Search

Background and Purpose: This stroke center has neuro-interventional capabilities and is part of a five hospital network surrounding a metropolitan area. As the center that offers mechanical thrombectomy, patients are received for this procedure from the other hospitals in the network in addition to other outside facilities. The time to transfer these patients was taking too long, sometimes hours, and a way to shorten that time was needed to improve patient outcomes. Methods: The stroke team decided to use the Code Stroke nurse to facilitate this process. A process was put into place in which the receiving facility pulls the patient in rather than waiting for the sending facility to push the patient out. The Code Stroke nurse, once learning of the acceptance of the patient by the interventionalist, proactively calls the sending facility to get report, instructs that facility to call EMS for transfer, and records an estimated time of arrival (ETA) for the patient. This information is then disseminated to the rest of the stroke team to prepare for the patient’s arrival. Results: Before implementation of this process, the average time to receive these transfers was approximately 120 minutes. After the Pull Technique was implemented, the average time of transfer is 40 minutes. This is a reduction of 67% of time to transfer. Conclusion: Decreasing the time of transfer can significantly impact the outcome for these patients. This process has shown a lot of promise and is continuing to be evaluated. Not only has the time of transfer decreased, the sending facilities are happier because some of the burden of facilitating the transfer is taken by the receiving facility, and the receiving facility is even more prepared to receive the patient leading to decreased door-to-device (DTD) times.

Background and Purpose: In this 600 bed, non-academic community hospital, door-to-needle times soared to as high as 120 minutes in some cases. Issues ranged from high acuity patients in the Emergency Department to RN’s not knowing how to mix and give tPA. The stroke neurologist and ED physicians desired to come up with a protocol that would better serve this population of patients. Methods: A Stroke Team was established, led by the Stroke Neurologist. The team designed a Code Stroke Protocol and determined that the protocol should be led by a critical care nurse from the SICU. They would be intensely trained on the stroke protocol and would respond to all code strokes. In addition, a “code stroke backpack” was created that carries everything the nurse could need to administer tPA. The backpack includes the tPA and a nicardipine drip, among other medications that could be used during the code stroke. Having a strict protocol, a trained critical care nurse, and the medicine in a backpack, would streamline the process. Results: After initiating the new code stroke process, there was a significant decrease in door-to-needle times [78.9 min average (January 2016-February 2017)] to [36.8 min average (March 2017-December 2017)]. There was an immediate 36 minute drop the month of initiation. NIH scores have shown dramatic decreases in post tPA patients. Conclusions: In conclusion, the use of a critical care nurse to run the code stroke, proved to be highly successful and more importantly, sustainable. With a core of nurses that are proficient at the code stroke protocol, pressure was taken off of the emergency department nurses and limited issues that would prolong the administration of tPA. This process is differentiated from others by the stroke-trained nurse carrying the backpack with the medications. It should be considered in rural community hospitals with less resources than larger medical centers.

Background: Angiography negative perimesencephalic subarachnoid hemorrhage (SAH) is considered a relatively benign entity compared to aneurysmal SAH. However, some patients with angiography negative perimesencephalic subarachnoid hemorrhage with extension of hemorrhage beyond the perimesencephalic area are at increased risk for vasospasm. Here we present a series of 21 patients with angiography negative perimesencephalic pattern of SAH both with and without ventricular extension and describe their incidence of vasospasm and clinical outcomes. Methods: Retrospective chart review was performed among patients who underwent invasive angiography from 8/2007-6/2010. Inclusion criteria were presenting clinical symptoms typical of SAH, computed tomography (CT) evidence of perimesencephalic SAH with or without ventricular extension, no recent trauma or stroke, and cerebral angiography negative for aneurysm or arteriovenous malformation. 21 patients, 8 men and 13 women, with a mean age of 55.1 years met these criteria. The presenting CTs were examined and a modified Fisher Grade assigned. The patients’ clinical course was reviewed for incidence and treatment of vasospasm. The patients’ discharge summaries were evaluated and each patient given a modified Rankin Scale score. Results: The modified Fisher Scale score derived from the presenting CT was 1 for 29% (n=6), 2 for 5% (n=1), 3 for 19% (n=4), and 4 for 47% (n=10) of the patients. Amongst the 52% (n=11) of patients with intraventricular hemorrhage as defined by a modified Fisher Scale score of 2 or 4, 24% (n=5) developed angiographical evidence of vasospasm. 10% (n=2) of the patients required intra-arterial verapamil. 90% (n=9) of patients without intraventricular extension had good outcomes at discharge as defined by modified Rankin Scale score less than or equal to 2, while only 36% (n=4) of patients with angiography negative SAH with intraventricular extension had good outcomes. Conclusions: Although angiography negative perimesencephalic SAH is considered to have less associated morbidity and mortality than aneurysmal perimesencephalic SAH, patients with extension of hemorrhage into the ventricles are at increased risk for vasospasm and poor functional outcomes.

BACKGROUND AND PURPOSE: Thromboembolic events are the most common complication seen in elective coil embolization of cerebral aneurysms. Previous studies have shown that administration of oral clopidogrel and/or aspirin may lower the thromboembolic complication rate but little data exists regarding clinical outcome with the use of antiplatelet monotherapy in stent assisted elective aneurysm coil embolization. Objectives: To assess the safety and efficacy of antiplatelet monotherapy (clopidogrel) in elective stent assisted coil embolization of cerebral aneurysms MATERIALS AND METHODS: Retrospective chart review was performed in 94 consecutive patients who underwent endovascular treatments for elective coil embolization of cerebral aneurysms between 2008-2010. Thirty patients were included in this study who met the inclusion criteria of stent assisted coil embolization. All these patients received 75mg clopidogrel for one week prior to the procedure. Clopidogrel was continued post procedure for six to eight weeks. Primary outcome measure was peri-procedure and post-procedure symptomatic thromboembolic complications. RESULTS The study included 23 females and 7 males with mean age 52.6 years.Twenty (66.7%) patients had anterior circulation aneurysms and 10 (33.3%) patients had posterior circulation aneurysms. Twenty (66.7%) patients were treated with Neuroform, 9 (30%) patients with Enterprise stent and 1 (3.3%) patient was treated with both Neuroform and Enterprise stent assisted coil embolization. One (3.3%) patient had an iatrogenic flow limiting vertebral artery dissection during embolization of vertebrobasilar artery aneurysm with no clinical deficit. The patient’s vertebral artery dissection was treated with 2 Wingspan stents and 1 Medtronic driver stents. Symptomatic thromboembolic complication was seen in 1 patient (3.3%) at discharge. The patient had a giant basilar tip aneurysm which was treated with stent assisted coil embolization. Postprocedure the patient had a right facial palsy with gaze deviation. The MRI was consistent with acute posterior circulation stroke. The patient was discharged home with a modified Rankin Scale CONCLUSION: Oral clopidogrel is safe and efficacious as an antiplatelet monotherapy during elective stent assisted coil embolization. Further multicenter prospective trials are warranted to evaluate safety and efficacy of clopidogrel as a monotherapy for elective stent assisted coil embolization.

Background: As is seen in the early door-to-needle times of intravenous thrombolysis in the treatment of acute ischemic stroke (AIS), prior endovascular management trials have demonstrated early revascularization can lead to improved outcomes. We aimed to study the relationship of the time from acute stroke onset to the time of arterial groin puncture (OTP) as a possible predictor of successful revascularization. Methods: We retrospectively analyzed 149 patients who presented to our hospital with AIS and underwent emergent endovascular treatment from January 1, 2008 to March 31, 2011. Charts were reviewed for baseline characteristics, OTP times, and endovascular therapies employed. Primary outcomes included successful revascularization (TIMI 2 to 3 flow), improvement of baseline NIHSS ≥ 4, symptomatic ICH (increase of NIHSS ≥ 4), in-hospital mortality, and mRS two or less at discharge. We excluded patients with OTP times greater than eight hours to ensure consistency with approved usage of mechanical thrombectomy devices. Independent samples T-tests were performed to determine relationships of OTP with our primary outcomes. Results: Of the 149 patients who underwent endovascular therapy, 120 had OTP times less than eight hours. Of these 120, 44% were male, median age was 73 years (range 17, 93), median baseline NIHSS was 18 (range 5, 28), 53% received intravenous tissue plasminogen activator (tPA), 69% received intra-arterial tPA, and mechanical thrombectomy was performed in 69%. Internal carotid artery occlusions were seen in 32% of patients, 50% had M1 segment occlusions, and only five patients had posterior circulation occlusions. Successful revascularization was achieved in 70% of interventions, 10% of patients had mRS ≤ 2 at discharge, symptomatic hemorrhage was 18%, and in-hospital mortality was 24%. Patients with TIMI 2 to 3 flow had significantly shorter mean OTP times (3.9 vs 4.5 hours; p=0.024). No significant associations of mean OTP times were found with symptomatic hemorrhage rate (4.4 vs 4.0; p=0.628), in-hospital mortality (4.0 vs 4.0; p=0.677), improvement in NIHSS (3.9 vs 4.2; p=0.283), or a mRS ≤ 2 at discharge (3.7 vs 4.1; p=0.185). Conclusions: The recanalization rate in our study is comparable to prior endovascular trials. Patients with OTP times less than 3.9 hours were more likely to result in successful revascularization. Onset to groin puncture did not predict in-hospital mortality, symptomatic hemorrhage, or condition at discharge in our study. Further study is needed to determine if advanced perfusion imaging prior to intervention may impact treatment time and ultimately clinical outcome.

Background: In the setting of acute ischemic stroke, endovascular intervention, once considered experimental, is now gold standard of care of appropriately selected patients. Among the elderly, aged 80 and above, patients have multiple comorbidities, and little data exists regarding clinical outcome for those undergoing different endovascular treatment modalities. Objectives: To assess the safety and efficacy of different endovascular treatment modalities in elderly, aged 80 and above, compared to patients younger than 80 with acute ischemic stroke Methods: Restrospective chart review was performed in 150 consecutive patients who underwent endovascular treatments for acute ischemic stroke at our center between 2008 and 2011, between age range 17 -93 years. Elderly patients (EP) age 80 and above (n=34) were compared to nonelderly patients age Results: In EP, mean age was 84.9 ± 3.3, with 32.3% (n=11) males and 67.6% (n=23) females. In NEP mean age was 63.6 ± 13.1, with 50.9% (n=59) males and 49.1% (n=57) females. 91.3% (n=106) In EP vs NEP, mean initial NIHSS were 19±7 and 16±6, and discharge NIHSS 9±7 and 12±8, respectively. Rates of recanalization occurred in 67.6% (n=23) in EP, and 71.6% (n=83) in NEP. Discharge mRS 3 or less was 2.9% (n=1) in EP, and 17.2% (n=20) in NEP. Symptomatic ICH occurred in 20.6% (n=7) in EP and 14.7% (n=17) in NEP. All cause mortality rate at discharge in EP group was 41.2% (n=14) and 19.8% (n=23) in NEP. Conclusions: In our experience EP had poor clinical outcomes with increased mortality and hemorrhage rate compared to NEP irrespective of similar recanalization rate. Further prospective trial is warranted to evaluate safety and efficacy of endovascular treatment in patients aged 80 years old and above.