scholarly journals One-Stop Management of 230 Consecutive Acute Stroke Patients: Report of Procedural Times and Clinical Outcome

2019 ◽  
Vol 8 (12) ◽  
pp. 2185 ◽  
Author(s):  
Marios-Nikos Psychogios ◽  
Ilko L. Maier ◽  
Ioannis Tsogkas ◽  
Amélie Carolina Hesse ◽  
Alex Brehm ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Multidetector Ct ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Flat Detector ◽  
Treatment Delays ◽  
Angiography Suite ◽  
One Stop

Background and purpose: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion. Methods: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 h after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥10 in 2016; ≥7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management. Results: A total of 230 patients (123 women, median age of 78 years (Interquartile Range (IQR) 69–84)) were included. Median symptom-to-door time was 130 min (IQR 70–195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56–87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85–117) to 68 min (IQR 53–89; p < 0.001). Rate of good functional outcome was significantly better in the one-stop management group (p = 0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups. Conclusions: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.

Abstract TMP3: One-stop Management of 230 Consecutive Acute Stroke Patients Report of Procedural Times and Clinical Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Marios Psychogios ◽  
Ilko Maier ◽  
Ioannis Tsogkas ◽  
Amelie Hesse ◽  
Alex Brehm ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Functional Outcome ◽  
Multidetector Ct ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Flat Detector ◽  
Treatment Delays ◽  
Angiography Suite ◽  
One Stop

Introdruction: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion. Methods: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 hours after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥ 10 in 2016; ≥ 7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management. Results: A total of 230 patients (123 women, median age of 78 years (IQR 69-84)) were included. Median symptom-to-door time was 130 min (IQR 70-195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56-87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85-117) to 68 min (IQR 53-89; P <0.001). Rate of good functional outcome was significantly better in the one-stop management group ( P =0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups. Conclusions: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.

scholarly journals Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Daria Antipova ◽  
Leila Eadie ◽  
Ashish Stephen Macaden ◽  
Philip Wilson
Keyword(s):  
Systematic Review ◽  
Diagnostic Accuracy ◽  
Acute Stroke ◽  
Clinical Assessment ◽  
Assessment Tools ◽  
Large Vessel ◽  
Cochrane Library ◽  
Direct Transfer ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Abstract Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

Abstract 1122‐000125: Underlying ICAD is Associated with Worse Outcome in Acute Large Vessel Occlusion Undergoing Endovascular Therapy

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Sonam Thind ◽  
Ali Mansour ◽  
Scott Mendelson ◽  
Elisheva Coleman ◽  
James Brorson ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Intravenous Thrombolysis ◽  
Fold Increase ◽  
Large Vessel ◽  
High Risk Population ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Intracranial Atherosclerotic Disease ◽  
Poor Outcomes

Introduction : Acute large vessel occlusion (LVO) can be secondary to thromboembolism or underlying intracranial atherosclerotic disease (ICAD). Data on the management of LVO due to underlying ICAD are scarce. We hypothesized that patients with ICAD would have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods : We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between 01/2018 and 05/2021. Presence of underlying ICAD at the site of LVO was determined by the treating interventionalist. We compared outcomes including in‐hospital mortality and 90‐day modified Rankin Scale (mRS) between those with and without underlying ICAD, adjusting for relevant covariates using logistic regression. Results : Among 195 patients (mean age 67.4+15.1 years, 56.9% female, 81% black, median NIHSS score 15), underlying ICAD was present in 39 (20.0%). Stent‐retrievers were used 196 patients with only 3 having rescue stent placement. There were no significant differences in baseline factors amongst the two groups except diabetes was more common (69.2% vs. 49.7%, p = 0.028) and intravenous thrombolysis provided less often (17.9% vs. 36.5%, p = 0.027) in those with ICAD. TICI 2B or higher was achieved in 82.1% of ICAD compared with 94.3% of non‐ICAD patients (p = 0.012). Mortality was more common (50.0% vs. 30.8%, p = 0.025) and good functional outcome (mRS 0–2) at 90 days was less common (10.8% vs. 30.0%, p = 0.002) in the ICAD group. Adjusting for age, diabetes, intravenous thrombolysis, baseline NIHSS score, and final TICI score, underlying ICAD was an independent predictor of mRS 0–2 at 90 days (OR 4.5, 95% CI 1.4‐14.2, p = 0.010). Conclusions : Underlying ICAD is associated with 4.5‐fold increase in poor functional outcome in patients with LVO undergoing traditional MT. Further research is needed to understand factors associated with poor outcomes investigate alternative interventional approaches and medical management in this high‐risk population.

Abstract 1122‐000223: Direct to Angiography Suite versus Conventional Imaging in Suspected Large Vessel Occlusion Strokes: A Meta‐Analysis

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Mahmoud H Mohammaden ◽  
Mohamed Elfil ◽  
Mohamed Fahmy Doheim ◽  
Agostinho Camara Pinheiro ◽  
Alhamza R Al‐Bayati ◽  
...  
Keyword(s):  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Cochrane Library ◽  
Conventional Imaging ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Angiography Suite ◽  
Significant Difference

Introduction : Direct transfer to angiography suite (DTAS) for patients with suspected large vessel occlusion strokes potentially requiring mechanical thrombectomy has been shown to shorten treatment times and improve outcomes compared to conventional imaging (CI) selection. This meta‐analysis compares both approaches to build more concrete evidence. Methods : The potentially relevant studies that were published in four electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) till August 2021 were reviewed. Eligible studies were included if they enrolled >10 patients in both groups, were published in English and reported baseline and procedural characteristics and 90‐day outcomes. Relevant data were then extracted and analyzed. Results : Among 4514 searched studies, six qualified for the analysis. Time from door to puncture (MD = ‐26.76minutes, 95 % CI [‐39.48, ‐14.03], P< 0.0001) as well as door to reperfusion (MD = ‐27.21 minutes,95% CI [‐47.42, ‐7.01], P = 0.008) were significantly shorter and the rates of functional independence(mRS0‐2: RR = 1.28, 95% CI [1.03, 1.60], P = 0.03) at 90‐days were significantly higher in the DTAS versus the CI approach. There was no statistically significant difference between DTAS and CI groups in terms of successful reperfusion (modified Thrombolysis In Cerebral Infraction [mTICI] score2B‐3: RR = 0.99, 95% CI [0.93, 1.06], P = 0.86), near complete/ full reperfusion (mTICI 2C‐3: RR = 0.84,95% CI [0.68, 1.04], P = 0.11), or fair outcomes at 90‐days (mRS 0–3: RR = 1.05, 95% CI [0.67, 1.64],P = 0.84). Moreover, there was no difference between groups regarding symptomatic intracranial hemorrhage (RR = 0.81, 95% CI [0.55, 1.17], P = 0.26) or 90 day‐mortality (RR = 0.85, 95% CI [0.59, 1.24],P = 0.41). Conclusions : Our meta‐analysis showed that DTAS significantly improves time metrics and functional outcome with comparable safety to the CI approach. Multicenter randomized clinical trials are ongoing to confirm these results.

Abstract 1122‐000022: Delays in Care for Patients with Acute Stroke During Hospitalization for Other Reasons

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Nicholas Vigilante ◽  
Parth Patel ◽  
Prasanth Romiyo ◽  
Lauren Thau ◽  
Mark Heslin ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Acute Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Single Center ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptom Recognition ◽  
Risk Patients ◽  
Recognition Imaging

Introduction : In‐hospital stroke (IHS) is defined as stroke that occurs during hospitalization for non‐stroke conditions. We aimed to understand the timing of symptom recognition for patients who experienced IHS and its impact on the care they receive. Methods : A prospective, single center registry of adult patients (9/20/19‐2/28/21) was queried for acute anterior circulation IHS. Indications for hospitalization, delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored. Results : Of 928 consecutively evaluated adults with acute stroke, 85 (9%) developed an anterior circulation IHS, 39 (46%) of whom were female, with a median age of 67 years (IQR 60–76) and median NIHSS of 15 (IQR 4–22). Sixty‐eight (80%) had a >1 hour delay from last known well to symptom recognition. Two patients (2%) received IV thrombolysis, although another 38 (45%) would have been eligible if not for a delay in symptom recognition. An ICA, M1, or M2 occlusion was observed in 18 patients (21%), 7 of whom were treated at a median of 174 minutes after LKW (IQR 65–219). Compared to the 11 patients who did not undergo thrombectomy with large vessel occlusion, those who underwent thrombectomy had non‐significantly shorter delays from LKW until neuroimaging (median 85 [IQR 65‐162] vs. 216 [IQR 133‐507], p = 0.12). Conclusions : While uncommon, patients with IHS experience delays in symptom recognition and treatment, which lead to exclusion from acute care treatment such as thrombolysis and thrombectomy. Earlier detection with more frequent nursing assessments or advanced neuromonitoring devices in at‐risk patients may reduce delays in care.

scholarly journals Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽  
2021 ◽  
Author(s):  
Raul G. Nogueira ◽  
Jason M. Davies ◽  
Rishi Gupta ◽  
Ameer E. Hassan ◽  
Thomas Devlin ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Acute Stroke ◽  
Systems Of Care ◽  
Ct Perfusion ◽  
Stroke Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph F Carrera ◽  
Joseph H Donahue ◽  
Prem P Batchala ◽  
Andrew M Southerland ◽  
Bradford B Worrall
Keyword(s):  
Linear Regression ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

Abstract WP26: Validation of Predictive Scales of Functional Outcome After Endovascular Therapy Using the REVASCAT Data

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Natalia Perez de la Ossa ◽  
Srikant Rangaraju ◽  
Tudor Jovin ◽  
Anoni Dávalos ◽  
Keyword(s):  
Functional Outcome ◽  
Endovascular Therapy ◽  
Predictive Accuracy ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Best Medical Treatment

Introduction: Various scales have been developed to predict long-term clinical outcome after endovascular therapy (EVT) in stroke patients. The objective of this study was to validate and compare five well-validated scales in terms of predictive accuracy for functional independence in a recent endovascular stroke trial (REVASCAT). Hypothesis: We hypothesize that predictive scales (PRE, THRIVE, HIAT2, SPAN-100, FAR) have good-excellent (AUC>0.7) predictive accuracy for good functional outcome and can predict the beneficial effect of EVT demonstrated in randomized clinical trials. Methods: REVASCAT (Randomized Trial of Revascularization with Solitaire-FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset) enrolled 206 patients who were randomized to receive EVT or best medical treatment. Five scores (PRE-score, THRIVE, HIAT2, SPAN-100 and FAR-score) were retrospectively calculated on patients who received EVT. Receiver-operator characteristics (ROC) for good outcome (mRS 0-2 at 90 days) for each scale were compared. Using the highest predictive scales, the proportion of patients with good outcome by the score categorized in quartiles was analyzed. Results: 103 patients received EVT in the REVASCAT trial (mean age 65.7, median NIHSS 17). Baseline NIHSS, baseline CT-ASPECTS, age and atrial fibrillation, but not previous iv tPA or DM, were associated with good outcome in multivariable analysis. AUC for good outcome was ≥0.70 for FAR (0.74) and PRE (0.70) scores while SPAN-100 (0.67), HIAT2 (0.65) and THRIVE (0.64) had lower AUCs although differences were not statistically significant. The higher the score on the PRE and FAR scores, the lower the proportion of patients with good outcome (PRE-score: 1QT 44.4%, 2QT 24.4%, 3QT 22.2%, 4 QT 8.9%; FAR-score: 1QT 57.8%, 2QT 22.2%, 3QT 6.7%, 4QT 3.3%). Benefit of EVT accordingly to the score on the different scales will be also presented. Conclusions: Of the 5 stroke scales, FAR and PRE had better predictive accuracy for functional independence after EVT. These tools may facilitate decision making for EVT in anterior circulation large vessel occlusion stroke.

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