scholarly journals Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke

2017 ◽  
Vol 8 (2) ◽  
pp. 60-65 ◽  
Author(s):  
Joshua S. Jacoby ◽  
Heather M. Draper ◽  
Lisa E. Dumkow ◽  
Muhammad U. Farooq ◽  
G. Robert DeYoung ◽  
...  
Keyword(s):  
Emergency Medicine ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Length Of Hospital Stay ◽  
Stroke Care ◽  
Neurological Status ◽  
National Institutes Of Health ◽  
Discharge Disposition ◽  
Scale Scores ◽  
The Impact

Background and Purpose: Decreased door-to-needle (DTN) time with tissue plasminogen activator (tPA) for acute ischemic stroke is associated with improved patient outcomes. Emergency medicine pharmacists (EMPs) can expedite the administration of tPA by assessing patients for contraindications, preparing, and administering tPA. The purpose of this study was to determine the impact of EMPs on DTN times and clinical outcomes in patients with acute ischemic stroke who receive tPA in the emergency department. Methods: A retrospective, single-center, cohort study of patients who received tPA between August 1, 2012, and August 30, 2014, was conducted to compare DTN times with or without EMP involvement in stroke care. Secondary outcomes included changes in neurological status as measured by the National Institutes of Health Stroke Scale (NIHSS), length of hospital stay, discharge disposition, symptomatic intracranial hemorrhage, and in-hospital all-cause mortality. Results: A total of 100 patients were included. The EMPs were involved in the care of 49 patients. The EMP involvement was associated with a significant improvement in DTN time (median 46 [interquartile range IQR: 34.5-67] vs 58 [IQR: 45-79] minutes; P = .019) and with receiving tPA within 45 minutes of arrival (49% vs 25%, odds ratio [OR]: 2.81 [95% confidence interval [CI]: 1.21-6.52]). National Institutes of Health Stroke Scale scores were significantly improved at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR: 0-4] vs 2 [IQR: 1-9.25]; P = .047). Conclusions: The EMP involvement in initial stroke care was associated with a significant improvement in DTN time.

Abstract WP9: Primary Aspiration Thrombectomy in Acute Ischemic Stroke: A Single-Center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ganesh Asaithambi ◽  
Amy L Castle ◽  
Lana J Stein ◽  
Sandra K Hanson ◽  
Jeffrey P Lassig
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
National Institutes Of Health ◽  
Stroke Severity ◽  
Single Center ◽  
Aspiration Thrombectomy ◽  
Discharge Disposition ◽  
Single Center Experience ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stent Retrievers

Background: Recent endovascular stroke studies utilizing primarily stent retrievers have proven clinical benefit among eligible patients. It remains unclear if this benefit is exclusive to stent retrievers. We present the results of a single-center experience for patients undergoing primary aspiration thrombectomy for acute ischemic stroke (AIS). Methods: A retrospective analysis of all AIS patients receiving primary aspiration thrombectomy from January 2014 to March 2016 was performed. We assessed stroke severity at admission and discharge as defined by the National Institutes of Health Stroke Scale score (NIHSSS), median onset to puncture and onset to recanalization times, location of target vessel treated, rate of concurrent intravenous (IV) alteplase use, and rate of TICI 2b/3 reperfusion. Outcomes adjudicated included rates of symptomatic intracerebral hemorrhage (sICH), favorable discharge disposition to home, and 90-day modified Rankin Scale (mRS) score ≤2. Results: During the study period, 121 patients (mean age 68.7±16.5 years, 53.7% women) received primary aspiration thrombectomy for 124 occlusions (26% terminal internal carotid artery, 45% M1, 15% M2, 11% basilar artery, 3% other). Median admission NIHSSS was 19 [11, 22] and improved to 6 [1, 15] upon discharge. Median onset to puncture and onset to recanalization times were 258 [148, 371] and 300 [180, 409] minutes, respectively. The rate of TICI 2b/3 reperfusion was 84.7%, and 52% received adjunctive IV alteplase. Rates of favorable discharge to home was 28.9% and 90-day mRS ≤2 was 39.8%. Only one patient developed sICH. Conclusion: Our single-center experience shows that primary aspiration thrombectomy can yield both favorable angiographic and clinical outcomes with minimal adverse effect.

Abstract WP88: Volumetric Measures of Hemorrhagic Transformation After Acute Ischemic Stroke Predicts Neurological Deterioration Better Than Radiologic Classification

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ali Hamzehloo ◽  
Atul Kumar ◽  
Laura Heitsch ◽  
Daniel Strbian ◽  
Agnieszka Slowik ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Neurological Status ◽  
Hemorrhagic Transformation ◽  
Neurological Deterioration ◽  
Receiver Operating Curve ◽  
Early Neurological Deterioration ◽  
Hemorrhage Volume ◽  
The Difference ◽  
The Impact

Introduction: Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) may contribute to neurologic deterioration. The current radiologic classification of HT is qualitative and distinguishes petechial hemorrhagic infarction from parenchymal hematoma (PH-1 and PH-2). However, this grading scheme is subjective and may not accurately reflect the impact of HT on neurological status and outcome. We sought to evaluate whether the volume of hemorrhage was a better marker of deterioration. Methods: We evaluated AIS patients with follow-up CT imaging from a prospective stroke genetics study. HT seen within 36 hours of AI was classified using ECASS criteria. In addition, we outlined all confluent areas of hemorrhage to derive hemorrhage volume (HV). We calculated ΔNIHSS as the difference between baseline and 24-hour NIHSS. Early neurological deterioration (END) was defined as ΔNIHSS of -4 points or more. Association of radiologic HT grade and HV with ΔNIHSS and END were analyzed using linear regression and receiver-operating-curve testing. Results: We analyzed 948 stroke patients with median NIHSS 7 (IQR 4-14), 64% receiving tPA and ΔNIHSS +2 (IQR 0-5). 294 (31%) had HT (146 HI1, 63 HI2, 42 PH1 and 43 PH2). HT was associated with higher baseline NIHSS but not with tPA treatment or ΔNIHSS. END occurred in 113 (12%) including 46 with HT (16%) vs. 67 (10%) without HT (p=0.02). Amongst those with HT, the radiologic grade was not associated with ΔNIHSS or END (20% of PH2, 20% of PH1 vs. 15% of HI1/HI2, p=0.40). However, greater HV was associated with ΔNIHSS (adjusting for baseline NIHSS and tPA, estimate -1.5 point per 10-ml, p=0.0001) and with END (those with END had median HV 7 vs. 3-ml, p=0.001). A cut-off of 12-ml had 45% sensitivity and 90% specificity for END (AUC of 0.72). Conclusion: We demonstrated that while HT was associated with a higher risk of END, the ECASS classification alone did not distinguish those who worsened. It appears that hemorrhage volume may better predict worsening NIHSS and END with moderate sensitivity.

Management of acute ischemic stroke

BMJ ◽  
2020 ◽  
pp. l6983 ◽  
Author(s):  
Michael S Phipps ◽  
Carolyn A Cronin
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Time ◽  
Recurrent Stroke ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Developed Countries ◽  
Future Research ◽  
The Impact

ABSTRACT Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

scholarly journals Acute Ischemic Stroke in Patients With COVID-19

Stroke ◽  
2021 ◽  
Vol 52 (5) ◽  
pp. 1826-1829
Author(s):  
Pratyaksh K. Srivastava ◽  
Shuaiqi Zhang ◽  
Ying Xian ◽  
Hanzhang Xu ◽  
Christine Rutan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Adverse Outcomes ◽  
National Institutes Of Health ◽  
Stroke Severity ◽  
Younger Age ◽  
Increased Risk ◽  
Scale Scores ◽  
Get With The Guidelines

Background and Purpose: Studies suggest an increased risk of adverse outcomes among patients with acute ischemic stroke (AIS) and coronavirus disease 2019 (COVID-19). Methods: Using Get With The Guidelines–Stroke, we identified 41 971 patients (AIS/COVID-19: 1143; AIS/no COVID-19: 40 828) with AIS hospitalized between February 4, 2020 and June 29, 2020, from 458 Get With The Guidelines–Stroke hospitals with at least one COVID-19 case and evaluated clinical characteristics, treatment patterns, and outcomes. Results: Compared with patients with AIS/no COVID-19, those with AIS/COVID-19 were younger, more likely to be non-Hispanic Black, Hispanic, or Asian, more likely to present with higher National Institutes of Health Stroke Scale scores, and had greater proportions of large vessel occlusions. Rates of thrombolysis and thrombectomy were similar between the groups. Door to computed tomography (median 55 [18–207] versus 35 [14–99] minutes, P <0.001), door to needle (59 [40–82] versus 46 [33–64] minutes, P <0.001), and door to endovascular therapy (114 [74–169] versus 90 [54–133] minutes, P =0.002) times were longer in the AIS/COVID-19 cohort. In adjusted models, patients with AIS/COVID-19 had decreased odds of discharge with modified Rankin Scale score of ≤2 (odds ratio, 0.65 [95% CI, 0.52–0.81], P <0.001) and increased odds of in-hospital mortality (odds ratio, 4.34 [95% CI, 3.48–5.40], P <0.001). ConclusionS: This analysis demonstrates younger age, greater stroke severity, longer times to evaluation and treatment, and worse morbidity and mortality in patients with AIS/COVID-19 compared with those with AIS/no COVID-19.

C-reactive Protein, Infection, and Outcome After Acute Ischemic Stroke: A Registry and Systematic Review

2020 ◽  
Vol 16 (5) ◽  
pp. 405-415 ◽  
Author(s):  
Lu Wang ◽  
Yuxiao Li ◽  
Changyi Wang ◽  
Wen Guo ◽  
Ming Liu
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Reactive Protein ◽  
Poor Outcome ◽  
Pubmed Database ◽  
Scale Scores ◽  
The Impact

Background: A number of studies have explored the prognostic role of CRP in patients with acute ischemic stroke, however, the results have been inconclusive. The aim of our study was to investigate the impact of infection on the association between CRP and 3-month functional outcome by performing a registry study and systematic review. Methods: Patients admitted within 24 hours of acute ischemic stroke onset and had CRP measured within 24 hours after admission were included. Patients admitted between June 2016 and December 2018 in Chengdu Stoke Registry were enrolled. The PubMed database was searched up to July 2019 to identify eligible studies. Poor outcome was defined as modified Rankin Scale scores at 3-month more than 3. Results: Totally, 368 patients in the registry and 18 studies involving 15238 patients in the systematic review were included. A statistically significant association between CRP values on admission and 3-month poor outcome in patients without infection was found, both in our registry (CRP per 1-mg/L increment, OR 1.04, 95% CI 1.01 to 1.07, p=0.008) and meta-analysis (CRP per 1-mg/dL increment, OR 1.66 [95% CI 1.37 to 2.01, p<0.001]). In patients with infection, CRP was not associated with a 3-month poor outcome according to registry data (OR 1.00, 95% CI 0.99 to 1.01, p=0.663) and meta-analysis (OR 1.01, 95% CI 0.99 to 1.01, p=0.128). Conclusion: High CRP value was independently associated with a 3-month poor outcome after stroke in patients without infection. Further studies are required to examine the value of infection on CRP measures and long-term functional outcomes.

Abstract WP251: Sleep Apnea and Early Neurological Deterioration in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Cindy W Yoon ◽  
Joung-Ho Rha ◽  
Hee-Kwon Park
Keyword(s):  
Ischemic Stroke ◽  
Sleep Apnea ◽  
Acute Ischemic Stroke ◽  
Acute Phase ◽  
National Institutes Of Health ◽  
Neurological Deterioration ◽  
Apnea Hypopnea Index ◽  
Early Neurological Deterioration ◽  
Multivariable Regression ◽  
The Impact

Background and Purpose: Evidence of an association between sleep apnea (SA) and early neurological deterioration (END) in acute phase ischemic stroke is scant. We investigated the prevalence of SA and the impact of SA severity on END in acute ischemic stroke (AIS) patients. Methods: We prospectively enrolled consecutive AIS patients admitted to our stroke unit within 72 hours of symptom onset. SA severity was assessed with ApneaLink - a validated portable respiratory monitor. SA was defined as an apnea-hypopnea index (AHI) of ≥ 5/hour. END was defined as an incremental increase in the National Institutes of Health Stroke Scale (NIHSS) score by ≥ 1 point in motor power, or ≥ 2 points in the total score within the first week after admission. Results: Of the 305 patients studied, 254 (83.3%) patients had SA (AHI ≥ 5/hour), and of these, 114 (37.4%) had mild SA (AHI 5-14/hour), 59 (19.3%) had moderate SA (AHI 15-29/hour), and 81 (26.6%) had severe SA (AHI ≥ 30/hour). Thirty-six (11.8%) patients experienced END: 2 of the 51 (3.9%) patients without SA and 34 of the 254 (14.4%) patients with SA. Multivariable regression analysis showed AHI independently predicted END (odds ratio 1.024; 95% confidence interval 1.006 to 1.042; p = 0.008). Conclusions: SA is common in the acute phase of ischemic stroke, and SA severity is associated with the risk of END.

Abstract T P72: Baseline Variables Have Little Influence on Early Change in Neurological Status (ΔNIHSS) After Acute Ischemic Stroke: Basis For a Genetic Study

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Laura Heitsch ◽  
Carlos Cruchaga ◽  
Naim Khoury ◽  
Rebecca Weisenhan ◽  
Ford L Andria ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Neurological Status ◽  
Neurological Recovery ◽  
Neurological Deficits ◽  
Dramatic Improvement ◽  
Scale Scores ◽  
Multivariable Regression ◽  
Jewish Hospital ◽  
The Difference

Introduction: Neurological deficits can be highly unstable within the first 24 hours after acute ischemic stroke (AIS), with some patients showing dramatic improvement while others rapidly deteriorate. We are interested in genetic influences on early neurological recovery/deterioration. Here, we characterize NIHSS changes within the first 24 hours after stoke onset (ΔNIHSS) in a large cohort to determine baseline clinical variables that influence this outcome measure. Methods: AIS patients presenting to two sites (Barnes-Jewish Hospital, St Louis and Vall D’Hebron Hospital Barcelona) between 2008-2013 were prospectively enrolled. Baseline NIHSS was collected within 6 hours and again at 24 hours after symptom onset. ΔNIHSS was calculated as the difference in these stroke scale scores. Demographics, baseline comorbidities and medications, as well as acute treatment variables were recorded for each subject. Stepwise multivariable regression (SAS) was used to determine variables that significantly influence ΔNIHSS. Results: There were 954 patients enrolled (St Louis = 433, Barcelona = 521). Table 1 demonstrates the frequencies and means (SD) of the baseline variables. ΔNIHSS follows a normal distribution (figure). All baseline variables listed in table 1 were analyzed for influence on ΔNIHSS. Only baseline NIHSS (R2 = 0.0597, p<0.0001), baseline glucose (R2 = 0.0176, p=<0.0001,) and age (R2 = 0.0106, p=0.0011) independently influenced ΔNIHSS, accounting for only 8.79% of the variance. Conclusion: Baseline variables (NIHSS, glucose and age) modestly influence early neurological recovery/deterioration. However, 91% of ΔNIHSS variability remains unexplained, suggesting that other factors such as genetics, could play an important role in early outcomes following AIS. A GWAS of ΔNIHSS is currently underway.

scholarly journals Accuracy of Serial National Institutes of Health Stroke Scale Scores to Identify Artery Status in Acute Ischemic Stroke

Circulation ◽  
2007 ◽  
Vol 115 (20) ◽  
pp. 2660-2665 ◽  
Author(s):  
Robert Mikulik ◽  
Marc Ribo ◽  
Michael D. Hill ◽  
James C. Grotta ◽  
Marc Malkoff ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
National Institutes Of Health ◽  
Scale Scores

scholarly journals Decreased plasma miR-335 expression in patients with acute ischemic stroke and its association with calmodulin expression

2016 ◽  
Vol 44 (6) ◽  
pp. 1331-1338 ◽  
Author(s):  
Bin Zhao ◽  
Zilong Zhu ◽  
Junwei Hao ◽  
Zongming Wan ◽  
Xiaoqin Guo
Keyword(s):  
Ischemic Stroke ◽  
Protein Expression ◽  
Acute Ischemic Stroke ◽  
Clinical Significance ◽  
Independent Predictor ◽  
National Institutes Of Health ◽  
Regulatory Function ◽  
Healthy Controls ◽  
Scale Scores ◽  
Direct Target

Objective To determine the expression and clinical significance of plasma miR-335 in patients with acute ischemic stroke (AIS) and investigate its association with calmodulin (CaM) expression. Methods Plasma miR-335 and CaM expression levels in patients with AIS and healthy controls were examined. Correlations between miR-335, CaM, and National Institutes of Health Stroke Scale scores were also analysed. Furthermore, the potential regulatory function of miR-335 on CaM expression was investigated. Results Plasma miR-335 levels were significantly lower in AIS and negatively correlated with NIHSS scores. The converse was observed for plasma CaM levels. Plasma miR-335 and CaM levels were negatively correlated. Plasma miR-335 was confirmed as a novel biomarker for AIS diagnosis and an independent predictor of AIS. Up-regulation of miR-335 suppressed CaM protein expression, and CaM was confirmed as a direct target of miR-335. Conclusions Plasma miR-335 was down-regulated in AIS patients and represents a potential noninvasive circulating biomarker.

Abstract WP383: An Economic Model of Improved Acute Stroke Care in the Management of Acute Ischemic Stroke From A State Medicaid Perspective

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Zheng-Yi Zhou ◽  
Liangyi Fan ◽  
Er Chen ◽  
Jipan Xie ◽  
Eric Q Wu
Keyword(s):  
Ischemic Stroke ◽  
Nursing Home ◽  
Nursing Homes ◽  
Acute Ischemic Stroke ◽  
Economic Model ◽  
Stroke Care ◽  
The United States ◽  
Absolute Increase ◽  
Medicaid Spending ◽  
The Impact

Background: Stroke is a leading cause of long-term disability in the United States. Approximately one in four stroke survivors is admitted to a nursing home, accounting for a significant portion of Medicaid spending on stroke. Objective: To assess the impact of increasing access to primary stroke centers (PSCs) and implementing an emergency medical services (EMS) system on disability and Medicaid spending on nursing homes for ten geographically representative states. Methods: An economic model was developed to estimate potential reductions in stroke-related disability and corresponding reductions in Medicaid spending on nursing homes among Medicaid enrollees with acute ischemic stroke (AIS), due to improved stroke care infrastructure. The model assessed the increased use of intravenous (IV) thrombolysis as a result of a higher proportion of AIS treated in PSCs, or as a result of integrating an EMS system with PSCs. Based on published literature, more patients received IV thrombolysis in PSCs vs. non-PSCs (6.5 vs. 0.9%) and PSCs with an EMS routing protocol vs local services (10.5 vs. 2.5%). State-specific model inputs included the incidence of first-ever AIS in Medicaid enrollees, nursing home costs, and Medicaid spending on stroke-related care. Results: A 20% absolute increase in the proportion of AIS patients treated at PSCs will lead to 111 to 2004 more patients receiving IV thrombolysis; 9 to 160 fewer patients with disability; and a reduction in Medicaid nursing home spending of $299,442 to $5.6 million per year across the ten states analyzed (Table). The integration of an EMS system with PSCs will lead to 791 to 14,314 more patients receiving IV thrombolysis; 63 to 1145 fewer patients with disability; and a reduction in Medicaid nursing home spending of $2.1 to $40.0 million per year across the ten states (Table). Conclusions: States may achieve substantial savings through legislative policies that improve PSC access and integration of an EMS system with PSCs.

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