Abstract WP394: Impact of MRI/A versus CTA/P versus Direct Angiosuite Triage Protocols in Stroke Care Performance and Outcome of Transferred Patients for Endovascular Thrombectomy

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area.Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 (“first wave”), and between September 15 and November 30, 2020 (“second wave”). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19.Results: During the “first wave,” 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the “second wave” were infected with SARS-CoV-2 (p < 0.001). During the “second wave,” more SU staff members were infected with COVID-19 than during the “first wave” (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60–47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04–34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed.Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the “second wave” of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

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Abstract P128: Impact of the COVID-19 Pandemic in Houston on Stroke Care in a Health System of 10 Stroke Centers

Stroke ◽

10.1161/str.52.suppl_1.p128 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Sujan T Reddy ◽

Tzu-ching Wu ◽

Suja S Rajan ◽

Amirali Tahanan ◽

Mohammad H Rahbar ◽

...

Keyword(s):

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Health System ◽

Stroke Care ◽

Pandemic Preparedness ◽

Initial Drop ◽

Mild Stroke ◽

Transferred Patients ◽

The Impact

Introduction: We assessed the impact of COVID-19 pandemic on stroke admissions and care metrics within a health system of 10 stroke centers, with 4 comprehensive stroke centers (CSC) in the greater Houston region. Methods: Between January-June 2019 and January-June 2020, we compared the proportion of ischemic strokes (total & direct CSC presentations) & intracerebral hemorrhage (ICH) relative to total admissions using logistic regression, and among the direct CSC presentations, we compared door to tPA and thrombectomy times using Wilcoxon Rank Sum. Results: A total of 4808 cases were assessed (Table 1). There was an initial drop of ~30% in cases at the pandemic onset (Fig.1). Numerically fewer patients in the 2020 period were seen at primary and CSCs (Table 1). Compared to 2019, there was a significant reduction in transferred patients [N(%), 829 (36) vs. 637 (34), p=0.02], in hospital strokes [N(%), 111 (5) vs. 69 (4), p=0.04], and mild strokes (NIHSS 1-5) [N (%), 891 (43) vs. 635 (40),p=0.02], and no significant differences in the proportions of total ischemic strokes [OR (95% CI)=0.92 (0.79, 1.06), p=0.23], direct CSC presentations [OR (95% CI) =0.96 (0.86, 1.08), p=0.48] and ICH [OR (95% CI) =1.14 (0.98, 1.33), p=0.08] in 2020 (Fig. 1). Among the direct ischemic strokes at CSCs, there were similar mean (SD) (mins) door to tPA [44 (17) vs. 42 (17), p=0.14] but significantly prolonged door to thrombectomy times [94 (15) vs. 85 (20), p=0.005] in 2020. Conclusion: COVID-19 pandemic led to reduced mild stroke admissions, transfers and in hospital stroke alerts, & prolonged door to thrombectomy times. Identifying reasons to mitigate this discrepancy is crucial for next pandemic preparedness.

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Pediatric Thrombectomy

Stroke ◽

10.1161/strokeaha.120.032268 ◽

2021 ◽

Author(s):

David C. Lauzier ◽

Maria M. Galardi ◽

Kristin P. Guilliams ◽

Manu S. Goyal ◽

Catherine Amlie-Lefond ◽

...

Keyword(s):

Stroke Care ◽

Hospital Environment ◽

Pediatric Stroke ◽

Design Features ◽

Endovascular Thrombectomy ◽

Similar Role ◽

Stroke Imaging ◽

Workflow Integration

Endovascular thrombectomy has played a major role in advancing adult stroke care and may serve a similar role in pediatric stroke care. However, there is a need to develop better evidence and infrastructure for pediatric stroke care. In this work, we review 2 experienced pediatric endovascular thrombectomy programs and examine key design features in both care environments, including a formalized protocol and workflow, integration with an adult endovascular thrombectomy workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke.

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Economic evaluation of the Melbourne Mobile Stroke Unit

International Journal of Stroke ◽

10.1177/1747493020929944 ◽

2020 ◽

pp. 174749302092994 ◽

Cited By ~ 1

Author(s):

Joosup Kim ◽

Damien Easton ◽

Henry Zhao ◽

Skye Coote ◽

Garveeta Sookram ◽

...

Keyword(s):

Stroke Unit ◽

Standard Care ◽

Stroke Care ◽

Reperfusion Therapy ◽

Sensitivity Analyses ◽

Local Data ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Mobile Stroke Unit ◽

Life Years

Background The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy. Aims To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care). Methods The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses. Results In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care. Conclusions There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.

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Diagnosis and management of acute ischaemic stroke

Practical Neurology ◽

10.1136/practneurol-2020-002557 ◽

2020 ◽

Vol 20 (4) ◽

pp. 304-316 ◽

Cited By ~ 1

Author(s):

Robert Hurford ◽

Alakendu Sekhar ◽

Tom A T Hughes ◽

Keith W Muir

Keyword(s):

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Neuronal Damage ◽

Early Recognition ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Close Monitoring ◽

Endovascular Thrombectomy ◽

Early Neurological Deterioration ◽

Ischaemic Penumbra

Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.

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Studying Stroke Thrombus Composition After Thrombectomy: What Can We Learn?

Stroke ◽

10.1161/strokeaha.121.034289 ◽

2021 ◽

Author(s):

Senna Staessens ◽

Olivier François ◽

Waleed Brinjikji ◽

Karen M. Doyle ◽

Peter Vanacker ◽

...

Keyword(s):

Endovascular Procedures ◽

Stroke Care ◽

Lessons Learned ◽

Success Rates ◽

Complex Composition ◽

Comprehensive Overview ◽

Endovascular Thrombectomy ◽

Extracellular Traps ◽

Von Willebrand ◽

Willebrand Factor

The composition of ischemic stroke thrombi has gained an increasing amount of interest in recent years. The implementation of endovascular procedures in standard stroke care has granted researchers the unique opportunity to examine patient thrombus material. Increasing evidence indicates that stroke thrombi are complex and heterogenous, consisting of various biochemical (eg, fibrin, von Willebrand factor, and neutrophil extracellular traps) and cellular (eg, red blood cells, platelets, leukocytes, and bacteria) components. This complex composition may explain therapeutic limitations and also offer novel insights in several aspects of stroke management. Better understanding of thrombus characteristics could, therefore, potentially lead to improvements in the management of patients with stroke. In this review, we provide a comprehensive overview of the lessons learned by examining stroke thrombus composition after endovascular thrombectomy and its potential relevance for thrombectomy success rates, thrombolysis, clinical outcomes, stroke etiology, and radiological imaging.

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Validation of Hospital Performance Measures of Acute Stroke Care Quality. Riksstroke, the Swedish Stroke Register

Neuroepidemiology ◽

10.1159/000444679 ◽

2016 ◽

Vol 46 (4) ◽

pp. 229-234 ◽

Cited By ~ 9

Author(s):

Anna Söderholm ◽

Birgitta Stegmayr ◽

Eva-Lotta Glader ◽

Kjell Asplund ◽

Keyword(s):

Data Quality ◽

Acute Stroke ◽

Stroke Care ◽

Hospital Performance ◽

Care Quality ◽

Sufficient Data ◽

Stroke Patients ◽

Acute Stroke Care ◽

Stroke Register ◽

Care Performance

Background: Registers are increasingly used to monitor stroke care performance. Fair benchmarking requires sufficient data quality. We have validated acute care data in Riksstroke, the Swedish Stroke Register. Methods: Completeness was assessed by comparisons with diagnoses at hospital discharge recorded in the compulsory National Patient Register and content validity by comparisons with (a) key variables identified by European stroke experts, and (b) items recorded in other European stroke care performance registers. Five test cases recorded by 67 hospitals were used to estimate inter-hospital reliability. Results: All 72 Swedish hospitals admitting acute stroke patients participated in Riksstroke. The register was estimated to cover at least 90% of acute stroke patients. It includes 18 of 22 quality indicators identified by international stroke experts and 14 of 15 indicators used by at least 2 stroke performance registers in other European countries. Inter-hospital reliability was high (≥85%) in 77 of 81 Riksstroke items. Conclusions: A nationwide stroke care register can be maintained with sufficient data quality to permit between-hospital performance benchmarking. Our experiences may serve as a model for other stroke registers while evaluating data quality.

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Rapid Endovascular Treatment of Acute Ischemic Stroke: What a General Radiologist Should Know

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2016.10.002 ◽

2017 ◽

Vol 68 (2) ◽

pp. 154-160 ◽

Cited By ~ 4

Author(s):

Elizabeth H.Y. Du ◽

Jai J.S. Shankar

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Standard Of Care ◽

Stroke Care ◽

Large Vessel ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Disability Adjusted Life ◽

Life Years ◽

Workflow Efficiency

Stroke is the second leading cause of mortality and the third leading cause of disability-adjusted life-years worldwide. For each minute of an ischemic stroke, an estimated 1.9 million brain cells die. The year 2015 saw the unprecedented publication of 5 multicentre, randomized, controlled trials. These studies showed that patients with acute ischemic stroke caused by large-vessel thrombus occlusion of the proximal anterior circulation had significantly reduced disability at 90 days when treated with endovascular thrombectomy and usual stroke care compared to usual stroke care alone. As a result, endovascular thrombectomy is now the new North American and European standard of care for suitable patients with acute ischemic stroke caused by large-vessel proximal anterior circulation occlusion. We review key take-home messages in this paradigm shift for radiologists, including the importance of time and workflow efficiency, what currently constitutes appropriate preimaging patient selection and imaging criteria, the use of newer generation thrombectomy devices, safety outcomes, as well as further areas still in need of elucidation.

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Abstract P589: Pediatric Thrombectomy: Design And Workflow Lessons From Two Experienced Centers

Stroke ◽

10.1161/str.52.suppl_1.p589 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

David C Lauzier ◽

Maria M Galardi ◽

Kristin Guilliams ◽

Manu S Goyal ◽

Catherine Amlie-Lefond ◽

...

Keyword(s):

Case Reports ◽

Quality Care ◽

Stroke Care ◽

Outcome Data ◽

Hospital Environment ◽

Pediatric Stroke ◽

Endovascular Thrombectomy ◽

Stroke Imaging ◽

Workflow Integration ◽

Low Incidence

Introduction: While clinical trials have demonstrated the remarkable efficacy of endovascular thrombectomy (EVT) for treating adult patients suffering from acute ischemic stroke (AIS), benefits reaped from advances in adult stroke care have unfortunately not occurred in parallel with pediatric stroke care. Randomized trials of EVT in childhood stroke are unlikely given the low incidence of stroke in children compared to adults, and despite promising outcomes in small case reports and series, EVT in children remains an off-label procedure lacking established consensus guidelines. Along with a clear need to collect prospective pediatric EVT outcome data, there is a need to enhance pediatric stroke care infrastructure to provide high-quality care to children experiencing stroke. Methods: In this work, we review two successful pediatric thrombectomy programs, examining key workflow design features that are likely to be important for other programs that aspire to implement pediatric EVT capability. Discussion: While pediatric EVT workflows will vary between centers, we identify several key elements of programmatic success shared between the two reviewed stroke programs that may serve as foundational design considerations for centers aiming to develop their own pediatric EVT programs. These elements include a formalized protocol and workflow, integration with an adult EVT workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke. Conclusion: EVT shows promise in reducing stroke-associated morbidity in children. To maximize the efficacy of this intervention, workflow optimizations discussed here should be implemented by centers seeking to develop local pediatric EVT capability.

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