Richard Jung

Overview of key factors in improving access to acute stroke care

Background: Despite recent advances in acute stroke therapy, only a small proportion of patients with acute ischemic stroke receive IV and endovascular revascularization therapies. This article provides an overview of factors influencing access to stroke therapy. Methods: The key factors influencing access to stroke care highlighted during the Society of Vascular and Interventional Neurology (SVIN) roundtable meeting are summarized. Pertinent selected references on prehospital, hospital, and legislative and economic factors influencing access to stroke care, from the Medline database (between 1995 to 2011), are included. A brief summary of these key factors in improving access to stroke therapy is provided. Results: Prehospital factors include the community; education of hospital administrators and health care personnel; dispatchers; the medical transport system; and preparedness and stroke education of emergency medical services (EMS). Stroke-ready hospitals and networking with other regional tertiary stroke hospitals play important roles in increasing access to stroke care. In addition, legislation at the state and federal levels is a key factor in providing high-quality, timely access to stroke care for the population in general. Strategies to facilitate access to stroke therapy are critical to improving mortality and functional outcome and increasing the proportion of patients treated by systemic thrombolysis and endovascular approaches. Conclusion: This is a brief overview and summary of selected factors influencing access to stroke care. These factors are divided into prehospital, hospital, legislative, and economic categories. Multilevel education of the population, public health care personnel, hospital preparedness, and legislative and economic factors are important in improving access to stroke care.

Risk of contrast-induced nephropathy in patients undergoing endovascular treatment of acute ischemic stroke

Background and purpose We report the incidence and risk factors for contrast-induced nephropathy after the use of iodinated contrast for endovascular treatment of acute ischemic stroke. Methods A retrospective chart review was performed in 194 consecutive patients who underwent endovascular treatment for acute ischemic stroke between January 2006 and January 2011. No patients were excluded from treatment for elevated creatinine (Cr). Each patient received approximately 150 ml intra-arterial non-ionic low-osmolar contrast agent (Optiray 320) during the endovascular procedure. Contrast-induced nephropathy (CIN) was defined according to the Acute Kidney Injury Network criteria as a relative increase of serum Cr 50% above the baseline or an absolute increase of 0.3 mg/dl at 48 h following the endovascular procedure. Results Of 194 patients (mean age 65±14 years), 52% were women (n=100) and 25% (n=48) were diabetic. Baseline Cr levels for 191 patients ranged between 0.4 and 2.7 mg/dl. Three patients on chronic hemodialysis had baseline Cr levels ranging between 5.3 and 6.1 mg/dl. Cr was ≤1.5 mg/dl in 163 patients (84%) and ≥ 1.5 mg/dl in 31 (16%). Three of the 191 patients (1.5%) developed CIN as noted from Cr measurements between baseline and within 48 h. One patient who developed an elevated Cr level had a known history of chronic renal insufficiency (Cr > 1.5 mg/dl) and two had baseline Cr levels within the normal range. An additional CT angiogram was obtained in 44 patients, none of which developed CIN. Female gender and diabetes were not associated with a higher risk of developing CIN. Conclusions The risk of developing CIN is low among patients with acute stroke who undergo emergency endovascular treatment. Treatment of acute stroke should be performed irrespective of Cr levels.

In Vivo Characterization of Carotid Neointimal Hyperplasia by use of Optical Coherence Tomography: Before and After Cutting Balloon Angioplasty.

Optical coherence tomography (OCT) is a modern intravascular imaging modality that has the capability to provide detailed, in vivo characterization of the arterial wall and atherosclerotic plaque. The current understanding of the appearance of atherosclerotic plaque via OCT is largely based on coronary arterial studies where OCT information has been employed to guide therapeutic management and permits the immediate evaluation of percutaneous intervention. The clinical success of OCT in the coronary arteries has laid the foundation for investigation of the carotid artery and thus, stroke risk assessment. We report the novel use of OCT for tissue characterization of severe stenosis subsequent to carotid artery stenting (CAS), both before and after treatment with cutting balloon angioplasty.

E-066 A favorable profile for selecting acute ischemic stroke patients for thrombolytic therapy

Background There is currently an intense interest in defining predictive profiles from MRI based diffusion/perfusion information for acute ischemic stroke patients. Perfusion/diffusion ratio (mismatch ratio) and penumbra volumes are factors used to select patients for thrombolysis. The current literature considers a mismatch ratio of 1.2 as the minimum for thrombolysis. There is much debate, however, as to how mismatch ratios and penumbra volumes affect patient outcome. Methods 31 acute ischemic stroke patients were selected at random and had their presenting acute stroke-protocol MRI processed through OLEA Medicals PerfScape, which calculated the penumbral volume and mismatch ratio, using a Tmax of 4 s. A mismatch ratio of 1.2–4.5 with a penumbra volume >80 cc was labeled as a Favorable Profile (FP). NIHSS scores were collected both at stroke presentation and at time of discharge. An improvement of NIHSS ≥4 at time of discharge was considered a good outcome. Results Eight patients were found to have a FP with a mismatch ratio between 1.2 and 4.5 and a penumbra volume >80 cc. Twenty-three patients did not have an FP. Of the eight patients with an FP, all 8 had an improvement of ≥4 in their NIHSS score. Of the 23 patients who did not have an FP, 7 had an improvement of ≥4 in their NIHSS score, while 16 had no improvement or an improvement of <4 in their NIHSS score, (p=0.0008). Furthermore, a homogenous subset of patients (N=20) who underwent thrombolytic therapy and achieved TIMI 2 or greater recanalization, showed similar findings (p=0.02) Conclusion This small study demonstrates that our definition of a favorable MRI perfusion profile in ischemic stroke patients (mismatch ratio of 1.2–4.5 and a penumbra volume >80 cc) was associated with a good outcome at discharge, for all patients as well as an endovascularly treated homogeneous subset. Furthermore, the clinical application of this upper limit of 4.5 for the mismatch ratio warrants further investigation.Abstract E-066 Table 1 Favorable profile and NIHSS improvement NIHSS improvement ≥4 NIHSS improvement <4 Favorable Profile (Mismatch ratio of 1.2–4.5 and penumbra volume >80 cc) 8 0 Not a Favorable Profile 7 16 Competing interests None.

E-067 Safety and efficacy of the starclose vascular closure device with use of large French femoral sheath

Background Large French (Fr) sheaths are commonly used to obtain optimum common femoral artery (CFA) access while performing acute stroke endovascular treatments. The StarClose Vascular Closure System (Abott Vascular) is currently indicated for the percutaneous closure of CFA access sheaths of 5 Fr or 6Fr procedural size. Limited data exists regarding off-label use of the StarClose device in patients who had 7–9 French CFA access. Objectives To evaluate the safety and efficacy of the StarClose extravascular closure device in achieving post femoral artery catheterization hemostasis after placement of large Fr femoral sheath. Methods Retrospective chart review was performed between 2009 and 2011 of 73 patients who underwent endovascular treatment for acute stroke who were closed with the StarClose device. The study included 39 females and 34 males with mean age 68.1 years. 86.4% (n=63) had hypertension, 26% (n=19) had diabetes mellitus, 75.34% (n=55) had dyslipidemia, 42.5% (n=31) had coronary artery disease, and 39.7% had (n=29) had atrial fibrillation. The primary endpoints were successful hemostasis and sheath related post procedure major and minor complication rates. Results A 5Fr (1.4%) sheath was used in 1 patient, 6Fr sheaths in 37 (58.7%) patients, 7Fr sheaths in 2 (2.7%) patients, 8Fr sheaths in 14 (19%) patients, and 9Fr sheaths in 19 (26%) patients during acute stroke interventions. Overall, successful hemostasis was achieved in 72 (99%) cases. One (0.95%) minor complication was observed post procedure in the patient with a 6Fr access size. The patient had intermittent minor bleeding from the groin site and was found to have a CFA pseudoaneursym. No mortality or significant morbidity was observed associated with groin site closure in this study. Conclusion The StarClose vascular closure device is safe and effective in achieving hemostasis during acute stroke endovascular interventions while using large French procedural access sheaths. Competing interests None.

P-042 Combined intra-arterial thrombolysis and mechanical thrombectomy versus mechanical thrombectomy endovascular outcomes in acute ischemic stroke

Background Endovascular intervention is an important treatment option for patients with acute ischemic stroke who are ineligible for intravenous thrombolysis or fail to respond to such therapy. Endovascular treatments include intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT). Limited data exists regarding the safety and efficacy of a combination approach using IAT and MT. Objectives To assess the safety and efficacy of combined mechanical and IAT therapy compared to MT alone. Methods Retrospective chart review was performed in 200 consecutive patients who underwent endovascular treatments for acute ischemic stroke at our center between 2007 and 2011. 115 patients met inclusion criteria of MT alone versus combined MT and IAT. We compared outcome parameters between these two groups including discharge NIHSS, modified Rankin Score (mRS), rate of partial to complete recanalization (TIMI 2–3), symptomatic intracerebral hemorrhage, and all cause mortality. Results A total of 115 patients underwent MT alone or received combined therapy. In the MT only group, mean age was 69±13.32 and median initial NIHSS was 17. Of the combined therapy group, 66±16 was the mean age and median initial NIHSS was 18. Conclusions In our experience combination MT and IAT in the treatment of acute ischemic stroke had a trend toward higher recanalization rates and number of patients with clinical improvement, as well as, lower discharge NIHSS and higher percentage of independently ambulating patients discharged as compared to MT alone. Despite higher hemorrhage and slightly increased mortality rates, the combined therapy group trended toward better clinical outcomes. Competing interests None.Abstract P-042 Table 1 Primary outcomes between MT only and combined therapy groups Outcome Mechanical thrombectomy only (N=40) Combined MT and IAT (N=75) Discharge NIHSS 12 9 Clinical improvement (NIHSS >4) 19 (47.5%) 37 (55.2%) TIMI 2–3 25 (62.5%) 57 (76.0%) Discharge mRS ≤3 3 (7.5%) 10 (13.3%) Symptomatic ICH 3 (7.5%) 13 (17.0%) Mortality 8 (20%) 20 (26.7%)