Stroke Centers of Excellence in the United States: Certification, Access and Outcomes

Introduction: Stroke is a leading cause of morbidity, mortality and healthcare costs in the United States. Evidence suggests that certified stroke centers have improved patient outcomes relative to non-certified hospitals. Our study explains the process, associated cost, quality and geographic proclivities of different certifying organizations. Methods: Data was collected from published literature, information on certifying organizations’ websites and through direct communication with representatives of The Joint Commission (TJC), Det Norske Veritas and Germanischer Lloyd (DNV-GL), and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of thrombectomy capable centers and comprehensive stroke centers was performed with the ArcGIS online tool. Results: Among the three certifying organizations, standards for recognition as acute, primary, thrombectomy capable and comprehensive stroke centers are not standardized. At the time of this review, there were 1406 TJC-certified stroke centers, 241 DNV-GL certified stroke centers and 66 HFAP-certified stroke centers in the United States. Cost for certification was similar with price scaled by complexity of capabilities. Quality metrics revealed a significantly higher rate of tPA administration and shorter door-to-needle time for TJC and DNV-GL centers than HFAP. All primary stroke centers exhibited improved in-hospital, 30-day and 1-year mortality when compared to non-stroke centers. Discussion: Despite lack of standardization of criteria between organizations, certification provides a mechanism for ensuring hospitals deliver higher standards of stroke care. Understanding variations in quality and scope of different organizations enables targeting of at-risk regions to maximize access and availability of care

Mechanical Thrombectomy in Acute Ischemic Stroke Patients Greater than 90 years of age experience in 26 patients in a Large Tertiary Care Center: Outcome comparison with younger patients

Introduction: Several independent randomized control trials have shown the superior efficacy of mechanical thrombectomy for acute ischemic stroke (AIS). However, the elderly has been underrepresented or excluded in these trials. In this study, we investigated the feasibility and safety of mechanical thrombectomy in patients with AIS aged 90 years or greater. Methods: A retrospective review of patients age 90 years or older presenting with AIS who underwent mechanical thrombectomy between 2010 and 2018. Results: Of total 453 patients with AIS, 5.74 % (26) were aged 90 or older, and 69.32 % (314) ranged from 60-89 years of age. Of all baseline characteristics between both groups, there is a significant difference in age, gender, body mass index (BMI), smoking, hyperlipidemia (HLD), atrial fibrillation, and diabetes mellitus. The mean NIHSS upon admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tPA (57.69%, 15 vs. 42.68%, 134, p=0.14). There was no difference in peri & post-procedural complications, good TICI score (88.46%, 23 vs. 87.58%, 275, p=1.00), “good” mRS scores (34.62%, 4 vs. 49.36%, 155, p=0.40), and mortality (11.54%, 3 vs. 13.06%, 41, p= 0.82). Discussion: Age is one of the factors that affect functional outcome following mechanical thrombectomy. Advancements in catheter techniques, technical experience, and great outcomes with mechanical thrombectomy allow for pushing the envelope to deal with age as one of the factors, rather, than an exclusion criterion. Our results show that mechanical thrombectomy is safe and feasible in nonagenarians

Process design for optimizing text-based communication between physicians and nurses

Background and Aim Communication between physicians and nurses is a cornerstone of high-quality inpatient care. HIPAA-compliant text-based methods offer an alternative to the pager for communication between nurses and physicians. While messaging is popular in the personal setting, text-based professional communication in hospitals may increase the number of messages without improving coordination between care providers. (1) In addition, urgent messages that are more appropriately calls could be missed by the physician, leading to a delay in action. Other institutions use triage systems to communicate a question or clinical change by the urgency of expected physician response, which have attempted to mitigate this issue. (2) We aimed to improve bidirectional communication between housestaff and nursing with a communication process developed jointly by both parties using QI methods such as stakeholder analysis and a structured Work-Out session to brainstorm solutions

Implications of serial measurements of natriuretic peptides in heart failure: insights from BIOSTAT‐CHF

No abstract available

Abstract Number ‐ 168: Conventional angiography versus non‐invasive imaging in the assessment of symptomatic carotid disease

Introduction The indication for carotid endarterectomy in symptomatic carotid stenosis of 50% or more was established based on catheter angiography. Yet, in practice, operative referral is still largely based on non‐invasive imaging. We sought to determine the discrepancy between the two modalities in our retrospective cohort. Methods We retrospectively collected data from consecutive symptomatic patients between 2019 and 2021 at our institution who were referred for evaluation and possible stenting of carotid disease based on non‐invasive imaging showing moderate to severe stenosis or occlusion. All patients underwent digitally subtracted angiography (DSA) and were treated with stenting if there was stenosis of 50% or above or if there was presence of a string sign. Otherwise, they were continued on best medical therapy. Results 98 total patients were referred for evaluation of carotid disease (Median age 60, 37% women). 21/98 were found to have a carotid occlusion on non‐invasive imaging, of those, 6 (28%) were found to have a string sign on CTA and were treated with stenting. 77/98 were found to have moderate to severe carotid artery stenosis based on non‐invasive imaging. Of those, 31 patients (40%), were not found to have significant carotid artery stenosis and were not treated with stenting. Out of total 99 patients who were referred for carotid intervention based on non‐invasive imaging, 38 (40%) patients had a change in the treatment plan. Conclusions 40% of the patients who were referred for revascularization based on non‐invasive imaging had a change in the treatment after conventional catheter angiography. Larger studies are warranted to confirm our findings

Abstract Number ‐ 39: Comparison of Clinical and Radiographic Efficacy of Particles versus nBCA/Onyx in MMA Embolization for cSDH

Introduction Middle meningeal artery (MMA) embolization has emerged as a minimally invasive alternative to open surgery for treatment of chronic subdural hematoma (cSDH). Different embolic materials are utilized in this procedure per operators’ discretion; however, limited data currently exists regarding the clinical and radiographic efficacy of these embolic materials, with available studies lumping Onyx and N‐Butyl cyanoacrylate (n‐BCA) into a single group of liquid embolic material. Methods Series of consecutive patients undergoing MMA embolization (MMAE) for cSDH at 2 North American centers (2019‐2021) were included. The primary outcomes included cSDH radiographic resolution of cSDH with at least 50% reduction of hematoma thickness to be considered treatment success. Clinical outcomes were defined as the proportion of patients requiring additional unplanned surgical intervention. These outcomes compared between the particles group, the liquid group which were further subdivided into the n‐BCA and Onyx groups. Results Overall, 185 patients undergoing 198 MMAE procedures (median age 72 years, 27.5% women) were included in this analysis. In this cohort, 42.6% of the procedures were performed utilizing particles embolic material, while n‐BCA and Onyx were utilized in 29.5% and 26.8% of procedures, respectively. On last follow‐up imaging (median 3.5 months), ≥ 50% reduction in hematoma thickness was achieved in 67.7%, 71.1%, and 72.3% in the particles, Onyx and the n‐BCA group, respectively (p = 0.2). There were no differences in the proportion of patients requiring additional unplanned surgery between the groups (p = 0.6). Similarly, there was no difference in procedural complications between the 3 embolic materials groups. Conclusions MMAE for cSDH utilizing particles and liquid embolic materials (including Onyx and n‐BCA) appears to have an overall equivalent safety and efficacy profiles in cSDH treatment. Further studies with larger sample sizes and longer follow‐up are warranted

Safety Outcomes of Antiplatelet Therapy During Endovascular Treatment of Tandem Lesions in Acute Ischemic Stroke Patients

Risk of hemorrhage remains with antiplatelet medications required with carotid stenting during endovascular therapy (EVT) for tandem lesion (TLs). We evaluated the safety of antiplatelet regimens in EVT of TLs. This multicenter study included anterior circulation TL patients from 2015 to 2020, stratified by periprocedural EVT antiplatelet strategy: (1) no antiplatelets, (2) single oral, (3) dual oral, and (4) intravenous IV (in combination with single or dual oral). Primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were any hemorrhage, favorable functional status (mRS 0-2) at 90 days, successful reperfusion (mTICI score ≥ 2b), in-stent thrombosis, and mortality at 90 days. Of the total 691 patients, 595 were included in the final analysis. One hundred and nineteen (20%) received no antiplatelets, 134 (22.5%) received single oral, 152 (25.5%) dual oral, and 196 (31.9%) IV combination. No significant association was found for sICH (ref: no antiplatelet: 5.7%; single:4.2%; aOR 0.64, CI 0.20-2.06, p = 0.45, dual:1.9%; aOR 0.35, CI 0.09-1.43, p = 0.15, IV combination: 6.1%; aOR 1.05, CI 0.39-2.85, p = 0.92). No association was found for parenchymal or petechial hemorrhage. Odds of successful reperfusion were significantly higher with dual oral (aOR 5.85, CI 2.12-16.14, p = 0.001) and IV combination (aOR 2.35, CI 1.07-5.18, p = 0.035) compared with no antiplatelets. Odds of excellent reperfusion (mTICI 2c/3) were significantly higher for cangrelor (aOR 4.41; CI 1.2-16.28; p = 0.026). No differences were noted for mRS 0-2 at 90 days, in-stent thrombosis, and mortality rates. Administration of dual oral and IV (in combination with single or dual oral) antiplatelets during EVT was associated with significantly increased odds of successful reperfusion without an increased rate of symptomatic hemorrhage or mortality in patients with anterior circulation TLs

Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study.

BACKGROUND The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. METHODS This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. RESULTS Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). CONCLUSIONS In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted

Aspiration Versus Stent‐Retriever as First‐Line Endovascular Therapy Technique for Primary Medium and Distal Intracranial Occlusions: A Propensity‐Score Matched Multicenter Analysis

Background For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry. Methods Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups. Results Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9; P<0.01), higher National Institutes of Health Stroke Scale scores (median 13 versus 11; P=0.02), and nonsignificantly fewer medium‐distal occlusions (M3, A2, P2, or other: 17.4% versus 23.8%; P=0.10). Use of a stent‐retriever was associated with 15% lower odds of successful recanalization (odds ratio [OR], 0.85; [95% CI 0.74–0.98]; P=0.02), but this was not significant after multivariable adjustment in the total cohort (adjusted OR, 0.88; [95% CI 0.72–1.09]; P=0.24), or in the propensity‐score matched cohort (n=105 in each group) (adjusted OR, 0.94; [95% CI 0.75–1.18]; P=0.60). There was no significant association between technique and secondary outcomes in the propensity‐score matched adjusted models. Conclusion In this large, diverse, multinational medium vessel occlusion cohort, we found no significant difference in imaging or clinical outcomes with aspiration versus stent‐retriever thrombectomy