Multicenter comparison using two AI stroke CT perfusion software packages for determining thrombectomy eligibility.

BACKGROUND: Stroke AI platforms assess infarcted core and potentially salvageable tissue (penumbra) to identify patients suitable for mechanical thrombectomy. Few studies have compared outputs of these platforms, and none have been multicenter or considered NIHSS or scanner/protocol differences. Our objective was to compare volume estimates and thrombectomy eligibility from two widely used CT perfusion (CTP) packages, Viz.ai and RAPID.AI, in a large multicenter cohort. METHODS: We analyzed CTP data of acute stroke patients with large vessel occlusion (LVO) from four institutions. Core and penumbra volumes were estimated by each software and DEFUSE-3 thrombectomy eligibility assessed. Results between software packages were compared and categorized by NIHSS score, scanner manufacturer/model, and institution. RESULTS: Primary analysis of 362 cases found statistically significant differences in both software's volume estimations, with subgroup analysis showing these differences were driven by results from a single scanner model, the Canon Aquilion One. Viz.ai provided larger estimates with mean differences of 8cc and 18cc for core and penumbra, respectively (p<0.001). NIHSS subgroup analysis also showed systematically larger Viz.ai volumes (p<0.001). Despite volume differences, a significant difference in thrombectomy eligibility was not found. Additional subgroup analysis showed significant differences in penumbra volume for the Phillips Ingenuity scanner, and thrombectomy eligibility for the Canon Aquilion One scanner at one center (7 % increased eligibility with Viz.ai, p=0.03). CONCLUSIONS: Despite systematic differences in core and penumbra volume estimates between Viz.ai and RAPID.AI, DEFUSE-3 eligibility was not statistically different in primary or NIHSS subgroup analysis. A DEFUSE-3 eligibility difference, however, was seen on one scanner at one institution, suggesting scanner model and local CTP protocols can influence performance and cause discrepancies in thrombectomy eligibility. We thus recommend centers discuss optimal scanning protocols with software vendors and scanner manufacturers to maximize CTP accuracy.

Statin treatment intensity and cerebral vasomotor reactivity response in patients with ischemic stroke.

BACKGROUND AND PURPOSE: Cerebral vasomotor reactivity (VMR) is vital for regulating brain blood flow and maintaining neurological function. Impaired cerebral VMR is linked to a higher risk of stroke and poor post-stroke outcomes. This study explores the relationship between statin treatment intensity and VMR in patients with ischemic stroke. METHODS: Seventy-four consecutive patients (mean age 69.3 years, 59.4% male) with recent ischemic stroke were included. VMR levels were assessed 4 weeks after the index stroke using transcranial Doppler, measuring the breath-holding index (BHI) as an indicator of the percentage increase in middle cerebral artery blood flow (higher BHI signifies higher VMR). Multistep multivariable regression models, adjusted for demographic and cerebrovascular risk factors, were employed to examine the association between statin intensity treatment and BHI levels. RESULTS: Forty-one patients (55%) received high-intensity statins. Patients receiving high-intensity statins exhibited a mean BHI of 0.85, whereas those on low-intensity statins had a mean BHI of 0.67 (mean difference 0.18, 95% confidence interval: 0.13-0.22, p-value<.001). This significant difference persisted in the fully adjusted model (adjusted mean values: 0.84 vs. 0.68, p-value: .008). No significant differences were observed in BHI values within patient groups on high-intensity or low-intensity statin therapy (all p-values>.05). Furthermore, no significant association was found between baseline low-density lipoprotein (LDL) levels and BHI. CONCLUSIONS: High-intensity statin treatment post-ischemic stroke is linked to elevated VMR independent of demographic and clinical characteristics, including baseline LDL level. Further research is needed to explore statin therapy's impact on preserving brain vascular function beyond lipid-lowering effects.

(VISIION-S): Viz.ai Implementation of Stroke augmented Intelligence and communications platform to improve Indicators and Outcomes for a comprehensive stroke center and Network - Sustainability.

OBJECTIVES: As Comprehensive Stroke Centers (CSCs) strive to improve neuro-intervention (NIR) times, process improvements are put in place to streamline workflows. Our prior publication (VISIION) demonstrated improvements in key performance indicators (KPIs). The purpose VISIION-S was to analyze whether those results were sustainable. MATERIALS AND METHODS: Consecutive Direct Arriving LVO (DALVO) and telemedicine transfer LVO (BEMI) stroke NIR cases were assessed, including subgroups of DALVO-OnHours, DALVO-OffHours, BEMI-OnHours, and BEMI-OffHours. We analyzed times for the original 6 months pre (6/10/20-1/15/21) and compared them to a 17 month post-implementation period (1/16/21- 6/25/22) to evaluate for sustainability. Mann-Whitney U was utilized. RESULTS: 150 NIR cases were analyzed pre (n = 47) v. post (n = 103) implementation (DALVO-OnHours 7 v. 20, DALVO-OffHours 10 v. 25, BEMI-OnHours 13 v. 20, BEMI-OffHours 17 v. 38). For Door-to-groin (DTG), improvement was noted for DALVO-OffHours 39%(157 min,96 min;p < 0.001), DALVO-ALL 25%(127 min,95 min;p = 0.006), BEMI-OffHours 46%(45 min,25 min;p = 0.023), and BEMI-ALL 40%(42 min,25 min;p = 0.005). Activation-to-groin (ATG), door-to-device (DTD), and door-to-recanalization (DTR) also showed statistical improvements. For DALVO-OffHours, there were reductions in door to CT (DTC) 80%(26 min,5 min;p < 0.001), ATG 32%(90 min,61 min;p = 0.036), DTG 39%(157 min,96 min;p < 0.001), DTD 31%(178 min,123 min;p = 0.002), and DTR 32%(197 min,135 min;p = 0.003). CONCLUSIONS: We noted sustainability over a 17 month period with sustained reduction in KPIs for even more NIR time interval comparisons. In the greatest opportunity subgroup (DALVO-OffHours), we noted a reduction in all 5 time interval metrics. Our sustainability finding is important to show that process improvements continued even after the immediate period, adding credibility to the results. Models such as this could be useful for other centers striving to optimize workflow and improve times.

Tele-Untethered: Telemedicine Without Waiting Rooms.

BACKGROUND AND OBJECTIVES: Telemedicine bridges the gap between care needs and provider availability. The value of telemedicine can be eclipsed by long wait times, especially if patients are stuck in virtual waiting rooms. UCSD Tele-Untethered allows patients to join visits without waiting in virtual waiting rooms. Tele-Untethered uses a text-to-video link to improve clinic flow, decrease virtual waiting room reliance, improve throughput, and potentially improve satisfaction. METHODS: This institutional review board (IRB)-approved quality improvement pilot (IRB #210364QI) included patients seen in a single vascular neurology clinic, within the pilot period, if they had a smartphone/cell phone, and agreed to participate in a flexible approach to telehealth visits. Standard work was disseminated (patient instructions, scripting, and workflows). Patients provided a cell phone number to receive a text link when the provider was ready to see them. Metrics included demographics, volumes, visit rates, percentage seen early/late, time savings, and satisfaction surveys. RESULTS: Over 2.5 months, 22 patients were scheduled. Of those arriving, 76% were "Tele-Untethered" and 24% were "Standard Telemedicine." Text-for-video link was used for 94% of Tele-Untethered. Fifty-five percent were seen early. There was a 55-minute-per-session time savings. CONCLUSION: This UCSD Tele-Untethered pilot benefitted patients by allowing scheduling flexibility while not being tied to a "virtual waiting room." It benefited providers as it allowed them to see patients in order/not tied to exact times, improved throughput, and saved time. Even modest time savings for busy providers, coupled with Lean workflows, can provide critical value. High Tele-Untethered uptake and use of verbal check-in highlight that patients expect flexibility and ease of use. As our initial UCSD Tele-Untethered successes included patient flexibility and time savings for patients and providers, it can serve as a model as enterprises strive for optimal care and improved satisfaction. Expansion to other clinic settings is underway with a mantra of "UCSD Tele-Untethered: Your provider can see you now."

Telestroke Across the Continuum of Care: Lessons from the COVID-19 Pandemic.

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Medical Undistancing Through Telemedicine: A Model Enabling Rapid Telemedicine Deployment in an Academic Health Center During the COVID-19 Pandemic.

Background: The authors draw upon their experience with a successful, enterprise-level, telemedicine program implementation to present a "How To" paradigm for other academic health centers that wish to rapidly deploy such a program in the setting of the COVID-19 pandemic. The advent of social distancing as essential for decreasing viral transmission has made it challenging to provide medical care. Telemedicine has the potential to medically undistance health care providers while maintaining the quality of care delivered and fulfilling the goal of social distancing. Methods: Rather than simply reporting enterprise telemedicine successes, the authors detail key telemedicine elements essential for rapid deployment of both an ambulatory and inpatient telemedicine solution. Such a deployment requires a multifaceted strategy: (1) determining the appropriateness of telemedicine use, (2) understanding the interface with the electronic health record, (3) knowing the equipment and resources needed, (4) developing a rapid rollout plan, (5) establishing a command center for post go-live support, (6) creating and disseminating reference materials and educational guides, (7) training clinicians, patients, and clinic schedulers, (8) considering billing and credentialing implications, (9) building a robust communications strategy, and (10) measuring key outcomes. Results: Initial results are reported, showing a telemedicine rate increase to 45.8% (58.6% video and telephone) in just the first week of rollout. Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period). Conclusion: This article is designed to offer a "How To" potential best practice approach for others wishing to quickly implement a telemedicine program during the COVID-19 pandemic.

Encephalopathy only stroke codes (EoSC) do not result in rt-PA treatments.

BACKGROUND: Isolated mental status changes as a presenting sign (EoSC+), are not uncommon stroke code triggers. As stroke alerts, they still require the same intensive resources be applied. We previously showed that EoSC+ strokes (EoSC+ Stroke+) account for 0.1-0.2% of all codes. Whether these result in thrombolytic treatment (rt-PA), and the characteristics/ risk factor profiles of EoSC+ Stroke+ patients, have not been reported. METHODS: Retrospective analysis of stroke codes from an IRB approved registry, from 2004 to 2018, was performed. EoSC+ was defined as a NIHSS>0 for Q1a, 1b, or 1c with remaining elements scored 0. Characteristics and risk factors were compared for EoSC+, EoSC-, EoSC+ Stroke+, and rt-PA (EoSC+ Stroke+TPA+) patients. RESULTS: EoSC+ occurred in 55/2982 (1.84%) of all stroke codes. EoSC+ Stroke+ occurred in 8/55 (14.5%) of EoSC+ codes and 8/2982 (0.27%) of all stroke codes. 6/8 (75%) of EoSC+ Stroke+ scored NIHSS=1. When comparing EoSC++versus EoSC-, Hispanic ethnicity (p=0.009), hypertension (p=0.02), and history of stroke/TIA (p=0.002) were less common in EoSC+. No demographic/risk factor differences were noted for EoSC+ Stroke+ vs. EoSC+ Stroke-. No cases of rt-PA eligibility/treatment were noted. In EoSC+ Stroke+ analysis, imaging positive stroke/intracranial hemorrhage was noted on only 3 cases (3/2982=0.10% of all stroke codes) and none were posterior stroke. CONCLUSIONS: EoSC+ rarely results in stroke/TIA (0.27%) or stroke (0.10%), and in our analysis never (0%) resulted in rt-PA. Sub-analysis did not show missed rt-PA or posterior strokes. Understanding characteristics, and knowing that EoSC+ Stroke+ patients are unlikely to receive rt-PA, may help triage stroke resources.

A Stroke Care Model at an Academic, Comprehensive Stroke Center During the 2020 COVID-19 Pandemic.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes. METHODS: The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE. AIMS: The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management. CONCLUSIONS: The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis.

RAcial Disparities in Ich after IV-tPA and Neurointerventional Treatment (RADIANT).

OBJECTIVE: To study the rate of symptomatic intracerebral hemorrhage (SxICH) and major systemic hemorrhage (MSH) after acute stroke treatments among different ethnicities/races. BACKGROUND: Studies have reported ethnic/racial disparities in intravenous tPA treatment (IV tPA). The adverse outcome of tPA and/or intra-arterial intervention (IA) among different ethnicities/races requires investigation. METHODS: We retrospectively reviewed all patients from an IRB-approved registry between June 2004 and June 2018. Patients who received IV tPA, IA, or both for acute stroke were identified and classified into 2 ethnic groups: non-Hispanics or Hispanics (NH/H) and 4 racial groups: Asian, Black, Other (Native Americans and Pacific Islanders), and White (A/B/O/W). RESULTS: We identified 916 patients that received acute therapy (A/B/O/W: n = 50/104/16/746, H/NH: n = 184/730). For those received IV tPA only (n = 759), IA only (n = 85), and IV tPA+IA (n = 72), the SxICH rate was 4.3%, 4.7%, and 6.9%; the MSH rate was 1.3%, 0%, and 0%, respectively. No significant difference in the rate of SxICH or MSH among different racial or ethnic groups was found after either therapy. Asian race (OR 14.17, P = .01), in association with age, international normalized value (INR), and Partial thromboplastin time (PTT) (OR 1.06, 46.52, and 1.18, P = .020, 0.037, and 0.042, respectively), was predictive of SxICH after IV tPA. There was a significant correlation between age and National Institute of Health Stroke Scale with SxICH (P < .01, P = .02, respectively). Age, INR, and PTT were independent predictors of SxICH after IV tPA (OR 1.06, 46.52, and 1.18, P = .02, 0.04, and 0.04, respectively). CONCLUSIONS: There was no significant difference in the rate of SxICH or MSH after IV tPA, IA, or IV tPA+IA among different racial or ethnic groups. Larger studies are needed to elucidate the race specific causes of SxICH and MSH after acute stroke treatment.

PREMISE: Posterior Circulation Results Comparing Embolectomy to Medical Intervention in Stroke Emergencies.

Background Intravenous (IV) tissue plasminogen activator (rt-PA) is a proven therapy for stroke in the acute treatment window. Recent published data has shown efficacy for embolectomy for acute ischemic strokes within up to six, 16 and 24 hours in the anterior circulation but there is no guideline for optimal therapy for patients with posterior circulation stroke, specifically basilar artery occlusion (BAO) outside the standard IV rt-PA treatment window. Aim To evaluate differences in outcomes between maximal medical treatment versus thrombectomy in BAO. Method We retrospectively evaluated prospectively collected acute stroke code patients from our stroke registry from 7/2004 to 7/2016. Patients who received IV rt-PA were excluded. Patients with evidence of posterior circulation ischemia and a hyper dense artery sign on initial non-contrast CT were included as a surrogate for direct vessel data before 2014. Patients after 9/2014 were selected by evidence of BAO on vessel imaging. All patients were categorized either as endovascular therapy or standard medical treatment alone. Demographics, hospital discharge location and Modified Rankin Scale (mRS) at 90 days were compared. Two-sample t-test and Fisher's exact test compared continuous and categorical variables across groups respectively. Results A total of 18 patients were included (three embolectomy and 15 medical therapy only). There were no significant differences in demographic data (age, gender, race, ethnicity, blood pressure, diabetes mellitus, hypertension, atrial fibrillation, tobacco use, alcohol use and initial NIHSS). Results for outcome and efficacies showed no statistical difference between medical management and endovascular intervention for functional outcome mRS (0-3) at 90 days (p = 0.2) and discharge location of home/inpatient rehabilitation vs other locations (p = 0.52). Conclusions Our single-center review showed the expected transition from predominantly medically treated posterior circulation BAOs, to a mixed pattern including embolectomy. Although the sample size was small, this study also illustrates the lack of clear efficacy data for optimal treatment strategies, and the ongoing treatment challenges in posterior circulation stroke population in a population of patients outside the rt-PA window.

Timing of symptomatic intracerebral hemorrhage after rt-PA treatment in ischemic stroke.

BACKGROUND: We investigated patterns in the time from recombinant tissue-type plasminogen activator (rt-PA) treatment to symptomatic intracranial hemorrhage (sICH) onset in acute ischemic stroke. METHODS: We retrospectively reviewed all admitted "stroke code" patients from 2003 to 2017 at the University of California San Diego Medical Center from a prospective stroke registry. We selected patients that received IV rt-PA within 4.5 hours after onset/last known well and had sICH prehospital discharge. sICH diagnosis was made by prospective review. Endovascular-treated patients were excluded, given the variability of practice. sICH was prospectively defined as any new radiographic (CT/MRI) hemorrhage after rt-PA treatment and any worsened neurologic examination. Time to sICH was the time from rt-PA administration start to documented STAT head CT order time with the first evidence of new hemorrhage. Charts were reviewed for examination time metrics, demographics, clinical history, and neuroimaging. RESULTS: sICH was identified in 28 rt-PA-only treated patients. The mean time to sICH was 18.28 hours (range 2.4-34 hours). Median time to sICH was 18.25 hours. sICH was correlated with increased age (p = 0.02) and increased NIH Stroke Scale (p = 0.01). CONCLUSIONS: Our findings suggest that rt-PA patients have the highest risk of post rt-PA sICH within the first 24 hours after treatment. This supports monitoring of rt-PA-treated patients in specialized settings such as neuro-intensive care units or stroke units. Our findings suggest that the probability of sICH is low 36 hours post rt-PA. Future larger studies are warranted to identify the patterns of bleeding after rt-PA administration.

Novel Definition of Stroke "Good Responders" Predicts 90-Day Outcome after Thrombolysis.

INTRODUCTION: Identifying predictors of good response in thrombolytic-treated stroke is important to clinical care, resource allocation, and research design. We developed a simple, novel measure of "Good Responders" to assess if 2 short-term variables could predict 90-day outcomes after thrombolysis in stroke. METHODS: Intravenous thrombolysis-treated stroke cases from June 2004 to June 2018 were analyzed from a stroke registry. Intraarterial treatment cases were excluded. Good responders (GR++) were defined as those with length of stay less than or equal to 3 days and discharge to home. Poor responders (GR- -) had length of stay more than 3 days and discharge other than home. Mixed responders (GR+/-) composed the remainder. Baseline characteristics and predictors of 90-day outcome were assessed. RESULTS: Of 261 patients, there were 101(38.7%) GR++, 67(25.7%) GR- -, and 93(35.6%) GR+/-. For GR++ versus GR- - versus GR+/-, there were differences in mean age (62.7, 71.2, 69.2; P = .0016), and baseline modified Rankin score (mRS) 0-2 (%: 94.9, 74.6, 84.8; P = .008). Younger age, male sex, lower values for systolic BP, glucose, and baseline mRS were associated with good responders. Older age, atrial fibrillation, symptomatic intracerebral hemorrhage, and baseline mRS greater than 2 were associated with poor responders. At 90 days, mortality was reduced in GR++ versus GR- - versus GR+/- (%alive: 92.6, 72, 86; P = .04), and mRS(0-2) (%: 36.8, 0, 11.8; P < .001). CONCLUSIONS: Good responders to thrombolysis are younger and have better baseline functional status. Our novel definition of "Good Responders", using 2 early variables of home disposition and short length of stay, may help predict 90-day post-thrombolytic outcome. Future work should focus on validating this definition.

Mapping a Reliable Stroke Onset Time Course Using Signal Intensity on DWI Scans.

BACKGROUND AND PURPOSE: Identifying a last known well (LKW) time surrogate for acute stroke is vital to increase stroke treatment. Diffusion-weighted imaging (DWI) signal intensity initially increases from onset of stroke but mapping a reliable time course to the signal intensity has not been demonstrated. METHODS: We retrospectively reviewed stroke code patients between 1/2016 and 6/2017 from the prospective; Institutional review board (IRB) approved University of California San Diego Stroke Registry. Patients who had magnetic resonance imaging of brain from onset, with or without intervention, are included. All ischemic strokes were confirmed and timing from onset to imaging was calculated. Raw DWI intensity is measured using IMPAX software and compared to contralateral side for control for a relative DWI intensity (rDWI). LKW and magnetic resonance imaging (MRI) time were collected by chart review. Correlation is assessed using Pearson correlation coefficient between DWI intensity, rDWI, and time to MRI imaging. 1.5T, 3T, and combined modalities were examined. RESULTS: Seventy-eight patients were included in this analysis. Overall, there was statistically significant positive correlation (.53, P < .001) between DWI intensity and LKW time irrespective of scanner strength. Using 1.5T analyses, there was good correlation (.46, P < .001). 3T MRI analysis further showed comparatively stronger positive correlation (.66, P < .001). CONCLUSIONS: There is good correlation between DWI intensity and minutes from onset to MRI. This suggests a time-dependent DWI intensity response and supports the potential use of DWI intensity measurements to extrapolate an LKW time. Further studies are being pursued to increase both experience and generalizability.

"Encephalopathy Only Stroke Codes" (EoSC) Rarely Result in Stroke as Final Diagnosis.

Stroke codes prompted by isolated encephalopathy often result in nonstroke final diagnoses but require intensive stroke center resources. We assessed the likelihood of "Encephalopathy only Stroke Codes (EoSC)" resulting in a true stroke (EoSC CVA+) final diagnosis. 3860 patients were analyzed in a prospective stroke code registry from 2004 to 2016. EoSC was defined using a standard and an exploratory definition. Definition 1 included EoSC patients as stroke codes where NIHSS was nonzero for LOC questions (questions la, 1b, and lc) but remainder of the NIHSS was zero. Definition 2 included the same definition but allowed symmetric pairings on motor questions (5a/5b, 6a/6b, or Question 4 scoring a 3). Groups were assessed for final diagnosis of stoke (EoSC CVA+) or not stroke (EoSC CVA-). EoSC accounted for 60/3860 (1.55%) of total stroke codes. EoSC CVA+ was found in 5/3860 (0.13%) of all stroke codes, 5/60 (8.33%) of EoSC stroke codes, and 5/1514 (0.33%) of all strokes. For Definition 2, EoSC accounted for 96/3860 (2.5%) of total stroke codes. EoSC CVA+ was found in 9/3860 (0.23%) of all stroke codes, 9/96 (9.38%) of EoSC stroke codes, and 9/1514 (0.59%) of all strokes. On multivariable logistic regression analysis, diabetes was the highest predictor of stroke (p=0.05). Encephalopathy only Stroke Codes only rarely result in cases with a true final diagnosis of stroke (EoSC CVA+), accounting for 0.1-0.2% of all stroke codes and 8-9% of EoSC stroke codes. This may have important significance for mobilization of limited acute stroke code resources in the future.

Isolated Anisocoria as a Presenting Stroke Code Symptom is Unlikely to Result in Alteplase Administration.

BACKGROUND: Acute stroke codes may be activated for anisocoria, but how often these codes lead to a final stroke diagnosis or alteplase treatment is unknown. The purpose of this study was to assess the frequency of anisocoria in stroke codes that ultimately resulted in alteplase administration. METHODS: We retrospectively assessed consecutive alteplase-treated patients from a prospectively-collected stroke registry between February 2015 and July 2018. Based on the stroke code exam, patients were categorized as having isolated anisocoria [A+(only)], anisocoria with other findings [A+(other)], or no anisocoria [A-]. Baseline demographics, stroke severity, alteplase time metrics, and outcomes were also collected. RESULTS: Ninety-six patients received alteplase during the study period. Of the 94 who met inclusion criteria, there were 0 cases of A+(only). There were 9 cases of A+(other) (9.6%). A+(other) exhibited higher baseline National Institutes of Health (NIH) Stroke Scale scores compared to A- (17 versus 7; P = .0003), and no additional differences in demographics or alteplase time metrics. Final stroke diagnosis and other outcome measures were no different between A+(other) and A-. Of the A+ patients without pre-existing anisocoria, 5 of 6 (83%) had posterior circulation events or diffuse subarachnoid hemorrhage. CONCLUSIONS: In this exploratory analysis, zero patients with isolated anisocoria received alteplase treatment. Anisocoria as a part of the neurologic presentation occurred in 10% of alteplase patients, and was strongly associated with a posterior circulation event. Therefore, we conclude that anisocoria has a higher likelihood of leading to alteplase treatment when identified in the presence of other neurologic deficits.

The COAST stroke advance directive: A novel approach to preserving patient autonomy.

Within the field of neurology, there has been limited discussion of how to best respect patient autonomy in patients presenting with an acute stroke, who often have impairments in language and cognition. In addition to performing a detailed neurologic examination and providing a thorough timeline of their current presentation and medical history, these patients and their families are then asked to quickly make critical medical decisions regarding acute stroke therapies (thrombolysis and endovascular therapy). These discussions are often limited by time constraints and inadequate opportunities for patient education regarding acute stroke care. This article discusses some of the challenges of preserving patient autonomy in patients presenting with acute stroke and the advent of a stroke advance directive (Coordinating Options for Acute Stroke Therapy [COAST]) aimed to overcome these obstacles.

To Treat or Not to Treat?

Background and Purpose- The 2015 updated US Food and Drug Administration alteplase package insert altered several contraindications. We thus explored clinical factors influencing alteplase treatment decisions for patients with minor stroke. Methods- An expert panel selected 7 factors to build a series of survey vignettes: National Institutes of Health Stroke Scale (NIHSS), NIHSS area of primary deficit, baseline functional status, previous ischemic stroke, previous intracerebral hemorrhage, recent anticoagulation, and temporal pattern of symptoms in first hour of care. We used a fractional factorial design (150 vignettes) to provide unconfounded estimates of the effect of all 7 main factors, plus first-order interactions for NIHSS. Surveys were emailed to national organizations of neurologists, emergency physicians, and colleagues. Physicians were randomized to 1 of 10 sets of 15 vignettes, presented randomly. Physicians reported the subjective likelihood of giving alteplase on a 0 to 5 scale; scale categories were anchored to 6 probabilities from 0% to 100%. A conjoint statistical analysis was applied. Results- Responses from 194 US physicians yielded 156 with complete vignette data: 74% male, mean age 46, 80% neurologists. Treatment mean probabilities for individual vignettes ranged from 6% to 95%. Treatment probability increased from 24% for NIHSS score =1 to 41% for NIHSS score =5. The conjoint model accounted for 25% of total observed response variance. In contrast, a model accounting for all possible interactions accounted for 30% variance. Four of the 7 factors accounted jointly for 58% of total relative importance within the conjoint model: previous intracerebral hemorrhage (18%), recent anticoagulation (17%), NIHSS (13%), and previous ischemic stroke (10%). Conclusions- Four main variables jointly account for only a small fraction (<15%) of the total variance related to deciding to treat with intravenous alteplase, reflecting high variability and complexity. Future studies should consider other variables, including physician characteristics.

The Sustained DeyeCOM Sign as a Predictor of Large Vessel Occlusions and Stroke Mimics.

INTRODUCTION: Rapid imaging in acute stroke is critical and often occurs before full examination. Early, reliable examination findings clarify diagnosis and improve treatment times. The DeyeCOM sign has been described as a predictor of ischemic stroke. In this study, we evaluate a sustained DeyeCOM sign on serial computed tomography scans in prediction of large vessel occlusion. METHODS: Between April and June 2017, we retrospectively reviewed 46 patients with acute stroke from the University of California, San Diego Stroke Registry, who had both computed tomography and computed tomography angiography as part of their acute work-up. A DeyeCOM(+) sign was defined as a conjugate gaze deviation on imaging of at least 15°. DeyeCOM(++) was defined as sustained gaze deviation on both scans. RESULTS: Three groups of patients were observed: DeyeCOM(++), nonsustained gaze deviation, and no gaze deviation (DeyeCOM(--)). All patients in the DeyeCOM(++) (8 of 8, 100%) had large vessel occlusion. Of those with nonsustained gaze deviation, 2 of 7 (29%) had large vessel occlusion. No patients in the DeyeCOM(--) (0 of 31, 100%) had large vessel occlusion. The specificity and sensitivity of DeyeCOM(++) for large vessel occlusion was 100% (confidence interval [CI] .90-1.0) and 80% (CI .44-.97). The specificity and sensitivity of DeyeCOM(--) for absence of large vessel occlusion was 100% (CI .69-1.0) and 86% (CI .70-.95). CONCLUSIONS: DeyeCOM(++) had 100% specificity for large vessel occlusion, whereas DeyeCOM(--) had a 100% specificity for absence of large vessel occlusion. Sustained DeyeCOM, whether positive or negative, is a strong predictor of ultimate diagnosis that could lead to quicker endovascular treatment times.

Soluble ST2 predicts outcome and hemorrhagic transformation after acute stroke.

OBJECTIVE: ST2 is a member of the toll-like receptor superfamily that can alter inflammatory signaling of helper T-cells. We investigated whether soluble ST2 (sST2) could independently predict outcome and hemorrhagic transformation (HT) in the setting of stroke. METHODS: We measured sST2 in patients enrolled in the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) network biomarker study. 646 patients had plasma samples collected at the time of hospital admission and 210 patients had a second sample collected 48 h after stroke onset. Functional outcome was assessed using the modified Rankin Scale (mRS), with good and poor outcomes defined as mRS 0-2 and 3-6, respectively. HT was classified using ECASS criteria. The relationships between sST2, outcome, and HT were evaluated using multivariable logistic regression, Kaplan-Meier survival analysis and receiver operating characteristic curves. RESULTS: 646 patients were included in the analysis (mean age 69 years; 44% women), with a median NIHSS of 5 [IQR: 2-12]. The median sST2 level on hospital admission was 35.0 ng/mL [IQR: 25.7-49.8 ng/mL] and at 48 h it was 37.4 ng/mL [IQR 27.9-55.6 ng/mL]. sST2 was independently associated with poor outcome (OR: 2.77, 95% CI: 1.54-5.06; P = 0.003) and mortality (OR: 3.56, 95% CI: 1.58-8.38, P = 0.001) after multivariable adjustment. Plasma sST2 was also associated with hemorrhagic transformation after adjustment for traditional risk factors (OR: 5.58, 95% CI: 1.40-37.44, P = 0.039). INTERPRETATION: Soluble ST2 may serve as a prognostic biomarker for outcome and hemorrhagic transformation in patients with acute stroke. ST2 may link neuroinflammation and secondary injury after stroke.

Multiparametric Magnetic Resonance Imaging for Prediction of Parenchymal Hemorrhage in Acute Ischemic Stroke After Reperfusion Therapy.

BACKGROUND AND PURPOSE: Patients with acute ischemic stroke are at increased risk of developing parenchymal hemorrhage (PH), particularly in the setting of reperfusion therapies. We have developed a predictive model to examine the risk of PH using combined magnetic resonance perfusion and diffusion parameters, including cerebral blood volume (CBV), apparent diffusion coefficient, and microvascular permeability (K2). METHODS: Voxel-based values of CBV, K2, and apparent diffusion coefficient from the ischemic core were obtained using pretreatment magnetic resonance imaging data from patients enrolled in the MR RESCUE clinical trial (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy). The associations between PH and extreme values of imaging parameters were assessed in univariate and multivariate analyses. Receiver-operating characteristic curve analysis was performed to determine the optimal parameter(s) and threshold for predicting PH. RESULTS: In 83 patients included in this analysis, 20 developed PH. Univariate analysis showed significantly lower 10th percentile CBV and 10th percentile apparent diffusion coefficient values and significantly higher 90th percentile K2 values within the infarction core of patients with PH. Using classification tree analysis, the 10th percentile CBV at threshold of 0.47 and 90th percentile K2 at threshold of 0.28 resulted in overall predictive accuracy of 88.7%, sensitivity of 90.0%, and specificity of 87.3%, which was superior to any individual or combination of other classifiers. CONCLUSIONS: Our results suggest that combined 10th percentile CBV and 90th percentile K2 is an independent predictor of PH in patients with acute ischemic stroke with diagnostic accuracy superior to individual classifiers alone. This approach may allow risk stratification for patients undergoing reperfusion therapies. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00389467.