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

Patients transferred within a telestroke network for large-vessel occlusion

2020 ◽  
pp. 1357633X2095789
Author(s):  
Sujan T Reddy ◽  
Sean I Savitz ◽  
Elliott Friedman ◽  
Octavio Arevalo ◽  
Jing Zhang ◽  
...  
Keyword(s):  
Heart Association ◽  
Vascular Imaging ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Rapid Acquisition ◽  
Number Of Patients ◽  
Distal Occlusion ◽  
The Brain

Introduction In a telestroke network, patients at a referring hospital (RH) with large-vessel occlusion (LVO) are transferred to a comprehensive stroke centre (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 analysed 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 American Heart Association 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 computed tomography (CT) and CT angiography of the brain and neck compared to only CT of the 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, 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 >70 cc on perfusion imaging in late window), low National Institutes of Health Stroke Scale (<6), distal occlusion, and poor baseline modified Rankin Scale score (>1). Discussion Instituting rapid acquisition and interpretation of vascular imaging at RHs for LVO detection and establishing benchmarks for door to vascular imaging is urgently needed for RHs.

scholarly journals Thrombectomy 6-24 hours after stroke in trial ineligible patients

2018 ◽  
Vol 10 (11) ◽  
pp. 1033-1037 ◽  
Author(s):  
Shashvat M Desai ◽  
Marcelo Rocha ◽  
Bradley J Molyneaux ◽  
Matthew Starr ◽  
Cynthia L Kenmuir ◽  
...  
Keyword(s):  
Time Window ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Off Label ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

Clinical and neuroimaging criteria to improve the workflow in transfers for endovascular treatment evaluation

2019 ◽  
Vol 15 (9) ◽  
pp. 988-994 ◽  
Author(s):  
Manuel Requena ◽  
Marta Olivé-Gadea ◽  
Sandra Boned ◽  
Anna Ramos ◽  
Pere Cardona ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Treatment Success ◽  
Population Based ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Transfer protocols from primary to comprehensive stroke centers are crucial for endovascular treatment success. Aim To evaluate clinical and neuroimaging data of transferred patients and their likelihood of presenting a large infarct core at comprehensive stroke center arrival. Methods Retrospective analysis of population-based mandatory prospective registry of acute stroke patients evaluated for endovascular treatment. Consecutive patients evaluated at primary stroke center with suspected large vessel occlusion and PSC-ASPECTS ≥ 6 transferred to a comprehensive stroke center were included. PSC and CSC-ASPECTS, time-metrics, and clinical data were analyzed. Results During 28 months, 1185 endovascular treatment candidates were transferred from PC to comprehensive stroke center in our public stroke network, 477 had an anterior circulation syndrome and available neuroimaging information and were included. Median baseline NIHSS was 13 (8–19). On arrival to comprehensive stroke center, large vessel occlusion was confirmed in 60.2% patients, and 41.2% received endovascular treatment. Median interfacility ASPECTS decay was 1 (0–2) after a median of 150.7 (SD 101) min between both CT-acquisitions. A logistic regression analysis adjusted by age, time from symptoms to PC-CT, and time from PC-CT to CSC-CT showed that only a baseline NIHSS and PSC-ASPECTS independently predicted a CSC-ASPECTS < 6. ROC curves identified baseline NIHSS ≥ 16 and PSC-ASPECTS ≤ 7 as the best cut-off points. The rate of CSC-ASPECTS < 6 increased from 7% to 57% among patients with NIHSS ≥ 16 and PSC-ASPECS ≤ 7. Conclusion After a median transfer time >2 h, only 11.9% showed ASPECTS < 6 at the comprehensive stroke center. Activation of endovascular treatment teams should not require confirming neuroimaging on arrival and repeating neuroimaging at comprehensive stroke center should only be performed in selected cases.

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.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
2021 ◽  
Author(s):  
Laura C.C. van Meenen ◽  
Maritta N. van Stigt ◽  
Arjen Siegers ◽  
Martin D. Smeekes ◽  
Joffry A.F. van Grondelle ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Stroke Care ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
User Friendliness ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

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.

Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke

2021 ◽  
Author(s):  
Tareq Kass-Hout ◽  
Jungwha Lee ◽  
Katie Tataris ◽  
Christopher T. Richards ◽  
Eddie Markul ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center

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.

Developing a statewide protocol to ensure patients with suspected emergent large vessel occlusion are directly triaged in the field to a comprehensive stroke center: how we did it

2016 ◽  
Vol 9 (3) ◽  
pp. 330-332 ◽  
Author(s):  
Mahesh V Jayaraman ◽  
Arshad Iqbal ◽  
Brian Silver ◽  
Matthew S Siket ◽  
Caryn Amedee ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

We describe the process by which we developed a statewide field destination protocol to transport patients with suspected emergent large vessel occlusion to a comprehensive stroke center.

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