Teaching Impact on Telestroke Nurse Recognition of Large Vessel Occlusion Computerized Tomography Perfusion Patterns

Background and Purpose— A distinguishing feature of our Stroke Network is telestroke nurses who remotely facilitate evaluations. To enable expeditious transfer of large vessel occlusion (LVO) acute ischemic stroke patients presenting to nonthrombectomy centers, the telestroke nurses must immediately identify color thresholded computerized tomography perfusion (CTP) patterns consistent with internal carotid artery (ICA), middle cerebral artery (MCA) segment 1(M1), and MCA segment 2 (M2) LVO acute ischemic stroke. Methods— We developed a 6-month series of tutorials and tests for 16 telestroke nurses, focusing on CTP pattern recognition consistent with ICA, M1, or M2 LVO acute ischemic stroke. We simultaneously conducted a prospective cohort study to evaluate the impact of this intervention. Results— Telestroke nurses demonstrated good accuracy in detecting ICA, M1, or M2 LVO during the first 3 months of teaching (83%–94% accurate). This significantly improved during the last 3 months (99%–100%), during which the likelihood of correctly identifying the presence of any one of these LVOs exceeded that of the first 3 months ( P <0.001). There was a higher probability of correctly identifying any CTP pattern as consistent with either an ICA, M1, or M2 occlusion versus other types of occlusions or nonocclusions (odds ratio, 5.22 [95% CI, 3.2–8.5]). Over time, confidence for recognizing CTP patterns consistent with an ICA, M1, or M2 LVO did not differ significantly. Conclusions— A series of tutorials and tests significantly increased the likelihood of telestroke nurses correctly identifying CTP patterns consistent with ICA, M1, or M2 LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at 4 months.

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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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Cost-Effectiveness of Bridging Thrombolysis versus Direct Endovascular Thrombectomy in acute ischemic stroke patients with Large Vessel Occlusion (LVO)

10.26226/morressier.5e8335ba7cb08a046ef7c690 ◽

2020 ◽

Author(s):

Xiao Wu

Keyword(s):

Ischemic Stroke ◽

Cost Effectiveness ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Endovascular Thrombectomy

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Performance of angiographic parametric imaging in locating infarct core in large vessel occlusion acute ischemic stroke patients

Journal of Medical Imaging ◽

10.1117/1.jmi.7.1.016001 ◽

2020 ◽

Vol 7 (01) ◽

pp. 1

Author(s):

Ryan A. Rava ◽

Maxim Mokin ◽

Kenneth V. Snyder ◽

Muhammad Waqas ◽

Adnan H. Siddiqui ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Parametric Imaging ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Infarct Core ◽

Vessel Occlusion

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Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Neurology ◽

10.1212/wnl.0000000000012827 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012827

Author(s):

Adam de Havenon ◽

Alicia Castonguay ◽

Raul Nogueira ◽

Thanh N. Nguyen ◽

Joey English ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Primary Outcome ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die. 

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Cervical internal carotid artery tortuosity: A morphologic analysis of patients with acute ischemic stroke

Interventional Neuroradiology ◽

10.1177/1591019919891295 ◽

2019 ◽

Vol 26 (2) ◽

pp. 216-221

Author(s):

John C Benson ◽

Waleed Brinjikji ◽

Steven A Messina ◽

Giuseppe Lanzino ◽

David F Kallmes

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Ischemic Stroke ◽

Internal Carotid ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Procedure Time ◽

Vessel Occlusion ◽

Cervical Internal Carotid Artery

Background and purpose Cervical internal carotid artery (ICA) tortuosity is thought to impede distal catheterization during attempted mechanical thrombectomy in patients with acute ischemic stroke. This study sought to assess the morphologic characteristics of ICAs and the effects of tortuosity on thrombectomy attempts. Methods A retrospective review was completed of neck CTAs of patients with acute ischemic stroke due to a large vessel occlusion that underwent attempted endovascular recanalization. Significant tortuosity of ICAs was defined as the presence of kink(s) (acute (<90°) angulation), loop(s) (C- or S-shaped curvature with 2+ areas of acute (<90°) angulation), or coil(s) (full 360° turn arterial bend). Findings were statistically compared to procedure time, successful recanalization rate, patient demographics, and co-morbidities. Results Of 120 included patients, 47 (39.2%) had some form of tortuosity of one or both ICAs. Twenty-eight patients (23.3%) had a kink of one or both ICAs; this was followed in frequency by loops (n = 20; 16.7%) and coils (n = 8; 6.7%). Kinks were associated with lower rates of successful recanalization (p = 0.02). The presence of any tortuosity (kinks, loops, or coils) was not associated with number of passes during thrombectomy (p = 0.88), successful recanalization (p = 0.11), or total procedure time (p = 0.22). No association was noted between the presence of tortuosity and age (p = 0.96) or prior or current tobacco use (p = 0.75 and p = 0.69, respectively). Conclusion Among patients referred for urgent revascularization for large vessel occlusion, approximately 40% exhibit some tortuosity. Kinks may portend lower likelihood of recanalization success, although tortuosity as a whole seems to have little effect on endovascular thrombectomy.

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Mechanical thrombectomy techniques for acute ischemic stroke

Romanian Neurosurgery ◽

10.33962/roneuro-2020-007 ◽

2020 ◽

pp. 46-51

Author(s):

A. Chiriac ◽

Georgiana Ion ◽

N. Dobrin ◽

Dana Turliuc ◽

I. Poeata

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Current Trends

Mechanical thrombectomy technique was introduced as an effective and secure method in acute ischemic stroke patients suffering from intracranial large vessel occlusion (LVO). In this article, we will review the main mechanical thrombectomy techniques and current trends in this type of treatment for acute ischemic stroke.

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The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke

Frontiers in Neurology ◽

10.3389/fneur.2021.663472 ◽

2021 ◽

Vol 12 ◽

Author(s):

Taylor Haight ◽

Burton Tabaac ◽

Kelly-Ann Patrice ◽

Michael S. Phipps ◽

Jaime Butler ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Emergency Medical ◽

Suspected Stroke

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

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Abstract 60: Impact of Monthly Testing and Tutorials on Accuracy and Confidence of Telestroke Nurse Recognition of Anterior Circulation Large Vessel Occlusion CT Perfusion Patterns

Stroke ◽

10.1161/str.51.suppl_1.60 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Emily K Snider ◽

Brenda Chang ◽

Anna Maria Helms ◽

Laura Williams ◽

Sam Singh ◽

...

Keyword(s):

Good Accuracy ◽

Internal Carotid ◽

Ct Perfusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Confidence Levels ◽

Lower Confidence ◽

The Impact

Introduction: A distinguishing feature of our Stroke Network is Telestroke (TS) nurses (RNs) who remotely facilitate TS evaluations. To facilitate expeditious transfer the TS RNs, need to immediately identify CT perfusion (CTP) studies demonstrating patterns consistent with internal carotid artery (ICA), middle cerebral artery (M1), and first branch of the M1 (M2) large vessel occlusion (LVO) acute ischemic strokes (AIS). Methods: We developed a 6-month series of tutorials and tests (12 CTP scans/month) for 16 TS RNs to recognize CTP patterns consistent with ICA, M1 or M2 LVO AIS. We simultaneously conducted a prospective cohort study of these nurses on the impact of these tutorials and tests. Results: TS nurses demonstrated good accuracy in detecting ICA, M1 or M2 LVO presence during the first three months of teaching (83-94% accurate).This improved to excellent during the last three months (99-100%), during which the likelihood of correctly identifying the presence of any one of these LVOs was greater than in the first three months (OR 1.99, 95% CI: 1.83-2.17, p<0.001). The probability of correctly identifying ICA or M1 occlusions was much higher than correctly identifying all other LVOs (OR 68, 95% CI: 45-102, p<0.001). The likelihood of being at a higher confidence level compared to lower confidence levels in identifying any LVOs as being ICA or M1 was higher than in identifying other LVOs (OR 2.14, 95% CI: 1.6-2.8, p<0.001), but over time confidence for determining LVO presence did not differ significantly after controlling for subject variation. Conclusion: A series of structured tutorials significantly increased the odds of TS nurses correctly identifying anterior circulation LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at four months. Participating in TS nurse tutorials was associated with high odds and confidence for correctly identifying LVOs as being ICA or M1.

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