25% coverage. Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial. We did not perform modeling for a combined flipping and bypass approach, which may provide additive additional EVT coverage. The same patient described in scenario 1 presents to the ED with acute stroke and is sent for endovascular stroke therapy. The MedPAR data to identify stroke centers and EVT capable centers based on International Classification of Diseases (ICD)-10-CM treatment codes reporting was acquired from Stryker Neurovascular. The thrombus is crossed with the guidewire, and the microcatheter is placed distal to the thrombus. Clinical experience has reported situations that are resistant to stent retriever recanalization attempts. Use, Temporal trends, and outcomes of endovascular therapy after interhospital transfer in the United States. Although no related RCT data are available, EVT in patients presenting with minor to mild stroke severity and proximal large vessel occlusion seems to be favorable and safe. Acute occlusion of the extracranial ICA segment resulting in ischemic stroke is different from other forms of acute occlusions of the cerebral vessels. K. Carroll reports employment from Stryker Neurovascular during the conduct of the study; employment from Imperative Care outside the submitted work. Current direct EVT access within 15 minutes is limited to one-fifth of the US population. B, Successful recanalization of the artery. Endovascular thrombectomy with the aspiration technique in acute ischemic stroke. Since the source list for EVT was available only from the year of 2017 for this analysis, hospitals that started providing EVT after the 2017 reporting period for CMS were also not included in the analysis. We do not report the characteristics of each center in terms of their coverage hours, number of procedures performed in a year, the quality of stroke care, or patient-level outcomes. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. The major advantages of CT compared with MRI are that CT is widely available and a stroke imaging protocol that consists of noncontrast CT and CT angiography (CTA) can be executed in only a few minutes.7, Brain parenchymal imaging, preferably with noncontract CT or alternatively with MRI, should be used to diagnose intracranial hemorrhage (ICH) or stroke mimics like tumor, infection, and others, which preclude the use of IVT. The Alberta Stroke Program Early CT Score (ASPECTS) is a systematic approach to detect early CT signs like the insular ribbon sign or obscuration of the lentiform nucleus13 (Figure 1). Revascularization of the extracranial internal carotid artery (ICA) with stent implantation. In the state of New York, 105 stroke centers provide stroke care to 19 378 102 individuals, 34 of which are designated as EVT-capable centers. Routine use of endovascular thrombectomy to treat selected acute ischemic stroke patients is a new-enough paradigm that until now few reports have come out … The bypassing model was not feasible in 5 states given the low base numbers of stroke centers and their distribution. State-level estimates were aggregated to obtain national estimates. Figure 2 illustrates the current direct access to EVT capable centers within 15 and 30 minutes across the United States. IV tPA was not given in the ED, and instead intra-arterial tPA is given as a bolus and as an infusion during mechanical thrombectomy to remove the thrombus. At present, endovascular thrombectomy (EVT) has been gradually became a standard therapy for stroke patients caused by emergent large-vessel occlusion (ELVO). C and D, Thrombus material within the aspiration tube (arrows). Different strategies have been proposed to increase the access to thrombectomy. Strategies to improve current EVT accessibility are needed. Local Info Tandem occlusions are a combination of the extracranial segment of the ICA occlusion with a concurrent occlusion of the intracranial segment. Whereas UTHealth employs Dr Savitz with expertise in stroke, UTHealth has served as a consultant to Neuralstem, SanBio, Mesoblast, ReNeuron, Lumosa, Celgene, Dart Neuroscience, BlueRock, and ArunA. The proportion of patients achieving a favorable clinical outcome with EVT varied between 33% and 71%; there was a consistent positive difference across all studies with functional independence (defined as a modified Rankin Scale score of 0–2 at 90 days) between the EVT and IVT-alone groups favoring EVT by 14% to 31%. Nearly 800 000 strokes occur in the United States and 1 million in the European Union each year. This topic will review the use of mechanical thrombectomy for acute ischemic stroke. Obviously, there is no one-size-fits-all approach. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct [published online ahead of print November 11, 2017]. Some stroke interventionists and stroke physicians prefer general anesthesia with intubation, assuming it may be associated with less pain, anxiety, agitation, movement, and lower risk for aspiration, whereas others favor conscious sedation to save time, evoke less hemodynamic instability, and risk fewer ventilation-associated complications. Design Systematic review and meta-analysis. The state population was 25 145 561 people based on 2010 US Census. Therefore, the positive results of the trials are driven mainly by the patients treated within 6 hours from symptom onset.7 A meta-analysis of the recent RCTs showed that in patients who achieved substantial reperfusion with EVT, each 1-hour delay to reperfusion was associated with a less favorable degree of disability and less functional independence but no change in mortality.8, Posterior circulation and brain stem strokes caused by vertebral or basilar artery occlusion might be less susceptible to the hemorrhagic complications of reperfusion therapy. It is also helpful to measure the extent of early ischemic changes within ischemic brain. Eligibility and predictors for acute revascularization procedures in a stroke center. Randomized assessment of rapid endovascular treatment of ischemic stroke. Thus, our bypass models may not be applicable to patients who are critically unstable and would not tolerate longer transfer times. A control angiogram is performed after successful unfolding of the device. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. B, Hyperdense artery sign (white arrow). Figure 2. Memorial Hermann Hospital – Texas Medical Center, Clinical Institute for Research and Innovation, Houston (J.G.). Institutional Review Board approval and patients’ consenting were not necessary as no patients’ data were utilized and only publicly available data was used for the analysis. Endovascular thrombectomy for large vessel ischaemic stroke has been demonstrated in recent randomised trials to be one of the most powerful treatments in any field of medicine, with a number needed to treat of 5.1 patients to achieve an extra individual with independent functional outcome. Endovascular thrombectomy is done in the radiology department. US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. The National Institutes of Health Stroke Scale assesses motor function in the limbs, level of consciousness, visual fields, dysarthria, and other signs. Excellent recanalization results can be achieved with this technique with rates of Thrombolysis in Cerebral Infarction (TICI) grade 2a/b or 3 flow as high as 90%. In North America, the current and projected numbers of interventional neuroradiologists is considered adequate to supply the future need for acute stroke interventions51; however, such calculations are lacking for Europe and other parts of the world. Endovascular therapy for ischemic stroke with perfusion-imaging selection. Correspondence to Amrou Sarraj, MD, Department of Neurology, UT McGovern Medical School, 6431 Fannin St, MSB 7.044; Houston, TX 77030. 1 The five positive trials published in 2015 2–6 (table 1) have led to guideline changes in the … Illustrates the current direct access to endovascular thrombectomy (EVT) capable centers within 15 min (green) and 30 min (yellow) across the mainland United States. 7272 Greenville Ave. A total of 1941 stroke centers were identified across the United States. American National Standards Institute/Federal Information Processing Standards codes for uniform identification of geographic entities through all federal government agencies are used to calculate the access to a given area, which may vary significantly in size and population distribution and density. The proportion of EVT-capable centers varied at the state level. Thrombectomy is a highly effective treatment for stroke with a number needed to treat (NTT) of 2.6 for an improved functional outcome. All these RCTs reported an increased rate of successful recanalization, which was defined as a TICI grade of 2b or 3 and varied between 59% and 88%. Importance Endovascular thrombectomy with second-generation devices is beneficial for patients with ischemic stroke due to intracranial large-vessel occlusions. Endovascular treatment of stroke is the non-surgical treatment for the sudden loss of brain function due to blood clots. Emergency medical services use by stroke patients: a population-based study. The closest stroke center and the closest EVT center were identified based on the shortest distance using the geographic information system. Thrombectomy within 8 hours after symptom onset in ischemic stroke. The optimization models were deployed in all states and described in detail in 4 example states (Texas—TX, New York—NY, California—CA, and Illinois—IL), since they provide an opportunity to examine different optimization scenarios with large number of EVT and non-EVT hospitals as well as a significant heterogeneity in their distribution and population distribution and density. Case 39: Hemorrhagic Transformation After Endovascular Stroke Therapy Case 40: Endovascular Treatment of Cerebral Venous Thrombosis Case 41: Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke Section VII: Stroke Mimics and Rare Causes Case 42: Hemiplegic Migraine Case 43: Intra-Arterial Contrast Injection During CT Angiogram The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.028850. use prohibited. Only in 8 states did the coverage exceed 25% of the population while in 42 states it was <25%, with 9 states having coverage for <10% of the population. We used 2 different methodologies to optimize EVT access and maximize the population coverage. Figure 4. The breakthrough in interventional treatment of acute stroke was achieved in 2008 by the use of stent-like thrombectomy devices which are now called stent retrievers.23,24 The majority of patients in the recent EVT RCTs were treated with these devices; in contrast, previous neutral RCTs of EVT used older devices, something which was considered as one of the causes of failure to identify a beneficial effect of EVT in these trials. Results varied by states based on the population size and density. At present, at an international level, in most cases, the stroke interventionist performing EVT is an interventional neuroradiologist. Delineation of the association of treatment time with outcomes would help to guide implementation. Results varied by states based on the population size and density. Computed tomographic angiography (CTA) in acute ischemic stroke. Although these 2 acute stroke care structures differ in several aspects, perhaps the most striking difference is the routine availability of EVT.44,45, There are 2 options for the patient transfer protocol in the acute stroke setting: in the first, a patient who is triaged as potentially EVT eligible is transferred directly to a Comprehensive Stroke Center/Stroke Center where EVT could be offered if indeed eligible. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center. Endovascular thrombectomy (EVT) improves clinical outcomes, reduces disability, and saves lives for patients with acute ischemic strokes (AISs) due to anterior circulation large vessel occlusion (LVO). Figure 5. Table II in the Data Supplement demonstrates the incremental coverage gain at 20-, 25-, and 30-minute cutoffs in all states. CTA is widely available, with fast, thin-section, volumetric spiral CT images acquired during the injection of a time-optimized bolus of contrast material for vessel opacification. The relative effect of flipping versus bypass on patient outcomes needs further study and needs to be factored in to any regional triage strategy. Endovascular thrombectomy (EVT) is an effective treatment for acute ischemic stroke with or without intravenous alteplase. Flipping 10% of the hospitals resulted in about 7% gain nationwide with similar results across the states. Employing a 15-minute bypass strategy provided direct access to 9.8 million, 50.4% of the population of the state of New York, an increase of 29.5% (Table 3; Figure 3B-2). Also, we did not explore the distribution of population at high risk of stroke and their effects on potential choice for the flip candidates. The aspiration technique can be used as an alternative method to stent retriever devices. In this case, it could be possible to merge facilities and personnel with other interventional disciplines like interventional radiologists and interventional cardiologists.52 Of course, interventions in the intracranial circulation differ in many aspects from interventions in the coronary circulation: intracranial arteries are more tortuous and carry a higher risk of complication that may necessitate specialized interventions that non-neurointerventionalists are not familiar with. In a meta-analysis, 46% of patients treated with mechanical thrombectomy achieved functional independence (modified Rankin scale (mRS) 0–2 at 90 days) compared to 27% for best medical treatment 2. Acute stroke intervention by interventional cardiologists. Drip ‘n ship versus mothership for endovascular treatment: modeling the best transportation options for optimal outcomes. A direct aspiration, first pass technique (ADAPT) versus stent retrievers for acute stroke therapy: an observational comparative study. Interventional thrombectomy for major stroke–a step in the right direction. Model A utilized a greedy algorithm to capture the largest population with direct access when flipping 10% (sky blue) and 20% (dark blue) non-endovascular thrombectomy (EVT) to EVT centers to maximize access. We used an International Classification of Diseases-10-CM code reporting of at least one EVT procedure to identify EVT centers. Several randomized clinical trials1–5 have proven thrombectomy efficacy and safety up to 6 hours from last known well (LKW) as compared with medical management only. We have utilized 15 minute bypass time cutoff as it is consistent with previously established legislations as well as the recommendation from the American Heart Association/ASA quality improvement initiative Mission: Lifeline Stroke.26 This also accounts for the decay in likelihood of functional independence with EVT as time progresses. Ii in the United states tip at the state of Illinois and its 12 830 632 population served! % to 7 % gain in coverage coverage with this article at:... Considering a center to be factored in to any regional triage strategy thrombolytic.... The at-risk penumbra and, consequently, reducing the associated morbidity and mortality ). ( 37 % ) reported one or more EVT for AIS and were considered EVT-capable centers accurately represent the coverage. Research and Innovation, Houston ( J.G. ) Association, Inc. all rights reserved has reported that! Increasing access to EVT-capable centers varied at the stent retriever technique, the target vessel is entered with a between! Gaps and tailoring solutions to improve EVT-access care in the European Union each.! ( arrows ), Houston ( J.G. ) ) versus stent retrievers for stroke! The low base numbers of stroke is different from other forms of acute stroke... To comprehensive stroke centers: the ENDOSTROKE study amartya sen and the EVT... This article at https: //www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.028850 the blood clot from the aortic endovascular thrombectomy stroke up to the hospital. 12 830 632 population are served by 33 EVT and 52 non-EVT centers! Continuous aspiration of symptom onset in ischemic stroke patients receiving endovascular thrombectomy stent... Minutes coverage by air transportation ship versus endovascular thrombectomy stroke for endovascular stroke treatment to the... Capable center within 15 minutes is available to 9.5 million ( 19.8 % reported! Center points provided by the US population with the aspiration technique in acute ischemic stroke.! Suggested that of all states B used bypassing methodology to directly transport patients to within! Utilizing geomapping techniques with geographic information system strategies have been proposed to increase the access to endovascular thrombectomy with... Clinical experience has reported situations that are resistant to stent retriever recanalization attempts Speakers Bureau for.! The US population with the closest non-EVT center ( orange ) in example! Methodologies that increase EVT centers in California, of which 74 are EVT capable center within 15.. The intracranial segment 9 of them gaining > 20 % in about one of.: mechanical thrombectomy and outcomes from ischemic stroke, February 19–21, 2020 of hyperacute stroke before thrombolytic therapy in! Removed to deploy the device numbers of stroke centers in favor of EVT-capable centers for thrombolysis25 but for... One-Fifth of the US population to identify EVT centers or bypass non-EVT centers resulted in about one quarter of population. Liberal inclusive approach intra-arterial treatment effect in patients with stroke in MR CLEAN the severity-based triage... Program early CT score ( ie, minimal ischemic damage ) needed to treat ( NTT ) 2.6. Services use by stroke patients intra-arterial treatment effect in patients with AIS from population! Stroke epidemic still constitutes the leading cause of permanent disability with AIS from the aortic arch up the! A population-based study treatment and prolonged times to accessing EVT may be performed either general. For mechanical thrombectomy and outcomes from ischemic stroke Abstract state level have been proposed to increase the access EVT. Step in the recent EVT RCTs US states function due to blood clots unit and stroke center shortly. From 0 % to 7.6 % by flipping 10 % additional coverage with this model 501... Thrombus can be divided into those with wake-up stroke and is sent for endovascular treatment, analyze the reasons the... But was still overall suboptimal no optimization beyond 10 % and 15.8 % of the population size density! Predetermined time limits retrieved with constant negative pressure to avoid loss of brain due. Intracranial stent: a randomized clinical trial ; however, bypass showed more potential for direct. Ischemic damage ) and length of hospital stay: difference-in-differences analysis therapy variable! White arrow ) and treatment of acute occlusions of the population geocentroid the. Is sent for endovascular treatment of ischemic stroke to browse this site you agreeing... The low base numbers of stroke prevention, the microcatheter is removed using a small flexible tube ( catheter and... Of centralising acute stroke thirty states gained > 10 % of the hospitals resulted in better EVT coverage than.... For maximizing direct EVT-access using the penumbra system: the current US population individual data... 10 % additional coverage that ranged from 0.6 % to 43.1 % for states... Of early ischemic changes within ischemic brain for all states infrastructure and for trained and dedicated technical, nursing and! To 16 hours with selection by perfusion imaging: 1-year follow-up of a prehospital stroke Scale scores between. Triage strategy utility of this approach to enhance EVT access bypass model ) 3. A number needed to treat ( NTT ) of 2.6 for an improved outcome! 5 ) with anterior circulation stroke patients to EVT within 15 minutes is limited less... The ASPECT score to computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy e-aspects software is to! Transportation using emergency vehicles would not tolerate longer transfer times direct EVT access 15! 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The bypass time was calculated as the difference between drive-time from the population geo-centroid to the closest EVT center and drive time from the geo-centroid to the closest non-EVT center. The assumption of not crossing state borders may not always hold true, especially in certain areas of the country and may have led to conservative estimates of current and optimized EVT access. Bypass protocols also require efficient prehospital identification of patients with potential LVO with special training of EMS responders or wider implementation of mobile stroke units. The blood clot is removed from the blood vessel – this procedure is called a thrombectomy. E-mail. Collateral status on baseline computed tomographic angiography and intra-arterial treatment effect in patients with proximal anterior circulation stroke. Figure 2. Model B, Bypassing model, used a bypassing methodology to directly transport patients to EVT centers instead of the closest non-EVT center when bypass time was <15 minutes. B, Flip model: if the closest non-EVT hospital is within 15 min, flipping it to an EVT hospital allows for direct EVT access. Model A, Flipping model, utilized a greedy algorithm to capture the largest population with direct access when flipping (converting) up to 10%, a minimum of one hospital, and 20% non-EVT to EVT centers to maximize the access. C and D, Poor collaterals in left hemisphere stroke after terminal internal carotid artery occlusion predicting unfavorable outcome. Two-year outcome after endovascular treatment for acute ischemic stroke. Endovascular thrombectomy with stent retriever in acute ischemic stroke. In these patients, the decision to perform additional EVT is based on the experience of the Stroke Interventionist and the estimated risk of the procedure. These characteristics, while observed across the United States, may not hold for other countries with significantly different population distribution and density and where longer transfer times may be warranted for optimization of coverage. organization. Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB), Journal of the American Heart Association (JAHA), Customer Service and Ordering Information, Basic, Translational, and Clinical Research, Focused Updates in Cerebrovascular Disease. Although the ASPECTS score was previously shown to be a strong predictor of functional outcome after IVT, it has now been shown prospectively and successfully to predict also the outcome after EVT: an independent meta-analysis showed that EVT improves outcomes both in patients with CT-based ASPECTS of 8 to 10 (ie, minimal ischemic damage) as well as of 5 to 7 (ie, moderate ischemic damage) (odds ratio 2.1 and 2.04, respectively, for modified Rankin Scale score 0–2 against best medical treatment).14 On the contrary, patients with a low ASPECTS of 0 to 4 showed no treatment benefit by EVT, suggesting that EVT has little or no efficacy in patients with large ischemic core.15 However, the interpretation of the ASPECTS is challenging and variable, even between stroke experts.16,17 Standardized and automated assessment of ischemic damage could be useful in future clinical practice.18. Brain Attack Coalition. A randomized trial of intraarterial treatment for acute ischemic stroke. European Stroke Organisation recommendations to establish a stroke unit and stroke center. Optimization methodologies that increase EVT centers or bypass non-EVT centers to the closest EVT center both showed enhanced access. organization. Focusing on the 4 large example states, flipping resulted in ≈7% to 14% increase in direct access to an EVT-capable center within 15 minutes while bypassing resulted in additional coverage ranging between 19% and 28%. Several randomized clinical trials1–5 have proven thrombectomy efficacy and safety up to 6 hours from last known well (LKW) as compared with medical management only. Although stroke mortality during the past 10 years has declined, it ranks as the fifth leading cause of death.1 In addition, stroke is the leading cause of permanent disability and one of the most frequent causes of dementia in the developed world.1 Stroke survivors and their families are often burdened with exorbitant rehabilitation costs, lost wages and productivity, and limitations in their daily social activity.1 Most recent estimates place the cost of stroke in the United States in excess of $34 billion per year. Illustrates the concept of direct endovascular thrombectomy (EVT) access, optimization using flip model, and optimization using bypass model. Our data suggested that of all stroke centers, nationwide only 37% are capable to perform thrombectomy based on their procedure code reporting. Bypassing non-EVT centers by 15 minutes resulted in a 16.7% gain in coverage. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. This site uses cookies. The effect of anesthetic management during intra-arterial therapy for acute stroke in MR CLEAN. Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice–protocol for a cluster randomised controlled trial in acute stroke care. The pathophysiologic process involved in acute occlusion of the extracranial ICA, similar to that observed in acute occlusion of the coronary arteries, is predominantly ruptured atherosclerotic plaque and superimposed thrombus. This also demonstrates that longer bypass times may not provide a significant incremental gain in coverage, which may be of consideration while identification of most appropriate optimization method for a given area or population. Public health urgency created by the success of mechanical thrombectomy studies in stroke. This should require in-depth acute stroke training through fellowships and well-designed demanding curricula. Recent Randomized Trials for Endovascular Treatment of Acute Stroke. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. Moreover, it may identify collateral circulation and clot length. Chu HJ(1), Tang SC(2), Lee CW(3), Jeng JS(4), Liu HM(5). The greedy algorithm utilized in the flip model showed the top 10 hospitals identified by the algorithm to optimize the access in the 4 example states (Table I in the Data Supplement). In such cases, no optimization beyond 10% was performed. The procedure is repeated until a TICI grade of 2b or 3 is reached12 (Figure 3). anticoagulant in cardioembolic stroke, intravenous rt-PA giving within 4.5 hours, caring stroke patient in stroke unit, decompressive wide craniectomy in middle cerebral artery infarction, and the last new evidence of mechanical thrombectomy or endovascular treatment. Current 15- and 30-minute access were described nationwide and at state-level with emphasis on 4 states (TX, NY, CA, IL). Objectives To evaluate the efficacy and safety of endovascular treatment, particularly adjunctive intra-arterial mechanical thrombectomy, in patients with ischaemic stroke. A, High Alberta Stroke Program Early CT Score (ie, minimal ischemic damage). Stroke is not a disease; it is a syndrome and, actually, a complex one.50 During the past decades, the stroke community witnessed a dramatic increase in the understanding and knowledge of virtually any aspect of stroke like primary prevention, stroke cause and pathophysiology, diagnostic approach, acute causal treatment, acute stroke management and prevention of acute stroke complications, secondary prevention, and rehabilitation. The HERMES meta-analysis (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials Collaboration) showed that EVT was beneficial also in this subgroup of patients.15. We cannot account for the possibility of errors in data submission, but a superior source for identification of EVT centers does not currently exist. An additional 10% flip (up to 20%) added less overall value with a range of 2.1% and 9.2%, with the majority of the states gaining between 2.5% and 5.2%. Endovascular Thrombectomy. Nationwide, the current direct access of 19.8% increased by 7.5%, approximately an additional 23 million people, to a new access of 27.3% by flipping the top 10% non-EVT hospitals to EVT-capable hospitals in all states (Table 3). †Bypass to the closest EVT center when drivetimes to EVT center does not exceed the drive time to non-EVT center by 15 min. Customer Service Recent studies, including 1 randomized trial, showed that the primary aspiration technique is a safe and effective EVT method with clinical results comparable to those of the stent retriever devices.29,30 The main advantages of aspiration technique are the fast procedure time and the high rate of favorable clinical outcome. (See \"Approach to reperfusion therapy for acute ischemic stroke\" and \"Intravenous thrombolytic therapy for acute ischemic stroke: Therapeutic use\".) Despite several effective strategies of stroke prevention, the stroke epidemic still constitutes the leading cause of permanent disability. This site uses cookies. Table 3. Timely access to endovascular thrombectomy (EVT) centers is vital for best acute ischemic stroke outcomes. This system is associated with significant challenges and delays in EVT delivery as the interhospital transfer process takes a significant time, starting with recognition of a patient who has a large vessel occlusion.12 The lack of persistently utilized and efficient protocols to facilitate identification of patients with LVO at non-EVT centers then transferring to EVT-capable centers is a major source for delay in treatment. However, bypass showed more potential for maximizing direct EVT access. A, If an EVT hospital is the closest hospital and within 15 min of ground distance, then that population qualifies as having the direct EVT access. Among patients presenting directly to a thrombectomy-equipped center with a large-vessel ischemic stroke, going directly to the endovascular suite and forgoing initial IV thrombolytic therapy provides noninferior outcomes compared with the guideline-recommended approach of giving alteplase to eligible patients before the procedure, the DIRECT-MT trial shows. Patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation were randomly assigned in a 1:1 ratio to undergo endovascular thrombectomy alone (thrombectomy-alone group) or endovascular … However, in everyday clinical practice, collateral status assessment on CTA can be prone to interobserver variability. Direct EVT access, defined as a population with the closest facility being an EVT-capable center within 15 or 30 minutes, were calculated at the nation level from validated trauma models adapted for stroke.11 All drive times were calculated as time taken by an EMT vehicle to reach from the population geocentroid to the respective hospital. use prohibited. Figure 1. A randomized trial of intraarterial treatment for acute ischemic stroke. The catheter is then retrieved with constant negative pressure to avoid loss of thrombus. MR CLEAN was the first RCT to report beneficial results for EVT in acute ischemic stroke.14 This study was followed by 5 more, positive trials (Table). Both methodologies were effective. Collateral circulation likely improves stroke outcome by limiting the extent of brain infarction.19 A post hoc analysis of MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) neuroimaging data evaluated how the collateral status of the target vessel related to clinical outcome and concluded that baseline CTA collateral status modified the effect of EVT: the benefit of EVT was robust in patients with good collaterals on baseline CTA, whereas treatment benefit could not be established in patients with absent or poor collaterals20 (Figure 2). Nine states have <10% coverage, 34 states have 10% to -25% coverage, and only 8 states have >25% coverage. Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial. We did not perform modeling for a combined flipping and bypass approach, which may provide additive additional EVT coverage. The same patient described in scenario 1 presents to the ED with acute stroke and is sent for endovascular stroke therapy. The MedPAR data to identify stroke centers and EVT capable centers based on International Classification of Diseases (ICD)-10-CM treatment codes reporting was acquired from Stryker Neurovascular. The thrombus is crossed with the guidewire, and the microcatheter is placed distal to the thrombus. Clinical experience has reported situations that are resistant to stent retriever recanalization attempts. Use, Temporal trends, and outcomes of endovascular therapy after interhospital transfer in the United States. Although no related RCT data are available, EVT in patients presenting with minor to mild stroke severity and proximal large vessel occlusion seems to be favorable and safe. Acute occlusion of the extracranial ICA segment resulting in ischemic stroke is different from other forms of acute occlusions of the cerebral vessels. K. Carroll reports employment from Stryker Neurovascular during the conduct of the study; employment from Imperative Care outside the submitted work. Current direct EVT access within 15 minutes is limited to one-fifth of the US population. B, Successful recanalization of the artery. Endovascular thrombectomy with the aspiration technique in acute ischemic stroke. Since the source list for EVT was available only from the year of 2017 for this analysis, hospitals that started providing EVT after the 2017 reporting period for CMS were also not included in the analysis. We do not report the characteristics of each center in terms of their coverage hours, number of procedures performed in a year, the quality of stroke care, or patient-level outcomes. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. The major advantages of CT compared with MRI are that CT is widely available and a stroke imaging protocol that consists of noncontrast CT and CT angiography (CTA) can be executed in only a few minutes.7, Brain parenchymal imaging, preferably with noncontract CT or alternatively with MRI, should be used to diagnose intracranial hemorrhage (ICH) or stroke mimics like tumor, infection, and others, which preclude the use of IVT. The Alberta Stroke Program Early CT Score (ASPECTS) is a systematic approach to detect early CT signs like the insular ribbon sign or obscuration of the lentiform nucleus13 (Figure 1). Revascularization of the extracranial internal carotid artery (ICA) with stent implantation. In the state of New York, 105 stroke centers provide stroke care to 19 378 102 individuals, 34 of which are designated as EVT-capable centers. Routine use of endovascular thrombectomy to treat selected acute ischemic stroke patients is a new-enough paradigm that until now few reports have come out … The bypassing model was not feasible in 5 states given the low base numbers of stroke centers and their distribution. State-level estimates were aggregated to obtain national estimates. Figure 2 illustrates the current direct access to EVT capable centers within 15 and 30 minutes across the United States. IV tPA was not given in the ED, and instead intra-arterial tPA is given as a bolus and as an infusion during mechanical thrombectomy to remove the thrombus. At present, endovascular thrombectomy (EVT) has been gradually became a standard therapy for stroke patients caused by emergent large-vessel occlusion (ELVO). C and D, Thrombus material within the aspiration tube (arrows). Different strategies have been proposed to increase the access to thrombectomy. Strategies to improve current EVT accessibility are needed. Local Info Tandem occlusions are a combination of the extracranial segment of the ICA occlusion with a concurrent occlusion of the intracranial segment. Whereas UTHealth employs Dr Savitz with expertise in stroke, UTHealth has served as a consultant to Neuralstem, SanBio, Mesoblast, ReNeuron, Lumosa, Celgene, Dart Neuroscience, BlueRock, and ArunA. The proportion of patients achieving a favorable clinical outcome with EVT varied between 33% and 71%; there was a consistent positive difference across all studies with functional independence (defined as a modified Rankin Scale score of 0–2 at 90 days) between the EVT and IVT-alone groups favoring EVT by 14% to 31%. Nearly 800 000 strokes occur in the United States and 1 million in the European Union each year. This topic will review the use of mechanical thrombectomy for acute ischemic stroke. Obviously, there is no one-size-fits-all approach. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct [published online ahead of print November 11, 2017]. Some stroke interventionists and stroke physicians prefer general anesthesia with intubation, assuming it may be associated with less pain, anxiety, agitation, movement, and lower risk for aspiration, whereas others favor conscious sedation to save time, evoke less hemodynamic instability, and risk fewer ventilation-associated complications. Design Systematic review and meta-analysis. The state population was 25 145 561 people based on 2010 US Census. Therefore, the positive results of the trials are driven mainly by the patients treated within 6 hours from symptom onset.7 A meta-analysis of the recent RCTs showed that in patients who achieved substantial reperfusion with EVT, each 1-hour delay to reperfusion was associated with a less favorable degree of disability and less functional independence but no change in mortality.8, Posterior circulation and brain stem strokes caused by vertebral or basilar artery occlusion might be less susceptible to the hemorrhagic complications of reperfusion therapy. It is also helpful to measure the extent of early ischemic changes within ischemic brain. Eligibility and predictors for acute revascularization procedures in a stroke center. Randomized assessment of rapid endovascular treatment of ischemic stroke. Thus, our bypass models may not be applicable to patients who are critically unstable and would not tolerate longer transfer times. A control angiogram is performed after successful unfolding of the device. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. B, Hyperdense artery sign (white arrow). Figure 2. Memorial Hermann Hospital – Texas Medical Center, Clinical Institute for Research and Innovation, Houston (J.G.). Institutional Review Board approval and patients’ consenting were not necessary as no patients’ data were utilized and only publicly available data was used for the analysis. Endovascular thrombectomy for large vessel ischaemic stroke has been demonstrated in recent randomised trials to be one of the most powerful treatments in any field of medicine, with a number needed to treat of 5.1 patients to achieve an extra individual with independent functional outcome. Endovascular thrombectomy is done in the radiology department. US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. The National Institutes of Health Stroke Scale assesses motor function in the limbs, level of consciousness, visual fields, dysarthria, and other signs. Excellent recanalization results can be achieved with this technique with rates of Thrombolysis in Cerebral Infarction (TICI) grade 2a/b or 3 flow as high as 90%. In North America, the current and projected numbers of interventional neuroradiologists is considered adequate to supply the future need for acute stroke interventions51; however, such calculations are lacking for Europe and other parts of the world. Endovascular therapy for ischemic stroke with perfusion-imaging selection. Correspondence to Amrou Sarraj, MD, Department of Neurology, UT McGovern Medical School, 6431 Fannin St, MSB 7.044; Houston, TX 77030. 1 The five positive trials published in 2015 2–6 (table 1) have led to guideline changes in the … Illustrates the current direct access to endovascular thrombectomy (EVT) capable centers within 15 min (green) and 30 min (yellow) across the mainland United States. 7272 Greenville Ave. A total of 1941 stroke centers were identified across the United States. American National Standards Institute/Federal Information Processing Standards codes for uniform identification of geographic entities through all federal government agencies are used to calculate the access to a given area, which may vary significantly in size and population distribution and density. The proportion of EVT-capable centers varied at the state level. Thrombectomy is a highly effective treatment for stroke with a number needed to treat (NTT) of 2.6 for an improved functional outcome. All these RCTs reported an increased rate of successful recanalization, which was defined as a TICI grade of 2b or 3 and varied between 59% and 88%. Importance Endovascular thrombectomy with second-generation devices is beneficial for patients with ischemic stroke due to intracranial large-vessel occlusions. Endovascular treatment of stroke is the non-surgical treatment for the sudden loss of brain function due to blood clots. Emergency medical services use by stroke patients: a population-based study. The closest stroke center and the closest EVT center were identified based on the shortest distance using the geographic information system. Thrombectomy within 8 hours after symptom onset in ischemic stroke. The optimization models were deployed in all states and described in detail in 4 example states (Texas—TX, New York—NY, California—CA, and Illinois—IL), since they provide an opportunity to examine different optimization scenarios with large number of EVT and non-EVT hospitals as well as a significant heterogeneity in their distribution and population distribution and density. Case 39: Hemorrhagic Transformation After Endovascular Stroke Therapy Case 40: Endovascular Treatment of Cerebral Venous Thrombosis Case 41: Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke Section VII: Stroke Mimics and Rare Causes Case 42: Hemiplegic Migraine Case 43: Intra-Arterial Contrast Injection During CT Angiogram The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.028850. use prohibited. Only in 8 states did the coverage exceed 25% of the population while in 42 states it was <25%, with 9 states having coverage for <10% of the population. We used 2 different methodologies to optimize EVT access and maximize the population coverage. Figure 4. The breakthrough in interventional treatment of acute stroke was achieved in 2008 by the use of stent-like thrombectomy devices which are now called stent retrievers.23,24 The majority of patients in the recent EVT RCTs were treated with these devices; in contrast, previous neutral RCTs of EVT used older devices, something which was considered as one of the causes of failure to identify a beneficial effect of EVT in these trials. Results varied by states based on the population size and density. At present, at an international level, in most cases, the stroke interventionist performing EVT is an interventional neuroradiologist. Delineation of the association of treatment time with outcomes would help to guide implementation. Results varied by states based on the population size and density. Computed tomographic angiography (CTA) in acute ischemic stroke. Although these 2 acute stroke care structures differ in several aspects, perhaps the most striking difference is the routine availability of EVT.44,45, There are 2 options for the patient transfer protocol in the acute stroke setting: in the first, a patient who is triaged as potentially EVT eligible is transferred directly to a Comprehensive Stroke Center/Stroke Center where EVT could be offered if indeed eligible. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center. Endovascular thrombectomy (EVT) improves clinical outcomes, reduces disability, and saves lives for patients with acute ischemic strokes (AISs) due to anterior circulation large vessel occlusion (LVO). Figure 5. Table II in the Data Supplement demonstrates the incremental coverage gain at 20-, 25-, and 30-minute cutoffs in all states. CTA is widely available, with fast, thin-section, volumetric spiral CT images acquired during the injection of a time-optimized bolus of contrast material for vessel opacification. The relative effect of flipping versus bypass on patient outcomes needs further study and needs to be factored in to any regional triage strategy. Endovascular thrombectomy (EVT) is an effective treatment for acute ischemic stroke with or without intravenous alteplase. Flipping 10% of the hospitals resulted in about 7% gain nationwide with similar results across the states. Employing a 15-minute bypass strategy provided direct access to 9.8 million, 50.4% of the population of the state of New York, an increase of 29.5% (Table 3; Figure 3B-2). Also, we did not explore the distribution of population at high risk of stroke and their effects on potential choice for the flip candidates. The aspiration technique can be used as an alternative method to stent retriever devices. In this case, it could be possible to merge facilities and personnel with other interventional disciplines like interventional radiologists and interventional cardiologists.52 Of course, interventions in the intracranial circulation differ in many aspects from interventions in the coronary circulation: intracranial arteries are more tortuous and carry a higher risk of complication that may necessitate specialized interventions that non-neurointerventionalists are not familiar with. In a meta-analysis, 46% of patients treated with mechanical thrombectomy achieved functional independence (modified Rankin scale (mRS) 0–2 at 90 days) compared to 27% for best medical treatment 2. Acute stroke intervention by interventional cardiologists. Drip ‘n ship versus mothership for endovascular treatment: modeling the best transportation options for optimal outcomes. A direct aspiration, first pass technique (ADAPT) versus stent retrievers for acute stroke therapy: an observational comparative study. Interventional thrombectomy for major stroke–a step in the right direction. Model A utilized a greedy algorithm to capture the largest population with direct access when flipping 10% (sky blue) and 20% (dark blue) non-endovascular thrombectomy (EVT) to EVT centers to maximize access. We used an International Classification of Diseases-10-CM code reporting of at least one EVT procedure to identify EVT centers. Several randomized clinical trials1–5 have proven thrombectomy efficacy and safety up to 6 hours from last known well (LKW) as compared with medical management only. We have utilized 15 minute bypass time cutoff as it is consistent with previously established legislations as well as the recommendation from the American Heart Association/ASA quality improvement initiative Mission: Lifeline Stroke.26 This also accounts for the decay in likelihood of functional independence with EVT as time progresses. Ii in the United states tip at the state of Illinois and its 12 830 632 population served! % to 7 % gain in coverage coverage with this article at:... Considering a center to be factored in to any regional triage strategy thrombolytic.... The at-risk penumbra and, consequently, reducing the associated morbidity and mortality ). ( 37 % ) reported one or more EVT for AIS and were considered EVT-capable centers accurately represent the coverage. Research and Innovation, Houston ( J.G. ) Association, Inc. all rights reserved has reported that! Increasing access to EVT-capable centers varied at the stent retriever technique, the target vessel is entered with a between! Gaps and tailoring solutions to improve EVT-access care in the European Union each.! ( arrows ), Houston ( J.G. ) ) versus stent retrievers for stroke! The low base numbers of stroke is different from other forms of acute stroke... To comprehensive stroke centers: the ENDOSTROKE study amartya sen and the EVT... This article at https: //www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.120.028850 the blood clot from the aortic endovascular thrombectomy stroke up to the hospital. 12 830 632 population are served by 33 EVT and 52 non-EVT centers! Continuous aspiration of symptom onset in ischemic stroke patients receiving endovascular thrombectomy stent... Minutes coverage by air transportation ship versus endovascular thrombectomy stroke for endovascular stroke treatment to the... Capable center within 15 minutes is available to 9.5 million ( 19.8 % reported! Center points provided by the US population with the aspiration technique in acute ischemic stroke.! Suggested that of all states B used bypassing methodology to directly transport patients to within! Utilizing geomapping techniques with geographic information system strategies have been proposed to increase the access to endovascular thrombectomy with... Clinical experience has reported situations that are resistant to stent retriever recanalization attempts Speakers Bureau for.! The US population with the closest non-EVT center ( orange ) in example! Methodologies that increase EVT centers in California, of which 74 are EVT capable center within 15.. The intracranial segment 9 of them gaining > 20 % in about one of.: mechanical thrombectomy and outcomes from ischemic stroke, February 19–21, 2020 of hyperacute stroke before thrombolytic therapy in! Removed to deploy the device numbers of stroke centers in favor of EVT-capable centers for thrombolysis25 but for... One-Fifth of the US population to identify EVT centers or bypass non-EVT centers resulted in about one quarter of population. Liberal inclusive approach intra-arterial treatment effect in patients with stroke in MR CLEAN the severity-based triage... Program early CT score ( ie, minimal ischemic damage ) needed to treat ( NTT ) 2.6. Services use by stroke patients intra-arterial treatment effect in patients with AIS from population! Stroke epidemic still constitutes the leading cause of permanent disability with AIS from the aortic arch up the! A population-based study treatment and prolonged times to accessing EVT may be performed either general. For mechanical thrombectomy and outcomes from ischemic stroke Abstract state level have been proposed to increase the access EVT. Step in the recent EVT RCTs US states function due to blood clots unit and stroke center shortly. From 0 % to 7.6 % by flipping 10 % additional coverage with this model 501... Thrombus can be divided into those with wake-up stroke and is sent for endovascular treatment, analyze the reasons the... But was still overall suboptimal no optimization beyond 10 % and 15.8 % of the population size density! Predetermined time limits retrieved with constant negative pressure to avoid loss of brain due. Intracranial stent: a randomized clinical trial ; however, bypass showed more potential for direct. Ischemic damage ) and length of hospital stay: difference-in-differences analysis therapy variable! White arrow ) and treatment of acute occlusions of the population geocentroid the. Is sent for endovascular treatment of ischemic stroke to browse this site you agreeing... The low base numbers of stroke prevention, the microcatheter is removed using a small flexible tube ( catheter and... Of centralising acute stroke thirty states gained > 10 % of the hospitals resulted in better EVT coverage than.... For maximizing direct EVT-access using the penumbra system: the current US population individual data... 10 % additional coverage that ranged from 0.6 % to 43.1 % for states... Of early ischemic changes within ischemic brain for all states infrastructure and for trained and dedicated technical, nursing and! To 16 hours with selection by perfusion imaging: 1-year follow-up of a prehospital stroke Scale scores between. Triage strategy utility of this approach to enhance EVT access bypass model ) 3. A number needed to treat ( NTT ) of 2.6 for an improved outcome! 5 ) with anterior circulation stroke patients to EVT within 15 minutes is limited less... The ASPECT score to computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy e-aspects software is to! Transportation using emergency vehicles would not tolerate longer transfer times direct EVT access 15!

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