Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions

Introduction: Given the time-critical nature of acute stroke, reducing door-in-door-out (DIDO) times at primary stroke centers (PSC) prior to transfer to comprehensive stroke centers (CSC) is a priority. We applied Failure Modes Effects and Criticality Analysis (FMECA) to the DIDO process at a PSC, an engineering methodology widely used in other industries, to understand the most critical areas negatively impacting DIDO time. Methods: We collected data during 2 in-person and 5 virtual Learning Collaborative (LC) meetings, enhanced by electronic surveys. The LC team consisted of 18 clinicians affiliated with 6 different healthcare systems including 3 PSCs and 3 CSCs, 2 participants from EMS agencies, and 5 patients and caregivers. The LC team created a DIDO process map with individual steps. For each step, we asked LC members to identify ways in which the process could be performed incorrectly, incompletely, skipped or delayed (failures) along with the clinical impact, their causes, frequency and existing safeguards. Each clinical impact, frequency and safeguard was scored from 1-10 (lowest to highest). Frequency, severity, and safeguards scores were multiplied to calculate a criticality score to rank the top DIDO process failures. Results: Among 61 DIDO process steps, the top 12 steps with the highest criticality score represented 40.4% of the sum of criticalities (Figure). Among these, the highest criticality scores were for: 1) Delay in the decision to obtain CTA; 2) Delay in stroke recognition by the EMS team; 3) Delay in stroke identification at triage. Conclusion: We identified opportunities to re-design the DIDO process for acute stroke. Existing safeguards for the identified “high” criticality failures rely on human factors (e.g., multiple visual inspections, provider’s experience). There is a need to develop better stroke identification tools and automatic triggers within the DIDO process to increase timely stroke transfers from PSC to CSCs.

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Clinical impact of MRI perfusion disturbances and normal diffusion in acute stroke patients

European Journal of Radiology ◽

10.1016/j.ejrad.2008.04.003 ◽

2009 ◽

Vol 71 (1) ◽

pp. 1-10 ◽

Cited By ~ 4

Author(s):

D. Blondin ◽

R.J. Seitz ◽

O. Rusch ◽

H. Janssen ◽

K. Andersen ◽

...

Keyword(s):

Acute Stroke ◽

Clinical Impact ◽

Stroke Patients ◽

Normal Diffusion

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Abstract WP21: Extracranial Carotid Revascularization May Have Higher Mortality Rate in Acute Stroke Intervention

Stroke ◽

10.1161/str.48.suppl_1.wp21 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Nazli Janjua ◽

Karen Tse-Chang ◽

Kimberly Jones ◽

Katrina Woolfolk ◽

Kessarin Panichpisal ◽

...

Keyword(s):

Acute Stroke ◽

Antiplatelet Agents ◽

Chi Square ◽

Carotid Revascularization ◽

Risk Of Mortality ◽

Tandem Occlusion ◽

Significant Difference ◽

Scale Scores ◽

Chi Square Analysis ◽

Tandem Lesions

Background: The endovascular management of acute extracranial carotid artery (EcCA) occlusion is unclear, as hypotension, a known phenomenon with carotid revascularization (CR), may exacerbate stroke symptoms. Most studiesinclude patients with tandem intracranial occlusions requiring thrombectomy, and even in those cases, there remains variability in regards to the order and manner of endovascular therapy (e.g. extra- vs intracranial revascularization first. Objective: We sought to compare the clinical and radiographic differences in EcCA patients who did or did not undergo proximal CR. Methods: We identified patients screened for possible intervention with acute EcCA occlusion from our prospective stroke database from 1/2014-8/2016and abstracted their demographic, clinical, and radiographic data. We compared differences between groups using chi-square analysis. Results: Thirty-four patients had EcCA: (10, 29% sole EcCA; 24, 71% tandem occlusions; these included 19 of our 143 (13%) patients undergoing acute stroke intervention (16 with tandem lesions, 3 without). Nine of the 16 tandem occlusion patients underwent specific CR, whereas in four we were unable to cross the EcCA, and in 3 only targeted the intracranial occlusion. The mean age was 69±14 years among 19 males and 15 females, with no intergroup differences. Most (19, 56%) received IV tPA in the whole group as well as the CR subset (7, 58%), who were loaded with antiplatelet agents afterwards; 11 underwent stent placement and 1 angioplasty alone. Although there were trends towards higher baseline and discharge National Institutes of Health Stroke scale scores (NIHSSS) among the CR group (19 vs 16 and 21 vs 18) and median discharge modified Rankin scales (5 vs 4), these were not significant (p>0.05). There were 5 deaths in both groups. As a comparison to the rest of our thrombectomy cohort, there was no significant difference in discharge NIHSSS (11 vs 13) among patients undergoing CR though there proportionately more deaths (25, 18%, no CRvs 5, 42%, CR, p<0.05). Conclusion: These data suggest that EcCA patients should be informed of possible greater risk of mortality during acute stroke intervention. Further analyses may better identify practice standards to improve outcomes in this population.

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