Abstract WP142: Intravenous Tissue Plasminogen Activator for Patients with Mild and Rapidly Improving Ischemic Strokes and Large Vessel Occlusions: Examining In-hospital Outcomes

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jeffrey Wagner ◽  
Constance McGraw ◽  
Kathryn McCarthy ◽  
Judd Jensen ◽  
Alessandro Orlando ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Heart Association ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Increased Risk ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Upon hospital arrival, patients with mild or rapidly improving acute ischemic strokes (AIS) are frequently not treated with IV-tPA. Recent guidelines from the American Heart Association report that diagnosis on imaging of large vessel occlusion (LVO) despite mild stroke severity leads to increased risk of poorer outcomes. The objective of our study was to examine outcomes following tPA in this AIS population. Methods: The study included all AIS patients with an admission NIHSS ≤7 and diagnosis of a LVO on imaging from a single comprehensive stroke center between 2010-2016. Patients were excluded due to missing contraindications to tPA or with a symptom to arrival time of >4.5 hours (n=234). We compared patients who received tPA to those who received no treatment because of mild or rapidly improving symptoms. Outcomes were sICH, improvement in NIHSS score, discharge mRS ≤2, and in-hospital mortality. Patient characteristics were compared univariately, and step-wise logistic regression was used to adjust for confounding variables. Entry criterion was P=0.2 and exit criterion was P=0.07. Results: There were 76 patients with an AIS diagnosis of LVO. Of these patients, 39 (51%) were treated with tPA and 37 (49%) were not treated. Overall, the median (IQR) age was 72 (61-82.5). Patients treated with tPA had a median admission NIHSS of 5 (3-6), and a larger proportion were male (77%) and smokers (4%). Patients without tPA treatment had a median NIHSS of 2 (1-3), and a larger proportion had hypertension (49%). All outcomes were not significantly different between groups after adjustment (Table 1). There were no patients with sICH. Conclusions: Our study suggests that tPA in mild LVO patients does not introduce additional risk in terms of sICH, in-hospital mortality, change in NIHSS, or discharge mRS. Further justification for withholding tPA in this group should be based on 90-day mRS scores, in order to better understand long-term functional outcomes.

scholarly journals Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

2021 ◽  
pp. neurintsurg-2020-017155
Author(s):  
Alexander M Kollikowski ◽  
Franziska Cattus ◽  
Julia Haag ◽  
Jörn Feick ◽  
Alexander G März ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Before And After ◽  
Transferred Patients ◽  
Stroke Center

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

Abstract TP292: Telestroke vs Phone Consultation in Stroke Patients Eligible for Intra-Arterial Therapy

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Nicholas Osteraas ◽  
James Conners ◽  
Shawna Cutting ◽  
Sarah Song ◽  
Laurel Cherian ◽  
...  
Keyword(s):  
Female Gender ◽  
Large Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Telephone Consultation ◽  
Transfer Programs ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Mean Time

Background and Objective: Intra-arterial therapy (IA) is beneficial for acute ischemic stroke patients with large vessel occlusions who have received intravenous tissue plasminogen activator (IVtPA). Telestroke has not been associated with increased IVtPA utilization rates when compared to phone consultations. We sought to determine whether telestroke improved the process of evaluation and transfer of patients who may be eligible for intra-arterial therapy (IA). Methods: The Rush telestroke program consists of an academic hub (comprehensive stroke center) that serves 10 spoke emergency departments (EDs). For sites outside of the telestroke program, the patient receives telephone consultation from the same pool of telestroke neurologists. IA therapy is considered for patients clinically suspected of having a large vessel occlusion who could potentially be treated with IA within 6 hours of last known normal (LKN). We compared IA eligible stroke patients transferred via the telestroke program to those non-telestroke transfer patients. Results: From July 1, 2013 to July 1, 2015, 126 patients were transferred from outside hospital ERs to our institution for potential IA; 6 patients were excluded for non-stroke diagnosis. Among 119 patients, 79 (66%) were evaluated via telestroke and 40 (34%) via phone consultation. There was no difference between groups for age (63.3 vs 59.3 years, p=0.14) female gender (52% vs 58%, p=0.70), hypertension (66% vs 78%, p 0.21), atrial fibrillation (27% vs 20%, p=0.50), initial arrival NIHSS (17 vs 19, p=0.12), frequency of IA (66% vs 55%, p=0.31), mean time from LKN to IVtPA administration (139 vs 138 minutes, p=0.96), mean time from IVtPA administration to arrival (106 vs 94 minutes, p=0.31), and mean time from arrival to IA start (35 vs 31 minutes, p=0.44). More patients who were evaluated via telestroke received TPA compared to those evaluated via phone (80% vs 63%, p<0.05). Conclusions: Telestroke improves the evaluation of IA eligible stroke transfer patients by increasing the rates of IVtPA compared with telephone consultation alone. Comprehensive stroke centers may benefit patients by incorporating telestroke systems into their IA transfer programs.

IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion?

2020 ◽  
pp. neurintsurg-2020-016045 ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Laurie Preston ◽  
Wondwossen Tekle ◽  
Adnan I Qureshi
Keyword(s):  
Length Of Stay ◽  
Intracerebral Hemorrhage ◽  
Endovascular Treatment ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

BackgroundEndovascular treatment (EVT) is a widely proved method to treat patients diagnosed with intracranial large vessel occlusions (LVOs); however, there has been controversy about the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT.ObjectiveTo compare the outcomes of all patients with LVO treated with IV tPA +EVT versus EVT alone within 4.5 hours of stroke onset.MethodsA prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2019 was used to examine variables such as demographics, comorbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (ICH), mortality rate, and good/poor outcomes as shown by the modified Thrombolysis in Cerebral Infarction score and modified Rankin Scale (mRS) assessment at discharge. The outcomes between patients receiving IV tPA+EVT on admission and patients who underwent EVT alone were compared.ResultsOf 588 patients with acute ischemic stroke treated with EVT, a total of 189 met the criteria for the study (average age 70.44±12.90 years, 42.9% women). Analysis of 109 patients from the group receiving EVT+IV tPA (average age 68.17±14.28 years, 41.3% women), and 80 patients from the EVT alone group was performed (average age 73.54±9.84 years, 45.0% women). Four patients (5.0%) in the EVT alone group experienced symptomatic ICH versus 15 patients (13.8%) in the IV tPA+EVT group (p=0.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; p=0.0056).ConclusionIV tPA in addition to EVT was associated with an increase in the rate of ICH in patients with LVO treated within 4.5 hours and in patients’ length of stay. Further research is required to determine whether EVT treatment alone in patients with LVO treated within 4.5 hours is a more effective option.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

2021 ◽  
pp. neurintsurg-2021-017365
Author(s):  
Mais Al-Kawaz ◽  
Christopher Primiani ◽  
Victor Urrutia ◽  
Ferdinand Hui
Keyword(s):  
Mobile Application ◽  
Secondary Analysis ◽  
Multiple Linear Regression Model ◽  
Stroke Care ◽  
Mobile App ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
2021 ◽  
Author(s):  
Laura C.C. van Meenen ◽  
Maritta N. van Stigt ◽  
Arjen Siegers ◽  
Martin D. Smeekes ◽  
Joffry A.F. van Grondelle ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Stroke Care ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
User Friendliness ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

Abstract WP389: Improving Systems of Care With Stroke Severity Adjusted EMS Triaging and Bypass Criteria Protocols to a Comprehensive Stroke Center

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mary E Deleener ◽  
Brett Greenfield
Keyword(s):  
New Jersey ◽  
Near Infrared ◽  
Assessment Tool ◽  
Systems Of Care ◽  
Hospital Setting ◽  
Large Vessel ◽  
Atlantic City ◽  
Stroke Severity ◽  
Comprehensive Stroke Center ◽  
Stroke Center

A validated pre-hospital assessment tool to detect severe strokes including intracranial hemorrhages and large vessel occlusions along with protocols for bypassing to comprehensive stroke centers remains an ongoing debate. The long term goals align with the emphasis of developing formalized stroke severity adjusted EMS triaging and bypass protocols to recognize both large vessel ischemic and intracerebral hemorrhagic stroke patients early in the pre-hospital setting with the utilization of a recognized, validated assessment tool, formal bypass criteria protocols, and formalized training for emergency medical service personnel. These goals align with the topic of careful selection of patients who meet strict criteria for bypassing acute stroke ready and primary stroke centers throughout the Southeastern New Jersey region which includes one acute ready hospital and two primary stroke centers to the closest Comprehensive Stroke Center in Atlantic City, New Jersey. The first specific aim is to analyze the EMS field diagnostic accuracy completed by both AtlantiCare EMS ACLS providers and Mid Atlantic Medevac EMS personnel. A therapeutic bypass yield will be analyzed in order to determine the effectiveness of the formalized training to conduct effective stroke severity EMS triaging assessments and a formal bypass protocol to the Comprehensive Stroke Center in Atlantic City, New Jersey. Sensitivity results of the near-infrared (NIR) technology device as a pre-scanning tool for hemorrhages prior to CT scan and operator error will be analyzed. Final diagnosis, CT results, and the need for comprehensive services will serve as the sole factor for the therapeutic bypass yield analysis. The second aim is to analyze the percentage of bypassed patients to the Comprehensive Stroke Center that undergo comprehensive interventions or medical services. Policy/Protocol Design (refer to images) IRB Information : FWA#00011915 and RP# 15-039ex IRB

scholarly journals Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke

2019 ◽  
Vol 8 (12) ◽  
Author(s):  
Ludwig Schlemm ◽  
Matthias Endres ◽  
Jan F. Scheitz ◽  
Marielle Ernst ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Disability Adjusted Life Years ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.

Developing a statewide protocol to ensure patients with suspected emergent large vessel occlusion are directly triaged in the field to a comprehensive stroke center: how we did it

2016 ◽  
Vol 9 (3) ◽  
pp. 330-332 ◽  
Author(s):  
Mahesh V Jayaraman ◽  
Arshad Iqbal ◽  
Brian Silver ◽  
Matthew S Siket ◽  
Caryn Amedee ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

We describe the process by which we developed a statewide field destination protocol to transport patients with suspected emergent large vessel occlusion to a comprehensive stroke center.

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