Abstract 95: The Mobile Interventional Stroke Team (MIST) Model Improves Early Outcomes in Elvo Stroke: The NYC Mist Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jacob R Morey ◽  
Thomas J Oxley ◽  
Daniel Wei ◽  
Hazem Shoirah ◽  
Xiangnan Zhang ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Standard Of Care ◽  
Patient Transfer ◽  
Vessel Occlusion ◽  
Delivery Of Care ◽  
Stroke Team ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
Patient Presentation

Introduction: Endovascular therapy (EVT) has become the standard of care for treatment of emergent large vessel occlusion (ELVO) in ischemic stroke. It is a time sensitive procedure that has previously only been performed at comprehensive stroke centers (CSC). Transfer was required for patients presenting at a primary stroke center (PSC). PSCs with interventional capacity (PSCI) have emerged to increase access to EVT. We have developed a Mobile Interventional Stroke Team (MIST) model, in which a MIST transfers from a CSC to PSCI to perform EVT. Hypothesis: The delivery of care by the MIST at PSCIs is more time efficient and leads to improved clinical outcomes in comparison to transferring patients from a PSC to PSCI or CSC and comparable to direct presentation to a CSC. Methods: Analysis of prospectively collected data from 228 patients who received EVT for ELVO at a CSC or 4 PSCIs between June 2016 - December 2018 was performed. The cohorts include: Mothership with patient presentation to CSC (n=20), Drip-and-Ship with patient transfer from PSC or PSCI to CSC (DS) (n=114), MIST and patient presentation to PSCI (n=64), and DS with patient transfer from PSC to PSCI and MIST (DS/MIST) (n=30). The primary outcome was initial door-to-recanalization. Secondary outcomes measured other time intervals and clinical outcomes at discharge and 3 months. Results: MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes (p < 0.05). MIST and Mothership had similar median times of 192 minutes and 181 minutes, respectively (p = 0.84). A greater proportion of patients reached a discharge NIHSS of 0 or 1 in MIST compared to DS (34% vs. 17%; p < 0.01). MIST led to 53% with a mRS of ≤ 2 at 3 months compared to 39% in DS, although not statistically significant (p = 0.10). Conclusions: MIST has led to significantly faster initial door-to-recanalization times compared to DS. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes.

scholarly journals Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke

Stroke ◽  
2020 ◽  
Vol 51 (12) ◽  
pp. 3495-3503 ◽  
Author(s):  
Jacob R. Morey ◽  
Thomas J. Oxley ◽  
Daniel Wei ◽  
Christopher P. Kellner ◽  
Neha S. Dangayach ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Endovascular Therapy ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Team ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Patient Presentation

Background and Purpose: Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models. Methods: This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months. Results: MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes ( P <0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively ( P =0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%; P <0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS ( P =0.10). Conclusions: MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03048292.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

2021 ◽  
pp. 194187442110070
Author(s):  
Felix Ejike Chukwudelunzu ◽  
Bart M Demaerschalk ◽  
Leonardo Fugoso ◽  
Emeka Amadi ◽  
Donn Dexter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Statistical Significance ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Community Based ◽  
Chi Square ◽  
Stroke Team ◽  
Primary Stroke Center ◽  
Stroke Center

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

Real-World Experience with Artificial Intelligence-Based Triage in Transferred Large Vessel Occlusion Stroke Patients

2021 ◽  
pp. 1-6
Author(s):  
Jacob R. Morey ◽  
Xiangnan Zhang ◽  
Kurt A. Yaeger ◽  
Emily Fiano ◽  
Naoum Fares Marayati ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Clinical Outcomes ◽  
Warning System ◽  
Large Vessel ◽  
Time Interval ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Left Behind ◽  
Stroke Center

<b><i>Background and Purpose:</i></b> Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) in clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A computer-aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, a communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment, leading to improved clinical outcomes. <b><i>Methods:</i></b> A retrospective analysis of a prospectively maintained database was assessed for patients who presented to a stroke center currently utilizing Viz LVO and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. Time intervals and clinical outcomes were compared for 55 patients divided into pre- and post-Viz cohorts. <b><i>Results:</i></b> The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 min [IQR = 12.0] vs. 40.0 min [IQR = 61.0]; <i>p</i> = 0.01) with less variation (<i>p</i> &#x3c; 0.05) following Viz LVO implementation. The median initial door-to-skin puncture time interval was 25 min shorter in the post-Viz cohort, although this was not statistically significant (<i>p</i> = 0.15). <b><i>Conclusions:</i></b> Preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times. This application can serve as an early warning system and a failsafe to ensure that no LVO is left behind.

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.

scholarly journals Impact of Viz LVO on Time-to-Treatment and Clinical Outcomes in Large Vessel Occlusion Stroke Patients Presenting to Primary Stroke Centers

2020 ◽  
Author(s):  
Jacob R. Morey ◽  
Emily Fiano ◽  
Kurt A. Yaeger ◽  
Xiangnan Zhang ◽  
Johanna T. Fifi
Keyword(s):  
New York ◽  
Clinical Outcomes ◽  
Large Vessel ◽  
Similar Proportion ◽  
Time Interval ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Time To Treatment ◽  
Comprehensive Stroke Center ◽  
Stroke Center

AbstractIntroductionRandomized controlled trials have demonstrated the importance of time-to-treatment on clinical outcomes in large vessel occlusion (LVO) stroke. Delays in interventional radiology (INR) consultation are associated with a significant delay in overall time to endovascular treatment (EVT). Delays in EVT are particularly prevalent in Primary Stroke Centers (PSC), hospitals without thrombectomy capability onsite, where the patient requires transfer to a Thrombectomy Capable or Comprehensive Stroke Center for EVT. A novel computer aided triage system, Viz LVO, assists in early notification of the PSC stroke team and affiliated INR team. This platform includes an image viewer, communication system, and an artificial intelligence algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts.HypothesisViz LVO will decrease time-to-treatment and improve clinical outcomes.MethodsA prospectively maintained database was assessed for all patients who presented to a PSC currently utilizing Viz LVO in the Mount Sinai Health System in New York and underwent EVT following transfer for LVO stroke between October 1, 2018 and March 15, 2020. There were 42 patients who fit the inclusion criteria and divided into pre- and post-Viz ContaCT implementation by comparing the periods of October 1, 2018, to March 15, 2019, “Pre-Viz”, and October 1, 2019, to March 15, 2020, “Post-Viz.” Time intervals and clinical outcomes were collected and compared.ResultsThe Pre- and Post-Viz cohorts were similar in terms of gender, age, proportion receiving IV-tPA, and proportion with revascularization of TICI > 2B. The presenting NIHSS and pre-stroke mRS scores were not statistically different.The median initial door-to-INR notification was significantly faster in the post-Viz cohort (21.5 minutes vs 36 minutes; p=0.02). The median initial door-to-puncture time interval was 20 minutes shorter in the Post-Viz cohort, but this was not statistically significant (p=0.20).The 5-day NIHSS and discharge mRS were both significantly lower in the Post-Viz cohort (p=0.02 and p=0.03, respectively). The median 90-day mRS scores were also significantly lower post-Viz implementation, although a similar proportion received a good outcome (mRS score ≤ 2) (p=0.02 and p=0.42, respectively).ConclusionsEVT is a time-sensitive intervention that is only available at select stroke centers. Significant delays in time-to-treatment are present when patients require transfer from PSCs to a EVT capable stroke center. In a large health care system, we have shown that Viz LVO implementation is associated with improved time to INR notification and clinical outcomes. Viz LVO has the potential for wide-spread improvement in clinical outcomes with implementation across large hub and stroke systems across the country.

Abstract TP3: What Hospital Characteristics Drive Faster Thrombectomy For Emergent Large Vessel Occlusion (ELVO)?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jason Tarpley ◽  
Lindsay Lucas ◽  
Joseph T Ho ◽  
Renee Ovando ◽  
Elizabeth Baraban
Keyword(s):  
Arrival Time ◽  
High Volume ◽  
Reperfusion Therapy ◽  
Multivariate Logistic Regression Model ◽  
Vessel Occlusion ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Treatment Volume ◽  
Transferred Patients ◽  
Stroke Center

Introduction: Recent thrombectomy trials for ELVO have reverberated the importance of speed in reperfusion therapy. Identifying hospital practices and features associated with faster door to thrombectomy times is critical to evolving our hospital systems to effectively deliver this powerful therapy. Methods: A multi-hospital, Get with the Guidelines stroke registry was used to identify AIS patients who received intra-arterial (IA) intervention between January 2012 and May 2016. Transferred patients were excluded since their door to reperfusion times don’t typically include a primary evaluation. Patients were categorized as having door to reperfusion (Door-to-IA) time over 135 minutes or Door-to-IA time below or equal to 135 minutes. A multivariate logistic regression model was used to identify which of the following variables were associated with Door-to-IA times over 135 minutes: age, gender, IV alteplase treatment, admit NIHSS score, patient arrival time to hospital, hospital certification (primary stroke center (PSC) versus comprehensive stroke center (CSC)), hospital annual IA treatment volume, and hospital annual percentage of transfers for thrombectomy. Results: We identified 229 AIS patients from ten hospitals who received IA intervention between January 2012 and May 2016. Of those, 49% (n=113) had Door-to-IA times over 135 minutes and 51% (n=116) had Door-to-IA time below or equal to 135 minutes. Patients with Door-to-IA times over 135 minutes were more likely to be older (adjusted odds ratio (AOR) = 1.02 per year; p=.040), treated at a PSC (AOR = 2.26; p=.028), and treated at a hospital with a higher percentage of transfers (AOR = 1.08 per percentage point; p<.001). IV-alteplase treatment, gender, NIHSS, patients’ arrival time and volume were not significant. Conclusion: Comprehensive stroke centers had shorter Door-to-IA times than Primary Stroke Centers in our system. However, hospital annual IA treatment volume did not impact Door-to-IA and centers with larger transfer volume actually had worse Door-to-IA times for patients evaluated and treated locally. This suggests that high volume centers with a larger volume of transferred patients may have tuned their practices to treating transfers rather than treating local ELVO patients.

Abstract MP35: Blood Pressure Reductions Before Arrival at a Thrombectomy-Capable Hospital Are Associated With Neurologic Worsening in Patients With Large-Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jessica Kobsa ◽  
Ayush Prasad ◽  
Alexandria Soto ◽  
Sreeja Kodali ◽  
Cindy Khanh Nguyen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Management Strategies ◽  
Vessel Occlusion ◽  
Time Points ◽  
Good Outcome ◽  
Primary Stroke Center ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Radiographic Data

Introduction: Decreases in blood pressure (BP) during thrombectomy are associated with infarct progression and worse outcomes. Many patients present first to a primary stroke center (PSC) and are later transferred to a comprehensive stroke center (CSC) to undergo thrombectomy. During this period, important BP variations might occur. We evaluated the association of BP reductions with neurological worsening and functional outcomes. Methods: We prospectively collected hemodynamic, clinical, and radiographic data on consecutive patients with LVO ischemic stroke who were transferred from a PSC for possible thrombectomy between 2018 and 2020. We assessed systolic BP (SBP) and mean arterial pressure (MAP) at five time points: earliest recorded, average pre-PSC, PSC admission, average PSC, and CSC admission. We measured neurologic worsening as a change in NIHSS (ΔNIHSS) from PSC to CSC >3 and functional outcome using the modified Rankin Scale (mRS) at discharge and 90 days. Relationships between variables of interest were evaluated using linear regression. Results: Of 91 patients (mean age 70±16 years, mean NIHSS 12) included, 13 (14%) experienced early neurologic deterioration (ΔNIHSS>3), and 34 (37%) achieved a good outcome at discharge (mRS<3). We found that patients with good outcome had significantly lower SBP at all five assessed time points compared to patients with poor outcome (Figure 1, p<0.05). Percent change in MAP from initial presentation to CSC arrival was independently associated with ΔNIHSS after adjusting for age, sex, and transfer time (p=0.03, β=0.27). Conclusions: Patients with poor outcomes have higher BP throughout the pre-CSC period, possibly reflecting an augmented hypertensive response. Reductions in SBP and MAP before arrival at the CSC are associated with neurologic worsening. These results suggest that BP management strategies in the pre-CSC period to avoid large reductions in BP may improve outcomes in patients affected by LVO stroke.

Abstract WP340: Impact of Increasing Primary Stroke Center Transfers on Comprehensive Stroke Center Capacity

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jane Holl ◽  
Andy Cai ◽  
Lauren Ha ◽  
Alin Hulli ◽  
Melina Paan ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Vessel Occlusion ◽  
Capacity Limits ◽  
Transfer Rates ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Occupancy Rates ◽  
Bed Occupancy Rates

Introduction: Given the time-sensitive benefits of acute stroke (AS) treatments, stroke systems of care must balance reducing door-in-door-out (DIDO) time at primary stroke centers (PSCs) with capacity limits at comprehensive stroke centers (CSCs). For example transferring more AS patients earlier in the process (e.g., prior vascular imaging for large vessel occlusion) from PSCs would result in more inappropriate transfers to CSCs that could overburden these centers.We conducted a simulation to estimate the balance between increased AS transfers from PSCs to CSCs and the percent of CSC time on “bypass” (inability to accept transfers to neuro-ICU). Methods: Clinicians from 3 Chicago-area CSCs and 3 affiliated PSCs and the Chicago Emergency Medical Services (EMS) created a PSC DIDO process map. We assumed CSC time on bypass is affected by AS and non-AS admissions from the CSC and from the affiliated PSCs. Input data were obtained fromtheChicago region registry (e.g., # PSC to CSC transfers), peer reviewed literature (US average transfer rate of AS patients to CSCs), EMS (PSC-CSC affiliations), and CSCs (e.g., average bed occupancy rates). CSC size was estimated by #neuro-ICU beds: small (12 beds), medium (23 beds), and large (28 beds). The simulation output was % time of CSC on “bypass”. Results: Table shows % time of CSC on bypass by varying PSC AS transfer rates for each category of CSC size. Larger increases in PSC transfer rates resulted in modest increases in CSC bypass rates, particularly for medium and large CSCs. Validation with data from one CSC showed < 4% overestimate of CSC % time on bypass. Conclusion: CSCs with more beds have efficiencies of scale leading to lower % time on bypass, even with increases in PSC AS transfer rates proportionate to CSC size. This model allows stroke systems of care to compute regional CSCs’ % time on bypass based on actual PSCs’ transfer rates and CSC size.

Sign in / Sign up

Export Citation Format

Share Document