Extending tPA Use for Wake-up Stroke

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A transition of care program to reduce stroke related hospital readmissions

Introduction: Readmission to the hospital after discharge following a stroke or TIA remains a nation-wide problem. While the CMS national benchmark was approximately 12% in 2015, our hospital Medicare stroke readmission rate rose from approximately 12% at the end of 2014 to 28.6% in February 2015. Our goal was a reduction in stroke readmission rates to below the national benchmark of 12% by December 2015. Hypothesis: We hypothesized that implementing a transition of care program at our 200 bed community hospital would reduce hospital stroke-related readmissions. Methods: In March 2015, a random sample of forty stroke/TIA patients that were discharged home between December of 2014 and February of 2015 were interviewed. The patients were asked about barriers to discharge, what could have improved the discharge experience, and what problems they encountered that could have resulted in a readmission. Based on their answers, risk factors were identified using an inverse Pareto graph and a transition of care program was implemented which included the following work flow: 1) daily rounding to query patients regarding insight into stroke risk factors, environmental concerns, and social impacts to discharge in the stroke unit by the stroke coordinator (a registered nurse); 2) a discharge telephone call within two business days to high risk patients identified during rounds focusing on review of the discharge summary, re-education regarding stroke risk factors, and ensuring that follow-up appointments were in place; 3) an outpatient follow-up appointment with a board certified vascular neurologist within two weeks of discharge. Results: Our transition of care program resulted in an improvement of 82.5%, with a Medicare stroke readmission rate of 5% in December 2015. As of May 2016, our year-to-date hospital stroke readmission rate is 8.1%, while the current CMS national average is 12.7%. Conclusions: A transition of care program is implementable in a community hospital setting, and results in reduced stroke-related hospital readmissions. Its success emphasizes the importance of identifying high risk patients and assessing individual drivers of readmission risk

Nitrous oxide-induced demyelination: Clinical presentation, diagnosis and treatment recommendations

BACKGROUND: Recreational use of nitrous oxide (NO) in the general public has led to increasing reports of NO-induced demyelination (NOID). We describe the varying clinical presentations and pathophysiology, and offer a treatment paradigm. METHODS: A literature search of MEDLINE and EMBASE resulted in 42 publications with 37 studies meeting the inclusion criteria, for a total of 51 patients. Our case series included 5 patients seen from 2014 to 2018 followed over 3-60 months. RESULTS: Those with sensory symptoms and subjective weakness were categorized as having mild symptoms (25%). Symptoms indicating involvement outside the dorsal columns such as observer-graded weakness were categorized as moderate (61%). Patients with the aforementioned plus cognitive effects were categorized as severe (12%). There was no dose-dependent relationship between the amount of NO used and clinical impairment. There was a trend between the severity of neurologic impairment and serum levels of B12. Two patients were noncompliant. One initiated only oral therapy and did not improve. One received injections a month apart and worsened. CONCLUSIONS: Patients with NOID tend to have worse symptoms when presenting with lower serum vitamin B12 levels and have good recovery rates when treated with intramuscular B12 and oral supplementation

Analysis of hypoplastic variants of the circle of willis in patients with first-ever lacunar stroke

Background: Cerebral small vessel disease is related to widespread endothelial dysfunction, and suspected hypoperfusion at the level of the microcirculation. Lacunar infarcts are a major manifestation of small vessel disease, and result in significant long-term neurological morbidity and mortality. Congenital hypoplastic variants of the vessels of the Circle of Willis may result in impairment of collateral channels at the time of ischemia. Hypothesis: We hypothesized that lateralization of first-ever lacunar infarcts is related to relative hypoperfusion of the ipsilateral hemisphere due to asymmetric hypoplasia of the vessels of the Circle of Willis and inadequate side-to-side collateral circulation. Methods: We analyzed 40 consecutive patients that presented to a stroke center with a first-ever supratentorial lacunar infarct. All patients were able to undergo intracranial vascular imaging. Patients with significant large-vessel disease (even if asymptomatic) were excluded. A neuroradiologist, blinded to the laterality of the lacunar infarct, assessed for lateralized hypoplasia of the Circle of Willis (either anteriorly at the level of the A1 artery and AComA as one functional unit, or posteriorly at the level of the PCA and PComA as one functional unit). Proportions of ipsilateral and contralateral hypoplasia were compared directly, as well as with historical controls, with the chi-squared test. Results: Among analyzed patients, ipsilateral and contralateral anterior pathway hypoplastic variants were not significantly different from historical controls (p=0.145 and p=0.99 respectively). However, ipsilateral and contralateral posterior pathway hypoplastic variants were significantly different from historical controls (p\u3c0.001 for both). There was no statistical difference between ipsilateral and contralateral posterior pathway hypoplasia (p=0.21). Conclusion: Hypoplasia of the posterior part of the Circle of Willis is significantly more common among patients with first-ever lacunar stroke, compared to historical controls. However, the asymmetry of hypoplasia does not affect the laterality of first-ever lacunar infarct. Further studies are required to explain this phenomenon

Analysis of hypoplastic variants of the circle of willis in patients with first-ever lacunar stroke.

Background: Cerebral small vessel disease is related to widespread endothelial dysfunction, and suspected hypoperfusion at the level of the microcirculation. Lacunar infarcts are a major manifestation of small vessel disease, and result in significant long-term neurological morbidity and mortality. Congenital hypoplastic variants of the vessels of the Circle of Willis may result in impairment of collateral channels at the time of ischemia. Hypothesis: We hypothesized that lateralization of first-ever lacunar infarcts is related to relative hypoperfusion of the ipsilateral hemisphere due to asymmetric hypoplasia of the vessels of the Circle of Willis and inadequate side-to-side collateral circulation. Methods: We analyzed 40 consecutive patients that presented to a stroke center with a first-ever supratentorial lacunar infarct. All patients were able to undergo intracranial vascular imaging. Patients with significant large-vessel disease (even if asymptomatic) were excluded. A neuroradiologist, blinded to the laterality of the lacunar infarct, assessed for lateralized hypoplasia of the Circle of Willis (either anteriorly at the level of the A1 artery and AComA as one functional unit, or posteriorly at the level of the PCA and PComA as one functional unit). Proportions of ipsilateral and contralateral hypoplasia were compared directly, as well as with historical controls, with the chi-squared test. Results: Among analyzed patients, ipsilateral and contralateral anterior pathway hypoplastic variants were not significantly different from historical controls (p=0.145 and p=0.99 respectively). However, ipsilateral and contralateral posterior pathway hypoplastic variants were significantly different from historical controls (p\u3c0.001 for both). There was no statistical difference between ipsilateral and contralateral posterior pathway hypoplasia (p=0.21). Conclusion: Hypoplasia of the posterior part of the Circle of Willis is significantly more common among patients with first-ever lacunar stroke, compared to historical controls. However, the asymmetry of hypoplasia does not affect the laterality of first-ever lacunar infarct. Further studies are required to explain this phenomenon

CTA for All : Emergency CT Angiography for All Stroke Patients Presenting Within 24 Hours of Onset Improves Outcome After Large Vessel Occlusion

Introduction: Computed tomographic angiography (CTA) is an important initial assessment for detecting large vessel occlusion (LVO) in acute ischemic stroke (AIS) and for selecting patients for mechanical thrombectomy (MT). This study is designed to evaluate the impact of an emergency CTA protocol on outcome of AIS patients with LVO. Methods: On July 1, 2017 we implemented the policy of performing CTA at the same time as non-contrast CT (NCCT) in all AIS patients presenting within 24 hours of symptom onset regardless of baseline NIHSS. Previously emergency CTA was reserved for patients presenting within 6 hours with an NIHSS ≥6. We compared treatment processes and outcomes between AIS patients admitted 1-year before (N=396) and 1-year after (N=494) protocol implementation. Results: After protocol implementation, more patients underwent CTA (90% VS 60%, P \u3c 0.001) and had CTA performed at the time of the initial NCCT (77% VS 34%,

A widely accepted metric (telephone assessment of the modified Rankin scale score at 90 days) may not accurately reflect the real-life outcome of endovascular stroke treatment

Introduction: The modified Rankin Score (mRS) collected at approximately 90 days after stroke onset is a reliable and reproducible measure of stroke outcome. It was utilized in the randomized controlled trials that established the safety and efficacy of endovascular stroke treatment. It has been incorporated as a core metric for measuring quality of care in comprehensive stroke centers. We aimed to evaluate the value of the 90-day mRS considering that a certain percentage of patients may fail to respond to coordinator phone calls. Methods: We retrospectively analyzed patients who received endovascular stroke treatment in a comprehensive stroke center from January 2015 to March 2017, and who were prospectively enrolled in the Get With The Guidelines-Stroke Registry. We calculated the response rates to coordinator phone calls at approximately 90 days from stroke onset. Several calls were placed according to the established institutional policy. We compared the response rates of patients who had successful or unsuccessful recanalization, as reported by the endovascular specialist at the time of the procedure. Results: We identified 79 patients who received endovascular treatment, and who were contacted by the coordinators at approximately 90 days after stroke onset. 58 patients had successful recanalization (as defined by reported TICI grades IIb and III), whereas 21 patients had unsuccessful recanalization (as defined by reported TICI grades O, I, and IIa). 44/58 patients with successful recanalization responded to coordinator calls, compared to 11/21 patients with unsuccessful recanalization. The difference in proportions was statistically significant (p=0.045). Conclusions: Patients who have unsuccessful recanalization after endovascular stroke treatment are significantly less likely to respond to coordinator calls. Therefore, their mRS cannot be estimated, and the long-term outcome of the endovascular procedure cannot be assessed. Since these patients are more likely to have died, or be in a supervised facility (and therefore not accessible at their previous phone number), the telephone assessment of the mRS is likely not an accurate measure for the long-term therapeutic effect of endovascular stroke treatment

Discussing Spirituality With Patients: A Rational and Ethical Approach

BACKGROUND This study was undertaken to determine when patients feel that physician inquiry about spirituality or religious beliefs is appropriate, reasons why they want their physicians to know about their spiritual beliefs, and what they want physicians to do with this information. METHODS Trained research assistants administered a questionnaire to a convenience sample of consenting patients and accompanying adults in the waiting rooms of 4 family practice residency training sites and 1 private group practice in northeastern Ohio. Demographic information, the SF-12 Health Survey, and participant ratings of appropriate situations, reasons, and expectations for physician discussions of spirituality or religious beliefs were obtained. RESULTS Of 1,413 adults who were asked to respond, 921 completed questionnaires, and 492 refused (response rate = 65%). Eighty-three percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%). Among those who wanted to discuss spirituality, the most important reason for discussion was desire for physician-patient understanding (87%). Patients believed that information concerning their spiritual beliefs would affect physicians’ ability to encourage realistic hope (67%), give medical advice (66%), and change medical treatment (62%). CONCLUSIONS This study helps clarify the nature of patient preferences for spiritual discussion with physicians

Risk for Major Bleeding in Patients Receiving Ticagrelor Compared With Aspirin After Transient Ischemic Attack or Acute Ischemic Stroke in the SOCRATES Study (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes)

Abstract: Background: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)\u2013defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). Methods: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. Results: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52\u20131.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. Conclusions: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994720.Abstract: BACKGROUND: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)-defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). METHODS: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. RESULTS: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52-1.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. CONCLUSIONS: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs