Introduction: The hyperdense MCA sign has been used as a marker of an underlying large vessel occlusion (LVO)/thrombus in the non-contrast head CT of acute stroke patients. However, due its low sensitivity, it has not been used routinely for definitive diagnosis of LVO. Furthermore, clinicians also have the ability to obtain further imaging with CT angiography to better visualize the vessels in most patients. However, this further imaging can take on average up to an additional 30 minutes due to delays in acquisition, patient cooperation, processing and image transmission time. We wanted to look for a simple sign on the early imaging (non-contrast HCT) to determine if we could activate the neuro interventional suite faster. Hypothesis: When present, the hyperdense MCA sign can accurately predict presence of a LVO and identify patients eligible for endovascular therapy sooner than vessel imaging. Methods: We retrospectively looked at all initial non-contrast head CTs for all consecutive stroke patients presenting to our facility in 2017 (n=86), with a last known well time (LKW) < 6 hours and NIHSS > 4, for the presence of a hyperdense MCA sign. We then reviewed subsequent imaging (CTA) to determine if LVO was actually present. Results: The hyperdense MCA sign was present in 17 (out of 86) cases, all of which had an LVO on CTA. The positive predictive value (PPV) was 100% indicating that there was a high probability that subjects with a positive hyperdense MCA sign will have a LVO. There were 12 cases with an LVO on CTA did not have a hyperdense MCA sign showing a sensitivity of 58.6%, thus the absence of a hyperdense MCA sign does not exclude LVO. Conclusion: Quick delivery of appropriate treatments for acute stroke patients have been linked to better outcomes. Given our analysis of cases with NIHSS > 4 and LKW < 6 hours, it seems that presence of a hyperdense MCA sign on the initial non-contrast HCT leads to a high level of certainty that an LVO is present. Perhaps this sign, in combination of LKW and NIHSS, can be used to activate the neuro interventional team while additional imaging is being obtained.
Introduction: Risk-adjusted stroke mortality is a publicly-reported CMS quality measure. Patients (pts) admitted with stroke who are discharged to hospice prior to the first midnight are excluded in reported metrics. It is difficult to prognosticate outcomes early in ischemic stroke; additionally, the sudden nature of the disease makes it difficult for families to make rapid decisions. We hypothesized that the decision to proceed to comfort care in ischemic stroke pts takes longer than 24 hours. Methods: This was an observational study of all ischemic stroke pts seen at Intermountain Medical Center in 2016 (n=581) who were discharged to hospice (n=27) or died in hospital on comfort care (n=27). A Wilcoxon sign rank test was used to compare time to decision regarding comfort care to the CMS standard of 24 hours. Differences in the time to decision or death for the pt characteristics were also compared using Wilcoxon-Mann-Whitney test. Results: The average age was 80 years old ± 13 (range 44 - 98), 59% were female, all were Caucasian Non-Hispanic, and 65% reported a religious affiliation. NIH stroke score was reported in 42 subjects with an average of 15.9±7.9 (range 2-31). The mean time from admission to initiation of comfort care orders was 3.12 days (±3.6) with a median of 1.8 days and a range from 12.5 hours to 14.1 days. The time was significantly greater than 24 hours (p<0.0001) with only a third (n=18) having the time less than 24 hours and with only a fifth (n=11) having the time before the first midnight. The table below contains the differences in the times based on pt characteristics and none of these were significantly associated with time differences. Conclusions: The decision to transition to comfort care or hospice often takes greater than 24 hours. If the stroke mortality metric is meant to exclude hospice pts or those that prefer comfort measures only, the time window for initiation of those orders should be extended beyond the first midnight.
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