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Background: During the initial emergence of the 2019 novel coronavirus (COVID-19) and the subsequent surge of patients requiring critical care, our Joint Commission certified thrombectomy-capable stroke center sought to utilize a low-intensity monitoring protocol in stable, post intravenous (IV) thrombolysis patients in our intensive care unit (ICU). The acuity level in our ICU jumped to an all-time high, with many critically ill COVID-19 patients. Our goal was simple, provide safe patient care, free up precious nursing time, and preserve the personal protective equipment supply. Purpose: The purpose of this study was to use a rapid cycle process improvement project to implement a low-intensity monitoring (LIM) protocol in stable, suspected stroke patients, who are deemed at low risk for complications, in the first twenty-four hours following IV thrombolysis. Methods: We utilized the Plan-Do-Study-Act (PDSA) model to implement this project. Collaboration between physician, nursing, and stroke program leaders occurred during the month of April 2020. Our new process utilized the O ptimal P ost T -pa I v M onitoring in I schemic ST roke (OPTIMIST) protocol. We continued to admit our post IV alteplase patients to the ICU, rather than a step-down unit, in order to accommodate the 3:1 patient to nurse ratio, ensure protocol adherence, and maximize patient safety with this high-risk medication. We used change of shift huddles to educate the ICU nursing staff over a two-week period. Stroke program advanced practice nurses were on-site to ensure compliance. Results: Since implementation of the new protocol, two IV alteplase patients have met protocol criteria; both remained stable throughout the twenty-four-hour LIM period. The protocol’s nursing ratio changes allowed the other, critically ill patients, to be staffed with traditional ICU ratios. Conclusion: Rapid cycle PI projects can be accomplished during times of extreme challenge, as evidenced during the COVID-19 pandemic. Nursing staff was able to adapt and even welcomed the change, while maintaining patient safety. Further study is needed to document the ongoing effect of this protocol.

Intra-arterial therapy (IAT) is most effective when performed rapidly after ischemic stroke onset. However, there are limited performance benchmarks in IAT and there is a scarcity of information on how to structure an effective IAT protocol and its impact on time to treatment. The objective of our study was to detail a standardized IAT protocol, and to assess its influence on time to treatment in ischemic stroke.This was a retrospective observational study over 4 years at a comprehensive stroke center. A standardized IAT protocol was implemented in June 2013 that included pre-notifying the stroke team before hospital arrival, defining clinician roles, processing tasks in parallel, and standardizing IAT procedures. Three time metrics were examined and reported as median (IQR) minutes: arrival to CT imaging, CT to groin puncture, and puncture to recanalization. We compared these metrics in patients admitted before implementation (January 2012-May 2013) to patients admitted after (June 2013-December 2015) using Wilcoxon Mann-Whitney tests.380 patients were included. After the protocol was implemented, there were significant reductions in time from arrival to CT (17 (14-21) vs 13 (11-19) min, p0.001), CT to puncture (46 (30-82) vs 31 (23-54) min, p0.001), and puncture to recanalization (65 (33-90) vs 37 (22-65) min, p0.001). 60% of time was saved during puncture to recanalization. Significant reductions in time were observed during both normal working hours and off-hours.Implementation of a standardized protocol resulted in a significant reduction in time to recanalization for patients with an ischemic stroke. A standardized IAT protocol decreases time to recanalization when team roles are clearly defined, tasks are processed in parallel, and procedures are standardized.

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes ( P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

ObjectiveThe safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT.DesignDemographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ2 tests and multivariate logistic regression.ResultsThere were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34).ConclusionsIAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

Background To describe the 4-year experience of symptomatic intracranial hemorrhage (sICH) rate at a high-volume comprehensive stroke center. Methods All admitted adult (≥18 years) patients presenting with an ischemic stroke from 2010 to 2013 were included in this study. The primary outcome was sICH, defined as any hemorrhage with neurological deterioration (change in National Institutes of Health Stroke Scale score ≥4) within 36 hours of intravenous tissue plasminogen activator (IV-tPA) treatment, or any hemorrhage resulting in death. Secondary outcomes were in-hospital mortality and having a favorable modified Rankin Scale (mRS) score (≤2). Results A total of 1925 did not receive intravascular (IV) or intra-arterial (IA) therapy; only 451 received IV therapy; and 175 received both IV and IA therapies. In IV-only patients, the overall rate of sICH was 2.2%; in IV and IA patients, the rate was 5.7%; and in patients who received no therapy, the rate was .4%. The IV-only group had an sICH rate of .9% in 2013. There were no differences in the adjusted odds of dying in the hospital between the study groups. IV-only treatment offered significantly better odds of achieving a favorable functional outcome, compared to no therapy, among patients with moderate stroke severity, whereas IV and IA treatments offered significantly better odds among patients with severe strokes. The odds of achieving a favorable functional outcome by discharge were decreased by 97% if patients suffered an sICH (OR = .03, 95%CI = .004, .19). Conclusions Despite an increased risk of sICH with IV-tPA, treatment with IV-tPA continues to be associated with increased odds of a favorable discharge mRS.

Background: The Colorado Stroke Advisory Board (COSAB) asked three Joint Commission (JC) comprehensive stroke centers (CSC) and one primary stroke center (PSC) to assist with determining the usefulness of the Cincinnati Pre-Hospital Stroke Severity Score (CPSSS) in predicting large vessel occlusion (LVO) in patients with acute stroke symptoms. Purpose: The purpose of the study was to determine the real world applicability of the CPSSS in predicting LVO. Methods: CPSSS and LVO data was collected by stroke coordinators at three CSCs and one PSC for all patients brought to their respective emergency departments via local emergency medical services (EMS) from June 2016 to July 2016 as stroke alerts. The CPSSS was calculated retrospectively using the initial documented neurological exam and LVO was determined by initial computed tomography (CT) imaging results or physician notes in the electronic medical record. Results: Our study included 235 patients that were brought to 4 certified stroke centers in the Denver metropolitan area during a two month period in 2016. Eighty percent of patients (N=187/235) correctly screened negative on the CPSSS. Ten percent (N=23/235) of patients screened positive and were later determined to have LVO based on initial imaging. Four patients went on for endovascular treatment at a CSC that initially screened negative using the CPSSS. Nine percent (N=21/235) of patients screened false-positive for LVO. Top reasons for false positive CPSSS include intracerebral hemorrhage, altered mental status, seizure, and brain stem stroke. Conclusion: CPSSS is a reasonable screening tool to assess for LVO. More study is recommended to determine how to avoid missing LVO in stroke patients with mild symptoms on initial presentation.

Background: Recent nursing initiatives encourage early mobilization of neurocritical care patients, but whether this intervention can be safely generalized to acute stroke is debatable. We performed a systematic review of findings from recent studies to provide direction for patient management and future research. Methods: An exhaustive literature search was performed in Medline, SCOPUS and the Cochrane Central Register of Controlled Trials to identify published clinical trial research using a very early mobility intervention (within 24 hours) in acute ischemic stroke patients. The primary efficacy outcome supporting the search was neurologic disability reduction or improved functional outcomes, and the primary safety outcome was neurologic deterioration. Studies were critically reviewed for inclusion by 3 separate investigators, findings were synthesized, and an overall recommendation for very early mobilization use in acute stroke was assigned according to GRADE criteria. Results: We initially identified 12 papers focused on early mobilization in acute stroke; of these, 6 observational studies were excluded, 1 study was excluded due to an ambiguous population, and 3 studies were excluded due to first initial mobilization out of bed occurring greater than 24 hours after admission. Two prospective randomized outcome blinded evaluation (PROBE) studies were retained, consisting of a total 2160 patients; ischemic stroke subtype was not disclosed in either study, limiting an understanding of the impact of very early mobilization on small versus large artery occlusion. Slower mobilization occurring beyond the first 24 hours was associated with higher rates of favorable outcome (mRS 0-2) at 90 days, whereas very early mobilization within the first 24 hours was associated with a number needed to harm of 25. Conclusions: In acute stroke, evidence supports a rested approach to care within the first 24 hours of hospitalization (GRADE: Strong recommendation, high quality of evidence). Similar to acute myocardial infarction, vascular insufficiency experienced in stroke likely warrants a more guarded approach to mobility. Additional studies exploring timing beyond 24 hours and dose of mobility interventions are warranted in discreet populations.

Introduction: Cervical artery dissection is a recognized cause of acute ischemic stroke (AIS). Intra-arterial treatment (IAT) may be a complementary option to IV tPA and antithrombotic therapy. Hypothesis/Purpose: To describe a large series of patients with dissection treated with IAT. Methods: Demographics, clinical characteristics, treatment, and outcomes were summarized for all dissection patients treated with IAT from 1/2010 - 5/2015. Outcomes included functional independence (modified Rankin score ≤ 2 at 90 days or discharge, or discharge home), recanalization, procedural complications, sICH, and mortality. Data are presented as median (interquartile range) or (n). Results: Of 161 patients with dissection, 24 (15%) were managed with IAT and comprise our population, which was primarily male (75%) aged 52 (42-59.5) and NIHSS of 13 (12 -16). Internal carotid artery dissections (ICAD, 18) were more common than vertebral artery dissections (VAD, 6); three patients had bilateral dissections (1 ICAD, 2 VAD). In all but two patients there was associated intracranial embolus. Dissections were idiopathic (17), traumatic (5) or cough-related (2). Eleven patients were treated with IV tPA. IAT techniques included thrombectomy (19), IA thrombolysis (17), stent (13), and angioplasty (7). The majority of patients had multiple techniques: 2 (2 -3). Functional independence was achieved in 63% (12/19). There were four deaths, none were attributable to IAT. There was one sICH and three procedural complications (2 groin pseudoaneurysm, one catheter induced acute dissection). Among the 6 VADs, 2 were left untreated and the remaining 4 were successfully recanalized (100%). All 6 VADs had a basilar artery occlusion; recanalization was successful in 2 and partial in 4 cases. Among the 18 ICADs, 6 were left untreated and the remaining 12 were successfully recanalized (100%). Sixteen of 18 ICADs had middle cerebral artery occlusion; recanalization was successful in 4, partial in 10, and unsuccessful in 2 cases. Conclusions: Despite the additional intravascular risk, outcomes appear to be similar to those presented in large RCTs with stroke from all causes, suggesting utility of IAT when performed in patients with dissection.

Background: Best practice recommends that hospitals treating acute stroke patients have protocols in place to ensure rapid transfer to an advanced facility for a higher level of care, if needed. Our system of hospitals consists of five primary stroke centers (PSC) and one comprehensive stroke center (CSC) in a major metropolitan area. PSCs utilize telemedicine for acute stroke decision-making and patients are transferred to the CSC for consideration of advanced treatments when deemed appropriate by the care team. Purpose: Our study objective was to streamline processes at our PSCs to decrease the door to transport time (DTT) to the CSC. Methods: Stroke coordinators from the six sister hospitals meet quarterly to collaborate and share best practices in patient care. Our team of nurse leaders determined potential strategies to eliminate wasted time in the transfer process. Team members went back to their home facilities with the goal of generating buy-in from individual caregivers to decrease the time to transport out to the CSC. An overall attitude of urgency was encouraged during meetings with stroke councils and providers. Preliminary imaging results were used to guide decision to transfer, rather than waiting for final results. Some hospitals chose to notify the flight team of potential transport earlier in the emergency department stay, while others are still in the process of affecting change. We collected data on transferred patients with a diagnosis of acute stroke between the dates of 2/1/15-7/31/15 (n=23) and compared against the same time period in 2014 (n=11). Results: A total of 34 patients were included in our retrospective chart review. The number of patients transferred for consideration of additional acute treatment increased from 11 in 2014 to 23 during the study period in 2015. When examining patients who transferred and actually received endovascular treatment for acute stroke (n=8 in 2014 versus n=11 in 2015), the mean DTT decreased from 84 minutes in 2014, to 77 minutes in 2015. We also noted that patient transfers were faster during day time hours when compared to night. Conclusions: A system-wide, collaborative approach between PSCs and CSCs can decrease DTT when nurse leaders and providers streamline processes.

Introduction: Target:Stroke recommends pre-mixing intravenous tPA before brain imaging for high likelihood acute ischemic stroke (AIS) patients, allowing the drug to be available immediately after the decision to treat is made. However, premixing tPA is rarely practiced despite potential benefits of improving door-to-needle time. Hypothesis: We describe our experience developing criteria to eliminate avoidable wasting of the drug by identifying patients most likely to benefit from pre-mixed tPA and compare rates of wasted tPA before and after criteria development. We hypothesized this would result in a substantial reduction in wasted tPA. Methods: On 4/1/14, our Comprehensive Stroke Center instituted a series of interventions to reduce door-to-needle times, including pre-mixing tPA for AIS patients presenting within the tPA treatment window. Seven vials of pre-mixed tPA were wasted over the next five weeks, revealing the need for specific criteria to guide the medical decision to order tPA prior to brain imaging. A multi-disciplinary team examined cases of wasted pre-mixed tPA through peer review and determined four would have been avoided if criteria identified patients ineligible for tPA pre-mixing. Revised criteria were implemented for ordering pre-mixed tPA on 6/1/14. Results: Our revised criteria restricted pre-mixing tPA for patients taking anticoagulants, or presenting with a decreased level of consciousness, elevated blood pressure, headache, nausea, vomiting, or advanced stage cancer. Between 6/1/14-6/1/15, there has been one case of non-avoidable wasting, and no cases of avoidable tPA wasting. Conclusions: While pre-mixing tPA does not incur financial risk as drug manufacturers replace unused vials without cost, stroke centers remain wary of wasting the drug. We believe succinct criteria can reduce avoidable tPA waste, allowing health care providers to remain fiscally responsible while ensuring AIS patients are treated as fast as possible.

Introduction: There are no data to support the hypothesis of an increased risk of symptomatic ICH (sICH) with the later 3-4.5h IV-tPA treatment window, compared to the Hypothesis: There is a significant difference in the odds of suffering a sICH if treated with IV-tPA Methods: This was a 6-year retrospective observational cohort study. All adult (≥18 yrs) patients admitted with an ischemic stroke between 1/2010-6/2015 and treated with IV-tPA were included in the study. Patients receiving IA treatment were excluded (n=244). Outcomes for this study were sICH (4-point increase in NIHSS within 36h with new ICH seen on CT), in-hospital mortality and favorable discharge mRS (≤2). Chi-squared, Fisher’s exact and Wilcoxon rank-sum tests were used to compare proportions and medians between groups. Multivariate, stepwise logistic regression was used to assess differences in the odds of outcomes; entry and exit criteria for covariates were p=0.20 and p=0.10. Results: 561 (90%) were treated Conclusions: tPA treatment windows impact sICH, mortality and favorable mRS rates. Ensuring thrombolytic therapy is received

Introduction: The safety and efficacy of intraarterial treatment (IAT) for acute ischemic stroke (AIS) due to cervical artery dissection (CAD, carotid and vertebral) has not been studied in a controlled trial. Hypothesis: There will be no differences in safety and efficacy of IAT for AIS due to CAD compared to non-CAD mechanism. Methods: We studied consecutive admissions with AIS who received IAT between 1/2010 - 4/2015 and compared outcomes for AIS patients who presented with CAD mechanism vs. other causes. Outcomes included in-hospital mortality, symptomatic intracerebral hemorrhage (sICH), procedural complications, and functional independence (Modified Rankin Score ≤ 2 at 90-days or discharge, or discharge home). Outcomes were univariately analyzed with Chi-square tests. Co-primary outcomes of functional independence and sICH were analyzed with multivariate logistic regression. Results: Of 3,671 patients with AIS, 445 patients received IAT and comprise our study population: 24 with CAD (5%: 18 carotid, 6 vertebral) and 421 with another cause. Patients with CAD were younger (median age: 52 vs. 70, p < 0.001) with less severe stroke (median NIHSS: 13 vs. 18, p=0.03) than those with another cause of AIS. Unadjusted outcomes were similar by AIS cause (Table 1). After adjustment for NIHSS and age, the odds of achieving functional independence (OR: 0.58 [0.19-1.78], p=0.34) and sICH (OR: 0.57 [0.07-4.66], p=0.60) were not significantly different in patients with CAD vs. other mechanism. Conclusions: Intraarterial treatment appears to be as safe and effective when used in patients with ischemic stroke due to CAD as in AIS patients with other causes. Following the major advances in IAT for AIS in the general population, IAT should be considered in patients with AIS due to a CAD.

Introduction: Clinical trials confirmed the benefits of intra-arterial therapy (IAT) for managing acute ischemic stroke (AIS). Yet not all hospitals are able to perform IAT, requiring rapid transfer of potential IAT candidates. Hypothesis: AIS patients receiving IAT who were admitted directly to a Comprehensive Stroke Center (CSC) would have similar outcomes to those transferred to the CSC from a less specialized hospital. Methods: Data were retrospectively abstracted for AIS patients treated with IAT at a CSC (1/2014 – 5/2015). Clinical characteristics and the following outcomes were compared in patients directly admitted to the CSC and those transferred: recanalization to TICI ≥2b, discharge and 90-day mRS (favorable, ≤2), sICH, and in-hospital mortality. Univariate and multiple logistic regression analyses were conducted. Results: IAT was performed in 133 patients; 34 (25.6%) directly admitted and 99 (74.4%) transferred to the CSC. Transferred patients were significantly younger, more often male, with fewer comorbidities, a longer time from symptom onset to arrival, but shorter time from arrival to groin puncture (table 1). Unadjusted outcomes were similar between groups (table 1). After adjusting for significant covariates (p0.4 for all). Discharge mRS remained worse in transferred patients (p=0.01) after limiting the data to those arriving to the CSC Conclusion: Even after limiting the analysis to patients arriving to the CSC

Background: Clinical trials confirmed the safety and efficacy of intra-arterial therapy (IAT) in the management of ischemic stroke. At a community hospital, we compared outcomes in patients aged ≥80 and patients in the age range 55-79 years receiving IAT following ischemic stroke. Methods: Data were retrospectively abstracted for ischemic stroke patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. Baseline demographics, incidence of symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge modified Rankin scale (mRS) score (favorable ≤2) and improvement in National Institutes of Health Stroke Scale Score (NIHSS; decreased score at discharge) were compared between patients in the age range 55-79 and patients ≥80 years. Data were analyzed using univariate analyses and multivariate logistic regression. Results: IAT was performed in 239 patients with ischemic stroke; 63 (26.4%) were ≥80 years. When compared to patients aged 55-79, the elderly patients were more often female and non-smokers, with a history of atrial fibrillation. No differences were observed in those ≥80 years compared to patients in the age range 55-79 years for sICH (10 vs. 5%, p = 0.23), mortality (24 vs. 18%, p = 0.28), favorable discharge mRS score (13 vs. 19%, p = 0.27), or improvement in NIHSS (83 vs. 92%, p = 0.10). The nonsignificant association of age with the outcomes persisted after adjusting for covariates and when analyzing the subset of patients who received IAT only. Conclusions: These findings suggest that in a cohort not subject to the criteria of a clinical trial, age ≥80 years should not be a contraindication to IAT.

Background: Benefits of intravenous tissue plasminogen activator (IV-tPA) are greatest when patients are treated immediately. Our Comprehensive Stroke Center hires Advanced Practice Nurse stroke program coordinators (APN SPC) to respond to the bedside of all acute stroke alert calls. Between 08:00-17:00, an APN SPC works with dedicated on-duty neurologists to rapidly treat acute stroke patients with IV-tPA. Purpose: The purpose of this study was to determine if the presence of an APN SPC decreases door-to-needle (DTN) times in acute stroke patients. Methods: Data were collected by stroke coordinator abstractors from January 1, 2010 to June 14, 2014. DTN times were compared using a Student’s t-test between times when an APN SPC was on duty with times the APN SPC was not present. Patient age, time between symptom onset to hospital arrival, and NIH Stroke Scale (NIHSS) categories were compared between groups using Student’s t-test and chi-squared test. Results: There were 245 patients who received IV-tPA over the study period. Over half (52%, n=127) of patients were treated in the presence of an APN SPC; 48% of patients (n=118) were not treated in the presence of an APN SPC. There were no significant differences in age, time between symptom onset to hospital arrival, or NIHSS values between groups. Median DTN time for patients treated with an APN SPC present was 36 minutes versus 45 minutes for patients treated without an APN SPC present; this 9-minute difference in median DTN time was borderline statistically significant (p=.051). Conclusion: The presence of an APN SPC was associated with reduced median DTN times. The presence of an APN SPC, in addition to an on duty neurologist, may reduce time between door and needle, engendering improvements in patient outcomes.

Background: Improvements in functional outcomes are greatest when intravenous tissue plasminogen activator (IV-tPA) is administered immediately following acute ischemic stroke (AIS). Our study objectives were to describe interventions administered by our Comprehensive Stroke Center to improve door-to-needle (DTN) time, report median DTN times, and determine if interventions influenced functional outcomes and sICH rates. Methods: A DTN task force was created to streamline care of suspected AIS patients; interventions included developing a launch pad for emergent evaluation near registration staffed by a neurologist, physician and stroke program coordinator, transferring patients directly to CT room before entering an ED room, and giving IV-tPA in the CT room. We examined patients that received IV-tPA between 1/1/10 - 6/25/14 and compared median DTN times and discharge mRS over the study period using the Kruskal-Wallis analysis of variance. The chi-square trend test was used to compare proportions of patients receiving IV-tPA in less than 60 minutes. Results: During the study period 245 patients received IV-tPA. There was a significant decrease in median DTN times over time, from 46 minutes in 2010 to 29 minutes in 2014 (p=.001, Graph), and there was a significant trend towards shorter DTN times over time (p Conclusions: Streamlining initial evaluation of suspected AIS patients can reduce DTN times, and was also associated with improvements in functional outcomes at discharge. There was no change in sICH rates.

Introduction: Acute ischemic stroke (AIS) occurs most frequently in old age. Currently, conflicting evidence exists on the safety and efficacy of intra-arterial treatment (IAT) in the management of AIS in the elderly. We purported to compare the outcomes of patients ≥80 years receiving IAT after AIS to those of patients 55-79 years old. Methods: Data were retrospectively abstracted for consecutive AIS patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. The following outcomes were compared between patients 55-79 vs. ≥80 years following IAT: safety was assessed by incidence of sICH and in-hospital mortality; efficacy was examined using discharge mRS (favorable, ≤2) and improvement in NIHSS (decreased score at discharge). All analyses were performed with Pearson or Fisher’s exact chi-square tests. The subset of patients receiving IAT only was also examined. Results: IAT was performed in 300 patients, of which 241 were aged ≥55 and comprise our study cohort; of the 241, 104 received IAT only. There were no significant differences between the two age groups receiving IAT in race, presence of comorbidities and time to IAT while significant differences were observed for gender and NIHSS, with the ≥80 population presenting with lower mean stroke severity and more females (p

Background: Stroke coordinators (SC) in Colorado meet monthly to share best practice and collaborate with the ASA and industry representatives. Based on informal observation, we believed that many of the coordinators were new in their roles and desired additional information and education on how to be successful. We teamed with the ASA and hosted two conferences; one for Colorado SCs and a larger conference for ASA Southwest affiliates. Demographic data was collected at both conferences. Methods: For the CO conference, surveys were sent to all SCs in the state. For the ASA conference, only those who attended were given the survey. Results were combined and content included: educational preparation, hospital volumes, certification status, reporting structure, orientation plan, role responsibilities, data expectations, and job satisfaction. Partial responses were included. Results: 94 surveys were returned. 70% were SCs for less than 2 years but 40% worked in their hospital for 1 - 5 years and 38% for >5 years. 32/41 worked at a primary stroke center (PSC) and 6/41 worked at a comprehensive stroke center. The majority (81%) were nurses (36% Diploma, 64% Bachelor’s prepared). 18% were Master’s prepared (NP, CNS, and MS in nursing but not NP or CNS). 43% either had a mentor or a structured orientation plan and exactly the same (43%) made up their orientation. 45% reported to Nursing, 40% to Quality, and few (2%) to Neurology. Respondents liked the ability to be creative and affect change at their hospital but disliked the lack of clarity in their role and the number of job functions they are expected to perform. Conclusion: SCs in the Southwest affiliate are primarily nurses with less than 2 years of experience as a SC who had worked at their hospital for at least 1 year but many for over 5 years. Most hospitals are PSCs. They equally had mentorship and training versus developing their role without much direction. SCs enjoy the ability to be creative and affect change but would like additional clarity and expectations to succeed in their roles.

OBJECTIVE: To describe the 4-year symptomatic intracranial hemorrhage (sICH) rate at a high-volume comprehensive stroke center. METHODS: This was a retrospective observational cohort study. All admitted adult (≥18 years) patients presenting with an ischemic stroke (IS) from 2010 to 2013 were included in this study. Chi-square, Wilcoxon rank-sum, Student’s t-tests and Cochran-Armitage trend tests were used to compare groups and analyze data. sICHs were defined by a 4-point increase in NIHSS within 36h with new ICH seen on CT; sICHs were included only if they were directly related to IV-tPA treatment. Favorable mRS outcome was defined as a score ≤2. In-patient stroke alerts were excluded from door-to-needle (DTN) times. RESULTS: 2673 patients were admitted with IS. Of these, 627 (23%) were treated with IV-tPA (90% CONCLUSIONS: These data show that expeditious care and careful selection of patients for IV-tPA treatment can lead to very low rates of sICHs. The few sICHs subsequent to IV-tPA are likely to be a consequence of long symptom-to-arrival times and stroke severity.

Introduction: A novel device was developed to measure oxidation reduction potential (ORP), which is the balance of oxidants and reductants, providing a direct measure of oxidative stress. Our purpose was to measure ORP in patients admitted with stroke symptoms. Methods: This prospective observational study included patients admitted to our Primary Stroke Center from 1/2010-12/2012; children ≤18 and transfers were excluded. We examined ORP’s association with stroke type, demographics (age, gender, race), NIHSS, thrombolytic therapy, and outcomes (in-hospital mortality, mRS, LOS, readmission) using Pearson correlation, generalized linear models, chi-square and student’s t-tests. Blinded operators tested plasma samples in duplicate for static ORP (resting ORP, mV), where greater values indicate more oxidative stress, as well as Capacity (antioxidant reserve, uC). Capacity was inverse-transformed (icORP), where greater values indicate less reserves. Results: There were 101 patients including 52 ischemic strokes, 10 hemorrhagic strokes, 19 TIAs, and 20 mimics. Six patients died (6%); arrival ORP was significantly lower in patients who died than who survived (sORP: 137.2 vs 163.9, p = 0.004; icORP: 2.7 vs. 4.5, p = 0.02); the change in ORP between day 2 and arrival (ΔORP) was significantly greater in patients who died (sORP: 26.3 vs 5.4, p = 0.002; icORP: 1.5 vs. 0.0, p = 0.004). Arrival ORP was lowest in patients with severe stroke, while ΔORP was greatest in these patients (table 1), independent of thrombolytic therapy (interaction p =0.36). Arrival ORP was positively correlated with LOS (p = 0.003). Conclusions: These results demonstrate the ability of ORP to identify oxidative stress and amount of antioxidant reserves in a stroke population. We propose ORP monitoring as a potentially useful tool in evaluation of acute stroke patients.

Background: Stroke coordinators are essential to stroke programs. An international survey demonstrates lack of formal guidance and role expectations. The ASA Southwest Affiliate observed high turnover of stroke coordinators and lack of general knowledge of their role. Additionally, there were few local experts available to individually mentor new coordinators. ASA staff teamed with experienced stroke coordinators to host the first conference of this kind in the region. Purpose: The purpose of this conference was to impact practice and longevity by offering content focused on successful stroke program development and key stroke coordinator responsibilities. Methods: ASA staff recruited successful stroke coordinators from the SW Affiliate to plan a 2 day conference with a keynote, 2 hours of breakout sessions and 8.5 hours of CE. Topics included: stroke coordinator role, certification preparation, team leadership, resources, and PI. Sponsors and vendors participated, and registrants paid $150. To encourage attendance, the committee chose an upscale Denver hotel with reasonable room prices, identified the theme of Survivor and the tagline “From Surviving to Thriving”. Mirroring the TV show, team challenges reinforced important concepts and encouraged networking. Results: 45% of attendees came from GWTG Stroke hospitals in the SWA. Sixty-nine online evaluations indicated 77% were in the role less than 2 years. Only 5% reported a structured orientation plan and 39% answered “no, I made it up as I went along.” At the conclusion of the conference, 90% stated they could define key responsibilities of the stroke coordinator and 90% indicated they could articulate the important role evidenced-based guidelines play in the care of the stroke patient. Conclusion: Stroke programs success depend greatly on the competency and ability of the stroke coordinator. The ASA’s support of programs that spotlight the stroke coordinator’s responsibilities offer a unique venue to gather colleagues and discuss the evolution of the position as it pertains to the stroke continuum of care. The SW Affiliate will host the 2 nd event in May 2015 in Houston. A long term goal of this SW Affiliate group is to offer this conference annually.

Background: Our institution is a comprehensive stroke center in Englewood, Colorado with 55,000 visits to the emergency department (ED) annually. Our 2012 mean door to needle (DTN) time was 41 minutes, with a fastest DTN of 22 minutes. Inspired by the 2012 Finnish study touting mean DTN times of less than 20 minutes, ED leaders developed and implemented the computed tomography (CT) Direct protocol using lean principles to decrease mean door to CT first slice times. Purpose: Use of the CT Direct protocol will decrease DTN times. Methods: The CT Direct protocol details the process of the first few minutes after a stroke alert patient arrives to the facility. The Launch Pad was created and is a designated hallway spot located directly between the emergency medical services (EMS) entrance and CT. Formal signage was installed denoting this special area. The patient arrives to the Launch Pad for rapid registration, brief EMS presentation of history of present illness, medications, and assessment findings. The patient stays on the EMS pram until transport to the CT table and does not enter the ED room until after imaging is completed. An eight week pilot study was performed in 2013 utilizing the CT Direct protocol. This data was compared against information collected during the same period of time in 2012. All stroke alerts brought to the facility via EMS or private car were included in the data sample. Stroke alerts called for patients transferred from an outside hospital were excluded. Results: In the control group (2012) there were 29 stroke alerts called with a door to first slice (DFS) CT mean of 24 minutes and DTN of 43 minutes. This is compared to the CT Direct group (2013) data with 38 stroke alerts called with a mean DFS CT of 20 minutes and DTN of 35 minutes. During the pilot study, the stroke team achieved a record DTN of 17 minutes for one patient, as well as DTN times between 20 and 29 minutes in 3 other patients. Statistical analysis was performed, but failed to demonstrate significance due to small sample size. Conclusions: Use of the CT Direct protocol decreased the DFS CT by 5 minutes and DTN by 8 minutes. Further study is recommended with a sample size of 214.

Background The treatment of acute ischemic stroke is traditionally centered on time criteria, although recent evidence suggests that physiologic neuroimaging may be useful. In a multicenter study we evaluated the use of CT perfusion, regardless of time from symptom onset, in patients selected for intra-arterial treatment of ischemic stroke. Methods Three medical centers retrospectively assessed stroke patients with a National Institute of Health Stroke Scale of ≥8, regardless of time from symptom onset. CT perfusion maps were qualitatively assessed. Patients with defined salvageable penumbra underwent intra-arterial revascularization of their occlusion. Functional outcome using the modified Rankin Score (mRS) was recorded. Results Two hundred and forty-seven patients were selected to undergo intra-arterial treatment based on CT perfusion imaging. The median time from symptom onset to procedure was 6 h. Patients were divided into two groups for analysis: ≤8 h and >8 h from symptom onset to endovascular procedure. We found no difference in functional outcome between the two groups (42.8% and 41.9% achieved 90-day mRS ≤ 2, respectively (p=1.0), and 54.9% vs 55.4% (p=1.0) achieved 90-day mRS ≤ 3, respectively). Overall, 48 patients (19.4%) had hemorrhages, of which 20 (8.0%) were symptomatic, with no difference between the groups (p=1.0). Conclusions In a multicenter study, we demonstrated similar rates of good functional outcome and intracranial hemorrhage in patients with ischemic stroke when endovascular treatment was performed based on CT perfusion selection rather than time-guided selection. Our findings suggest that physiologic imaging-guided patient selection rather than time for endovascular reperfusion in ischemic stroke may be effective and safe.

Introduction: Telemedicine for Acute Stroke Evaluation and Treatment has been widely used for providing expert stroke neurology advice for patients presenting to rural hospitals. Iv-TPA administration rates in these experiences are high (20-25%). However, national iv-tPA administration rates still are below this level. In addition, less than 30% of patients are receiving iv-tPA in less than 60 minutes. We describe a novel telemedicine network that augments existing on-call neurological support to decrease door to needle times for iv-tPA administration. Methods: Data from 6 metropolitan hospitals in the Denver area were collected to assess rapidity of iv-tPA administration for Acute Ischemic Stroke. All hospitals had existing acute stroke protocols, on-call board certified neurologists, board certified Emergency Room Physicians (EDP) available on a 24/7 basis. Stroke Program leaders including Emergency Room Physicians, Neurologists, and administrators from these hospitals were invited to participate in an initiative to decrease door to needle times. Through this committee, consensus was reached that the arrival of a neurologist be less than 15 minutes from arrival of the patient to the Emergency Room. At times and places where this could not be achieved by physical presence, telemedicine technology was employed. This Telemedicine Intiative (TI) was instituted on May 1st, 2011. Time data regarding patient arrival, time to CT scan, time in CT scan, arrival of neurologist, first Emergency Room physician evaluation, tPA administration will be tracked. Results: Prior to institution of the Telemedicine Initiative, average door to needle times for the six hospital network was 86 minutes. In the first month of institution of TI, average door to needle times decreased to 67 minutes across the network. 102 telemedicine consultations have been performed to date. All telemedicine consultations were instituted within 10 minutes of arrival of the patients to the emergency room. Conclusions: Employing Telemedicine in a metropolitan hospital setting with exisiting neurological coverage, acute stroke protocols and board certified ED Physicians may decrease the time needed to administer iv-TPA in acute ischemic stroke patients.