scholarly journals How a CT-Direct Protocol at an American Comprehensive Stroke Center Led to Door-to-Needle Times Less Than 30 Minutes

2016 ◽  
Vol 7 (2) ◽  
pp. 70-73 ◽  
Author(s):  
Lisa M. Caputo ◽  
Judd Jensen ◽  
Michelle Whaley ◽  
Mark J. Kozlowski ◽  
Christopher V. Fanale ◽  
...  
Keyword(s):  
Implementation Process ◽  
Evaluation Process ◽  
Protocol Implementation ◽  
Time Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Before And After ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes ( P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

Abstract W P308: A Four-Year Experience of Symptomatic Intracranial Hemorrhage Rate Following Intravenous Tissue Plasminogen Activator at a Comprehensive Stroke Center

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jeffrey C Wagner ◽  
Alessandro Orlando ◽  
Christopher V Fanale ◽  
Michelle Whaley ◽  
Kathryn L McCarthy ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
High Volume ◽  
Stroke Severity ◽  
Chi Square ◽  
Arrival Times ◽  
Intravenous Tissue Plasminogen Activator ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

OBJECTIVE: To describe the 4-year symptomatic intracranial hemorrhage (sICH) rate at a high-volume comprehensive stroke center. METHODS: This was a retrospective observational cohort study. All admitted adult (≥18 years) patients presenting with an ischemic stroke (IS) from 2010 to 2013 were included in this study. Chi-square, Wilcoxon rank-sum, Student’s t-tests and Cochran-Armitage trend tests were used to compare groups and analyze data. sICHs were defined by a 4-point increase in NIHSS within 36h with new ICH seen on CT; sICHs were included only if they were directly related to IV-tPA treatment. Favorable mRS outcome was defined as a score ≤2. In-patient stroke alerts were excluded from door-to-needle (DTN) times. RESULTS: 2673 patients were admitted with IS. Of these, 627 (23%) were treated with IV-tPA (90% <3h from symptom onset, 69% at an outside facility). There was a significant increase in the percentage of IS patients treated with IV-tPA over the four years (p-trend=0.02). Compared to patients not receiving IV/IA therapy, patients receiving IV-tPA had significantly higher NIHSS scores, higher prevalence of atrial fibrillation, hyperlipidemia, and cardioembolic etiology, and lower proportion of small vessel occlusive IS. The median (IQR) DTN was 41m (32-53). In the 627 IS patients treated with IV-tPA, 11 (1.8%) developed a sICH; in 2013, the sICH rate was 0.6% (1/158). IV-tPA patients who developed a sICH were similar to those who were sICH-free; however, sICH patients had a significantly higher proportion of coronary artery disease (p=0.04) and severe strokes (p=0.19), and higher median symptom to arrival times (237m vs 187m, p=0.19), but similar median DTN (40m vs 41m, p=0.84). The in-hospital mortality rate for the IV-tPA group was 11% (n=71), and 37% had favorable mRS discharge scores. CONCLUSIONS: These data show that expeditious care and careful selection of patients for IV-tPA treatment can lead to very low rates of sICHs. The few sICHs subsequent to IV-tPA are likely to be a consequence of long symptom-to-arrival times and stroke severity.

Abstract WP68: Impact on ER Arrival & IV TPA Treatment Times Following Hospital Bypass Protocol Implementation: Northwest Ohio Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Julie Sahwver ◽  
Theodore Popa ◽  
Sharjeel Panjwani ◽  
Rami Abdelaziz ◽  
Gretchen Tietjen ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Treatment Time ◽  
Arterial Occlusion ◽  
Significant Delay ◽  
Protocol Implementation ◽  
Before And After ◽  
Lucas County ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: There is concern regarding hospital bypass stroke protocols potentially compromising IVtPA treatment due to transit time delay. We compared our IV thrombolysis time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: RA protocol whereby RACE score ≥5 patients are transferred directly to comprehensive stroke center (CSC) for potential mechanical thrombectomy (MT) was implemented in Jul 2015. All stroke alerts (SA) that required MT from July 2013 through June 2015 were compared to MT cases performed following RA protocol implementation. Transfers from other counties, private transport and in-hospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 activation to treatment time, and outcomes were compared. Results: Between Jul 2015-Jun 2016, 37 RA patients underwent MT of which 21 (56.8%) were given IV tPA at the CSC. Whereas in the preceding 2 years from Jul 2013-Jun 2015, 56 SA patients underwent MT, of which 22 (39%) received IVtPA. Of these SA cases, 11 (50%) were drip and transfer from other LC ERs and the remaining 11 (50%) presented directly to CSC. The 911 activation to 1 st ER arrival remained unchanged (34 vs. 32 mins, p 0.4), whereas tPA administration was significantly faster (64 vs. 88 mins, p <0.05) in the RA cohort (see graphic). Conclusions: Within LC, the RA bypass protocol did not result in a significant delay to ER arrival and it significantly expedited IV tPA delivery to patients undergoing MT. Further prospective studies are warranted.

Abstract TMP69: Incidence of Intracranial Hemorrhage After Intravenous Thrombolysis in Telestroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nabeel A Herial ◽  
Evan M Fitchett ◽  
Maureen DePrince ◽  
Giuliana Labella ◽  
Kimon Bekelis ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Intravenous Thrombolysis ◽  
Study Data ◽  
Hemorrhagic Complication ◽  
Stroke Outcomes ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: Promoting intravenous tissue plasminogen activator (IV tPA) in treating eligible patients with acute ischemic stroke (AIS) is critical in reducing overall stroke burden. Effective telestroke networks are proven to facilitate higher rates of IV tPA use. Increasing data on stroke outcomes continues to emerge with expansion of telestroke services nationwide. Objective: To estimate the incidence of intracranial hemorrhage (ICH) in AIS patients treated with IV tPA via telestroke evaluation. Methods: In this study, data from a large telestroke network comprising 36 hospitals from 3 States and associated with a university-based health system and comprehensive stroke center was utilized. Data included total of 3198 acute telestroke evaluations performed within the network between January 2014 and June 2016. Distance of spoke hospitals from the hub ranged between 2.5 and 125 miles. All telestroke consultations were done using the remote presence robotic technology. 15% of all telestroke evaluations and 51% of post-IV tPA patients were transferred to the hub. CT imaging was used for identification and ICH as defined mainly in the NINDS trial was used for comparison. Results: Mean age of patients was 67 years (sd=16) and majority were women (n=1759, 55%). Average NIHSS score at presentation was 7. IV tPA was administered to 18% of all telestroke patients. Post IV tPA, any ICH (symptomatic or not) was noted in 8.7% of patients. Petechial hemorrhage was most frequently reported finding. Rate of any ICH in our telestroke population was relatively lower compared to the ECASS II (39%, p<0.001), ECASS III (27%, p<0.001), SITS-MOST (9.6%, p=0.63), ATLANTIS (11.4%, p=0.30), and higher than the NINDS (6.4%, p=0.29). Conclusions: Higher rate of IV tPA use and lower rate of hemorrhagic complication observed in this large study further supports and strengthens the role of telestroke technology and expertise in treatment of AIS.

scholarly journals Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina

2020 ◽  
Vol 78 (1) ◽  
pp. 39-43
Author(s):  
Matías ALET ◽  
Federico Rodríguez LUCCI ◽  
Sebastián AMERISO
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Demographic Data ◽  
Reperfusion Therapy ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Abstract Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Objective: Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke. Methods: Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed. Results: We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%. Conclusions: With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.

Abstract TMP10: Impact on Mechanical Thrombectomy Time Efficiencies Following Hospital Bypass Protocol Implementation: Northwest Ohio Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sharjeel Panjwani ◽  
Julie Shawver ◽  
Rami Abdelaziz ◽  
Gretchen Tietjen ◽  
Mouhammad Jumaa ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prospective Studies ◽  
Mechanical Thrombectomy ◽  
Arterial Occlusion ◽  
Before And After ◽  
Lucas County ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
Early Stroke

Background: Early stroke identification and treatment with mechanical thrombectomy (MT) increases likelihood of favorable outcome. We compared our MT time efficiencies before and after Rapid Arterial oCclusion Evaluation Alert (RACE) bypass protocol (RA) implementation in Lucas County (LC) Ohio. Methods: Our RA protocol mandates emergent comprehensive stroke center transfer for patients with RACE score ≥ 5. We compared MT cases for RA patients (N=37) from Jul 2015-Jun 2016 with procedures performed on Stroke Alerts [(SA) N=56] from preceding 2 years. Transfers from outside LC, private transport and inhospital cases were excluded and only patients brought via LC-EMS were included in the analysis. Basic demographics, risk factors, 911 call to treatment, and outcomes were compared. Results: Treatment times including 911 call to IV tPA treatment, groin puncture, and recanalization were all significantly faster in the RA cohort (see graphic). Overall RA patients achieved recanalization and favorable outcomes at higher rate, although the latter was not statistically significant. Conclusion: Our experience indicates that RA protocol is highly effective in enhancing overall time efficiency for MT and may contribute to improved clinical outcomes. Further prospective studies are warranted.

Abstract T P211: Continued Participation in a Telestroke Program Improves Time to Intravenous Thrombolysis

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jamal N Muthana ◽  
James J Conners ◽  
Shawna Cutting ◽  
Sarah Y Song ◽  
Elizabeth Diebolt ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Nihss Score ◽  
Period 2 ◽  
Intravenous Tissue Plasminogen Activator ◽  
Educational Partnership ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Mean Time ◽  
Iv Tpa

Background: Improved clinical outcomes after intravenous tissue plasminogen activator (IV tPA) are time dependent. Participation in a telestroke program allows the spoke hospitals 24/7 access to a vascular fellowship trained neurologist for a telestroke consult, as well as educational partnership with the hub site, shared protocols, and access to quality improvement feedback. We sought to assess the effects of continued participation in a telestroke program on times to administration of IV tPA. Methods: Our institutional telestroke program began in March 2011 and consists of an academic hub (comprehensive stroke center) that serves 8 community spoke hospitals. We retrospectively reviewed acute ischemic stroke patients treated with IV tPA via the telestroke program. We compared 2 cohorts of patients: Period 1 (July 2011 to June 2013) and Period 2 (July 2013 to July 2014). We collected data on demographics, National Institutes of Health Stroke Scale (NIHSS), and times from initiation of telestroke consult to IV tPA administration. Results: Among 259 consecutive stroke patients (mean: 69.6 years, 56% female) treated with IV tPA via telestroke, the median NIHSS score was 11.8, and 41.7% of patients were transferred to the hub. The mean time from initiation of telestroke consult to IV tPA administration was 42.2 minutes. Period 1 included 129 patients and Period 2 included 130 patients, and the two groups did not differ by age (p=0.2), gender (p=0.3), or NIHSS score (p=0.3). Time from initiation of telestroke consult to IV tPA administration improved from Period 1 to Period 2 (35 vs. 49.9 minutes, p<0.0001). This improvement was due to faster mean time from initiation of telestroke consult to IV tPA advised (12.5 vs. 17.4 minutes, p<0.0001) and faster mean time from IV tPA advised to administration (22.5 vs. 33.1 minutes, p<0.0001). Conclusions: Maturation of a telestroke program is associated with improvement in the timeliness of IV tPA delivery, possibly due to a learning effect that continues the longer the sites participate in the program. This improvement is due to faster responses in both the hub site (recommending IV tPA earlier) and spoke site (administering IV tPA quicker). Further studies aimed at improving delivery of IV tPA in telestroke program are warranted.

IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion?

2020 ◽  
pp. neurintsurg-2020-016045 ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Laurie Preston ◽  
Wondwossen Tekle ◽  
Adnan I Qureshi
Keyword(s):  
Length Of Stay ◽  
Intracerebral Hemorrhage ◽  
Endovascular Treatment ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

BackgroundEndovascular treatment (EVT) is a widely proved method to treat patients diagnosed with intracranial large vessel occlusions (LVOs); however, there has been controversy about the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT.ObjectiveTo compare the outcomes of all patients with LVO treated with IV tPA +EVT versus EVT alone within 4.5 hours of stroke onset.MethodsA prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2019 was used to examine variables such as demographics, comorbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (ICH), mortality rate, and good/poor outcomes as shown by the modified Thrombolysis in Cerebral Infarction score and modified Rankin Scale (mRS) assessment at discharge. The outcomes between patients receiving IV tPA+EVT on admission and patients who underwent EVT alone were compared.ResultsOf 588 patients with acute ischemic stroke treated with EVT, a total of 189 met the criteria for the study (average age 70.44±12.90 years, 42.9% women). Analysis of 109 patients from the group receiving EVT+IV tPA (average age 68.17±14.28 years, 41.3% women), and 80 patients from the EVT alone group was performed (average age 73.54±9.84 years, 45.0% women). Four patients (5.0%) in the EVT alone group experienced symptomatic ICH versus 15 patients (13.8%) in the IV tPA+EVT group (p=0.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; p=0.0056).ConclusionIV tPA in addition to EVT was associated with an increase in the rate of ICH in patients with LVO treated within 4.5 hours and in patients’ length of stay. Further research is required to determine whether EVT treatment alone in patients with LVO treated within 4.5 hours is a more effective option.

Mechanical thrombectomy versus intravenous alteplase alone in acute isolated posterior cerebral artery occlusion: a systematic review

2021 ◽  
pp. neurintsurg-2021-018017
Author(s):  
Andre Monteiro ◽  
Slah Khan ◽  
Muhammad Waqas ◽  
Rimal H Dossani ◽  
Nicco Ruggiero ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Artery Occlusion ◽  
Favorable Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage ◽  
Cerebral Artery Occlusion ◽  
Iv Tpa

BackgroundAcute isolated posterior cerebral artery occlusions (aPCAOs) were excluded or under-represented in major randomized trials of mechanical thrombectomy (MT). The benefit of MT in comparison to intravenous tissue plasminogen activator (alteplase; IV-tPA) alone in these patients remains controversial and uncertain.MethodsWe performed a systematic search of PubMed, MEDLINE, and EMBASE databases for articles comparing MT with or without bridging IV-tPA and IV-tPA alone for aPCAO using keywords (‘posterior cerebral artery’, ‘thrombolysis’ and ‘thrombectomy’) with Boolean operators. Extracted data from patients reported in the studies were pooled into groups (MT vs IV-tPA alone) for comparison. Estimated rates for favorable outcome (modified Rankin scale score 0–2), symptomatic intracranial hemorrhage (sICH), and mortality were extracted.ResultsSeven articles (201 MT patients, 64 IV-tPA) were included, all retrospective. There was no statistically significant difference between pooled groups in median age, median presentation National Institutes of Health Stroke Scale (NIHSS) score, PCAO segment, and median time from symptom onset to puncture or needle. The recanalization rate was significantly higher in the MT group than the IV-tPA group (85.6% vs 53.1%, p<0.00001). Odds ratios for favorable outcome (OR 1.5, 95% CI 0.8 to 2.5), sICH (OR 1.1, 95% CI 0.2 to 5.5), and mortality (OR 1.4, 95% CI 0.5 to 3.6) did not significantly favor any modality.ConclusionsWe found no significant differences in odds of favorable outcome, sICH, and mortality in MT and IV-tPA in comparable aPCAO patients, despite superior MT recanalization rates. Equipoise remains regarding the optimal treatment modality for these patients.

Abstract WP435: Post Procedural Monitoring Tool Improves the Joint Commission Comprehensive Stroke Center Standard Compliance

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Denise Gaffney ◽  
Lorina Punsalang ◽  
Alvina Mkrtumyan ◽  
Raeesa Dhanji ◽  
David McCartney ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Electronic Monitoring ◽  
Vital Signs ◽  
Joint Commission ◽  
Monitoring Tool ◽  
Post Intervention ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa ◽  
The Joint Commission

Background: The Joint Commission (TJC) Comprehensive Stroke Center standard requires monitoring of patients after IV tPA administration, diagnostic angiography, aneurysm coiling, carotid angioplasty and stenting, mechanical endovascular reperfusion (MER) and carotid endarterectomy. Meeting 100% compliance of the standard is challenging. In 2018, monitoring and documentation were among the TJC’s top ten cited survey findings. Purpose: To determine if an electronic tool can improve documentation compliance and reduce delays in monitoring of vital signs, and neurologic, pedal pulse and skin site assessments. Methods: The initiative was implemented in 2018 with the objective for all patients to have 100% of their post procedural monitoring completed. A documentation tool was created and introduced to nursing units via annual stroke education updates. The tool was added to an online nursing resource SharePoint website and application, which was accessible to all nurses within the hospital. The procedure end time was entered in the tool, which automatically calculated the documentation times. Data was compared 12 months pre and post intervention. Analysis and reporting of data were conducted monthly via the program’s quality oversight committee. Data was analyzed using T-Test. Results: In post-IV tPA patients, more patients had 100% complete documentation (79% post vs. 29% pre-implementation; p=0.006). For all post neuro-interventional radiology procedures, more patients had 100% complete documentation (68% post vs. 17% pre-implementation; p<0.001). For post carotid endarterectomy revascularization, there was a trend toward more patients with 100% complete documentation (83% vs 38%; p=0.07). Conclusion: Utilization of an electronic monitoring tool for post procedural documentation adherence can improve the percentage of patients who have 100% completed assessments and help meet the TJC standard.

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