scholarly journals Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability

Stroke ◽  
2021 ◽  
Author(s):  
Minerva H. Zhou ◽  
Akash P. Kansagra
Keyword(s):  
Acute Stroke ◽  
Modest Improvement ◽  
Absolute Increase ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Primary Stroke Center ◽  
Treatment Volume ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Patient Referrals

Background and Purpose: With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center. Methods: In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials. Results: Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population. Conclusions: Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.

Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts

2018 ◽  
Vol 13 (5) ◽  
pp. 469-472 ◽  
Author(s):  
Carlos Garcia-Esperon ◽  
Andrew Bivard ◽  
Christopher Levi ◽  
Mark Parsons
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Treatment Decision ◽  
Added Value ◽  
Stroke Treatment ◽  
Computed Tomography Perfusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Weighted Sequences ◽  
Perfusion Maps

Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the “lesions” on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.

scholarly journals Implementing the SNIS recommendations for neurointerventional emergent care in the setting of COVID-19: impact on stroke metrics and patient outcomes

2021 ◽  
pp. neurintsurg-2021-017415
Author(s):  
Benjamin Atchie ◽  
Stephanie Jarvis ◽  
Erica Stoddard ◽  
Kristin Salotollo ◽  
Amy Nieberlein ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Endovascular Therapy ◽  
Guideline Implementation ◽  
Treatment Utilization ◽  
Stroke Treatment ◽  
Acute Stroke Treatment ◽  
Stroke Type ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Treatment Use

BackgroundIt is not clear whether the COVID-19 pandemic and subsequent Society of Neurointerventional Surgery (SNIS) recommendations affected hospital stroke metrics.MethodsThis retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic April 1 2020 to June 30 2020 (COVID-19) to patients admitted April 1 2019 to June 30 2019. We examined stroke admission volume and acute stroke treatment use.ResultsThere were 637 stroke admissions, 52% in 2019 and 48% during COVID-19, with similar median admissions per day (4 vs 3, P=0.21). The proportion of admissions by stroke type was comparable (ischemic, P=0.69; hemorrhagic, P=0.39; transient ischemic stroke, P=0.10). Acute stroke treatment was similar in 2019 to COVID-19: tPA prior to arrival (18% vs, 18%, P=0.89), tPA treatment on arrival (6% vs 7%, P=0.85), and endovascular therapy (endovascular therapy (ET), 22% vs 25%, P=0.54). The door to needle time was also similar, P=0.12, however, the median time from arrival to groin puncture was significantly longer during COVID-19 (38 vs 43 min, P=0.002). A significantly higher proportion of patients receiving ET were intubated during COVID-19 due to SNIS guideline implementation (45% vs 96%, P<0.0001). There were no differences by study period in discharge mRS, P=0.84 or TICI score, P=0.26.ConclusionsThe COVID-19 pandemic did not significantly affect stroke admission volume or acute stroke treatment utilization. Outcomes were not affected by implementing SNIS guidelines. Although there was a statistical increase in time to groin puncture for ET, it was not clinically meaningful. These results suggest hospitals managing patients efficiently can implement practices in response to COVID-19 without impacting outcomes.

scholarly journals Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays

2020 ◽  
pp. 1-5
Author(s):  
Joel Neves Briard ◽  
Célina Ducroux ◽  
Grégory Jacquin ◽  
Walid Alesefir ◽  
William Boisseau ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Negative Impact ◽  
Reperfusion Therapy ◽  
Observational Cohort Study ◽  
Treatment Delays ◽  
Stroke Treatment ◽  
Time Period ◽  
Observational Cohort ◽  
Comprehensive Stroke Center ◽  
Stroke Center

ABSTRACT: This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

scholarly journals Decision Analysis Model for Prehospital Triage of Patients With Acute Stroke

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 970-977 ◽  
Author(s):  
Yaqian Xu ◽  
Neal S. Parikh ◽  
Boshen Jiao ◽  
Joshua Z. Willey ◽  
Amelia K. Boehme ◽  
...  
Keyword(s):  
Decision Analysis ◽  
Acute Stroke ◽  
Real World ◽  
Tissue Type ◽  
Decision Analysis Model ◽  
Transport Time ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background and Purpose— We used a decision analysis approach to analyze triage strategies for patients with acute stroke symptoms while accounting for prehospital large vessel occlusion (LVO) screening methods and key time metrics. Methods— Our decision analysis compared anticipated functional outcomes for patients within the IV-tPA (intravenous tissue-type plasminogen activator) treatment window in the mothership and drip-and-ship frameworks. Key branches of the model included IV-tPA eligibility, presence of an LVO, and endovascular therapy eligibility. Our decision analysis evaluated 2 prehospital LVO screening approaches: (1) no formal screening and (2) the use of clinical LVO screening scales. An excellent outcome was defined as modified Rankin Scale scores 0–1. Probabilities and workflow times were guideline-based or imputed from published studies. In sensitivity analyses, we individually and jointly varied transport time to the nearest primary stroke center, additional time required to transport directly to a comprehensive stroke center, and LVO screening scale predictive probabilities. We evaluated 2 separate scenarios: one in which ideal time metrics were achieved and one under current real-world metrics. Results— In the ideal metrics scenario, the drip-and-ship strategy was almost always favored in the absence of formal LVO screening. For patients screened positive for an LVO, mothership was favored if the additional transport time to the comprehensive stroke center was <3 to 23 minutes. Under real-world conditions, in which primary stroke center workflow is slower than ideal, the mothership strategy was favored in more scenarios, regardless of formal LVO screening. For example, mothership was favored with an additional transport time to the comprehensive stroke center of <32 to 99 minutes for patients screened positive for an LVO and <28 to 39 minutes in the absence of screening. Conclusions— Joint consideration of LVO probability, screening, workflow times, and transport times may improve prehospital stroke triage. Drip-and-ship was more favorable when more ideal primary stroke center workflow times were modeled.

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.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

2021 ◽  
pp. 174749302098526
Author(s):  
Juliane Herm ◽  
Ludwig Schlemm ◽  
Eberhard Siebert ◽  
Georg Bohner ◽  
Anna C Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Poor Functional Outcome ◽  
Stroke Registry ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Center Time

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

Abstract W P292: A Comparative Analysis of the Requirements for Certification of Stroke Programs, by Type and by Nationally Recognized Certifying Body

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Stacey Lang
Keyword(s):  
Selection Process ◽  
Evaluation Process ◽  
Program Leaders ◽  
Primary Stroke Center ◽  
Similarities And Differences ◽  
Certification Organizations ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Core Measures ◽  
Certification Requirements

Background and Purpose: There are currently three main, nationally recognized organizations that certify facilities as primary or comprehensive stroke centers. One of these organizations also offers a “Stroke Ready” designation. While each of these organizations share many of the same requirements, there are likewise many unique requirements between certifying bodies with respect to the certification requirements, process, performance, and on-going expectations. All should be considered when choosing a partner for certification by organizations that are committed to achieving an appropriate level of certification as determined by clinical capabilities. Differences in core measure requirements and definitions, data collection expectations and re-certification cycles among other factors are often overlooked when stroke program leaders are identifying the best certification partner for their particular organization. This poster will detail the similarities and differences among the various stroke program certifying organizations and present a detailed methodology to assist program leaders with the partner selection process. Methods: The three stroke program certifying organizations were examined for review cycles, levels of certification offered, requirements related to hospital certifications, and reportable core measures. Other factors such as cost, the actual certification process, and other considerations that may impact the successful achievement of certification within a particular organization were also reviewed. Results/Conclusion: While there are many similarities in the stroke center certification requirements and processes among the three certifying organizations, there are also significant differences. In order to ensure that the end product of a journey to certification will align with a hospital’s values, budget, and vision for the stroke program, an evaluation process in advance of certifying body selection is essential. Awareness of the similarities and differences among the stroke certification organizations can facilitate a hospital’s decision-making process for pursuit of certification as a stroke ready center, primary stroke center or comprehensive stroke center

Abstract WP240: Ultra-acute Diagnostics for Stroke: Large-scale Implementation of Prehospital Biomarker Sampling

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Olli S Mattila ◽  
Heini Harve ◽  
Saana Pihlasviita ◽  
Juhani Ritvonen ◽  
Gerli Sibolt ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Large Scale ◽  
Biomarker Discovery ◽  
Cost Effective ◽  
Blood Sampling ◽  
Blood Samples ◽  
And Performance ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Acute Diagnostics

Background and purpose: Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. However, large prehospital sample sets required for biomarker discovery and validation are missing, and the feasibility of large-scale blood sampling by emergency medical services (EMS) has not been determined. We set out to establish extensive prehospital blood sampling of thrombolysis candidates in the catchment area of our comprehensive stroke center, with a 1.5 million population base. Methods: EMS personnel were trained to collect prehospital blood samples using a cannula-adapter technique. Time delays, sample quality and performance bottlenecks were investigated between May 20, 2013 and May 19, 2014. Results: Prehospital blood sampling and study recruitment were successfully performed in 430 thrombolysis candidates, of which 55.3% were admitted outside office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than admission blood sampling, and 37 minutes (30-47) earlier than admission neuroimaging. Quality control data from 25 participating EMS units indicated a 4-minute increase in median transport time (from arrival on-scene to hospital door) for study patients compared to patients of the preceding year. The hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples collected with venipuncture. Conclusions: Prehospital biomarker sampling is feasible in standard EMS units and provides a median timesaving of over 30 minutes to obtain first blood samples. Large biobanks of prehospital blood samples will facilitate development of ultra-acute stroke biomarkers.

Abstract TP289: Code Neuro-Intervention a New Necessity: Reality of Shifting Stroke Care Paradigm

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Laura Suhan ◽  
Spozhmy Panezai ◽  
Jaskiran Brar ◽  
Audrey Z Arango ◽  
Anna Pullicino ◽  
...  
Keyword(s):  
Stroke Care ◽  
Work Hours ◽  
Stroke Treatment ◽  
Angiography Suite ◽  
Stroke Team ◽  
Cross Training ◽  
Code Process ◽  
Time Parameters ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Various strategies have been implemented to reduce acute stroke treatment times. A unique code process pathway was designed at our hospital specifically to be activated by the stroke team for the purpose of rapidly assembling the Neurointerventional team. Methods: Code Neurointervention (NI), was designed and tested from January 2014 to April 2014 for all the patients who presented with ischemic strokes to our community based, university affiliated comprehensive stroke center. We retrospectively analyzed all patients who had Code NI called from May 1, 2014 to April 30, 2015 and compared them to patients who underwent acute endovascular treatment the prior year (Non Code NI). The following parameters were compared: decision to recanalization and door to recanalization times. Further analysis was done to compare patients presenting during business hours (Monday-Friday 8am-5pm) and off hours using GraphPad QuickCalcs Web site. Results: There were 28 Code NI; 14 were called during work hours and 14 during off hours. The previous year 25 patients underwent acute endovascular intervention; 12 during work hours and 13 during off hours. Mean decision to recanalization time was 106 (Code NI) vs 115 minutes (Non Code NI) (p<0.0.6) during work hours and 154 (Code NI) vs 139 minutes (Non Code NI) (p<0.37) during off hours. Mean door to recanalization time was 169 (Code NI) vs 173 minutes (Non Code NI) (p<0.85) during work hours and 252 (Code NI) vs 243minutes (Non Code NI) (p< 0.75) during off hours. Subset analysis of time parameters for patients in Code NI group showed mean decision to recanalization times of 106 minutes during work hours vs 154 minutes off work hours (p<0.004). Mean door to recanalization times were 169 minutes vs 251 minutes (p<0.0003), respectively. Conclusion: Institution of Code NI significantly improved intervention time parameters during work hours as compared to off hours. Rapid assembly of the neurointervention team, rapid availability of imaging and angiography suite likely contribute to these differences. Further initiatives, such as improving neurointervention staff availability during off hours or cross training other staff can further improve acute intervention time parameters.

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