Stroke Code Research Articles

Abstract TP40: Magnetic Resonance Versus Computed Tomography As Preferred Screening Of Suspected Acute Stroke: A Retrospective Comparative Cohort Analysis

Background: In published cohorts, MRI screened patients tend to have better outcomes than CT-screened, even though MRI takes longer to acquire and may delay initiation of thrombolysis. However, overall differences in stroke workflow and clinical outcomes in stroke centers that prefer MRI over CT have not been reported. Methods: Between 2019 and 2021 three stroke centers in our network, switched their code-stroke imaging protocol from CT-first preferred to MR-first preferred. Under the MR-first protocol, CT was performed for MRI contraindications, patient instability, or MR not immediately available during a code stroke. Data from one year prior to the switch (CT-first) was compared to the year following the switch (MR-first). Patient demographics, quality stroke metrics and outcomes were obtained from a prospectively maintained patient database. Results: A total of 1027 (CT-first) and 1056 (MR-first) cases were evaluated (Table). Ischemic stroke was more frequent and TIA less frequent under the MR-first protocol. Cross-over scanning occurred more frequently under the MR-first protocol (p<0.0001). Rate of thrombolysis was 11.8% of all cases under CT-first and 13.3% under MR-first. Door-to-treatment for thrombolytic and thrombectomy was longer under MR-first but fewer stroke mimics were treated under MR-first (0.7% vs 9.2%, p=0.0014). Clinical outcomes did not differ for thrombolysis, but discharge disposition to home vs hospice or death after thrombectomy was favored under the MR-first protocol (p =0.0176). Conclusion: Under an MR-first stroke protocol there was a greater rate of cross-over imaging and delayed workflow and treatment times, but less frequent thrombolytic treatment of stroke mimics and better outcomes in thrombectomy patients. Workflow metrics and outcomes for patients as imaged will be presented at the conference.

Abstract 62: Stroke Busters High School Stroke Education Initiative

Background: It is estimated that 91% of stroke risk can be attributed to modifiable risk factors; however, on a population level, these risk factors are not well controlled. One recent response to reducing the burden of stroke has been to improve childhood knowledge about stroke. The purpose of our initiative was to educate high school students about stroke and careers in neuroscience. Methods: Thirteen students in Yale University Pathways to Science Summer Scholars participated in a 5-day program called Stroke Busters. Summer Scholars is a free summer science day program for rising 10th- 12th grade students. The demographic breakdown is 32% Asian, 30.1% Black, 20.4% Latinx, 15.5% White, and 1.9% Middle Eastern. Stroke Busters is a program within Pathways that includes an interactive stroke lecture, mock stroke code simulation, interactive mechanical thrombectomy demonstration, and a workshop where students created their own stroke learning materials. Students completed an 8 question pre and post-test that assessed stroke knowledge. Results: Between 7/11-7/15/22 thirteen students participated in Stroke Busters . The average test scores increased from 38% to 73%. Prior to the program, eight students (62%) listed that a stroke occurred in the brain and four students (31%) correctly identified the acronym “FAST”; 100% of students got these items correct in the post-test. The score for identifying 4/4 stroke symptoms improved from 56% to 92%. Twelve students provided feedback; the overall satisfaction rating for the program was 4.44/5. Students commented on the stroke simulation as the most enjoyable part of the program. Conclusion: In this high school stroke educational program students improved their knowledge about stroke significantly. This is the first stroke education program to our knowledge that focuses on high school students using a multi-day curriculum led by a diverse group of healthcare professionals.

Abstract WP81: Validation Of Artificial Intelligence To Limit Delays In Acute Stroke Treatment And Endovascular Therapy (VALIDATE)

Introduction: Analyses from early- and late-window thrombectomy trials for acute large vessel occlusion (LVO) stroke have consistently demonstrated a strong time-dependent treatment effect for best outcomes. The utilization of an artificial intelligence (AI)-based care coordination platform to support LVO diagnosis and treatment has the potential to assist in reducing door to puncture times and improve outcomes. Hypothesis: Utilization of an AI-based care platform in the management of LVO patients may significantly decrease door to Neurointerventionalist (NIR) notification time. Methods: Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 166 facilities (17 states) that utilized VIZ.AI software or did not have an AI software from December 1, 2021 through March 31, 2022 were extracted from the Telecare TM database. Facilities that neurology does not initiate contact with NIR were excluded. The encounters were analyzed by age, ethnicity, last known normal, arrival time, initial telemedicine stroke code activation time (TCA), candidacy for thrombolytics, door to needle time (DTN), advanced imaging, presence of LVO, time NIR accepted, premorbid modified Rankin Score, and NIHSS score. Patients were divided into two groups (utilization and non-utilization of the AI platform) and median door to NIR notification times were compared. There was a 4 minute shorter time to TCA at AI hospitals. Results: A total of 14,116 patients (8,557 AI and 5,559 non-AI) were included. The median door to NIR notification time for AI was 50 minutes (40, 82) and non-AI was 89.5 minutes (59.3, 122), p <0.001. There was a small but significantly shorter time (3 minutes) from door to TCA at AI hospitals. Median DTN times for thrombolytics was also lower with AI, 40 minutes (30, 52) vs 44 minutes (32, 57.5) for non-AI, p=0.018. The AI group had more advanced imaging performed, a higher percentage of LVOs identified, and a higher percentage accepted by NIR. Conclusion: Hospital utilization of an AI-based care coordination platform was associated with a significant decrease of 39.5 minutes in the time to NIR contact, increase in patients taken for intervention, and lower DTN times for thrombolytics.

Abstract TP77: Point Of Care Inr And R-tpa Decision Making In Acute Ischemic Stroke

Introduction: IV r-tPA is the standard of care treatment in acute ischemic stroke presenting within 4.5 hours of last known well. Exclusion criteria for administering IV r-tPA include conditions that predispose to bleeding, including an INR of ≥ 1.7 . Point of care (POC) INR testing is significantly faster than laboratory derived INR results and can expedite IV r-tPA administration. However, POC INR testing is less accurate than laboratory-based testing with an acceptable variance range of +/- 0.4, which may lead to improper r-tPA exclusion or inclusion. Objectives: We demonstrate the utility of a protocolized approach to POC INR testing in acute ischemic stroke, in which known or suspected warfarin use requires a lab INR result to determine if r-tPA is contraindicated when POC INR is between 1.3-2.1. This approach prevents IV r-tPA from being inappropriately administered or withheld. Methods: We stratified a subset of real world paired POC and laboratory INR results (n=892) for stroke code patients at our institution from January 1st through July 4 th , 2022 by known or suspected warfarin status and calculated a positive predictive value for POC INR > 1.7. Results: Fifty-four of 892 paired POC and laboratory INR results represented patients with known or suspected warfarin use. Twenty-five (46%) had a POC INR within 1.3-2.1 warranting a lab INR verification prior to safe administration of r-tPA. Thirteen of which had a POC INR < 1.7 but a lab INR of ≥ 1.7. In 5.25% of cases where the POC INR > 1.7 the laboratory INR was < 1.7. The positive predictive value for POC INR >= 1.7 among patients with known or suspected warfarin status is 88.2%. Conclusions: POC INR testing rapidly screens for coagulopathy in IV tPA eligible stroke patients, but due to inherent inaccuracy may inadvertently rule patients in or out for IV r-tPA treatment. Our institution has instituted a policy of requiring laboratory verified INR results when the POC INR is within +/- 0.4 of the laboratory based INR tPA cutoff. In our 892 patient sample, this policy would prevent 13 patients from inadvertently receiving IV tPA due to an inaccurate POC INR. Up to five percent of patients excluded from r-tPA based on POC INR may in-fact be treatment candidates.

Abstract TP44: No Differences In Outcomes For Stroke Patients Presenting To A Comprehensive Stroke Center And Treated Using Telestroke Vs. In-person Assessments During The Covid-19 Pandemic.

Introduction: Telestroke is the use of videoconferencing technology by a stroke specialist to assess and treat acute ischemic stroke patients who present elsewhere. It has been well-studied previously in a “Hub-and-Spoke” model. In 2021, Telestroke was used to assess and treat acute ischemic stroke patients who presented primarily after-hours to our comprehensive stroke center because we were concerned the COVID-19 pandemic could affect the timeliness of in-person code stroke assessments. After implementation, we determined the efficacy and safety outcomes for patients treated with Telestroke versus in-person assessments. Hypothesis: We hypothesized that there will be no difference in the efficacy or safety outcomes between patients treated using Telestroke vs. in-person assessments. Methods: A retrospective chart review identified acute ischemic stroke patients who presented to our center in 2021, who were assessed and treated using either Telestroke or an in-person assessment. The primary outcomes for efficacy were door-to-needle (DTN) time for alteplase administration and door to puncture (DTP) time for endovascular thrombectomy. The primary safety outcomes were 3-month mortality and symptomatic intracranial hemorrhage rates (sICH). Results: We treated 302 acute stroke patients in 2021, with 18.2% (n=55/302) of patients treated using Telestroke. There were no differences in clinical outcomes between patients treated using Telestroke vs. in-person assessments: median DTN (35.5min (n=42) vs. 33min (n=182), p<0.76), median DTP (86.5min (n=30) vs. 85min (n=134), p<0.97), sICH (0% (n=0/55) vs. 1.6% (n=4/245, p<0.59) or 3 month mortality (20.6% (n=7/34) vs. 22.1% (n=40/181), p<0.29). Conclusion: This is the first study to our knowledge that reports on using Telestroke at a comprehensive stroke center. In this study, there were no differences in the clinical outcomes between stroke patients treated with Telestroke vs. in-person assessments. These results support using Telestroke to meet the increasing demands for acute stroke assessments at other comprehensive stroke centers.

National Institutes of Health Stroke Scale (NIHSS) scoring inconsistencies between neurologists and emergency room nurses.

Little is known about the consistency of initial NIHSS scores between neurologists and RNs in clinical practice. A cohort study of patients with a code stroke was conducted at an urban academic Primary Stroke Center in the Midwest between January 1, 2018, and December 31, 2019 to determine consistency in National Institutes of Health Stroke Scale Scores (NIHSS) between neurologists and registered nurses (RNs). Among the 438 patients included in this study 65.3% (n = 286) of neurologist-RN NIHSS scoring pairs had congruent scores. One-in-three, (34.7%, n = 152) of neurologist-RN NIHSS scoring pairs had a clinically meaningful scoring difference of two points or greater. Higher NIHSS (p ≤ 0.01) and aphasia (p ≤ 0.01) were each associated with incongruent scoring between neurologist and emergency room RN pairs. One-in-three initial NIHSS assessed by both a neurologist and RN had a clinically meaningful score difference between providers. More severe stroke, as indicated by a higher NIHSS was associated with scoring inconsistency between neurologist-RN pairs. Subjective scoring measures, especially those involving a patient having aphasia, was associated with greater score incongruency. Score differences may be attributed to differences in NIHSS training requirements between neurologists and RNs.

Utility of the RIPS Scale and 2CAN Score for In-Hospital Stroke Prediction.

In-hospital strokes are a small but sizeable proportion of all strokes. Identification of in-hospital strokes is confounded by stroke mimics in as many as half of in-patient stroke codes. A quick scoring system based on risk factors and clinical signs during the initial evaluation of a suspected stroke might be helpful to distinguish true strokes from mimics. Two such scoring systems based on ischemic and hemorrhagic risk factors are the risk for in-patient stroke (RIPS) and the 2CAN score. This prospective clinical study was conducted at a quaternary care hospital in Bengaluru, India. All hospitalized patients aged 18 years and above for whom a "stroke code" alert was recorded during the study period of January 2019 to January 2020 were included in the study. A total of 121 in-patient "stroke codes" were documented during the study. Ischemic stroke was the most common etiological diagnosis. A total of 53 patients were diagnosed to have ischemic stroke, 4 had intracerebral hemorrhage, and the rest were mimics. Receiver operative curve analysis was performed and at a cut-off of RIPS ≥3, it predicts stroke with a sensitivity of 77% and a specificity of 73%. At a cut-off of 2CAN ≥3, it predicts stroke with a sensitivity of 67% and a specificity of 80%. RIPS and 2CAN significantly predicted stroke. There was no difference in the use of either RIPS or 2CAN for differentiating stroke from mimics, and hence they may be used interchangeably. They were statistically significant with good sensitivity and specificity, as a screening tool to determine in-patient stroke.

Door to Needle Time in Acute Ischemic Stroke Patients before and after Initiation of Quality Improvement Project - Single Local Centre Experience

Background and Aims: Thrombolysis has been shown to improve stroke outcomes by reducing disability, particularly when administered early. Lowering the door-to-needle time (DNT) for administering intravenous thrombol¬ysis (IVT) is an important objective for improving the quality of acute stroke care. This study aims to compare DNT before and after implementing the code stroke pathway protocol. Methods: The study evaluated the impact of a quality improvement project, Code Stroke, on acute ischemic stroke patients at King Fahd General Hospital in Jeddah, Saudi Arabia, September 2019 to April 2020, using a retrospective record-based analysis, with data extracted using a standardized format and cat¬egorized into pre and post code groups. Results: 81 stroke patients were reviewed, with 47 in the pre-code group and 34 in the post-code group. The re¬ported tPA DNT time was less than 60 minutes in only 8.5% of patients before the implementation of stroke code activation, compared to 55.9% after implementation (p=.001). Incidence of symptomatic hemorrhagic transformation was 8.6%. Post-code group had a lower median length of hospital stay (8 days) compared to the pre-code (13 days), with a marginal trend towards statistical significance, and half of the post-code group patients had a modified Rankin Scale of 0-2 compared to one third of the pre-code group at three months of discharge. Conclusions: The Code Stroke project resulted in a significant reduction in DNT, improved functional outcomes, and a reduction in hospital length of stay, but the incidence of symptomatic intracranial hemorrhage and in-hospital mortality rates were slightly higher than expected, requiring continued improvement efforts.

Protocolo diagnóstico y terapéutico del ictus isquémico

Acute stroke is a disease with a time-dependent prognosis and thus, diagnostic and treatment protocols are designed to guarantee that patients with acute stroke have rapid, safe access to specific care. The stroke code, early care by expert neurologists, admission to stroke units, and the early use of reperfusion treatments have been demonstrated to considerably reduce the mortality and sequelae of acute stroke patients. The chain of care must be adequately protocolized to ensure accessibility and equity in the treatment of this disease. The etiological study and prevention of complications are also fundamental for personalizing hospital care and secondary prevention for these patients.

Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study

Objective‘Code Stroke’ (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent...

Impact of JSS-PCS on the In-Hospital Workflow and Outcomes of Reperfusion Therapy for Acute Ischemic Stroke: Cases of a Metropolitan Secondary Emergency Facility.

Protected code stroke has been widely introduced in the emergency medical system for acute stroke in the current coronavirus disease 2019 (COVID-19) pandemic. This study aims to confirm the effects of protected code stroke formulated by the Japan Stroke Society (JSS-PCS) on the quality and outcomes of reperfusion therapy for acute ischemic stroke (AIS), followed by evaluating its validity. The subjects were 109 consecutive patients with AIS who underwent reperfusion therapy between January 2016 and July 2021, excluding in-hospital onset cases. Patients were classified according to the treatment date into the pre-COVID-19 (n = 82) and the with-COVID-19 (n = 27) groups. JSS-PCS was applied to all patients in the latter group. Statistical comparisons were made between groups on time indicators for initial treatment (onset-to-door time, door-to-imaging time [DTI], door-to-needle time [DTN], door-to-puncture time [DTP], door-to-reperfusion time, and puncture-to-reperfusion time [PTR]). The time indicator transition over the entire period was also evaluated by subgroup analysis. Subsequently, the outcomes at discharge were statistically compared between the two periods, followed by a subgroup comparison. Finally, univariate and multivariate analyses examined whether the application of JSS-PCS affected clinical outcomes. Slight delays were revealed in DTI, DTN, DTP, and PTR in the with-COVID-19 group with no statistical significance. The time indicators were delayed once entering the period of the COVID-19 pandemic and then shortened again. The outcomes at discharge tended to worsen slightly in the with-COVID-19 group with no significance. Subgroup analysis depicted a transient deterioration of outcomes early in the pandemic. Applying JSS-PCS did not significantly affect clinical outcomes in univariate and multivariate analyses. Regarding reperfusion therapy at our facility, the introduction and application of JSS-PCS during the COVID-19 pandemic significantly affected neither time indicators nor outcomes. Infection control should be a top priority in the first medical practice for AIS in today's world, where COVID-19 shows no signs of termination.

Actualización del código ictus en urgencias

“Code Stroke” is a multidisciplinary procedure designed to detect acute ischemic strokes and transfer patients for early reperfusion. Selecting these patients requires multimodal imaging with either CT or MRI. 1) Conventional studies without contrast material are obligatory to detect bleeding. Applying the ASPECTS scale, these studies can also identify and quantify areas of early infarction. 2) In candidates for mechanical thrombectomy, angiographic studies are necessary to identify stenoses and obstructions and to evaluate the collateral circulation. 3) Patients with known onset between 6 and 24hours or with unknown onset require perfusion studies to distinguish between infracted tissue and recoverable ischemic tissue. Semi-automatic software facilitates diagnosis, but radiologists must interpret its output.

The need for Stroke code and Thrombectomy in Pakistan.

Stroke is one of the oldest studied medical illnesses, but it remains the second leading cause of mortality worldwide. The yearly mortality rate is over 5.5 million (1). However, in Pakistan, the estimated annual incidence of stroke is 250/100,000 or 350,000 cases; with the bulk occurring in the middle-aged. Due to a lack of information about the illness and its treatment choices, hundreds of individuals die each year, and an even more significant number live with a lifelong disability (2). If determined to be ischemic, stroke is treated immediately with an intravenous injection of recombinant tissue plasminogen activator, r-tPA, which is the standard gold treatment, according to guidelines, as long as the patients are transferred to a stroke unit within 4.5 hours. Thrombectomy, stents, surgery, and other medicines are also used (1). ---Continue

Performance of door-to-CT time of code stroke in Indonesian tertiary referral center hospital

BackgroundThis study was aimed to analyze the performance of door-to-CT scan (DTC) time of code stroke at the central referral hospital in Indonesia. Data from 310 patients were obtained in this cross-sectional study. Inclusion criteria were: notified with code stroke within the period between November 2016 and April 2019. Bivariate and multivariate analyses were carried out to find which factors affecting DTC time.ResultsA tendency of decreasing DTC time was reported from November 2016 until April 2019. The median DTC time at study endpoint was 19.5 (1–210) minutes. Chi-square analysis showed that CT scan location was the factor associated with DTC (OR: 12.6, 95% CI 6.8–23.35, p < 0.001). Logistic regressions analysis also showed significant relationship of CT scan location and DTC (OR: 24.27, 95% CI 17.71–30.81, p < 0.05).ConclusionsRefinement of the code stroke implementation and CT scan placement in the Emergency Department (ED) are effective in reduction of DTC time, and as a result, improving acute stroke management.

Automated detection of intracranial large vessel occlusions using Viz.ai software: Experience in a large, integrated stroke network.

Endovascular thrombectomy is an evidence-based treatment for large vessel occlusion (LVO) stroke. Commercially available artificial intelligence has been designed to detect the presence of an LVO on computed tomography angiogram (CTA). We compared Viz.ai-LVO (San Francisco, CA, USA) to CTA interpretation by board-certified neuroradiologists (NRs) in a large, integrated stroke network. From January 2021 to December 2021, we compared Viz.ai detection of an internal carotid artery (ICA) or middle cerebral artery first segment (MCA-M1) occlusion to the gold standard of CTA interpretation by board-certified NRs for all code stroke CTAs. On a monthly basis, sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Trend analyses were conducted to evaluate for any improvement of LVO detection by the software over time. 3851 patients met study inclusion criteria, of whom 220 (5.7%) had an ICA or MCA-M1 occlusion per NR. Sensitivity and specificity were 78.2% (95% CI 72%-83%) and 97% (95% CI 96%-98%), respectively. PPV was 61% (95% CI 55%-67%), NPV 99% (95% CI 98%-99%), and accuracy was 95.9% (95% CI 95.3%-96.5%). Neither specificity or sensitivity improved over time in the trend analysis. Viz.ai-LVO has high specificity and moderately high sensitivity to detect an ICA or proximal MCA occlusion. The software has the potential to streamline code stroke workflows and may be particularly impactful when emergency access to NRs or vascular neurologists is limited.

Bundled Approach to Improve Inpatient Stroke Recognition and Time to Treatment.

BACKGROUND: Early recognition of inpatient stroke is critical in reducing poor outcomes. A gap in knowledge and recognition of stroke by nursing staff was observed; protocols did not incorporate the Balance, Eyes, Face, Arms, Speech, and Time (BE-FAST) symptom mnemonic, and code stroke documentation was frequently incomplete. PURPOSE: This initiative aimed to improve timely recognition, evidence-based treatment, and nursing documentation of stroke-related symptoms. METHODS: This quality improvement initiative implemented an inpatient nurse-driven code stroke bundle. A pre-post prospective intervention design was implemented over 3 months. Code stroke bundle components included an evidence-based protocol, algorithm, visual aids, and education. Nursing communication and documentation used the BE-FAST mnemonic in a Situation, Background, Assessment, Recommendation format. RESULTS: Nursing stroke knowledge improved 8% (88% vs 96%, P < .001); stroke response times improved 15 minutes (25.9 vs 11 minutes, P = .383), although not significant; the code stroke documentation completion rate was increased 48.1% (0 [0%] vs 13 [48.1%], P < .001); and improved utilization of the BE-FAST tool with Situation, Background, Assessment, Recommendation communication (0 [0%] vs 20 [47.6%], P = < .001) was observed. The code stroke cancelation rate slightly worsened (10 [26.3%] vs 14 [26.9%], P = .949), code stroke notifications for altered mental status improved (15 [39.5%] vs 8 [15.7%], P = .015), and the stroke mimic rate improved (27 [71.1%] vs 35 [67.3%], P = .708). CONCLUSION: Nurses provide hospital patient care continuously and are in a key position to intervene when patients present changes in symptoms. Through education and creating an evidence-based protocol, nurses can impact patient outcomes in early recognition and activation of the code stroke system. Further studies are warranted to refine strategies leading to continued improvement in early stroke identification.

Stroke Code Implementation in A Physician-Led District Hospital in Malaysia

Introduction: The past few years have shown a marked improvement in acute ischaemic stroke (AIS) thrombolysis therapy in Malaysia. We analysed our data on stroke code activation performed in a non-neurologist hospital. Methods: Data of all stroke code activated patients from September 2019 to September 2020 was collected. Demographic, clinical characteristics and outcomes of these patients were analysed and reviewed with published data in Malaysia. Results: Seventy cases were stroke code activated. Majority of the stroke cases (80%) were ischaemic in nature with the highest subgroups of lacunar infarct at 60.7%. Hypertension is the most prevalent risk factor followed by dyslipidaemia and diabetes. The median time for onset-to-door was 95minutes, door-to-CT was 24minutes, door-to-decision was 46.5 minutes and door-to-needle was 80minutes. There was a sequential reduction in median door-to-CT and door-to-needle time to 16.5 and 65.5minutes respectively. Fifteen patients (21.4%) were given thrombolysis therapy. The median NIHSS score was 7.5 on arrival and 6 upon discharge. They had an improvement of mRS from a median of 4 upon discharge to 1 at six months follow-up. There were no haemorrhage incidences post thrombolysis. The outcome of LACI strokes versus non-LACI strokes was similar at 3 and 6-months follow-up despite non-LACI strokes having a more severe presentation upon admission. Conclusion: With AIS thrombolysis therapy, non-LACI strokes may have similar functional outcomes as LACI strokes. With backup support from hospitals with neurologists and neurosurgeons, physician-led AIS thrombolysis therapy is implementable in a non-neurologist centre. Strong adherence to protocol is pertinent to ensure success.

Implementation of a wake-up and unknown symptom onset stroke protocol

Background: Establishing a symptom onset timeline for stroke patients is one of the essential aspects of thrombolytic therapy. Implementing an MRI protocol can potentially increase the rate of thrombolytic therapy and expand treatment to patients who would otherwise be excluded.Objective: This project aimed to increase the rate of thrombolytic therapy by incorporating an additional layer of evaluation within the established acute stroke code process for patients with wake-up stroke (WUS) or unknown symptom onset stroke.Methods: Patients 18 years of age and older who presented as WUS eligible for thrombolytic therapy underwent acute MRI. Patients with a diffusion weighted image and fluid attenuated inversion recovery mismatch (DWI-FLAIR Mismatch) on MRI were treated with thrombolytic therapy.Results: Chi-square test of independence showed patients who underwent the MRI protocol (N = 35) had a higher proportion of alteplase (tissue plasminogen activator,tPA) treatment when compared to a similar sample (N = 44) from 2019 acute stoke logs; ꭓ2 (1, N = 79) = 8.16, p = .006. Six patients received thrombolytic. Safety showed no symptomatic intracerebral hemorrhage (sICH) or deaths.

False hypoperfusion detected by RAPID software due to status epilepticus

Introduction: Automated CT Perfusion (CTP) has become an essential decision-making tool for treatment decision in the extended-time window of acute ischemic stroke. But its interpretation can be challenging. Making a correct diagnosis requires a good clinical examination, in conjunction with neuroimaging. Case report: We present a case of an 85-year-old patient who presented a seizure in the emergency room, followed by a left hemiplegia, language impairment and left gaze deviation. Stroke code protocol was performed, and RAPID software showed left hemisphere hypoperfusion. Detailed examination showed right hemisphere hyperperfusion with decreased Tmax in the left hemisphere. Active seizures were suspected, and an electroencephalogram was performed, which confirmed Non-convulsive status epilepticus from the right side. Conclusion: RAPID software should be interpreted cautiously. Clinical examination is essential, in order to not misdiagnose ischemic stroke in cases of images suggestive of hypoperfusion.

Determinants of Exclusion from Treatment with Alteplase in Acute Ischemic Stroke at the Largest Tertiary Center in Lebanon

Objectives: Thrombolysis remains underutilized for Acute Ischemic Stroke (AIS) in healthcare systems in low- and middle-income countries. We aimed to investigate the factors associated with utilization of intravenous thrombolysis in an academic medical center in Lebanon. Materials and Methods: This is a retrospective, cross-sectional, singlecentered, chart review-based study of AIS patients presenting to the American University of Beirut Medical Center (AUBMC) between January 2015 and October 2019. Included patients were older than 18 years and presented to the Emergency Department (ED) within 48 hours from symptom onset. Patient, disease, and health system response characteristics were collected and those eligible for and those who received thrombolysis within 4.5 hours onset by guidelines criteria were identified by chart review. Descriptive statistics, bivariate and multivariate analyses were performed for association with thrombolysis administration. Results: Out of the 373 AIS patients, 17.4% were candidate for rTPA and of those, 38.5% did not receive treatment. Patients who were candidate for IV alteplase had a higher NIHSS (OR 1.22 [1.14-1.31], p&lt;0.0001), total or partial anterior circulation stroke (OR 3.58 [1.49-8.6, p=0.004) as compared to posterior or lacunar strokes and a shorter duration since symptom onset (OR 0.14 [0.07- 0.27, p&lt;0.0001). The multivariate analysis showed that thrombolysis among eligible patients associated with younger age (OR 1.05 [1.01-1.10], p=0.029), a higher NIHSS (OR 1.12 [1.01-1.25], p=0.041), and stroke code activation (OR 2.81 [1.16-6.81], P=0.022). Conclusion: A good proportion of eligible AIS patients did not receive thrombolysis. To increase thrombolysis use in low- and middle-income countries, more consistent stroke code activation and education on age and stroke severity in eligibility are needed.