Rates Of Mechanical Thrombectomy Research Articles

Nationwide Incidence and Trends in Central Retinal Arterial Occlusion Management: A 5000-Patient Analysis.

Central retinal artery occlusion (CRAO) is a rare and visually debilitating vascular condition characterized by sudden and severe vision loss. CRAO is a compelling target for intravenous alteplase (tPA) and endovascular mechanical thrombectomy (MT) due to pathophysiological similarities with acute ischemic stroke; however, the utility of these interventions in CRAO remains dubious due to limited sample sizes and potential risks. To assess usage and outcomes of tPA and MT in CRAO, we queried the National Inpatient Sample database using International Classification of Disease, Ninth and Tenth edition for patients with CRAO and acute ischemic stroke between 2010 and 2019. Our cohort of 5009 CRAO patients were younger with higher rates of obesity, hypertension, long-term anticoagulant use, and tobacco use compared to acute ischemic stroke patients. CRAO patients had lower rates of tPA administration (3.41% vs 6.21%) and endovascular MT (0.38% vs 1.31%) but fewer complications, including deep vein thrombosis, pneumonia, urinary tract infection, acute kidney injury, and acute myocardial infarction (all P < 0.01). CRAO patients had lower rates of poor functional outcome (31.74% vs 58.1%) and in-hospital mortality (1.2% vs 5.64%), but higher rates of profound blindness (9.24% vs 0.58%). A multivariate regression showed no relationship between tPA and MT and profound blindness, although the limited sample size of patients receiving interventions may have contributed to this apparent insignificance. Further investigation of larger patient cohorts and alternative treatment modalities could provide valuable insights for revascularization therapies in CRAO to optimize visual restoration and clinical outcomes.

In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case-control study.

Stroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment. Observational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients. The in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0-2 at discharge was similar in both groups when adjusting for NIHSS score and age. The same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care.

Abstract 139: Regional Disparities in Mechanical Thrombectomy Utilization for Treatment of Acute Ischemic Stroke in the United States

Background: A current national priority is to understand geographic disparities in mechanical thrombectomy (MT) provision for patients with acute ischemic stroke (AIS). We examine variation in rates of MT by geographic region and urban-rural areas to identify utilization disparities across the United States. Methods: The state-specific annual incidence of AIS in 2019 was determined using data from the Global Burden of Disease Collaborative Network. We determined the number of patients who were admitted with AIS due to thrombosis or embolism of anterior circulation arteries and those who received MT in a particular region/state based on the State Inpatient Database of NIS. The National Inpatient Sample data were used to create national weighted estimates of the size of subject populations, age at admission, length of stay, and discharge status. Results: In the United States, approximately 28,165 MT were performed in 2019, representing 4% of the AIS population. In large central metropolitan areas, the proportion of thrombectomies performed to the AIS patient population was significantly higher than the national estimate (4.34%, P &lt; 0.001); small metropolitan areas and rural settings (micropolitan and noncore) had significantly lower proportions of MT-treated patients with 3.2% and 2.9%, respectively (P &lt; 0.001), when compared with the national estimate. West region had significantly higher proportions of MT-treated patients with 4.3%, compared with the national estimate (P &lt; 0.001), whereas South region had significantly lower proportions with 3.8% (P &lt; 0.001). Conclusions: We found prominent regional disparities in the utilization rates of MT in acute ischemic stroke patients in the United States, which may have implications for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities.

WITHDRAWN: Malignant transformation of ischemic stroke in the era of mechanical thrombectomy: When is decompressive craniectomy required?

ObjectiveThe treatment of choice for ischemic stroke due to intracranial arterial occlusion of the anterior circulation has been mechanical thrombectomy (MT). The success rate of MT is described as 71%, but malignant infarction can nonetheless ensue. In these cases, decompressive craniectomy (DHC) is often necessary. To date, only few factors are known to correlate significantly with the need for DHC after MT. MethodsWe conducted a retrospective analysis of patients admitted with anterior circulation stroke at our department who underwent MT with and without subsequent DHC. Patients were matched according to ASPECT score on pre-MT CT scan. Established predictors for neurological outcome, TICI grade of recanalization, as well as imaging were then compared between the groups to elucidate which of them were predictive of DHC. ResultsA total of 86 patients were included in the analysis. DHC was performed in 43 patients (50%). In a univariate analysis, male sex (p = 0.037), lower TICI grade of recanalization (p < 0.001) and hemorrhagic transformation (p = 0.014) were predictive of DHC. Patients who received later intravenous thrombolysis were also at higher risk for needing DHC (p = 0.050). Patients suffering from hypercholesterolemia (p < .001) and who were on antiplatlet agents (p = .039) were at lower risk for needing DHC. ConclusionsPatients with higher rates of recanalization were protected against DHC. Later administration of IV tPA was correlated with DHC, thus suggesting a synergistic effect of IV tPA and MT in protecting against malignant transformation. Prior use of antiplatelet agents appears to be a protective factor against DHC in stroke, which warrants further investigation.

Abstract TP46: Improving Efficiency of Interfacility Transfer for Mechanical Thrombectomy: Delaware Stroke System Experience

Introduction: Delaware (DE) created a stroke system with a primary objective to improve the interfacility transfer process between DE PSCs and its only CSC to improve efficiency and outcomes for mechanical thrombectomy (MT) transfer patients. Methods: The DE stroke system, including stroke coordinators/medical directors and EMS, defined criteria for MT eligibility, identified barriers to transfer, and implemented the interventions listed below. Data on transfer volumes, thrombectomy rates, and outcomes were collected. Objectives were to improve early detection of MT eligible patients, improve rate of thrombectomy on MT transfers, and track patient outcomes (mRS 0-2 at 90 days). • MT eligibility defined as any patient with a significant/disabling deficit with target lesion identified on CTA. • Implementation of “EZ” button in PSC EDs for early activation of flight team for suspected MT candidates upon initial clinical evaluation. • Time goal of 30 min for PSC arrival to call out to CSC for MT candidates. • Implementation of RAPID.AI platform at PSCs to allow CSC immediate access to imaging. • Revision of CSC transfer process: conference call with transfer center, PSC physician, and CSC stroke team physicians to discuss case. • Transport expedited for MT eligible patients; ineligible patients stay at PSC. • CSC provides outcome feedback and time goals to PSC on each transfer. • Variant cases reviewed by CSC and DE Stroke System Quality &amp; Data committee as needed. Results: From FY22 to FY23, there was a 39% increase in MT transfers, 20% increase from 52% to 72% in rate of thrombectomy, and 15% increase in # patients in mRS 0-2 category at 90d (figure 1). Conclusion: By implementing collaborative and focused interventions, the DE stroke system increased rates of MT in transferred patients while reducing unnecessary transfers and improving patient outcomes.

Abstract TP208: Pre-Existing Dementia Should Not Be Independently Associated Short-Term Functional Outcome in Patients With Acute Ischemic Stroke: A Sub-Analysis of the PASTA Registry Study

Background: The aging of the population is associated with an increasing number of stroke patients with pre-existing dementia. However, the association between pre-stroke dementia and functional outcome after acute ischemic stroke (AIS) has not been fully investigated. We aimed to investigate the association between PED and functional outcome in patients with AIS. Methods: We conducted a sub-analysis of the PASTA registry, an observational, multicenter registry of 1,043 patients with stroke receiving oral anticoagulants in Japan, by including patients with AIS with atrial fibrillation (AF). PED was defined as any type of dementia that was present prior to the index stroke. Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-5 or death (mRS score 6). We compared the clinical characteristics and the rate of recanalization therapy between PED and non-PED and determined the effect of PED on stroke outcome. Results: Of all 493 participants (median age, 80 years; 212, 43.0% women), 86 (17.4%) had PED. PED were older (P&lt;0.001), had a higher prevalence of congestive heart failure (P&lt;0.001), a greater severity at onset and upon discharge compared to those with non-PED (P=0.0015 and P&lt;0.001, respectively). Although the rate of rtPA was higher in patients with PED than those with non-PED (P=0.0398), there was no significant difference of the rate of mechanical thrombectomy (MT) and rtPA with MT (P&gt;0.05) and intracerebral hemorrhage between PED and non-PED groups (Both P&gt;0.05). The frequencies of poor functional outcome were significantly higher in patients with PED than in those without PED (80.2 vs. 57.0%, P &lt; 0.0001). In multivariable analyses, age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00-1.09, P=0.0318], pre-stroke mRS (OR; 2.05, 95% CI 1.61-2.67, P&lt;0.001), initial National Institutes of Health Stroke Scale score (OR; 1.21, 95% CI 1.16-1.27, P&lt;0.001) and parenchymal hematoma type1/2 (OR; 5.35, 95% CI 1.15-24.88, P=0.0323), but not PED (OR; 1.74, 95% CI 0.76-3.98, P=0.1919), were associated with poor functional outcome. Conclusions: PED is not independently associated with poor functional outcome upon discharge after adjustment for baseline characteristics, pre-stroke dependency, initial stroke severity or stroke management.

The impact of thrombus surface morphology of the basilar artery on the successful rate of mechanical thrombectomy

The impact of thrombus surface morphology of the basilar artery on the successful rate of mechanical thrombectomy

Abstract 274: Mechanical Thrombectomy for Ischemic Stroke in Elderly Population

Introduction Stroke is a leading cause of mortality and morbidity worldwide and the risk increases with age. Mechanical thrombectomy (MT) in eligible patients is proven to improve outcomes and is ow standard of care for acute ischemic stroke. Clinical trials evaluating MT often exclude patients older than 80 and available scientific evidence supporting MT in elderly is limited and varied. Purpose of this systematic review is to examine current literature on efficacy and outcomes of MT in octogenarian and nonagenarian stroke patients. Methods A literature search was conducted using PubMed and Scopus from 2013‐2023. All studies that included patients 80 yrs and older with acute ischemic stroke who underwent MT and provided 90‐day clinical outcomes and rates of complications were reviewed. Results Review identified 25 publications and the median age of study populations ranged from 82 to 93.3 years with proportion of female patients higher in all studies. Success rate of MT ranged from 66.7% to 97%. Symptomatic intracranial hemorrhage was the common complication ranging from 3% to 28%. The 90‐day mortality rate ranged from 7% to 70%. No differences were noted between octogenarians and nonagenarians. Conclusion MT in elderly patients had high reperfusion rates indicating procedural success, and variable clinical outcomes with wide range of complication and mortality rates. Factors influencing MT outcomes in elderly are discussed and the need for randomized control trials providing the highest level of scientific evidence for MT in this population is emphasized.

Abstract 279: Angiography Utilization in LVO Drip‐and‐Ship Patients: Comparing Air and Ground

Introduction Patients with acute intracranial large vessel occlusions (LVO) in the drip‐and‐ship model are transferred from an outside hospital (OSH) to a comprehensive stroke center (CSC) after receiving thrombolysis. In our practice, while most of these patients go directly to the angiography suite (DTA), some of them spontaneously recanalize and may not need mechanical thrombectomy (MT). We aim to assess the impact of transport modality on the efficacy of tPA‐induced recanalization by assessing rates of groin puncture, MT, and clinical outcomes. Methods We retrospectively evaluated 270 patients from 2020‐mid 2022 with either confirmed or suspected LVO in our healthcare network who received tPA at an OSH and were transported by either air or ground transport to our spoke hospital (CSC) with the intention of receiving MT. We compared baseline characteristics and then applied linear regression with propensity score matching to compare the air and ground groups. Between the two groups, we looked at the difference in the rates of change in NIHSS between OSH and TTH (delta NIHSS), groin puncture rates, rate of receiving mechanical thrombectomy (MT), rate of angiography alone without MT, and modified Rankin Scale (mRS) at 90 days. Results Of the 270 patients evaluated, 1 patient was excluded due to missing transport modality. 130 (48.33%) were transferred by ground transport and 139 (51.67%) by air. Baseline characteristics were similar between the air and ground groups with the exception of OSH NIHSS which was higher in the air group (13.59±8.3 vs. 10.4±7.81, p&lt;0.001). In a linear regression model, air transport was not a significant predictor of improvement of NIHSS from OSH to CSC (p=0.69, R2=0.002) or groin puncture rate (OR=1.5, 95% CI 0.412‐ 5.471, p=0.54). Of the 198 confirmed LVO on CTA, 47.26% of air patients received MT compared with 48.74% (OR: 1.1, p=0.62) of ground patients. 11.32% of these confirmed LVO patients who were transported by air received angiography without mechanical thrombectomy compared to 11.68% of ground patients (OR: 2.1, p=0.1). A linear regression model with propensity matching did not show transport modality as a predictor of mRS at 90 days (p=0.32, R2=0.14). Conclusion LVO patients who receive tPA and are transferred by air directly to the angiography suite have a higher baseline NIHSS than those transported by ground. Mode of transport does not seem to predict changes in NIHSS or 90 day mRS in this population. Groin puncture, mechanical thrombectomy, and angiography without MT rates are similar between these groups. Mode of transport alone may not influence angiography utilization or clinical outcome so distance between sites and speed of transport should be used to determine whether air or ground is the better choice in each individual case.

The effect of COVID-19 on treatment and outcomes following ischemic stroke: A national assessment

IntroductionCOVID-19 has had innumerable impacts on the healthcare system, both by worsening patient illness and impeding effective and efficient care. Further, COVID-19 has been tied to increased rates of ischemic stroke, particularly among young patients. We utilized a national database to assess associations of COVID-19 with thrombectomy rates, mortality, and discharge disposition among stroke patients. MethodsPatients were identified from the National Inpatient Sample (NIS, 2020). Inclusion criteria selected for adult ischemic stroke patients; those with venous thrombosis or unspecified cerebral infarction were excluded. Patients were stratified by presence or absence of COVID-19 diagnosis. Outcome variables included mechanical thrombectomy, in-hospital mortality, and discharge disposition. Additional patient demographics, hospital characteristics, and disease severity metrics were collected. Statistical analysis was performed via multivariable logistic regression and log-binary regression. Results54,368 patients were included in the study; 2116 (3.89%) were diagnosed with COVID-19. COVID-19 was associated with lower rates of mechanical thrombectomy (OR 0.94, p < 0.0001), higher rates of in-hospital mortality (OR 1.14, p < 0.0001), and unfavorable discharge disposition (OR 1.08, p < 0.0001), even when controlling for illness severity. Other relationships, such as a male predominance among stroke patients with COVID-19, were also identified. ConclusionThis study identified a relationship between COVID-19 diagnosis and worse outcomes for each metric assessed, including mechanical thrombectomy rates, in-hospital mortality, and discharge disposition. Several factors might underly this, ranging from systemic/multisystem inflammation and worsened disease severity to logistical barriers to treatment caused by COVID-19. Further research is needed to determine causality of these findings.

Mechanical Thrombectomy for Acute Ischemic Stroke in A Mekong Delta Medical University Hospital

Introduction: Mechanical thrombectomy has become more and more common in the treatment of acute cerebral ischemic stroke. We report our 3-year outcomes of mechanical thrombectomy for ischemic stroke.&#x0D; Method and subjects: A descriptive study was conducted cross-sectionally. Each patient with a National Institute of Health Stroke Scale (NIHSS) score of 10 or higher who presented to our hospital within eight hours of the onset of the first symptom would be considered. The mechanical thrombectomy procedure is performed with aspiration techniques or in combination with stent retrievers, with or without rescue angioplasty and stenting.&#x0D; Results: From January 1st, 2018, to December 31st, 2020 (36 months), a total of 53 patients were included. Forty-four (44) patients had thrombectomy only, and another 9 patients had thrombectomy with stenting. The total technical success rates were 47/53 (88.6%). The death rate was 15/53 (28.3%). There were 31/53 patients (58.4%) who had significant recovery in motor movement, language, and cognition within 2 months.&#x0D; Conclusion: Our revascularization rate of mechanical thrombectomy was 88.6% with 58.4% of patients showing improved outcomes.

The gut-brain connection: Inflammatory bowel disease increases risk of acute ischemic stroke.

Chronic inflammation of the gastrointestinal tract is a hallmark of inflammatory bowel disease (IBD). This increased inflammation is thought to induce a hypercoagulable state that increases the risk for stroke. However, few studies have examined the association between IBD and acute ischemic stroke (AIS). Thus, this study aims to investigate the incidence, treatments, complications, and outcomes of AIS in patients with IBD. ICD-9-CM and ICD-10-CM codes were used to query the National Inpatient Sample for AIS and IBD diagnosis. Baseline demographics, clinical characteristics, complications, treatments, and outcomes were assessed through descriptive statistics, multivariate regression, and propensity score matching (PSM) analysis. Acute stroke severity was assessed using the National Institute of Heath's Stroke Severity Score (SSS) as a template. 1,609,817 patients were diagnosed with AIS between 2010 through 2019. 7468 (0.46%) had concomitant diagnoses of IBD. AIS patients with IBS were younger, more likely to be white and female, but less likely to be obese. Although IBD patients had comparable stroke severities (p = 0.64) to their non-IBS counterparts, they received stroke intervention at statistically different rates than their non-IBD counterparts. Additionally, IBD patients had higher rates of in-hospital complications (p < 0.01) and longer lengths of stay (LOS) (p < 0.01). IBD patients develop AIS at a younger age with similar rates of stroke severity to their non-IBD counterparts, but receive higher rates of tissue plasminogen activator administration and decreased rates of mechanical thrombectomy. Our research shows that patients with IBD are at risk for AIS at an earlier age and are more likely to have complications. This underlies a connection between IBD and a hypercoagulable state that could predispose patients to AIS.

Current territorial organization for access to revascularization therapies for acute ischemic stroke in the Veneto region (Italy) from 2017 to 2021.

To evaluate the access to treatments with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) in acute ischemic stroke patients admitted to stroke units (SUs) of Veneto region (Italy) according to current "hub-and-spoke" model from 2017 to 2021. We retrospectively analyzed data on treatments with IVT and/or MT for stroke patients admitted to the 23 SUs (6 Hubs and 17 Spokes) of the 6 macro-areas including 9 local sanitary units (LSUs) and 2 hospitals. We reported 6093 treatments with IVT alone, 1114 with IVT plus MT, and 921 with MT alone. Number of stroke unit (SU) beds/100,000 inhabitants ranges from 2.3 to 2.8, and no difference was found among different macro-areas. Number of treatments/100,000 inhabitants/year ranges from 19 to 34 for IVT alone, from 2 to 7 for IVT plus MT, and from 2 to 5 for MT alone. Number of IVT alone/SU bed/year ranges from 9 to 21 in the Hub and from 6 to 12 in the Spokes. Rate of IVT plus MT in patients directly arrived in the same LSU's Hub ranges from 50 to 81%, likewise the one of MT alone ranges from 49 to 84%. Treatment target rates of IVT and MT set by Action Plan for Stroke in Europe 2018-2030 has been globally exceeded in the Veneto region. However, the target rate of MT and access revascularization treatments is heterogeneous among different macro-areas. Further efforts should be made to homogenize the current territorial organization.

Abstract HUP2: Assessment Of Acute Ischemic Stroke Disparities By Primary Language In A High Patient Volume Comprehensive Stroke Center Serving A Diverse Metropolitan City

Background: Language barriers can have a major impact on the quality of care that patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of patient language on quality benchmarks of AIS therapy and clinical outcomes at a high-volume comprehensive stroke center (CSC). Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores (NIHSS), discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent primary languages including English, Spanish, Russian, Farsi, Korean and Other. All non-English speaking patients received medical interpretation via digital or in-person translation. Results: 3,812 AIS patients were identified. English language represented 80.2% (n=3091), Spanish 7.6% (n=238), Russian 4.1% (n=184), Farsi 3.0% (n=129), Korean 1.5% (n=47) and Other 3.6% (n=122).There were no significant differences in the rate of intravenous thrombolysis (P=0.52), door-to-needle time (P=0.91), door-to-puncture time (P=0.85), LOS (P=0.089) and 30 day readmission (P=0.74) among groups. In univariable analysis, Spanish 74.7%, Korean 84.4%, Russian 73.4%, Farsi 78.2% and Other 70.0% had significantly (P&lt; 0.05) higher rates of post stroke disability (mRS&gt; 2) compared to the English group 60.7%. A higher rate of 30-day mortality was noted in the Korean 17.8% compared to the English group 7.3%. The Spanish group had a higher rate of mechanical thrombectomy than the English group (11.8 vs 6.5%, P=0.009). Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression models for post stroke disability (mRS&gt;2) continued to show significant differences with Spanish (OR=1.66, P=0.008) and Farsi (OR=1.89, P=0.017) vs English. Conclusions: Our analysis reveals persistent disparities in AIS outcomes by primary language, with patients with limited English proficiency suffering worse disability after AIS. The effect of communication barriers on outcomes of stroke care in the inpatient setting requires further evaluation to close this gap.

The Effect of Atrial Fibrillation on Recanalization and Prognosis in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy and/or Intravenous Thrombolysis

ABSTRACT Background: Atrial fibrillation (AF) is the most common cause of cardioembolic ischemic strokes. It causes large-vessel occlusions and a poor prognosis. Regardless of ischemic stroke etiology, hyperacute therapy strategies are effective treatment modalities. Methods: Patients who were diagnosed as having AF were classified as AF (+) and others without AF were classified as AF (-). It is not clear which treatment should be preferred in patients with stroke who are AF (+). We studied demographic characteristics, recanalization rates, and clinical outcomes in acute patients with ischemic stroke with or without nonvalvular AF who underwent hyperacute treatments. Results: We detected that clinical findings were more severe and the NIHSS scores were significantly higher at admission inpatients who were AF (+). In our study, mechanical thrombectomy rates were high in patients who were AF (+), whereas intravenous tissue plasminogen activator treatment rates were higher in patients who were AF (-). Thrombolysis in cerebral infarction scores were similar in our patient groups. We found high rates of both symptomatic (PH 2) and asymptomatic hemorrhagic transformation in patients who were AF (+) in 24th-h cranial computed tomography. A positive correlation was found between symptom-admission, symptom-needle, and symptom-groin times and discharge-modified Rankin Scale scores regardless of the hyperacute treatments in all patient groups. Conclusion: As a result, physicians should focus on the diagnosis of AF, and appropriate anticoagulant treatment is important for primary prevention.

Association Between Stroke Presentation During Off‐Hours and Mechanical Thrombectomy

Background Access to mechanical thrombectomy (MT) in the United States remains limited. Given potential staffing challenges, we hypothesized that access to thrombectomy would be worse off hours. Methods We used 2016 to 2018 all‐payer claims data from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Using recorded arrival times, hospital presentation was classified as on hours if it fell between 8:00 a.m. and 6:00 p.m. on weekdays and as off hours otherwise. We examined the association between off‐hours arrival and MT using multiple adjusted logistic regression models. In a subset of patients with available National Institutes of Health Stroke Scale data, we performed a sensitivity analysis limited to patients who presented to a thrombectomy hub with a probable large‐vessel occlusion, defined as a documented National Institutes of Health Stroke Scale score ≥12, and underwent intravenous thrombolysis. Similar analyses were performed to assess MT odds during extreme off hours, defined as midnight to 6:00 a.m., compared to 8:00 a.m. to 2:00 p.m. Results Among 169 199 patients with ischemic stroke, the 82 784 (48.9%) who presented during off hours more often presented to thrombectomy hubs and teaching hospitals and more often received intravenous thrombolysis. Among 31 148 patients with documented National Institutes of Health Stroke Scale scores, those presenting off hours had higher scores (4 [interquartile range, 2–10] versus 2 [interquartile range, 1–9]; P &lt;0.001). There were no differences between groups in rates of MT (3.4% on hours versus 3.5% off hours; P =0.25). In adjusted models, off‐hours presentation was not significantly associated with lower odds of MT (odds ratio [OR], 0.94; [95% CI, 0.85–1.03]). Our findings were similar in a sensitivity analysis limited to patients with a probable large‐vessel occlusion who initially presented to a thrombectomy hub and underwent intravenous thrombolysis (OR, 0.87; [95% CI, 0.69–1.09]). Extreme off‐hours presentation was associated with a lower likelihood of MT (OR, 0.83; [95% CI, 0.75–0.93]). Conclusion In a large, population‐based sample of ischemic stroke patients across the United States, the odds of MT were similar during on and off hours. Extreme off hours seem to be associated with decreased access to treatment.

Differences in Performance on Quality Measures for Thrombectomy‐Capable Stroke Centers Compared With Comprehensive Stroke Centers in 2019 to 2020

Background Thrombectomy‐Capable Stroke Center (TSC) certification was created to improve timely access to mechanical thrombectomy (MT), where travel to a Comprehensive Stroke Center (CSC) would entail prolonged transport time. No study has evaluated the quality of MT and stroke care at TSCs compared with CSCs. Methods We compared performance for 3 MT measures for all TSCs and CSCs certified by The Joint Commission in 2019 and 2020: (1) time from arrival to skin puncture, (2) the percentage of patients who achieved Thrombolysis in Cerebral Infarction ≥2B perfusion, and (3) the proportion of patients with symptomatic hemorrhagic transformation following MT. Wilcoxon ranked‐sum tests and signed‐rank tests were used to compare TSCs and CSCs within years and changes in performance from 2019 to 2020. Results The median time from arrival to skin puncture was 75.8 minutes for CSCs compared with 106.1 minutes for TSCs in 2019 ( P &lt;0.001) and 74.8 minutes for CSCs compared with 91.7 minutes for TSCs in 2020 ( P &lt;0.001). For TSCs, the median time was 11.2 minutes lower in 2020 compared with 2019 ( P &lt;0.005). There were no differences in the median proportion of patients who had Thrombolysis in Cerebral Infarction ≥ ${\text{Thrombolysis in Cerebral Infarction}} \ge $ 2b perfusion achieved for CSCs compared with TSCs in 2019 (85.2% versus 84.3%, respectively; P =0.87) or 2020 (86.9% versus 88.6%, respectively; P =0.73). Rates of symptomatic hemorrhagic complications were similar. Conclusions Times from arrival to skin puncture were longer at TSCs compared with CSCs, although this difference narrowed significantly in 2020. This improvement and the similar rates of successful MT and complications at TSCs and CSCs support current recommendations to transport patients with suspected large‐vessel occlusion to a TSC if a CSC is &gt;30 minutes longer transport time. However, routing decisions for suspected large‐vessel occlusion must be made at a local level based on the performance data for TSCs and CSCs.

Abstract WP57: Association Between Stroke Presentation During Off-hours And Mechanical Thrombectomy

Background: Access to mechanical thrombectomy in the US remains limited, in part due to a relative lack of trained interventionalists. Given potential staffing challenges, we hypothesized that access to thrombectomy would be worse on nights and weekends. Methods: We used 2016-2018 all-payer claims data from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Using recorded arrival times, hospital presentation was classified as on-hours if it fell between 8:00 a.m. and 6:00 p.m. on weekdays and as off-hours otherwise. For patients who underwent interhospital transfer, we used the arrival time at the initial hospital. We examined the association between off-hours arrival and mechanical thrombectomy using multiple logistic regression adjusted for age, sex, race/ethnicity, insurance type, socioeconomic status, urban-rural location of residence, the Charlson comorbidity index, initial presentation to a thrombectomy hub, and treatment with intravenous thrombolysis. We performed a sensitivity analysis limited to patients who presented with a probable large-vessel occlusion, defined as a documented NIHSS score ≥12, to a thrombectomy hub and underwent intravenous thrombolysis. Results: Among 169,199 patients with ischemic strokes, the 82,784 (48.9%) who presented during off-hours had higher NIHSS scores (4 [IQR, 2-10] vs 2 [IQR, 1-9], P &lt;0.001) and underwent thrombolysis more often (9.3% vs 8.5%, P &lt;0.001). There were no differences between groups in rates of mechanical thrombectomy (3.4% on-hours vs 3.5% off-hours, P = 0.25). In adjusted models, off-hours presentation was not significantly associated with lower odds of mechanical thrombectomy (OR, 0.94; 95% CI, 0.85-1.03). Our findings were similar in a sensitivity analysis limited to patients with a probable large-vessel occlusion who initially presented to a thrombectomy hub and underwent intravenous thrombolysis (OR, 0.87; 0.69-1.09). Conclusions: In a large population-based sample of ischemic stroke patients across the US, the odds of mechanical thrombectomy did not vary by time of presentation.

Abstract WP42: FAST Implementation Of An Urban County Severity-based Stroke Triage Protocol: Impact And Outcomes On A Comprehensive Stroke Center

Background: Severity scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers however require additional EMS education and performance. The Cincinnati prehospital stroke scale (CPSS) is a commonly used pre-hospital stroke screen and has been validated as a severity scale to identify large vessel occlusion (LVO). This study objective is to determine the impact of a county-based implementation of CPSS as a stroke severity scale to directly triage selected patients to a comprehensive stroke center (CSC). Methods: Dekalb County, Georgia in Atlanta implemented a CPSS-based triage protocol with a score of 3 and last seen normal (LSN) time &lt; 24 hours mandating transfer to the nearest CSC if added time was &lt;15 minutes. We compared patients presenting by EMS to the CSC six months before and after the protocol change (November 1, 2020) including frequencies of stroke alerts, diagnoses, LVO, IV tPA use, thrombectomy treatment and LSN time to treatment. Results: During the study period, 802 suspected acute stroke patients presented to the CSC by EMS including 95 (12%) with a FAST score of 3. There was a significant increase in monthly EMS stroke alerts with the protocol implementation (Pre- 43 ± 5.6, Post- 54 ± 5.9; p=0.005). Overall, 325 (41%) patients had a final diagnosis of stroke or TIA, including 228 (28%) with ischemic stroke. There was a significant increase in ischemic stroke patients presenting with LVO (Pre- 26%, Post- 36%; p=0.01) and the monthly rate of mechanical thrombectomy (Pre- 2.0 ± 2.0, Post- 5.5 ± 2.4; p= 0.005) but no difference in tPA administration rate. LSN to tPA median times were similar (Pre- 2.8 ± 1.1, Post- 2.6 ± 0.87 hours; p=0.66) though LSN to groin puncture median times increased (Pre- 3.2, Post- 7.1 hours; p=0.04). CPSS score of 3 was associated with the final diagnosis of ischemic stroke, IV tPA administration and presence of LVO (p=&lt;0.001). Conclusion: County-based implementation of a CPSS score of 3 is a quick, easy and effective approach to triage suspected stroke patients to a thrombectomy-capable center that identifies stroke patients with LVO and increases thrombectomy treatment rates without delays in tPA treatment.

Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy.

ObjectiveSince the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time. MethodsThe last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time. ResultsThe door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively). ConclusionThe COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and door-to-recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.