Drip and ship method of IV-tPA for acute ischemic stroke patients in a depopulated area using a telemedicine system for emergency medicine (k-support)

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

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Abstract P201: Octogenarian and Nonagenarian Outcomes Among Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p201 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

RAJAN R GADHIA ◽

Farhaan S Vahidy ◽

Tariq Nisar ◽

Destiny Hooper ◽

David Chiu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Combined Treatment ◽

Stroke Patients ◽

Stroke Treatment ◽

Intravenous Tissue Plasminogen Activator ◽

Significant Difference ◽

Acute Stroke Treatment ◽

Iv Tpa

Objective: Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80. Methods: We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation. Results: A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively). Conclusion: Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.

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Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.tp267 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Kerrin Connelly ◽

Rishi Gupta ◽

Raul Nogueira ◽

Arthur Yancey ◽

Alexander Isakov ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Transport Protocol ◽

Stroke Patients ◽

Stroke Registry ◽

The Public ◽

State Office ◽

Stroke Center ◽

Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

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Abstract 3275: Early Neurological Improvement After Intravenous Thrombolysis in Acute Stroke Predicts Long-Term Functional Outcome

Stroke ◽

10.1161/str.43.suppl_1.a3275 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Leonard L Yeo ◽

Liang Shen ◽

Ben Wakerley ◽

Aftab Ahmad ◽

Kay W Ng ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Symptom Onset ◽

Functional Outcomes ◽

Treatment Time ◽

Favorable Outcome ◽

Stroke Patients ◽

Neurological Improvement ◽

Iv Tpa

Background: Intravenously administered tissue plasminogen activator (IV-TPA) remains the only approved therapeutic agent for arterial recanalization in acute ischemic stroke (AIS). Wide variations in the rates and timing of neurological recovery are observed in thrombolyzed patients. While all IV-TPA treated patients are routinely evaluated for neurological recovery at 24-hours, considerable improvement occurs in some cases within 2-hours of treatment initiation. We evaluated whether early neurological improvement at 2-hours after IV-TPA bolus (ENI-2) can predict functional outcomes in thrombolyzed AIS patients at 3-months. Methods: Data for consecutive stroke patients treated with IV-TPA within 4.5 hours of symptom-onset during 2007-2010 were prospectively entered in the thrombolyzed registry maintained at our tertiary care center. Data were collected for demographic characteristics, vascular risk factors, stroke subtypes and blood pressure levels before IV-TPA bolus. National Institute of Health Stroke Scale (NIHSS) scores were obtained before IV-TPA bolus and at 2-hours. ENI-2 was defined as a reduction in NIHSS score by more than 10-points from baseline score or an absolute score of 4-points or less at 2-hours after IV-TPA bolus. Functional outcomes at 3-months were determined by modified Rankin scale (mRS). Data were analyzed by SPSS 19.0. Results: Of the 2238 AIS patients admitted during the study period, 240 (11%) received IV-TPA within 4.5-hours of symptom-onset. Median age was 65yrs (range 19-92), 63% males, median NIHSS 17points (range 3-35) and median onset-to-treatment time 149 minutes. Overall, 122 (50.8%) patients achieved favorable functional outcome (mRS 0-1) at 3-months. Factors associated with favorable outcome at 3-months on univariable analysis were younger age, female gender, presence of atrial fibrillation, baseline NIHSS, onset-to-treatment time (OTT) and ENI-2. However, multivariable analysis demonstrated NIHSS at onset (OR per 1-point increase 0.907, 95%CI 0.848-0.969) and ENI-2 (OR 4.926 95%CI 1.66-15.15) as independent predictors of favorable outcome at 3-months. Conclusion: Early Neurological improvement at 2-hours after IV-TPA bolus is a strong predictor of the functional outcome at 3-months in acute ischemic stroke patients.

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Abstract WP72: Why Are Acute Ischemic Stroke Patients Not Receiving IV tPA in Telestroke Network

Stroke ◽

10.1161/str.49.suppl_1.wp72 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Sanjeeva Reddy Onteddu ◽

Sukanthi Kovvuru ◽

Krishna Nalleballe ◽

Aliza Brown ◽

Supriya Kairamkonda ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

Iv Tpa

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E-119 Feasibility for extracranial carotid artery stenting in acute ischemic stroke patients after IV-tPA treatment

10.1136/neurintsurg-2019-snis.194 ◽

2019 ◽

Author(s):

J Seo ◽

E Kim

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Acute Ischemic Stroke ◽

Carotid Artery Stenting ◽

Stroke Patients ◽

Extracranial Carotid Artery ◽

Iv Tpa

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Letter re: Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry

Neurology ◽

10.1212/wnl.0000000000003802 ◽

2017 ◽

Vol 88 (14) ◽

pp. 1383.2-1383

Author(s):

Zhiping Hu ◽

Chunli Chen ◽

Liuwang Zeng

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

National Registry ◽

Stroke Patients ◽

Iv Tpa

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Abstract 2268: Trends In Reasons For Non-eligibility For tPA

Stroke ◽

10.1161/str.43.suppl_1.a2268 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Xin Tong ◽

Mary G George

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Advanced Age ◽

Stroke Patients ◽

Rapid Improvement ◽

Nihss Score ◽

Mild Stroke ◽

Over Time ◽

Iv Tpa

Background: Use of IV tPA has increased over time, as has the adherence to the NQF endorsed performance measure for receipt of IV tPA within 3 hours. Little is known about trends in the reasons for patient ineligibility for IV tPA. This study examines trends in reasons for not providing IV tPA over time and by race and gender among acute ischemic stroke patients in the Paul Coverdell National Acute Stroke Registry (PCNASR), a quality improvement program for acute stroke implemented by state health departments. Methods: There were 13,164 PCNASR patients enrolled from 2008- 2010 with a clinical diagnosis of acute ischemic stroke with documentation of LKW and who arrived within 2 hours of LKW. Cochran-Armitage tests were used to test for trend on accepted reasons for not providing IV tPA within 3 hours of time last known well (LKW). Chi-square tests were used to test for differences among reasons between men and women and between non-Hispanic whites and minorities. Multiple reasons for not giving tPA could be selected. Results: Among 13,164 acute ischemic patients admitted between 2008 and 2010 with documentation of LKW and who arrived within 2 hours of LKW, 3781 (28.7%) received IV tPA, 7284 (55.3%) had documented reasons for not receiving IV tPA, and 2099 (16.0%) did not receive IV tPA. Contraindications to IV tPA, advanced age, rapid improvement and inability to determine eligibility increased over time. Mild stroke decreased over time. Conditions with warning, advanced age, limited life expectancy and family refusal were more common in women; mild stroke and rapid improvement were more common in men. Contraindications were more common in minorities; advanced age, mild stroke and rapid improvement, and family refusal were more common in non-Hispanic whites. When advanced age was selected, 46.6% of patients were over age 90 and 3.4% were under age 80. When stroke too mild was selected, 44.8% of patients had missing NIHSS scores, 42.1% of scores were 0-4, 8.8% were 5-9, and 4.3% were ≥ 10. The three most common reasons for not providing tPA were rapid improvement (40.9%), mild stroke (33.0%), and contraindications (29.2%) in 2010. Conclusions: More than half of ischemic stroke patients arriving within 2 hours of LKW were ineligible to receive IV tPA. There was little use of advanced age for patients under age 80. Documentation of stroke too mild was not substantiated by an NIHSS score in nearly half of patients. Better documentation of NIHSS score should be provided.

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DWI Lesion Characteristics As A Predictor For Outcome In Acute Stroke Patients Treated By IV-tPA

QJM ◽

10.1093/qjmed/hcab102.012 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

H Aref ◽

S Farag ◽

S Helmy ◽

H Mahmoud

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Type ◽

P Value ◽

Stroke Patients ◽

Tissue Type Plasminogen Activator ◽

Type Plasminogen Activator ◽

Iv Tpa

Abstract Background Thrombolysis with tissue-type plasminogen activator (IV-tPA) is a well-proved, widely used treatment in acute ischemic stroke patients, many predictors of functional outcome have been proposed as Age, vascular risk factors, initial clinical evaluation on admission using National institute of health stroke scale(NIHSS), functional state of patient(b.L) baseline before stroke and 3 months (3m) after stroke using modified Rankin stroke scale (MRS)and the most controversial Diffusion weighted image characteristics (volume, heterogeneity) Objective To evaluate DWI MRI characteristics (volume, heterogeneity) as a predictor for outcome in Acute stroke patients treated by IV-tPA Patients and Methods This study will be done on a sample of 100 acute ischemic stroke Egyptian patients receiving intra-venous tissue -type plasminogen activator presenting to Ain-Shams university hospitals Results Highly statistically significant (p-value < 0.001) Positive correlation (r = 0.394) between volume (DWI) and MRS (3m) post discharge in studied patients, No statistically significant (pvalue > 0.05) relation between heterogeneity and other studied parameters (MRS, NIHSS D & ADC values) in studied patients Conclusion DWI infarct volume is a predictor for outcome in acute ischemic stroke patients treated by tPA

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Abstract WP246: Acute Ischemic Stroke Patients With a Primary Language Other Than English Do Not Have Significantly Increased Door-to-Needle Times for Intravenous TPA

Stroke ◽

10.1161/str.47.suppl_1.wp246 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Natalie T Cheng ◽

Elizabeth A Cahill ◽

Tomas Tesfasilassie ◽

Molly M Burnett ◽

Lara Zimmermann ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Family Member ◽

San Francisco ◽

Primary Language ◽

Stroke Patients ◽

Discharge Disposition ◽

Clinical Records ◽

Iv Tpa

Background: Rapid administration of intravenous alteplase (IV tPA) leads to better outcomes, but language barriers have the potential to introduce delays and to hinder effective communication with patients and collateral historians during the acute evaluation. Hypothesis: Acute ischemic stroke patients with a non-English primary language will have significantly longer door-to-needle times for IV tPA. Methods: We abstracted information on primary language for all adults that received IV tPA for acute ischemic stroke in the emergency department of an academic referral center in San Francisco, CA, from February 2008 to May 2015. Approximately 38% of San Francisco residents speak a language other than English at home. Primary language was determined from the electronic medical record and was confirmed by reviewing specific documentation in subsequent speech therapy evaluations and admission notes. Age, sex, race, presenting NIHSS, aphasia as a presenting symptom, whether the patient was accompanied to the emergency department by a family member or caregiver, discharge disposition, and door-to-needle (DTN) administration time for IV tPA were abstracted from clinical records and quality improvement registries. Results: A total of 237 patients received IV tPA for acute ischemic stroke in the emergency department during the study period. Median age was 76 years (IQR 64-86), 53% were female, and median DTN time was 62 minutes (IQR 48-86). A total of 34% of patients had a primary language other than English (20% Cantonese, 6% Russian, 3% Spanish). These patients were more likely to be older (median age 80 vs. 73 years, p = 0.001), to be accompanied by a family member or caregiver (80% vs. 59%, p = 0.003), and to have a higher NIHSS (median 9 vs. 11, p = 0.03), but DTN times were similar among English and non-English primary language speakers (median 62 vs. 62, p=0.88) and short-term outcomes were not significantly different (in-hospital mortality 9% English primary language vs 14% non-English primary language, p=0.27; discharge to home 43% vs 32%, p=0.16) . Conclusions: At a center serving a multiethnic population, a patient’s primary language did not appear to predict DTN times for acute ischemic stroke.

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