During the coronavirus disease 2019 (COVID-19) pandemic, infectious disease control is of utmost importance in acute stroke treatment. This is a new situation for most stroke teams that often leads ...to uncertainty among physicians, nurses, and technicians who are in immediate contact with patients. The situation is made even more complicated by numerous new regulations and protocols that are released in rapid succession. Herein, we are describing our experience with simulation training for COVID-19 stroke treatment protocols. One week of simulation training allowed us to identify numerous latent safety threats and to adjust our institution-specific protocols to mitigate them. It also helped our physicians and nurses to practice relevant tasks and behavioral patterns (eg, proper donning and doffing PPE, where to dispose potentially contaminated equipment) to minimize their infectious exposure and to adapt to the new situation. We therefore strongly encourage other hospitals to adopt simulation training to prepare their medical teams for code strokes during the COVID-19 pandemic.
Endovascular treatment (EVT) has emerged as the gold standard therapy for stroke due to large vessel occlusion (LVO). There is however limited evidence to suggest that similar efficacy can be ...expected in elderly patients. We aimed to assess the efficacy and safety of EVT in elderly patients (aged > 80), comparing outcomes to younger patients (aged < 80).
A total of 195 patients with LVO stroke treated with EVT were included and dichotomized by age. We compared neurological improvement, clinical 90 day outcome, technical recanalization rates, procedure-related complications, and mortality in between the groups.
Both groups showed equally marked neurological improvement. A favorable outcome modified Rankin Scale (mRS < 2) was seen in 28% of the elderly patients compared to 46% of the younger patients (p = 0.01). mRS 0-3 was seen in 46% of the elderly patients and 58% of the younger patients (p = 0.09). The rates of successful technical recanalization did not differ between the groups and there were no differences in procedural complication rates or incidence of symptomatic intracranial bleeding. Three-month mortality rates were however higher in the elderly group.
EVT in the elderly resulted in equally notable neurological improvement as compared to younger patients. Although the elderly had a higher mortality rate and fewer favorable clinical outcomes at 3 month follow-up, a strict upper age limit for EVT seems unjustified.
Objectives
Endovascular treatment (EVT) is the gold standard treatment for emergent large vessel occlusion (LVO). The benefit of EVT for emergent LVO in elderly patients (>80 years old) is still ...debated as they have been under‐represented in randomized controlled trials. Elderly patients with an emergent LVO are a growing population warranting further study.
Materials & Methods
We included 225 consecutive patients treated with EVT for LVO either in the anterior or posterior circulation. The clinical outcome was assessed using the National Institute of Health Stroke Scale (NIHSS). Long‐term functional outcome was assessed using 90‐day modified ranking scale (mRS).
Results
Neurological improvement: A five‐year higher age predicted a 0.43 higher mean NIHSS score after EVT (p = .027). After adjusting for confounders (influencing variables), the association between age and post‐interventional NIHSS was reduced and non‐significant (p = .17). At discharge, a five‐year higher age predicted a 0.74 higher mean NIHSS (p = .003). After adjusting for confounders this association was reduced and non‐significant (p = .06).
Long‐term functional outcome: A five‐year higher age predicted a 0.20 higher mRS at three months (p < .001). When adjusting for confounders this number was reduced to 0.16, yet still highly significant (p < .001).
Conclusions
Age seems to have a minor role in predicting neurological improvement after EVT but has an impact on long‐term functional outcome. The decision to perform or withhold EVT should therefore not solely be based on age.
The golden hour of acute ischemic stroke Advani, Rajiv; Naess, Halvor; Kurz, Martin W
Scandinavian journal of trauma, resuscitation and emergency medicine,
05/2017, Letnik:
25, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Acute Ischemic Stroke (AIS) treatment has been revolutionised in the last two decades with the increasing use of Intravenous Thrombolysis (IVT) and with the advent of Endovascular therapy (EVT). AIS ...treatment and outcome are time dependant and time saving measures are being implemented at every step of the treatment chain. These changes have resulted in lower treatment times in-hospital, but it is unclear if this translates into more patients being treated within 60 min of symptom onset - the Golden Hour. The clinical outcome of IVT therapy in this patient group was our secondary outcome.
From 2009 onwards, systematic changes were made to the AIS treatment chain leading to a dramatic decrease in Door-to-Needle (DTN) time. Analyses were performed on the number of these treatments year on year and their clinical outcomes within the Golden Hour at Stavanger University Hospital (SUS).
Six-hundred and thirteen patients were included; seventy-three were treated within the Golden Hour. The percentage of total IVT treatments occurring in the Golden Hour rose from 2.2% in 2009 to 14.5% in 2015 (p = 0.006) with a high of 18.3% in 2012 (p < 0.001). All of these patients had a Median NIHSS of 0 at discharge, irrespective of age and pre-existing comorbidity. There was no incidence of any ICH and in-hospital mortality was only 2.7% in this group.
The time from AIS symptom onset to treatment is filled with delays. Despite the inherence of some delays,significant efforts on the part of the pre- and in- hospital treatment chain have made IVT therapy within 60 min a possibility. The allocation and use of resources in the setting of rapid AIS treatment is warrantedand yields unprecedented results.
Our study shows that improved treatment routines led to an increase in the number of patients treated within the Golden Hour. Treatment in the Golden Hour leads to excellent outcomes in all patients, irrespective of age and pre-existing comorbidity.
Introduction. The majority of patients with occipital infarcts display homonymous visual field defects (VFD), with negative implications on activities of daily living and quality of life. To overcome ...the disability, better prognostic markers in the acute phase, as well as more targeted rehabilitation, would be useful. The aim of the current study was to present an overview of the topographic distribution of occipital infarcts and to investigate whether lesion volume can predict VFD at baseline and after six months. Materials and Methods. Multicenter, prospective study including patients with acute occipital infarcts (NOR-OCCIP project). All patients were examined by a neurologist in the acute phase, admitted to a stroke unit, and further assessed by an ophthalmologist within two weeks. Topographic and volumetric data from brain imaging in 72 patients were analyzed and computed by an experienced neuroradiologist. Results. A majority (81%) had occipital infarcts with involvement of the primary visual cortex, and VFD were detected on perimetry in 80% of the examined patients. Higher infarct volume led to more severe VFD at baseline (p=0.019); this was more evident if the infarct was located on the right side (p=0.001). The odds for VFD improvement after six months were higher the larger the infarcts were (p=0.020). There was a statistically significant association between volume of infarcts and atrial fibrillation (p=0.016), previous myocardial infarction (p=0.023), and modified Rankin Scale at three months (p=0.007). Conclusion. Higher infarct volumes led to more severe VFD at baseline. More than half of the patients (54%) experienced improvement of their VFD at six months; a higher grade of improvement was seen in patients with larger occipital infarcts. Large infarcts were more common in patients with cardiovascular disease, strengthening the argument for secondary prevention.
Objective
Metric based virtual reality simulation training may enhance the capability of interventional neuroradiologists (INR) to perform endovascular thrombectomy. As pilot for a national ...simulation study we examined the feasibility and utility of simulated endovascular thrombectomy procedures on a virtual reality (VR) simulator.
Methods
Six INR and four residents participated in the thrombectomy skill training on a VR simulator (Mentice VIST 5G). Two different case-scenarios were defined as benchmark-cases, performed before and after VR simulator training. INR performing endovascular thrombectomy clinically were also asked to fill out a questionnaire analyzing their degree of expectation and general attitude towards VR simulator training.
Results
All participants improved in mean total procedure time for both benchmark-cases. Experts showed significant improvements in handling errors (case 2), a reduction in contrast volume used (case 1 and 2), and fluoroscopy time (case 1 and 2). Novices showed a significant improvement in steps finished (case 2), a reduction in fluoroscopy time (case 1), and radiation used (case 1). Both, before and after having performed simulation training the participating INR had a positive attitude towards VR simulation training.
Conclusion
VR simulation training enhances the capability of INR to perform endovascular thrombectomy on the VR simulator. INR have generally a positive attitude towards VR simulation training. Whether the VR simulation training translates to enhanced clinical performance will be evaluated in the ongoing Norwegian national simulation study.
Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the ...availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.
Purpose
Endovascular treatment (EVT) is traditionally performed by neurointerventional radiologists at tertiary medical centres imposing long transport ways to large vessel occlusion (LVO) stroke ...patients in rural areas. The purpose of this study is to evaluate the technical and clinical results over time at Stavanger University Hospital, a hospital without neurointerventional expertise, where trained general interventional radiologist performs EVT.
Methods
All patients with LVO stroke treated with EVT from May 2009 to December 2018 were included in the analysis. Technical outcome was measured by the modified treatment in cerebral ischaemia (mTICI) score, functional outcome by the modified Rankin Scale (mRS), complications registered.
Results
A total of 235 patients were treated with EVT. An angiographically good result (mTICI 2b or 3) could be seen in 66.7% of the patients treated the first year. In 2011, the year EVT with stent retrievers was introduced, the recanalization rate rose to 81.8%, and from 2014 onwards, it was stable around 80%. After introduction of aspiration together with stent retrievers in 2012, a good functional outcome (mRS 0‐2) was obtained in >40% of the treated patients. In 2018, 61.1% of the patients got a good functional outcome.
Conclusions
Endovascular treatment of LVO stroke performed by general vascular interventional radiologist in close collaboration with diagnostic neuroradiologists and stroke neurologists can achieve technical revascularization results and clinical patient outcomes in line with international recommendations, and the randomized controlled studies performed. This approach may help to introduce EVT in geographical areas where this service is lacking due to the absence of neurointerventional specialists.
Background
Tenecteplase has probably pharmacological and clinical advantages in the treatment of acute ischemic stroke. There are lacking data about safety and efficacy of tenecteplase in wake‐up ...stroke (WUPS).
Aims
To investigate safety and efficacy of tenecteplase compared to alteplase in WUPS patients included in NOR‐TEST.
Methods
WUPS patients in NOR‐TEST were included in the study based on DWI‐FLAIR mismatch. Included patients randomly assigned (1:1) to receive intravenous tenecteplase 0.4 mg/kg (to a maximum of 40 mg) or alteplase 0.9 mg/kg (to a maximum of 90 mg). Neurological improvement was defined as 1) favorable functional outcome at 90 days modified Rankin Scale (mRS) of 0 or 1 and 2) neurological improvement measured with the National Institutes of Health Stroke Scale (NIHSS) of 4 points within 24 hours as compared to admission NIHSS or NIHSS 0 at 24 hours.
Results
Of 1100 patients from 13 stroke centers included in NOR‐TEST, 45 were WUPS patients. Of these, 5 patients were stroke mimics and excluded. Of the remaining 40 patients (3.6%), 24 were treated with alteplase (60%). There was no difference in the number of patients achieving a good clinical outcome (mRS 0‐1) in either treatment group. Patients treated with tenecteplase showed a better early neurological improvement (87.5% vs 54.2%, P = 0.027). No ICH was detected on MRI/CT 24‐28 hours after thrombolysis.
Conclusions
In WUPS patients treated in NOR‐TEST, there was no difference in clinical outcomes at 90 days and no ICH events or deaths were observed in either alteplase‐ or tenecteplase‐treated patients.
Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT01949948.
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