Time remains a crucial factor in stroke progression. Rapid and complete revascularization has been well correlated with favorable clinical outcome in patients with acute ischemic stroke secondary to large vessel occlusion. To mitigate the deleterious effects due to treatment delay, an initiative has been implemented to shorten the time for patient processing, expediting LVO patients for immediate intervention. The Launchpad protocol was established to ensure admitting stroke patients are triaged quickly and accurately identified in order to reduce time from arrival to intervention, and overall to revascularization. Herein, we assess the efficacy of the Launchpad paradigm in triaging presenting stroke patients.
Methods
A retrospective review of the stroke database was conducted between September 2014 and January 2016, 3 months prior and 13 months post Launchpad implementation. Prior to Launchpad, patients presenting with stroke were triaged through the traditional Emergency Department (ED) pathway. Through Launchpad, incoming patients bypass the traditional ED pathway and are taken straight for a CT scan by a dedicated stroke team. A CT scan positive for LVO and penumbral tissues will permit patients to continue through the Launchpad pathway for further evaluation and subsequent intervention. Time differences during patient triage before and after Launchpad initiation are assessed to determine the efficiency of this paradigm.
Results
In total, 764 patients were identified in the retrospective analysis, 137 were admitted prior, and 627 were admitted post Launchpad implementation. In the pre-Launchpad cohort, the median time from admission to CT imaging was 20 minutes. Patients under the Launchpad paradigm showed a reduction in time from presentation to imaging of 5 minutes (p = 0.0004). An increase in efficiency by roughly 25% to CT was observed following Launchpad implementation.
Conclusion
The streamlined stroke activation Launchpad protocol demonstrated an increased speed in patient admission and significant reduction in time from presentation to CT scan. This significant improvement in processing time allowed for an increased number of patients to meet the therapeutic window for IV tPA eligibility. A prospective trial will strengthen the current finding and support the implementation of this paradigm amongst other stroke centers.
Disclosures
K. Sivakumar: None. S. Feuerwerker: None. D. Turkel-Parrella: None. A. Tiwari: None. J. Farkas: None. K. Arcot: None.
Abstract Background Patients with carotid artery disease undergoing carotid endarterectomy (CEA) have a high risk of experiencing Major Adverse Cardiovascular Events (MACE) after surgery. The occurrence of MACE in CEA-treated patients is not predicted by common cardiovascular (CV) risk factors. Purpose We aimed to identify the association between plasma and plaque inflammatory cytokines and the incidence of MACE in the follow-up after CEA. We hypothesized that MACE is related to a higher level of circulating inflammatory cytokines at the time of surgery. Methods We prospectively enrolled patients with carotid artery disease undergoing CEA. Plasma and carotid plaques were collected during the surgery. Inflammatory cytokines (MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL-1beta/IL-1F2, IL-6, PDGF-AA, PDGF-AB/BB, TNF-alpha, VEGF) were measured in plasma and tissue homogenates using a customized 10-plex Luminex assay. Baseline demographics and clinical data for all the patients were extracted from electronic health records. MACE after CEA was defined as a composite measure of nonfatal cardiac events such as myocardial infarction with or without revascularization, cerebrovascular events (ischemic stroke, TIA, and amaurosis fugax), and all-cause mortality. Results Of 107 patients who underwent CEA with a median age of 73 (67-78) years, 57 (53.2%) experienced MACE during a median follow-up of 5.2 [2.2-9.3] years: 23 (40.3%) cardiac events, 9 (15.7%) CVA, and 25 (43.8%) all-cause mortality. Plaque cytokines levels did not differ between the groups with and without MACE in the follow-up after CEA. Instead, plasma cytokines were associated with MACE in the follow-up after CEA, as summarized in Figure 1. In the logistic regression analysis, plasma levels of MCP-1/CCL2, IFN-gamma, and TNF-alpha were independent predictors of MACE in follow-up post-CEA in univariate and multivariable models adjusted for CV risk factors such as age, BMI, systolic and diastolic blood pressure, low-density lipoprotein, high-density lipoprotein, and glucose level: MCP1/CCL2 (HR 1.009 [1.002-1.015]; p=0.007), IFN-gamma (HR 1.368 [1.014-1.845]; p=0.040), and TNF-alpha (HR 1.121 [1.022-1.228]; p=0.015) (Table 1). Conclusions Plasma levels of CCL2, IFN-gamma, and TNF-alpha are associated with the high incidence of MACE in the follow-up after CEA, indicating that these are potential biomarkers of MACE in this patient population and potential therapeutic targets in patients' progression of systemic atherosclerosis.Plasma cytokines and MACE after CEACytokines logistic regression analysis
The COVID-19 pandemic has accelerated neurological, mental health disorders, and neurocognitive issues. However, there is a lack of inexpensive and efficient brain evaluation and screening systems. As a result, a considerable fraction of patients with neurocognitive or psychobehavioral predicaments either do not get timely diagnosed or fail to receive personalized treatment plans. This is especially true in the elderly populations, wherein only 16% of seniors say they receive regular cognitive evaluations. Therefore, there is a great need for development of an optimized clinical brain screening workflow methodology like what is already in existence for prostate and breast exams. Such a methodology should be designed to facilitate objective early detection and cost-effective treatment of such disorders. In this paper we have reviewed the existing clinical protocols, recent technological advances and suggested reliable clinical workflows for brain screening. Such protocols range from questionnaires and smartphone apps to multi-modality brain mapping and advanced imaging where applicable. To that end, the Society for Brain Mapping and Therapeutics (SBMT) proposes the Brain, Spine and Mental Health Screening (NEUROSCREEN) as a multi-faceted approach. Beside other assessment tools, NEUROSCREEN employs smartphone guided cognitive assessments and quantitative electroencephalography (qEEG) as well as potential genetic testing for cognitive decline risk as inexpensive and effective screening tools to facilitate objective diagnosis, monitor disease progression, and guide personalized treatment interventions. Operationalizing NEUROSCREEN is expected to result in reduced healthcare costs and improving quality of life at national and later, global scales.
To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome.Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications.A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome.There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.
Introduction: Direct comparisons of stroke risk factors and rates of acute stroke treatment between Asians, Blacks and Whites are limited due to a lack of racial diversity in typical hospital catchment areas. Methods: Consecutive patients with ischemic or hemorrhagic stroke (intracerebral [ICH] or subarachnoid hemorrhage [SAH]) admitted to a single, comprehensive stroke center located in a racially diverse, underserved metropolitan area were prospectively enrolled in a registry between 9/2014-2/2017. Stroke risk factors, admission NIHSS, insurance status and acute stroke treatments (including IV tPA and/or mechanical thrombectomy) were compared between Asian, White and Black patients. Results: Of 1045 stroke patients, 170 (16%) were Asian, 226 (22%) were Black and 649 (62%) were White. Asians had significantly higher rates of ICH than Blacks or Whites (17% versus 6% and 8%, respectively, P<0.001), while Blacks had higher rates of SAH than other race groups (12% versus 3% among Asians and Whites, P=0.002). Compared to Whites and Asians, Blacks were younger, more often female and had higher BMI (body mass index) than other race groups, though they had lower rates of hyperlipidemia (all P<0.05). Asians and Blacks were more than twice as likely to be uninsured or on Medicaid than whites (28%, 27% and 11%, respectively; P<0.001). Rates of IV tPA use among patients with ischemic stroke were significantly lower in Blacks (3%) than Asians (10%) or Whites (10%) after adjusting for NIHSS, anticoagulation and insurance status (P=0.002). While mechanical thrombectomy occurred more often in Asians (23%) and Blacks (23%) than whites (15%), this difference was non-significant after adjusting for NIHSS. Good discharge disposition (home, acute or home rehabilitation) was similar across racial groups after adjusting for age and NIHSS. Conclusions: In a single site study with minimal geographic/environmental heterogeneity, Asians and Blacks had higher rates of hemorrhagic strokes than Whites and higher rates of being underinsured. Rates of IV tPA utilization were lowest among Blacks, though rates of mechanical thrombectomy were similar across races. Lower rates of IV tpa use appear related to factors other than insurance status or treatment bias.
Abstract Background One of the main features of vulnerability in atherosclerotic carotid plaques is intraplaque hemorrhage (IPH), which is related to a higher incidence of cerebrovascular events in patients with carotid artery disease. Additionally, inflammation plays a pivotal role in the progression of atherosclerotic disease. Purpose We aimed to determine plasma and tissue levels of inflammatory cytokines in patients with carotid artery disease hypothesizing that plaques with IPH are characterized by the presence of a more inflamed environment. Methods We retrospectively enrolled 104 consecutive patients undergoing carotid endarterectomy (CEA) with symptomatic (ischemic stroke, TIA, amaurosis fugax) or asymptomatic ipsilateral carotid artery disease. Plasma and carotid plaque specimens were collected at CEA. The tissue samples were stained with H&E to identify IPH and classified as specimens with and without IPH. Frozen homogenates of both plasma and tissue were analyzed using a customized 10-plex Luminex assay to determine the levels of inflammatory cytokines such as MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL-1beta/IL-1F2, IL-6, PDGF-AA, PDGF-AB/BB, TNF-alpha, and VEGF. Results IPH was identified in 53 patients (51.0 %). Cytokine levels in plasma and tissue from patients with and without IPH are reported in Table 1. In the univariate logistic regression MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL6, PDGF-AA, and PDGF-AB/BB were associated with IPH (Table 2). In the multivariate logistic regression, IL-6 was an independent predictor of IPH (HR 1.026 [95% CI 1.005-1.047]; p=0.014) after adjusting for cardiovascular risk factors such as age, BMI, sex, hypertension, diabetes mellitus, hyperlipidemia, ipsilateral carotid stenosis %. Conclusions Carotid plaques with IPH have an elevated inflammatory burden, potentially impacting adverse outcomes in this patient cohort. The local inflammatory cytokines in carotid plaques with IPH might serve as biomarkers and therapeutic targets in patients with carotid artery disease.
April 25, 2018April 10, 2018Free AccessAssessing the Affect of Clot Firmness on the Speed and Grade of Recanalization in Hyperacute Neuroendovascular Therapy (P4.210)Gregory Kurgansky, Phillip Ye, Ryan Bo, Jeffrey Farkas, Karthikeyan Arcot, David Turkel-Parrella, and Ambooj TiwariAuthors Info & AffiliationsApril 10, 2018 issue90 (15_supplement)https://doi.org/10.1212/WNL.90.15_supplement.P4.210 Letters to the Editor
April 27, 2018April 10, 2018Free AccessSubclavian Steal Syndrome secondary to Dialysis AVF treated with Balloon Mounted Stent (P6.214)Shashank Agarwal, Patrick Kwon, George Selas, Jeffrey Farkas, Karthikeyan Arcot, Lisa Schwartz, and Ambooj TiwariAuthors Info & AffiliationsApril 10, 2018 issue90 (15_supplement) Letters to the Editor
Introduction: Thrombectomy for acute ischemic stroke with large vessel occlusion is a highly effective therapy. However, meta-analyses of seminal trials show as many as 54% of thrombectomy patients do not achieve functional independence at 90 days (Goyal et al, Lancet 2016) and 72% of patients do not get discharged to home (Jahan et al, NEJM 2019). Here we investigate technical factors associated with maximizing the likelihood of good discharge outcome. Specifically, we evaluated how thrombectomy technique (clot suction alone, stentretriever alone, or combination therapy with both) and reperfusion grade (partial TICI 2b or complete TICI 3) affected the likelihood of good outcome defined as discharge to home or acute rehab. Methods: Retrospective data from 15 hospitals were used including patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was discharge to home or inpatient rehabilitation (IRF) versus other discharge dispositions, including death. Multivariate logistic regression was used to determine if TICI 3 versus TICI 2b and/or procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) were associated with better outcome of discharge to home/IRF, adjusting for age, race, medical history, and NIHSS at admission. Main effects and interaction between technique and TICI were included in the model. Results: The analysis included 787 patients, 55.3% (n=435) were discharged home/IRF and 44.7% (n=352) were discharged elsewhere or expired. Patients with TICI 3 grade were more likely to be discharged to home/IRF compared to those with TICI 2b (Adjusted Odds Ratio (AOR)=1.35, p=.018). Those who received distal aspiration only (AOR=1.87. p<.001) and combination approach (AOR=1.64, p=.047) were also more likely to have favorable discharge status compared to stent retriever only. The interaction effect of TICI score and procedure technique was not significant (p=.873). Conclusion: Our analysis suggested that both TICI grade 3 and distal aspiration or combination approach techniques independently predicted more favorable disposition outcome.
