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BackgroundEndovascular thrombectomy (EVT) is efficacious for appropriately selected patients with large vessel occlusions (LVO) up to 24 hours from symptom onset. There is limited information on outcomes of nonagenarians, selected with computed tomography perfusion (CTP) imaging.MethodsWe retrospectively analyzed data from a large academic hospital between December 2017 and October 2019. Patients receiving EVT for anterior circulation LVO were stratified into nonagenarian (≥90 years) and younger (ResultsOverall, 214 consecutive patients (26 nonagenarians, 188 younger) underwent EVT. Nonagenarians were aged 92.8±2.9 years and younger patients were 74.5±13.5 years. Mortality rate was significantly greater in nonagenarians compared with younger patients (43.5% vs 10.4%, OR 9.33, 95% CI 2.88 to 47.97, PConclusionsNonagenarians were noted to have greater mortality and sICH rates following EVT compared with matched younger patients, which may be ameliorated by selecting patients with smaller CTP core volumes. Nonagenarians undergoing EVT had similar rates of successful reperfusion and functional independence compared with the younger cohort.

A 67-year-old man presented with acute right hemiparesis and hemianesthesia (NIH Stroke Scale score 5). Hyperacute neuroimaging was interpreted as normal. Following IV tissue plasminogen activator, his symptoms worsened, with concern for cervical radiculopathy. Upon reviewing the CT angiogram (CTA), a possible spinal epidural hematoma (EDH) was noted and subsequently confirmed with MRI (figure 1) . Cryoprecipitate was administered. His symptoms gradually improved with conservative management. Spontaneous spinal EDH is rare (incidence: 0.1/100,000 per year).1 Risk factors include hypertension and coagulopathy.1 Although cervical spine EDH is best visualized with MRI,2 dedicated attention to the CTA may reveal this uncommon stroke mimic prior to thrombolysis (figure 2) .

Objective: To determine the clinical correlates bilateral independent periodic discharges (BIPDs) and their association with electrographic seizures and outcome. Methods: Retrospective case-control study of patients with BIPDs compared to patients without periodic discharges (“No PDs”) and patients with lateralized periodic discharges (“LPDs”), matched for age, etiology and level of alertness. Results: We included 85 cases and 85 controls in each group. The most frequent etiologies of BIPDs were stroke, CNS infections, and anoxic brain injury. Acute bilateral cerebral injury was more common in the BIPDs group than in the No PDs and LPDs groups (70% vs. 37% vs. 35%). Electrographic seizures were more common with BIPDs than in the absence of PDs (45% vs. 8%), but not than with LPDs (52%). Mortality was higher in the BIPDs group (36%) than in the No PDs group (18%), with fewer patients with BIPDs achieving good outcome (moderate disability or better; 18% vs. 36%), but not than in the LPDs group (24% mortality, 26% good outcome). In multivariate analyses, BIPDs remained associated with mortality (OR: 3.0 [1.4–6.4]) and poor outcome (OR: 2.9 [1.4–6.2]). Conclusion: BIPDs are caused by bilateral acute brain injury and are associated with a high risk of electrographic seizures and of poor outcome. Significance: BIPDs are uncommon but their identification in critically ill patients has potential important implications, both in terms of clinical management and prognostication., SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction: Limited access to stroke specialist expertise produces disparities in inpatient stroke treatment. The impact of telestroke on the remote delivery of guideline-based inpatient stroke care is yet to be comprehensively studied. The TELECAST trial (NCT03672890) prospectively examined the impact of a 24-7 telestroke specialist service dedicated to inpatient acute stroke care spanning admission to discharge. Methods: AHA stroke guidelines were used to derive outcome metrics in the following acute stroke inpatient care categories: diagnostic stroke evaluation (DSE), secondary stroke prevention (SSP), health screening and evaluation (HSE), and stroke education (SE). Adherence to AHA guidelines for stroke inpatients pre-telestroke (July 1, 2016-June 30, 2018) and post-telestroke intervention (July 1, 2018-June 30, 2019) were studied. The primary outcome was a composite score of all guideline-based stroke care. Secondary outcomes consisted of subcategory composite scores in DSE, SSP, HSE, and SE. Chi-squared tests were utilized to assess primary and secondary outcomes. Statistical analysis was performed using STATA 15.0. Results: Following institution of a comprehensive inpatient telestroke service, overall adherence to guideline-based metrics improved (composite score: 85% vs 94%, p Conclusion: The implementation of a 24-7 inpatient telestroke service improved adherence to AHA guidelines for inpatient acute stroke care. Dedicated inpatient telestroke specialist coverage may improve inpatient stroke care and reduce stroke recurrence in hospitals without access to stroke specialists.

Author(s): Lawner, Benjamin J.; Szabo, Kelly; Daly, Jonathan; Foster, Krista M.; McCoy, Philip; Poliner, David; Poremba, Matthew; Nawrocki, Philip S.; Rahangdale, Rahul | Abstract: Introduction: There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol.Methods: We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of “stroke/TIA,” “CVA,” or “neurological problem” were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score’s metrics were evaluated as a surrogate marker for a successful EMS triage protocol.Results: We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%.Conclusion: In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.

Background Rapid arterial occlusion evaluation (RACE) scale is a valid prehospital tool used to predict large vessel occlusion of major cerebral arteries in patients with suspected acute stroke. RACE scale administered by Emergency medicine services (EMS) technicians in the prehospital setting correlates well with NIH Stroke Scale score after patient arrival at a hospital. Despite this, the RACE scale is often characterized as too difficult for EMS technicians to accurately utilize. There are no data examining RACE scale accuracy in the prehospital setting comparing EMS technicians with neurologists. We sought to examine agreement between RACE scores calculated by EMS technicians and stroke neurologists in the prehospital setting during telestroke consultation. Methods Data for this observational cohort study were prospectively collected and retrospectively analyzed. EMS technicians in person and stroke specialized neurologists via televideo connection independently assessed suspected stroke patients and calculated RACE scores in the prehospital setting. We used a linearly weighted Cohen's kappa (kw) to estimate the extent of agreement for RACE score between EMS technicians and stroke neurologists. Results Thirty-one patients with stroke symptoms were independently examined and assessed with the RACE scale by EMS technicians and stroke neurologists in the prehospital setting. Exact agreement on the RACE score was found in 24 of 31 (77%) patients. We found very good agreement between EMS technicians and stroke neurologists, kw = .818 (95% CI, .677-.960), P Conclusions EMS technicians provide reliable RACE assessments in patients with suspected stroke, with agreement similar to stroke specialized neurologists in the prehospital setting.

Introduction: Timeliness of a response to page by telestroke physicians is an important component in a telestroke network. Accrediting organizations such as the Joint Commission require telemedicine to be available within 20 minutes of the request. We implemented a secure messaging system to improve physician communication. We hypothesized that implementation of a secure messaging system would improve communication, reduce telestroke physician response to page and reduce door-to-needle (DTN) times compared to the previous pager-based system. Methods: We reviewed data collected as part of our telestroke quality program. We compared response to page times for one year before and after initiation of the secure messaging system. Additionally, we compared DTN times during the same epochs. Results: Seven hundred and sixty-five telestroke consults were completed in the year prior to implementation of the secure messaging system and 941 telestroke consults were completed in the year following implementation. Telestroke response to page time decreased significantly between pre ( mean rank 1005; median 4 min) and post ( mean rank 731 ; median 2 min) implementation of the secure messaging system ( U = 244,240 , p < .001, r = .28). A significantly greater percentage of telestroke neurologist response times occurred within 20 minutes when using secure messaging 936/941 (99.5%) compared to pagers, 751/765 (98.2%), χ 2 (1, N = 1706) = 6.46, p = .01, φ = .06. DTN was lower when using secure messaging (64 min) compared to the prior paging system (66 min), but this difference was not statistically significant ( p = .74). Conclusions: In conclusion, implementation of a secure messaging system improved communication in our telestroke network and reduced telestroke response to page compared to our prior paging system. Implementation of the secure messaging system did not significantly reduce DTN times.