Welcome to the WSC 2022 Interactive Program

Background and Aims

To compare clinical outcomes and safety of transradial (TRA) versus transfemoral access (TFA) for endovascular
mechanical thrombectomy in acute stroke patients.

Methods

Retrospective analysis of 832 consecutive patients with acute stroke undergoing interventional thrombectomy
using TRA (n = 64) or TFA (n = 768).

Results

Direct TFA failures occurred in 36 patients, 18 of which underwent crossover TFA to TRA, while direct TRA failures
occurred in 2 patients having both crossovers to TFA. Successful catheterization was achieved in 96.8% (62/64) and
95.3% (732/768) of patients undergoing direct TRA and direct TFA, respectively, without significant differences. The median
(IQR) catheterization time was 10 (8–16) min in the direct TRA group and 15 (10–20) in the direct TFA group (P < 0.001).
This difference was also significant in the subgroup of anterior circulation strokes and in patients younger and older than
80 years of age. The majority of procedures yielded thrombolysis in cerebral infarction grade 2b/2c/3 revascularization in
patients undergoing direct TRA (88.5%) and direct TFA (90.8%), without statistically significant differences. The median
(IQR) puncture to recanalization time was 37 (24–58) min for the direct TRA group and 42 (28–70) min for the direct TFA
group. Significant differences in access site complications, symptomatic ICH, and mRS score 0–2 at 90 days between both
TRA and TFA accesses were not found.

Conclusions

TRA is not inferior to TFA in the probability of catheterization, times of catheterization and revascularization,
and other clinical outcomes for mechanical thrombectomy in acute stroke.

Background and Aims

Access to emergent mechanical thrombectomy (MT) for acute ischemic stroke with large vessel occlusions is limited worldwide with vast disparities between countries. MT2020+, a global initiative of SVIN, aimed to create a global MT access score using systematic, mixed methods approach performed to objectively measure the drivers of access needed to accelerate treatment worldwide.

Methods

Four independent investigators performed an in-depth systematic literature review using the Peer Review of Electronic Search Strategies. Access drivers were identified and categorized into 3 groups: information and diagnostic access, physical access and financial access. A multispecialty international expert panel was created and scored each attribute using a modified Delphi process with assistance of University of Calgary W21C. A 1–9-point scale was used, with 1 being not at all important and 9 being extremely important, followed by virtual face to face meeting to deliberate attributes whose mean fell between 4-6.

Results

After initial screening of 2864 abstracts, 523 studies were included in the final systematic review. A total of 34 possible attributes that drive access were identified. After the modified Delphi process, 26 individual attributes were determined to be of significance in the creation of a MT access score. 5 attributes were related to financial access, 11 were related to physical access and 10 were information and diagnostic drivers of access.

Conclusions

The global MT access score represents a tool to evaluate MT access barriers in different world regions. Weighting of the individual attributes and validation of the score will be needed prior to its implementation.

Background and Aims

The severity-based ACT-FAST algorithm for pre-hospital triage of large vessel occlusion (LVO) has previously been validated in a large paramedic-led study. We examined the subsequent real-world diagnostic utility of this tool for ambulance triage in the western metropolitan region of Melbourne, Australia.

Methods

A manual audit was conducted of all patients presenting to a central comprehensive center for patients in the catchment of two spoke primary centers where ACT-FAST bypass was active from April 2020 to March 2021. Diagnostic performance was determined for LVO and overall need for comprehensive center care, including and excluding concurrent mobile stroke unit (MSU) cases.

Results

Of 1222 presentations screened, 182 (15%) patients were in the bypass zone. These included 15 secondary inter-hospital LVO transfers, of which 9 had high severity (NIHSS≥10). In contrast, 23 ACT-FAST-Positive LVOs were bypassed (6 MSU-facilitated) in addition to 11 ICH and 1 intracerebral tumour. There were 8 bypassed false-positives (6 infarcts, 2 mimics) of which only 1 received thrombolysis. Bypassed patients received significantly faster EVT from ambulance dispatch (median 177min vs 237 min, p=0.001) whereas there was no significant difference in thrombolysis time (113min vs 101min, p=0.486).

Conclusions

Implementation of ACT-FAST triaging avoided >70% of secondary transfers for high-severity LVO with significant time savings to thrombectomy and low rates of false-positive bypass (<1/month). Thrombolysis delay was minimal in our metropolitan setting and triage benefit was complementary to that provided by an active MSU service in the area.

Background and Aims

This study aims to measure the changes in volume of ischaemic stroke and TIA presentations across various hospitals internationally and whether the pandemic has reduced the number and proportion of patients receiving reperfusion therapies.

Methods

Three centres from Australia, and one centre each from England, Canada, USA, and Italy described presentation numbers for ischaemic stroke, TIA, intravenous thrombolysis (IVT) , and endovascular thrombectomy (EVT) over a baseline pre-COVID period (April 2018 to March 2020), and an intra-COVID period (March 2020 to March 2021). Interrupted time series analysis using autoregressive integrated moving average techniques was used to measure the impact of the pandemic.

Results

A total of 14,607 ischaemic stroke and 6,424 TIA presentations were included. Of the ischaemic strokes, there were 1,856 (12.7%) instances of intravenous thrombolysis and 2,298 (15.7%) instances of EVT. There was a 5.6% decline in ischaemic stroke presentations (estimate: -23, SE=11, p<0.05) and 16.4% decline in instances of IVT (estimate: -9, SE=2, p<0.001). Neither presentations to TIA clinic (estimate: 6, SE=4, p=0.16) nor EVT counts (estimate: 1, SE=4.80, p=0.91) changed significantly. The percentage of ischaemic strokes receiving IVT decreased from 13.2% to 11.6% (p<0.05), while those requiring EVT did not change (15.4 to 16.5%, p=0.09).

Conclusions

There was a significant reduction in monthly ischaemic stroke counts, thrombolysis counts, and proportion receiving thrombolysis during the pandemic. The disproportionate decrease in IVT during this period suggests that patients may be presenting outside the IVT window during the pandemic.

Background and Aims

Access to acute stroke treatment is limited, particularly in low- and middle-income countries. Geomapping of stroke centers using reproducible algorithms could help design stroke systems of care, especially in regions where resources are limited.

Methods

We collected data on stroke centers from all MT2020+ regional committees in India. The geospatial files with the administrative boundaries and transportation layers were obtained from the Survey of India website. Centroids of the polygons and geographic coordinates were generated. MT-capable stroke centers were geocoded using the Google Geocoding application programming interface (API) and passed to the Google Distance Matrix API to estimate the distance and driving time. All analyses were performed using reproducible algorithms in R version 4.05.

Results

Maps demonstrating country-level travel times to the nearest MT-center from sub-district centroids and Kerala state level travel times to the nearest MT center from population centers were generated (Fig. 1,2,3, and 4).

Figure 1. Travel times to the nearest MT-capable center from sub-district centroids (India)

Figure 2. Distribution of stroke centers in Kerala (IVT- intravenous thrombolysis, EVT - endovascular treatment)

Figure 3. Distribution of population centers (grey) in relation to the stroke centers (red) in Kerala

Figure 4. Travel times to the nearest stroke center from population centers (Kerala)

Conclusions

The 60-minute access to an MT-capable center in India is extremely low. Geomapping analysis using reproducible algorithms could provide valuable information to policymakers in designing stroke services and could potentially be implemented in other regions of the world.

Background and Aims

Limited evidence is available for the safety of recanalization therapy in acute ischemic stroke (AIS) patients with direct oral anticoagulants (DOAC) and without DOAC following endovascular therapy (EVT) or intravenous thrombolysis (IVT) treatment. We aimed to update the evidence on the safety of recanalization therapy in AIS patients with and without DOAC following EVT or IVT.

Methods

A comprehensive literature search was performed for all the published observational studies from 01^st Jan 1950 to 31^st Jan 2022. The primary outcome was to investigate the incidence of symptomatic intracerebral hemorrhage (sICH), while secondary outcomes include arterial recanalization, good functional recovery, and mortality at 3 months.

Results

Seventeen studies (14 for EVT and 3 for IVT) were finally included in the analysis. A significant decrease in the incidence of sICH [Risk ratio (RR)=0.85,95%CI =0.72 to 1.00, p=0.04], and a lower chance of good functional recovery at three months (RR = 0.79, 95% CI = 0.73 to 0.85, p<0.001) was observed in AIS patients with DOAC therapy as compared to AIS patients without DOAC following EVT. Additionally, a higher risk of mortality was observed in AIS patients who were without DOAC after EVT [RR=1.29, 95% CI=1.15-1.44, p=<0.001]. However, no significant differences for sICH events were observed in AIS patients with DOAC as compared to without DOAC therapy following IVT [RR=0.87, 95 % CI = 0.48 to 1.58, p=0.64].

Conclusions

Our findings suggest that Patients with AIS on DOAC therapy have a lower incidence of sICH following EVT but not after IVT.

Background and Aims

Over the years, the number of stroke activations has increased due to increased public awareness through public campaigns, extended time window for re-perfusion treatment and national diversion of acute strokes to hyperacute stroke centres. The sheer volume of patients and the time-sensitive treatment has led to the need for very coordinated and prompt care approach so that every eligible patient receives the treatment in a timely manner. Thus, code stroke nurses play an integral role in leading and facilitating the acute stroke activation service.

Methods

A group of Advanced Practice Nurses (APNs) in our hospital were trained to perform the role of a code stroke nurse. A new workflow was established, embedding the code stroke nurse as the first responders in the Emergency Department (ED). They also play an integral role and work closely with the ED physicians to assess all stroke activations to determine whether to activate neurology Senior Residents (SRs) or to standdown stroke mimics.

Results

There were a total of 2007 pre-hospital stroke activations in our hospital from March 2021 to February 2022 and 357 patients received hyperacute stroke treatment. For patients who received hyperacute stroke therapy with the presence of a code stroke nurse, the door-to-needle treatment time was 10 minutes faster for thrombolysis and 17 minutes faster for door-to-groin puncture for endovascular therapy.

Conclusions

The presence of code stroke nurses reduce door-to-treatment times in acute stroke care.