E-128 five-year endovascular acute ischemic stroke intervention experience at a rural academic medical center

2015 ◽  
Vol 7 (Suppl 1) ◽  
pp. A99.2-A100
Author(s):  
E Akture ◽  
C O'Neill ◽  
M Gorman ◽  
C Commichau ◽  
G Linnell ◽  
...  
Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Josephine F Huang ◽  
Jennifer E Fugate ◽  
Alejandro A Rabinstein

INTRODUCTION: Studies suggest 8%-28% of ischemic strokes present as wake-up strokes (WUS). The unknown time of symptom onset precludes these patients from approved treatments for acute ischemic stroke, but a substantial proportion of patients may be deemed candidates for treatment if other factors are considered. The aim of this study was to identify characteristics associated with clinical outcomes of WUS patients. METHODS: We retrospectively reviewed the medical record of patients with ischemic stroke admitted to a large academic medical center between January 2011 and May 2012. We identified patients with stroke symptoms upon awakening or those who were found with stroke symptoms with an unknown time of onset. Baseline demographics, stroke mechanism, presenting NIHSS, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and modified Rankin Scale (mRS) scores on discharge and at 3-month follow-up were obtained. A good outcome was defined as mRS 0-2. RESULTS: WUS patients comprised 22% (162/731) of all patients with ischemic stroke at our institution during this time period. Median age was 74 years (range 15-100), median presenting NIHSS was 5 (range 0-28), and median initial ASPECTS 10 (range 0-10). A cardioembolic mechanism was identified in 68 patients (42%). Predictors of good outcome at hospital discharge were lower initial NIHSS (3.5 versus 12.0, p<0.0001) and higher ASPECTS (9.8 versus 8.1, p=0.0002). The predictors of good outcomes at 3 months were younger age (69.1 versus 75.8, p=0.009), lower initial NIHSS (5.0 versus 12.6, p<0.0001), and higher ASPECTS (9.5 versus 8.1, p=0.0006). One hundred and eleven patients (68.5%) had initial ASPECTS of 10. Of those, 19 had NIHSS≥10 and 7 were treated with acute recanalization therapies. Four of the 7 treated patients had good outcomes, and 2 of the 12 untreated patients had good outcomes. CONCLUSIONS: Few patients with strokes of unknown onset and severe deficits have good outcomes without acute stroke treatment. Patients with NIHSS≥10 and ASPECTS 10 may be candidates for acute recanalization therapy.


2016 ◽  
Vol 42 (1-2) ◽  
pp. 10-14 ◽  
Author(s):  
Lester Y. Leung ◽  
Louis R. Caplan

Objectives: Young adults with ischemic stroke may present late to medical care, but the reasons for these delays are unknown. We sought to identify factors that predict delay in presentation. Methods: We performed a retrospective cohort study of adults aged 18-50 admitted to a single academic medical center between 2007 and 2012. Results: Eighty six of 141 (61%) young adults with ischemic stroke presented at the health center more than 4.5 h after stroke onset. Diabetes was associated with delays in presentation (p = 0.033, relative risk (RR) 1.4 (95% CI 1.1-1.8)), whereas systemic cancer was associated with early presentations (p = 0.033, RR 0.26 (95% CI 0.044-1.6)). Individuals who were single were more likely to present late than those who were married or living with a partner (p = 0.0045, RR 1.7 (95% CI 1.3-2.2)). Individuals who were unemployed were more likely to present late than those who were employed or in school (p = 0.020, RR 1.4 (95% CI 1.1-1.8)). Age (dichotomized as 18-35 and 36-50), race, home medications, other medical conditions (including common stroke mimics in young adults), and stroke subtype were not determinants of delay in presentation, although there was a trend toward delayed presentations in women (p = 0.076) and with low stroke severity (dichotomized as National Institutes of Health Stroke Scale (NIHSS) ≤5 and NIHSS >5, p = 0.061). Conclusions: A majority of young adults with ischemic stroke presented outside the time window for intravenous fibrinolysis. Diabetes, single status, and unemployed status were associated with delayed presentation.


Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Branko N Huisa ◽  
William P Neil ◽  
Nhu T Bruce ◽  
Marcel Maya ◽  
Benedict Pereira ◽  
...  

Background: Diffusion-weighted imaging (DWI) detects acute ischemia with a high sensitivity. In research centers, qualitative CT perfusion (CTP) mapping correlates well with DWI and may accurately differentiate the infarct core from ischemic penumbra. The value of the CTP in real-world clinical practice, however, has not been fully established. We investigated the yield of CTP - derived cerebral blood volume (CBV) and mean transient time (MTT) for the detection of cerebral ischemia in a sample of acute ischemic stroke (AIS) patients. Methods: In a large metropolitan academic medical center that is a certified Primary Stroke Center (PSC) we retrospectively studied 162 patients who presented between January 2008 and July 2010 with symptoms suggestive of AIS. All patients had an initial Code Brain protocol including non-contrast head CT, CTP, and CTA. As clinically indicated, some patients underwent follow up brain MRI within 48 hours. Acute perfusion maps were derived in real time by a trained operator. From the obtained images CBV, MTT and DWI lesion volumes were manually traced using planimetry (ImageJ v1.42) by two stroke neurologists blinded to clinical information. Volumes were calculated using the Cavaleri theorem. Sensitivity, specificity and statistical analysis were calculated using Graph Pad 5.0. Results: Of 162 patients with acute stroke-like symptoms, 73 had DWI lesions. The sensitivity and specificity to detect abnormal DWI signals were 23% and 100%, for CBV; and 43.8% and 98.9% for MTT. For DWI lesions ≥5ml the yield was 59.3% for CVB and 77.8% for MTT. For lesions ≥10ml the yield was 68.4% for CBV and 89.5% for MTT. In patients with NIHSS ≥5, CBV predicted abnormal DWI in 22.6% and MTT in 35.5%. In patients with NIHSS ≥10, CBV and MTT, both had a yield of 50.0%. A CBV - MTT mismatch of >25% predicted MRI lesion extension in 81.25% of the cases. There were small but significant correlations for DWI versus CBV lesion volumes ( r 2 0.32, P= 0.0001), and for DWI versus MTT lesion volumes ( r 2 0.29, P <0.0001). Correlation between DWI and perfusion maps for MCA territory infarcts were CBV ( r 2 0.3, P <0.0001) and MTT ( r 2 0.45, P <0.0001). Conclusions: In real-world deployment during a Code Brain protocol in a busy PSC, acute imaging with CTP did not predict DWI lesions on brain MRI with sufficient accuracy. In patients with large lesions the predictive value was better.


2016 ◽  
Vol 30 (6) ◽  
pp. 606-611 ◽  
Author(s):  
Elise L. Metts ◽  
Abby M. Bailey ◽  
Kyle A. Weant ◽  
Stephanie B. Justice

Background: Tissue plasminogen activator (tPA) is the only pharmacotherapy shown to improve outcomes in acute ischemic stroke. The American Heart Association (AHA) recommends a door-to-needle (DTN) time of <60 minutes in at least 50% of patients presenting with acute ischemic stroke. Objective: The purpose of this study was to analyze the possible barriers that may delay tPA administration within the emergency department (ED) of an academic medical center. Methods: A retrospective chart review was conducted from February 2011 to October 2013. Patients were included if they were admitted through the ED with a diagnosis of acute ischemic stroke and received tPA. Results: Of the 130 patients who met inclusion criteria, 43.1% received tPA in ≤60 minutes. Several factors were identified to be significantly different in those with a DTN time of >60 minutes—time to ED physician consultation, neurologist arrival, blood sample acquisition, and result time ( P < .05 for all comparisons). Correlation analysis demonstrated several independent variables associated with DTN time of ≤60 minutes—time from admission to ED physician consultation, receipt of computed tomography (CT) scan, blood sample acquisition, laboratory results, and neurology service arrival ( P < .05 for all comparisons). Conclusion: The findings from this study highlight the importance of prompt physician evaluation, direct transfer to the CT scanner, and a quick turnaround time on laboratory values. The development of protocols to ensure the rapid receipt of tPA therapy should focus on limiting any potential delay these steps may cause.


Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Maryam Pourebadi ◽  
Jamie N LaBuzetta ◽  
Cynthia Gonzalez ◽  
Preetham Suresh ◽  
Laurel Riek

Introduction: It is now well-accepted that simulation-based learning (SBL) is an important component of medical education. At our institution, we have a state-of-the-art simulation center, and SBL is already incorporated into many medical subspecialties. However, commercially available patient simulators have static faces and lack the realistic depiction of non-verbal facial cues important for rapid diagnosis of neurological emergencies such as stroke. This multidisciplinary project addresses the urgent need for expressive patient simulators by developing acute stroke avatars for use in simulated healthcare training. Methods: Using a previously published and validated method, we developed techniques to display stroke pathologies on a virtual patient simulator (VPS). After obtaining patient or surrogate consent, we obtained source videos from patients admitted to an academic medical center who had experienced acute ischemic stroke resulting in neurological findings such as facial droop, eyelid apraxia, dysarthria, and coma. We then extracted facial features using shape-based modeling techniques, leaving anonymous feature points. Next, we applied a novel algorithm to use these feature points to build accurate computational models (masks) representing the facial characteristics of stroke. We then overlaid these prebuilt masks onto a live facial video stream to generate asymmetric expressions on a virtual avatar. This project was IRB approved. Results: More than 21 videos of stroke patients were made. Once the feature points were extracted from these videos, we were able to develop VPSs capable of expressing realistic asymmetric facial expressions. These avatars were then validated amongst neurologists with clinical experience in diagnosing acute ischemic stroke. Conclusions: This multidisciplinary effort using patient-inspired facial expressions resulted in a tool that aids the stroke education community by making virtual and robotic simulators of acute stroke more varied, interactive, and realistic.


Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sara K Rostanski ◽  
Benjamin R Kummer ◽  
Joshua I Stillman ◽  
Randolph S Marshall ◽  
Olajide Williams ◽  
...  

Introduction: Use of emergency medical services (EMS) is associated with decreased door-to-needle time in acute ischemic stroke. While racial and ethnic disparities in EMS use are well documented, the role of patient language in EMS use has been understudied. We sought to characterize EMS use by patient language among IV-tPA treated patients at a single center with a large Spanish-speaking patient population. Methods: We identified all patients who received IV-tPA over five years (7/2011-6/2016) at an academic medical center in New York City. Primary language, EMS use, pre-notification, and patient demographics were recorded from the EMR. We compared baseline characteristics, EMS use, and stroke pre-notification between English and Spanish-speaking patients. Logistic regression was used to measure the association between primary patient language and EMS use, adjusting for potential confounders. Results: Over the study period, 391 patients received IV-tPA; 208 (53%) primarily spoke English and 174 (45%) primarily spoke Spanish. Nine patients (2%) spoke other languages and were excluded. Mean age (66 vs. 69, p=0.09), male sex (43% vs. 33%, p=0.05) and median NIHSS (7 vs. 6, p=0.12) did not differ between English and Spanish-speaking patients. Of the 380 (97%) patients with EMS data, EMS use was higher among Spanish-speaking patients (69% vs. 80%, p<0.01). Pre-notification did not differ by language (63% vs. 61%, p=0.8). In a multivariable model adjusting for age, sex, and initial NIHSS, Spanish speakers remained more likely to use EMS (OR 1.9, 95% CI 1.1-3.2, p=0.02). Conclusion: Among patients treated with IV-tPA at an urban academic medical center, EMS usage was higher in Spanish-speakers compared to English-speakers. Although language is not an exact surrogate for ethnicity, these findings are in contrast to previously published work demonstrating low rates of EMS usage among Hispanics. Future studies should evaluate differences in EMS utilization according to primary language as well as ethnicity.


Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Randheer S Yadav ◽  
Sushil Lakhani ◽  
Cassanda Forrest ◽  
Bryan Gough ◽  
Archana Hinduja ◽  
...  

Introduction: Vizient clinical database-resource manager (CDB/RM) is an alliance of Academic Medical Centers and their affiliated hospital that collects data to enhance patient care by aligning cost, quality and market performance. The observed-to-expected mortality (O/E) is a risk-adjusted measure of a hospital’s mortality and is based upon documentation of specific variables associated with mortality. Methods: Our comprehensive stroke program participates in Vizient CDB/RM. We defined observed mortality as the rate of patient deaths in the hospital each month. Expected mortality is calculated as the sum of all individually calculated risks with conditions that affect severity, for discharges each month. The O/E ratio is calculated by dividing observed mortality by the expected mortality. An O/E ratio score higher than 1.0 means the hospital’s mortality is higher than expected. Results: We identified the most common discharge diagnosis-related group (DRG) codes for ischemic stroke used by our neurovascular service in 2018. We used the Academic Medical Center Hospital: Risk Modeling Summary for 2016 to determine the model group that was relevant for our population. We chose Model group 23 as the highest yield, as that model covers nearly half our volume based upon our frequently used DRG codes. The team used a shared mortality risk factor standard template to improve documentation practices. The Quality Intervention (QI) plan was implemented July 22, 2019 using an interdisciplinary approach. Clinical teams were educated on specific documentation of variables associated with in-hospital mortality. Vizient CDB/RM data on stroke mortality will be reviewed in September 2019 to determine the effect of the QI on mortality O/E ratio for our ischemic stroke population. Conclusions: Our comprehensive stroke program implemented a clinical documentation improvement QI plan to improve Vizient CDB/RM Risk Adjusted Mortality for our ischemic stroke population. We expect that improving appropriate documentation will assist coding specialist to capture the severity of cases, which should improve the mortality O/E ratio.


2002 ◽  
Vol 2 (3) ◽  
pp. 95-104 ◽  
Author(s):  
JoAnn Manson ◽  
Beverly Rockhill ◽  
Margery Resnick ◽  
Eleanor Shore ◽  
Carol Nadelson ◽  
...  

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