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Reimer J, Wang F, Ramiro J, Welch E, Christopher KM, Braun J. Evaluation of Post-thrombolytic Events to Determine Appropriate ICU Monitoring Duration for Patients with Ischemic Stroke. Neurocrit Care 2024:10.1007/s12028-024-01979-3. [PMID: 38589692 DOI: 10.1007/s12028-024-01979-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/08/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Standard treatment for eligible patients presenting with acute ischemic stroke (AIS) is thrombolysis with tissue plasminogen activators alteplase or tenecteplase. Current guidelines recommend monitoring patients in an intensive care unit (ICU) for 24 h after thrombolytic therapy. However, recent studies have questioned the need for prolonged ICU monitoring. This retrospective cohort study aims to identify potential candidates for early transition to a lower level of care by assessing risk factors for neurological deterioration, symptomatic intracranial hemorrhage (sICH), or need for ICU intervention within 24 h post-thrombolysis. METHODS This retrospective cohort study included adult patients 18 years and older with AIS who received thrombolysis. Patients were excluded if they were transferred to another facility, if they were transitioned to comfort care or hospice care within 24 h, or if they lacked imaging and National Institutes of Health Stroke Scale (NIHSS) score data. The primary end point was incidence of sICH between 0-12 and 12-24 h. Secondary end points included the need for ICU intervention and rates of neurological deterioration. RESULTS The analysis included 204 patients who received the full dose of alteplase. Among them, ten patients (4.9%) developed sICH, with the majority (n = 7) occurring within 12 h post-thrombolysis. Sixty-two patients required ICU interventions within 12 h compared with four patients after 12 h. Twenty-four patients had neurological deterioration within 12 h, and seven patients had neurological deterioration after 12 h. Multivariable analysis identified mechanical thrombectomy and increased blood pressure at presentation as predictors of ICU need beyond 12 h post-thrombolysis. CONCLUSIONS Our study demonstrates that sICH, neurological deterioration, and need for ICU intervention rarely occur beyond 12 h after thrombolytic administration. Patients presenting with blood pressures < 140/90 mm Hg, NIHSS scores < 10, and not undergoing mechanical thrombectomy may be best candidates for early de-escalation. Larger prospective studies are needed to more fully evaluate the safety, feasibility, and financial impact of early transition out of the ICU.
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Affiliation(s)
- James Reimer
- Department of Pharmacy, Hospital Sisters Health System St. Elizabeth's Hospital, O' Fallon, IL, USA
| | - Fajun Wang
- Department of Neurology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Joanna Ramiro
- Department of Neurology, Mercy Hospital, St. Louis, MO, USA
| | - Emily Welch
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Kara M Christopher
- Department of Neurology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - James Braun
- Department of Pharmacy, Sisters of Saint Mary Health Saint Louis University Hospital, 1201 South Grand Blvd, St. Louis, MO, 63104, USA.
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Kim J, Shin H. Exploring the effects of extended reality head-mounted display nervous system assessment training for nursing students: A pilot feasibility study. Nurse Educ Today 2024; 133:106089. [PMID: 38154214 DOI: 10.1016/j.nedt.2023.106089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Health assessment is crucial for planning nursing interventions. Specifically, cerebrovascular diseases involve rapid neurological changes that necessitate precise hands-on assessment skills training. OBJECTIVES This study developed and implemented an extended reality head-mounted display (HMD) nervous system assessment training program for nursing students to identify the usability and effectiveness of the system by analyzing their experiences. DESIGN This was a mixed-methods study that combined the quantitative element of a one-group pre-post-test design with the qualitative element of qualitative content analysis. SETTING University in Korea. PARTICIPANTS The study involved 36 nursing students in their 4th year who completed classes in health assessments and adult nursing (nervous system). METHODS An extended reality nervous system assessment training program was developed using the National Institutes of Health Stroke Scale and limb strength assessment. The learners wore HMD and received training at their own pace. System usability, confidence in nervous system assessment, learning satisfaction, and performance ability were measured and analyzed using SPSS Windows software version 28.0. Descriptive data were used for qualitative content analysis of the training experience. RESULTS The usability of the extended-reality HMD nervous system assessment training received positive feedback and most participants (94.4 %) agreed with the system's consistency. Confidence in nervous system assessment significantly improved after the training (p < .001). After the training, learning satisfaction and performance ability were high. Furthermore, advantages of XR-based learning devices and positive learning were observed. Nonetheless, issues such as difficulties in operating the device, inconvenience, physical side effects of wearing the device, and technical limitations existed. CONCLUSIONS This study developed and implemented an extended-reality HMD nervous system assessment training program to confirm its feasibility. However, challenges regarding device utilization need to be resolved for its effective development as a learning tool.
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Affiliation(s)
- Jiyoung Kim
- Department of Nursing, Inha University, Incheon, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea.
| | - Hyunjung Shin
- Department of Nursing, Inha University, Incheon, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea
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Sun J, Lam C, Christie L, Blair C, Li X, Werdiger F, Yang Q, Bivard A, Lin L, Parsons M. Risk factors of hemorrhagic transformation in acute ischaemic stroke: A systematic review and meta-analysis. Front Neurol 2023; 14:1079205. [PMID: 36891475 PMCID: PMC9986457 DOI: 10.3389/fneur.2023.1079205] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/31/2023] [Indexed: 02/22/2023] Open
Abstract
Background Hemorrhagic transformation (HT) following reperfusion therapies for acute ischaemic stroke often predicts a poor prognosis. This systematic review and meta-analysis aims to identify risk factors for HT, and how these vary with hyperacute treatment [intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)]. Methods Electronic databases PubMed and EMBASE were used to search relevant studies. Pooled odds ratio (OR) with 95% confidence interval (CI) were estimated. Results A total of 120 studies were included. Atrial fibrillation and NIHSS score were common predictors for any intracerebral hemorrhage (ICH) after reperfusion therapies (both IVT and EVT), while a hyperdense artery sign (OR = 2.605, 95% CI 1.212-5.599, I 2 = 0.0%) and number of thrombectomy passes (OR = 1.151, 95% CI 1.041-1.272, I 2 = 54.3%) were predictors of any ICH after IVT and EVT, respectively. Common predictors for symptomatic ICH (sICH) after reperfusion therapies were age and serum glucose level. Atrial fibrillation (OR = 3.867, 95% CI 1.970-7.591, I 2 = 29.1%), NIHSS score (OR = 1.082, 95% CI 1.060-1.105, I 2 = 54.5%) and onset-to-treatment time (OR = 1.003, 95% CI 1.001-1.005, I 2 = 0.0%) were predictors of sICH after IVT. Alberta Stroke Program Early CT score (ASPECTS) (OR = 0.686, 95% CI 0.565-0.833, I 2 =77.6%) and number of thrombectomy passes (OR = 1.374, 95% CI 1.012-1.866, I 2 = 86.4%) were predictors of sICH after EVT. Conclusion Several predictors of ICH were identified, which varied by treatment type. Studies based on larger and multi-center data sets should be prioritized to confirm the results. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=268927, identifier: CRD42021268927.
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Affiliation(s)
- Jiacheng Sun
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christina Lam
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Lauren Christie
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,Allied Health Research Unit, St Vincent's Health Network Sydney, Sydney, NSW, Australia.,Faculty of Health Sciences, Australian Catholic University, North Sydney, NSW, Australia
| | - Christopher Blair
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Xingjuan Li
- Queensland Department of Agriculture and Fisheries, Brisbane, QLD, Australia
| | - Freda Werdiger
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Qing Yang
- Apollo Medical Imaging Technology Pty Ltd., Melbourne, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Longting Lin
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Mark Parsons
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
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van der Steen W, van der Ende NAM, van Kranendonk KR, Chalos V, Brouwer J, van Oostenbrugge RJ, van Zwam WH, van Doormaal PJ, van Es ACGM, Majoie CBLM, van der Lugt A, Dippel DWJ, Roozenbeek B. Timing of symptomatic intracranial hemorrhage after endovascular stroke treatment. Eur Stroke J 2022; 7:393-401. [PMID: 36478761 PMCID: PMC9720857 DOI: 10.1177/23969873221112279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/20/2022] [Indexed: 02/13/2024] Open
Abstract
INTRODUCTION Little is known about the timing of occurrence of symptomatic intracranial hemorrhage (sICH) after endovascular therapy (EVT) for acute ischemic stroke. A better understanding could optimize in-hospital surveillance time points and duration. The aim of this study was to delineate the probability of sICH over time and to identify factors associated with its timing. PATIENTS AND METHODS We retrospectively analyzed data from the Dutch MR CLEAN trial and MR CLEAN Registry. We included adult patients who underwent EVT for an anterior circulation large vessel occlusion within 6.5 h of stroke onset. In patients with sICH (defined as ICH causing an increase of ⩾4 points on the National Institutes of Health Stroke Scale [NIHSS]), univariable and multivariable linear regression analysis was used to identify factors associated with the timing of sICH. This was defined as the time between end of EVT and the time of first CT-scan on which ICH was seen as a proxy. RESULTS SICH occurred in 205 (6%) of 3391 included patients. Median time from end of EVT procedure to sICH detection on NCCT was 9.0 [IQR 2.9-22.5] hours, with a rapidly decreasing incidence after 24 h. None of the analyzed factors, including baseline NIHSS, intravenous alteplase treatment, and poor reperfusion at the end of the procedure were associated with the timing of sICH. CONCLUSION SICHs primarily occur in the first hours after EVT, and less frequently beyond 24 h. Guidelines that recommend to perform frequent neurological assessments for at least 24 h after intravenous alteplase treatment can be applied to ischemic stroke patients treated with EVT.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nadinda AM van der Ende
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear
Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The
Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
| | - Josje Brouwer
- Department of Neurology, Amsterdam
University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht
University Medical Center, Cardiovascular Research Institute Maastricht (CARIM),
Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear
Medicine, Maastricht University Medical Center, Cardiovascular Research Institute
Maastricht (CARIM), Maastricht, The Netherlands
| | - Pieter J van Doormaal
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
| | - Adriaan CGM van Es
- Department of Radiology, Leiden
University Medical Center, Leiden, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear
Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The
Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC
University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Maqueda CE, Perme C. A Novel Mobilization Criteria Checklist 12 to 24 Hours After Intravenous Thrombolysis in Acute Ischemic Stroke. Journal of Acute Care Physical Therapy 2022; 13:198-205. [DOI: 10.1097/jat.0000000000000194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cencer S, Tubergen T, Packard L, Gritters D, LaCroix H, Frye A, Wills N, Zachariah J, Wees N, Khan N, Min J, Dejesus M, Combs J, Khan M. Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients. Neurohospitalist 2022; 12:504-507. [DOI: 10.1177/19418744211048014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) ( P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.
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Affiliation(s)
- Samantha Cencer
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Tricia Tubergen
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Laurel Packard
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | | | - Hattie LaCroix
- Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Angela Frye
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Nicole Wills
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Joseph Zachariah
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nabil Wees
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nadeem Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jiangyong Min
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Michelle Dejesus
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jordan Combs
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
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Eldeeb HM, Elsalamawy DH, Elabd AM, Abdelraheem HS. Predictors of the functional outcome after thrombolysis in an Egyptian patients’ sample. Egypt J Neurol Psychiatry Neurosurg 2021. [DOI: 10.1186/s41983-020-00261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
About 6.2 million individuals worldwide and approximately 200 Egyptians/100,000 citizens have cerebrovascular stroke annually, and only less than 1% of stroke patients received intravenous (IV) thrombolysis in 2014. Outcome of the ischemic stroke after IV thrombolysis varies, and there is lack of data about the predicting factors that contributes to the outcome of ischemic strokes after IV thrombolysis in Egypt.
Objective
The aim of this work is to study the predictors of the functional outcome of ischemic cerebrovascular stroke after IV thrombolysis in Egyptian patients.
Patients and methods
This is a prospective study that includes acute ischemic stroke patients who received IV thrombolysis at the Alexandria University Hospital during the year from February 2017 to February 2018, and they were evaluated initially by Rapid Arterial Occlusion Evaluation (RACE) scale and followed-up serially for 6 months after thrombolysis using the National Institutes of Health Stroke Scale (NIHSS) and modified ranking score (mRS).
Results
Forty-five patients are included; 56% had favorable functional outcome (mRS 0–2) after 6 months, 68% had ≥ 4 points improvement in NIHSS after 6 months, and 13% had hemorrhagic conversion with 18% mortality rate. High initial RACE scale and long hospital stay are associated with poor functional outcome 6 months after thrombolysis.
Conclusion
Stroke severity demonstrated by high initial RACE and the duration of hospital stay are the two most significant predictors with an impact on the functional outcome of ischemic cerebrovascular stroke after thrombolysis.
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8
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Duan Y, Shammassian B, Srivatsa S, Sunshine K, Chugh A, Pace J, Opaskar A, Bambakidis NC. Bypassing the intensive care unit for patients with acute ischemic stroke secondary to large-vessel occlusion. J Neurosurg 2021:1-5. [PMID: 34653995 DOI: 10.3171/2021.6.jns21308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular mechanical thrombectomy is safe and effective for the treatment of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). Still, despite high rates of procedural success, it is routine practice to uniformly admit postthrombectomy patients to an intensive care unit (ICU) for postoperative observation. Predictors of ICU criteria and care requirements in the postmechanical thrombectomy ischemic stroke patient population are lacking. The goal of the present study is to identify risk factors associated with requiring ICU-level intervention following mechanical thrombectomy. METHODS The authors retrospectively analyzed data from 245 patients undergoing thrombectomy for AIS from anterior circulation LVO at a comprehensive stroke and tertiary care center from January 2015 to March 2020. Clinical variables that predicted the need for critical care intervention were identified and compared. The performance of a binary classification test constructed from these predictive variables was also evaluated using a validation cohort. RESULTS Seventy-six patients (31%) required critical care interventions. A recanalization grade lower than modified Thrombolysis in Cerebral Infarction (mTICI) scale grade 2B (odds ratio [OR] 3.625, p = 0.001), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) < 8 (OR 3.643, p < 0.001), and presence of hyperdensity on postprocedure cone-beam CT (OR 2.485, p = 0.005) were significantly associated with the need for postthrombectomy critical care intervention. When applied to a validation cohort, a clearance classification scheme using these three variables demonstrated high positive predictive value (0.88). CONCLUSIONS A recanalization grade lower than mTICI 2B, ASPECTS < 8, and postprocedure hyperdensity on cone-beam CT were shown to be independent predictors of requiring ICU-level care. Routine admission to ICU-level care can be costly and confer increased risk for hospital-acquired conditions. Safely and reliably identifying low-risk patients has the potential for cost savings, value-based care, and decreasing hospital-acquired conditions.
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Affiliation(s)
| | | | - Shaarada Srivatsa
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Kerrin Sunshine
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | | | - Jonathan Pace
- 3Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Amanda Opaskar
- 4Neurology, University Hospitals Cleveland Medical Center, Cleveland
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Abstract
BACKGROUND AND PURPOSE Stroke patients are currently monitored for neurological deterioration for 24 h following treatment with intravenous tissue plasminogen activator (IV tPA) or mechanical thrombectomy. This requires low nursing ratios and an intensive-care-like setting. As the half-life of IV tPA is short, many patients may not require such prolonged intensive monitoring and could be downgraded much earlier. We evaluate the frequency of neurological deterioration in the 0-12 and 12-24 h post-treatment windows. METHODS Patients presenting with acute ischemic stroke treated with IV tPA and/or thrombectomy at our institution from 2016-2018 were prospectively followed per protocol for 24 h post-therapy (examinations every 15 min for 2 h, every 30 min for 6 h, and hourly thereafter). Neurological deteriorations were recorded along with interventions and complications. Frequency of deterioration within the 0-12 and 12-24 h post-treatment windows was determined, along with factors associated with decline at each time point. RESULTS A total of 172 patients were treated (IV:135, IA:65, both:30). Thirty-six (21%) experienced a documented neurologic deterioration [8 due to intracerebral hemorrhage (4.7%)]. Five patients deteriorated in the 12-24 h window; all but one had experienced earlier examination changes. Elevated NIHSS was associated with a higher likelihood of deterioration overall. Early fluctuation was associated with decline after 12 h. CONCLUSIONS New onset of neurologic deterioration is rare 12-24 h after treatment of acute stroke. Stable patients with low NIHSS scores and no ICU needs may not require intensive monitoring greater than 12 h post-treatment.
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Affiliation(s)
- Sheena Khan
- Department of Neurology, Johns Hopkins School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA
| | - Alexandria Soto
- Department of Neurology, Johns Hopkins School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA
| | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA.
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Llinas EJ, Max A, Khan S, Marsh EB. The Routine Follow-up Head CT: Is it Still a Necessary Step in the Thrombolysis Pathway? Neurocrit Care 2021; 36:595-601. [PMID: 34580828 PMCID: PMC8964541 DOI: 10.1007/s12028-021-01348-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/01/2021] [Indexed: 12/03/2022]
Abstract
Background The 24-h head computed tomography (CT) scan following intravenous tissue plasminogen activator or mechanical thrombectomy (MT) is currently part of most acute stroke protocols. However, as evidence emerges regarding who is at highest risk for treatment complications, the utility of routine neuroimaging for all patients has become less clear. Methods Four hundred seventy-five patients presenting with acute ischemic stroke to Johns Hopkins Bayview Medical Center between 2004 and 2018 and treated with intravenous tissue plasminogen activator and/or MT were evaluated. Neuroimaging performed during the first 48 h of hospitalization was reviewed for edema, hemorrhagic transformation (HT), or other findings altering management. Early imaging (< 24 h), performed for neurologic deterioration, was compared with imaging performed per protocol (24 ± 6 h). Factors predictive of radiographically and clinically significant findings on per-protocol imaging were determined. Results One hundred fifty-three patients (32%) underwent early imaging. These patients generally had more severe strokes. HT was found in 15% of cases. For the remaining patients (n = 322), imaging at 24 h impacted acute management for only 24 patients: resulting in emergent hemicraniectomy in 1 (0.3%) and leading to additional imaging to monitor asymptomatic HT or edema in 23 (7.1%). Advanced age, higher stroke severity, MT, and atrial fibrillation were associated with significant findings on the 24-h CT scan. Only 2 of the 24 patients had an initial National Institutes of Health Stroke Scale score of < 7. Conclusions The 24-h head CT scan does not change management for most patients, particularly those with low National Institutes of Health Stroke Scale scores who do not undergo MT. Consideration should be given to removing routine follow-up imaging from postthrombolysis protocols in favor of an examination-based approach.
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Affiliation(s)
- Edward J Llinas
- Department of Neurology, School of Medicine, Johns Hopkins University, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA
| | - Alexandra Max
- Department of Neurology, School of Medicine, Johns Hopkins University, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA
| | - Sheena Khan
- Department of Neurology, School of Medicine, Johns Hopkins University, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA
| | - Elisabeth B Marsh
- Department of Neurology, School of Medicine, Johns Hopkins University, 600 North Wolfe St. Phipps 446C, Baltimore, MD, 21287, USA.
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Faigle R, Johnson B, Summers D, Khatri P, Anderson CS, Urrutia VC. Low-Intensity Monitoring After Stroke Thrombolysis During the COVID-19 Pandemic. Neurocrit Care 2020; 33:333-337. [PMID: 32514708 PMCID: PMC7279712 DOI: 10.1007/s12028-020-00998-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 481, Baltimore, MD, 21287, USA
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 481, Baltimore, MD, 21287, USA
| | - Debbie Summers
- Saint Luke's Hospital of Kansas City, Marion Bloch Neuroscience Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, 260 Stetson St, ML 0525, Cincinnati, OH, 45217, USA
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2050, Australia
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 481, Baltimore, MD, 21287, USA.
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Lin X, Cao Y, Yan J, Zhang Z, Ye Z, Huang X, Cheng Z, Han Z. Risk Factors for Early Intracerebral Hemorrhage after Intravenous Thrombolysis with Alteplase. J Atheroscler Thromb 2020; 27:1176-1182. [PMID: 32115471 PMCID: PMC7803839 DOI: 10.5551/jat.49783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aim: Intracerebral hemorrhage (ICH) is one of the most severe complications of thrombolysis. Symptomatic ICHs are associated with adverse outcomes. It has been reported that symptomatic ICHs most commonly occur within the first few hours after the initiation of intravenous thrombolysis. Our aim here was to determine the risk factors for early ICH (within 12 h) after thrombolysis. Methods: We analyzed patients with acute ischemic stroke who received intravenous alteplase at two hospitals affiliated to Wenzhou Medical University between March 2008 and November 2017. The ICH diagnosis time was defined as the time from the intravenous administration of alteplase to the first detection of hemorrhage on computed tomography. Demographic data, medical history, clinical features, and laboratory examination results were collected. Univariate analysis followed by multivariable logistic regression analysis was performed to determine the predictors of early ICH (within 12 h) after thrombolysis. Results: Among 197 patients, early ICH (within 12 h) after thrombolysis occurred in 13 patients (6.6%). In the univariate analysis, patients with early ICHs were significantly correlated with prior stroke (P = 0.04). After adjusting for potential confounders in the multivariate analysis, prior stroke (odds ratio [OR]: 5.752, 95% confidence interval [CI]: 1.487–22.248; P = 0.011) and atrial fibrillation (OR: 5.428, 95% CI: 1.427–20.640; P = 0.013) were associated with early ICH. Conclusions: Prior stroke and atrial fibrillation are independent risk factors for early ICHs (within 12 h) after intravenous thrombolysis with alteplase.
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Affiliation(s)
- Xianda Lin
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University.,Department of Neurology, The Wenzhou Third Clinical Institute Affiliated To Wenzhou Medical University
| | - Yungang Cao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Jueyue Yan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Zheng Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University
| | - Zusen Ye
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University
| | - Xiaoyan Huang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Zicheng Cheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
| | - Zhao Han
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University
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Morotti A, Goldstein JN. WITHDRAWN: Anticoagulant-associated intracerebral hemorrhage. Hemorrhagic Stroke 2019. [DOI: 10.1016/j.hest.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Chen PM, Lehmann B, Meyer BC, Rapp K, Hemmen T, Modir R, Agrawal K, Hailey L, Mortin M, Meyer DM. Timing of symptomatic intracerebral hemorrhage after rt-PA treatment in ischemic stroke. Neurol Clin Pract 2019; 9:304-308. [PMID: 31583184 DOI: 10.1212/cpj.0000000000000632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/20/2018] [Indexed: 01/01/2023]
Abstract
Background We investigated patterns in the time from recombinant tissue-type plasminogen activator (rt-PA) treatment to symptomatic intracranial hemorrhage (sICH) onset in acute ischemic stroke. Methods We retrospectively reviewed all admitted "stroke code" patients from 2003 to 2017 at the University of California San Diego Medical Center from a prospective stroke registry. We selected patients that received IV rt-PA within 4.5 hours after onset/last known well and had sICH prehospital discharge. sICH diagnosis was made by prospective review. Endovascular-treated patients were excluded, given the variability of practice. sICH was prospectively defined as any new radiographic (CT/MRI) hemorrhage after rt-PA treatment and any worsened neurologic examination. Time to sICH was the time from rt-PA administration start to documented STAT head CT order time with the first evidence of new hemorrhage. Charts were reviewed for examination time metrics, demographics, clinical history, and neuroimaging. Results sICH was identified in 28 rt-PA-only treated patients. The mean time to sICH was 18.28 hours (range 2.4-34 hours). Median time to sICH was 18.25 hours. sICH was correlated with increased age (p = 0.02) and increased NIH Stroke Scale (p = 0.01). Conclusions Our findings suggest that rt-PA patients have the highest risk of post rt-PA sICH within the first 24 hours after treatment. This supports monitoring of rt-PA-treated patients in specialized settings such as neuro-intensive care units or stroke units. Our findings suggest that the probability of sICH is low 36 hours post rt-PA. Future larger studies are warranted to identify the patterns of bleeding after rt-PA administration.
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Affiliation(s)
- Patrick M Chen
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Brittney Lehmann
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Brett C Meyer
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Karen Rapp
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Thomas Hemmen
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Royya Modir
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Kunal Agrawal
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Lovella Hailey
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Melissa Mortin
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
| | - Dawn M Meyer
- Department of Neurosciences, Stroke Center, University of California San Diego, San Diego, CA
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