Intrasaccular flow diversion is a new endovascular option for managing unruptured intracranial aneurysms.1–6 However, catheter ejection can occur during placement of an intrasaccular flow diverter, especially in tortuous vasculature that creates unfavorable angles between the aneurysm neck and the parent vessel.5 The Bendit steerable microcatheter (Bendit Technologies, Petah Tikva, Israel) can dynamically change its tip angle and may mitigate these placement concerns.7–9 Here, we report the placement of an intrasaccular flow diverter for the treatment of an unruptured internal carotid artery sidewall aneurysm at an unfavorable neck angle using the Bendit microcatheter (video 1). The Bendit was navigated around the 180° turn of the carotid siphon and held a stable position during device delivery. The device was sequentially deployed as the Bendit was progressively straightened and was successfully placed within the aneurysm. No neurological complications were experienced and the patient was asymptomatic on follow-up 3 months later.Video 1Placement of an intrasaccular flow diverter in an intracranial sidewall aneurysm using the Bendit articulating microcatheter.
Background/Objective: Higher volumes in the emergency department (ED) and lower staffing ratios exist during hospital “off hours,” outside of weekday business hours, but the impact of these factors on emergent acute stroke metrics is unknown. As part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we sought to assess the impact of time of day on acute stroke code process metrics. Methods: We retrospectively analyzed de-identified metrics for 646 stroke codes between January, 2017 and March, 2018. We calculated median times to neuroimaging, tPA administration, and preparation for endovascular therapy (ET) in the endovascular suite based on time of day (“on hours” = weekday business hours vs “off hours” = non-weekday business hours) and patient setting (ED, outside hospital transfer [OSH], inpatient). Results: Of all stroke codes, 57 (8.8%) received tPA and 98 (15.1%) received ET. Of these, 44 (77.2%) occurred during “off hours” for tPA and 69 (70.4%) for ET. Median door-to-needle (n=48) and door-to-groin puncture (n=84) time for ED presentations is higher during “off hours” (56 vs 44 min, 111 vs 92 min, respectively). Median door-to-groin puncture is similar for OSH transfers (n=64) regardless of arrival time (56 vs 60 min). For all groups, median time for preparation for ET in the endovascular suite is higher during “off hours” compared to “on hours” (ED 21 vs 19 min, OSH 20 vs 15 min, inpatient 26.5 vs 20 min). Conclusion: In our center, acute stroke codes during “off hours” have higher median times to tPA, groin puncture, and preparation for ET. Based on this data we are working to implement earlier activation of the endovascular team at triage for potential large vessel occlusion cases and increase staffing availability during “off hours.”
Introduction: With the continued expansion of acute stroke treatment options, urban tertiary referral centers such as ours are treating an increasingly diverse patient population. As we attempted to better understand barriers to improved door to treatment times in our acute stroke code protocol, we postulated that there might be differences in severity of presentation and swiftness of acute stroke care based on English fluency. Methods: Through a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we compared National Institute of Health Stroke Scale (NIHSS) at presentation, time to presentation, and time to treatment of fluent English speakers to patients who were not fluent in English. We analyzed data from 667 acute stroke codes from January 2017 to March 2018 with Statistical Package for the Social Science (SPSS) using two-tailed t-tests. Results: In-Hospital stroke codes included 415 English speakers and 97 non-English speakers, while Outside Hospital (OSH) transfers comprised 92 English speakers and 35 non-English speakers. Non-English-speaking patients had higher average NIHSS scores at time of acute stroke presentation (11 vs 8 (p=0.013) in-hospital and 17 vs 13(p = 0.007) OSH transfer). Last known well (LKW) to stroke code time upon arrival to our center was significantly shorter in non-English speakers compared to English speakers coming from an OSH (315 minutes vs 515 minutes, p = 0.016), but there were no statistically significant differences between language groups for in-hospital codes’ LKW to stroke code times. There were no statistically significant differences in acute treatment times, but in the OSH transfer group, average LKW to groin puncture was 349 minutes for non-English speakers compared to 545 minutes for English speakers (p=0.085). Conclusions: This data suggests that at our center, non-English speakers present with more severe strokes and present more quickly. Increased stroke severity may partially explain an observed trend towards faster times from LKW to thrombectomy for non-English speakers transferred from an OSH.
Introduction: Patients with emergent large vessel occlusions (ELVO) are often brought to the closest hospital, possibly given intravenous tPA, and transferred to a hospital capable of performing endovascular intervention. This results in significant delays to thrombectomy and worse patient outcomes when compared with patients brought directly to endovascular centers. In New York City, the pre-hospital system has created a protocol for EMS to use a clinical screening tool to triage stroke patients, and bring those with suspected ELVO directly to comprehensive (CSC) or thrombectomy-capable stroke centers (TSC). Objective: To model the impact of EMS triage protocols on administration of tPA, initiation of endovascular therapy, and recanalization of large vessel occlusions using a real life cohort of thrombectomy patients. Methods: Using our system wide prospectively collected stroke database, we selected a consecutive cohort of 80 thrombectomy patients who were brought by EMS to a primary stroke center then transferred to a TSC or CSC for endovascular intervention. The patient’s initial EMS pickup address was used to calculate the closest TSC or CSC using Google Maps API. Driving time was calculated based on traffic patterns at the time of pickup. Using data from a cohort of 69 consecutive patients that were brought directly to a TSC or CSC by EMS and underwent endovascular intervention, we derived median door to needle and door to groin puncture times. These times, combined with calculated driving distance, were used to model the timing of treatment in the triage model. Timings in the actual cohort versus the model were compared. Results: In the “actual” drip and ship cohort versus our model, first medical contact (FMC) to endovascular center door was 211 versus 32 minutes (p<0.01), first medical contact (FMC) to tPA was 91 versus 81 minutes (p=0.07), FMC to groin puncture was 265 versus 154 minutes (p<0.01), and FMC to TICI2B+ recanalization was 313 versus 205 minutes (p<0.01). Conclusions: Modeled EMS pre-hospital triage of ELVO patients results in a significant decrease in endovascular treatment times without change in tPA times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.
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