Background and Aims

Mechanical thrombectomy can only be performed in comprehensive stroke centres (CSC) which provide on-site interventional radiology and neurosurgical services. The benefits of direct admission to a CSC versus secondary transfer following initial admission to a stroke unit without MT service are heavily contested.

Nottingham University Hospitals provides the East Midlands’ Mechanical Thrombectomy (MT) service in the United Kingdom. With an aim to reduce the number of transfers for patients eligible for MT within the region, we relocated our stroke services from Nottingham City Hospital (NCH) to Queens’ Medical Centre (QMC), a major trauma centre with on-site interventional services in July 2020.

Methods

We compared timings of stroke assessment and outcomes for consecutive patients transferred from NCH to those who were directly admitted to QMC after the change in our service model.

Results

101 patients admitted from Nottingham underwent MT between January 2019 and January 2022. For patients transferred (n=48) and patients directly admitted (n=53) respectively: average time from CT scan to groin puncture were 163 and 151 minutes; reperfusion rates (TICI>2a) were 100% and 96%. The median modified Rankin Score on discharge were 3.5 and 3.6 respectively.

Conclusions

Although shorter imaging-to-groin puncture time was demonstrated post-relocation, comparable functional outcomes were seen between patients transferred and directly admitted to our CSC. This could be attributed to an increased time window of MT eligibility from 6 to 24 hours post symptom onset after our relocation. Further studies are required to establish its effects and explore the impacts of the COVID-19 pandemic on our stroke service.

Background and Aims

In patients with strokes caused by large vessel occlusions, delays in door-to-groin puncture time (DGPT) are associated with worse clinical outcomes. Nottingham University Hospitals (NUH) provides the East Midlands’ Mechanical Thrombectomy (MT) service in the United Kingdom. We present results from a series of changes leading to the development of the NUH Comprehensive Stroke Centre (CSC) with a view to show improvement in DGPT and patient outcomes.

Methods

242 patients admitted from eight hospitals across the Trust’s referral network underwent MT between January 2019 and January 2022. The development of the NUH CSC included relocation of stroke services from Nottingham City Hospital to Queens’ Medical Centre (QMC), a major trauma centre where interventional services including MT and neurosurgery are based, as well as the integration of stroke assessment within the QMC Emergency Department pathways.

Results

Comparing the outcomes before (n=131) and after (n=111) our interventions in patients with a mean age of 69.9 and 70.2 years respectively demonstrated a reduction in DGPT time from 5.6 to 3.4 hours, improvement in the average modified Rankin Score on discharge from 3.71 to 3.67 and NIHSS improvement at 24 hours post-MT from 8.43 to 8.46.

Conclusions

Our interventions led to a reduction in DGPT time and better functional outcomes on discharge. A comparable NIHSS improvement may be due to an increase in the proportion of patients eligible for MT (e.g. change in selection criteria to beyond 6 hours after symptom onset). Further studies are required to establish the effects of our interventions in the long term.

Background and Aims

Giant cell arteritis (GCA) is an immune-mediated systemic vasculitis usually seen in elderly women.

Methods

We describe two 76-year-old women who presented with jaw claudication and temporal headache. Biopsy of the temporal artery confirmed GCA. They were treated with oral prednisolone.

Results

Both women subsequently presented with acute unilateral visual loss and limb weakness within six months of their GCA diagnosis. Their magnetic resonance brain scans demonstrated acute bilateral multi-territory infarcts predominantly affecting posterior circulation. Both patients demonstrated features of cardio-embolic and vasculitic origins of stroke. Our first patient presented with persistent fast atrial fibrillation with vasculitic and atherosclerotic changes noted in a subsequent computed tomography angiogram. Our second patient suffered an in-hospital cardiac arrest, and following return of spontaneous circulation, coronary angiogram and echocardiogram demonstrated coronary artery and left ventricular thrombus. Both patients unfortunately continued to deteriorate and passed away within a week.

Conclusions

Coronary artery and intraventricular thrombosis and GCA are risk factors for cerebrovascular accidents. The presence of pre-existing atherosclerotic risk factors further poses a diagnostic dilemma for physicians as GCA requires a low threshold of suspicion and early treatment with corticosteroids to improve prognosis. Although a temporal artery biopsy remains to be the definitive diagnostic modality for GCA, the use of radiological investigations in the diagnosis of GCA is increasingly common. A duplex ultrasonography of the temporary artery could be used to assess GCA in highly-suspected patients. Echocardiograms and contrast-enhanced body imaging should be performed in patients with suspected or established GCA to assess secondary thromboembolic and vascular diseases.