Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic

Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P <0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores ( P =0.003), lower comorbidity score ( P <0.001), and arrived more often by ambulance ( P <0.001). Post-SIP, more patients had large vessel occlusions ( P =0.03), and there were fewer stroke mimics ( P =0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts. Conclusions: In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.

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Evaluation of Patients with High National Institutes of Health Stroke Scale as Thrombectomy Candidates Using the Kentucky Appalachian Stroke Registry

Cerebrovascular Diseases ◽

10.1159/000504834 ◽

2019 ◽

Vol 48 (3-6) ◽

pp. 251-256 ◽

Cited By ~ 1

Author(s):

Parneet Grewal ◽

Michael R. Dobbs ◽

Keith Pennypacker ◽

Richard J. Kryscio ◽

Patrick Kitzman ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

High Blood Pressure ◽

Medical Condition ◽

Temporal Trends ◽

Patient Characteristics ◽

National Institutes Of Health ◽

Large Vessel ◽

Vessel Occlusion ◽

Stroke Registry

Introduction: Mechanical thrombectomy has become standard of care for emergent large vessel occlusive stroke. Estimates of incidence for thrombectomy eligibility vary significantly. National Institutes of Health Stroke Scale (NIHSS) of 10 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated temporal trends in stroke admissions with NIHSS ≥10 to determine patient characteristics among that group along with effects and needs in thrombectomy utilization. Methods: Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS ≥10. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was used as an indicator of inpatient outcome. Results: Between 2010 and 2016, 1,510 patients were admitted with NIHSS ≥10. 87.2% had high blood pressure, 69.6% had dyslipidemia, and 41.7% used tobacco. There were significant sex differences in the types of patients presenting with NIHSS ≥10 with females being older on average and having more atrial fibrillation and obesity. There was an increase in thrombectomy utilization from 2010 to 2016, but only 7.5% of the potentially eligible patients underwent the procedure. In comparison to the period 2010–2014, the 2015–2016 period had higher rates of obesity and tobacco abuse. Conclusion: Among patients with significant burden of ischemic stroke, the most common coexisting medical condition was high blood pressure. Patients who underwent thrombectomy had significantly better inpatient clinical improvement. These data support the need to maximize utilization of thrombectomy along with need to devote increased resources on modifiable stroke risk factors.

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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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Artificial intelligence to diagnose ischemic stroke and identify large vessel occlusions: a systematic review

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015135 ◽

2019 ◽

Vol 12 (2) ◽

pp. 156-164 ◽

Cited By ~ 15

Author(s):

Nick M Murray ◽

Mathias Unberath ◽

Gregory D Hager ◽

Ferdinand K Hui

Keyword(s):

Artificial Intelligence ◽

Machine Learning ◽

Systematic Review ◽

Ischemic Stroke ◽

Acute Stroke ◽

Feature Detection ◽

Performance Metrics ◽

Large Vessel ◽

Image Feature ◽

Stroke Treatment

Background and purposeAcute stroke caused by large vessel occlusions (LVOs) requires emergent detection and treatment by endovascular thrombectomy. However, radiologic LVO detection and treatment is subject to variable delays and human expertise, resulting in morbidity. Imaging software using artificial intelligence (AI) and machine learning (ML), a branch of AI, may improve rapid frontline detection of LVO strokes. This report is a systematic review of AI in acute LVO stroke identification and triage, and characterizes LVO detection software.MethodsA systematic review of acute stroke diagnostic-focused AI studies from January 2014 to February 2019 in PubMed, Medline, and Embase using terms: ‘artificial intelligence’ or ‘machine learning or deep learning’ and ‘ischemic stroke’ or ‘large vessel occlusion’ was performed.ResultsVariations of AI, including ML methods of random forest learning (RFL) and convolutional neural networks (CNNs), are used to detect LVO strokes. Twenty studies were identified that use ML. Alberta Stroke Program Early CT Score (ASPECTS) commonly used RFL, while LVO detection typically used CNNs. Image feature detection had greater sensitivity with CNN than with RFL, 85% versus 68%. However, AI algorithm performance metrics use different standards, precluding ideal objective comparison. Four current software platforms incorporate ML: Brainomix (greatest validation of AI for ASPECTS, uses CNNs to automatically detect LVOs), General Electric, iSchemaView (largest number of perfusion study validations for thrombectomy), and Viz.ai (uses CNNs to automatically detect LVOs, then automatically activates emergency stroke treatment systems).ConclusionsAI may improve LVO stroke detection and rapid triage necessary for expedited treatment. Standardization of performance assessment is needed in future studies.

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Abstract TMP8: Predictors of Large Vessel Occlusion in Kaiser Stroke EXPRESS Program

Stroke ◽

10.1161/str.48.suppl_1.tmp8 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey G Klingman ◽

Anne C Kim ◽

Meghan Hatfield ◽

Benjamin Wilson ◽

Lauren Klingman ◽

...

Keyword(s):

Acute Stroke ◽

Patient Characteristics ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Acute Stroke Care ◽

Kaiser Permanente ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Improved Outcomes

Background: In 2015, trials showed that rapid endovascular stroke treatment (EST) of qualified patients with large vessel occlusion (LVO) resulted in improved outcomes over treatment with IV tPA alone. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for its 21 stroke centers, which included expedited IV t-pa treatment, rapid CTA investigation, expedited transfer of appropriate patients for EST. We assessed for predictors of LVO post-implementation. Methods: The KPNC Stroke EXPRESS program was live in all centers by January 2016. Using clinical data for 1/1/16 - 7/10/16, we evaluated the frequency and locations of LVO, and patient characteristics of those with LVO. Multivariate logistic regression was used to examine whether age, gender, race, or an NIHSS ≥ 8 are predictors of LVO. Results: There were 2,204 tele-stroke alert cases from the ED. Among 993 (39.3%) that proceeded as likely acute stroke, 812 (81.8%) were evaluated with CTA. Out of those who had a CTA, 152 (18.7%) were found to have LVO as followed: 27 (17.8%) ICA, 87 (57.2%) M1, 24 (15.8%) M2, 6 (4.0%) basilar, 5 (3.3%) PCA, and 3 (2.0%) vertebral. Of those with LVO, 97 (63.8%) were treated with EST. Patients with LVO had a higher median NIHSS (15 vs. 5 in those without LVO). Neglect (27% vs. 7%) and gaze deviation (16% vs. 1%) were more likely to be seen among those with LVO and treated with EST compared to those without LVO. In multivariate analysis, age (OR=1.02, 95% CI 1.00 - 1.03, p=0.01) and NIHSS ≥8 (OR = 4.99, 95% CI 3.32- 7.49, p < 0.001) were associated with LVO. PPV for NIHSS ≥8 was 75.7%. Conclusions: In our large multi-ethnic population of acute stroke patients, a relatively small percentage (19%) was found to have LVO and only a subset qualified for EST. Predictors of LVO included NIHSS ≥8, increasing age, and presence of neglect and gaze preference. Given the low numbers of patients brought in for acute stroke treatment who ended up with a LVO requiring EST, further research is needed to assess a given system’s ability to rapidly evaluate and transfer as appropriate for EST rather than paramedic based diversion.

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Temporal Trends in Patient Characteristics and Treatment With Intravenous Thrombolysis Among Acute Ischemic Stroke Patients at Get With the Guidelines–Stroke Hospitals

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.111.000095 ◽

2013 ◽

Vol 6 (5) ◽

pp. 543-549 ◽

Cited By ~ 158

Author(s):

Lee H. Schwamm ◽

Syed F. Ali ◽

Mathew J. Reeves ◽

Eric E. Smith ◽

Jeffrey L. Saver ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Patient Characteristics ◽

Stroke Patients ◽

Get With The Guidelines

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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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Duration of symptomatic stroke and successful reperfusion with endovascular thrombectomy for anterior circulation large vessel occlusive stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016961 ◽

2021 ◽

pp. neurintsurg-2020-016961

Author(s):

Adam de Havenon ◽

Matthew D Alexander ◽

Raul G Nogueira ◽

Diogo C Haussen ◽

Alicia C Castonguay ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Stroke Patients ◽

Anterior Circulation ◽

First Pass ◽

Adjusted Logistic Regression

BackgroundIt has been reported that longer time intervals from stroke onset to endovascular therapy are associated with lower rates of successful reperfusion in acute ischemic stroke patients with large vessel occlusion. However, procedural variables and potential mechanisms of this association have not been fully elucidated.MethodsWe performed a secondary analysis of individual patient data from the North American Solitaire Stent Retriever Acute Stroke (NASA) and Trevo Stent-Retriever Acute Stroke (TRACK) registries. We included patients with occlusion of the internal carotid artery or middle cerebral artery (M1 and M2 segments) who were treated by mechanical thrombectomy within 24 hours of last known normal. The primary outcome was reperfusion, defined as a Thrombolysis In Cerebral Infarction (TICI) score ≥2b. The secondary outcome was reperfusion on the first pass. The primary predictor was duration of symptomatic stroke, defined as time from last known normal to time of final pass. Adjusted logistic regression models were utilized to determine associations between variables and outcome.ResultsWe included 506 patients, of which 401 (79.3%) achieved successful reperfusion (TICI 2b/3). The mean (SD) duration of symptomatic stroke was 6.8 (3.5) hours and in the adjusted logistic regression model the duration of symptomatic stroke was associated with reperfusion (OR 0.90, 95% CI 0.84 to 0.96) and reperfusion on the first pass (OR 0.89, 95% CI 0.83 to 0.95). In that model, the predicted probability of reperfusion was 88% (95% CI 0.83 to 0.92) at 1 hour, 81% (95% CI 0.78 to 0.84) at 6 hours, 70% (95% CI 0.63 to 0.77) at 12 hours, and 42% (95% CI 0.17 to 0.67) at 24 hours (ptrend=0.001). Reperfused patients were significantly younger, more likely to be male, and to have had a balloon guide catheter used during the procedure.ConclusionIn a real-world cohort of acute ischemic stroke patients with anterior circulation occlusion treated with endovascular therapy, longer duration of symptomatic stroke is associated with lower rates of successful reperfusion and reperfusion on the first pass.

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Temporal trends in incidence and patient characteristics in cardiogenic shock following acute myocardial infarction from 2010 to 2017: a Danish cohort study

European Journal of Heart Failure ◽

10.1002/ejhf.1566 ◽

2019 ◽

Vol 21 (11) ◽

pp. 1370-1378 ◽

Cited By ~ 29

Author(s):

Ole K.L. Helgestad ◽

Jakob Josiassen ◽

Christian Hassager ◽

Lisette O. Jensen ◽

Lene Holmvang ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cohort Study ◽

Cardiogenic Shock ◽

Temporal Trends ◽

Patient Characteristics ◽

Danish Cohort

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Intraarterial Thrombolysis as Rescue Therapy for Large Vessel Occlusions

Stroke ◽

10.1161/strokeaha.118.024442 ◽

2019 ◽

Vol 50 (4) ◽

pp. 1003-1006 ◽

Cited By ~ 11

Author(s):

Syed F. Zaidi ◽

Alicia C. Castonguay ◽

Mouhammad A. Jumaa ◽

Tim W. Malisch ◽

Italo Linfante ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Rescue Therapy ◽

Stent Retriever ◽

Large Vessel ◽

Stroke Patients ◽

Stroke Registry ◽

The North ◽

Intraarterial Thrombolysis

Background and Purpose— Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry. Methods— The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT. Results— A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%; P =0.13) with faster times to recanalization (100±85 versus 164±235 minutes; P =0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%; P =0.29) and mortality (42.9% versus 44.7%; P =0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%; P =0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%; P =0.02). Conclusions— Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.

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