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.

Abstract P483: Immediate Feedback to Emergency Medical Services Reduce Door to Angiogram and Transfer Time for Endovascular Treatment of Large Vessel Occlusion Ischemic Strokes

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kimberley Stephania Yescas Garibay ◽  
Nguyen Vo ◽  
Syung Jung ◽  
Sun Lee
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Transfer Time ◽  
Large Vessel Occlusion ◽  
Immediate Feedback ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The morbidity of acute ischemic Stroke (AIS) caused by a large vessel occlusion (LVO) can be significantly reduced with endovascular intervention. However, delay in diagnosis can exclude a patient from therapy.Rapid Arterial Occlusion evaluation (RACE) score of five or more have an 85% chance of being LVO acute ischemic stroke. Pre-arrival notification of potential LVO cases by EMS (Emergency Medical Service) is an important factor to reduce door-to-transfer time from a Primary Stroke Center (PSC) to a Comprehensive Stroke center (CSC). We hypothesize that immediate feedback to EMS teams on their pre-hospital RACE score reporting will improve prehospital recognition of LVO strokes. Therefore, reducing the Door to Needle CTA (CT Angiogram) and/or Door to Transfer Time for endovascular treatment. Methods: Our inclusion criteria included patients with a diagnosis of AIS brought in by EMS with a RACE score of five or more, was given IV thrombolytics, or transferred to a comprehensive stroke center for endovascular treatment. A 5-item feedback form was developed for each case and was reviewed biweekly with our EMS liaison. Feedback included compliance with RACE score reporting, presence of IV access, CTA time, and TPA/Transfer time. Direct feedback was verbally given to the EMS transport team. Results: Comparison of data from a twelve-month preintervention period (n=29) to a four-month postintervention period (n=12) was conducted through direct comparison. This showed a decrease in mean Door-to-CTA time from 212.14 (CI ±83.3) to 97.08 (CI ±54.92) minutes with a p-value of 0.0126 in a one-tailed t-Test, a 54% reduction and a reduction in door to transfer time (305 minutes to 132 minutes, a 56.7 % reduction ). Conclusion: A pilot project focused on providing immediate feedback to EMS regarding accurate prehospital notification of RACE score showed a statistically significant improvement in door to CTA time and door to transfer time. Extension of the post study period is needed to confirm the significance of transfer time. This study demonstrates the importance of collaboration between a PSC and EMS to ensure prompt diagnosis and transfer for endovascular treatment of AIS caused by LVO.

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.

Abstract 32: Intravenous Tpa Delays Door-to-puncture Time in Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Shashvat Desai ◽  
Jay Dolia ◽  
Kavit Shah ◽  
Merritt Brown ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Empirical Studies ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Negative Effect ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: The current 2018 AHA/ASA Guidelines for early stroke management recommend use of IV tPA in all eligible acute ischemic stroke patients within 4.5 hours of onset while being considered for mechanical thrombectomy (MT). Whether or not tPA administration is beneficial prior to thrombectomy is still an ongoing debate. Potential delay of MT initiation due to tPA start is a major concern but has not been well-delineated in empirical studies. Methods: In a prospective large volume comprehensive stroke center registry, we analyzed all patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with thrombectomy between 2012-2017, who arrived directly from field to ED within 4.5h of last known well. Patients without contraindication to IV-tPA are given bolus dose in the scanner suite and the remainder of the 1h infusion en route to and in the angio-suite to prevent delay. Results: Among 777 thrombectomy patients identified in the database, 237 arrived directly within 4.5 hours from onset, including 65.8% (156) not treated with IV-tPA and 34.2% (81) receiving IV-tPA, both well-matched in age and NIHSS. Overall, the door-to-needle (DTN) time was 40m (IQR31-56), surpassing the Target Stroke national targets (60m and 45m) active during the study period. However, median door-to-puncture (DTP) time was 22m longer in the IV-tPA group, 74 vs 52m (p<0.001). IV-tPA was not independently associated with better recanalization rate (TICI 2B-3 95.9% vs 92.9%) or functional independent outcome (modified Rankin score 0-2) at 90 days, 37.3% vs 39.4%. Conclusion: IV-tPA administration in AIS-LVO was associated with delayed door-to-puncture times in a comprehensive stroke center with efficient DTN times surpassing advanced national targets, without change in recanalization rate or outcomes. Randomized trials are needed to determine the net positive, neutral, or negative effect of IV-tPA in this population.

Abstract TP1: The Promising System to Support Rural Area Where No Intervenitionists to Perform Embolectomy for Acute Ischemic Stroke "Drive and Retrieve Method"

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Toshiya Osanai
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Rural Area ◽  
Median Time ◽  
Prospective Trial ◽  
Large Vessel ◽  
Full Time ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Introduction: In Japan, endovascular treatment for acute ischemic stroke from large vessel occlusion should be performed by neurointerventionists. However, most hospitals in rural area , that offer treatment for cerebral vascular disease do not have access to a neurointerventionist; the rural areas are especially affected. Thus, Our University has offered support to institutions without a neurointerventionist, to perform endovascular treatment. The neurointerventionists stationed in other hospitals drive to retrieve the resultant clot since the acute ischemic stroke from large vessel occlusion. We called this the “drive and retrieve system” method, and launched the prospective trial to evaluate the validity and efficacy of this method. Herein, we report the initial results of this trial. Methods: Nine institutes across our affiliated hospitals within a one-hour drive from Sapporo City took part in this trial. Three of these 9 institutes that have a full-time neurointerventionist were registered as the source. When an episode of acute ischemic stroke requiring intervention occurred in the other 6 hospitals, the available neurointerventionist provided treatment based on the drive and retrieve method. The neurointerventionists’ schedules was updated and distributed to all participating units twice a week, so that the supported hospitals could immediately make contact when required. We analysis the data of 44 cases in this trial from July 2015 to April 2016. Results: For 41 out of 44 cases (93%), Neurointerventionaists were able to respond immediately. The median time from door-to-puncture was 90 min (interquartile range [IQR]: 72-125). The median time from puncture to recanalization was also 76 min (IQR: 57.5-99.5). The recanalization rate (TICI 2b/3) was 77 %. mRS 0-2 was 39%. Conclusion: The drive and retrieve system has the potential to support rural medical institutes that do not have access to a full-time neurointerventionist.

Abstract TP19: Clinical Outcomes In Patients With Acute Ischemic Stroke Due To Large Vessel Occlusion In The Modern Era: 2010-2011 Experience With 423 Patients.

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Maxim Mokin ◽  
Tareq Kass-Hout ◽  
Omar Kass-Hout ◽  
Erol Veznedaroglu ◽  
Fadi Nahab ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Medical Management ◽  
Mortality Rates ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose: Acute ischemic stroke due to large vessel occlusion is associated with a poor prognosis. With no consensus about the best treatment option, various treatment modalities including conservative management, intravenous tissue plasminogen activator, and endovascular approach are currently being used. Methods: Retrospective data including demographic information, baseline NIHSS score, site of occlusion (based on CTA, MRA or angiogram), type of treatment and clinical outcomes were collected from 4 centers in the United States during the period of 2010-2011. Results: A total of 423 were included in final analysis: 175 patients received conservative medical management, 54 patients received intravenous (IV) thrombolysis alone, and 194 patients had endovascular treatment (with or without prior IV tPA). Younger patients were more likely to receive endovascular treatment (p<0.001). There was no statistically significant difference among the sex and co-morbid conditions among the three groups. Proximal middle cerebral artery was the most commonly involved vessel. Strokes due to basilar artery occlusion or internal carotid artery occlusion were associated with worst outcomes in all three groups. Conservative medical management had the lowest rates of symptomatic intracerebral hemorrhage but also the highest mortality rates at 3 months. Patients who received endovascular treatment within the first 3 hrs had better outcome and lower mortality rates as compared to patients with intervention during 3-8 hours or beyond 8 hrs. Conclusions: Our study represents real world experience on the management and outcomes of acute ischemic strokes due to large vessel occlusion. Our results help understand natural history of strokes with large vessel occlusion, as well as modern trends in managing these patients with intravenous and intraarterial treatment approaches.

Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Omar Kass-Hout ◽  
Tareq Kass-Hout ◽  
Maxim Mokin ◽  
David Orion ◽  
Shadi Jahshan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Combined Therapy ◽  
Large Vessel ◽  
P Value ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

scholarly journals Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

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