Kumiko Owada

Comparison of Final Infarct Volumes in Patients Who Received Endovascular Therapy or Intravenous Thrombolysis for Acute Intracranial Large-Vessel Occlusions

IMPORTANCE Studies comparing the efficacy of intra-arterial therapy (IAT) and medical therapy in reducing final infarct volume (FIV) in intracranial large-vessel occlusions (ILVOs) are lacking. OBJECTIVES To assess whether patients with ILVOs who received IAT have smaller FIVs than patients who received either intravenous tissue plasminogen activator therapy (IVT) or no reperfusion therapy (NRT) and to determine a National Institutes of Health Stroke Scale (NIHSS) threshold score that identifies patients most likely to benefit from IAT. DESIGN Retrospective cohort study of patients with ILVOs between 2009 and 2011. SETTING Two large-volume stroke centers. PARTICIPANTS Adults with anterior circulation ILVOs who presented within 360 minutes from the time last seen as normal. Patients with isolated extracranial occlusions were not included. EXPOSURE Intra-arterial therapy, IVT, or NRT. MAIN OUTCOMES AND MEASURES Final infarct volumes, rates of acceptable outcome defined as a modified Rankin Scale score of 0 to 3 at hospital discharge, and NIHSS threshold scores. RESULTS A total of 203 consecutive patients with ILVOs were evaluated. Baseline characteristics were similar among the 3 groups. The median infarct volume was significantly smaller for the IAT group (42 cm3) than for the IVT group (109 cm3; P = .001) or the NRT group (110 cm3; P < .01). A higher magnitude of infarct volume reduction in more proximal occlusions was noted in the IAT group compared with the IVT and NRT groups combined: internal carotid artery terminus (75 vs 190 cm3; P < .001), M1 middle cerebral artery (39 vs 109 cm3; P = .004), and M2 middle cerebral artery (33 vs 59 cm3; P = .04) occlusions. Patients were stratified based on NIHSS score at presentation (8-13, 14-19, and ≥20). For patients with an NIHSS score of 14 or higher at presentation, IAT significantly reduced FIV (46 cm3 with IAT vs 149 cm3 with IVT or NRT; P < .001) compared with patients with an NIHSS score of 8 to 13 (22 cm3 with IAT vs 44 cm3 with IVT or NRT; P = .40). Patients with an NIHSS score of 14 or higher who received IAT appear to benefit most from IAT. CONCLUSIONS AND RELEVANCE Our data suggest a greater reduction of FIV with IAT compared with either IVT or NRT. Moreover, patients with an NIHSS score of 14 or higher may be the best candidates for endovascular reperfusion therapy.

CODE FAST: a quality improvement initiative to reduce door-to-needle times

Background Rapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions. Objective To start a quality improvement project called CODE FAST in order to reduce DTN times at our institution. Materials and methods We retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol. Results A total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (p<0.0001) and DTN time with a reduction in the median from 62 to 25 min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era. Conclusions We present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30 min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.

Severe hemiparesis as a prehospital tool to triage stroke severity: a pilot study to assess diagnostic accuracy and treatment times.

Introduction With the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes. Materials and methods We retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy. Results 45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101 min, with 8 of the 12 patients (66.7%) being discharged to home. Conclusions We have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.

Clinical Outcomes after Thrombectomy for Acute Ischemic Stroke on Weekends versus Weekdays

BACKGROUND The objective of this study was to determine whether clinical outcomes differed in acute ischemic stroke (AIS) patients who underwent thrombectomy on weekends versus weekdays. METHODS Patients with a primary diagnosis of AIS who underwent thrombectomy were identified from the Nationwide Inpatient Sample from 2005 to 2011 and stratified according to weekend or weekday admission. Logistic regression analysis was performed to identify factors associated with moderate-to-severe disability at hospital discharge in teaching and nonteaching hospitals. RESULTS Of 12,055 patients with AIS who underwent thrombectomy during the study period, 2862 (23.7%) were admitted on a weekend. In a multivariate logistic regression analysis, factors associated with moderate or severe disability at discharge in nonteaching hospitals were weekend admission (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.8; P = .04), diagnosis of hypertension (OR, 1.9; 95% CI, 1.0-3.6; P = .05), and Medicare or Medicaid insurance status (OR, 2.1; 95% CI 1.1-4.3; P = .02); factors associated with moderate or severe disability at discharge in teaching hospitals were age >70 years (OR, 1.5; 95% CI, 1.1-2.2; P = .02), pneumonia (OR, 4.7; 95% CI, 2.2-10.2; P < .0001), sepsis (OR, 8.2; 95% CI, 1.2-54.8; P = .03), intracranial hemorrhage (OR, 3.3; 95% CI, 1.8-6.1; P = .0001), and treatment in a Northwest hospital region (OR, 1.7; 95% CI, 1.2-2.4; P = .03). CONCLUSIONS AIS patients undergoing thrombectomy who were admitted to nonteaching hospitals on weekends were more likely to be discharged with moderate-to-severe disability than those admitted on weekdays. No weekend effect on discharge clinical outcome was seen in teaching hospitals.

Endovascular Therapy in Strokes with ASPECTS 5-7 May Result in Smaller Infarcts and Better Outcomes as Compared to Medical Treatment Alone

Introduction: Intra-arterial therapy (IAT) for large vessel occlusion strokes (LVOS) has been increasingly utilized. The benefit of IAT in patients with midrange Alberta Stroke Program Early Computed Tomography Score (ASPECTS) remains to be established. Materials and Methods: This was a retrospective analysis of LVOS with ASPECTS 5-7 treated with IAT (n = 86) or medical therapy alone (intravenous tissue plasminogen activator; n = 15) at two centers from 2009 to 2012. Definitions were as follows: symptomatic intracranial hemorrhage = any parenchymal hematoma; successful reperfusion = mTICI ≥2b; good and acceptable outcomes = 90-day mRS 0-2 and 0-3, respectively. Final infarct volumes (FIV) were calculated based on 24-hour CT/MRI scans. Results: Mean age (67 ± 14 vs. 67 ± 19 years) and baseline NIHSS (20 ± 5 vs. 20 ± 6) were similar in the two groups. Successful reperfusion was achieved in 58 (67%) IAT patients. Symptomatic and asymptomatic intracranial hemorrhage occurred in 9 (10%) and 31 (36%) IAT patients, respectively. The proportion of 90-day good and acceptable outcomes was 20 (17/86) and 33% (28/86), respectively. Successful IAT reperfusion was associated with smaller FIV (p = 0.015) and higher rates of good (p = 0.01) and acceptable (p = 0.014) outcomes. There was a strong trend towards a higher hemicraniectomy requirement in medically as compared to endovascularly treated patients (20 vs. 6%; p = 0.06) despite similar in-hospital mortality. The median FIV was significantly lower with IAT versus medical therapy [80 ml (interquartile range, 38-122) vs. 190 ml (121-267); p = 0.015]. Conclusions: Despite a relatively low probability of achieving functional independence, IAT in LVOS patients with ASPECTS 5-7 appears to result in lower degrees of disability and may lessen the need for hemicraniectomy. Therefore, it may be a reasonable option for patients and families who favor a shift from severe to moderate disability.

O-020 A comparison of infarct volumes in patients with large vessel occlusions based on treatment modality: a retrospective analysis

Introduction Intra-arterial (IA) therapy for large vessel occlusions (LVO) results in higher recanalization rates compared to intravenous (IV) thrombolysis. Recanalization after LVO is also a predictor of better clinical outcome. Whether IA therapy results in lower stroke infarct burden has not previously been determined. Infarct volume has been shown to have a strong correlation to 90-day clinical outcome. We hypothesized that patients treated with IA therapy will have lower post-procedure infarct volumes compared to IV thrombolysis or untreated patients. Materials and methods A retrospective chart review was performed on consecutive patients with LVO between November 2010 and December 2011 at Emory University Hospital and Grady Memorial Hospital. LVO was defined as extracranial/intracranial internal carotid artery (ICA), M1 middle cerebral artery (MCA) or M2 MCA occlusions identified by CT, MR or conventional angiography. Adults (>18 years) with LVO who presented within 8 h from time last seen normal were included and grouped as follows: those receiving intra-arterial/endovascular therapy (IA group), intravenous thrombolysis only (IV group) and no thrombolysis (Untreated group). Baseline characteristics were recorded on all patients. Infarct volume was measured using subsequent CT or MRI imaging after the first 24 h and compared using the Mann–Whitney U test. Data are represented as box plots showing the median infarct volume and the first and third IQRs for each group (Abstract O-020 figure 1A,B).Abstract O-020 Figure 1 (A) Infarct Volumes in LVO. (B) Infarct volume based on location of occlusion and treatment modality. Results 192 patients with LVO met inclusion criteria (IA: 127 patients, IV: 35 patients, Untreated: 30 patients). The mean age for the entire cohort was 66±16 years and the mean NIHSS was 19±6. Baseline clinical characteristics were comparable between the three groups. In all LVOs, median infarct volume was significantly smaller in the IA group compared to the untreated group (Abstract O-020 figure 1A, p=0.02) while infarct volume in the untreated and IV groups was similar (p=0.8). Based on level of occlusion, infarct volume was significantly smaller in the IA group compared to the untreated/IV group (Abstract O-020 figure 1B) in patients with terminal ICA (ICA-T) (p=0.005) and M1 MCA occlusions (p=0.02). Infarct volume in M2 occlusions was similar between the groups (p=0.3). Conclusions Endovascular therapy for anterior circulation LVO appears to reduce infarct volumes in patients presenting within 8 h from symptom onset especially in ICA-T and M1 occlusions but not M2 occlusions. Prospective studies are needed to replicate these findings and correlate with clinical outcomes. Competing interests None.

P-029 Outcomes in patients with ASPECTS of 5–7 undergoing endovascular reperfusion therapy for acute ischemic stroke

Introduction Intra-arterial (IA) therapy for large vessel occlusions (LVO) has been increasingly utilized to treat patients with acute stroke with high NIHSS. The size of pre-treatment infarct core has been linked to a higher rate of intracranial hemorrhage and worse clinical outcomes. Patients with ASPECTS scores >7 appear to have the best clinical outcomes. Whether the benefits of endovascular reperfusion can be extended to patients with lower ASPECTS remains to be studied. We sought to determine the clinical outcomes in patients with LVO who presented with ASPECTS of 5–7. Materials and methods A retrospective chart review was performed on patients with LVO who presented to Grady Memorial Hospital and University of Pittsburgh Medical Center between 2009 and 2011. LVO was defined as extracranial/ intracranial internal carotid artery (ICA), M1 middle cerebral artery (MCA) or M2 MCA identified by CT, MR or conventional angiography. Patients with ASPECTS 5–7 on pre-treatment CT were included in the analysis. Demographic, clinical and radiographic variables were assessed. Symptomatic hemorrhage was defined as PH2 hemorrhage based on the ECASS definition. Successful reperfusion was defined as TICI 2A or greater. A good clinical outcome was defined as 90-day mRS of 0–2 while acceptable outcome was defined as mRS of 0–3. Infarct volume was tabulated with summation of the regions of interest around the final infarct on a CT or MRI obtained more than 24 h after the procedure. Results A total of 76 patients were identified (mean age 66±13 years, mean NIHSS 20±6.) Fifty patients (66%) were transferred from an outside hospital and 34 (45%) received IV tPA prior to endovascular therapy. Successful reperfusion was achieved in 43 patients (57%). Symptomatic hemorrhages occurred in nine patients (12%) while asymptomatic hemorrhages were noted in 29 (38%) patients. Fourteen patients (18%) achieved a good clinical outcome while 23 (30%) achieved an acceptable outcome. The median final infarct volume was 90 cm3 (IQR 49-155 cm3). Patients with successful reperfusion were more likely to achieve a good clinical outcome (26% vs 9%, p<0.045) and acceptable clinical outcome (40% vs 12%, p<0.03). Conclusions Despite the low probability of achieving good clinical outcome in patients with ASPECTS 5–7 who underwent IA therapy, successful revascularization still results in less disability when compared to non-reperfused patients. Therefore, IA therapy may be a reasonable option in patients and families who favor a shift from severe to moderate disability. Further larger prospective studies are warranted to confirm these results. Competing interests A Noorian: None. S Rangaraju: None. K Owada: None. T Jovin: None. B Glenn: None. S Belagaje: None. A Anderson: None. F Nahab: None. M Frankel: None. R Nogueira: Concentric Medical, ev3 Neurovascular, CoAxia, and Rapid Medical. R Gupta: Concentric Medical, Codman Neurovascular, CoAxia, and Rapid Medical.