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Bustamante A, Balboa M, Ezcurra G, Sánchez-Fortún A, Ruiz J, Castellví J, Castillo-Acedo S, Matas È, Bouchikh R, Martínez-Sánchez M, Castaño C, Remollo S, Werner M, Salgado MC, Villodres S, Gea M, Millán M, Pérez de la Ossa N, Ruiz-Bilbao S. Implementation of a retinal stroke-code protocol results in visual recovery in patients receiving reperfusion therapies. Eur Stroke J 2024:23969873231221366. [PMID: 38189284 DOI: 10.1177/23969873231221366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Reperfusion therapies represent promising treatments for patients with Central Retinal Artery Occlusion (CRAO), but access is limited due to low incidence and lack of protocols. We aimed to describe the benefit of implementing a Retinal Stroke-Code protocol regarding access to reperfusion, visual acuity and aetiological assessment. PATIENTS AND METHODS Prospective cohort study performed at a Comprehensive Stroke Centre. Criteria for activation were sudden monocular, painless vision loss within 6 h from onset. Eligible patients received IAT when immediately available and IVT otherwise. All patients were followed by ophthalmologists to assess best-corrected visual acuity (BCVA) and visual complications, and by neurologists for aetiological workup. Visual amelioration was defined as improvement of at least one Early Treatment Diabetic Retinopathy Study (ETDRS) letter from baseline to 1 week. RESULTS Of 49 patients with CRAO, 15 (30.6%) received reperfusion therapies (12 IVT, 3 IAT). Presentation beyond 6 h was the main contraindication. Patients receiving reperfusion therapies had better rates of visual improvement (33.3% vs 5.9%, p = 0.022). There were no complications related to reperfusion therapies. Rates of neovascular glaucoma were non-significantly lower in patients receiving reperfusion therapies (13.3% vs 20.6%, p = 0.701). Similar rates of atherosclerotic, cardioembolic and undetermined aetiologies were observed, leading to 10 new diagnosed atrial fibrillation and five carotid revascularizations. CONCLUSION A comprehensive acute management of CRAO is feasible despite low incidence. In our study, reperfusion therapies were safe and associated with higher rates of visual recovery. A similar etiological workup than ischemic stroke led to of high proportion of underlying aetiologies.
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Affiliation(s)
- Alejandro Bustamante
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Balboa
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Garbiñe Ezcurra
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Adrián Sánchez-Fortún
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Judith Ruiz
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Castellví
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susana Castillo-Acedo
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Èric Matas
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rachid Bouchikh
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marina Martínez-Sánchez
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Castaño
- Neuroradiology Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastiá Remollo
- Neuroradiology Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mariano Werner
- Neuroradiology Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Carmen Salgado
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Samuel Villodres
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Gea
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mònica Millán
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natàlia Pérez de la Ossa
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susana Ruiz-Bilbao
- Retina Unit, Oftalmology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
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Ramos-Pachón A, García-Tornel Á, Millán M, Ribó M, Amaro S, Cardona P, Martí-Fàbregas J, Roquer J, Silva Y, Ustrell X, Purroy F, Gómez-Choco M, Zaragoza-Brunet J, Cánovas D, Krupinski J, Sala NM, Palomeras E, Cocho D, Redondo L, Repullo C, Sanjurjo E, Carrión D, López M, Almendros MC, Barceló M, Monedero J, Catena E, Rybyeba M, Diaz G, Jiménez-Fàbrega X, Solà S, Hidalgo V, Pueyo MJ, Pérez de la Ossa N, Urra X. Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia. Cerebrovasc Dis 2021; 50:551-559. [PMID: 34023822 PMCID: PMC8247826 DOI: 10.1159/000516309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/02/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system's bottlenecks from a territorial point of view. METHODS Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15-May 2, 2020) and an immediate prepandemic period (January 26-March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. RESULTS Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = -0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05-2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4-0.9], p 0.015) during the pandemic period. CONCLUSION During the COVID-19 pandemic, Catalonia's stroke system's weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system's analysis is crucial to allocate resources appropriately.
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Affiliation(s)
| | | | - Mònica Millán
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Marc Ribó
- Hospital Universitari Vall D'Hebron-VHIR, Barcelona, Spain
| | - Sergi Amaro
- Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Pere Cardona
- Stroke Unit, Hospital Universitari Bellvitge, Hospitalet de Llobregat, Spain
| | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Jaume Roquer
- Stroke Unit, Department of Neurology, Mar Hospital, Barcelona, Spain
| | - Yolanda Silva
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | - Xavier Ustrell
- Department of Neurology, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Francisco Purroy
- Department of Neurology, Stroke Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | | | | | - David Cánovas
- Department of Neurology, Hospital Parc Taulí, Sabadell, Spain
| | - Jurek Krupinski
- Department of Neurology, Hospital Mútua Terrassa, Terrassa, Spain
| | - Natalia Mas Sala
- Department of Neurology, Hospital Sant Joan de Déu - Fundació Althaia, Manresa, Spain
| | | | - Dolores Cocho
- Department of Neurology, Hospital General Granollers, Granollers, Spain
| | - Laura Redondo
- Emergency Department, Hospital Universitari Vic, Vic, Spain
| | - Carmen Repullo
- Emergency Department, Fundació Hospital Seu Urgell, La Seu d'Urgell, Spain
| | | | - Dolors Carrión
- Emergency Department, Hospital Mora Ebre, Mora Ebre, Spain
| | - Mercè López
- Emergency Department, Hospital Figueres, Figueres, Spain
| | | | - Miquel Barceló
- Emergency Department, Hospital Cerdanya, Puigcerdà, Spain
| | | | - Esther Catena
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedés, Spain
| | - Maria Rybyeba
- Emergency Department, Fundació Hospital d'Olot, Olot, Spain
| | - Gloria Diaz
- Emergency Department, Hospital Campdevànol, Campdevànol, Spain
| | | | - Silvia Solà
- Sistema d'Emergències Mèdiques, Barcelona, Spain
| | | | | | | | - Xabier Urra
- Stroke Unit, Hospital Clínic, Barcelona, Spain
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Ramos-Pachón A, López-Cancio E, Bustamante A, Pérez de la Ossa N, Millán M, Hernández-Pérez M, Garcia-Berrocoso T, Cardona P, Rubiera M, Serena J, Ustrell X, Garcés M, Terceño M, Dávalos A, Montaner J. D-Dimer as Predictor of Large Vessel Occlusion in Acute Ischemic Stroke. Stroke 2021; 52:852-858. [PMID: 33563016 DOI: 10.1161/strokeaha.120.031657] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Improving prehospital triage of large vessel occlusion (LVO) would reduce time to reperfusion therapies. We aimed to study early predictors of LVO in acute ischemic stroke to identify candidates for endovascular treatment. METHODS The Stroke-Chip was a prospective observational study conducted at 6 Stroke Centers in Catalonia. Blood samples were obtained in the first 6 hours from symptom onset of consecutive patients. Stroke severity was evaluated with National Institutes of Health Stroke Scale (NIHSS) and LVO was assessed. Independent association of multiple blood biomarkers with LVO was evaluated using logistic regression models adjusted by covariates. Sensitivity, specificity, and predictive values were assessed for NIHSS and the combination of NIHSS and selected serum biomarkers levels. RESULTS One thousand three hundred eight suspected strokes were enrolled for a 17-month period. LVO was not assessed in 131 patients. One thousand one hundred seventy-seven patients were selected for analysis (mean age 69.3 years, 56% men, median baseline NIHSS of 6, and median time to blood collection 2.5 hours). LVO was detected in 262 patients. LVO patients were older, had higher baseline NIHSS, history of atrial fibrillation, and lower time from stroke onset to admission. After logistic regression analysis, D-dimer remained an independent predictor of LVO (odds ratio, 1.59 [1.31-1.92]). Specificity and positive predictive value to exclude or detect LVO were higher when using combined D-dimer levels and NIHSS score assessment rather than NIHSS alone. CONCLUSIONS Early D-dimer levels are an independent predictor of LVO and may be useful to better optimize prehospital patient transport to the appropriate stroke center.
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Affiliation(s)
- Anna Ramos-Pachón
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.)
| | - Elena López-Cancio
- Neurology Department, Hospital Universitario Central de Asturias, Oviedo, Spain (E.L.-C.)
| | - Alejandro Bustamante
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.)
| | - Natàlia Pérez de la Ossa
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.)
| | - Mònica Millán
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.)
| | - Maria Hernández-Pérez
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.)
| | - Teresa Garcia-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Spain (T.G.-B., J.M.)
| | - Pere Cardona
- Neurology Department, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Spain (P.C.)
| | - Marta Rubiera
- Neurology Department, Hospital Universitari Vall D'Hebron-VHIR, Barcelona, Spain (M.R.)
| | - Joaquín Serena
- Neurology Department, Hospital Universitari Josep Trueta, Girona, Spain (J.S., M.T.)
| | - Xavier Ustrell
- Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U.)
| | - Moisés Garcés
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain (M.G.)
| | - Mikel Terceño
- Neurology Department, Hospital Universitari Josep Trueta, Girona, Spain (J.S., M.T.)
| | - Antoni Dávalos
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.)
| | - Joan Montaner
- Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P., A.B., N.P.d.l.O., M.M., M.H.-P., A.D.).,Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Spain (T.G.-B., J.M.)
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Dorado L, Castaño C, Millán M, Aleu A, de la Ossa NP, Gomis M, López-Cancio E, Vivas E, Rodriguez-Campello A, Castellanos M, Dávalos A. Hemorrhagic Risk of Emergent Endovascular Treatment Plus Stenting in Patients with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2013; 22:1326-31. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.12.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/08/2012] [Accepted: 12/15/2012] [Indexed: 11/17/2022] Open
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