ISC 2022: New study finds better outcomes in patients treated at advanced stroke centres

So it was still a complete failure(not 100% recovery!) except you defined 'better outcomes' as a success. You'd be fired immediately in my lab.

And since you are measuring 'better outcomes' rather than 100% recovery survivors will never get to 100% recovery.

 This just proves how fucking bad stroke leadership is; they aren't even trying for the only goal in stroke; 100% RECOVERY.

 

ISC 2022: New study finds better outcomes in patients treated at advanced stroke centres

When comparing outcomes for acute ischaemic stroke patients treated at various levels of stroke centres, patients who received care at comprehensive stroke centres (CSC) or thrombectomy-capable stroke centres (TSC) were more likely to receive rapid treatment with clot-busting medication and/or mechanical clot removal—and be discharged home or to rehabilitation centres— compared to those treated at primary stroke centres (PSC) in the USA.

This was the key finding of preliminary research from a national study presented at the International Stroke Conference (ISC 2022; 9–11 February, New Orleans, USA).

“Certification status of the centre where a stroke patient receives care matters, and it is important to know that the specific requirements to become a CSC or TSC are validated by these data. The quality of care is higher in these centres, as also confirmed by our findings,” said lead author of the study Radoslav Raychev (University of California, Los Angeles [UCLA], Los Angeles, USA).

PSCs are hospitals with the necessary resources to manage patients with acute ischaemic stroke—the most common type of stroke that is caused by a clot blocking an artery supplying blood to areas of the brain. CSCs are hospitals that meet specific standards for managing more severe ischaemic and haemorrhagic strokes that require advanced endovascular and surgical interventions including mechanical thrombectomy. TSCs meet all the rigorous standards for performing a thrombectomy and are essentially the same as CSCs in treating acute ischaemic strokes, according to an American Heart Association (AHA) press release. However, unlike CSCs, TSCs may not have the necessary resources to treat the less common and more complex haemorrhagic strokes.

“TSC is a relatively new designation, introduced in 2018 by the accreditation agencies in cooperation with the American Heart Association/American Stroke Association,” Raychev added. “This is the first study to include the new thrombectomy-capable designation when comparing outcomes in the treatment of ischaemic stroke at the different levels of stroke centres.”

Researchers compared outcomes and quality of care indicators for 84,903 patients (median age=70, 49.2% female) with ischaemic stroke treated between 2018 and 2020 at stroke centres participating in the Get With The Guidelines (GWTG) Stroke Registry. The study analysed 185 CSCs, 29 TSCs and 169 PSCs in the registry. As part of their treatment, each patient had received either intravenous clot-busting medication or thrombectomy to restore blood flow in a blocked artery.

Among their findings on quality of care measures, the study found more patients treated at a CSC or TSC had intravenous clot-busting treatment started within the target time period set by GWTG than those treated at a PSC, and that the thrombectomy procedure started within the target time period set by GWTG compared to patients treated at a PSC—although the difference between TSC and PSC timing was not statistically significant.

“Our data indicate that nearly one quarter of all endovascular thrombectomies in the USA are being performed in primary stroke centres,” Raychev said. “This is unfortunate because PSCs are not required to have close oversight and implementation of thrombectomy-specific American Stroke Association standards. We hope that clinicians recognise the importance of the certification status and its impact on the quality of acute stroke care, and we hope they advocate for appropriate changes within their institutions.”

Patients also had better outcomes if they were treated at a CSC or TSC, the AHA release states, with the analysis finding:

• CSC and TSC patients were more likely to have their blood flow successfully restored after endovascular thrombectomy than PSC patients.
• Fewer patients treated at CSC and TSC died or were discharged to hospice than PSC patients.
• More CSC and TSC patients were discharged to their homes or to rehabilitation facilities than PSC patients (however, the difference between TSC and PSC rates was not statistically significant).
• Overall, there was no significant difference in outcomes between CSC and TSC patients.

The data identified differences in the baseline characteristics of the stroke patients at each centre status. The patients treated at TSCs and CSCs tended to have more severe strokes. They were also more likely to have been transferred from another hospital because they required a higher level of care, and they arrived at the centres after a longer time since the onset of their stroke symptoms. The study’s results underscore the value of participating in the certification process to improve stroke care, the release adds.

“Our findings demonstrate that patients with acute ischaemic stroke receive a better quality of care and have a higher chance of improved outcome when treated at a Comprehensive or Thrombectomy-capable stroke centre,” Raychev said. “Patients should keep this in mind when researching the level of stroke care available in their area. The good news is that, in most parts of the country, the emergency medical systems of acute stroke care are designed to triage and expedite patients to appropriate centres based on the severity of their stroke symptoms. Patients and their loved ones should always remember to call 911 when there is a suspected stroke.”

“Everyone involved in the acute stroke chain of survival should be aware of the importance of certification status. One of the biggest challenges in achieving TSC-level status is that a PSC must perform 15 or more endovascular thrombectomies per year. In our study, the median volume at PSCs was 32—therefore, most PSCs far exceed the minimum thrombectomy volume requirements. Advancing certification for PSCs that meet the volume requirement is very feasible, yet it does require coordinated efforts and additional resources. Our data should serve as strong evidence for initiating such important changes and ultimately elevate the standard of acute ischaemic stroke care nationwide,” Raychev said.

The analysis is limited, the researchers state, by the relatively small number of TSCs included in the registry. Another limitation was that the sample only included centres certified by two accreditation agencies, The Joint Commission and DNV (Det Norske Veritas) Healthcare. Centres that have received state-specific designations or were certified by other national accreditation agencies were not part of the study.

 

Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

So it was still a complete failure(not 100% recovery!) except you defined 'better outcomes' as a success. You'd be fired immediately in my lab.

Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Jacob R. Morey

,

Xiangnan Zhang

,

Naoum Fares Marayati

,

Stavros Matsoukas

,

Emily Fiano

,

Thomas Oxley

,

Neha Dangayach

,

Laura K. Stein

,

Michael G. Fara

,

Maryna Skliut

, … See all authors

Originally published5 Aug 2021https://doi.org/10.1161/STROKEAHA.121.034222Stroke. ;0:STROKEAHA.121.034222

Abstract

Background and Purpose:

Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model.

Methods:

The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale.

Results:

Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model (P<0.01). In the late window, outcomes were similar (35% versus 41%; P=0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window (P<0.01) and 5.0 and 11.0 in the late window (P=0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model (P<0.01) and similar in the late window (P=0.41).

Conclusions:

The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point.

REGISTRATION:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03048292.

 

Correlations Between Physician and Hospital Stroke Thrombectomy Volumes and Outcomes: A Nationwide Analysis

My conclusion on this is that because you don't have ANY OBJECTIVE DAMAGE DIAGNOSIS LEADING TO EXACT STROKE PROTOCOLS, you will never get the recovery results you want. And since you are measuring 'better outcomes' rather than 100% recovery you will never get to 100% recovery.

Correlations Between Physician and Hospital Stroke Thrombectomy Volumes and Outcomes: A Nationwide Analysis

Laura K. Stein

,

J Mocco

,

Johanna Fifi

,

Nathalie Jette

,

Stanley Tuhrim

,

Mandip S. Dhamoon

Originally published7 Jun 2021https://doi.org/10.1161/STROKEAHA.120.033312Stroke. ;0:STROKEAHA.120.033312

Abstract

Background and Purpose:

Despite the Joint Commission’s certification requirement of ≥15 stroke thrombectomy (ST) cases per center and proceduralist annually, the relationship between ST case volumes and outcomes is uncertain. We sought to determine whether a proceduralist or hospital volume threshold exists that is associated with better outcomes among Medicare beneficiaries.

Methods:

Retrospective cohort study using validated International Classification of Diseases,Tenth Revision, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ST. We used de-identified, national 100% inpatient Medicare data sets from January 1, 2016, to December 31, 2017 for US individuals aged ≥65 years. We calculated total procedures by proceduralist and hospital. We performed adjusted logistic regression of total cases as a predictor of inpatient mortality, good outcome (defined by dichotomized discharge disposition of inpatient rehabilitation or better), and 30-day readmission. We adjusted for sex, age, Charlson Comorbidity Index, availability of neurocritical care, teaching hospital status, socioeconomic status, 2-year stroke volume, and urban versus rural hospital location. We dichotomized case numbers incrementally to determine a volume threshold for better outcomes.

Results:

Thirteen thousand three hundred thirty-five patients were treated with ST by 2754 proceduralists at 641 hospitals. For every 10 more proceduralist cases, patients had 4% lower adjusted odds of inpatient mortality (adjusted odds ratio, 0.96 [95% CI, 0.95–0.98], P<0.0001) and 3% greater adjusted odds of good outcome (adjusted odds ratio, 1.03 [95% CI, 1.02–1.04], P<0.0001). For every 10 more hospital cases, patients had 2% lower odds of inpatient mortality (adjusted odds ratio, 0.98 [95% CI, 0.98–0.99], P=0.0003) and 2% greater odds of good outcome (adjusted odds ratio, 1.02 [95% CI, 1.01–1.02], P<0.0001). With increasing volumes, there were higher odds of better outcomes.

Conclusions:

Nationally, higher proceduralist and hospital ST case volumes were associated with reduced inpatient mortality and better outcome. These data support volume requirements in guidelines for ST training and certification.

• Download figure
• Download PowerPoint

 

ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study

 What you consider a 'better outcome' is still failure by any survivors reckoning. 100% recovery is the only goal in stroke. WHEN THE HELL ARE YOU GOING TO ACTUALLY GET AROUND TO SOLVING STROKE? This chipping at the edges is barely helping.

ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study

Show all authors

Stefania Nannoni*, Johannes Kaesmacher*, Federico Ricciardi, ...

First Published April 22, 2021 Research Article Find in PubMed 

https://doi.org/10.1177/17474930211009806

Article information

Abstract

Introduction

The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of endovascular treatment patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late endovascular treatment.

Methods

We retrospectively analyzed all consecutive acute ischemic stroke patients admitted 6–24 h after last proof of good health in two stroke centers, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS ≥ 10 and ASPECTS ≥ 7, or NIHSS ≥ 20 and ASPECTS ≥ 5. We assessed the interaction between the presence of the clinical-ASPECTS mismatch and late endovascular treatment using ordinal shift analysis of the three-month modified Rankin Scale and adjusting for multiple confounders.

Results

The included 337 patients had a median age of 73 years (IQR = 61–82), admission NIHSS of 18 (15–22), and baseline ASPECTS of 7 (5–9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late endovascular treatment. Among 141 (41.8%) mismatch negative patients, late endovascular treatment was performed in 72 (51.1%) patients. In the adjusted analysis, late endovascular treatment was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted odd ratio, aOR = 2.83; 95% confidence interval, CI: 1.48–5.58) but not in its absence (aOR = 1.32; 95%CI: 0.61–2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late endovascular treatment was 0.073.

Conclusions

In our retrospective two-site analysis, late endovascular treatment seemed effective(Since you didn't get to 100% recovery, in no sense of the word can it be considered effective.) in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late endovascular treatment decisions, obviating the need for advanced imaging.

Keywords Acute ischemic stroke, late time window, endovascular treatment, ASPECTS

Introduction

Recent randomized clinical trials have provided class I evidence for the efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients from proximal anterior circulation large vessel occlusion (LVO) in the late-time window, if properly selected based on their neuroimaging profile.^1–3 However, we previously demonstrated that the proportion of late-admitted AIS eligible for EVT according to strict trial criteria was low in the real-life scenario.⁴

Enlarging the selection criteria for late EVT could allow a larger population of AIS patients to benefit from the revascularization procedures. Notably, the use of a simpler neuroimaging protocol could help with the decision to proceed with mechanical thrombectomy in case of absent, failed or contraindicated advanced imaging, or in situations of discordant imaging profile.⁵

The Alberta Stroke Program Early CT Score (ASPECTS) is an easily applicable tool to estimate the amount of irreversibly damaged brain tissue in the middle cerebral artery (MCA) territory strokes.⁶ Originally designed for non-contrast CT scan (NCCT), it has been also applied to diffusion-weighted imaging (DWI) sequences, after one-point adjustment.⁷ However, the role of ASPECTS in selecting patients who are most likely to benefit from EVT is not clearly established in the late time window.^8,9 Also, to the best of our knowledge, its use in association of clinical stroke severity as a surrogate of the core-penumbra mismatch¹ has not been evaluated.

The main aim of our study was to analyze the clinical outcome of late-arriving AIS patients with proximal anterior circulation LVO depending on the presence of a clinical-ASPECTS mismatch and of treatment with mechanical thrombectomy in two comprehensive stroke centers.

More at link.

 

Mobile Stroke Units Improve Outcomes, Data Show

 NOT GOOD ENOUGH! Why are you accepting failure to 100% recover as a success? That to me is complete failure and survivors would agree. No excuses allowed. Don't cry to me that brain research is hard. Recovery is way harder than that.

Hope you are OK with failure to recover when you are the 1 in 4 per WHO that has a stroke.

Mobile Stroke Units Improve Outcomes, Data Show

By Thomas R. Collins

March 19, 2021

•  

​Stroke patients treated by mobile stroke units received faster treatment and had better outcomes  (Whoopee! NOT 100% RECOVERY.)compared to patients who arrived in the standard way to emergency departments (EDs), according to results presented at the International Stroke Conference 2021.

James C. Grotta, MD, FAAN, director of stroke research at the Memorial Hermann-Texas Medical Center and the primary author of the study, said the findings demonstrate the benefits of mobile stroke units, adding to the evidence base that could lead to reimbursement to make their use more widespread.

“A mobile stroke unit is a primary stroke center, basically," Dr. Grotta told Neurology Today At the Meetings. “We get everything done that needs to be done at a primary stroke center."

Mobile units are ambulances equipped to treat patients on board with tissue plasminogen activator (tPA), with a vascular neurologist on board and the ability to do a CT scan and CT angiogram.

In the BEST-MSU study, mobile stroke units were deployed to 911 stroke calls for one week, and patients were treated on board or via telemedicine if they were deemed tPA-eligible. On alternating weeks, the units were not deployed, but staff met the EMS squad and determined whether the patient was tPA-eligible when they arrived on scene, so that the two arms included the same kinds of patients.

In the mobile stroke units, 33 percent of patients were treated during the first 60 minutes—the so-called “golden hour"—compared with just 3 percent of patients treated the standard way; in addition, 97.1 percent of those who were tPA-eligible received tPA in the mobile stroke unit group, compared to 79.1 percent of those in the standard treatment group. Most of that difference, Dr. Grotta said, was probably due to a greater inclination and willingness to use tPA by the mobile stroke unit vascular neurologist, compared to physicians in the ED.

Researchers used a utility-weighted modified Rankin score (uw-mRS), which takes into account patient perceptions about the levels of disability on the scale. For instance, an improvement from four to three—going from being unable to walk to being able to walk—is considered more significant than one to zero—non-significant symptoms versus no symptoms at all. At three months, there was a 0.07 difference in uw-mRS in favor of the mobile stroke unit group (p=0.002).

Based on these results, for every 100 patients treated with a mobile unit rather than standard management, 27 would have less final disability and 11 more will be disability-free, he said.

In the study, the units were used in fairly metropolitan areas, such as Los Angeles and Memphis, Dr. Grotta said, adding the value in rural areas remains to be seen.

Researchers will continue to assess health care utilization related to mobile stroke units for a year. But he said that if a mobile unit is active about half the time it treats 100 patients a year, resulting in 10 more patients completely recovering, that would likely more than cover the cost of the operating units.

“Even with a back-of-the-envelope calculation, I would predict that it's cost-effective to the health care system," he continued.

Commenting on the study, Robert J. Adams, MD, professor of neurology at the Medical University of South Carolina, said the data from this and other studies signal support for more frequent use of mobile stroke units.

“The data are consistent that earlier treatment leads to better outcomes, unless there are more hemorrhages," Dr. Adams told Neurology Today At the Meetings. “This study shows earlier treatment and a qualitative benefit, which is the ability for us to get experience in the 'golden hour.' We have very little data in that time domain. In my mind, these data—and I have been doing this since before there were stroke systems of care, prior to tPA and prior to the stroke certification effort—clearly provide a 'go' signal. These units should be part of the stroke treatment ecosystem."

Using the mobile stroke unit as a primary stroke center “surrogate" in an area with a high stroke rate but no hospital might be a way to increase its value, he said.

“The unit could be placed there more of the time and defer the community cost of building a facility primarily to treat stroke, for example," Dr. Adams said. “Another way to look at this would be for there to be a hefty surcharge to insurance carriers when the unit is used, to increase its ability to generate funds to defer its cost."

Dr. Grotta disclosed receiving a grant for research from Frazer Ltd and Genentech. Dr. Adams disclosed receiving consulting fees from Global Blood Products, a company that makes treatment for sickle cell disease. He has also received travel expenses from Zeriscope, Inc., a company that make mobile telemedicine platforms.

Link Up for More Information:​

ISC Abstract LB2: Grotta JC, Parker S, Bowry R, et al. Benefits of stroke treatment delivered by a mobile stroke unit compared to standard management by emergency medical services (BEST-MSU Study).

Stroke Imaging Selection Modality and Endovascular Therapy Outcomes in the Early and Extended Time Windows

NOT GOOD ENOUGH! 'Better outcomes' is the tyranny of low expectations in full display. The goal is 100% recovery. WHEN THE HELL WILL YOU EVEN TRY TO GET THERE?

Stroke Imaging Selection Modality and Endovascular Therapy Outcomes in the Early and Extended Time Windows

Raul G. Nogueira

,

Diogo C. Haussen

,

David Liebeskind

,

Tudor G. Jovin

,

Rishi Gupta

,

Ashutov Jadhav

,

Ron F. Budzik

,

Blaise Baxter

,

Antonin Krajina

,

Alain Bonafe

,

Ali Malek

, … See all authors

Originally published12 Jan 2021https://doi.org/10.1161/STROKEAHA.120.031685Stroke. 2021;52:491–497

Abstract

Background and Purpose:

Advanced imaging has been increasingly used for patient selection in endovascular stroke therapy. The impact of imaging selection modality on endovascular stroke therapy clinical outcomes in extended time window remains to be defined. We aimed to study this relationship and compare it to that noted in early-treated patients.

Methods:

Patients from a prospective multicentric registry (n=2008) with occlusions involving the intracranial internal carotid or the M1- or M2-segments of the middle cerebral arteries, premorbid modified Rankin Scale score 0 to 2 and time to treatment 0 to 24 hours were categorized according to treatment times within the early (0–6 hour) or extended (6–24 hour) window as well as imaging modality with noncontrast computed tomography (NCCT)±CT angiography (CTA) or NCCT±CTA and CT perfusion (CTP). The association between imaging modality and 90-day modified Rankin Scale, analyzed in ordinal (modified Rankin Scale shift) and dichotomized (functional independence, modified Rankin Scale score 0–2) manner, was evaluated and compared within and across the extended and early windows.

Results:

In the early window, 332 patients were selected with NCCT±CTA alone while 373 also underwent CTP. After adjusting for identifiable confounders, there were no significant differences in terms of 90-day functional disability (ordinal shift: adjusted odd ratio [aOR], 0.936 [95% CI, 0.709–1.238], P=0.644) or independence (aOR, 1.178 [95% CI, 0.833–1.666], P=0.355) across the CTP and NCCT±CTA groups. In the extended window, 67 patients were selected with NCCT±CTA alone while 180 also underwent CTP. No significant differences in 90-day functional disability (aOR, 0.983 [95% CI, 0.81–1.662], P=0.949) or independence (aOR, 0.640 [95% CI, 0.318–1.289], P=0.212) were seen across the CTP and NCCT±CTA groups. There was no interaction between the treatment time window (0–6 versus 6–24 hours) and CT selection modality (CTP versus NCCT±CTA) in terms of functional disability at 90 days (P=0.45).

Conclusions:

CTP acquisition was not associated with better outcomes in patients treated in the early or extended time windows. While confirmatory data is needed, our data suggests that extended window endovascular stroke therapy may remain beneficial even in the absence of advanced imaging.