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Atchie B, Jarvis S, Bellon R, Barton T, Disalvo L, Salottolo K, Bar-Or R, Bar-Or D. Oxidation‑reduction potential parameters worsen following intraarterial therapy in patients with reduced collateral circulation and middle cerebral artery occlusions. Exp Ther Med 2023; 25:295. [PMID: 37229324 PMCID: PMC10203750 DOI: 10.3892/etm.2023.11994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 03/24/2023] [Indexed: 05/27/2023] Open
Abstract
Collateral circulation is important for cerebral perfusion in acute ischemic strokes. Monitoring the oxidation-reduction potential (ORP) may be useful to assess collateral status or treatment efficacy. The objectives of the present study were to determine if the ORP was associated with collateral circulation status in middle cerebral artery (MCA) occlusions and to identify patterns in the ORP and the collateral circulation status among patients treated with intraarterial therapy (IAT) over time. The present pilot study was nested within a prospective cohort study measuring the ORP of the peripheral venous plasma of stroke patients. The population included in the present study were patients with MCA (M1/M2) occlusions. Two ORP parameters were examined: Static ORP (sORP; mV), indicating oxidative stress, and capacity ORP (cORP; µC), indicating antioxidant reserves. Collateral status was retrospectively graded using Miteff's system as good (grade 1) or reduced (grade 2/3). Comparisons were made between collateral status groups (reduced vs. good collaterals) in all patients, within a subset including only patients who received IAT, and between thrombolysis in cerebral infraction scale score (TICI) groups (0-2a vs. 2b/3). The Fisher's exact test, Student's t-test and Wilcoxon tests were used (α<0.20). The 19 patients were categorized based on their collaterals: Good collaterals (53%) and reduced collaterals (47%). The baseline characteristics were similar with the exception that the patients with good collaterals had a lower international normalized ratio (P=0.12) and were more likely to have a stroke on the left side (P=0.18) or to have a mismatch (P=0.05). The admission sORP values were comparable (169.5 vs. 164.2 mV; P=0.65), as was admission cORP (P=0.73). When considering only the patients who received IAT (n=12), admission sORP (P=0.69) and cORP (P=0.90) were also statistically similar. On day 2, after IAT, both groups experienced a worsening in ORP measures; however, the patients with good collaterals had a significantly lower sORP (169.4 vs. 203.5 mV; P=0.02) and a higher cORP (0.2 vs. 0.1 µC; P=0.002) compared with the patients with reduced collaterals. Neither sORP nor cORP were significantly different between TICI score groups on admission or on day 2. Upon discharge, patients with a TICI of 2b-3 had a significantly better sORP (P=0.03) and cORP (P=0.12) compared with those with a TICI of 0-2a. In conclusion, upon patient admission, the ORP parameters were not significantly different between the collateral circulation status groups for MCA occlusions. The ORP parameters worsened after IAT regardless of the collateral circulation status; however, after IAT, on day 2, patients with good collaterals experienced less oxidative stress (sORP) and had higher antioxidant reserves (cORP) than patients with reduced collaterals.
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Affiliation(s)
- Benjamin Atchie
- Department of Neuroradiology, Swedish Medical Center, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
- Department of Neurointerventional Surgery, Radiology Imaging Associates, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - Stephanie Jarvis
- Department of Epidemiology, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - Richard Bellon
- Department of Neuroradiology, Swedish Medical Center, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
- Department of Neurointerventional Surgery, Radiology Imaging Associates, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - Trevor Barton
- Department of Neurology, Swedish Medical Center, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - Lauren Disalvo
- Department of Neurology, Swedish Medical Center, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - Kristin Salottolo
- Department of Epidemiology, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - Raphael Bar-Or
- Department of Basic Science, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
| | - David Bar-Or
- Department of Directors, Injury Outcomes Network (ION) Research, Englewood, CO 80113, USA
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Boltyenkov AT, Martinez G, Pandya A, Katz JM, Wang JJ, Naidich JJ, Rula E, Sanelli PC. Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care. Front Neurol 2021; 12:774657. [PMID: 34899583 PMCID: PMC8662622 DOI: 10.3389/fneur.2021.774657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/02/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC). Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure. Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%. Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.
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Affiliation(s)
- Artem T Boltyenkov
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Gabriela Martinez
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Ankur Pandya
- Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA, United States
| | - Jeffrey M Katz
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States.,Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Jason J Wang
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States
| | - Jason J Naidich
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Elizabeth Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA, United States
| | - Pina C Sanelli
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
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Stefanou MI, Stadler V, Baku D, Hennersdorf F, Ernemann U, Ziemann U, Poli S, Mengel A. Optimizing Patient Selection for Interhospital Transfer and Endovascular Therapy in Acute Ischemic Stroke: Real-World Data From a Supraregional, Hub-and-Spoke Neurovascular Network in Germany. Front Neurol 2020; 11:600917. [PMID: 33343500 PMCID: PMC7746873 DOI: 10.3389/fneur.2020.600917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/10/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Interhospital transfer for endovascular treatment (EVT) within neurovascular networks might result in transfer of patients who will not undergo EVT (futile transfer). Limited evidence exists on factors associated with the primary patient selection for interhospital transfer from primary stroke centers (PSCs) to comprehensive stroke centers (CSCs), or EVT-workflow parameters that may render a transfer futile. Methods: A prospective, registry-based study was performed between July 1, 2017 and June 30, 2018, at a hub-and-spoke neurovascular network in southwest Germany, comprising 12 referring PSCs and one designated CSC providing round-the-clock EVT at the University Hospital Tübingen. Patients with acute ischemic stroke due to suspected large artery occlusion (LAO) were included upon emergency interhospital transfer inquiry (ITI). Results: ITI was made for 154 patients, 91 (59%) of whom were transferred to the CSC. Non-transferred patients (41%) had significantly higher premorbid modified Rankin scale scores (mRS) compared to transferred patients [median (IQR): 2 (1–3) vs. 0 (0–1), p < 0.001]. Interhospital transfer was denied due to: distal vessel occlusion (44.4%), or non-verifiable LAO (33.3%) in computed tomography angiography (CTA) upon teleconsultation by CSC neuroradiologists; limited Stroke-Unit or ventilation capacity (9.5%), or limited neuroradiological capacity at the CSC (12.7%). The CT-to-ITI interval was significantly longer in patients denied interhospital transfer [median (IQR): 43 (29–56) min] compared to transferred patients [29 (15–55), p = 0.029]. No further differences in EVT-workflow, and no differences in the 3-month mRS outcomes were noted between non-transferred and transferred patients [median (IQR): 2 (0–5) vs. 3 (1–4), p = 0.189]. After transfer to the CSC, 44 (48%) patients underwent EVT. The Alberta stroke program early CT score [ORadj (95% CI): 1.786 (1.573–2.028), p < 0.001] and the CT-to-ITI interval [0.994 (0.991–0.998), p = 0.001] were significant predictors of the likelihood of EVT performance. Conclusion: Our findings show that hub-and-spoke neurovascular network infrastructures efficiently enable access to EVT to patients with AIS due to LAO, who are primarily admitted to PSCs without on-site EVT availability. As in real-world settings optimal allocation of EVT resources is warranted, teleconsultation by experienced endovascular interventionists and prompt interhospital-transfer-inquiries are crucial to reduce the futile transfer rates and optimize patient selection for EVT within neurovascular networks.
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Affiliation(s)
- Maria-Ioanna Stefanou
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Vera Stadler
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Dominik Baku
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Florian Hennersdorf
- Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany.,Department of Diagnostic & Interventional Neuroradiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany.,Department of Diagnostic & Interventional Neuroradiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Centre for Neurovascular Diseases Tübingen, ZNET: Zentrum für neurovaskuläre Erkrankungen Tübingen, Tübingen, Germany
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Abstract
Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.
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Affiliation(s)
- Robert Hurford
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Alakendu Sekhar
- Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Tom A T Hughes
- Department of Neurology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
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Huang Q, Zhang JZ, Xu WD, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore) 2018; 97:e11205. [PMID: 29924046 PMCID: PMC6024468 DOI: 10.1097/md.0000000000011205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jing-ze Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Wen-deng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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El-Tawil S, Wardlaw J, Ford I, Mair G, Robinson T, Kalra L, Muir KW. Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol. Int J Stroke 2017; 12:671-678. [PMID: 28730951 DOI: 10.1177/1747493017696099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.
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Affiliation(s)
- Salwa El-Tawil
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Joanna Wardlaw
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Ian Ford
- 3 Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Grant Mair
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Tom Robinson
- 4 Department of Cardiovascular Sciences, Ageing and Stroke Medicine Group, University of Leicester, Leicester, UK
| | - Lalit Kalra
- 5 Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Keith W Muir
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
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Vagal A, Foster LD, Menon B, Livorine A, Shi J, Qazi E, Yeatts SD, Demchuk AM, Hill MD, Tomsick TA, Goyal M. Multimodal CT Imaging: Time to Treatment and Outcomes in the IMS III Trial. AJNR Am J Neuroradiol 2016; 37:1393-8. [PMID: 26988811 DOI: 10.3174/ajnr.a4751] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The importance of time in acute stroke is well-established. Using the Interventional Management of Stroke III trial data, we explored the effect of multimodal imaging (CT perfusion and/or CT angiography) versus noncontrast CT alone on time to treatment and outcomes. MATERIALS AND METHODS We examined 3 groups: 1) subjects with baseline CTP and CTA (CTP+CTA), 2) subjects with baseline CTA without CTP (CTA), and 3) subjects with noncontrast head CT alone. The demographics, treatment time intervals, and clinical outcomes in these groups were studied. RESULTS Of 656 subjects enrolled in the Interventional Management of Stroke III trial, 90 (13.7%) received CTP and CTA, 216 (32.9%) received CTA (without CTP), and 342 (52.1%) received NCCT alone. Median times for the CTP+CTA, CTA, and NCCT groups were as follows: stroke onset to IV tPA (120.5 versus 117.5 versus 120 minutes; P = .5762), IV tPA to groin puncture (77.5 versus 81 versus 91 minutes; P = .0043), groin puncture to endovascular therapy start (30 versus 38 versus 44 minutes; P = .0001), and endovascular therapy start to end (63 versus 46 versus 74 minutes; P < .0001). Compared with NCCT, the CTA group had better outcomes in the endovascular arm (OR, 2.12; 95% CI, 1.36-3.31; adjusted for age, NIHSS score, and time from onset to IV tPA). The CTP+CTA group did not have better outcomes compared with the NCCT group. CONCLUSIONS Use of CTA with or without CTP did not delay IV tPA or endovascular therapy compared with NCCT in the Interventional Management of Stroke III trial.
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Affiliation(s)
- A Vagal
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - L D Foster
- Department of Public Health Sciences (L.D.F., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - B Menon
- Radiology (B.M, E.Q., M.G.), University of Calgary, Calgary Alberta, Canada
| | - A Livorine
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - J Shi
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - E Qazi
- Radiology (B.M, E.Q., M.G.), University of Calgary, Calgary Alberta, Canada
| | - S D Yeatts
- Department of Public Health Sciences (L.D.F., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | | | - M D Hill
- Departments of Neurology (A.M.D., M.D.H.)
| | - T A Tomsick
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - M Goyal
- Radiology (B.M, E.Q., M.G.), University of Calgary, Calgary Alberta, Canada
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Glober NK, Sporer KA, Guluma KZ, Serra JP, Barger JA, Brown JF, Gilbert GH, Koenig KL, Rudnick EM, Salvucci AA. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2016; 17:104-28. [PMID: 26973735 PMCID: PMC4786229 DOI: 10.5811/westjem.2015.12.28995] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Nancy K Glober
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kama Z Guluma
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - John P Serra
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Joe A Barger
- EMS Medical Directors Association of California, California
| | - John F Brown
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California, California; Stanford University, Department of Emergency Medicine, Stanford, California
| | - Kristi L Koenig
- EMS Medical Directors Association of California, California; University of California Irvine, Center for Disaster Medical Sciences, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California, California
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11
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The emerging age of endovascular treatment of acute ischaemic stroke and the role of CT angiography in patient work-up: a guide for the radiologist. Clin Radiol 2015; 71:2-8. [PMID: 26549867 DOI: 10.1016/j.crad.2015.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/26/2015] [Accepted: 09/30/2015] [Indexed: 11/21/2022]
Abstract
Recent trial evidence suggests that for patients suffering large-vessel occlusive stroke, endovascular therapy based on the stent-retriever technique is associated with superior clinical outcomes when compared to intravenous thrombolysis alone. The challenge now is how this service is to be delivered. This may involve both centralisation of services around large cities and development of robust networks to receive patients from district general hospitals situated further afield. Both diagnostic and interventional neuroradiology will need to expand. Furthermore, we suggest that it would be advantageous for radiology departments in those hospitals receiving hyperacute stroke patients to perform computed tomography (CT) angiography in addition to non-contrast CT, which also has implications for service delivery in these units. This could swiftly aid identification of patients who might benefit from thrombectomy and improve decision-making through demonstration of occlusive thrombus and of collateral status.
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12
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Jeromel M, Miloševicˇ Z, Zaletel M, Žvan B, Švigelj V, Oblak JP. Endovascular Therapy for Acute Stroke Is a Safe and Efficient Evolving Method: A Single-Center Retrospective Analysis. J Vasc Interv Radiol 2015; 26:1025-30. [DOI: 10.1016/j.jvir.2015.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022] Open
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13
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Morgan CD, Stephens M, Zuckerman SL, Waitara MS, Morone PJ, Dewan MC, Mocco J. Physiologic imaging in acute stroke: Patient selection. Interv Neuroradiol 2015; 21:499-510. [PMID: 26063695 DOI: 10.1177/1591019915587227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Treatment of acute stroke is changing, as endovascular intervention becomes an important adjunct to tissue plasminogen activator. An increasing number of sophisticated physiologic imaging techniques have unique advantages and applications in the evaluation, diagnosis, and treatment-decision making of acute ischemic stroke. In this review, we first highlight the strengths, weaknesses, and possible indications for various stroke imaging techniques. How acute imaging findings in each modality have been used to predict functional outcome is discussed. Furthermore, there is an increasing emphasis on using these state-of-the-art imaging modalities to offer maximal patient benefit through IV therapy, endovascular thrombolytics, and clot retrieval. We review the burgeoning literature in the determination of stroke treatment based on acute, physiologic imaging findings.
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Affiliation(s)
- Clinton D Morgan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mouth Sinai, USA
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14
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Pastor AG, Otero FD, Navarro SG, Cuello JP, García PS, Arratibel AG, Mohedano AMI, Alen PV, Bullido YF, Osorio JAV, Nuñez AG. Vascular Imaging Before Intravenous Thrombolysis: Consequences of In-Hospital Delay in Applying Two Diagnostic Procedures. J Neuroimaging 2014; 25:397-402. [DOI: 10.1111/jon.12148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 03/14/2014] [Accepted: 04/26/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Andrés García Pastor
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Fernando Díaz Otero
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Silvia Gil Navarro
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Juan Pablo Cuello
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Pilar Sobrino García
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Amaia García Arratibel
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | | | - Pilar Vázquez Alen
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | | | | | - Antonio Gil Nuñez
- Stroke Unit, Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
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15
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Eichel R, Cohen JE, Gomori JM, Ben-Hur T, Keigler G, Leker RR. Is vascular imaging valuable prior to administration of intravenous tissue plasminogen activator? J Clin Neurosci 2014; 21:1691-4. [PMID: 24874695 DOI: 10.1016/j.jocn.2014.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/22/2014] [Accepted: 01/28/2014] [Indexed: 11/28/2022]
Abstract
Our goals were to explore whether performing computerized tomography angiography (CTA) prior to administration of tissue plasminogen activator (tPA) delays treatment and impacts outcome in patients with proximal middle cerebral artery occlusions (pMCAO). Patients with pMCAO with a National Institutes of Health Stroke scale (NIHSS) score >10 were identified from a prospective Stroke Registry. Patients underwent multi-parametric imaging studies whenever possible. Patients who underwent CTA were compared to those who only had non-contrast CT scan. Disability was measured with the modified Rankin Scale. Logistic regression was used to determine outcome modifiers. We included 73 patients (median age 73 years, 52% men) with moderate-severe stroke (median admission NIHSS 14). Of those, 44 underwent CTA and 29 did not. There were no differences between the groups in risk factor profile or baseline characteristics including stroke severity and door to needle, door to imaging or imaging to treatment times. At 90 days post-stroke there were no statistically significant differences in outcomes between the groups. On multivariate analysis, performing CTA had no impact on the chance of obtaining favorable outcome. In conclusion, CTA does not have a major impact on outcome in patients with pMCAO treated with tPA. Therefore, performing CTA should be considered on an individual basis prior to administration of tPA.
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Affiliation(s)
- Roni Eichel
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - John M Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tamir Ben-Hur
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel
| | - Galina Keigler
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.
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16
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Bracco S, Tassi R, Gennari P, Grazzini I, Leonini S, D'Andrea P, Martini G, Cerase A. Wake-up (or wake-up for) stroke: a treatable stroke. Neuroradiol J 2013; 26:573-8. [PMID: 24199818 DOI: 10.1177/197140091302600511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 08/28/2013] [Indexed: 11/16/2022] Open
Abstract
A 74-year-old man was admitted to the Emergency Room of our institution with worsening dysarthria, left-side weakness and hypoesthesia (NIHSS score: 5) since his awakening at 7:30 a.m. The evening before, he had gone to sleep at 10:30 p.m. Brain computed tomography (CT) and cervicocranial CT angiography showed low density attenuation of the right caudate nucleus head and lenticular nucleus and sub-total occlusion of ipsilateral middle cerebral artery (MCA) pre-bi/trifurcation M1 segment. Brain CT perfusion showed an ischemic core in the right striatal region, surrounded by a wide region of ischemic penumbra. Although the onset of symptoms, defined as "time last-seen well", was 14 hours before presentation, the following worsening of neurological conditions (NIHSS score: 12) and the evidence of cerebral blood flow / cerebral blood volume mismatch at CT perfusion led us to propose neuroendovascular treatment on the basis of an off-label use. Neuroendovascular treatment by Penumbra system was achieved and the right MCA was only partially recanalized. The patient was discharged with NIHSS score of 12. At six months, modified Rankin scale score was 3. To the best of our knowledge, this is the first Italian case report describing a patient who underwent successful neuroendovascular treatment for a "wake-up stroke" without clinical worsening nor major complications and an acceptable clinical outcome. This was possible thanks to an extension of the therapeutic window guided by CT perfusion.
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Affiliation(s)
- Sandra Bracco
- Unit NINT Neuroimaging and Neurointervention, Department of Neurological and Sensorineural Sciences, Siena Hospital Trust, "Santa Maria alle Scotte Hospital"; Siena, Italy - -
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17
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Asif KS, Lazzaro MA, Zaidat O. Identifying delays to mechanical thrombectomy for acute stroke: onset to door and door to clot times. J Neurointerv Surg 2013; 6:505-10. [DOI: 10.1136/neurintsurg-2013-010792] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Sacks D, Connors J(B, Black CM. Society of Interventional Radiology Position Statement on Endovascular Acute Ischemic Stroke Interventions. J Vasc Interv Radiol 2013; 24:1263-6. [DOI: 10.1016/j.jvir.2013.05.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022] Open
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19
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Menon BK, Demchuk AM. Computed Tomography Angiography in the Assessment of Patients With Stroke/TIA. Neurohospitalist 2013; 1:187-99. [PMID: 23983855 DOI: 10.1177/1941874411418523] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Rapid advance in medical technology has resulted in the availability of numerous tests and treatment strategies in the management of acute stroke. The increasingly evidence-based context of clinical medicine necessitates that clinicians use only appropriate tools to facilitate the diagnostic process and patient management. In this review, we seek to explore the use of computed tomography angiography (CTA) in the diagnosis and management of patients presenting with acute stroke (ischemic and hemorrhagic) or transient ischemic attack (TIA). We present evidence in favor of the use of CTA, highlight the disadvantages of this imaging modality, and present a heuristic model based on our experience at utilizing CTA for decision making in acute stroke and TIAs.
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Affiliation(s)
- Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary Stroke Program, Calgary, Canada
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20
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Johnson JM, Reed MS, Burbank HN, Filippi CG. Quality of extracranial carotid evaluation with 256-section CT. AJNR Am J Neuroradiol 2013; 34:1626-31. [PMID: 23471025 DOI: 10.3174/ajnr.a3433] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE To date, no systematic evaluation of image quality has been performed on the 256-section multidetector CT scanner for extracranial carotid evaluations. We evaluated image quality, patient dose, and examination time and compared these parameters with a 64-section multidetector CT. MATERIALS AND METHODS We reviewed extracranial CTA scans obtained on a 256-detector CT scanner in 50 consecutive patients. Image quality was analyzed for artifacts and vessel contrast opacification from the aortic arch to the skull base, dose to patient, and scan time. Results were compared with a control group of 50 patients imaged on a 64-section CT scanner. A Fisher exact test was used to analyze both groups with respect to vessel contrast opacification and presence of artifacts, and a Student t test was used to assess differences in patient dose between the 2 groups. RESULTS Quantitative and qualitative evaluations revealed >95% acceptable vessel opacification at all levels measured on the 256-section scanner. Scan time was improved (4 seconds on 256-channel). There were fewer artifacts related to metallic streak on the 256-channel CTA study, and DLP was lower on the 256-channel CTA (113.9 versus 159.8 mGy). CONCLUSIONS The 256-channel CTA imaging protocol for carotid arteries yielded similar vessel contrast opacification compared with the 64-channel CTA but with fewer metallic artifacts, a modest decrease in scan time, similar image quality, and a statistically significant reduction in radiation dose of 10%.
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Affiliation(s)
- J M Johnson
- Section of Neuroradiology, Department of Radiology, Fletcher Allen Health Care, Burlington, VT, USA.
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21
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Affiliation(s)
- Howard A Rowley
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792-3252, USA.
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22
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Kamalian S, Kamalian S, Pomerantz SR, Tanpitukpongse TP, Gupta R, Romero JM, Katz DS. Role of cardiac and extracranial vascular CT in the evaluation/management of cerebral ischemia and stroke. Emerg Radiol 2013; 20:417-28. [DOI: 10.1007/s10140-013-1116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 03/03/2013] [Indexed: 01/09/2023]
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23
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Mortimer AM, Simpson E, Bradley MD, Renowden SA. Computed tomography angiography in hyperacute ischemic stroke: prognostic implications and role in decision-making. Stroke 2013; 44:1480-8. [PMID: 23493735 DOI: 10.1161/strokeaha.111.679522] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alex M Mortimer
- Department of Neuroradiology, Frenchay Hospital, Frenchay Park Rd, Bristol, BS161LE, United Kingdom.
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24
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Goyal M, Menon BK, Derdeyn CP. Perfusion Imaging in Acute Ischemic Stroke: Let Us Improve the Science before Changing Clinical Practice. Radiology 2013; 266:16-21. [DOI: 10.1148/radiol.12112134] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Menon BK, Goyal M. A systems approach towards intra-arterial management of acute ischemic stroke: need for novel outcome measures and a focus on sequence rather than steps. Interv Neuroradiol 2011; 17:296-8. [PMID: 22005690 DOI: 10.1177/159101991101700303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 06/25/2011] [Indexed: 02/02/2023] Open
Abstract
In this editorial, we seek to focus attention of neurointerventionists and stroke physicians towards a systems approach to the intra-arterial management of acute ischemic stroke. We highlight the need to pay attention to the overall sequence and workflow of a neurointerventional procedure rather than individual steps. We also stress the importance of novel outcome measures in analyzing procedural efficacy when managing patients with acute ischemic stroke.
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Affiliation(s)
- B K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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