric BP assessment in detecting potentially harmful blood pressure peaks. Figure 1: Bland Altman plot

scholarly journals Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients

2020 ◽  
Vol 11 ◽  
Author(s):  
Benjamin Maïer ◽  
Jean Philippe Desilles ◽  
Mikael Mazighi
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Tissue Type ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Early Reperfusion ◽  
Iv Tpa

Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.

Abstract 2483: No Increased Risk of sICH in tPA Treated Stroke Patients With ECASS Exclusion Criteria

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Carolyn A Cronin ◽  
Nikeith Shah ◽  
Tanya Morovati ◽  
Lisa D Hermann ◽  
Kevin N Sheth
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Exclusion Criterion ◽  
Stroke Patients ◽  
Control Blood Pressure ◽  
Exclusion Criteria ◽  
Increased Risk ◽  
Iv Tpa

Introduction: Only about 2% of ischemic stroke patients are currently treated with IV tPA, with the most common reason for exclusion from treatment being time. The positive results of ECASS III expanded the time window for treatment to 4.5 hours, however it used more stringent exclusion criteria than are in use for <3 hrs in the USA. For patients who present 3-4.5 hours from symptom onset, the scientific advisory from the AHA/ASA recommends use of the more narrow ECASS III criteria. We evaluated the outcomes of patients who had been treated with IV tPA to test the hypothesis that thrombolysis is not safe in patients with one of the additional exclusion criteria (age >80, NIHSS >25, combination of previous stroke and diabetes, aggressive measures required to control blood pressure (IV infusion), or oral anticoagulant treatment). Methods: We performed a retrospective analysis of all acute ischemic stroke patients treated with IV tPA at our tertiary care academic medical center between June 2006 and June 2010. 191 patients were identified and stratified based on presence of each of the listed exclusion criteria. The primary outcomes are rate of symptomatic intracerebral hemorrhage (sICH) and in-hospital mortality. Additionally, patients with and without sICH were analyzed for differences in baseline characteristics. Results: There were 31 patients older than 80 years, 5 with NIHSS >25, 14 with the combination of prior stroke and diabetes, 19 required continuous IV infusions to control blood pressure below 185/110 mmHg, and 11 were taking oral anticoagulants. No exclusion criterion was associated with increased risk of sICH. There was higher in hospital mortality in patients >80 years (5 of 31 (16%) vs. 6 of 160 (4%), p=0.0186, RR = 3.15, 95% CI: 1.50 to 6.59), and those with NIHSS >25 (2 of 5 (40%) vs. 7 of 159 (4.4%), Relative risk = 11.48, 95% CI: 2.19 to 60.30). sICH was associated with atrial fibrillation (5 of 9 (55%), vs. 35 of 182 (19.2%), p=0.021; RR = 4.72, 95% CI: 1.33 to 16.77), larger final infarct volume (mean 173 ml 3 (SEM 43.3) vs. 42 ml 3 (SEM 6.3),p=0.0002), and elevated glucose (mean 166 mg/dL (SEM 23.1) vs. 127 mg/dL (SEM 4.1), p=0.038). Conclusions: In our cohort, none of the exclusion criteria from ECASS III, which were more stringent than those used in 0-3 hour US labeling, were associated with increased risk of sICH. tPA may be safe in these patients, who represent an important patient population of acute stroke patients. In agreement with prior studies, we have found that older patients and those with more severe deficits at presentation have higher mortality after acute ischemic stroke. Prospective studies are urgently needed to determine the safety and efficacy of tPA in this group of patients through all treatment time windows.

Association between Blood Urea Nitrogen-to-creatinine Ratio and Three-Month Outcome in Patients with Acute Ischemic Stroke

2019 ◽  
Vol 16 (2) ◽  
pp. 166-172 ◽  
Author(s):  
Linghui Deng ◽  
Changyi Wang ◽  
Shi Qiu ◽  
Haiyang Bian ◽  
Lu Wang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Blood Urea Nitrogen ◽  
Univariate Analysis ◽  
Density Lipoprotein ◽  
Hydration Status ◽  
Creatinine Ratio ◽  
Urea Nitrogen

Background: Hydration status significantly affects the clinical outcome of acute ischemic stroke (AIS) patients. Blood urea nitrogen-to-creatinine ratio (BUN/Cr) is a biomarker of hydration status. However, it is not known whether there is a relationship between BUN/Cr and three-month outcome as assessed by the modified Rankin Scale (mRS) score in AIS patients. Methods: AIS patients admitted to West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled and baseline data were collected. Poor clinical outcome was defined as three-month mRS > 2. Univariate and multivariate logistic regression analyses were performed to determine the relationship between BUN/Cr and three-month outcome. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. Results: A total of 1738 patients were included in the study. BUN/Cr showed a positive correlation with the three-month outcome (OR 1.02, 95% CI 1.00-1.03, p=0.04). However, after adjusting for potential confounders, the correlation was no longer significant (p=0.95). An interaction between BUN/Cr and high-density lipoprotein (HDL) was discovered (p=0.03), with a significant correlation between BUN/Cr and three-month outcome in patients with higher HDL (OR 1.03, 95% CI 1.00-1.07, p=0.04). Conclusion: Elevated BUN/Cr is associated with poor three-month outcome in AIS patients with high HDL levels.

scholarly journals Impact of Early Blood Pressure Lowering in Patients Presenting with Acute Ischemic Stroke

2021 ◽  
Vol 23 (6) ◽  
Author(s):  
A. Maud ◽  
G. J. Rodriguez ◽  
A. Vellipuram ◽  
F. Sheriff ◽  
M. Ghatali ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Negative Impact ◽  
Systemic Blood Pressure ◽  
Hemodynamic Response ◽  
Collateral Flow ◽  
Early Management ◽  
Ischemic Tissue

Abstract Purpose of Review In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. Recent Findings Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Summary Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.

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