Population health impact of extended window thrombectomy in acute ischemic stroke

2020 ◽  
pp. 159101992097220
Author(s):  
Minerva H Zhou ◽  
Akash P Kansagra
Keyword(s):  
Clinical Outcome ◽  
Clinical Outcomes ◽  
Clinical Trial Data ◽  
Population Level ◽  
Health Impact ◽  
Stroke Severity ◽  
Good Clinical Outcome ◽  
Absolute Increase ◽  
Stroke Center ◽  
The Impact

Background Recent trials support endovascular thrombectomy (EVT) in select patients beyond the conventional 6-hour window. Objective In this work, we estimate the impact of extended window EVT on procedural volumes and population-level clinical outcomes using Monte Carlo simulation. Methods We simulated extending EVT eligibility in a system comprising an EVT-incapable primary stroke center (PSC) and EVT-capable comprehensive stroke center (CSC) using routing paradigms that initially direct patients to (1) the nearest center, (2) the CSC, or (3) either CSC or nearest center based on stroke severity. EVT eligibility and outcomes are based on HERMES, DEFUSE-3, and DAWN studies in the 0-6, 6-16, and 16-24 hour windows, respectively. Probability of good clinical outcome is determined by type and timing of treatment using clinical trial data. Results Relative increase in EVT volume in the three tested routing paradigms was 15.7-15.8%. The absolute increase in the rate of good clinical outcome 0.4% in all routing paradigms. NNT for extended window EVT was 239.9-246.4 among the entire stroke population. Conclusion Extended window EVT with DEFUSE-3 and DAWN criteria increases EVT volume and modestly improves population-level clinical outcomes.

Effect of routing paradigm on patient-centered outcomes in acute ischemic stroke

2018 ◽  
Vol 11 (3) ◽  
pp. 251-256
Author(s):  
Minerva H Zhou ◽  
Akash P Kansagra
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Rhode Island ◽  
Clinical Trial Data ◽  
Population Level ◽  
Urban Setting ◽  
Rural Setting ◽  
Good Clinical Outcome ◽  
Stroke Center

ObjectiveTo compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.MethodsWe simulated different routing paradigms in a system comprising one primary stroke center (PSC) and onecomprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the Nearest Center paradigm, patients are initially sent to the nearest center, while in CSC First, patients are sent to the CSC. In Rhode Island and Distributive paradigms, patients with Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome determined by type and timing of treatment using clinical trial data and number needed to bypass (NNB).ResultsGood clinical outcome was achieved in 43.67% of patients in Nearest Center and 44.62% in CSC First, Rhode Island, and Distributive in an urban setting; 42.79% in Nearest Center and 43.97% in CSC First and Rhode Island in a suburban setting; and 39.76% in Nearest Center, 41.73% in CSC First, and 41.59% in Rhode Island in a rural setting. In all settings, the NNB was considerably higher for CSC First than for Rhode Island or Distributive.ConclusionRouting paradigms that allow bypass of nearer hospitals for thrombectomy-capable centers improve population-level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, the choice of model may have greater effect in rural settings. Selective bypass, as implemented in Rhode Island and Distributive paradigms, improves system efficiency with minimal effect on outcomes.

Effect of routing paradigm on patient centered outcomes in acute ischemic stroke

2019 ◽  
Vol 11 (8) ◽  
pp. 762-767 ◽  
Author(s):  
Minerva H Zhou ◽  
Akash P Kansagra
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Rhode Island ◽  
Clinical Trial Data ◽  
Urban Setting ◽  
Rural Setting ◽  
Good Clinical Outcome ◽  
Minimal Impact ◽  
Stroke Center

BackgroundTo compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.MethodsWe simulated different routing paradigms in a system comprising one primary stroke center (PSC) and one comprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the nearest center paradigm, patients are initially sent to the nearest center, while in CSC first, patients are sent to the CSC. In the Rhode Island and distributive paradigms, patients with a FAST-ED (Facial palsy, Arm weakness, Speech changes, Time, Eye deviation, and Denial/neglect) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome, determined by type and timing of treatment using clinical trial data, and number needed to bypass (NNB).ResultsGood clinical outcome was achieved in 43.76% of patients in nearest center, 44.48% in CSC first, and 44.44% in Rhode Island and distributive in an urban setting; 43.38% in nearest center, 44.19% in CSC first, and 44.17% in Rhode Island in a suburban setting; and 41.10% in nearest center, 43.20% in CSC first, and 42.73% in Rhode Island in a rural setting. In all settings, NNB was generally higher for CSC first compared with Rhode Island or distributive.ConclusionRouting paradigms that allow bypass of nearer hospitals for thrombectomy capable centers improve population level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, paradigm choice may be most impactful in rural settings. Selective bypass, as implemented in the Rhode Island and distributive paradigms, improves system efficiency with minimal impact on outcomes.

scholarly journals Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

2021 ◽  
Vol 11 (4) ◽  
pp. 504
Author(s):  
Dalibor Sila ◽  
Markus Lenski ◽  
Maria Vojtková ◽  
Mustafa Elgharbawy ◽  
František Charvát ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Stent Retriever ◽  
Good Clinical Outcome ◽  
Significant Difference ◽  
Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

Abstract T P276: Calling Stroke Alert: Does It Make a Difference in the Chain of Survival?

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Cristine W Small ◽  
Donald L Price ◽  
Jeffrey D Ferguson ◽  
Lawrence I Madubeze ◽  
Susan D Freeman
Keyword(s):  
Clinical Outcomes ◽  
Stroke Severity ◽  
Golden Hour ◽  
Discharge Disposition ◽  
Improved Outcomes ◽  
Stroke Team ◽  
Severity Scores ◽  
Response Team ◽  
Chain Of Survival ◽  
The Impact

Purpose: To determine whether the stroke alert process results in improved outcomes, as reflected in door to lytic times and other outcome measures. Introduction: The diagnosis and treatment of stroke is time-sensitive and should be inclusive of all seven D’s in the “chain of survival” - Detection, Dispatch, Delivery, Door, Data, Decision and Drug (Adams, Stroke, 2007). Early stroke activation is part of the “Delivery” which incorporates transport and management by Emergency Medical Services (EMS). Clinical suspicion of stroke by EMS resulted in a process of early activation which was labeled “Stroke Alert.” This expedited the code stroke process upon arrival, preparing the hospital based stroke team to provide immediate triage and evaluation. The goal was to improve clinical efficiency and possibly clinical outcomes. Methods: • Implementation of a notification process from EMS to ED - Stroke Alert • Incorporated Stroke Alert to include Stroke Response Team (SRT) nurses January 22, 2011 • Retrospective review of internal stroke database (January 22, 2011 to July 2013) for comparative analysis of Stroke Alerts called versus those where no stroke alert was called • Evaluate clinical outcomes directly related to Stroke Alert process Results: From January 22, 2011 to July 2013: Stroke Alert Called: • 37 t-PA patients and 14 of those, 37.8%, met the 60 minute benchmark • Average Door to Lytic time - 65 minutes Stroke Alert NOT Called: • 35 t-PA patients and 10 of those, 28.6% met the 60 minute benchmark • Average Door to Lytic time - 79 minutes Conclusions: The ability for a SRT to meet the golden hour of stroke benchmark occurs more frequently when a Stroke Alert is called to the SRT nurse. Future plans include review of stroke severity scores, length of stay (LOS), and discharge disposition, to determine the impact a Stroke Alert may have on clinical outcomes.

Abstract W P48: Flair Vessel Hyper-intensities Could Predict Target Mismatch Signs in Acute Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Michael Mlynash ◽  
Carlo W Cerada ◽  
Nishant K Mishra ◽  
Soren Christensen ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Pooled Analysis ◽  
Stroke Patients ◽  
Good Clinical Outcome ◽  
Kappa Score ◽  
Early Reperfusion ◽  
Diffusion Weighted Images ◽  
Fluid Attenuated Inversion Recovery

Background and purpose: Fluid-attenuated inversion recovery (FLAIR) vessel hyper-intensities (FVH) have been hypothesized to have a positive correlation with good collaterals and more favorable clinical outcomes in acute stroke patients. We assessed if FVH predict the Target mismatch profile (TMM) and clinical outcomes in the DEFUSE studies. Methods: Patients with technically adequate baseline diffusion weighted images (DWI), perfusion images (PWI), and FLAIR images were included in this pooled analysis of the DEFUSE 1 and 2 studies. The FVH sign was defined as visible hyper-intense vessels on FLAIR images and assessed at basal ganglia levels by two independent raters. Clinical outcomes were assessed using modified Rankin Scale (mRS) at 90 days. The Target mismatch profile was based on baseline DWI and PWI volumes using automated software (RAPID). Results: Seventy seven patients met the inclusion criteria. Median time (IQR) from symptom onset to baseline MRI was 4.6 hours (3.9 - 5.4) and median (IQR) DWI lesion was 13.1 (5.0 - 32.0) ml. Of these, 66 patients (86%) had the FVH sign. Kappa score for inter-rater agreement was 0.621 (95CI: 0.33 - 0.91). Seventy (74%) cases with FVH had TMM profile vs. 33% of No FVH patients (p=0.023). Good clinical outcome (mRS 0-2) did not differ (50% with FVH vs. 73% without FVH, p=0.203). Only 38% of the patients with FVH had good angiographic collaterals and the rate of early reperfusion did not differ (45% with FVH vs. 25% without FVH, p=0.45). Conclusions: FVH is common in acute stroke patients (86%) and is associated with the Target Mismatch profile. However, FVH was not associated with favorable angiographic collaterals, good clinical outcome or early reperfusion in the DEFUSE 1 and 2 cohorts.

Abstract P122: The Impact of Center Certification Status on Acute Stroke Care Within a Multi-Hospital System in Western United States

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Radoslav I Raychev ◽  
CrystalAnn Moreno ◽  
Leslie Corless ◽  
Jason W Tarpley ◽  
John F Zurasky ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Clinical Outcome ◽  
Regression Models ◽  
Process Of Care ◽  
Chi Square ◽  
Hospital System ◽  
Logistic Regression Models ◽  
Stroke Center ◽  
The Impact ◽  
Iv Tpa

Introduction: We aimed to investigate the impact of certification status on process of care metrics and clinical outcome in a large multi-center hospital system. Methods: We analyzed data obtained from the Providence Stroke Registry between January 2016 and December 2019. Key process of care metrics and clinical outcome were compared among patients with a discharge diagnosis of stroke and stratified based on site certification: comprehensive stroke center (CSC), thrombectomy-capable stroke center (TSC), primary stroke center (PSC) and no certification (NC). Donner’s adjusted chi-square tests were used to compare proportions for each metric grouped by certification. Generalized linear mixed effects logistic regression models were used to adjust for mode of patient arrival, age, sex, admit NIHSS, and medical history. Results: Data included 45,278 patients. Results from the analyses are summarized in the table. Donner’s adjusted chi-square analyses showed significant differences for metrics across certification groups. Results from the logistic regression models indicated significant differences in IV TPA and EVT treatment, as well as IV TPA treatment times across certification groups. There were no significant differences between TSC and CSC. Conclusions: Patients presenting with acute ischemic stroke at NC and PSC were significantly less likely to receive IV TPA or EVT with significantly less efficient IV tPA treatment times as compared to CSC. However, CSC and TSC sites performed similarly.

P5472Social economic deprivation and adverse clinical outcomes after acute coronary syndrome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
Y C Lau ◽  
J Latter ◽  
A Jong ◽  
R Weir
Keyword(s):  
Clinical Outcome ◽  
Secondary Prevention ◽  
Clinical Outcomes ◽  
Statistical Difference ◽  
Independent Predictor ◽  
Composite Endpoint ◽  
Socioeconomic Deprivation ◽  
Angiotensin Ii Receptor Blocker ◽  
The Impact

Abstract Background NHS was created in 1948 to redress the healthcare inequality through provision of universal healthcare service in the UK. However even of late, significant health inequality persists. Socioeconomic deprivation is known to result in increased overall morbidity and mortality. Aim To assess the impact of socioeconomic deprivation (as categorised by Scottish Index of Multiple Deprivation, SIMD) on the medical management and clinical outcomes of patients with ACS (NSTEMI/STEMI) who were treated with PCI Methods A retrospective study of NSTEMI/NSTEMI patients after inpatient treatment with coronary angiogram and PCI. The parameters include basic demographics, risk factors, LV EF on echocardiogram, lipid profile and discharge medication. Individual's socioeconomic deprivation index, as described SIMD was also recorded (1 – most deprived and 10 – least deprived), and accordingly placed into quintile (SIMD 1–2, 3–4, 5–6,7 –8, 9–10). Follow-up for 24 months. Clinical outcome assessed was composite endpoint event of MACE. Results 357 from the lowest quintile (SIMD 1–2), 319 from SIMD 3–4, 191 from SIMD 5–6, 120 from SIMD 7–8, and 99 from the highest quintile (SIMD 9–10) were included. No statistical difference exists between age or gender. No difference in past medical history (inclusive of hypertension, diabetes, dyslipidemia, family history. No difference in incidence of nicotine use. Prescription of aspirin, P2Y12 inhibitors (clopidogrel, ticagrelor or prasugrel) as well as secondary prevention medications (such as ace inhibitor/angiotensin II receptor blocker, beta blocker, statin and GTN) were good and not statistically different between all groups. No statistical difference exists between all groups relating to pre-discharge LV ejection fraction on echocardiogram or random cholesterol level check on admission. 24 months follow-up demonstrated composite endpoint of MACE was statistically higher among patients of lowest socioeconomic quintile (Kaplan Meier plot, p<0.001). Step-wise multiple regression analysis also confirmed multiple socioeconomic deprivation as an independent predictor for more adverse clinical outcomes (p<0.001, R2=14.5%). Patients from the least deprived quintile possess survival advantage almost 14-folds as compared to those of most deprived group (Odd-ratio 13.8 (95% CI: 39.4–48.5)). Summary After an ACS event, despite initial coronary intervention and subsequent optimal prescription of prognostically beneficial secondary prevention medications, patients from the lower socioeconomic group (as described by SIMD) are still more likely to experience readmission for cardiovascular death, non-fatal myocardial infarction and non-fatal stroke. Socioeconomic deprivation has been shown to be an independent predictor of adverse clinical outcome for those who survived initial ACS. Acknowledgement/Funding None

scholarly journals Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

2017 ◽  
Vol 6 (3-4) ◽  
pp. 242-253 ◽  
Author(s):  
Hisham Salahuddin ◽  
Aixa Espinosa ◽  
Mark Buehler ◽  
Sadik A. Khuder ◽  
Abdur R. Khan ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Outcome ◽  
Middle Cerebral Artery ◽  
Clinical Outcomes ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Total N ◽  
Clinical Databases ◽  
The Impact

Background: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. Objective: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. Methods: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. Results: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). Conclusions: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.

Impact of thrombus length on recanalization and clinical outcome following mechanical thrombectomy in acute ischemic stroke

2016 ◽  
Vol 9 (10) ◽  
pp. 937-939 ◽  
Author(s):  
Fatih Seker ◽  
Johannes Pfaff ◽  
Marcel Wolf ◽  
Silvia Schönenberger ◽  
Simon Nagel ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Neurological Outcome ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Artery Occlusion ◽  
Good Clinical Outcome ◽  
Stent Retrievers ◽  
The Impact

PurposeThe impact of thrombus length on recanalization in IV thrombolysis for acute intracranial artery occlusion has been well studied. Here we analyzed the influence of thrombus length on the number of thrombectomy maneuvers needed for recanalization, intraprocedural complications, recanalization success, and clinical outcome after mechanical thrombectomy.MethodsWe retrospectively analyzed angiographic and clinical data from 72 consecutive patients with acute occlusion of the M1 segment of the middle cerebral artery who were treated with mechanical thrombectomy using stent retrievers. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. Good neurological outcome was defined as a modified Rankin Scale score of ≤2 at 90 days after stroke onset.ResultsMean thrombus length was 13.4±5.2 mm. Univariate binary logistic regression did not show an association of thrombus length with the probability of a good clinical outcome (OR 0.95, 95% CI 0.84 to 1.03, p=0.176) or successful recanalization (OR 0.92, 95% CI 0.81 to 1.05, p=0.225). There was no significant correlation between thrombus length and the number of thrombectomy maneuvers needed for recanalization (p=0.112). Furthermore, thrombus length was not correlated with the probability of intraprocedural complications (p=0.813), including embolization in a new territory (n=3).ConclusionsIn this study, thrombus length had no relevant impact on recanalization, neurological outcome, or intraprocedural complications following mechanical thrombectomy of middle cerebral artery occlusions. Therefore, mechanical thrombectomy with stent retrievers can be attempted with large clots.

scholarly journals Expectations of Continuous Vital Signs Monitoring for Recognizing Complications After Esophagectomy: Interview Study Among Nurses and Surgeons (Preprint)

2020 ◽  
Author(s):  
Mathilde van Rossum ◽  
Jobbe Leenen ◽  
Feike Kingma ◽  
Martine Breteler ◽  
Richard van Hillegersberg ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Clinical Outcome ◽  
Clinical Outcomes ◽  
Early Recognition ◽  
Vital Signs ◽  
Patient Characteristics ◽  
Situational Factors ◽  
Vital Signs Monitoring ◽  
Surgical Ward ◽  
The Impact

BACKGROUND Patients undergoing esophagectomy are at serious risk of developing postoperative complications. To support early recognition of clinical deterioration, wireless sensor technologies that enable continuous vital signs monitoring in a ward setting are emerging. OBJECTIVE This study explored nurses’ and surgeons’ expectations of the potential effectiveness and impact of continuous wireless vital signs monitoring in patients admitted to the ward after esophagectomy. METHODS Semistructured interviews were conducted at 3 esophageal cancer centers in the Netherlands. In each center, 2 nurses and 2 surgeons were interviewed regarding their expectations of continuous vital signs monitoring for early recognition of complications after esophagectomy. Historical data of patient characteristics and clinical outcomes were collected in each center and presented to the local participants to support estimations on clinical outcome. RESULTS The majority of nurses and surgeons expected that continuous vital signs monitoring could contribute to the earlier recognition of deterioration and result in earlier treatment for postoperative complications, although the effective time gain would depend on patient and situational factors. Their expectations regarding the impact of potential earlier diagnosis on clinical outcomes varied. Nevertheless, most caregivers would consider implementing continuous monitoring in the surgical ward to support patient monitoring after esophagectomy. CONCLUSIONS Caregivers expected that wireless vital signs monitoring would provide opportunities for early detection of postoperative complications in patients undergoing esophagectomy admitted to the ward and prevent sequelae under certain circumstances. As the technology matures, clinical outcome studies will be necessary to objectify these expectations and further investigate overall effects on patient outcome.

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