Abstract WP65: Clinical and Radiographic Characterization of Cerebral Hyperdensities on Post-thrombectomy Conventional Non-contrast Ct Brain: Differentiating Between Contrast Staining and Post-thrombectomy Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Hyung K Kang ◽  
Raffi Ourfalian ◽  
Emilie T Nguyen ◽  
Fernando A Torres ◽  
Lei T Feng ◽  
...  
Keyword(s):  
Statistical Significance ◽  
Anterior Circulation ◽  
Chi Square ◽  
Imaging Characteristics ◽  
Increase Risk ◽  
Patient’S Outcome ◽  
Ct Brain ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct

Background: Post-interventional cerebral hyperdensities (PCHD) are present 31.2 to 87.5% of the time on post-thrombectomy (PT) CT. It can be difficult for radiologists to differentiate if PCHD represents intracerebral hemorrhage (ICH) or contrast staining using conventional CT. The ability to accurately determine the etiology of PCHD may be important for a patient’s outcome. Methods: We retrospectively investigated clinical risk factors, imaging findings, and interventional technique of patients who had a thrombectomy from 2011-2017 (n=238) at a Comprehensive Stroke Center. 112 patients with anterior circulation infarcts and immediate PT CTs as well as either a PT MRI or follow-up CT within 48 hours were included. Two experienced neuroradiologists interpreted all imaging. Baseline demographics and imaging characteristics were collected. The presence of ICH was determined by dephasing on gradient echo or by its persistence > 2 days on repeat CT. Chi-square and Fisher’s exact tests were used for statistical significance, and logistic regression to determine risk estimates. Results: 84% of patients had PCHD, of which 56% had ICH. Patients had similar demographics (ICH: median age 69, 47.5% female; non-ICH: median age 71, 42.5% female). Higher pre-thrombectomy ASPECTS score (OR 0.62, p < 0.05) decreased the risk of ICH, and higher Hounsfield units (HU) of PCHD both on immediate (OR 1.04, p < 0.05) and intermediate (OR 1.1, p < 0.0005) PT CT increased the risk of ICH. PCHDs in the deep grey matter (OR 2.84, p < 0.05) and demonstrating a confluent pattern (OR 3.9 p < 0.05) increased the likelihood of ICH. 10% increase risk of ICH was seen for every HU increase in density on PT CT at 24 or 48 hours. A 50% decrease in ICH was observed for each unit increase of the pre-thrombectomy ASPECTS score. ROC revealed the optimal cut-off for predicted probability as 0.64, sensitivity 70.2% and specificity 69.2%. The AUC for the predicted model was 0.84 (95%CI= (0.75- 0.92, p <0.0001). Conclusion: Several imaging characteristics of PCHDs and ASPECTS score can help differentiate between the PT ICH and contrast staining. Application of these variables to patients in the immediate PT period may change clinical management.

Abstract TP365: Stroke Nurse Navigator Improves Post-Acute Transition of Care

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Karen Sher ◽  
Armani Edgar ◽  
Sarah Clark ◽  
Ilene Staff ◽  
Amre Nouh
Keyword(s):  
Positive Impact ◽  
Statistical Significance ◽  
Stroke Care ◽  
Primary Diagnosis ◽  
Transition Of Care ◽  
Chi Square ◽  
Nurse Navigator ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Post stroke care is multifaceted and should not end at hospital discharge. Patients often lack understanding of the importance of outpatient care to prevent secondary stroke. Objective: To demonstrate the positive impact of a stroke nurse navigator in improving the post-acute transition of care by promoting outpatient follow up after hospitalization. Methods: We retrospectively reviewed all patients discharged from our comprehensive stroke center (excluding hospice) with a primary diagnosis of ischemic or hemorrhagic stroke from January -December 2018, yielding 685 patients. We evaluated whether or not our nurse navigator influenced three aspects of follow up: if stroke clinic appointment was made before discharge, if patient attended the appointment and if patient called the clinic after discharge. Four categories were used based on level of navigator contact with the patient: (SC) Seen in-house and called within 30 days after discharge, (S) Seen only, (C) Called only or (N) No navigator contact. Chi-square test of proportions was used to evaluate the statistical significance among all four groups. Results: Out of the 685 patients, 77.5% (n=531) were scheduled for clinic follow-up before discharge, 60.7% (n=416) attended the appointment and 20% called after discharge (n=137). The distribution of navigator contact level was (SC) 26.7%, (S) 17.5%, (C) 19.3% and (N) 36.5%. Both seeing and calling the patient was proven to be the most effective in all three areas: appointment made prior to discharge (SC) 89.6%, (S) 82.5%, (C) 74.2%, (N) 68% ( p=<0.001 ); patient attended the appointment (SC) 68.9%, (S) 60%, (C ) 65.9%, (N) 52.4% ( p=0.001 ) and patient called the clinic after discharge (SC) 26.2%, (S) 15.8%, (C ) 23.5%, (N) 15.6% ( p=0.02 ). Of interest, patients who were only called but not seen were more likely to attend the appointment or call the clinic as compared to being seen alone. Conclusion: Contact with our nurse navigator increased post-acute follow up in our stroke clinic. An increased number of patient calls associated with navigator interaction showed these patients had a better understanding of the need for continued care. The nurse navigator improves continuity of post-acute care.

scholarly journals Non-Contrast CT and CT-Angiogram for Late Window Ischemic Stroke Treatment Selection

2020 ◽  
Vol 47 (3) ◽  
pp. 309-313
Author(s):  
Marie-Claude Beaulieu ◽  
Ahmad Nehme ◽  
Francis Fortin ◽  
Fatine Karkri ◽  
Nicole Daneault ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Functional Independence ◽  
Pragmatic Approach ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Ct Angiogram ◽  
Retrospective Comparison ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct

ABSTRACT:Introduction:The benefit of late window endovascular treatment (EVT) for anterior circulation ischemic stroke has been demonstrated using perfusion-based neuroimaging. We evaluated whether non-contrast CT (NCCT) and CT-angiogram (CTA) alone can select late-presenting patients for EVT.Methods:We performed a retrospective comparison of all patients undergoing EVT at a single comprehensive stroke center from January 2016 to April 2017. Patients planned for EVT were divided into early (<6 hours from onset) and late (≥6 hours from onset or last time seen normal) window groups. Incidence of symptomatic hemorrhagic transformations (sHTs) at 24 hours and 3-month modified Rankin scores (mRSs) were compared.Results:During the study period, 204 (82%) patients underwent EVT in the early and 44 (18%) in the late window. Median (interquartile range) NIH Stroke Scale Score was similar between groups (early: 18 [15–23] vs. late: 17 [13–21]), as were median ASPECT scores (early: 9 [8–10] vs. late: 9 [7–9]). In the late window, 42 (95%) strokes were of unknown onset. Similar proportions of sHT occurred at 24 hours (early: 12 [6%] vs. late: 4 [9%], p = 0.43). At 3 months, the proportion of patients achieving functional independence (mRS 0–2) were comparable in the early (80/192 [42%]) and late (16/41 [39%]) windows (p = 0.76).Conclusion:NCCT- and CTA-based patient selection led to similar functional independence outcomes and low proportions of sHT in the early and late windows. In centers without access to perfusion-based neuroimaging, this pragmatic approach could be safe, particularly for strokes of unknown onset.

Abstract P159: Patients Transferred Within a Telestroke Network for Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Sujan T Reddy ◽  
Sean I Savitz ◽  
Elliott Friedman ◽  
Octavio Arevalo ◽  
Jing Zhang ◽  
...  
Keyword(s):  
Vascular Imaging ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Rapid Acquisition ◽  
Number Of Patients ◽  
Ct Brain ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: In a telestroke network, patients at a referring hospital (RH) with large vessel occlusion (LVO) are transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). However, a significant number of patients do not ultimately undergo thrombectomy after CSC arrival. Methods: Within a 17 hospital telestroke network, we retrospectively analyzed patients with suspected or confirmed LVO transferred to a CSC and characterized the reasons why these patients did not undergo EVT based on the 2019 AHA guidelines. Results: Of 400 patients transferred to our hub, 68 (17%) were based on vascular imaging at RH. Time from RH arrival to neuroimaging was significantly longer in patients that underwent both CT & CTA brain and neck compared to only CT brain (53 vs. 13 minutes, p <0.05). Accuracy of anterior circulation LVO (ACLVO) detection based on clinical suspicion was 62% (205 of 332 patients). Among 234 ACLVO patients (Table 1), overall 175 (74%) [early window group: 123 (73%) patients and late window group: 52 (80%) patients] met at least one EVT ineligibility criterion. The reasons for EVT ineligibility varied from large core infarct (aspects <6 or core volume >70cc on perfusion imaging in late window), low NIHSS (<6), distal occlusion, and poor baseline mRS (>1) (Table 2). Conclusion: Instituting rapid acquisition and interpretation of vascular imaging at referring hospitals for LVO detection and establishing benchmarks for door to vascular imaging is urgently needed for referring hospitals. Table 1: Study flowchart

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.

Abstract WP290: Endovascular Treatment Of In-hospital Strokes: An Open Book

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Dolora Wisco ◽  
KEN UCHINO ◽  
ESTEBAN CHENG CHING ◽  
Shazia Alam ◽  
SHUMEI MAN ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Valve Repair ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ct Brain ◽  
Contrast Ct ◽  
Iv Tpa

INTRODUCTION: In-hospital stroke (IHS) presents a different treatment challenge than out of hospital stroke. IHS often has contraindication to IV tPA, such as such as recent surgery, MI, and use of anticoagulation. Intra-arterial therapy (IAT) with tPA and/or mechanical thrombectomy is an option for large vessel acute IHS with contraindications to or fail to recanalize with IV tPA, to restore cerebral perfusion. Objective: To assess the characteristics and outcomes of patients with in-hospital strokes large vessel occlusion who receive IAT. Methods: From our database of patients from 1/1/2008 to 12/31/2011 who had IAT for an acute stroke due to large vessel occlusion, in hospital strokes and out of hospital strokes were identified. Patient characteristics, imaging, and outcomes were retrospectively collected. Statistical analysis was performed on JMP 9.0. Result: 151 patients were included, 23 (15%) were in-hospital strokes (IHS) and 128 (85%) were out of hospital strokes (OHS). Initial median NIHSS of 17 and 16 respectively (p=0.3). IHS were frequently in the cardiology/CTS service (14, 60%) for CHF and cardiac valve repair (12, 52%). Other comorbidities present were atrial fibrillation (68%), hypertension (68%), and hyperlipidemia (56%). Seven (30%) were on warfarin prior to admission, but all had subtherapeutic INR. Three (13%) IHS received IV tPA. The time from last known well (LKW) to non-contrast CT brain was 80 min, and to CTA was 113 min in IHS, and 147 min and 229 min respectively in OHS (p = 0.0003). 20 (87%) had lesion in the anterior circulation. LKW to IAT recanalization was 248 min in IHS, compared to 375 min in OHS. Recanalization rate was 68% for IHS and 81% for OHS (p=0.2). Nine (39%) IHS had favorable mRS of 1 to 3 at 90 days, compared to 44 (34%) OHS, (p = 0.6). Despite faster recanalization time, there was no difference in the 90 day mortality of IHS v OHS (48% vs 30%, p = 0.1), and IHS had greater 1 year mortality (65% vs 30%, p = 0.005). Discussion: In-hospital strokes have higher mortality than out of hospital strokes. There is a role for IAT In carefully selected IHS with large vessel occlusion. A multicenter study is needed to reveal the characteristics of IHS patients who may benefit from IAT.

Abstract TP373: Classification of sICH in Stroke Center Hospitals: Reliability in Question

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Victoria Swatzell ◽  
Fern Cudlip ◽  
Andrei V Alexandrov ◽  
Anne W Alexandrov
Keyword(s):  
Pay For Performance ◽  
Reperfusion Therapy ◽  
Hemorrhagic Transformation ◽  
Quality Data ◽  
Treatment Rate ◽  
Team Members ◽  
Common Definition ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct

Background: Measuring sICH is an important accountability of Stroke Centers. Since the NINDS rt-PA Study, the sICH definition has changed as knowledge of reperfusion-associated hemorrhagic transformation has grown. We aimed to determine what sICH definition was used by Stroke Centers and how this impacts sICH rates. Methods: Stroke Centers were invited to participate in a survey with the option to complete it via SurveyMonkey TM or by mail. Instructions to adhere to the sICH definition adopted in policies/procedures were provided, and to ask for clarification from Stroke Team members if needed. Data were assembled in SPSS, and analyzed using descriptive statistics and Student t-tests. Results: 229 responses were received representing 84% of U.S. states and the District of Columbia; 31% represented academic medical centers and 69% community hospitals. 64% of respondees were responsible for collecting the stroke quality data that supports certification. Overall tPA treatment rate for the sample was 8.7% + 6.4 (median 7%), with an overall reported sICH rate of 9.5% + 16.4 (median 5%). Official definitions supported sICH for 86% of responding hospitals, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.” Only 17% identified the definition for sICH adopted by TJC for Comprehensive Stroke Center reporting. Among those that adhered to the TJC definition, sICH rates were significantly lower at 3%+2.3 (median 3%; t=4.7; mean difference = 7.7%; p<.0001, 95% CI 4.4-10.95), compared to 10.6%+17.5 (median 6%). Conclusions: Our study documents a significant need for education and inter-rater reliability monitoring of the use of sICH classification after intravenous tPA to ensure accuracy in local quality improvement processes, as well as the validity of data submitted to national stroke registries. Additionally, because sICH associated with reperfusion therapy is a new measure undergoing testing by TJC that could ultimately be tied to future pay-for-performance and public reporting, consensus on its definition as well as reliable sICH classification will be essential to future Stroke Center evaluation.

scholarly journals Contemporary Management of Distal Anterior Cerebral Artery Aneurysms: A Dual-Trained Neurosurgeon's Perspective

2021 ◽  
Author(s):  
Sunil V. Furtado ◽  
Dravya Jayakumar ◽  
Parichay J. Perikal ◽  
Dilip Mohan
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Statistical Significance ◽  
Endovascular Coiling ◽  
World Federation ◽  
Anterior Circulation ◽  
Chi Square ◽  
Good Outcome ◽  
Fisher Grade ◽  
Distal Anterior Cerebral Artery

Abstract Objectives Distal anterior cerebral artery (DACA) aneurysms are a subset of aneurysms located in the anterior circulation but away from the circle of Willis. We analyze the clinical presentation and outcomes of two treatment groups—surgical and endovascular—for DACA aneurysms managed by a dual-trained neurosurgeon. Material and Methods A retrospective evaluation of radiological and operative/interventional data of 34 patients with 35 DACA aneurysms over a 12-year period was analyzed. Twenty-seven patients underwent surgery, whereas seven underwent endovascular coiling of the aneurysms. Modified Fisher grade and World Federation of Neurosurgical Societies scale (WFNS) were used to note the subarachnoid hemorrhage (SAH) severity. Statistical Analysis Categorical data were presented as frequency and percentage, while noncategorical data were represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using Chi-square test, and p < 0.05 was considered statistically significant. Results Of 34 patients, 33 presented with a bleed and 23.5% patients were noted to have another aneurysm in addition to the DACA aneurysm. Patients who underwent clipping for another aneurysm along with the DACA aneurysm in a single surgical exercise had a poor outcome compared with those who underwent surgery for the lone DACA aneurysm (7 vs. 20, p = 0.015). Most patients in both surgical (70.37%) and endovascular (85.71%) groups had good outcome (mRS ≤ 2). Conclusions A good outcome can be achieved with either surgery or endovascular coiling in the management of DACA aneurysms. In patients with multiple aneurysms, SAH with aneurysmal rupture of DACA should be managed first; the other unruptured aneurysm may be operated after an interval to avoid morbidity.

Abstract P822: In-Hospital Stroke Treated With IV tPA at a Comprehensive Stroke Center Compared to Primary Stroke Centers Pre and Post Telestroke Implementation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Manya Khrlobyan ◽  
Jiaxiao M Shi ◽  
Zahra Ajani ◽  
Duy Le ◽  
Pamela Cheng ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Small Sample Size ◽  
Small Sample ◽  
Complication Rates ◽  
Recognition Time ◽  
Chi Square ◽  
Wilcoxon Rank Sum Test ◽  
Delayed Recognition ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: In-hospital strokes (IHS) often have delayed recognition time and a delay in physician assessment, playing a role in unfavorable outcomes. Telestroke (TS) participation is linked to lower odds of hospital mortality and is safe and effective in treating acute ischemic stroke. We implemented a TS program for IHS patients at primary stroke centers (PSC) and assessed tPA time metrics, complications and 90-day functional outcomes as compared to a robust in hospital stroke system of care at a comprehensive stroke center (CSC). Methods: Using a network database, data for all in-hospital code strokes were retrospectively abstracted between 2010-2020 at a CSC and 11 PSC’s. The CSC was compared to PSC’s pre and post implementation of a TS program. Data were analyzed using Wilcoxon rank-sum test, chi-square and exact tests. Results: We identified 193 patients, 77 at the CSC, 71 at pre-tele PSC’s, and 45 at post-tele PSC’s. Symptom-recognition-time (SRT) to neurology evaluation (median 15min {IQR 10-27} vs 75min {IQR 45-126, p=<0.0001) and SRT to IV t-PA (median 65min {IQR 46-91} vs 94min {IQR 73-112}, p=<0.001) were all faster at the CSC vs pre-tele PSC’s. There was no difference in rate of complications (p=0.05). When stroke mimics were excluded, CSC patients had a favorable 90-day mRS of 0-1 (24 patients, 35% vs 11 patients, 19%, p=0.04). After implementation of TS at PSC’s, there was no difference in tPA time metrics, except SRT to neurology evaluation remained faster at CSC (median 15min {IQR 10-27} vs 31min {IQR 18.5-52.5}, p=0.0002). There was no difference in rate of complications (p=0.21) and mRS at 90 days (p=0.82). Conclusions: Implementation of a TS program for IHS at PSC’s may improve tPA time metrics and 90 functional outcomes to the standards of CSC’s without increasing complication rates. Our study was limited by retrospective design and small sample size.

Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Raul G Nogueira ◽  
Laurie Preston ◽  
Adnan I Qureshi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method ◽  
Morbid Conditions

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

Sign in / Sign up

Export Citation Format

Share Document