Abstract WP304: Real-World Experience with the RAPID Platform to Screen Acute Ischemic Stroke Patients at a U.S. Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Rami-James Assadi ◽  
Julia Henn ◽  
Ajlana Varmaz ◽  
Peter Panagos ◽  
Michelle Miller-Thomas ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Perfusion Imaging ◽  
Number Needed To Screen ◽  
Significant Difference ◽  
Screening Efficiency ◽  
Rapid Perfusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Mechanical thrombectomy (MT) is an important part of acute ischemic stroke (AIS) treatment. Recent trials of MT beyond the 6-hour window have utilized RAPID perfusion imaging for patient selection. The utility of this method is established in patients with large vessel occlusions (LVO) but screening efficiency in real-world practice remains unknown. We present the experience of a single, large volume, Comprehensive Stroke Center (CSC) utilizing RAPID to screen patients for LVO and MT. Methods: We performed a retrospective analysis of prospectively collected consecutive patients who presented to our emergency department (ED) between 01/2018 to 06/2019 with suspected LVO. Protocol was based on 2018 AHA guideline Level IA recommendations and followed DAWN and DEFUSE-3 time and imaging parameters. Patients who underwent RAPID imaging were selected for inclusion. Results: 865 patients met criteria for RAPID perfusion imaging (median age 67, females 52%, outside hospital transfers 29%). Of these, 178 (21% of total) were confirmed to have an LVO (40% ED presentation, 10% inpatient, 50% transfer). For patients presenting to the ED (N=509), 14% had an LVO (median NIHSS 13 [IQR 8-19]), of which 41% underwent MT. Mean CTP core and penumbra volume was 25mL and 100mL respectively. Number needed-to-screen in the ED cohort was 7 to detect LVO and 17 to perform MT. Transfer patients showed no significant difference in LVO detection or MT rates compared to ED patients (56%, p=0.3). Conclusions: In ED-presenting patients at a CSC, the number of RAPID perfusion imaging studies needed to detect an additional case of LVO was 7.1, and to perform an additional MT was 17.4. Current AHA Class IA recommendations for evaluation and treatment of AIS yield a reasonably high rate of LVO detection and subsequent MT in real-world practice. Additional multicenter data will be useful to establish benchmarks and improve screening efficiency.

scholarly journals Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

2021 ◽  
Vol 12 ◽  
Author(s):  
Christian A. Taschner ◽  
Alexandra Trinks ◽  
Jürgen Bardutzky ◽  
Jochen Brich ◽  
Ralph Hartmann ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Rural Areas ◽  
Mortality Rates ◽  
Functional Independence ◽  
Stroke Onset ◽  
Significant Difference ◽  
Direct Admission ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Organizing regional stroke care considering thrombolysis as well as mechanical thrombectomy (MTE) remains challenging in light of a wide range of regional population distribution. To compare outcomes of patients in a stroke network covering vast rural areas in southwestern Germany who underwent MTE via direct admission to a single comprehensive stroke center [CSC; mothership (MS)] with those of patients transferred from primary stroke centers [PSCs; drip-and-ship (DS)], we undertook this analysis of consecutive stroke patients with MTE.Materials and Methods: Patients who underwent MTE at the CSC between January 2013 and December 2016 were included in the analysis. The primary outcome measure was 90-day functional independence [modified Rankin score (mRS) 0–2]. Secondary outcome measures included time from stroke onset to recanalization/end of MTE, angiographic outcomes, and mortality rates.Results: Three hundred and thirty-two consecutive patients were included (MS 222 and DS 110). Median age was 74 in both arms of the study, and there was no significant difference in baseline National Institutes of Health Stroke Scale scores (median MS 15 vs. 16 DS). Intravenous (IV) thrombolysis (IVT) rates differed significantly (55% MS vs. 70% DS, p = 0.008). Time from stroke onset to recanalization/end of MTE was 112 min shorter in the MS group (median 230 vs. 342 min, p < 0.001). Successful recanalization [thrombolysis in cerebral infarction (TICI) 2b-3] was achieved in 72% of patients in the MS group and 73% in the DS group. There was a significant difference in 90-day functional independence (37% MS vs. 24% DS, p = 0.017), whereas no significant differences were observed for mortality rates at 90 days (MS 22% vs. DS 17%, p = 0.306).Discussion: Our data suggest that patients who had an acute ischemic stroke admitted directly to a CSC may have better 90-day outcomes than those transferred secondarily for thrombectomy from a PSC.

Abstract TP253: Ongoing Quality Improvement for Acute Ischemic Stroke at Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Shimeng Liu ◽  
Zhu Zhu ◽  
Mohammad Shafie ◽  
Hermelinda Abcede ◽  
Jay Shah ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Discharge ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference ◽  
Time Periods ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: Ongoing quality improvement is essential for better outcomes and healthcare cost control. The aim of this study is to examine the progressive quality benchmarks for acute ischemic stroke (AIS) at an academic comprehensive stroke center (CSC). Methods: We retrospectively analyzed consecutive patients with AIS at University of California Irvine Medical Center from Jan 1 st , 2013 to Dec 31 th , 2018.Demographics and clinical data were collected from the Get-With-The-Guideline (GWTG) -Stroke registry and electronic medical records. Patients were stratified into 3 time periods according to their admission dates: 2013 to 2014; 2015 to 2016; and 2017 to 2018. Quality benchmarks for AIS, including door-to-needle (DTN) times, rates of receiving IV tPA and/or endovascular thrombectomy (EVT), rate of symptomatic intracerebral hemorrhage (sICH), and outcomes at hospital discharge were analyzed to identify trends of quality improvement in the last 6 years. Results: A total of 1369 patients were included in the study; 398 (29%) patients received acute reperfusion therapy, with 231 (17%) receiving IV tPA, 97 (7%) receiving both IV tPA and EVT, 70 (5%) receiving EVT only. There was no significant difference in baseline characteristics of the patients during the 3 time periods. IV tPA rates were 20% in 2013-2014, 30% in 2015-2016, and 22% in 2017-2018 ( p =0.0005). The EVT rates in 2017-2018 (15% vs. 9%; OR: 1.77; 95% CI: 1.16 - 2.68; p = 0.008) and 2015-2016 (14% vs. 9%; OR: 1.70; 95% CI: 1.11 - 2.59; p = 0.01) were significantly higher than in 2013-2014. There were significant ongoing improvements in median DTN times, with 57 minutes in 2013-2014, 45 minutes in 2015-2016, and 39 minutes in 2017-2018. Among patients receiving IV tPA, significantly more patients had favorable outcomes (mRS score 0-3) at hospital discharge in 2015-2016 (67% vs. 42%; OR: 2.80; 95% CI: 1.46 - 5.40; p =0.002) than in 2013-2014. Conclusions: We demonstrate ongoing improvement in rates of IV tPA and EVT as well as DTN times for IV tPA in patients with AIS.

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.

Abstract P348: Perfusion Collateral Index vs. Hypoperfusion Intensity Ratio in Assessment of Angiographic Collateral Scores in Patients With Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Brian Tsui ◽  
Iris Chen ◽  
Joe Qiao ◽  
Kasra Khatibi ◽  
Lucido Ponce Mejia ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Intensity Ratio ◽  
Roc Analysis ◽  
Cerebral Blood Volume ◽  
Imaging Biomarker ◽  
Lesion Volume ◽  
Significant Difference ◽  
Sensitivity Specificity

Background and Purpose: In acute ischemic stroke (AIS), perfusion imaging, while not directly visualizing collateral vessels, can provide important insight into collateral robustness, indexed by perfusion lesion volume and by perfusion lesion heterogeneity. Two proposed perfusion lesion heterogeneity measures indexing collateral status are the Perfusion Collateral Index (PCI) and Hypoperfusion Intensity Ratio (HIR), but their accuracy compared with direct collateral assessment on DSA has been incompletely characterized. Methods: Consecutive AIS patients with anterior circulation large vessel occlusion who underwent pre-endovascular thrombectomy MRI perfusion imaging were included. MRI measures analyzed were: 1) Perfusion Collateral Index ( PCI) - the volume of moderately hypoperfused tissue (arterial tissue delay time between 2 and 6 seconds: ATD 2-6sec ) multiplied by its corresponding relative cerebral blood volume using Olea software; 2) Hypoperfusion Intensity Ratio (HIR) ratio of moderate TMax >6 s lesion volume versus severe Tmax >10 s lesion volume with the RAPID software program. DSA collateral scores were evaluated by ASITN grading and dichotomized to inadequate (ASTIN <2) vs. adequate (ASTIN ≥3). Results: Among 48 patients meeting entry criteria, age (mean ± SD) was 70 (± 15.2), 54% were female, and NIHSS (median, IQR) was 15 (10-19). For HIR, there was no significant difference in score values in patients with adequate vs inadequate collaterals: 0.35 ± 0.20 vs 0.39 ± 0.25, p=0.68. ROC analysis using previously described cut-off of 0.4 resulted in an AUC of 0.52 and sensitivity/specificity of 71% / 33%. For PCI, score values were significantly higher in patients with adequate vs inadequate collaterals, 117 ± 61 vs. 57 ± 41, p=0.002. ROC analysis using previously described cut-off of 62 resulted in an AUC of 0.8 and sensitivity/specificity of 84% / 78%. Conclusion: Collateral status can be accurately assessed on perfusion MRI with the Perfusion Collateral Index, which outperformed the Hypoperfusion Intensity Ratio. MRI-PCI is an informative imaging biomarker of collateral status in patients with AIS.

Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Vivien H Lee ◽  
Paul A Segerstrom ◽  
Ciarán J Powers ◽  
Sharon Heaton ◽  
Shahid M Nimjee ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Transfer Model ◽  
Transfer Time ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Er Status

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.

scholarly journals Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke

2019 ◽  
Vol 8 (12) ◽  
Author(s):  
Ludwig Schlemm ◽  
Matthias Endres ◽  
Jan F. Scheitz ◽  
Marielle Ernst ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Disability Adjusted Life Years ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.

scholarly journals Mandatory Neuroendovascular Evolution: Meeting the New Demands

2018 ◽  
Vol 8 (1) ◽  
pp. 69-82
Author(s):  
Mohammad El-Ghanem ◽  
Francisco E. Gomez ◽  
Prateeka Koul ◽  
Rolla Nuoman ◽  
Justin G. Santarelli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Mechanical Thrombectomy ◽  
Stroke Care ◽  
Endovascular Intervention ◽  
Stroke Patients ◽  
Hub And Spoke ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center

2017 ◽  
Vol 26 (1) ◽  
pp. 192-195 ◽  
Author(s):  
Thomas V. Kodankandath ◽  
Paul Wright ◽  
Paul M. Power ◽  
Marcella De Geronimo ◽  
Richard B. Libman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Patients ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Transfer Times
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