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Habib P, Dimitrov I, Pinho J, Schürmann K, Bach JP, Wiesmann M, Schulz JB, Reich A, Nikoubashman O. Point-of-Care Ultrasound to Detect Acute Large Vessel Occlusions in Stroke Patients: A Proof-of-Concept Study. Can J Neurol Sci 2023; 50:656-661. [PMID: 35872570 DOI: 10.1017/cjn.2022.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A primary admission of patients with suspected acute ischemic stroke and large vessel occlusion (LVO) to centers capable of providing endovascular stroke therapy (EVT) may induce shorter time to treatment and better functional outcomes. One of the limitations in this strategy is the need for accurately identifying LVO patients in the prehospital setting. We aimed to study the feasibility and diagnostic performance of point-of-care ultrasound (POCUS) for the detection of LVO in patients with acute stroke. METHODS We conducted a proof-of-concept study and selected 15 acute ischemic stroke patients with angiographically confirmed LVO and 15 patients without LVO. Duplex ultrasonography (DUS) of the common carotid arteries was performed, and flow profiles compatible with LVO were scored independently by one experienced and one junior neurologist. RESULTS Among the 15 patients with LVO, 6 patients presented with an occlusion of the carotid-T and 9 patients presented with an M1 occlusion. Interobserver agreement between the junior and the experienced neurologist was excellent (kappa = 0.813, p < 0.001). Flow profiles of the CAA allowed the detection of LVO with a sensitivity of 73%, a positive predictive value of 92 and 100%, and a c-statistics of 0.83 (95%CI = 0.65-0.94) and 0.87 (95%CI = 0.69-0.94) (experienced neurologist and junior neurologist, respectively). In comparison with clinical stroke scales, DUS was associated with better trade-off between sensitivity and specificity. CONCLUSION POCUS in acute stroke setting is feasible, it may serve as a complementary tool for the detection of LVO and is potentially applicable in the prehospital phase.
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Affiliation(s)
- Pardes Habib
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Ivaylo Dimitrov
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Kolja Schürmann
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Jan Philipp Bach
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
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2
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Equiza J, de la Riva P, Angel Larrea J, Marta-Enguita J, Albájar I, Lüttich A, Garmendia E, Alonso M, de Arce A, Díez N, Gonzalez F, Iruzubieta P, Sulibarria N, Puig J, Martínez-Zabaleta M. Impact on functional outcome of an adaptive Stroke Unit based system of care for patients undergoing endovascular treatment during pandemic times. Eur Stroke J 2022; 7:248-256. [DOI: 10.1177/23969873221098269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: The COVID19 pandemic collapsed intensive care units (ICUs) all around the world, conditioning systems of care (SOC) for other critical conditions such as severe ischemic stroke requiring endovascular treatment (EVT). Our aim was to evaluate the impact of an adaptive Stroke Unit (SU) based SOC on functional outcomes, with the goal of avoiding both general anesthesia (GA) and ICU admission in stroke patients treated with EVT. Material and methods: We performed an observational study comparing data from our traditional ICU-GA based SOC and the adaptive SU-Conscious Sedation (CS) based SOC (consecutive patients undergoing EVT 1 year prior and after onset of the pandemic). Primary outcome was 90-days modified Rankin Scale (mRS), and secondary outcomes included, among others, in-hospital complications, and hospital length of stay (LOS). Results: A total of 210 EVT were performed during the study period (107 under the traditional-SOC and 103 under the adaptive-SOC). A significantly greater proportion of patient was treated under CS (15.9% vs 57.3%; p < 0.001) and admitted for post-procedural care at SU (15% vs 66%; p < 0.001) in the adaptive SOC. Rates of in-hospital complications were similar in both periods, with reduced hospital LOS in the adaptive SOC (10 (7–15) vs 8 (6–12); p = 0.005). The adaptive SOC was associated with higher odds for 90 days favorable outcome (mRS 0–2) (aOR 3.15 (1.34–7.39); p = 0.008). Conclusion: In our case, an adaptive SOC that combined both preference for CS and postprocedural care in SU was associated with better functional outcomes and reduced healthcare resource use for patients undergoing EVT.
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Affiliation(s)
- Jon Equiza
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Patricia de la Riva
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - José Angel Larrea
- Interventional Neuroradiology Section, Department of Radiology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Juan Marta-Enguita
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Inés Albájar
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Alex Lüttich
- Interventional Neuroradiology Section, Department of Radiology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Eñaut Garmendia
- Interventional Neuroradiology Section, Department of Radiology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Maitane Alonso
- Interventional Neuroradiology Section, Department of Radiology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Ana de Arce
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Noemí Díez
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Félix Gonzalez
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Pablo Iruzubieta
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Naroa Sulibarria
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
| | - Josep Puig
- Department of Radiology, Dr. Josep Trueta University Hospital and Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Maite Martínez-Zabaleta
- Stroke Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
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3
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Zhu F, Ben Hassen W, Bricout N, Kerleroux B, Janot K, Gory B, Anxionnat R, Richard S, Marchal A, Blanc R, Piotin M, Consoli A, Trystram D, Rodriguez Regent C, Desilles JP, Weisenburger-Lile D, Escalard S, Herbreteau D, Ifergan H, Lima Maldonado I, Labreuche J, Henon H, Naggara O, Lapergue B, Boulouis G. Effect of Operator's Experience on Proficiency in Mechanical Thrombectomy: A Multicenter Study. Stroke 2021; 52:2736-2742. [PMID: 34233462 DOI: 10.1161/strokeaha.120.031940] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate among trained interventional neuroradiologist, whether increasing individual experience was associated with an improvement in mechanical thrombectomy (MT) procedural performance metrics. METHODS Individual MT procedural data from 5 centers of the Endovascular Treatment in Ischemic Stroke registry and 2 additional high-volume stroke centers were pooled. Operator experience was defined for each operator as a continuous variable, cumulating the number of MT procedures performed since January 2015, as MT became standard of care or, if later than this date, since the operator started performing mechanical thrombectomies in autonomy. We tested the associations between operator's experience and procedural metrics. RESULTS A total of 4516 procedures were included, performed by 36 operators at 7 distinct centers, with a median of 97.5 endovascular treatment procedures per operator (interquartile range, 57-170.2) over the study period. Higher operator's experience, analyzed as a continuous variable, was associated with a significantly shorter procedural duration (β estimate, -3.98 [95% CI, -5.1 to -2.8]; P<0.001), along with local anesthesia and M1 occlusion location in multivariable models. Increasing experience was associated with better Thrombolysis in Cerebral Infarction scores (estimate, 1.02 [1-1.04]; P=0.013). CONCLUSIONS In trained interventional neuroradiologists, increasing experience in MT is associated with significantly shorter procedural duration and better reperfusion rates, with a theoretical ceiling effect observed after around 100 procedures. These results may inform future training and practice guidelines to set minimal experience standards before autonomization, and to set-up operators' recertification processes tailored to individual case volume and prior experience.
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Affiliation(s)
- François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, F-54000, CHRU Nancy and IADI, INSERM U1254, F-54000, Université de Lorraine, Nancy, France (F.Z., B.G., R.A.)
| | - Wagih Ben Hassen
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Nicolas Bricout
- Department of Neuroradiology, CHRU Lille, France (N.B., A.M.)
| | - Basile Kerleroux
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.).,Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | - Kevin Janot
- Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, F-54000, CHRU Nancy and IADI, INSERM U1254, F-54000, Université de Lorraine, Nancy, France (F.Z., B.G., R.A.)
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, F-54000, CHRU Nancy and IADI, INSERM U1254, F-54000, Université de Lorraine, Nancy, France (F.Z., B.G., R.A.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU Nancy and INSERM U1116, F-54000, Université de Lorraine, Nancy, France (S.R.)
| | - Adrien Marchal
- Department of Neuroradiology, CHRU Lille, France (N.B., A.M.)
| | - Raphael Blanc
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | - Michel Piotin
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Suresnes, France (A.C.)
| | - Denis Trystram
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Christine Rodriguez Regent
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Jean-Philippe Desilles
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | | | - Simon Escalard
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | - Denis Herbreteau
- Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | - Heloise Ifergan
- Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | | | - Julien Labreuche
- CHRU Lille, EA 2694, Santé Publique: épidémiologie et Qualité des Soins, Lille, France (J.L.)
| | - Hilde Henon
- Department of Neurology, Stroke Unit, CHRU Lille, Lille, France (H.H.)
| | - Olivier Naggara
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Bertrand Lapergue
- Department of Neurology, Stroke Unit, Foch Hospital, Suresnes, France (D.W.-L., B.L.)
| | - Grégoire Boulouis
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.).,Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
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4
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Stein LK, Mocco J, Fifi J, Jette N, Tuhrim S, Dhamoon MS. Correlations Between Physician and Hospital Stroke Thrombectomy Volumes and Outcomes: A Nationwide Analysis. Stroke 2021; 52:2858-2865. [PMID: 34092122 DOI: 10.1161/strokeaha.120.033312] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Laura K Stein
- Department of Neurology (L.K.S., J.F., N.J., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - J Mocco
- Department of Neurosurgery (J.M., J.F.), Icahn School of Medicine at Mount Sinai, NY
| | - Johanna Fifi
- Department of Neurology (L.K.S., J.F., N.J., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, NY.,Department of Neurosurgery (J.M., J.F.), Icahn School of Medicine at Mount Sinai, NY
| | - Nathalie Jette
- Department of Neurology (L.K.S., J.F., N.J., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, NY.,Department of Population Health Science and Policy (N.J.), Icahn School of Medicine at Mount Sinai, NY
| | - Stanley Tuhrim
- Department of Neurology (L.K.S., J.F., N.J., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Mandip S Dhamoon
- Department of Neurology (L.K.S., J.F., N.J., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
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5
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Stein LK, Tuhrim S, Jette N, Fifi J, Mocco J, Dhamoon MS. Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke. Stroke 2020; 51:3651-3657. [DOI: 10.1161/strokeaha.120.029989] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and Purpose:
Determine the extent of cerebrovascular expertise among the specialties of proceduralists providing endovascular thrombectomy (ET) for emergent large vessel occlusion stroke in the modern era of acute stroke among Medicare beneficiaries
Methods:
Retrospective cohort study using validated
International Classification of Diseases, Tenth Revision
, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ET. We identified proceduralist specialty by linking the National Provider Identifier provided by Medicare to the specialty listed in the National Provider Identifier database, grouping into radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, ET team specialty composition by hospital, and number of proceduralists who performed ET at multiple hospitals.
Results:
Forty-two percent (n=5612) of ET were performed by radiology-background proceduralists, with unclear knowledge of how many were cerebrovascular specialists. Neurosurgery- and neurology-background interventionalists performed fewer but substantial numbers of cases, accounting for 24% (n=3217) and 23% (n=3124) of total cases, respectively. ET teams included a neurology- or neurosurgery-background proceduralist at 65% (n=407) of hospitals that performed ET and included both in 26% (n=160) of teams.
Conclusions:
Almost two-thirds of ET teams nationwide include a neurology- or neurosurgery-background proceduralist and higher volume centers in urban areas were more likely to have neurology- or neurosurgery-background proceduralists with cerebrovascular expertise on their team. It is unclear how many radiology-background interventionalists are cerebrovascular specialists versus generalists. Significant work remains to be done to understand the impact of proceduralist specialty, training, and cerebrovascular expertise on ET outcomes.
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Affiliation(s)
- Laura K. Stein
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Stanley Tuhrim
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Nathalie Jette
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
| | - Johanna Fifi
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
- Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, NY
| | - J Mocco
- Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, NY
| | - Mandip S. Dhamoon
- Department of Neurology (L.K.S., S.T., N.J., J.F., M.S.D.), Icahn School of Medicine at Mount Sinai, NY
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6
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Asaithambi G, Tong X, Lakshminarayan K, Coleman King SM, George MG. Trends in hospital procedure volumes for intra-arterial treatment of acute ischemic stroke: results from the paul coverdell national acute stroke program. J Neurointerv Surg 2020; 12:1076-1079. [PMID: 32169931 DOI: 10.1136/neurintsurg-2020-015844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Rates of intra-arterial revascularization treatments (IAT) for acute ischemic stroke (AIS) are increasing in the USA. Using a multi-state stroke registry, we studied the trend in IAT use among patients with AIS over a period spanning 11 years. We examined the impact of IAT rates on hospital procedure volumes and patient outcome after stroke. METHODS We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) and explored trends in IAT between 2008 and 2018. Patient outcomes were examined by rates of IAT procedures across hospitals. Specifically, outcomes were compared across low-volume (<15 IAT per year), medium-volume (15-30 IAT per year), and high-volume hospitals (>30 IAT per year). Favorable outcome was defined as discharge to home. RESULTS There were 612 958 patients admitted with AIS to 687 participating hospitals within the PCNASP during this study. Only 2.9% of patients (mean age 68.5 years, 49.3% women) received IAT. The percent of patients with AIS receiving IAT increased from 1% in 2008 to 5.3% in 2018 (p<0.001). The proportion of low-volume hospitals decreased over time (p<0.001), and the proportions of medium-volume (p=0.007) and high-volume hospitals (p<0.001) increased between 2008 and 2018. When compared with medium-volume hospitals, high-volume hospitals had a higher (p<0.0001) and low-volume hospitals had a lower (p<0.0001) percent of patients discharged to home. CONCLUSION High-volume hospitals were associated with a higher rate of favorable outcome. With the increased use of IAT among patients with AIS, the proportion of low-volume hospitals performing IAT significantly decreased.
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Affiliation(s)
| | - Xin Tong
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Mary G George
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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7
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Bresette LM. What Is Stroke Certification and Does It Matter? Crit Care Nurs Clin North Am 2019; 32:109-119. [PMID: 32014157 DOI: 10.1016/j.cnc.2019.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Many academic and community hospitals have obtained, or are considering obtaining, stroke center certification. Participation in structured quality improvement programs that also incorporate an objective assessment has been shown to improve outcomes and foster team building. Although obtaining certification can be challenging and costly, it can provide a framework to ensure hospitals deliver high- level, evidence-based stroke care. For the intensive care unit nurse, awareness and participation in the certification programs process is an important part of professional nursing practice.
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Affiliation(s)
- Linda M Bresette
- Comprehensive Stroke Program, Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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8
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Miller JB, Heitsch L, Madsen TE, Oostema J, Reeves M, Zammit CG, Sabagha N, Sozener C, Lewandowski C, Schrock JW. The Extended Treatment Window's Impact on Emergency Systems of Care for Acute Stroke. Acad Emerg Med 2019; 26:744-751. [PMID: 30664306 DOI: 10.1111/acem.13698] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 01/01/2023]
Abstract
The window for acute ischemic stroke treatment was previously limited to 4.5 hours for intravenous tissue plasminogen activator and to 6 hours for thrombectomy. Recent studies using advanced imaging selection expand this window for select patients up to 24 hours from last known well. These studies directly affect emergency stroke management, including prehospital triage and emergency department (ED) management of suspected stroke patients. This narrative review summarizes the data expanding the treatment window for ischemic stroke to 24 hours and discusses these implications on stroke systems of care. It analyzes the implications on prehospital protocols to identify and transfer large-vessel occlusion stroke patients, on issues of distributive justice, and on ED management to provide advanced imaging and access to thrombectomy centers. The creation of high-performing systems of care to manage acute ischemic stroke patients requires academic emergency physician leadership attentive to the rapidly changing science of stroke care.
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Affiliation(s)
- Joseph B. Miller
- Department of Emergency Medicine Henry Ford Hospital Detroit MI
- Wayne State University Detroit MI
| | - Laura Heitsch
- Department of Emergency Medicine Washington University School of Medicine St. Louis MO
| | - Tracy E. Madsen
- Department of Emergency Medicine Brown University School of Medicine Providence RI
| | - John Oostema
- Department of Emergency Medicine Michigan State University College of Human Medicine East Lansing MI
| | - Mat Reeves
- Department of Epidemiology and Biostatistics Michigan State University College of Human Medicine East LansingMI
| | - Christopher G. Zammit
- Departments of Emergency Medicine, Neurology, and Neurosurgery University of Rochester Medical Center Rochester NY
| | - Noor Sabagha
- Department of Emergency Medicine Henry Ford Hospital Detroit MI
| | - Cemal Sozener
- Department of Emergency Medicine University of Michigan Ann Arbor MI
| | - Christopher Lewandowski
- Department of Emergency Medicine Henry Ford Hospital Detroit MI
- Wayne State University Detroit MI
| | - Jon W. Schrock
- Department of Emergency Medicine MetroHealth Medical Center Case Western Reserve University Cleveland OH
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9
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Linfante I, Nogueira RG, Zaidat OO, Arthur AS, Klucznik RP, Mack WJ, Welch BG, Siddiqui AH, Mocco J. A joint statement from the Neurointerventional Societies: our position on operator experience and training for stroke thrombectomy. J Neurointerv Surg 2019; 11:533-534. [DOI: 10.1136/neurintsurg-2019-015047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 11/03/2022]
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10
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Kim BM, Baek JH, Heo JH, Kim DJ, Nam HS, Kim YD. Effect of Cumulative Case Volume on Procedural and Clinical Outcomes in Endovascular Thrombectomy. Stroke 2019; 50:1178-1183. [DOI: 10.1161/strokeaha.119.024986] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Byung Moon Kim
- From the Interventional Neuroradiology, Severance Stroke Center, Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea (B.M.K., D.J.K.)
| | - Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.-H.B.)
| | - Ji Hoe Heo
- Department of Neurology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, South Korea (J.H.H., H.S.N., Y.D.K.)
| | - Dong Joon Kim
- From the Interventional Neuroradiology, Severance Stroke Center, Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea (B.M.K., D.J.K.)
| | - Hyo Suk Nam
- Department of Neurology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, South Korea (J.H.H., H.S.N., Y.D.K.)
| | - Young Dae Kim
- Department of Neurology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, South Korea (J.H.H., H.S.N., Y.D.K.)
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11
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Arthur AS, Mocco J, Linfante I, Fiorella D, Hussain MS, Jovin TG, Nogueira R, Schirmer C, Barr JD, Meyers PM, De Leacy R, Albuquerque FC. Stroke patients can’t ask for a second opinion: a multi-specialty response to The Joint Commission’s recent suspension of individual stroke surgeon training and volume standards. J Neurointerv Surg 2018; 10:1127-1129. [DOI: 10.1136/neurintsurg-2018-014536] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2018] [Indexed: 11/04/2022]
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12
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Mack WJ, Mocco J, Hirsch JA, Chen M, Elijovich L, Tarr RW, Albuquerque FC. Thrombectomy stroke centers: The current threat to regionalizing stroke care. J Neurointerv Surg 2018; 10:99-101. [DOI: 10.1136/neurintsurg-2017-013721] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/04/2022]
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13
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Blacker DJ. Penumbral freeze: travel distance and delays provide an opportunity to study prerecanalization therapy neuroprotection. FUTURE NEUROLOGY 2017. [DOI: 10.2217/fnl-2017-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- David J Blacker
- Department of Neurology, Charles Gairdner Hospital & The Perron Institute for neurological & translational science, Nedlands, Australia
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14
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Shkirkova K, Akam EY, Huang J, Sheth SA, Nour M, Liang CW, McManus M, Trinh V, Duckwiler G, Tarpley J, Vinuela F, Saver JL. Feasibility and utility of an integrated medical imaging and informatics smartphone system for management of acute stroke. Int J Stroke 2017; 12:953-960. [DOI: 10.1177/1747493017694386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Rapid dissemination and coordination of clinical and imaging data among multidisciplinary team members are essential for optimal acute stroke care. Aim To characterize the feasibility and utility of the Synapse Emergency Room mobile (Synapse ERm) informatics system. Methods We implemented the Synapse ERm system for integration of clinical data, computerized tomography, magnetic resonance, and catheter angiographic imaging, and real-time stroke team communications, in consecutive acute neurovascular patients at a Comprehensive Stroke Center. Results From May 2014 to October 2014, the Synapse ERm application was used by 33 stroke team members in 84 Code Stroke alerts. Patient age was 69.6 (±17.1), with 41.5% female. Final diagnosis was: ischemic stroke 64.6%, transient ischemic attack 7.3%, intracerebral hemorrhage 6.1%, and cerebrovascular-mimic 22.0%. Each patient Synapse ERm record was viewed by a median of 10 (interquartile range 6–18) times by a median of 3 (interquartile range 2–4) team members. The most used feature was computerized tomography, magnetic resonance, and catheter angiography image display. In-app tweet team, communications were sent by median 1 (interquartile range 0–1, range 0–13) users per case and viewed by median 1 (interquartile range 0–3, range 0–44) team members. Use of the system was associated with rapid treatment times, faster than national guidelines, including median door-to-needle 51.0 min (interquartile range 40.5–69.5) and median door-to-groin 94.5 min (interquartile range 85.5–121.3). In user surveys, the mobile information platform was judged easy to employ in 91% (95% confidence interval 65%–99%) of uses and of added help in stroke management in 50% (95% confidence interval 22%–78%). Conclusion The Synapse ERm mobile platform for stroke team distribution and integration of clinical and imaging data was feasible to implement, showed high ease of use, and moderate perceived added utility in therapeutic management.
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Affiliation(s)
- Kristina Shkirkova
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | | | - Josephine Huang
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Sunil A Sheth
- Department of Neurology and Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - May Nour
- Department of Neurology and Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Conrad W Liang
- Department of Neurology and Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Michael McManus
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Van Trinh
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Gary Duckwiler
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jason Tarpley
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Fernando Vinuela
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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15
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Holodinsky JK, Yu AYX, Assis ZA, Al Sultan AS, Menon BK, Demchuk AM, Goyal M, Hill MD. History, Evolution, and Importance of Emergency Endovascular Treatment of Acute Ischemic Stroke. Curr Neurol Neurosci Rep 2016; 16:42. [PMID: 27021771 DOI: 10.1007/s11910-016-0646-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
More than 800,000 people in North America suffer a stroke each year, with ischemic stroke making up the majority of these cases. The outcomes of ischemic stroke range from complete functional and cognitive recovery to severe disability and death; outcome is strongly associated with timely reperfusion treatment. Historically, ischemic stroke has been treated with intravenous thrombolytic agents with moderate success. However, five recently published positive trials have established the efficacy of endovascular treatment in acute ischemic stroke. In this review, we will discuss the history of stroke treatments moving from various intravenous thrombolytic drugs to intra-arterial thrombolysis, early mechanical thrombectomy devices, and finally modern endovascular devices. Early endovascular therapy failures, recent successes, and implications for current ischemic stroke management and future research directions are discussed.
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Affiliation(s)
- Jessalyn K Holodinsky
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
| | - Amy Y X Yu
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zarina A Assis
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abdulaziz S Al Sultan
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Community Health Sciences, Cumming School of Medicine, Health Sciences Centre, University of Calgary, HBA 2935D, 3300 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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16
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The Impact of Transferring Stroke Patients: An Analysis of National Administrative Data. Can J Neurol Sci 2016; 43:760-764. [PMID: 27619350 DOI: 10.1017/cjn.2016.285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Interhospital transfer is an important but resource-intensive pattern of care. The use for stroke patients is highly dependent upon health system structure. We examined the impact of hospital transfers for stroke care in Canada. METHODS We analyzed hospital administrative data within the Canadian Institute for Health Information (CIHI) Database for the 3 fiscal years 2011/12, 2012/13 and 2013/14. Patients with clinical stroke syndrome (ischemic or hemorrhagic) were identified using International Classification of Diseases. Stroke centers were defined by Heart & Stroke Foundation of Canada stroke report. RESULTS During the 3-year period,397 patients in Canada (excluding Quebec) were admitted to hospital for clinical stroke syndrome. Median age was 75 (interquartile range [IQR] 64-84) years; 50.6 % were male. Less than 5% (n=4030) of patients were transferred. Patients transferred to stroke centers were younger (p<0.001) and had shorter median length of stay (p<0.001). The highest probability of discharge home was associated with sole care at stroke center (43.8%). Transfer to stroke center from community hospital had the highest probability for discharge to rehabilitation facility (25%) and lowest to either long-term (2.1%) or complex community care (2.0%). Transferred patients had lower mortality at discharge. CONCLUSION Younger patients were transferred more frequently to stroke centers; older patients were more likely treated in community hospitals. Sole stroke center care was associated with high discharge rate to home; transfer to a stroke center was associated with high discharge rate to rehabilitation and lower mortality rates.
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17
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Blacker DJ. The future of stroke is small. FUTURE NEUROLOGY 2016. [DOI: 10.2217/fnl-2016-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- David J Blacker
- The Western Australian Neuroscience Research Institute, Nedlands, Australia
- Sir Charles Gairdner Hospital, Nedlands, Australia
- University of Western Australia, Crawley, Australia
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18
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Appireddy R, Zerna C, Menon BK, Goyal M. Endovascular Interventions in Acute Ischemic Stroke: Recent Evidence, Current Challenges, and Future Prospects. Curr Atheroscler Rep 2016; 18:40. [DOI: 10.1007/s11883-016-0588-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Affiliation(s)
- Bruce C V Campbell
- From the Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Parkville, Victoria, Australia.
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20
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Chiu AH, Phillips TJ, Phatouros CC, Singh TP, Hankey GJ, Blacker DJ, McAuliffe W. CT perfusion in acute stroke calls: A pictorial review and differential diagnoses. J Med Imaging Radiat Oncol 2015; 60:165-71. [DOI: 10.1111/1754-9485.12422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 10/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Albert H Chiu
- Neurological Intervention and Imaging Service of WA (NIISwa); Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Timothy J Phillips
- Neurological Intervention and Imaging Service of WA (NIISwa); Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Constantine C Phatouros
- Neurological Intervention and Imaging Service of WA (NIISwa); Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Tejinder P Singh
- Neurological Intervention and Imaging Service of WA (NIISwa); Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Graeme J Hankey
- Department of Neurology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; The University of Western Australia; Crawley Western Australia Australia
| | - David J Blacker
- Department of Neurology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- Western Australian Neuroscience Research Institute; Nedlands Western Australia Australia
| | - William McAuliffe
- Neurological Intervention and Imaging Service of WA (NIISwa); Sir Charles Gairdner Hospital; Perth Western Australia Australia
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21
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Balami JS, Sutherland BA, Edmunds LD, Grunwald IQ, Neuhaus AA, Hadley G, Karbalai H, Metcalf KA, DeLuca GC, Buchan AM. A systematic review and meta-analysis of randomized controlled trials of endovascular thrombectomy compared with best medical treatment for acute ischemic stroke. Int J Stroke 2015; 10:1168-78. [PMID: 26310289 PMCID: PMC5102634 DOI: 10.1111/ijs.12618] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/13/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Acute ischemic strokes involving occlusion of large vessels usually recanalize poorly following treatment with intravenous thrombolysis. Recent studies have shown higher recanalization and higher good outcome rates with endovascular therapy compared with best medical management alone. A systematic review and meta-analysis investigating the benefits of all randomized controlled trials of endovascular thrombectomy where at least 25% of patients were treated with a thrombectomy device for the treatment of acute ischemic stroke compared with best medical treatment have yet to be performed. AIM To perform a systematic review and a meta-analysis evaluating the effectiveness of endovascular thrombectomy compared with best medical care for treatment of acute ischemic stroke. SUMMARY OF REVIEW Our search identified 437 publications, from which eight studies (totaling 2423 patients) matched the inclusion criteria. Overall, endovascular thrombectomy was associated with improved functional outcomes (modified Rankin Scale 0-2) [odds ratio 1·56 (1·32-1·85), P < 0·00001]. There was a tendency toward decreased mortality [odds ratio 0·84 (0·67-1·05), P = 0·12], and symptomatic intracerebral hemorrhage was not increased [odds ratio 1·03 (0·71-1·49), P = 0·88] compared with best medical management alone. The odds ratio for a favorable functional outcome increased to 2·23 (1·77-2·81, P < 0·00001) when newer generation thrombectomy devices were used in greater than 50% of the cases in each trial. CONCLUSIONS There is clear evidence for improvement in functional independence with endovascular thrombectomy compared with standard medical care, suggesting that endovascular thrombectomy should be considered the standard effective treatment alongside thombolysis in eligible patients.
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Affiliation(s)
- Joyce S. Balami
- Centre for Evidence Based MedicineUniversity of OxfordOxfordUK
- Norfolk and Norwich University Teaching Hospital NHS TrustNorwichUK
| | - Brad A. Sutherland
- Acute Stroke ProgrammeRadcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Laurel D. Edmunds
- Acute Stroke ProgrammeRadcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Iris Q. Grunwald
- NeuroscienceFaculty of Medical SciencePost Graduate Medical InstituteAnglia Ruskin UniversityChelmsfordUK
- Southend University Hospital NHS Foundation TrustSouthend‐on‐SeaUK
- CardioVascular Center Frankfurt (CVC Frankfurt)FrankfurtGermany
| | - Ain A. Neuhaus
- Acute Stroke ProgrammeRadcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Gina Hadley
- Acute Stroke ProgrammeRadcliffe Department of MedicineUniversity of OxfordOxfordUK
| | | | | | - Gabriele C. DeLuca
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Alastair M. Buchan
- Acute Stroke ProgrammeRadcliffe Department of MedicineUniversity of OxfordOxfordUK
- Medical Sciences DivisionUniversity of OxfordOxfordUK
- Acute Vascular Imaging CentreUniversity of OxfordOxfordUK
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