Anterior vertebral tethering: imaging of tether rupture.

Anterior vertebral tethering, also known as vertebral body tethering, is an evolving, minimally invasive surgical technique to correct spinal curvature in skeletally immature patients. The procedure involves placement of vertebral screws that are connected by an anterolateral tether. This procedure may be complicated by rupture of the non-radiopaque tether. The radiologist should be aware of imaging findings that suggest this complication on follow-up spine radiographs.

Detection of emergent large vessel occlusion stroke with CT angiography is high across all levels of radiology training and grayscale viewing methods.

OBJECTIVES: CT angiography (CTA) is essential in acute stroke to detect emergent large vessel occlusions (ELVO) and must be interpreted by radiologists with and without subspecialized training. Additionally, grayscale inversion has been suggested to improve diagnostic accuracy in other radiology applications. This study examines diagnostic performance in ELVO detection between neuroradiologists, non-neuroradiologists, and radiology residents using standard and grayscale inversion viewing methods. METHODS: A random, counterbalanced experimental design was used, where 18 radiologists with varying experiences interpreted the same patient images with and without grayscale inversion. Confirmed positive and negative ELVO cases were randomly ordered using a balanced design. Sensitivity, specificity, positive and negative predictive values as well as confidence, subjective assessment of image quality, time to ELVO detection, and overall interpretation time were examined between grayscale inversion (on/off) by experience level using generalized mixed modeling assuming a binary, negative binomial, and binomial distributions, respectively. RESULTS: All groups of radiologists had high sensitivity and specificity for ELVO detection (all > .94). Neuroradiologists were faster than non-neuroradiologists and residents in interpretation time, with a mean of 47 s to detect ELVO, as compared with 59 and 74 s, respectively. Residents were subjectively less confident than attending physicians. With respect to grayscale inversion, no differences were observed between groups with grayscale inversion vs. standard viewing for diagnostic performance (p = 0.30), detection time (p = .45), overall interpretation time (p = .97), and confidence (p = .20). CONCLUSIONS: Diagnostic performance in ELVO detection with CTA was high across all levels of radiologist training level. Grayscale inversion offered no significant detection advantage. KEY POINTS: • Stroke is an acute vascular syndrome that requires acute vascular imaging. • Proximal large vessel occlusions can be identified quickly and accurately by radiologists across all training levels. • Grayscale inversion demonstrated minimal detectable benefit in the detection of proximal large vessel occlusions.

Emergency medical systems education may improve knowledge of pre-hospital stroke triage protocols.

BACKGROUND: Following the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs. PURPOSE: We developed a single-session training curriculum for EMS personnel focused on the Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate in the field, and our state-wide EMS stroke protocol. We assessed the effect of our training on EMS knowledge. METHODS: We assembled a focus group to develop a training curriculum and assessment questions that would mimic real-life conditions under which EMS personnel operate. Ten questions were formulated to assess content knowledge before and after training, and scores were compared using generalized mixed models. RESULTS: Training was provided for 179 EMS providers throughout the state.Average pre-test score was 52.4% (95% CI 49% to 56%). Average post-test score was 85.6% (83%-88%, P<0.0001). Each of the 10 questions was individually assessed and all showed significant gains in EMS knowledge after training (P<0.0001). CONCLUSIONS: A brief educational intervention results in substantial improvements in EMS knowledge of prehospital stroke severity scales and severity-based field triage protocols. Further study is needed to establish whether these gains in knowledge result in improved real-world performance.

Door-in-Door-Out Time at Primary Stroke Centers May Predict Outcome for Emergent Large Vessel Occlusion Patients.

Background and Purpose- Interfacility transfers for thrombectomy in stroke patients with emergent large vessel occlusion (ELVO) are associated with longer treatment times and worse outcomes. In this series, we examined the association between Primary Stroke Center (PSC) door-in to door-out (DIDO) times and outcomes for confirmed ELVO stroke transfers and factors that may modify the interaction. Methods- We retrospectively identified 160 patients transferred to a single Comprehensive Stroke Center (CSC) with anterior circulation ELVO between July 1, 2015 and May 30, 2017. We included patients with acute occlusions of the internal carotid artery or proximal middle cerebral artery (M1 or M2 segments), with a National Institutes of Health Stroke Scale score of ≥6. Workflow metrics included time from onset to recanalization, PSC DIDO, interfacility transfer time, CSC arrival to arterial puncture, and arterial puncture to recanalization. Primary outcome measure was National Institutes of Health Stroke Scale at discharge and modified Rankin Scale (mRS) score at 90 days. Results- The median (Q1-Q3) age and National Institutes of Health Stroke Scale of the 130 ELVO transfers analyzed was 75 (64-84) and 17 (11-22). Intravenous alteplase was administered to 64% of patients. Regarding specific workflow metrics, median (Q1-Q3) times (in minutes) were 241 (199-332) for onset to recanalization, 85 (68-111) for PSC DIDO, 26 (17-32) for interfacility transport, 21 (16-39) for CSC door to arterial puncture, and 24 (15-35) for puncture to recanalization. Median discharge National Institutes of Health Stroke Scale score was 5 (2-16), and 46 (35%) patients had a favorable outcome at 90 days. Complete reperfusion (modified Thrombolysis in Cerebral Ischemia 2c/3) modified the deleterious association of DIDO on outcome. Conclusions- For patients diagnosed with ELVO at a PSC who are being transferred to a CSC for thrombectomy, longer DIDO times may have a deleterious effect on outcomes and may represent the single biggest modifiable factor in onset to recanalization time. PSCs should make efforts to decrease DIDO and routine use of DIDO as a performance measure is encouraged.

Accuracy of smartphone-based evaluation of Emergent Large Vessel Occlusion on CTA.

OBJECTIVES: Mechanical thrombectomy is the standard of care for stroke caused by an emergent large vessel occlusion in the anterior circulation, and the ability to rapidly review CTA is one hurdle in minimizing the time from diagnosis to intervention. We evaluated the diagnostic accuracy and confidence in review of stroke CTA for ELVO via a smartphone-based application as compared to PACS workstation. PATIENTS AND METHODS: Seventy-six head and neck CTA studies performed for stroke from one comprehensive and seven primary stroke centers were independently reviewed remotely on smartphone by two blinded interventional neuroradiologists in actual-use circumstances. The presence and location of large vessel occlusion(s), diagnostic quality, and confidence in interpretation were recorded. Comparison was made to blinded PACS workstation review performed at a delayed interval. Weighted Kappa and Kendall's Tau statistics were calculated to evaluate intra- and inter-observer reliability. RESULTS: Of the 76 studies, 20 (26%) had a large vessel occlusion. 14 M1 segment occlusions (18%); 2 ICA terminus (3%); 2 tandem carotid and M1 (3%); and 2 basilar artery (3%). There was 100% diagnostic accuracy by both PACS workstation and smartphone review (p = .9999) with high inter- and intra-rater reliability for assessments of both image quality and diagnostic confidence. CONCLUSION: In actual-use circumstances, experienced neuroradiologists can diagnose ELVOs on CTA using a smartphone application as accurately as on PACS workstation without degradation of confidence. These findings support the use of mobile electronic devices by stroke centers to rapidly triage patients for mechanical thrombectomy.

Rethinking Thrombolysis in Cerebral Infarction 2b: Which Thrombolysis in Cerebral Infarction Scales Best Define Near Complete Recanalization in the Modern Thrombectomy Era?

BACKGROUND AND PURPOSE: Within the thrombolysis in cerebral infarction (TICI) classification, TICI 2b has been historically considered successful recanalization. Recent studies have suggested that TICI 3 and a proposed TICI 2c should be separately reported from TICI 2b, in both the original (>66% reperfusion) and modified (>50% reperfusion) definitions, because of differences in clinical outcomes with greater reperfusion. The purpose of this study was to evaluate differences in early neurological improvement and independence at 90 days using the original TICI, modified TICI, and modified TICI with 2c scales. METHODS: A retrospective review of 129 consecutive patients with middle cerebral artery, M1 segment or intracranial internal carotid artery occlusions. Patient angiograms were graded by 2 experienced readers by percentage recanalization. This was then categorized into original TICI, modified TICI (mTICI), and mTICI with TICI 2c (mTICI 2c) grading scales. Comparison of baseline demographics, early neurological improvement, and independence at 90 days was performed. RESULTS: A significant difference in early neurological improvement was observed between 2b and 3 (P=0.032), as well as between 2b and 2c (P=0.028) under the mTICI 2c grading scale. Similarly, a significant difference in functional independence was observed between 2b and 3 (P=0.037), as well as between 2b and 2c (P=0.047) under the mTICI 2c scale. The difference in early neurological improvement or functional independence between 2b and 3 for the original TICI and mTICI scales was not significant. When combining the 2c and 3 groups under the mTICI 2c scale, there were significant differences between 2b and 2c/3 in regards to both early neurological improvement (P=0.011) and independence (P=0.018). CONCLUSIONS: Using a TICI grading system that includes an additional category beyond TICI 2b allows for refined prediction of early neurological improvement and functional independence.

Development of an Assessment to Examine Training of the Hospice Primary Caregiver.

BACKGROUND: Key to high-quality care of dying hospice patients at home is whether the hospice provides adequate training so the caregiver can safely care for the patient. OBJECTIVE: The study objective was to develop and validate a survey of hospice training for caregivers to ensure safe, high-quality care in the home setting. DESIGN: Our survey design was cross-sectional. Bereaved respondents of individuals who died at home under the care of hospice were surveyed three to six months postdeath. MEASUREMENTS: Items were developed based on advice of an expert panel, focus groups of hospice caregivers, and literature review, with 12 items developed for testing and examining 8 key processes of care. We examined the validity and reliability of the assessment using factor analysis, correlational analyses, and multivariable modeling. RESULTS: Our sample consisted of 262 primary caregivers (mean age 62.4, 76.7% female, 58.8% non-Hispanic white). Six questions focused on providing the caregiver with information, while another six focused on the training that hospice provided. Based on model fit and Cronbach's alpha, we dropped the information items. The items that examined hospice training demonstrated a one-factor solution and a Cronbach's of 0.90. We examined correlations of the multi-item composite with overall rating of quality of care (0.53), overall distress (0.31), and whether the respondent would recommend this hospice to others (0.49). There were no significant sociodemographic correlates of concerns with training. CONCLUSIONS: Sufficient preliminary reliability and validity warrants further testing of this composite to examine the adequacy of training provided to family members to care safely for the patient.

Timing of Survey Administration After Hospice Patient Death: Stability of Bereaved Respondents.

CONTEXT: The Centers for Medicare & Medicaid Services have elected to include a bereaved family member survey in public reporting of hospice quality data as mandated in the Affordable Care Act. However, it is not known what time point after death offers the most reliable responses. OBJECTIVES: To examine the stability of bereaved family members' survey responses when administered three, six, and nine months after hospice patient death. METHODS: Bereaved family members from six geographically diverse hospices were interviewed three, six, and nine months after patient death. All respondents completed a core survey. Those whose family member died at home, in a freestanding inpatient unit, or in a nursing home also completed a site-specific module. Stability was based on top-box scoring of each item with kappa statistics, and multivariable regression models were used to assess directionality and predictors of change. To analyze the effects of grief, we assessed response stability among respondents at least one SD from the mean change in grief between three and six months. RESULTS: We had 1532 surveys (536 three-month surveys, 529 six-month surveys, and 467 nine-month surveys) returned by 643 respondents (average age 61.7 years, 17.4% black, and 50.5% a child respondent) about hospice decedents (55.3% females, average age 78.6 years, 57.0% noncancer, and 40.0% at home). The average kappa for core items between three and nine months was 0.54 (range 0.42-0.74), 0.58 (0.41-0.69) for home-specific items, and 0.54 (0.39-0.63) for nursing home. Even among individuals demonstrating large grief changes, core items demonstrated moderate to high stability over time. CONCLUSION: Bereaved family member responses are stable between three and nine months after the death of the patient.