Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion.

OBJECTIVE: Acute stroke due to tandem cervical internal carotid artery (ICA) and intracranial large-vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. In this study, we report our institutional outcomes with two approaches: emergent carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: Patients with tandem ICA-ILVO were identified in a prospective mechanical thrombectomy (MT) database between July 2012 and April 2016. Patients had a concomitant complete ICA origin occlusion and occlusion of the intracranial ICA or M1 or M2 middle cerebral artery segment. Baseline characteristics, procedural data, and treatment times were reviewed. End points included good recanalization of both ICA and ILVO, symptomatic intracerebral hemorrhage (defined by clinical decline of >4 points on the National Institutes of Health Stroke Scale), and functional outcome at 90 days. RESULTS: Forty-five patients had tandem ICA-ILVO occlusion; 27 patients underwent emergent CAS and 12 patients underwent emergent CEA after MT. Successful Thrombolysis in Cerebral Infarction grade 2B/3 recanalization was achieved in 92% of the CEA and 96% of the CAS patients (P = .53). Three CAS patients (11%) and none of the CEA patients had symptomatic intracerebral hemorrhage (P = .54). At 90 days, 75% (9/12) of the CEA patients were functionally independent compared with 70% (19/27) in the CAS group (P = 1.0). No deaths were noted in the CEA group compared with five (18.5%) in the CAS arm (P = .30). CONCLUSIONS: Our study indicates that early recanalization with MT followed by emergent CEA is safe and feasible, which suggests that both CAS and CEA should be considered in the emergent treatment of patients with tandem occlusion.

Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience.

BACKGROUND: Data on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA. OBJECTIVE: To report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score. METHODS: Our prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated. RESULTS: Between July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively. CONCLUSIONS: We have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

Monitored Anesthesia Care by Sedation-Trained Providers in Acute Stroke Thrombectomy.

Background: Mechanical thrombectomy (MT) for ischemic stroke can be performed under local anesthesia (LA), conscious sedation (CS), or general anesthesia (GA). The need for monitoring by anesthesia providers may be resource intensive. We sought to determine differences in outcomes of MT when sedation is performed by an anesthesia team compared to sedation-trained providers. Methods: We performed a retrospective analysis on patients who were screened by a pre-hospital stroke severity screening tool and underwent MT at two stroke centers. Baseline characteristics, time metrics, sedatives, peri-procedural intubation, complications, and outcomes were recorded. Good outcome was defined as modified Rankin score of ≤2. Results: We analyzed 104 patients (sedation-trained provider = 63, anesthesia team = 41) between July 2015 and December 2017. In the sedation-trained provider group, four patients required intervention by an anesthesia team. There were no differences in patients receiving LA (sedation-trained provider 24% vs. anesthesia team 27% p = 0.82), CS (70 vs. 63%, p = 0.53), or GA (6 vs. 10%, p = 0.71) between groups. Sedation-trained providers were more likely to use only one drug during the procedure (62 vs. 34%, p = 0.009). The rate of procedural complications (9.5 vs. 4.5%, p = 0.48), good outcome (56 vs. 39%, p = 0.11), and mortality (22 vs. 24%, p = 0.82) was similar between groups. Sedation by provider type did not predict functional outcome or mortality at 3 months. Conclusions: Sedation-trained providers are capable of delivering appropriate sedation without compromising patient safety. The use of "as needed" anesthesia teams for MT may have considerable effect on resource allocation and cost.

Measurement of Patients' Perceptions of the Quality of Acute Stroke Services: Development and Validation of the STROKE Perception Report.

INTRODUCTION: Patients' perceptions of healthcare quality have become an important part of quality measurement. We explored patients' and family's lived experiences during acute stroke hospitalization to develop a quantitative instrument. METHODS: Focus groups were conducted using open-ended scripted questions. Interview data were coded and analyzed using an inductive approach to thematic analysis. Symmetric patient and family instruments were developed based on qualitative domains and serially refined to a set of 30 survey items, 12 stroke knowledge test items, and 5 subject demographic fields. Scales were evaluated for internal consistency reliability using Cronbach α; construct validity with exploratory factor analysis using principal components with varimax rotation was performed to determine the extent to which items in a scale measure the same underlying factor. Feasibility of an electronic cloud-based survey was also tested. RESULTS: Three main themes emerged: fast action to diagnose and treat stroke, genuine caring, and education to prevent and respond to stroke. A total of 1029 subjects completed the final instrument with no differences in perception found by race, ethnicity, or length of stay. Scales showed satisfactory internal consistency reliability (Cronbach α scores, .89-.94); factor loadings across each scale ranged from 0.55 to 0.87. Data entry by electronic pad was perceived by 77% to be more confidential than paper surveys; median score for difficulty was 4 ("easy to use"). CONCLUSION: The STROKE Perception Report enables understanding of patients' and family's beliefs about the quality of acute stroke care in essential new domains never explored before.

Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability.

BACKGROUND: The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. METHODS: Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0-2 or return to baseline. RESULTS: Of the 96 patients, 50 had mild baseline disability (mRS score 0-1) and 46 had moderate disability (mRS score 2-4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). CONCLUSION: Advanced age, baseline disability, and delayed treatment are associated with sub-optimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.

Stroke care: initial data from a county-based bypass protocol for patients with acute stroke.

BACKGROUND: Early identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes. OBJECTIVE: To describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio. METHOD: All county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard 'stroke-alert' (N=142) patients from the preceding 6 months. RESULTS: An increased treatment rate (25.6% vs 12.6%, p<0.05) and improved time efficiency (median door-to-CT 10 vs 28 min, p<0.05; door-to-needle 46 vs 75 min, p<0.05) of IV tissue plasminogen activator within the RA cohort was achieved. The rate of MT (20.1% vs 7.7%, p=0.06) increased and treatment times improved, including median arrival-to-puncture (68 vs 128 min, p=0.04) and arrival-to-recanalization times (101 vs 205 min, p=0.001) in favor of the RA cohort. A non-significant trend towards improved outcome (50% vs 36.4%, p=0.3) in the RA cohort was noted. The RA protocol also showed improved diagnostic specificity for ischemic stroke (52.3% vs 30.1%, p<0.05). CONCLUSIONS: Our results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.