Scott Olson

An Expedited Code Stroke Protocol Is Feasible and Safe

Background and Purpose— Stroke recovery critically depends on timely reperfusion. In July 2003, we set a benchmark onset-to-treatment time of ≤2 hours and instituted an expedited code stroke protocol to accomplish this. We aim to show that the protocol is feasible and safe. Methods— The expedited protocol includes: Benchmark onset-to-treatment within 2 hours; in-person triage of all code stroke patients; unmixed tissue plasminogen activator at the bedside during evaluation; no delays pending coagulation tests, chest x-ray, or stool guiac unless specifically indicated; and no delays pending formal CT interpretation or written consent. Results— Between July 2003 and June 2005, we evaluated 781 patients and treated 103 of 781 (13.2%) with intravenous recombinant tissue plasminogen activator within 3 hours. Of these, we treated 49 of 103 (47.6%) within 2 hours of symptom onset, and 54 of 103 (52.4%) between 2 and 3 hours. The overall risk of symptomatic intracerebral hemorrhage was 4 of 103 (3.9%; 95% CI, 1.1%, 9.6%), and not significantly different from 6.4% (P=0.42). The hemorrhage risks in those treated within 2 hours of symptom onset and those treated between 2 and 3 hours were not significantly different from each other or from 6.4%. Conclusions— The expedited code stroke protocol is feasible and appears safe. Further study is warranted to confirm its safety and determine whether it results in better clinical outcomes.

Comparative Evaluation of Noninvasive Compression Adjuncts for Hemostasis in Percutaneous Arterial, Venous, and Arteriovenous Dialysis Access Procedures

PURPOSE To assess the relative efficacy of three compression adjuncts -- D-Stat Dry (D-Stat), QR Powder (QR), and XS Powder (XS) -- for reducing time to hemostasis in patients who underwent diagnostic and interventional percutaneous procedures. MATERIALS AND METHODS D-Stat, QR, or XS was applied in 176 percutaneous diagnostic arterial, therapeutic arterial, venous, and arteriovenous dialysis access (AVDA) procedures in 138 patients. The mean time to hemostasis and application-related complications were retrospectively assessed. RESULTS Mean time to hemostasis was significantly reduced in all applications of QR (3.1 minutes +/- 1.1) and XS (3.7 minutes +/- 1.1) relative to D-Stat (6.2 minutes +/- 1.1, P < .001 vs both). For therapeutic arterial procedures, mean time to hemostasis for QR and XS was 3.6 minutes +/- 1.1 and 4.8 minutes +/- 1.1, respectively, and this was significantly less than that of D-Stat (10.0 minutes +/- 1.2; P < .001 vs QR, P < .01 vs XS). Mean times to hemostasis for QR and XS were also shorter than that with D-Stat in diagnostic arterial and AVDA procedures (P < .05). For venous procedures, mean time to hemostasis for QR (1.9 minutes +/- 1.2) was significantly shorter than that with both D-Stat (4.0 minutes +/- 1.2, P < .05) and XS (3.7 minutes +/- 1.2, P < .05). Minor immediate complications (hematoma <5 cm) occurred in 2.8% of applications. No access site infections were observed. CONCLUSIONS All three agents effectively reduced time to hemostasis with minimal associated complications. QR was found to be more effective than D-Stat in all four procedure types.

Survival in unresectable sinonasal undifferentiated carcinoma treated with concurrent intra-arterial cisplatin and radiation

We report the successful use of RADPLAT to treat a patient with an unresectable T4N0 sinonasal undifferentiated carcinoma. This patient received 4 cycles of weekly intra-arterial cisplatin together with thiosulfate infusion with concurrent radiation therapy. Radiation therapy was given in 28 daily fractions to 54 Gy using intensity-modulated radiation therapy followed by a hypofractionated stereotactic boost of 3 fractions to 13 Gy to a total dose of 67 Gy in 31 fractions to the nasal sinus and bilateral neck. Intra-arterial cisplatin was administered using a bilateral approach due to the midline site of this tumor. Within days of the first intra-arterial cisplatin, there was an obvious decrease in tumor size. She has been followed with magnetic resonance imaging and positron emission tomography, and remains disease-free 47 mo post-treatment. Centers with expertise in intra-arterial chemotherapy could consider the RADPLAT approach for patients with unresectable sinonasal undifferentiated carcinoma.

Rapid clot removal for acute stroke therapy : Technical case report

OBJECTIVE Endovascular therapy for acute ischemic stroke offers hope to those patients who do not meet the strict inclusion criteria for intravenous tissue plasminogen activator. Because no approach or device can be optimal for every patient, it is desirable to have options. This case is the first report on a novel retrieval device which proved to be very effective in our patient. CLINICAL PRESENTATION A 69-year-old woman with an acute ischemic stroke was excluded from treatment with intravenous tissue plasminogen activator because of an elevated international normalized ratio. INTERVENTION We successfully treated this patient endovascularly using a device newly approved by the Food and Drug Administration. We achieved rapid recanalization and an excellent clinical outcome. CONCLUSION Using a new retrieval device, we were able to rapidly and successfully treat an acute ischemic stroke in a patient not eligible for intravenous thrombolysis. This may offer another alternative in endovascular acute stroke therapy.

Improving Door to Groin Puncture Time for Mechanical Thrombectomy via Iterative Quality Protocol Interventions

Introduction: Delays in door to groin puncture time (DGPT) for patients with ischemic stroke caused by acute large vessel occlusions (LVO) are associated with worse clinical outcomes. We present the results of a quality improvement protocol for endovascular stroke treatment at the University of California, San Diego (UCSD) that aimed to minimize DGPT. Materials and Methods: Our stroke team implemented a series of quality improvement measures to decrease DGPT, with a target of 90 minutes or less. Sixty-three patients treated at our center were retrospectively divided into three groups based on the date of their intervention as a proxy for the implementation of process improvement protocols: 23 patients treated from July to December 2015, 24 patients treated from January to July 2016, and 16 patients treated from July 2016 to December 2016. Multivariate log-linear and logistic regression analyses were used to assess the predictors of prolonged DGPT and compliance with target DGPT (<90 min), respectively. Results: Date of intervention—a proxy for the implementation of process improvement protocols—was predictive of compliance with target DGPT. Patients treated from July 2016 to December 2016—after the full implementation of process improvements—were 3.2 times more likely to meet or exceed the target DGPT compared to patients treated from July 2015 to December 2015 (p=0.011). When adjusting for potential confounders in a multivariate analysis, patients in the final cohort were associated with shorter DGPT (Exp(B)=0.61, p=0.013) and remained significantly more likely to achieve the DGPT goal (OR=14.2, p=0.007). Conclusion: An iterative quality improvement process can significantly improve DGPT. This analysis demonstrates the utility of a formal quality improvement system at an academic comprehensive stroke center.

The circle of Willis predicts the antihypertensive effects of carotid artery stenting.

OBJECTIVE Carotid artery stenting (CAS) has antihypertensive effects, but the durability and degree of this response remain variable. The authors propose that this clinical variability is a function of the presence or absence of a complete circle of Willis (COW). Incomplete COWs perfuse through a higher-resistance pial collateral pathway, and therefore patients may require a higher mean arterial pressure (MAP). Carotid artery revascularization in these patients would reduce the end-organ collateral demand that has been hypothesized to drive the MAP response. METHODS Using a retrospective, nonrandomized within-subject case-control design, the authors compared the postoperative effects of CAS in patients with and without a complete COW by using changes in MAP and antihypertensive medication as end points. They recorded MAP and antihypertensive medications 3 months prior to surgery, preoperatively, immediately postoperatively, and at the 3-month follow-up. RESULTS Data were collected from 64 consecutive patients undergoing CAS. Patients without a complete COW (25%) were more likely to demonstrate a decrease in BP response to stenting (i.e., a drop in MAP of 10 mm Hg and/or a reduction or cessation of BP medications at 3 months postoperatively). Of the patients in the incomplete COW cohort, 75% had this outcome, whereas of those in the complete COW cohort, only 41% had it (p < 0.041). These findings remained statistically significant in a logistic regression analysis for possible confounders (p < 0.024). A receiver operating curve analysis of preoperative data indicated that a MAP > 96.3 mm Hg was 55.5% sensitive and 57.4% specific for predicting a complete COW and that patients with a MAP > 96.3 mm Hg were more likely to demonstrate a good MAP decrease following CAS (p < 0.0092). CONCLUSIONS CAS is associated with a significant decrease in MAP and/or a reduction/cessation in BP medications in patients in whom a complete COW is absent.