Management Of Acute Ischemic Stroke Research Articles

Effectiveness of a hybrid emergency room system in the management of acute ischemic stroke: a single-center experience

IntroductionHybrid emergency room systems (HERSs) have shown promise for the management of severe trauma by reducing mortality. However, the effectiveness of HERSs in the treatment of acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate the impact of HERSs on treatment duration and neurological outcomes in patients with AIS undergoing endovascular therapy.Materials and methodsThis single-center retrospective study included 83 patients with AIS who were directly transported to our emergency department and underwent endovascular treatment between June 2017 and December 2023. Patients were divided into the HERS and conventional groups based on the utilization of HERSs. The primary outcome was the proportion of patients achieving a favorable neurological outcome (modified Rankin Scale score 0–2) at 30 days. The secondary outcomes included door-to-puncture and door-to-recanalization times. Univariate analysis was performed using the Mann–Whitney U test for continuous variables and the chi-squared test or Fisher’s exact test for categorical variables, as appropriate.ResultsOf the 83 eligible patients, 50 (60.2%) were assigned to the HERS group and 33 (39.8%) to the conventional group. The median door-to-puncture time was significantly shorter in the HERS group than in the conventional group (99.5 vs. 131 min; p = 0.001). Similarly, the median door-to-recanalization time was significantly shorter in the HERS group (162.5 vs. 201.5 min, p = 0.018). Favorable neurological outcomes were achieved in 16/50 (32.0%) patients in the HERS group and 6/33 (18.2%) in the conventional group. The HERS and conventional groups showed no significant difference in the proportion of patients achieving favorable neurological outcomes (p = 0.21).ConclusionImplementation of the HERS significantly reduced the door-to-puncture and door-to-recanalization times in patients with AIS undergoing endovascular therapy. Despite these reductions in treatment duration, no significant improvement in neurological outcomes was observed. Further research is required to optimize patient selection and treatment strategies to maximize the benefits of the HERS in AIS management.

Experiencia de trombólisis en la ventana de tiempo terapéutica en pacientes con accidente cerebral isquémico agudo en una clínica de Lima

Experience of thrombolysis in the therapeutic time window in patients with acute ischemic stroke at Clínica Internacional, Lima is presented. An observational, descriptive, retrospective study was carried out for 5 years in 119 patients treated andhospitalized by the emergency service, of which 43 were acute ischemic cerebral events and only one met the criteria for emergency thrombolysis, having a favorable evolution and minimal sequelae. It is concluded that there is a need for a standardized protocol for the management of acute ischemic stroke, as well as the need for dissemination and education to the population for early recognition .

Differences between Acute Embolic and Atherosclerotic Middle Cerebral Artery Occlusion in Multiphase Arterial Spin-labeling Imaging.

Arterial spin-labeling magnetic resonance imaging (ASL-MRI) is widely used for evaluating collateral development in patients with acute ischemic stroke (AIS). This study aimed to characterize the findings of multiphase ASL-MRI between embolic and atherosclerotic large vessel occlusion (LVO) to aid in the differential diagnosis. Among 982 patients with AIS, 44 who were diagnosed with acute, symptomatic, and unilateral occlusion of the horizontal segment of the middle cerebral artery (MCA) were selected and categorized into embolic stroke (ES) and atherosclerosis (AT) groups. Using ASL-MRI (postlabeling delay [PLD] of 1.5, 2.0, and 2.5 s) at admission, the ipsilateral to contralateral ratio (ICR) of the signal intensity and its time-course increasing rate (from PLD 1.5 to 2.0 and 2.5, ΔICR) were measured and compared between the two groups. The mean ICR was significantly higher in the AT group than in the ES group (AT vs. ES: 0.49 vs. 0.27 for ICR1.5, 0.73 vs. 0.32 for ICR2.0, and 0.92 vs. 0.37 for ICR2.5). The ΔICR of PLD 1.5-2.0 (ΔICR2.0) and 2.5 (ΔICR2.5) were also significantly higher in the AT group than in the ES group (AT vs. ES: 50.9% vs. 26.3% for ΔICR2.0, and 92.6% vs. 42.9% for ΔICR2.5). Receiver operating characteristic curves showed moderate-to-strong discriminative abilities of each ASL-MRI parameter in predicting MCA occlusion etiology. In conclusion, multiphase ASL-MRI parameters may aid in differentiating intracranial LVO etiology during the acute phase. Thus, it is applicable to AIS management.

Comparative Analysis of Tenecteplase versus Alteplase in Acute Ischemic Stroke: A Multicentric Observational Study from Eastern India.

Tenecteplase is used as an alternative to alteplase and is considered noninferior for thrombolysis in acute ischemic stroke. To compare the effectiveness and adverse effects of tenecteplase and alteplase in the real-world management of acute ischemic stroke. In this retrospective observational study, we collected data from acute ischemic stroke patients admitted in six hospitals in West Bengal, India, and were thrombolysed with tenecteplase or alteplase between July 2021 and June 2022. Demographic data, baseline parameters, hospital course, and 3-month follow-up data were collected. The percentage of patients achieving a score of 0-2 in the modified Ranking scale at 3 months, rate of symptomatic intracranial hemorrhage, and all-cause mortality within 3 months were the main parameters of comparison between the two thrombolytic agents. A total of 162 patients were initially included in this study. Eight patients were excluded due to unavailability of follow-up data. Among the remaining patients, 71 patients received tenecteplase and 83 patients received alteplase. There was no statistically significant difference between tenecteplase and alteplase with respect to the percentage of patients achieving functional independence (modified Rankin scale score 0-2) at 3 months (53.5% vs. 60.2%, P = 0.706), rate of symptomatic intracranial hemorrhage (5.6% vs. 10.8%, P = 0.246), and all-cause mortality at 3 months (11.3% vs. 15.7%, P = 0.628). The effectiveness of tenecteplase is comparable to alteplase in the real-world management of acute ischemic stroke. Symptomatic intracranial hemorrhage and all-cause mortality rates are also similar in real-world practice.

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Alteplase in Acute Ischemic Stroke: A Time to Pass the Torch

Alteplase, a biosynthetic form of human tissue‐type plasminogen activator, is Food and Drug Administration‐approved for the treatment of acute ischemic stroke and currently the standard of care for thrombolytic therapy. Tenecteplase, a modified form of alteplase using recombinant technology, has several pharmacological advantages over alteplase, including longer half‐life, higher fibrin specificity, and greater resistance to plasminogen activator inhibitor‐1. Additionally, tenecteplase is given as a single bolus administration compared to the bolus plus 1‐hour continuous infusion of alteplase. Given these pharmacologic and logistical differences along with studies demonstrating noninferiority compared with alteplase, tenecteplase has become an alternative thrombolytic for the management of acute ischemic stroke. There is a growing body of evidence that suggests tenecteplase is a safe and effective alternative to alteplase. This systematic review evaluates the available literature for the use of tenecteplase in acute ischemic stroke and provides relevant discussion regarding role in therapy, therapeutic strategies, and areas requiring further research.

Critical Care: What You May Have Missed in 2023.

Critical care medicine is a specialty that brings together a truly wide spectrum of patient populations, disease states, and treatment methods. This article highlights 10 important pieces of research from 2023 (and 1 from 2022) in critical care. The literature was screened for new evidence relevant to internal medicine physicians and hospitalists whose focus of practice is not critical care but who may be taking care of seriously ill patients. The articles highlight the diverse spectrum of pathology and interplay of various specialties that go into critical care. Topics include transfusion medicine, fluid resuscitation, safe intubation practices and respiratory failure, and the management of acute ischemic stroke. Several trials are groundbreaking, forcing clinicians to reconsider preexisting dogma and likely adopt new treatment strategies.

Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke.

Stroke is the chief differential diagnosis in patient presenting to the emergency room with abrupt onset focal neurological deficits. Neuroimaging, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision-making. This review examines the current state of evidence behind the different imaging paradigms for acute ischemic stroke diagnosis and treatment, including current recommendations from the guidelines. Non-contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH), a pivotal juncture in stroke diagnosis and treatment algorithm, especially for early window thrombolytics. Advanced imaging such as MRI or perfusion imaging can also assist making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders. Identification of medium-large vessel occlusions with CT or MR angiography triggers consideration of endovascular thrombectomy (EVT), with additional perfusion imaging help identify salvageable brain tissue in patients who are likely to benefit from reperfusion therapies, particularly in the ≥6 h window. We also review recent advances in neuroimaging and ongoing trials in key therapeutic areas and their imaging selection criteria to inform the readers on potential future transitions into use of neuroimaging for stroke diagnosis and treatment decision making. ANN NEUROL 2024;95:1017-1034.

Remote Ischemic Conditioning With Medical Management or Reperfusion Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Remote ischemic conditioning (RIC) is a low-cost, accessible, and noninvasive neuroprotective treatment strategy, but its efficacy and safety in acute ischemic stroke are controversial. With the publication of several randomized controlled trials (RCTs) and the recent results of the RESIST trial, it may be possible to identify the patient population that may (or may not) benefit from RIC. This systematic review and meta-analysis aims to evaluate the effectiveness and safety of RIC in patients with ischemic stroke receiving different treatments by pooling data of all randomized controlled studies to date. We searched the PubMed, Embase, Cochrane, Elsevier, and Web of Science databases to obtain articles in all languages from inception until May 25, 2023. The primary outcome was the modified Rankin Scale (mRS) score at the specified endpoint time in the trial. The secondary outcomes were change in NIH Stroke Scale (NIHSS) and recurrence of stroke events. The safety outcomes were cardiovascular events, cerebral hemorrhage, and mortality. The quality of articles was evaluated through the Cochrane risk assessment tool. This study was registered in PROSPERO (CRD42023430073). There were 7,657 patients from 22 RCTs included. Compared with the control group, patients who received RIC did not have improved mRS functional outcomes, regardless of whether they received medical management, reperfusion therapy with intravenous thrombolysis (IVT), or mechanical thrombectomy (MT). In the medical management group, patients who received RIC had decreased incidence of stroke recurrence (risk ratio 0.63, 95% CI 0.43-0.92, p = 0.02) and lower follow-up NIHSS score by 1.72 points compared with the control group (p < 0.00001). There was no increased risk of adverse events including death or cerebral hemorrhage in the IVT or medical management group. In patients with ischemic stroke who are not eligible for reperfusion therapy, RIC did not affect mRS functional outcomes but significantly improved the NIHSS score at the follow-up endpoint and reduced stroke recurrence, without increasing the risk of cerebral hemorrhage or death. In patients who received IVT or MT, the benefit of RIC was not observed.

Update on the Acute Management of Ischemic Stroke

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. Bangladesh Crit Care J March 2024; 12 (1): 41-49

873 Code Brain Ultra-Early Clinical Pathway for Patient Identification and Management in Spontaneous Non-traumatic Intracranial Hemorrhage Single-Institution Study

INTRODUCTION: Spontaneous non-traumatic intracranial hemorrhage causes high morbidity and mortality. Clinical pathways for the management of acute ischemic stroke are well established but fall short in identifying intracranial hemorrhage, preventing early therapy. METHODS: Using Class 1 recommendations from the AHA/ASA Spontaneous Intracranial Hemorrhage Guidelines, our multi-disciplinary stroke team developed a hyper-acute clinical pathway. Once the hemorrhagic stroke patient was identified, protocolized measures were immediately initiated to lower systolic blood pressure to 140 mmHg, institute factor replacement therapies in coagulopathic patients and anti-platelet reversal when appropriate. Key performance indicators and quality metrics were established to compare post-intervention groups to the baseline cohort. RESULTS: Of 180 patients, 113 and 67 patients were treated pre- and post-protocol, respectively. From pre- to post-protocol, diagnosis of hemorrhagic stroke using the alert increased from 59% to 81%. Anti-hypertensive initiation within 60 minutes increased from 79.5% to 88.7%, with the average time from CT result decreasing from 32.7 to 21.7 minutes. Time to reversal agent decreased from 53 to 23 minutes for pro-coagulation agents and 106 to 55 minutes for DDAVP. Reversal agent initiation within 60 minutes of CT result increased from 66.6% to 100% for pro-coagulation agents and 28.5% to 84.6% for DDAVP. CONCLUSIONS: The initiation of this management protocol for hemorrhagic stroke resulted in a higher proportion of patients being rapidly identified and earlier initiation of anti-hypertensive and hemostatic therapies. These processes are the key to important interventions designed to reduce injury extension associated with intracranial hemorrhage, like “time to thrombolysis” measures for acute ischemic stroke.

Emerging therapies in the management of acute ischemic stroke: Innovative approaches and clinical outcomes- A comprehensive literature review

Worldwide, acute ischemic stroke continues to be the primary cause of death and disability, requiring ongoing improvements in treatment approaches. With an emphasis on current advancements in collateral evaluation, thrombolytic therapy, endovascular thrombectomy, and neuroprotective treatment, this review examines novel treatments for acute ischemic stroke. To find relevant research published in the past five years, a thorough search of academic databases was carried out. The inclusion criteria for the inclusion of articles on innovative therapeutics and their implications for managing acute stroke were methodological rigor and direct relevance. With an emphasis on the effectiveness and safety of Tenecteplase, the review emphasizes the crucial role that collateral circulation plays in forecasting patient response to reperfusion treatments and the changing landscape of thrombolytic drugs. Furthermore, the treatment of acute strokes has been transformed by developments in endovascular thrombectomy, which provides better functional results for patients with major artery occlusions. Additionally, neuroprotective drugs have potential as complementary treatments, especially when used in combination with reperfusion procedures. Novel treatments for acute ischemic stroke provide fresh chances to improve patient outcomes and lower stroke-related morbidity and death. To provide equal access to improved stroke care, solve outstanding difficulties, and enhance treatment regimens, further research is required.

Treatment of Acute Ischemic Stroke: The Last 30 Years of Trials and Tribulations.

The landscape of acute ischemic stroke management has undergone a substantial transformation over the past 3 decades, mirroring our enhanced comprehension of the pathology and progress in diagnostic techniques, therapeutic interventions, and preventive measures. The 1990s marked a pivotal moment in stroke care with the integration of intravenous thrombolytics. However, the most significant paradigm shift in recent years has undoubtedly been the advent of endovascular thrombectomy. This article endeavors to deliver an exhaustive analysis of this revolutionary progression.

Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions

BackgroundEndovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients...

Mechanical Thrombectomy via Transbrachial Approach in the Emergency Management of Acute Ischemic Stroke Patients with Aortic Pathologies: Our Experience and Literature Review.

Mechanical thrombectomy (MT) via the transbrachial approach (TBA) is a very rare option used in cases of patients with aortic pathologies and acute ischemic stroke (AIS) due to the insufficient evidence in the literature, the difficulty from a technical point of view and the result of this technique influenced by the complications that frequently accompany it. Only a few cases of patients with aortic pathologies and acute ischemic stroke where MT via TBA were reported in the literature, and its application in the emergency management of AIS has still not been dealt with in detail. Out of a need to clarify and clearly emphasize the effectiveness of this approach in emergency MT via TBA in patients with AIS and aortic pathologies, this literature review and case report has the following objectives: the first one is the presentation of an emergency MT via transbrachial approach performed in a 44-year-old patient with AIS and diagnosed aortic coarctation during transfemural approach (TFA), with successful reperfusion in our department and the second one is to review the cases reports of patients with different aortic pathologies and AIS reperfusion therapy performed by MT via TBA from the literature. A total of nine cases (one personal case and eight published cases) were revised in terms of aortic pathologies type, reperfusion therapy type, and the complication of both mechanical thrombectomy and local transbrachial approach. Mechanical thrombectomy through the transbrachial approach was the first choice in more than half of these cases (55.55%, n = 5 cases) in the treatment of acute ischemic stroke in the presence of previously diagnosed aortic pathologies. In one-third of all cases (33.33%, n = 3, our case and 2 case reports from the literature), the transbrachial approach was chosen after attempting to advance the guiding catheter through the transfemoral approach and intraprocedural diagnosis of aortic pathology. In only one case, after an ultrasound evaluation of the radial artery that showed a monophasic flow, MT was performed via TBA. Local transbrachial complication was reported in one case, and in two other cases, it was not stated if there were such complications. Hemorrhagic transformation of AIS was reported in two cases that underwent MT-only cerebral reperfusion via TBA, one with acute aortic dissection type A and our case of previously undiagnosed aortic coarctation. In the cases in whom short and long-term follow-up was reported, the outcome of treatment, which was not exclusively endovascular (77.77% cases with only MT and 33.33% with association of first thrombolysis and after MT), was good (six from nine patients). In two case reports, the outcomes were not stated, and one patient died after a long hospitalization in the intensive care unit from respiratory complications (our patient). Being a clinical emergency, acute ischemic stroke requires urgent medical intervention. In patients with aortic pathologies, where acute ischemic stroke emergency care is a challenge, mechanical thrombectomy via the transbrachial approach is a safe alternative method for cerebral reperfusion.

Is Thrombectomy Worth It for Isolated Posterior Cerebral Artery Occlusion? Meta‐Analysis and Trial Sequential Analysis

Background Thrombectomy is well‐established management for acute ischemic stroke involving large vessel occlusion. However. the potential efficacy of thrombectomy for isolated posterior cerebral artery occlusion remains limited. The study aims to evaluate the benefits of thrombectomy for isolated posterior cerebral artery occlusion. Methods We searched PubMed, Cochrane, and Embase for articles published until September 2023. The primary outcome was good functional outcome at 3 months. The secondary outcomes included excellent functional outcome at 3 months and early neurological improvement. The safety outcomes were symptomatic intracerebral hemorrhage, and mortality at 3 months. Results Seven retrospective studies involving 2560 patients with isolated posterior cerebral artery occlusion were included (876 patients receiving thrombectomy). The odds ratio (OR) of good functional outcome at 3 months was 0.93 (95% CI, 0.68–1.28) between 2 groups. The OR of excellent functional outcome (OR 1.23; 95% CI 0.92–1.64) and early neurological improvement (OR 1.82; 95% CI 0.97–3.40) were not different between the 2 groups. Compared with patients with best medical management, those with thrombectomy demonstrated a significantly increased risk of mortality (OR 1.81; 95% CI 1.24–2.65), whereas the risk of symptomatic intracerebral hemorrhage (OR 2.033; 95% CI 0.996–4.148) did not show an increase. Additionally, the results of trial sequential analysis indicated all outcomes were inconclusive. Conclusion Thrombectomy stands as an available procedure for patients with isolated posterior cerebral artery occlusion; however, it shows no notable benefits in reducing symptomatic intracerebral hemorrhage risk or enhancing function and may raise mortality compared with standard medical management. Further randomized controlled trials are necessary to yield more conclusive evidence.

Abstract HUP5: Patient and Hospital Characteristics Associated With Disparities in Acute Stroke Treatment in Community and Academic Hospitals

Introduction: Expedited transportation, identification, and coordination of care are essential drivers of optimal outcomes in the management of acute ischemic stroke (AIS), but systemic biases and barriers may affect these processes. We assessed patient- and hospital-level factors that may be associated with differences in prehospital and emergency department care processes for patients with AIS at academic medical centers (AMC) and those at community hospitals (CH). Methods: We retrospectively collected data from the electronic health record at an academic medical center (Tufts Medical Center) for adults age ≥ 18 hospitalized with AIS between 1/1/2018-12/31/2020, including patients who presented directly to the AMC versus patients transferred from a CH for further care. We performed multivariate analyses to assess predictors of emergency medical service (EMS) use, stroke code activation, door-to-CT time, and door-to-needle time across all patients and in each group. Results: 542 patients were included. AMC patients identifying as Asian (OR 0.25, 95% CI 0.13-0.47) and Hispanic (OR 0.19, 95% CI 0.05-0.72) and CH patients identifying as Black (OR 0.17, 95% CI 0.17-0.62) were less likely to use EMS compared to white patients. Patients with non-English primary language were less likely to use EMS (OR 0.38, 95% CI 0.23-0.63) compared to English-speaking patients in all hospitals. CH patients identifying as Hispanic were less likely to have stroke code activation (OR 0.24, 95% CI 0.05-0.86) compared to white patients. There were no differences in median door-to-CT or door-to-needle times between CH and AMC patients. In analyses including all patients, Asian race was associated with longer door-to-CT time (OR 1.25, 95% CI 1.03-1.49), and female sex was associated with longer door-to-needle time (OR 1.23, 95% CI 1.03-1.43). Conclusion: There are multiple potential sources of disparity in prehospital and hospital-based hyperacute care for patients with AIS including sex, race, ethnicity, and non-English primary language. These may represent opportunities for community outreach on EMS use, interventions to address systemic racism among healthcare providers, and interventions to alleviate language barriers.

Abstract WMP94: Quantifying the Enhanced Clinical Benefit of Endovascular Thrombectomy Performed With Contemporary Workflows and Devices

Background: To date, the magnitude of the benefit of endovascular thrombectomy (EVT) over medical management in acute ischemic stroke has been quantified by the data of the five breakthrough RCTs of 2015. But contemporary EVT care has faster EVT workflow speeds and achieves higher rates of reperfusion. Updated quantitative estimates of the benefit of EVT vs medical management are needed. Methods: Contemporary FDA-monitored (TIGER/ARISE II) and pivotal (HERMES) EVT trial group differences were quantified for workflow speed (door-to-reperfusion time) and reperfusion rates (eTICI distribution). The projected effect of the faster workflow speed in further improving disability (mRS) outcomes were calculated using established HERMES treatment time-benefit models and the projected effect of higher reperfusion rates using established HERMES eTICI tier-specific outcomes. Results: Contemporary EVT trial groups, compared with pivotal trial EVT groups, had door-to-reperfusion 57 minutes faster (146m vs 89m), successful reperfusion 22.6% more often (71.0% vs 93.6%), and excellent reperfusion 45.1% more often (29.4% vs 74.5%). Figure 1 shows the resulting projected improvements in mRS distributions. For functional independence (mRS 0-2), outcome rates for MM vs pivotal EVT vs contemporary EVT were 25.2% vs 44.6% vs 74.5%. The number needed to treat (NNT) for 1 more patient to achieve functional independence improved from 5.2 to 2.5. For nondisabled outcome (mRS 0-1), outcome rates were 10.1% vs 27.4% vs 46.0%. The NNT for 1 more patient to achieve nondisabled outcome improved from 5.8 to 2.8. Over the entire mRS range, the NNT for 1 more patient to have less disability by at least one mRS level improved from 2.6 to 1.6. Conclusion: Formal modeling indicates that contemporary EVT confers substantially enhanced benefits over medical management. Among every 100 patients treated with EVT, 63 will have a less disabled long-term outcome including 36 more becoming disability-free.

Abstract 152: Endovascular Therapy versus Medical Management for Acute Ischemic Stroke With Large Infarct: A Time-Benefit Relationship Analysis

Objective: Recent randomized trials demonstrated the benefit of endovascular thrombectomy for acute ischemic stroke with large infarct. We aimed to characterize the effect of time to treatment on the benefit of endovascular therapy compared to medical management among patients with acute large ischemic stroke. Methods: Analysis the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core trial (ANGEL-ASPECT), which was a multicenter, randomized trial at 46 comprehensive stroke centers in China from August 2020 to October 2022. Onset to arterial puncture time (OPT) associated with outcomes of endovascular therapy were analyzed as a category and continuous variable. The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Secondary outcomes included degree of disability (modified Rankin scale range), symptomatic intracranial hemorrhage, any intracranial hemorrhage, and mortality. Results: Among 455 eligible patients, the median age was 68 years, and median Alberta Stroke Program Early Computed Tomography Score was 3 (interquartile range 3-4). Compared with medical management alone, endovascular therapy plus medical management was associated with higher rates of favorable outcome with OPT within 6 hours (44.4% vs 29.9%, adjusted odds ratio[aOR] 2.78 [95% confidence interval [CI] 1.22-6.32]), 6-12 hours (45.7% vs 29.6%, aOR 2.39 [95% CI 1.21-4.71]), but not in OPT beyond 12 hours (51.6% vs 41.4%, aOR 2.05 [95% CI, 0.88-4.77]). The benefit in favorable outcome became nonsignificant after OPT of 13 hours and 22 minutes. In three OPT intervals, the odds of better disability outcome with endovascular therapy plus medical management than medical management alone were observed; the rates of symptomatic intracranial hemorrhage and mortality were similar, though the rates of any intracranial hemorrhage increased. Conclusion: In patients with large cerebral infarction, endovascular therapy plus medical management was efficacious in improving functional outcomes with acceptable safety in a broad time window of 0 to 24 hours, but greater benefit was observed with earlier treatment. A pooled analysis with larger sample size is needed.

Abstract TMP16: Impact of Door-to-Imaging and Imaging-to-Door Times on Door-in-Door-out Times in Interhospital Transfers of Patients With Stroke

Introduction: Urgent inter-hospital transfer ensures timely access to therapies for acute ischemic stroke. Door-in-door-out (DIDO) represents the total amount of time a patient spends in the transferring emergency department (ED) before transfer. DIDO time is an important quality metric for the care of acute stroke; however, little is known about the influence of process steps on DIDO times and which steps most often cause delays. Methods: This was a retrospective cohort study of patients in the American Heart Association Get With The Guidelines®-Stroke registry with ischemic stroke presenting January 2019 to December 2021 transferred from the ED at the presenting hospital to another acute care hospital for evaluation of thrombolytics, endovascular therapy or post-thrombolytic care. The primary independent variables were door-to-imaging and imaging-to-door times, and the primary outcome was DIDO time. Multivariate GEE regression models were performed to assess the comparative contributions of interval process times to variation in DIDO time, controlling for patient and hospital-level characteristics. Results: Among 24,662 patients (50.5% male, mean age 68.3 years, 73.2% White), mean DIDO time was 171.4 min (SD: 149.5), mean door-to-imaging time was 18.3 min (SD: 34.1) and mean imaging-to-door time was 153.1 min (SD: 141.5). A 1 min increase in door-to-imaging time was associated with a 1.33 min increase in the mean DIDO time, while a 1 min increase in imaging-to-door time was associated with a 1.02 min increase in mean DIDO time. The baseline model (without door-to-imaging or imaging-to-door included) had an R2 of 0.03. With door-to-imaging included in the GEE model, R2 was 0.13; whereas the model with imaging-to-door included had an R2 of 0.95. Conclusion: Imaging-to-door time accounts for a greater proportion of the variance in DIDO times than door-to-imaging time. Though the opportunity for improvement in DIDO is greater through reduction of imaging-to-door time, door-to-imaging time has greater per-minute effect on DIDO. While existing guidelines and care resources heavily focus on reducing door-to-imaging times, further attention is warranted to reduce imaging-to-door times in the management of acute ischemic stroke.

Clinical and organisational quality indicators for the optimal management of acute ischaemic stroke in the era of thrombectomy: a scoping review and expert consensus study

ObjectiveThe purpose of this study is to identify clinical and organisational quality indicators conducive to the optimal interdisciplinary management of acute-phase ischaemic stroke.MethodA scoping review based on the six-step methodological...