Abstract WP282: Use of Emergent Ambulance Transport With Lights and Siren Leads to Significant Time Savings for Inter-Facility Transfers of Patients With Large Vessel Occlusion

Introduction: When emergency medical services (EMS) responds to a field call for a patient experiencing stroke symptoms, the response is emergent, necessitating the use of lights and siren (L&S) to allow for expedited transport to a stroke-capable center. With the expanded use of endovascular therapy (EVT) for large-vessel occlusion (LVO), many stroke-capable centers are transferring larger numbers of LVO patients to EVT-capable centers for definitive care. Interestingly, many EMS systems do not respond to or transport inter-facility transfers emergently with L&S. This can potentially lead to delays in care and worse clinical outcomes. Given increased scrutiny surrounding the safety and utility of L&S transport among EMS providers, we investigated the difference between emergent and non-emergent transfer of confirmed LVO stroke patients from two institutions with varied distances and traffic patterns. Methods: A retrospective analysis was performed of 127 consecutive inter-facility transfers for LVO from two facilities, Hospital A (38.5 miles) and Hospital B (5.5 miles), to the University of Michigan Comprehensive Stroke Center over 3 years and 2 years respectively. Transfers by helicopter (17/127; 13.4%) and those without available EMS data (9/127; 7.1%) were excluded. Final review included 50 cases from Hospital A and 51 from Hospital B. Run times and use of L&S during transport were collected. A t-test was used to examine whether the observed differences in transport times were statistically significant. Results: Of the 50 transfers from Hospital A, 22 were transported without L&S use and 28 with L&S. The mean transport time was 44 minutes versus 35 minutes, respectively. From Hospital B, there were 14 transfers transported without L&S use and 37 with L&S. The mean transport time was 15 minutes versus 9 minutes, respectively. For both samples, p-value was <0.01. Conclusion: Despite a small sample size, this analysis demonstrates significant time savings using L&S during inter-facility transfer of stroke patients with confirmed LVO. While inherent risk is associated with the use of L&S during EMS transport, judicious use for confirmed time-sensitive indications seems warranted.

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Abstract 151: Early Neurologic Decline in Acute Ischemic Stroke Patients Receiving Thrombolysis With Large Vessel Occlusion and Initial Mild Deficits

Stroke ◽

10.1161/str.51.suppl_1.151 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Gaurav Thakur ◽

Ciaran J Powers ◽

Shahid M Nimjee ◽

Patrick Youssef ◽

Sushil Lakhani ◽

...

Keyword(s):

Ischemic Stroke ◽

Natural History ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Intravenous Tissue Plasminogen Activator ◽

The Mean

Introduction: A quarter of ischemic stroke patients with initial mild deficits have a poor outcome. We sought to determine the rate of early neurological decline in acute ischemic stroke patients with large vessel occlusion (LVO) who presented with mild deficits. Methods: Among 1022 acute ischemic stroke patients who received intravenous tissue plasminogen activator (IVtPA) admitted to our institution from January 1, 2014 to March 31, 2019, we identified 313 (30.6%) with LVO. We defined anterior circulation LVO as M1, M2, or carotid artery terminus (ICAT). Mild deficits were defined as National Institute of Health Stroke Scale (NIHSS) ≤ 7. Data was abstracted on demographics, neuroimaging, last known well (LKW), time to IVtPA, intra-arterial therapy (IAT) revascularization, Thrombolysis in Cerebral Infarction score (TICI), clinical presentation, and outcome. Early neurologic decline was defined as NIHSS worsening of ≥ 4 points within 24 hours. Results: Among 313 patients with LVO, we identified 94 (30%) who presented with initial low NIHSS (≤ 7) due to anterior circulation LVO. We excluded 13 patients who did not have natural history data (underwent IAT with mild deficits), leaving 81 patient for analysis. The mean age was 65.8 years (range 25 to 93) and 41% were female. IVtPA time from LKW was a mean 2.5 hours (range, 0.8 to 7). LVO sites were as follows: 5 (6%) ICAT, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 27 (33.3%) had early neurological decline. Patients with decline were significantly older (71.2 vs 63.1 years, p=0.03). Among the 27 patients with decline, the mean change in NIHSS was 10.5 (range, 4 to 22) and 12 patients (44%) underwent rescue IAT resulting in TICI 2B (6) and TICI 3 (6) revascularization. On hospital discharge, patients with decline were less likely to be discharged home (26% vs 65%, p=0.006). Conclusions: Among LVO patients who received IVtPA, 30% present with initial mild deficits. Early neurological decline occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA, and patients with decline were less likely to be discharged home. Clinicians need to be aware of the natural history of LVO with initial mid deficits, as patients who decline would be eligible for rescue IAT in the expanded 24 hour window.

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Abstract TP154: Infarct Volume and Prolonged Intubation are Critical Determinants of Inpatient Rehabilitation Cost in Anterior Circulation Large Vessel Occlusion Stroke Patients

Stroke ◽

10.1161/str.48.suppl_1.tp154 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Christopher Streib ◽

Srikant Rangaraju ◽

Ashutosh Jadhav ◽

Tudor Jovin

Keyword(s):

Infarct Volume ◽

Univariate Analysis ◽

Multivariable Analysis ◽

Inpatient Rehabilitation ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion

Introduction: Anterior circulation large vessel occlusion (ACLVO) stroke is one of the most devastating stroke subtypes. Significant recent advances, including endovascular thrombectomy, have markedly improved ACLVO stroke outcomes. The economic burden of ACLVO stroke treatment is now an important consideration. Our study investigates the critical determinants of acute inpatient rehabilitation (AIR) cost in ACLVO stroke. Methods: We utilized comprehensive patient-level cost-tracking software to calculate AIR costs for ACLVO stroke patients at our institution between July 2012-October 2014. Cost was calculated from the hospital perspective. Patient demographics, clinical course, neurologic exam, and imaging findings were analyzed. Variables with p-value <0.20 in univariate analysis were included in multivariable analysis to determine significant predictors of AIR cost (p<0.05). Results: 65 patients were included in our analysis (median age 61 [IQR 54-73], median AIR admit NIHSS 12 [6-16]). Univariate analysis results are shown (Figure). In our multivariable analysis the only statistically significant predictors of AIR cost were the patient’s final infarct volume (p<0.001) and intubation >48 hours during the hospitalization (p=0.044). AIR costs increased by $66.46 for every 1 cubic centimeter increase in infarct volume. Conclusion: Infarct volume and intubation >48 hours were significant predictors of AIR cost in ACLVO stroke patients at our institution. ACLVO stroke interventions that limit infarct volume may decrease AIR costs, in addition to avoidance of intubation and aggressive pursuit of extubation when feasible.

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

Scientific Reports ◽

10.1038/s41598-021-84269-8 ◽

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.

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Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2

Cerebrovascular Diseases ◽

10.1159/000514369 ◽

2021 ◽

Vol 50 (4) ◽

pp. 397-404

Author(s):

Kotaro Tatebayashi ◽

Kazutaka Uchida ◽

Hiroto Kageyama ◽

Hirotoshi Imamura ◽

Nobuyuki Ohara ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Characteristics ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Tandem Occlusion ◽

The Mean ◽

Patient Prognosis

Introduction: The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. Results: Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1–5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30–0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42). Discussion/Conclusion: The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

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Mechanical Thrombectomy for Minor Stroke Patients (NIHSS <6) With Large Vessel Occlusion

Turkish Journal of Cerebrovascular Diseases ◽

10.5505/tbdhd.2018.24483 ◽

2018 ◽

Vol 24 (2) ◽

pp. 67-70

Author(s):

Çetin Kürşad Akpınar ◽

Erdem Gürkaş ◽

Emrah Aytaç ◽

Murat Çalık

Keyword(s):

Mechanical Thrombectomy ◽

Large Vessel ◽

Minor Stroke ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Are we close to the twilight of IV thrombolysis for acute ischemic stroke patients with large vessel occlusion?

Neurology ◽

10.1212/wnl.0000000000005281 ◽

2018 ◽

Vol 90 (15) ◽

pp. 673-674

Author(s):

Emmanuel Carrera ◽

Daniel Strbian

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽

10.1161/str.43.suppl_1.a3314 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Omar Kass-Hout ◽

Tareq Kass-Hout ◽

Maxim Mokin ◽

David Orion ◽

Shadi Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Combined Therapy ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

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