Acute Ischemic Stroke (AIS) patient management in French stroke units and impact estimation of thrombolysis on care pathways and associated costs.

BACKGROUND: Stroke is the second leading cause of death and a first leading cause of acquired disability in adults worldwide. This study aims to evaluate the current management and associated costs of acute ischemic stroke (AIS) for patients admitted in stroke units in France and over a one-year follow-up period as well as to assess the impact of improved thrombolytic management in terms of increasing the proportion of patients receiving thrombolysis and/or treated within 3 h from the onset of symptoms. METHODS: A decision model was developed, which comprises two components: the first corresponding to the acute hospital management phase of patients with AIS up until hospital discharge, extracted from the national hospital discharge database (PMSI 2011), and the second corresponding to the post-acute (post-discharge) phase, based on national treatment guidelines and stroke experts' advice. Five post-acute clinical care pathways were defined. In-hospital mortality and mortality at 3 months post-discharge was taken into account into the model. Patient journeys and costs were determined for both phases. Improved thrombolytic management was modeled by increasing the proportion of patients receiving thrombolysis from the current estimated level of 16.7 to 25% as well as subsequently increasing the proportion of patients treated within 3 h of the onset of symptoms post-stroke from 50 to 100%. The impact on care pathways was derived from clinical data. RESULTS: Among 202,078 hospitalizations for a stroke or a transient ischemic attack (TIA), 90,528 were for confirmed AIS, and 33% (29,999) of them managed within a stroke unit. After hospitalization, 60% of discharges were to home, 25% to rehabilitative care and then home, 2% to rehabilitative care and then a nursing home, 7% to long-term care, and 6% of stays ended with patient death. Of a total cost over 1 year of €610 million (mean cost per patient of €20,326), 70% concern the post-acute phase. By increasing the proportion of patients being thrombolyzed, costs are reduced primarily by a decrease in rehabilitative care, with savings per additional treated patient of €1,462. By adding improved timing, savings are more than doubled (€3,183 per additional treated patient). CONCLUSIONS: This study confirms that the burden of AIS in France is heavy. By improving thrombolytic management in stroke units, patient journeys through care pathways can be modified, with increased discharges home, a change in post-acute resource consumption and net savings.

Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy.

BACKGROUND AND PURPOSE: Large vessel occlusion in ischemic stroke is associated with a high degree of morbidity. When intravenous thrombolysis fails, mechanical thrombectomy can provide an alternative and synergistic method for flow restoration. In this study we evaluate the safety and efficacy of our stroke management protocol (RECOST study). METHODS: Fifty consecutive ischemic stroke patients with large vessel occlusion were included. After clinical and MRI imaging assessment, 3 treatment strategies were selected according to time of symptom onset and location of vessel occlusion: rescue therapy; combined therapy; and stand-alone thrombectomy (RECOST study). MRI ASPECT score <5 was the main exclusion criterion. Mechanical thrombectomy was performed exclusively with the Solitaire flow restoration device. Clinical outcome was assessed after treatment, on day 1, and at discharge. RESULTS: Mean patient age was 67.6 years, mean NIHSS score was 14.7, and mean ASPECT score was 6 on presentation. Vessel occlusions were in the middle cerebral artery (40%), the internal carotid artery (28%), and the basilar artery (32%). Rescue treatment represented 24%, combined therapy represented 56%, and stand-alone thrombectomy represented 20%. Mean recanalization time from symptoms onset was 377 minutes, with overall recanalization rate TICI 3 of 84%. NIHSS score at discharge was 6.5, with 60% of patients demonstrating NIHSS score 0 to 1 or an improvement of >9 points. Symptomatic complication rate was 10%. At 3 months, 54% of patients had a modififed Rankin scale score of 0 to 2, with an overall mortality rate of 12%. CONCLUSIONS: The present integrated stroke management protocol (RECOST study) demonstrated rapid, safe, and effective recanalization. We postulate that the Solitaire device contributed to high recanalization and patient selection using MRI ASPECT score to low and complication rates, therefore avoiding futile and dangerous interventions.

Carotid thrombus formation and extension during anticoagulation: a case report of large vessel disease and hypercoagulable state in systemic sclerosis.

Systemic sclerosis (SSc) is an autoimmune multisystem disorder of connective tissue characterized by widespread vascular lesions and fibrosis. Limited cutaneous systemic sclerosis (lcSSc) and diffuse cutaneous systemic sclerosis (dsSSC) are both subsets of SSc. The vascular component of SSc is an important part of the disease. Especially Raynaud's phenomenon and microcirculatory abnormalities are well recognized. Enhanced coagulation pathways, decreased fibrinolysis, and endothelial dysfunction probably contribute to vascular events in SSc. Macrovascular disease is not recognized as a major feature of SSc. However, several studies report an increase in large vessel disease and mortality rate attributable to cardiovascular causes. We present a patient with lcSSc with an acute embolic stroke due to a large carotid thrombus. A hypercoagulable state was suspected because of thrombus formation during oral anticoagulation and extension during intravenous heparin treatment. This is one of the few reports of large vessel disease in systemic sclerosis. The hypercoagulable state may be related to systemic sclerosis.

Mechanical ventilation in ischemic stroke.

OBJECTIVE: Coma or respiratory failure in patients with acute ischemic stroke (IS) may require mechanical ventilation (MV). The inclusion criteria used in previous studies on MV for patients with stroke have been very heterogeneous. We carried out this prospective study in our neurologic stroke and intensive care department to assess clinical and radiologic features, mortality, outcome, and prognosis factors for patients presenting with acute IS involving the middle cerebral artery (MCA) and requiring MV. METHODS: Of 470 patients admitted with acute IS involving the MCA territory, we prospectively enrolled 50 patients requiring MV. Indications for intubation were a Glasgow coma score <10 or respiratory failure. RESULTS: The survival at 1 year was 30%. The mortality (70%) was independent of the reason for ventilation. Survivors had a mean Barthel index of 59 +/- 25 and a mean modified Rankin score of 4 +/- 1. Logistic regression showed that survivors were characterized by incomplete MCA territory involvement and atherosclerosis origin. CONCLUSION: Patients with MCA IS who require MV have high mortality regardless of the cause of intubation. Survival is associated with incomplete MCA territory involvement and atherosclerosis origin.

Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion.

AIMS: To evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire FR device in revascularization of patients with acute basilar artery occlusion (ABAO) and to identify the predictive factors for clinical outcome. METHODS: This prospective single-center study included 31 patients with acute ischemic stroke attributable to ABAO treated within the first 24 h after onset of symptoms with the Solitaire device. Nineteen patients simultaneously received intravenous thrombolysis. Recanalization rates after stent retrieval were determined and the clinical outcome and mortality rate were assessed 180 days after treatment. RESULTS: The mean ±SD age of the patients was 61±17 years, the median prethrombectomy NIH Stroke Scale score was 38 (IQR 9-38) and the median Glasgow Coma Scale (GCS) score was 7 (IQR 4-14). Successful recanalization (TICI 3 or 2b) was achieved in 23 patients (74%). Five symptomatic intracranial hemorrhages were related to the procedure. Ten symptomatic distal migrations of thrombotic material occurred. A favorable outcome, defined as a modified Rankin Score (mRS) of 0-2, was observed in 35% of patients (11/31). Overall mortality rate was 32% (10/31). In the univariate analysis, elevated baseline glucose (p=0.008) was significantly associated with a poor outcome (mRS >2), whereas a tendency towards significance was observed with age (p=0.06), GCS on admission (p=0.07) and symptom-related lesions on T2 sequences (p=0.10). Patients with successful recanalization tended to have a better outcome (p=0.20). CONCLUSION: Mechanical thrombectomy with the Solitaire FR device can rapidly and effectively contribute to a high rate of recanalization and improve functional outcome in patients with ABAO and has an acceptable complication rate.

Feasibility of hypothermia beyond 3 weeks in severe ischemic stroke: an open pilot study using γ-hydroxybutyrate.

PURPOSE: Hypothermia is a promising neuroprotective therapy. We studied the feasibility and safety of very prolonged moderate hypothermia for severe acute ischemic stroke. METHODS: Moderate hypothermia was induced within 24h after a severe ischemic stroke involving the middle cerebral artery. Hypothermia, with cooling blankets, reduced body-core temperature to 32-33°C, and was prolonged for up to 22 days until cerebral edema had significantly decreased (assessed by serial cerebral computed tomography) before slow rewarming (<1.5°C/day). Patients were mechanically ventilated and sedated with gamma-hydroxybutyrate (GHB), a naturally occurring metabolite of gamma-aminobutyric acid (GABA), which acts on the GABA(B) receptors. Outcomes and side effects at 12 months were recorded. RESULTS: Nineteen patients (mean age: 52.6 years, mean National Institute of Health Stroke Scale (NIHSS) score 21) were enrolled. Cooling was achieved in all patients. The mean time to reach target temperature was 11.4 ± 8.6h and the mean duration of rewarming was 4.0 ± 1.1 days. For the 10 survivors (53%), the mean duration of hypothermia and rewarming was 22.6 ± 4.9 days. Five patients underwent a hemicraniectomy. All patients presented with hypotension, bradycardia, and hematological side effects. Eight patients had pneumonia (42%). At 12 months, the mean NIHSS score was 8.3 ± 2.7, the Barthel Index was 67 ± 18, and the modified Rankin scale was 3.2 ± 0.9. CONCLUSIONS: This study shows the feasibility of very prolonged hypothermia beyond 3 weeks using GHB sedation in severe hemispheric infarcts.