acute stroke therapy
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Author(s):  
Deepa Krishnaswamy ◽  
Seetharaman Cannane ◽  
Meena Nedunchelian ◽  
Shriram Varadharajan ◽  
Santhosh Poyyamoli ◽  
...  

Abstract Background: Imaging of acute stroke patients in emergency settings is critical for treatment decisions. Most commonly, CT with CTA is used worldwide for acute stroke. However, MRI may be advantageous in certain settings. With advancements in endovascular clot retrieval techniques, there is a need to identify and use the best possible imaging for the diagnosis and outcome prediction of hyperacute stroke. Methods: This mixed retrospective and prospective observational study was conducted over 2 years in patients who underwent reperfusion therapies. Patients were included in this study if they had a baseline as well as follow-up noncontrast CT and diffusion-weighted imaging (DWI) MRI. We compared them for estimating final infarct size and outcomes after reperfusion therapy. Results: A total of 86 patients were included in the study. Baseline DWI found new infarcts in 33 patients compared to baseline CT. Sensitivity and specificity of CT and DWI in predicting the final infarct size was 75.3% and 76.9% and 97.2% and 92.3%, respectively. A positive correlation of 51.2% and 84.4% was noted between b-CT Alberta stroke programme early CT score (ASPECTS) and b-DWI with 72 hours DWI ASPECTS, respectively (p < 0.001). The positive predictive value of CT was 94.8% and DWI was 98.6%. None of the patients had reversible hyperintensities in the follow-up DWI. Conclusion: MRI is more sensitive and specific than noncontrast CT in predicting final infarct volume. It predicts final outcomes better and could be an alternative if available in acute stroke settings.


Author(s):  
Mersedeh Bahr-Hosseini ◽  
Marom Bikson ◽  
Marco Iacoboni ◽  
David S. Liebeskind ◽  
Jason D. Hinman ◽  
...  

AbstractMany neuroprotective and other therapies for treatment of acute ischemic stroke have failed in translation to human studies, indicating a need for more rigorous, multidimensional quality assessment of the totality of preclinical evidence supporting a therapy prior to conducting human trials. A consensus panel of stroke preclinical model and human clinical trial experts assessed candidate items for the translational readiness scale, compiled from prior instruments (STAIR, ARRIVE, CAMARADES, RoB 2) based on importance, reliability, and feasibility. Once constructed, the tool was applied by two independent raters to four current candidate acute stroke therapies, including two pharmacologic agents [nerinetide and trans-sodium crocetinate] and two device interventions [cathodal transcranial direct current stimulation and fastigial nucleus stimulation]. The Preclinical evidence of Readiness In stroke Models Evaluating Drugs and Devices (PRIMED2) assessment tool rates the totality of evidence available from all reported preclinical animal stroke model studies in 11 domains related to diversity of tested animals, time windows, feasibility of agent route of delivery, and robustness of effect magnitude. Within each content domain, clearly operationalized rules assign strength of evidence ratings of 0–2. When applied to the four assessed candidate agents, inter-rater reliability was high (kappa = 0.88), and each agent showed a unique profile of evidentiary strengths and weaknesses. The PRIMED2 assessment tool provides a multidimensional assessment of the cumulative preclinical evidence for a candidate acute stroke therapy on factors judged important for successful basic-to-clinical translation. Further evaluation and refinement of this tool is desirable to improve successful translation of therapies for acute stroke.


2021 ◽  
Vol 5 (1) ◽  
pp. 026-028
Author(s):  
Erdoğan Hacı Ali ◽  
Acır İbrahim ◽  
Yayla Vildan

Background and Objective: Thrombolytic and mechanical thrombectomy therapies are proven treatment methods in patients with acute stroke. Aim is to share our experience in acute stroke therapy with colleagues. Material and methods: In this study we evaluated the patients who underwent MT or MT + IV-tPA between 2018-2019 retrospectively. Demographic features, comorbid diseases of patients, symptom onset-to-gate and symptom gate-to-puncture durations, mRS (Modified Rankin Score) and NIHSS (National Institutes of Health Stroke Scale) score, treatment method and degree of recanalization were listed. Results: MT was applied to 29 patients, MT + bolus IV-tPA was applied to 12 patients and MT + full dose IV-tPA was applied to 7 patients. The mean age was 66 ± 15 years, arrival mRS was 2 ± 2, arrival NIHSS score was 14 ± 5, onset-to-gate duration was 185 minutes and gate-to-puncture duration was 118 minutes. Conclusion: The rate of recanalization, functional independence and mortality were similar to the HERMES study. It was observed a higher rate of intracranial hemorrhage in patients who received bolus or full dose IV-Tpa compared to patients who underwent MT. These results have led us to question the necessity of giving bolus or full dose IV-tPA before MT. Onset-to-gate and gate-to-puncture durations were found longer than the recommended durations. Rapid and effective management of AIS patients will provide good clinical results.


Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Paige Hargrove ◽  
Deborah Spann ◽  
Yvette Legendre ◽  
Ted Colligan ◽  
Sheryl Martin-Schild

Background: The first surge of COVID-19 cases in Louisiana began in late March 2020 in the Greater New Orleans Area and quickly spread throughout the state. We sought to determine if LVO screening and door in-door out (DIDO) among patients who screened positive for large vessel occlusions (LVO) deteriorated. Methods: Our statewide stroke registry, mandatory for hospitals attesting to Acute Stroke Ready Hospital status, was queried. We compared LVO screening and transfer efficiency during Q1 and Q2 2020 with Q3 and Q4 2019. Results: Patients presenting within 24hr of last seen normal declined by 11%. The proportion arriving by ambulance increased (50.6% vs 40.7%, p<0.0001). Screening for LVO increased (84.4% vs 77.0%%, p<0.0001). Use of Vision-Aphasia-Neglect assessment increased (74.6% vs 66.2%%, p<0.0001). The proportion screening positive for LVO insignificantly decreased (23.1% vs 26.0%, p=0.1233). The median time from door in to transfer request was stable (63min during both time periods). The median time from transfer request to departure increased (58min vs 48min). The DIDO increased by 24 minutes (135min vs 111min). Delay due to achieving acceptance in hub center and secondary transfer ambulance were the most common reasons documented for prolonged DIDO. Discussion: Louisiana experienced a reduction in acute stroke presentation during COVID-19. Screening for LVO actually improved during this time, but DIDO was compromised due to problems securing transfer acceptance and secondary ambulance service. Earlier identification and initiation of secondary transfer for patients screening positive for LVO should help improve efficiency in delivering acute stroke therapy.


Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jeffrey Shen ◽  
Deepika Budhraja ◽  
Seeta Shah ◽  
Kimberly Martin ◽  
Chen Lin

Introduction: The Southeastern United States, known as the “the stroke belt,” has the highest stroke mortality rate in the country. One possible reason is the high proportion of its residents living in rural areas. Studies suggest stroke care is worse for patients living in rural areas, and they are less likely to receive acute stroke therapy (intravenous thrombolysis or endovascular therapy), leading to worse outcomes. We compared 90-day modified Rankin Score (mRS) between patients living in urban versus rural areas who received acute stroke therapy. Methods: We performed a retrospective analysis of a tertiary care academic hospital in the Southeastern US, the University of Alabama at Birmingham. Patients admitted with imaging-confirmed ischemic stroke and had acute stroke therapy between 2014 and 2018 were included for analysis. Individuals were classified as rural or urban dwelling based on US Department of Agriculture’s 2010 Rural-Urban Commuting Area Codes. Clinical and demographic characteristics were collected from the chart. Stepwise logistic regression models were performed with these variables to compare good (mRS 0-1) vs poor (mRS 2-6) functional outcomes. Results: There were 232 patients included in the study (185 urban, and 47 rural). There were no significant differences between groups in age (urban 64.5±15.1; rural 66.2±14.7), gender (urban: 56% male 44% female, rural: 51% male 49% female), or proportion of African-Americans (33% of urban group and 25% of rural group). Mean baseline NIH stroke scale was higher in rural patients than urban (17.0 vs 14.8 respectively, p-value=0.03.). In logistical regression models for good functional outcome (mRS 0-1) at 90-days, analysis of factors including rural/urban status, gender, age, insurance, transfer, and acute stroke therapy, revealed only older age as a significant factor (OR 0.97, 95% CI 0.95-0.99). Conclusions: Our study demonstrated no significant differences in functional outcome between patients from urban and rural locations after receiving acute therapy for treating ischemic stroke. Importantly, only older age predicted poor functional outcome at 90 days. Our study demonstrates that patients from rural areas can recover similarly to those from urban areas.


Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kunal Agrawal ◽  
Ilana Spokoyny ◽  
Chia-Chun Chiang ◽  
Kevin McGehrin ◽  
Brett C Meyer

Introduction: Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke. Methods: In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option. Results: In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences. Conclusion: Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.


Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Paige Hargrove ◽  
Deborah Spann ◽  
Yvette Legendre ◽  
Ted Colligan ◽  
Sheryl Martin-Schild

Background: The first surge of COVID-19 cases in Louisiana began in late March 2020 and was centered on the Greater New Orleans Area. Louisiana is divided into 9 regions; New Orleans is in Region 1. A statewide survey indicated 100% of hospitals experienced a decline in stroke presentations. We sought to determine if treatment of stroke with intravenous (IV) thrombolytic declined or was delayed relative to pre-COVID-19. We also sought to evaluate a change in door in-door out (DIDO) for secondary transfers among patients who screened positive for large vessel occlusions (LVO). Methods: Our statewide stroke registry, mandatory for hospitals attesting to Acute Stroke Ready Hospital status, was queried. We compared stroke volume, treatment rate with IV thrombolytic, treatment efficiency, and DIDO in 2019 with March 2020 and Q2 2020. Results: Monthly stroke presentations declined by 20% starting March 2020 compared to the average monthly volume in 2019. The IV thrombolytic rate was down from 10.3% to 8.8% in Q2 2020. In Q2 2020, the median door-to-needle time was 12 minutes longer than it was during 2019 and the proportion with a documented reason for delay increased from 29.1 in 2019 to 33.3% in March 2020 and 37.5% in Q2 2020. The median DIDO increased by 13 minutes compared to 2019 (129 vs 116 minutes). Discussion: Louisiana experienced a reduction in stroke presentation following the initial surge of COVID-19 cases. The treatment rate and efficiency with IV thrombolytic declined and DIDO was prolonged among patients with suspected LVO. Careful evaluation of how the stroke code processes changed in response to COVID-19 may help to recover efficiency in delivering acute stroke therapy.


2020 ◽  
Vol 3 (2) ◽  
pp. 62-71
Author(s):  
Kaushik Sundar ◽  
Ajay Panwar ◽  
Dileep R. Yagaval ◽  
Vikram Huded ◽  
P.N. Sylaja

Large vessel occlusion has a disproportionately large contribution to overall mortality and morbidity from stroke. The Society of Vascular and Interventional Neurology in the year 2016 announced the launch of Mission Thrombectomy 2020 (MT2020), with the aim of increasing access to stroke thrombectomy globally. Despite 4 years since the start of MT2020, India is falling short in acute stroke therapy including thrombolysis and mechanical thrombectomy (MT). Access to timely MT leads to substantial mitigation of adverse stroke outcomes. This in turn leads to an enormous health benefit in that population. MT as a treatment is unevenly and unfairly distributed and increasing access to it is in need of strategies targeting political, economic, and environmental factors. Such strategies are slowly being adopted. In this article, we attempt to look at the major hurdles we face in improving acute stroke care in our country and we also explore options to address them.


Neurology ◽  
2020 ◽  
Vol 96 (1) ◽  
pp. e153-e156
Author(s):  
Maria Bres Bullrich ◽  
Sachin Pandey ◽  
Michael Mayich ◽  
Kayla McConvey ◽  
Sebastian Fridman ◽  
...  

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Bahareh Sianati ◽  
Russel Cerejo ◽  
David Wright ◽  
Ashish Tayal ◽  
Patty Noah ◽  
...  

Introduction: Brain perfusion imaging has become an integral part of acute stroke therapy, especially for the extended time window. A streamlined workflow is essential to reduce delays in acute stroke therapy. Incorporating standard and advanced imaging together may reduce time to endovascular therapy but may delay administration of intravenous (IV) tPA. Method: A retrospective analysis of all acute stroke therapy cases between August 2017 and March of 2018 was performed at a single stroke center. Brain perfusion imaging was instituted into the workflow in December of 2017. We included patients who received IV tPA before and after implementation of CT perfusion (CT-P). Demographics, clinical presentation, stroke treatment times and imaging characteristics were collected. Results: During the eight-month period, we identified 117 patients who met inclusion criteria. We divided the cohort into two groups, pre CT-P implementation (Group 1) and post CT-P implementation (Group 2). We identified 66 patients in Group 1 and 51 patients in Group 2. In Group 1, 29 (44%) were females with median age of 63 years. In Group 2, 33 (65%) were females, with median age of 72 years. There was no difference in median times for door to needle in Group 1 (57 minutes, interquartile range [IQR] 42 – 76) compared to Group 2 (53 minutes, [IQR] 40 – 68) ( P = 0.20). Conclusion: Incorporating CT-P in the imaging workflow did not delay door to needle time for IV tPA in acute stroke therapy.


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