WSO - February 2023 - 126

LEAVE YOUR LEGACY
Argentinian hospital's
10-minute " miracle "
On 2 May 2022, Dr Ignacio Cigalini, an interventional cardiologist and coordinator of the
AMI code at Hospital Privado de Rosario in Argentina, performs a transcatheter aortic valve
replacement (TAVR) on a 63-year-old man.
A TAVR procedure, in which a catheter
is used to fix a replacement valve
on top of the old one, has several
advantages over conventional surgery,
but does carry an elevated risk of acute
stroke. Despite every precaution, the
63-year-old suffers a stroke.
At precisely 1.12 pm a loudspeaker in
Hospital Privado de Rosario announces
Code Stroke.
The time to treatment will be a recordbreaking
10 minutes, during which
the hospital's head of neurology Dr
Guadalupe Maria Bruera will make
several life-changing decisions.
In-hospital vs communityonset
strokes
Up to 17% of all strokes occur during
acute care hospitalisation in patients
admitted for another diagnosis or
procedure, according to a paper on
in-hospital ischemic stroke by Dr
Ethan Cumbler of the University of
Colorado School of Medicine published
in Neurohospitalist in 2015. Between
half and two-thirds of these are
perioperative and periprocedural, with
cardiac surgery patients at greatest risk.
In-hospital strokes have substantially
worse outcomes than community-onset
strokes and not only because they
occur in patients who are older, already
ill and have higher rates of medical
or surgical contraindicactions for
thrombolysis. In-hospital strokes also
tend to have longer delays to evaluation
and treatment.
A February 2022 scientific statement
from the American Heart Association
cites evidence that patients with inhospital
stroke have a significantly
longer interval from symptom
recognition to neuroimaging compared
with stroke patients in the emergency
The reasons for this include stroke
symptoms being wrongly attributed
to the illness for which the patient was
hospitalised, to the effect of sedation
or anesthesia, or to side effects of
medications. Unlike patients with
community-onset stroke, the victims
of in-hospital stroke also do not enter
the system through the emergency
department with its culture of urgency.
Rather, they are likely to be cared
for by staff who are inexperienced in
stroke diagnosis and less aware of the
importance of acting fast.
Ten precious minutes
The 63-year-old citizen of Rosario is
one of the lucky ones. Dr Cigalini, like
everyone else at Hospital Privado de
Rosario, regularly attends the stroke
code training that takes place every
month, and is acutely aware of the
importance of immediate action in
case of stroke. When he recognises
that his patient is manifesting aphasia,
he activates Code Stroke without a
moment's hesitation.
In-hospital strokes have
substantially worse outcomes
than community-onset strokes
department setting (4.5 hours versus
1.2 hours). A study from the Get With
The Guidelines registry found that
compared with community-onset
stroke, the time that elapsed from
stroke recognition to thrombolysis was
also longer, at 81 minutes versus 60
minutes.
En route from the cath lab to the
imaging room a short distance
away, an NIHSS evaluation by the
neurologist on duty Dr Guadalupe
Bruera delivers a score of 12. Using
magnetic resonance angiography,
it takes just two minutes to rule out
bleeding and locate the occlusion
in the segment from M3 to the left
middle cerebral artery. Recognising
that the clot cannot be reached with
surgical thrombectomy, Dr Bruera
makes the decision to thrombolyse.
She administers the bolus herself. The
rest of the infusion will take place in
the ICU where the patient will remain
for 60 minutes.
Dr Cigalini has remained present
throughout, providing critical data
that informs the therapeutic decision
and managing communication with
the patient's family.
The entire process from stroke code
activation to treatment has taken just
10 precious minutes.
SPONSORED FEATURE I ARGENTINIAN HOSPITAL'S 10-MINUTE MIRACLE
Sponsored feature from Argentina

http://http://

WSO - February 2023

Table of Contents for the Digital Edition of WSO - February 2023