Abstract TMP72: Auto-Launching of Interfacility Transport for Presumed Emergent Large Vessel Occlusion Strokes Decreases Door-In-Door-Out (DIDO) Times and May Improve Outcomes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Zammit ◽  
Sarah Gallagher ◽  
Diana Proper ◽  
Benjamin George ◽  
David Halpert ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Medical Center ◽  
New York State ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Regional System ◽  
Post Code ◽  
Interfacility Transport

Introduction: Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care. Methods: Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC), Cayuga Medical Center (CMC), and Geneva General Hospital (GGH) are NYS-DSCs located 115, 91, and 50 miles from SMH, respectively. Clinical leaders at each site collaborated to implement an integrated regional system of care for LVO-AIS, dubbed “Code LVO”, which includes the auto-launching of an interfacility transport to the referring hospital for presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours. We retrospectively reviewed a QA database for transfer patients with an ASPECTS of >/= 6 and proximal anterior circulation LVO on a CTA at the referring hospital to identify the door-in-door-out (DIDO) times, thrombectomy attempt rate, and mortality of patients before and after Code LVO implementation. Wilcoxon Rank-Sum was used to analyze median DIDO times and Fisher’s exact was used to analyze the proportion of DIDO times of < 90 minutes, < 60 minutes, thrombectomy attempt rate, and mortality. Results: There were 51 pre- Code LVO versus 12 post Code-LVO transfers. The median DIDO times were significantly reduced post-Code LVO (80 vs 127 minutes, p=0.001). The proportion of DIDO times < 90 minutes and < 60 minutes were significantly improved (58% vs 16%, p=0.005 and 17% vs 0%, p=0.034, respectively). Mortality was numerically, but not significantly, reduced (17% vs 22%). Median DIDO times were significantly shorter in those undergoing thrombectomy (97 vs 136 minutes, p=0.008) and numerically longer in those who died (138 vs 112 minutes, p=0.24). Conclusions: Auto-launching of interfacility transport within an integrated regional system care for LVO-AIS decreases DIDO times and may improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.

Feasibility and safety of the strategy of first stenting without retrieval using Solitaire FR as a treatment for emergent large-vessel occlusion due to underlying intracranial atherosclerosis

2021 ◽  
pp. 1-9
Author(s):  
Jong-Hoon Kim ◽  
Young-Jin Jung ◽  
Chul-Hoon Chang
Keyword(s):  
Functional Outcomes ◽  
Medical Center ◽  
Large Vessel ◽  
Intracranial Atherosclerosis ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stent Retrieval ◽  
First Pass ◽  
Solitaire Fr

OBJECTIVEThe optimal treatment for underlying intracranial atherosclerosis (ICAS) in patients with emergent large-vessel occlusion (ELVO) remains unclear. Reocclusion during endovascular treatment (EVT) occurs frequently (57.1%–77.3%) after initial recanalization with stent retriever (SR) thrombectomy in ICAS-related ELVO. This study aimed to compare treatment outcomes of the strategy of first stenting without retrieval (FRESH) using the Solitaire FR versus SR thrombectomy in patients with ICAS-related ELVO.METHODSThe authors retrospectively reviewed consecutive patients with acute ischemic stroke and intracranial ELVO of the anterior circulation who underwent EVT between January 2017 and December 2019 at Yeungnam University Medical Center. Large-vessel occlusion (LVO) of the anterior circulation was classified by etiology as follows: 1) no significant stenosis after recanalization (embolic group) and 2) remnant stenosis > 70% or lesser degree of stenosis with a tendency toward reocclusion and/or flow impairment during EVT (ICAS group). The ICAS group was divided into the SR thrombectomy group (SR thrombectomy) and the FRESH group.RESULTSA total of 105 patients (62 men and 43 women; median age 71 years, IQR 62.5–79 years) were included. The embolic, SR thrombectomy, and FRESH groups comprised 66 (62.9%), 26 (24.7%), and 13 (12.4%) patients, respectively. There were no significant differences between the SR thrombectomy and FRESH groups in symptom onset–to-door time, but puncture-to-recanalization time was significantly shorter in the latter group (39 vs 54 minutes, p = 0.032). There were fewer stent retrieval passes but more first-pass recanalizations in the FRESH group (p < 0.001). Favorable functional outcomes were significantly more frequent in the FRESH group (84.6% vs 42.3%, p = 0.017).CONCLUSIONSThis study’s findings suggest that FRESH, rather than rescue stenting, could be a treatment option for ICAS-related ELVO.

scholarly journals Acute Stroke With Large Vessel Occlusion and Minor Clinical Deficits: Prognostic Factors and Therapeutic Implications

2021 ◽  
Vol 12 ◽  
Author(s):  
Bastian Volbers ◽  
Rebecca Gröger ◽  
Tobias Engelhorn ◽  
Armin Marsch ◽  
Kosmas Macha ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Functional Outcome ◽  
Mechanical Thrombectomy ◽  
Medical Center ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Poor Outcome ◽  
Clinical Deficits

Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients.Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor).Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p &lt; 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90.Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.

scholarly journals Factors associated with prominent vessel sign on susceptibility-weighted imaging in acute ischemic stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hai-fei Jiang ◽  
Yi-qun Zhang ◽  
Jiang-xia Pang ◽  
Pei-ning Shao ◽  
Han-cheng Qiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Large Vessel ◽  
Susceptibility Weighted Imaging ◽  
Regression Analyses ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Factors Associated ◽  
Univariate Analyses

AbstractThe prominent vessel sign (PVS) on susceptibility-weighted imaging (SWI) is not displayed in all cases of acute ischemia. We aimed to investigate the factors associated with the presence of PVS in stroke patients. Consecutive ischemic stroke patients admitted within 24 h from symptom onset underwent emergency multimodal MRI at admission. Associated factors for the presence of PVS were analyzed using univariate analyses and multivariable logistic regression analyses. A total of 218 patients were enrolled. The occurrence rate of PVS was 55.5%. Univariate analyses showed significant differences between PVS-positive group and PVS-negative group in age, history of coronary heart disease, baseline NIHSS scores, total cholesterol, hemoglobin, anterior circulation infarct, large vessel occlusion, and cardioembolism. Multivariable logistic regression analyses revealed that the independent factors associated with PVS were anterior circulation infarct (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.5–53.3), large vessel occlusion (OR 123.3; 95% CI 33.7–451.5), and cardioembolism (OR 5.6; 95% CI 2.1–15.3). Anterior circulation infarct, large vessel occlusion, and cardioembolism are independently associated with the presence of PVS on SWI.

Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eytan Raz ◽  
Seena Dehkharghani ◽  
Howard Riina ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Secondary Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Consumption Rates ◽  
Definition Of ◽  
Post Hoc ◽  
New Generation

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax > 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

Abstract 202: Endovascular Therapy for Acute Ischemic Stroke With Distal Large Vessel Occlusion in the Anterior Circulation

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Amrou Sarraj ◽  
Navdeep Sangha ◽  
Muhammad Shazam Hussain ◽  
Dolora Wisco ◽  
Nirav Vora ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Primary Outcome ◽  
Large Vessel ◽  
Secondary Outcome ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Baseline Characteristics ◽  
Iv Tpa

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P <0.001) even after adjustment for age, NIHSS, ASPECTS, IV tPA and LKN to door time (OR: 3.2, 95%CI: 2-5.2, P<0.001). sICH rate was 5.6 %, which was not statistically different than the MM group (table 1, P=0.1). Age, NIHSS, good ASPECTS, LKN to reperfusion time and successful reperfusion mTICI ≥ 2b were independent predictors of good outcome in EVT patients. There was a linear relationship between good outcome and time LKN to reperfusion (Figure 3). Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

Efficient Multimodal MRI Evaluation for Endovascular Thrombectomy of Anterior Circulation Large Vessel Occlusion

2020 ◽  
Vol 29 (12) ◽  
pp. 105271
Author(s):  
Kunakorn Atchaneeyasakul ◽  
David S. Liebeskind ◽  
Reza Jahan ◽  
Sidney Starkman ◽  
Latisha Sharma ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Multimodal Mri ◽  
Mri Evaluation

Abstract 1122‐000022: Delays in Care for Patients with Acute Stroke During Hospitalization for Other Reasons

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Nicholas Vigilante ◽  
Parth Patel ◽  
Prasanth Romiyo ◽  
Lauren Thau ◽  
Mark Heslin ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Acute Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Single Center ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptom Recognition ◽  
Risk Patients ◽  
Recognition Imaging

Introduction : In‐hospital stroke (IHS) is defined as stroke that occurs during hospitalization for non‐stroke conditions. We aimed to understand the timing of symptom recognition for patients who experienced IHS and its impact on the care they receive. Methods : A prospective, single center registry of adult patients (9/20/19‐2/28/21) was queried for acute anterior circulation IHS. Indications for hospitalization, delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored. Results : Of 928 consecutively evaluated adults with acute stroke, 85 (9%) developed an anterior circulation IHS, 39 (46%) of whom were female, with a median age of 67 years (IQR 60–76) and median NIHSS of 15 (IQR 4–22). Sixty‐eight (80%) had a >1 hour delay from last known well to symptom recognition. Two patients (2%) received IV thrombolysis, although another 38 (45%) would have been eligible if not for a delay in symptom recognition. An ICA, M1, or M2 occlusion was observed in 18 patients (21%), 7 of whom were treated at a median of 174 minutes after LKW (IQR 65–219). Compared to the 11 patients who did not undergo thrombectomy with large vessel occlusion, those who underwent thrombectomy had non‐significantly shorter delays from LKW until neuroimaging (median 85 [IQR 65‐162] vs. 216 [IQR 133‐507], p = 0.12). Conclusions : While uncommon, patients with IHS experience delays in symptom recognition and treatment, which lead to exclusion from acute care treatment such as thrombolysis and thrombectomy. Earlier detection with more frequent nursing assessments or advanced neuromonitoring devices in at‐risk patients may reduce delays in care.

scholarly journals Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽  
2021 ◽  
Author(s):  
Raul G. Nogueira ◽  
Jason M. Davies ◽  
Rishi Gupta ◽  
Ameer E. Hassan ◽  
Thomas Devlin ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Acute Stroke ◽  
Systems Of Care ◽  
Ct Perfusion ◽  
Stroke Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph F Carrera ◽  
Joseph H Donahue ◽  
Prem P Batchala ◽  
Andrew M Southerland ◽  
Bradford B Worrall
Keyword(s):  
Linear Regression ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

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