Chung-Huan J Sun

“Picture to Puncture” A Novel Time Metric to Enhance Outcomes in Patients Transferred for Endovascular Reperfusion in Acute Ischemic Stroke

Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P 7: 50% versus 76%; P <0.001) and significantly worse clinical outcomes (29% versus 51%; P =0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P =0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes. # Clinical Perspective {#article-title-29}Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P=0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

Dexmedetomidine: a safe alternative to general anesthesia for endovascular stroke treatment

Background and purpose There have been reports that general anesthesia (GA) is associated with worse clinical outcomes during intra-arterial treatment (IAT) for stroke. Since traditional sedatives carry the risk of respiratory depression, this retrospective study was designed to compare sedation with the α2 adrenergic agonist dexmedetomidine (DEX) and with GA for IAT procedures. Methods We reviewed our institutional endovascular database of 216 consecutive patients who received DEX or GA for IAT of anterior circulation strokes between September 2010 and July 2012. The demographic, radiographic and angiographic variables between the GA and DEX groups were compared, as well as hemodynamic changes during the procedure. Binary logistic regression models were generated to determine the independent predictors of a favorable outcome (defined as a modified Rankin Score at 90 days of 0–2). Results 83 patients had IAT performed under DEX sedation. Their demographic characteristics were similar to those given GA except that they were older and had less severe strokes. The GA group experienced greater variations in blood pressure, more hypotension with induction (54% vs 28%, p<0.001) and greater use of vasopressors (79% vs 58%, p<0.001). In our regression models, independent predictors of a good outcome included age, NIH Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT score (ASPECTS), successful reperfusion, lower baseline systolic blood pressure and higher blood pressures during the procedure. DEX was associated with a good outcome when models included NIHSS as the sole measure of stroke severity but was equivalent to GA when ASPECTS was added to the analysis. Conclusions DEX can be safely administered in patients undergoing endovascular reperfusion therapies. Further study is required to determine if outcomes are different among sedatives used during such procedures.

Door‐to‐Puncture: A Practical Metric for Capturing and Enhancing System Processes Associated With Endovascular Stroke Care, Preliminary Results From the Rapid Reperfusion Registry

Background In 2011, the Brain Attack Coalition proposed door‐to‐treatment times of 2 hours as a benchmark for patients undergoing intra‐arterial therapy (IAT). We designed the Rapid Reperfusion Registry to capture the percentage of stroke patients who meet the target and its impact on outcomes. Methods and Results This is a retrospective analysis of anterior circulation patients treated with IAT within 9 hours of symptom onset. Data was collected from December 31, 2011 to December 31, 2012 at 2 centers and from July 1, 2012 to December 31, 2012 at 7 centers. Short “Door‐to‐Puncture” (D2P) time was hypothesized to be associated with good patient outcomes. A total of 478 patients with a mean age of 68±14 years and median National Institutes of Health Stroke Scale (NIHSS) of 18 (IQR 14 to 21) were analyzed. The median times for IAT delivery were 234 minutes (IQR 163 to 304) for “last known normal‐to‐groin puncture” time (LKN‐to‐GP) and 112 minutes (IQR 68 to 176) for D2P time. The overall good outcome rate was 39.7% for the entire cohort. In a multivariable model adjusting for age, NIHSS, hypertension, diabetes, reperfusion status, and symptomatic hemorrhage, both short LKN‐to‐GP (OR 0.996; 95% CI [0.993 to 0.998]; P<0.001) and short D2P times (OR 0.993, 95% CI [0.990 to 0.996]; P<0.001) were associated with good outcomes. Only 52% of all patients in the registry achieved the targeted D2P time of 2 hours. Conclusions The time interval of D2P presents a clinically relevant time frame by which system processes can be targeted to streamline the delivery of IAT care nationally. At present, there is much opportunity to enhance outcomes through reducing D2P.

Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I)

Background The efficacy of hypothermia as a neuroprotectant has yet to be demonstrated in acute ischemic stroke. We conducted a phase I pilot study to assess the feasibility and safety of performing intravascular hypothermia after definitive intra-arterial reperfusion therapy (IAT). Methods ReCCLAIM (Reperfusion and Cooling in Cerebral Acute Ischemia) is a prospective single-arm open-label clinical trial conducted between May and August 2012 at Grady Memorial Hospital. Twenty patients with Alberta Stroke Program Early CT Score (ASPECTS) 5–7 and NIH Stroke Scale (NIHSS) score > 13 were enrolled and treated with intravascular cooling immediately after IAT. The incidence of pneumonia, deep vein thrombosis, cardiac arrhythmias and postoperative hemorrhages was documented for the entire length of stay. Secondary outcomes included blood–brain barrier (BBB) breakdown on gadolinium-enhanced MRIs and 90-day modified Rankin scores (mRS). Results The mean age, median NIHSS score and median final infarct volume were 59.7±14.6 years, 19 (IQR16–22) and 78 cm3 (IQR 16–107), respectively. The average time to the target temperature (33°C) was 64±50 min. Intracranial hemorrhages were found in three patients, of which one was symptomatic. Evidence of BBB breakdown was observed on 3 of 14 MRIs (21%). Six patients died due to withdrawal of care, whereas six patients (30%) achieved mRS of 0–2 at 90 days. In a binary logistical regression model comparing ReCCLAIM patients with 68 historical controls at our institution, hypothermia was protective against intracerebral hemorrhages (OR 0.09, 95% CI 0.02 to 0.56; p<0.01). Conclusions Hypothermia can be safely performed after definitive IAT in patients with large pretreatment core infarcts. A phase II study randomizing patients to hypothermia or normothermia is needed to properly assess the efficacy of hypothermia as a neuroprotectant for reperfusion injury. Trial registration number NCT01585597.

ASPECTS decay during inter-facility transfer predicts patient outcomes in endovascular reperfusion for ischemic stroke: a unique assessment of dynamic physiologic change over time

Background Pretreatment Alberta Stroke Program Early CT Scores (ASPECTS) is associated with clinical outcomes. The rate of decline between subsequent images, however, may be more predictive of outcomes as it integrates time and physiology. Methods A cohort of patients transferred from six primary stroke centers and treated with intra-arterial therapy (IAT) was retrospectively studied. Absolute ASPECTS decay was defined as ((ASPECTS First CT—ASPECTS Second CT)/hours elapsed between images). A logistic regression model was performed to determine if the rate of ASPECTS decay predicted good outcomes at 90 days (modified Rankin Scale score of 0–2). Results 106 patients with a mean age of 66±14 years and a median National Institutes of Health Stroke Scale score of 19 (IQR 15–23) were analyzed. Median time between initial CT at the outside hospital to repeat CT at our facility was 2.7 h (IQR 2.0–3.6). Patients with good outcomes had lower rates of absolute ASPECTS decay compared with those who did not (0.14±0.23 score/h vs 0.49±0.39 score/h; p<0.001). In multivariable modeling, the absolute rate of ASPECTS decay (OR 0.043; 95% CI 0.004 to 0.471; p=0.01) was a stronger predictor of good patient outcome than static pretreatment ASPECTS obtained before IAT (OR 0.64; 95% CI 0.38 to 1.04; p=0.075). In practical terms, every 1 unit increase in ASPECTS decline per hour correlates with a 23-fold lower probability of a good outcome. Conclusions Patients with faster rates of ASPECTS decay during inter-facility transfers are associated with worse clinical outcomes. This value may reflect the rate of physiological infarct expansion and thus serve as a tool in patient selection for IAT.

A Novel Approach to Diagnose Reversible Cerebral Vasoconstriction Syndrome: A Case Series

BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is classically diagnosed based on the presence of severe thunderclap headache, focal neurologic symptoms, and the radiographic findings of reversible diffuse segmental cerebral vasoconstriction. We present a diagnostic test that may assist in the clinical diagnosis and facilitate treatment. METHODS From October 1, 2010, to August 1, 2013, we identified consecutive patients who presented with a presumptive diagnosis of RCVS and underwent cerebral diagnostic angiography with intra-arterial (IA) vasodilator therapy. Medical records including clinical presentation, radiographic, and angiographic images were all reviewed. RESULTS We identified a total of 7 patients (4 females; age range, 22-56; mean, 45 years) who met our inclusion criteria. Four patients received a combination of milrinone and nicardipine infusion either in the internal carotid arteries or in the left vertebral artery; the remaining patients received IA therapy solely with either nicardipine or milrinone. Five patients had a positive angiographic response, defined as significant improvement or resolution of the blood vessels irregularities. All 5 patients had a definite discharge diagnosis of RCVS. The remaining 2 patients had a negative angiographic response and based on their clinical and radiographic course had a final diagnosis of intracranial atherosclerotic disease. CONCLUSIONS Our small case series suggest that IA administration of vasodilators is safe and may aid in distinguishing vasodilator responsive syndromes such as RCVS from other causes. Further study is required with long-term clinical outcome to determine the utility of this diagnostic test.

Endovascular Therapy for Stroke: Getting to the “Heart” of the Matter

> Those who cannot remember the past are condemned to repeat it.1 > > — George Santayana, 1863 to 1952 In the late 1970s, Gruentzig’s groundbreaking reports on a series of successfully performed coronary angioplasties created the field of endovascular medicine, setting the precedent for the Food and Drug Administration’s 510(k) approval of the procedure in 1981.2 Over the next decade, the number of angioplasties performed in the United States grew exponentially from 1000 procedures in 1980 to >300 000 by 1995.3 Despite robust growth, however, clinical trials failed to demonstrate the benefits of angioplasty over thrombolysis for the treatment of ST-segment–elevation myocardial infarction (STEMI).4–7 The Primary Angioplasty in Myocardial Infarction (PAMI) and ZWOLLE trials in 1993 were the first randomized, controlled studies to demonstrate the efficacy of percutaneous coronary intervention (PCI) over fibrinolytic therapy,8,9 nearly 10 years after reimbursement by the Centers for Medicare & Medicaid (diagnosis-related group 108) was granted.10 Although subsequent studies disputed the merits of PCI,11–13 several meta-analyses provided definitive evidence that PCI was superior for STEMI.14,15 In 1996, the American College of Cardiology/American Heart Association incorporated PCI as a Class I recommendation for STEMI if performed in a “timely fashion…by personnel in high volume center[s].”16 The use of PCI as a facilitated or rescue strategy after fibrinolysis, however, remained controversial, having only recently been shown to be effective.17–19 As history repeats itself, many challenges encountered by cardiology are being revisited by acute stroke trialists. Since the publication of the nonpositive results of the Interventional Management of Stroke (IMS) III, The Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS Expansion trials,20–22 endovascular procedures for stroke are being met with skepticism, similar …

Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis

Objective We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment. Methods Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes. Results 147 subjects were included in the analysis with a mean age of63±14 years and median NIHSS of 18 (IQR 14–21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0–2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p<0.04). Conclusions Subjects discharged to SNFs and IRFs after thrombectomy have similar medical and neurological severity at admission and similar final infarct volumes at discharge. Despite these similarities, patients discharged to an SNF had a significantly lower probability of achieving a good neurological outcome. These results have implications for future acute stroke trial design.

Clinical and Angiographic Outcomes with the Combined Local Aspiration and Retriever in the North American Solitaire Stent-Retriever Acute Stroke (NASA) Registry

Background: Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. Summary: Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, p = 0.04 and 26% in CGC, p = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, p = 0.001) and was comparable to the BGC time (54 vs. 67, p = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. Key Messages: The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.

“Picture to Puncture”Clinical Perspective

Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P 7: 50% versus 76%; P <0.001) and significantly worse clinical outcomes (29% versus 51%; P =0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P =0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes. # Clinical Perspective {#article-title-29}Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P=0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.