A Retrospective Analysis of Ischemic Stroke Patients Supports That Very Early Mobilization Within 24 Hours After Intravenous Alteplase Is Safe and Possibly Beneficial.

ABSTRACT: BACKGROUND: Stroke care guidelines recommend early mobilization of acute ischemic stroke patients, but there are sparse data regarding early mobilization of stroke patients receiving thrombolytic therapy. We developed the Providence Early Mobility for Stroke (PEMS) protocol to mobilize patients to their highest individual tolerance within 24 hours of stroke admission in 2010, and it has been in continuous use at our primary and comprehensive stroke centers for over a decade. In this study, we evaluated the PEMS protocol in all patients treated with intravenous alteplase without endovascular treatment. METHODS : This retrospective study includes 318 acute ischemic stroke patients treated with alteplase who were admitted to 2 urban stroke centers between January 2013 and December of 2017 and were mobilized with the PEMS protocol within 24 hours of receiving alteplase. Safety of PEMS was assessed by change in National Institutes of Health Stroke Scale at 24 hours by time first mobilized. Using multivariate and logistic regression models, we analyzed time first mobilized and 90-day modified Rankin scale (mRS). RESULTS : Median time first mobilized was 9 hours from administration of alteplase. For every hour delay in mobilization, the odds of being slightly or moderately disabled (mRS, 2-3) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .004), and the odds of being severely disabled or dead (mRS, 4-6) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .02). In addition, for every hour delay in mobilization, 24-hour National Institutes of Health Stroke Scale increased by 1.8%. DISCUSSION: Our results support that the PEMS protocol is safe, and possibly beneficial, for acute ischemic stroke patients treated with intravenous alteplase. Our protocol differs from other very early mobility protocols because it does not prescribe a "dose" of activity. Instead, each patient was mobilized to his/her individual highest degree as soon as it was safe to do so.

Telehealth Stroke Dysphagia Evaluation Is Safe and Effective.

BACKGROUND: Rapid evaluation of dysphagia poststroke significantly lowers rates of aspiration pneumonia. Logistical barriers often significantly delay in-person dysphagia evaluation by speech language pathologists (SLPs) in remote and rural hospitals. Clinical swallow evaluations delivered via telehealth have been validated in a number of clinical contexts, yet no one has specifically validated a teleswallow evaluation for in-hospital post-stroke dysphagia assessment. METHODS: A team of 6 SLPs experienced in stroke care and a telestroke neurologist designed, implemented, and tested a teleswallow evaluation for acute stroke patients, in which 100 patients across 2 affiliated, urban certified stroke centers were sequentially evaluated by a bedside and telehealth SLP. Inter-rater reliability was analyzed using percent agreement, Cohen's kappa, Kendall's tau-b, and Wilcoxon matched-pairs signed rank tests. Logistic regression models accounting for age and gender were used to test the impact of stroke severity and stroke location on agreement. RESULTS: We found excellent agreement for both liquid (91% agreement; kappa = 0.808; Kendall's tau-b = 0.813, p < 0.001; Wilcoxon signed rank = -0.818, p = 0.417) and solid (87% agreement; kappa = 0.792; Kendall's tau-b = 0.844, p < 0.001; Wilcoxon signed rank = 0.243, p = 0.808) dietary textures. From regression modeling, there is suggestive but inconclusive evidence that higher National Institute of Health Stroke Scale (NIHSS) scores correlate with lower levels of agreement for liquid diet recommendations (OR [95% CI] 0.895 [0.793-1.01]; p = 0.07). There was no impact of NIHSS score for solid diet recommendations and no impact of stroke location on solid or liquid diet recommendations. Qualitatively, we identified professional, logistical, technical, and patient barriers to implementation, many of which resolved with experience over time. CONCLUSIONS: Dysphagia evaluation by a remote SLP via telehealth is safe and effective following stroke. We plan to implement teleswallow across our multistate telestroke network as standard practice for poststroke dysphagia evaluation.

National Institutes of Health Stroke Scale in Plain English Is Reliable for Novice Nurse Users with Minimal Training.

The National Institutes of Health Stroke Scale (NIHSS) is commonly used in Comprehensive Stroke Centers, but it has not been easily implemented in smaller centers. The aim of this study was to assess whether nurse providers who were naive to stroke assessment scales could obtain accurate stroke severity scores using our previously validated NIH Stroke Scale in Plain English (NIHSS-PE) with minimal or no training. METHODS: We randomly assigned 122 nursing students who were naive to stroke assessment scales to 1 of 4 groups: trained on the NIHSS, untrained on the NIHSS, trained on the NIHSS-PE, or untrained on the NIHSS-PE. The Trained/NIHSS and Trained/NIHSS-PE groups watched assessment scale-specific training DVDs. All 4 study groups scored the same 3 patients from the National Institute of Neurological Disorders and Stroke certification DVD, in randomly assigned order. Two-way repeated measures analysis of variance was used to compare group scores with those obtained by a consensus panel of NIHSS-certified expert users, and with each other. RESULTS: NIHSS-PE users had scores significantly closer to the expert scores compared with NIHSS users (F(1,118) = 4.656, P = .033). Trained users had scores significantly closer to the expert scores than untrained users (F(1,118) = 6.607, P = .011). Scores from untrained users of the NIHSS-PE did not differ from those of trained users of the NIHSS (F(1,59) = 0.08, P = .780). DISCUSSION: With minimal or no training, novice nurse users of the NIHSS-PE can do as well as, if not better than, novice users of the NIHSS, making this tool useful for facilities pursuing Acute Stroke-Ready certification.

Spontaneous cerebral gas embolism and pulmonary arteriovenous malformation: a case report.

Pulmonary barotrauma can cause cerebral arterial gas embolism (CAGE) from pulmonary overdistension of alveoli forcing gas into the pulmonary vasculature. We report a case of CAGE in a man found to have occult pulmonary arteriovenous malformation (PAVM) and undiagnosed obstructive sleep apnea (OSA). A 46-year-old man was admitted to the hospital for an acute seizure and left-sided weakness, with telangiectasias on his lower lip and tongue. Brain-computed tomography (CT) showed gas emboli in the right hemisphere. Chest CT revealed a 1.8-cm PAVM in the posterior right costophrenic sulcus. A transthoracic echocardiogram showed no intracardiac shunt or patent foramen ovale. He was treated with phenytoin, lidocaine and hyperbaric oxygen. The PAVM was occluded with a detachable balloon followed by coil embolization. Polysomnography revealed severe obstructive sleep apnea, which was treated with CPAP. Seven years later, the patient was functioning at his pre-event baseline. We propose the CAGE was caused by high negative intrathoracic pressures while breathing against an obstructed upper airway, with air entrainment into the PAVM and subsequent arterialization.

National Institutes of Health Stroke Scale reliable and valid in plain English.

The National Institutes of Health Stroke Scale (NIHSS) is commonly used in the assessment of stroke severity. Nurses, who use the tool infrequently, find it difficult to use due to the neurologic terminology embedded in the scale. For this project, we modified the NIHSS by replacing the neurologic terminology for each component of the original scale with plain English. No components were deleted or changed; the language was merely simplified. Testing showed the modified tool to be reliable (0.96) and valid (0.977) when compared with the NIHSS.