Abstract TP304: Mimicking Acute Stroke Findings With a Digital Avatar

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Maryam Pourebadi ◽  
Jamie N LaBuzetta ◽  
Cynthia Gonzalez ◽  
Preetham Suresh ◽  
Laurel Riek
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Facial Expressions ◽  
Computational Models ◽  
Medical Center ◽  
Academic Medical Center ◽  
Video Stream ◽  
Feature Points ◽  
Patient Simulators

Introduction: It is now well-accepted that simulation-based learning (SBL) is an important component of medical education. At our institution, we have a state-of-the-art simulation center, and SBL is already incorporated into many medical subspecialties. However, commercially available patient simulators have static faces and lack the realistic depiction of non-verbal facial cues important for rapid diagnosis of neurological emergencies such as stroke. This multidisciplinary project addresses the urgent need for expressive patient simulators by developing acute stroke avatars for use in simulated healthcare training. Methods: Using a previously published and validated method, we developed techniques to display stroke pathologies on a virtual patient simulator (VPS). After obtaining patient or surrogate consent, we obtained source videos from patients admitted to an academic medical center who had experienced acute ischemic stroke resulting in neurological findings such as facial droop, eyelid apraxia, dysarthria, and coma. We then extracted facial features using shape-based modeling techniques, leaving anonymous feature points. Next, we applied a novel algorithm to use these feature points to build accurate computational models (masks) representing the facial characteristics of stroke. We then overlaid these prebuilt masks onto a live facial video stream to generate asymmetric expressions on a virtual avatar. This project was IRB approved. Results: More than 21 videos of stroke patients were made. Once the feature points were extracted from these videos, we were able to develop VPSs capable of expressing realistic asymmetric facial expressions. These avatars were then validated amongst neurologists with clinical experience in diagnosing acute ischemic stroke. Conclusions: This multidisciplinary effort using patient-inspired facial expressions resulted in a tool that aids the stroke education community by making virtual and robotic simulators of acute stroke more varied, interactive, and realistic.

Abstract 3048: Real-World Clinical Use of CT Perfusion for Diagnosis and Prediction of Lesion Growth in Acute Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Branko N Huisa ◽  
William P Neil ◽  
Nhu T Bruce ◽  
Marcel Maya ◽  
Benedict Pereira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Medical Center ◽  
Brain Mri ◽  
Academic Medical Center ◽  
Acute Ischemia ◽  
Perfusion Maps

Background: Diffusion-weighted imaging (DWI) detects acute ischemia with a high sensitivity. In research centers, qualitative CT perfusion (CTP) mapping correlates well with DWI and may accurately differentiate the infarct core from ischemic penumbra. The value of the CTP in real-world clinical practice, however, has not been fully established. We investigated the yield of CTP - derived cerebral blood volume (CBV) and mean transient time (MTT) for the detection of cerebral ischemia in a sample of acute ischemic stroke (AIS) patients. Methods: In a large metropolitan academic medical center that is a certified Primary Stroke Center (PSC) we retrospectively studied 162 patients who presented between January 2008 and July 2010 with symptoms suggestive of AIS. All patients had an initial Code Brain protocol including non-contrast head CT, CTP, and CTA. As clinically indicated, some patients underwent follow up brain MRI within 48 hours. Acute perfusion maps were derived in real time by a trained operator. From the obtained images CBV, MTT and DWI lesion volumes were manually traced using planimetry (ImageJ v1.42) by two stroke neurologists blinded to clinical information. Volumes were calculated using the Cavaleri theorem. Sensitivity, specificity and statistical analysis were calculated using Graph Pad 5.0. Results: Of 162 patients with acute stroke-like symptoms, 73 had DWI lesions. The sensitivity and specificity to detect abnormal DWI signals were 23% and 100%, for CBV; and 43.8% and 98.9% for MTT. For DWI lesions ≥5ml the yield was 59.3% for CVB and 77.8% for MTT. For lesions ≥10ml the yield was 68.4% for CBV and 89.5% for MTT. In patients with NIHSS ≥5, CBV predicted abnormal DWI in 22.6% and MTT in 35.5%. In patients with NIHSS ≥10, CBV and MTT, both had a yield of 50.0%. A CBV - MTT mismatch of >25% predicted MRI lesion extension in 81.25% of the cases. There were small but significant correlations for DWI versus CBV lesion volumes ( r 2 0.32, P= 0.0001), and for DWI versus MTT lesion volumes ( r 2 0.29, P <0.0001). Correlation between DWI and perfusion maps for MCA territory infarcts were CBV ( r 2 0.3, P <0.0001) and MTT ( r 2 0.45, P <0.0001). Conclusions: In real-world deployment during a Code Brain protocol in a busy PSC, acute imaging with CTP did not predict DWI lesions on brain MRI with sufficient accuracy. In patients with large lesions the predictive value was better.

Identification of Rate-Limiting Steps in the Provision of Thrombolytics for Acute Ischemic Stroke

2016 ◽  
Vol 30 (6) ◽  
pp. 606-611 ◽  
Author(s):  
Elise L. Metts ◽  
Abby M. Bailey ◽  
Kyle A. Weant ◽  
Stephanie B. Justice
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Blood Sample ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Heart Association ◽  
Turnaround Time ◽  
Ct Scanner ◽  
Physician Consultation

Background: Tissue plasminogen activator (tPA) is the only pharmacotherapy shown to improve outcomes in acute ischemic stroke. The American Heart Association (AHA) recommends a door-to-needle (DTN) time of <60 minutes in at least 50% of patients presenting with acute ischemic stroke. Objective: The purpose of this study was to analyze the possible barriers that may delay tPA administration within the emergency department (ED) of an academic medical center. Methods: A retrospective chart review was conducted from February 2011 to October 2013. Patients were included if they were admitted through the ED with a diagnosis of acute ischemic stroke and received tPA. Results: Of the 130 patients who met inclusion criteria, 43.1% received tPA in ≤60 minutes. Several factors were identified to be significantly different in those with a DTN time of >60 minutes—time to ED physician consultation, neurologist arrival, blood sample acquisition, and result time ( P < .05 for all comparisons). Correlation analysis demonstrated several independent variables associated with DTN time of ≤60 minutes—time from admission to ED physician consultation, receipt of computed tomography (CT) scan, blood sample acquisition, laboratory results, and neurology service arrival ( P < .05 for all comparisons). Conclusion: The findings from this study highlight the importance of prompt physician evaluation, direct transfer to the CT scanner, and a quick turnaround time on laboratory values. The development of protocols to ensure the rapid receipt of tPA therapy should focus on limiting any potential delay these steps may cause.

E-128 five-year endovascular acute ischemic stroke intervention experience at a rural academic medical center

2015 ◽  
Vol 7 (Suppl 1) ◽  
pp. A99.2-A100
Author(s):  
E Akture ◽  
C O'Neill ◽  
M Gorman ◽  
C Commichau ◽  
G Linnell ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical

Abstract TP208: Sleep Disordered Breathing (SDB) - An Overlooked Modifiable Risk Factor in Acute Stroke Care

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Vishal Shah ◽  
Ashrai Gudlavalleti ◽  
Julius G Latorre
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Sleep Disordered Breathing ◽  
Modifiable Risk Factor ◽  
Inclusion Criteria ◽  
Risk Of Death ◽  
Disordered Breathing

Introduction: In patients with acute stroke, part of the acute management entails identifying the risk factors; modifiable or non modifiable. Early recognition of these factors is essential for optimizing therapeutic procedures, especially those with a known effective treatment. In this sense, Sleep Disordered Breathing (SDB) has also been suggested as a modifiable and independent risk factor for stroke as defined by international guidelines and some studies have demonstrated that patients with stroke and particularly Obstructive Sleep Apnea (OSA) have an increased risk of death or new vascular events. Pathogenesis of ischemic stroke in SDB is probably related to worsening of existing cardiovascular risk factors such as hypertension and hypoxia driven cardiac arrhythmia leading to higher prevalence of ischemic stroke in patients with sleep disordered breathing disease. Despite strong evidence linking SDB to ischemic stroke, evaluation for SDB is rarely performed in patients presenting with an acute ischemic stroke. Hypothesis: Evaluation of SDB is rarely performed in patients presenting with acute ischemic stroke. Methods: We performed a retrospective review of all patients above the age of 18 who were admitted to the acute stroke service at University Hospital July 2014 to December 2014. Demographic data, etiology of stroke as identified per TOAST criteria, modifiable risk factors, presenting NIHSS and frequency of testing for SDB and their results were collected. The data was consolidated and tabulated by using STATA version 14. Results: Total of 240 patients satisfied our inclusion criteria. Only 24 patients ie 10% of those who satisfied our inclusion criteria received evaluation for SDB. Out of those evaluated, 62.5% ie 15 patients out of 24 patients had findings concerning for significant desaturation. Only 2 providers out of 8 stroke physicians ie 25% tested for SDB in more than 5 patients. Conclusions: Our observations highlight the paucity in evaluation for SDB in acute ischemic stroke in a tertiary care setting. Being a modifiable risk factor, greater emphasis must be placed on evaluation for SDB in patients in patients with acute stroke. Education must be provided to all patients and providers regarding identification of these factors.

Abstract 10: Predictors of Poor Outcome in Acute Ischemic Stroke Patients after Successful Recanalization

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Amy K Starosciak ◽  
Italo Linfante ◽  
Gail Walker ◽  
Osama O Zaidat ◽  
Alicia C Castonguay ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Predictive Power ◽  
Rescue Therapy ◽  
Univariate Analysis ◽  
Stroke Patients ◽  
Good Outcome ◽  
Poor Outcome

Background: Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS) ≤ 2 is present in 40-50% of patients . We aimed to evaluate predictors of poor outcomes (mRS > 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods: The NASA registry is a multicenter, non-sponsored, physician-conducted, post-marketing registry on the use of SOLITAIRE FR device in 354 acute, large vessel, ischemic stroke patients. Logistic regression was used to evaluate patient characteristics and treatment parameters for association with 90-day mRS score of 0-2 (good outcome) versus 3-6 (poor outcome) within patients who were recanalized successfully (Thrombolysis in Cerebral Infarction or TICI score 2b-3). Univariate tests were followed by development of a multivariable model based on stepwise selection with entry and retention criteria of p < 0.05 from the set of factors with at least marginal significance (p ≤ 0.10) on univariate analysis. The c-statistic was calculated as a measure of predictive power. Results: Out of 354 patients, 256 (72.3%) were successfully recanalized (TICI ≥ 2b). Based on 90-day mRS score for 234 of these patients, there were 116 (49.6%) with mRS > 2. Univariate analysis identified increased risk of mRS > 2 for each of the following: age ≥ 80 years (upper quartile of data), occlusion site other than M1/M2, NIH Stroke Scale (NIHSS) score ≥ 18 (median), history of diabetes mellitus (DM), TICI = 2b, use of rescue therapy, not using a balloon-guided catheter (BGC) or intravenous tissue plasminogen activator (IV t-PA), and time to recanalization > 30 minutes (all p ≤ 0.05). Three or more passes was marginally significant (p=0.097). In multivariable analysis, age ≥ 80 years, site other than M1/M2, initial NIHSS ≥18, DM, absence of IV t-PA, use of rescue therapy and three or more passes were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index = 0.80). Conclusions: Age, occlusion site, high NIHSS, diabetes, not receiving IV t-PA, use of rescue therapy and three or more passes, were associated with poor 90-day outcome despite successful recanalization.

Abstract T P10: Therapeutic Time Window for Endovascular Therapy of Acute Ischemic Stroke Depends on THRIVE Score: A Retrospective Single-center Study

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kenichi Todo ◽  
Nobuyuki Sakai ◽  
Tomoyuki Kono ◽  
Taku Hoshi ◽  
Hirotoshi Imamura ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Time Window ◽  
Medical Center ◽  
Multivariate Logistic Regression Analysis ◽  
Symptom Duration ◽  
Vascular Events ◽  
Good Outcome ◽  
Therapeutic Time Window

Background and purpose: The outcome after endovascular therapy in acute ischemic stroke is associated with onset-to-reperfusion time (ORT). The Totaled Health Risks in Vascular Events (THRIVE) score is also an important pre-thrapeutic predictor of outcome. We hypothesized that the therapeutic time window is narrower in patients with the higher THRIVE score. Methods: We retrospectively studied consecutive 109 ischemic stroke patients with successful reperfusion after endovascular therapy between October 2005 and March 2014 at a single institute (Kobe City Medical Center General Hospital). Inclusion criteria was as follows: National Institutes of Health Stroke Scale (NIHSS) score ≥8, stroke symptom duration ≤8 h, premorbid modified Rankin Scale (mRS) score ≤2, and thrombolysis myocardial infarction score 2-3. We analyzed the relationships of ORT, THRIVE score, and THRIVE+ORT score with good outcome (mRS ≤2 at 3 months). The THRIVE+ORT score was defined as the sum of the THRIVE score and ORT (h). Results: Median ORT was 5.5 h (IQR; 4.4-7.1 h), median THRIVE score was 5 (IQR; 4-6), and median THRIVE+ORT score was 10.8 (IQR; 9.2-12.5). Good outcome rates for patients with ORT ≤4 h, >4 and ≤6 h, >6 and ≤8 h, and >8h were 50.0%, 45.8%, 37.0%, and 21.4%, respectively (p=0.3), those with THRIVE score ≤3, >3 and ≤5, >5 and ≤7, and >7 were 57.1%, 51.4%, 28.3%, and 20.0%, respectively (p9 and ≤11, >11 and ≤13, and >13 were 64.0%, 44.1%, 34.4%, and 16.7%, respectively (p<0.05). Multivariate logistic regression analysis revealed that THRIVE+ORT score was an independent predictor of good outcome after adjusted for THRIVE score (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.082-1.728) or after adjusted for ORT (OR, 1.517: 95% CI, 1.160-1.983). Conclusion: Our study showed that THRIVE+ORT score was associated with outcome that was independent from THRIVE score or ORT. This is the first report to suggest that patients with the higher THRIVE score require the shorter ORT for good outcome.

Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

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