Ischemic Stroke without Infarctions: Occlusion and stenosis of carotid arteries ASN Conference September 12 th, 2013

Required Stroke Codes: GWTG Stroke Registry Ischemic Stroke Occlusion and stenosis of basilar artery with cerebral infarction Occlusion and stenosis of carotid artery with cerebral infarction Occlusion and stenosis of vertebral artery with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction Occlusion and stenosis of other specified precerebral artery with cerebral infarction Occlusion and stenosis of unspecified precerebral artery with cerebral infarction Cerebral thrombosis with cerebral infarction Cerebral embolism with cerebral infarction Cerebral artery occlusion unspecified with cerebral infarction 436Acute, but ill-defined, cerebrovascular disease Ischemic Stroke without Infarctions (These will be excluded when computing internal stroke volumes) Occlusion and stenosis of carotid artery without cerebral infarction Cerebral thrombosis without mention of cerebral infarction Hemorrhagic Stroke 430Subarachnoid hemorrhage 431Intracerebral hemorrhage 432Other and unspecified intracranial hemorrhage Nontraumatic extradural hemorrhage 432.1Subdural hemorrhage Transient Ischemic Attack (TIA) Basilar artery syndrome Vertebral artery syndrome Subclavian steal syndrome Vertebrobasilar artery syndrome Other specified Transient Cerebral Unspecified transient cerebral ischemia

Required Stroke Codes: Joint Commission Submissions Ischemic Stroke Occlusion and stenosis of basilar artery with cerebral infarction Occlusion and stenosis of carotid artery without cerebral infarction Occlusion and stenosis of carotid artery with cerebral infarction Occlusion and stenosis of vertebral artery with cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction Occlusion and stenosis of other specified precerebral artery with cerebral infarction Occlusion and stenosis of unspecified precerebral artery with cerebral infarction Cerebral thrombosis without mention of cerebral infarction Cerebral thrombosis with cerebral infarction Cerebral embolism with cerebral infarction Cerebral artery occlusion unspecified with cerebral infarction 436 Acute, but ill-defined, cerebrovascular disease Hemorrhagic Stroke 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage

Case Study #1 HPI: 73 yo F with recent admission to OUTSIDE FACILITY for anemia. CT scan done there showed 90% stenosis of left carotid artery. Patient denied any symptoms including dizziness, weakness in arms or legs, difficulty swallowing or slurred/altered speech. She had been aware of her carotid stenosis and has been followed for it, last that she was aware there was 70% stenosis. She was transferred for further care. The patient underwent a L CEA without complications. DISCHARGE DIAGNOSIS: Principle Problem: Internal carotid artery stenosis Principal dx (carotid artery stenosis) no infarct. Neurology/Stroke Service was never consulted on this patient. As a result, we were unable to make recommendations for managing care and failed several quality measures.

Case Study #2 HPI: 68 y.o., male with a h/o CAD s/p CABG 10 years ago, HTN, HLD who presented with dizziness for the past couple of weeks. He was evaluated by his cardiologist who performed a syncopal work-up. This included a CTA head/neck, which showed a high grade stenosis (85-90%) of the left ICA at the origin and complete occlusion of the right ICA. A carotid duplex showed left ICA stenosis (50-69%) and right ICA was occluded. Whenever he looks up or down he feels "light- headed" but has not passed out or fallen. He reports blurry vision. He denies any history of TIAs or strokes in the past. A repeat carotid duplex showed severe stenosis 80-99% of the left ICA and complete occlusion of the right ICA. He underwent a left carotid endarterectomy on 3/28/13. He tolerated the procedure well. It was noted post-operatively he had droop to the left side of his lip. He was watched in the ICU over night and his neuro checks remained unchanged. On POD 1, the patient was tolerating oral intake, pain was controlled with oral medication, and the patient was out of bed. At this point patient was deemed suitable for home discharge. DISCHARGE DIAGNOSIS: Principle Problem: Internal carotid artery stenosis Principal dx (carotid artery stenosis) no infarct. Neurology/Stroke Service was never consulted on this patient. (This was especially concerning due to the post procedure complication of a facial droop.) As a result, we were unable to make recommendations for managing care and failed several quality measures.

How does your institution handle these cases? Do you include them in your database? How do you identify them?