Improvement of Endovascular Stroke Treatment: A 24-Hour Neuroradiological On-Site Service Is Not Enough

Background and Purpose. With the advent of endovascular stroke treatment (EST) with mechanical thrombectomy, stroke treatment has also become more challenging. Purpose of this study was to investigate whether a fulltime neuroradiological on-site service and workflow optimization with a structured documentation of the interdisciplinary stroke workflow resulted in improved procedural times. Material and Methods. Procedural times of 322 consecutive patients, who received EST (1) before (n=96) and (2) after (n=126) establishing a 24-hour neuroradiological on-site service as well as (3) after implementation of a structured interdisciplinary workflow documentation (“Stroke Check”) (n=100), were analysed. Results. A fulltime neuroradiological on-site service resulted in a nonsignificant improvement of procedural times during out-of-hours admissions (p≥0.204). Working hours and out-of-hours procedural times improved significantly, if additional workflow optimization was realized (p≤0.026). Conclusions. A 24-hour interventional on-site service is a major prerequisite to adequately provide modern reperfusion therapies in patients with acute ischemic stroke. However, simple measures like standardized and focused documentation that affect the entire interdisciplinary pre- and intrahospital stroke rescue chain seem to be important

Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center

The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis (“combination or bridging therapy (C/BT)”). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects

Balintgruppenseminar im PJ-Unterricht Allgemeinmedizin: Was bewegt Studierende, welchen Benefit sehen sie?

Despite the potential immediate access to diagnosis and care, in-hospital stroke (IHS) is associated with delay in diagnosis, lower rates of reperfusion treatment, and unfavorable outcome. Endovascular reperfusion therapy has shown promising results in recent trials for community-onset strokes (COS) and is limited by less contraindications than systemic thrombolysis. Thus, endovascular approaches may offer additional acute treatment options for IHS. We performed a retrospective, observational monocentric analysis of patients with acute ischemic stroke between January 2010 and December 2014. Out of 3506 acute ischemic strokes, 331 (9.4 %) were IHS. In-hospital mortality (31.4 vs. 8.0 %) and duration of stay after stroke (19.5 vs. 12.1 days) were higher in IHS than in COS. Most IHS occurred in cardiologic and cardiosurgical patients after catheterization or surgery. In 111 cases (33.5 %) the time of onset could not be established as a result of sedation or delayed referral resulting in delayed symptom recognition. 52 IHS (15.7 %) and 828 COS (26.0 %, p < 0.001) patients received any kind of reperfusion therapy, of which 59.6 % (IHS) and 12.1 % (COS) comprised isolated endovascular interventions (p < 0.001). Intra-hospital delays (time to brain imaging, systemic thrombolysis, and angiography) were longer and outcome parameters (mRS d90, in-hospital mortality, length of stay) were worse in IHS, whereas rates of procedural complications and intracranial hemorrhages were similar in both groups. The overall rate of reperfusion treatment is lower in IHS compared to COS, as IHS patients are less likely to be eligible for systemic thrombolysis. Interventional stroke treatment is a safe and feasible therapeutic option for patients who are not eligible for systemic thrombolysis and should be anticipated whenever IHS is diagnosed