BackgroundThe first pass effect has been recently reported as a predictor of good clinical outcome after stroke thrombectomy. We evaluate the first pass effect on outcome and the influence of revascularization in these and other patients.MethodsWe performed a retrospective analysis of a prospectively maintained database on anterior cerebral circulation stroke thrombectomy cases from April 2012 to April 2018. Data compiled included patient demographics, presenting National Institutes of Health Stroke Scale score, vessel occlusion site, thrombectomy procedural details, and 90 day modified Rankin Scale scores.Results205 patients were included. The numbers of patients who underwent one, two, three, four, five, and six passes were 69, 70, 55, 9, 1, and 1, respectively. Successful revascularization was achieved in 87%, 83%, and 64% of patients in the one, two, and 3 or more passes groups, respectively (p=0.002). Good functional outcome was inversely correlated with number of passes when comparing the one, two, and three or more passes groups (54%, 43%, 29%; P=0.014). In patients with full revascularization, there was no significant difference in good functional outcomes between the one, two, and three or more passes groups (64%, 65%, 50%; P=0.432). Number of passes was not an independent negative predictor of good clinical outcome (OR 1.66, 95% CI 0.82 to 3.39; P=0.165).ConclusionsFirst pass thrombectomy patients have better functional outcomes compared with beyond-first pass patients. This effect is related at least in part to a higher rate of revascularization in one pass patients. Revascularization beyond the first pass should continue to be the goal of stroke thrombectomy.

Background and Purpose: During the coronavirus disease 2019 (COVID-19) pandemic, the various emergency measures implemented to contain the spread of the virus and to overcome the volume of affected patients presenting to hospitals may have had unintended consequences. Several studies reported a decrease in the number of stroke admissions. There are no data on the impact of the COVID-19 pandemic on stroke admissions and stroke care in Maryland. Methods: A retrospective analysis of quality improvement data reported by stroke centers in the State of Maryland. The number of admissions for stroke, overall and by stroke subtype, between March 1 and September 30, 2020 (pandemic) were compared with the same time period in 2019 (prepandemic). Median last known well to hospital arrival time, the number of intravenous thrombolysis and thrombectomy were also compared. Results: During the initial 7 months of the pandemic, there were 6529 total admissions for stroke and transient ischemic attack, monthly mean 938 (95% CI, 837.1–1038.9) versus prepandemic 8003, monthly mean 1156.3 (CI, 1121.3–1191.2), P <0.001. A significant decrease was observed in intravenous thrombolysis treatments, pandemic 617, monthly mean 88.1 (80.7–95.6) versus prepandemic 805, monthly mean 115 (CI, 104.3–125.6), P <0.001; there was no significant decrease for thrombectomies. The pandemic decreased the probability of admissions for stroke and transient ischemic attack by 19%, for acute ischemic stroke by 20%, for the number of intravenous thrombolysis performed by 23%. There was no difference in the number of admissions for subarachnoid hemorrhage, pandemic 199, monthly mean 28.4 (CI, 22.5–34.3) versus prepandemic 217, monthly mean 31 (CI, 23.9–38.1), respectively, P =0.507. Conclusions: Our findings suggest that the COVID-19 pandemic adversely affected the acute care of unrelated cerebrovascular emergencies.

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

Introduction: New EMS routing protocols are being proposed to divert acute stroke patients, based on the likelihood of having a large vessel occlusion (LVO), directly to Comprehensive Stroke Centers (CSC), in order to reduce the inherent delay of a secondary transfer from a Primary Stroke Center (PSC) to a CSC. Within Baltimore City, transfer from a PSC to a CSC for mechanical thrombectomy (MT) adds, on average, an additional 90-minute delay in achieving reperfusion. Aim: To determine the feasibility and safety of an EMS routing protocol in which, patients determined to have an LVO-related acute stroke, based on use of a stroke severity score in the field, are directed to the nearest CSC bypassing closer PSCs within Baltimore City. Methods: A prospective observational study was conducted over a six-month period, from September 2017 to March 2018. Acute stroke patients with a LAMS of ≥4 were taken by EMS to the nearest CSC, bypassing closer PSCs, as long as the travel time did not exceed an additional 30 minutes. Data collected at the three CSCs included transport times, IV-tPA and MT use in the diverted patients, time from onset to treatment and 90-day functional outcomes. Descriptive statistics were used to analyze the data. Results: Forty-five patients with LAMS of ≥4 were diverted to a CSC. Approximately 50% (20/45) had a final diagnosis of acute ischemic stroke and 35% of those were eligible for an intervention, either IV-tPA or MT or both. Average onset to IV-tPA bolus time was 114 minutes (93-163 minutes). Average onset to groin puncture was 197 minutes (192-202 minutes). There were 4 in-hospital deaths. Among survivors, the 90 day modified Rankin Scale (mRS) ranged from 0-3. Mean field transport time was 17 minutes (range: 4-63 minutes). None of the re-routed patients were ineligible for IV-tPA due to additional time to CSC. There were no reported adverse outcomes due to increased travel time associated with diversion. Conclusion: Implementation of EMS routing protocols to divert acute stroke patients suspected of having an LVO past PSCs to CSC within cities is feasible and appears safe. The limitations of this study include small size, short duration and small region of implementation. Further study is warranted on a larger scale both in population and geographic area.

BackgroundElevated International Normalized Ratio (INR) is a marker of coagulopathy, but its impact on outcomes following mechanical thrombectomy (MT) in patients with stroke is unclear. This study investigates the impact of mild INR elevations on clinical outcomes following MT.MethodsIn this retrospective cohort study, consecutive patients with stroke treated with MT were identified from 2015 to 2020 at a Comprehensive Stroke Center. Demographic information, past medical history, INR, National Institutes of Health Stroke Scale score, use of tissue plasminogen activator, and last known normal to arteriotomy time were recorded. Outcome measures included modified Thrombolysis in Cerebral Infarction (mTICI) score, modified Rankin Scale (mRS) score at 90 days, and intracerebral hemorrhage (ICH). Patients were divided into two groups: normal INR (0.8–1.1) and mildly elevated INR (1.2–1.7).ResultsA total of 489 patients were included for analysis, of which 349 had normal INR and 140 had mildly elevated INR. After multivariable adjustments, mildly elevated INR was associated with lower odds of excellent outcomes (mRS 0–1, OR 0.24, p=0.009), lower odds of functional independence (mRS 0–2, OR 0.38, p=0.038), and higher odds of 90-day mortality (OR 3.45, p=0.018). Elevated INR was not associated with a higher likelihood of ICH, and there were no differences in rates of HI1, HI2, PH1, or PH2 hemorrhagic transformations; however, elevated INR was associated with significantly higher odds of 90-day mortality in patients with ICH (OR 6.22, p=0.024). This effect size was larger than in patients without ICH (OR 3.38, p<0.001).ConclusionIn patients with stroke treated with MT, mildly elevated INR is associated with worse clinical outcomes after recanalization and may worsen the mortality risk of hemorrhagic transformations.