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Nurses are an integral part of the multidisciplinary team caring for a patient eligible for endovascular thrombectomy. Their care includes obtaining health history, performing clinical assessments, using critical thinking to anticipate the care path, and communicating findings to other team members. The prehospital and emergency department nurses utilize stroke severity scales to identify a possible thrombectomy candidate and help expedite intervention. In the interventional laboratory, nursing collaborates with radiology technologists and interventionalists to ensure patient safety and monitor for intraprocedural complications. Post-procedure, the intensive care nurse delivers complex care to ensure optimal neurological outcome and assess for postprocedural complications. Nursing is essential in every phase of care along with collaboration with other disciplines.

Background: We sought to determine and validate a pre-reperfusion blood pressure threshold for MCA occlusions patients with better thrombectomy outcomes. Methods: We reviewed patients from 2013 to 2015 treated with thrombectomy for a MCA M1 occlusion at our center. Blood pressure measurements from available records at the time of EMS activation to the time of reperfusion were used to calculate an averaged pre-reperfusion mean arterial pressure (MAP). All patients in our analysis had successful reperfusion. Our endpoint was a mRS ≤2 at 90 days. The averaged MAP was grouped as follows: ≥85mmHg, ≥90mmHg, ≥95mmHg, ≥100mmHg, ≥110 mmHg and ≥115mmHg. We considered hourly epochs from symptom onset to reperfusion, pre-treatment ASPECTS, thrombolytics, and collateral status. Significant parameters from a univariate analysis were included into a multivariate logistic regression to determine independent predictors of outcome. The multivariate findings were then validated with a prospective set of similar patients evaluated with our mobile stroke treatment unit. Results: We reviewed 52 patients. Mean age was 70; NIHSS was 16±6; 40% (21) received t-PA; median ASPECTS score was 10; TICI 3 score was achieved in 63% (33), and 67% (35) had a good outcome. The number of patients having a mean arterial blood pressure threshold were as follows: ≥85mmHg (96%), ≥90mmHg (83%), ≥95mmHg (73%), ≥100mmHg (58%), ≥110mmHg (31%) and ≥115mmHg (15%). Reperfusion occurred as follows: ≤3hrs (4%), ≤4hrs (21%), ≤5hrs (39%), ≤6hrs (52%), ≤7hrs (67%), ≤8hrs (79%), ≤9hrs (87%), and ≤12hrs (90%). Our multivariate logistic regression model identified an average pre-reperfusion MAP ≥95mmHg as the sole factor statistically associated with a better outcome post successful thrombectomy [OR 15.1, CI 1.3-170.1,p=0.02]. Good clinical outcome in those patients with an averaged MAP ≥95mmHg was 76% and 43% in those below the threshold [OR 5.2, p=0.02]. Our validation cohort consisted of 32 patients, and a pre-reperfusion averaged MAP ≥ 95 mmHg had a sensitivity of of 93% for a good outcome. Conclusion: Our analysis suggests with validation that a pre-reperfusion averaged MAP ≥ 95mmHg results in better outcomes with successful thrombectomy and may be used as a therapeutic target in the pre-hospital setting.

Title: Effect of hypertension on clinical recovery after stroke thrombectomy Objective: Our goal was to identify what vascular risk factors for stroke affect outcomes after mechanical thrombectomy. Methods: We retrospectively reviewed stroke thrombectomy patients at our comprehensive stroke center from June 2013 to August 2016. Patients were determined to have atrial fibrillation, hypertension, diabetes, or hyperlipidemia based on historical information pre-treatment or based on hospital records during their index hospitalization. All patients in our series achieved recanalization after thrombectomy defined as a Thrombolysis in cerebral infarction (TICI) score of 2b or higher. Our endpoint was mild to moderate disability at 90 days defined by the modified Rankin Scale (mRS) score of 2 or less. We performed a univariate analysis on the above covariates affecting clinical outcome and studies all variables with a p-value of < 0.2 in a multivariate analysis to determine which independent variables affected outcome. Multi-variate analyses were performed separately for males and females. Results: We reviewed 288 stroke patients that underwent thrombectomy. The mean age was 69±15; NIHSS was 17±6; 36% (104 of 288) received t-PA and 42% (121 of 288) had a modified Rankin Score of < 2. 42.7% (123 of 288) were females. From the entire group, 47.5% (137 of 288) had atrial fibrillation, 29% (83 of 288) had diabetes mellitus 68% (197 of 288) had hypertension, 38.5% (111 of 288) had hyperlipidemia and 16% (47 of 288) had a history of tobacco smoking. After considering positive univariates from above, our multivariate logistic regression model identified that not having hypertension [ OR 2.32, CI 1.01-5.41, p=0.05 ] predicted better outcome post thrombectomy procedure for males after a successful recanalization. Conclusion: Our analysis suggests that, for males, the odds of a positive outcome after a successful thrombectomy procedure is positively influenced when the patient is not hypertensive. No traditional risk factor appeared to influence the outcome in females. Further prospective study is required to validate these findings.

Introduction : We sought to determine a distance threshold where mode of transportation impacted treatment options for potential thrombectomy patients. Methods : We retrospectively reviewed transferred stroke patients to our comprehensive stroke center within 8 hours of onset from January 2017 to December 2019. In our analysis, all patients had a CTA confirmed large vessel occlusion, NIHSS >10 and arrived within 8 hours of onset as a candidate for thrombectomy. Patients were not treated with thrombectomy if they presented with a completed infarct or hemorrhagic conversion. Patients were transferred by air or ground based on availability and safety. Transfers were grouped based on distance: 0–30 miles, 31–60 miles, 61–90 and > 90 miles. We performed a binomial logistic regression for each distance group to determine a threshold where the odds of receiving thrombectomy statistically decoupled based on mode of transportation. Results : Of the 243 patients reviewed, 52.1% (126) received thrombectomy. Transport for 50.8% (123) patients was by air. Hospitals transferring within 0–30 miles accounted for 26.6% (65); 31–60 miles accounted for 22.1% (54); 61–90 miles accounted for25.8% (63) and >90 miles accounted for 24.8% (60). The odds of receiving a thrombectomy were significantly higher with air transportation (OR 3.0, CI 1.04‐8.74, p = 0.043) at a distance threshold of >90 miles. At a distance threshold of 10 to 30 miles, the odds of receiving a thrombectomy were significantly higher with ground transportation (OR 5.5, CI 1.15‐26.14, p = 0.032). There was no difference between modes of transportation for 31 to 90 miles. Conclusions : Our analysis suggests that air transport beyond 90 miles increases the odds of receiving a thrombectomy for patients arriving within 8 hours of symptom onset. Ground transport, rather than air transport, between 10 and 30 miles may be more beneficial. Our results suggest that specific regional transport thresholds based on distance do exist and if recognized and altered can result in more favorable transfers.

BACKGROUND A change in the pupillary light reflex (PLR) is a sensitive indicator for detecting expanding intracranial lesions. Changes in PLR may be a prognostic marker for patients with intracranial lesions. The purpose of this analysis was to explore how PLR readings, size, constriction velocity (CV), dilation velocity (DV), Neurologic Pupil Index (NPi), and latency predict clinical outcome in patients with subarachnoid hemorrhage. METHODS This is a secondary analysis of prospectively collected multicenter registry data. The within-subject standard deviation (WSD) of PLR values, NPi, size, CV, DV, and latency were explored as predictors of discharge modified Rankin Scale (mRS) in patients with subarachnoid hemorrhagic. RESULTS Among 4403 pupillary readings from 82 patients with a diagnosis of subarachnoid hemorrhage, with a mean age of 57.7 years, the admission Glasgow Coma Scale median score was 14 (eye, 4; verbal, 4; motor, 6), and the mRS median was 0 on admission and 4 at discharge. Correlation between standard deviation of PLR values and discharge mRS was moderate and negative (r = -0.3 to -0.47, P < .01). The standard deviations for NPi, size, CV, and DV were significant for predicting discharge mRS (r = 0.23-0.28, P < .05) after controlling for admission Glasgow Coma Scale. CONCLUSION Patients with higher WSD PLR values showed better outcomes (ie, lower mRS at discharge), suggesting that patients with narrower WSD PLR are at a higher risk for poor outcomes.

To enhance nursing staff retention and ensure a consistently high standard of care, a study was conducted to determine an appropriate nurse staffing model for a neurocritical care unit. In addition to being critically ill, these patients often require extensive diagnostic testing to determine treatment. Nurses traveling with patients leave higher nurse-patient ratios remaining on the unit.Prospective observation was used to assess relationships between neurologic assessment, documentation, and the amount of time spent traveling with patients. Patient acuity and nursing experience were also measured.Over the 30-day study period, more than 226 hours were spent traveling, equivalent to approximately 38% of a single nurse's shift. There was no correlation between the experience of nurses and the time necessary to perform a neurologic assessment. When controlling for acuity, a relationship was found between nursing experience and the time needed to chart an assessment.Significant time was spent every day off the floor, in addition to the documentation and performance of frequent assessments. These results advocate for a staffing position without a dedicated patient assignment but to assist with traveling and high-acuity patients so that safe and attentive care can be consistently given.

External ventricular drain (EVD) placement is a common practice in neurocritical care units. The EVDs are the "gold" standard and the most cost-effective treatment for intracranial hypertension and hydrocephalus caused by a variety of neurological conditions. The EVD drains excess cerebrospinal fluid in an attempt to maintain balance within the cranial vault and provides intermittent monitoring of intracranial pressure. This invasive procedure, as with any other procedures, carries an increased risk of a device-related infection that can lead to devastating consequences such as meningitis, ventriculitis, and death. This article will discuss how Riverside Methodist Hospital, which is located in Central Ohio, identified an increase in the rate of EVD infections in 2007 and responded with changes in procedure and processes. The implementation of the improvement plan has resulted in 25 months without an EVD infection, a triumph for the patients, staff, and the hospital system.