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Inoa V, Goyal N. Role of Stroke Scales and Scores in Cerebrovascular Disease. Neurol Clin 2024; 42:753-765. [PMID: 38937040 DOI: 10.1016/j.ncl.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
This article provides a comprehensive review of widely utilized stroke scales in both routine clinical settings and research. These scales are crucial for planning treatment, predicting outcomes, and helping stroke patients recover. They also play a pivotal role in planning, executing, and comprehending stroke clinical trials. Each scale presents distinct advantages and limitations, and the authors explore these aspects within the article. The authors' intention is to provide the reader with practical insights for a clear understanding of these scales, and their effective use in their clinical practice.
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Affiliation(s)
- Violiza Inoa
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nitin Goyal
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Katsanos AH, Poppe A, Swartz RH, Mandzia J, Catanese L, Shankar J, Yip S, Verreault S, Medvedev G, Maran I, Legault C, Ferguson D, Archer B, Bharatha A, Volders D, Kelly M, Carpani F, Pikula A, Tkach A, Moreau F, Beaudry M, Appireddy R, Deshmukh A, Almekhlafi M, Fahed R, Kamal N, Menon B, Shoamanesh A, Williams H, Yu AYX, Heran MKS, Hill MD, Sharma M, Earl K, Demchuk AM, Stotts G. Interhospital Transfer for Endovascular Stroke Treatment in Canada: Results From the OPTIMISE Registry. Stroke 2024; 55:2103-2112. [PMID: 39038099 DOI: 10.1161/strokeaha.124.046690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/12/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Interhospital transfer for patients with stroke due to large vessel occlusion for endovascular thrombectomy (EVT) has been associated with treatment delays. METHODS We analyzed data from Optimizing Patient Treatment in Major Ischemic Stroke With EVT, a quality improvement registry to support EVT implementation in Canada. We assessed for unadjusted differences in baseline characteristics, time metrics, and procedural outcomes between patients with large vessel occlusion transferred for EVT and those directly admitted to an EVT-capable center. RESULTS Between January 1, 2018, and December 31, 2021, a total of 6803 patients received EVT at 20 participating centers (median age, 73 years; 50% women; and 50% treated with intravenous thrombolysis). Patients transferred for EVT (n=3376) had lower rates of M2 occlusion (22% versus 27%) and higher rates of basilar occlusion (9% versus 5%) compared with those patients presenting directly at an EVT-capable center (n=3373). Door-to-needle times were shorter in patients receiving intravenous thrombolysis before transfer compared with those presenting directly to an EVT center (32 versus 36 minutes). Patients transferred for EVT had shorter door-to-arterial access times (37 versus 87 minutes) but longer last seen normal-to-arterial access times (322 versus 181 minutes) compared with those presenting directly to an EVT-capable center. No differences in arterial access-to-reperfusion times, successful reperfusion rates (85% versus 86%), or adverse periprocedural events were found between the 2 groups. Patients transferred to EVT centers had a similar likelihood for good functional outcome (modified Rankin Scale score, 0-2; 41% versus 43%; risk ratio, 0.95 [95% CI, 0.88-1.01]; adjusted risk ratio, 0.98 [95% CI, 0.91-1.05]) and a higher risk for all-cause mortality at 90 days (29% versus 25%; risk ratio, 1.15 [95% CI, 1.05-1.27]; adjusted risk ratio, 1.14 [95% CI, 1.03-1.28]) compared with patients presenting directly to an EVT center. CONCLUSIONS Patients transferred for EVT experience significant delays from the time they were last seen normal to the initiation of EVT.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K., L.C., A.S., M.S.)
| | - Alexandre Poppe
- Department of Neurosciences, Université de Montréal and Centre Hospitalier de l'Université de Montréal, QC, Canada (A. Poppe)
| | - Rick H Swartz
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (R.H.S., A.Y.X.Y.)
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | | | - Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Canada (J.S.)
| | - Samuel Yip
- Division of Neurology (S.Y.), The University of British Columbia, Vancouver, Canada
| | - Steve Verreault
- CHU de Québec, Hôpital de l'Enfant-Jésus, Montreal, Canada (S.V.)
| | - George Medvedev
- University of British Columbia and the Fraser Health Authority, New Westminster, Canada (G.M.)
| | - Ilavarasy Maran
- Department of Neurology, Trillium Health Partners, Missisauga, ON, Canada (I.M.)
| | - Catherine Legault
- Division of Neurology, McGill University Health Centre, Montreal, QC, Canada (C.L.)
| | - Darren Ferguson
- Department of Diagnostic Radiology, Dalhousie University, Saint John, NB, Canada (D.F., B.A.)
| | - Brian Archer
- Department of Diagnostic Radiology, Dalhousie University, Saint John, NB, Canada (D.F., B.A.)
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, ON, Canada (A.B.)
| | - David Volders
- Diagnostic Imaging, Dalhousie University, Halifax, NS, Canada (D.V.)
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada (M.K.)
| | - Federico Carpani
- Toronto Western Hospital and the University of Toronto, ON, Canada (F.C., A. Pikula)
| | - Aleksandra Pikula
- Toronto Western Hospital and the University of Toronto, ON, Canada (F.C., A. Pikula)
| | | | | | - Michel Beaudry
- Centre de santé et de services sociaux de Chicoutimi, Saguenay, QC, Canada (M.B.)
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A.)
| | - Aviraj Deshmukh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine, Sudbury, ON, Canada (A.D.)
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Robert Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital, ON, Canada (R.F., G.S.)
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada (N.K.)
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K., L.C., A.S., M.S.)
| | | | - Amy Y X Yu
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (R.H.S., A.Y.X.Y.)
| | - Manraj K S Heran
- Department of Radiology (M.K.S.H.), The University of British Columbia, Vancouver, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Mukul Sharma
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K., L.C., A.S., M.S.)
| | - Karen Earl
- Canadian Stroke Consortium, Oakville, ON (K.E.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (M.A., B.M., M.D.H., A.M.D.)
| | - Grant Stotts
- Division of Neurology, Department of Medicine, The Ottawa Hospital, ON, Canada (R.F., G.S.)
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Rowling H, Italiano D, Churilov L, Palanikumar L, Harvey J, Kleinig T, Parsons M, Mitchell P, Davis S, Kruyt N, Campbell B, Zhao H. Large vessel occlusive stroke with milder baseline severity shows better collaterals and reduced harm from thrombectomy transfer delays. Int J Stroke 2024; 19:772-778. [PMID: 38506406 DOI: 10.1177/17474930241242954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Patients with large vessel occlusion (LVO) stroke presenting with milder baseline clinical severity are common and require endovascular thrombectomy. However, such patients are difficult to recognize using pre-hospital severity-based triage tools and therefore are likely to require a secondary inter-hospital transfer if transported to a non-thrombectomy center. Given the potential for milder severity to represent better underlying cerebrovascular collateral circulation, it is unknown whether transfer delays are still associated with poorer post-stroke outcomes in this patient group. AIMS We primarily aimed to examine whether the harmful effect of inter-hospital transfer delay for thrombectomy was different for LVO patients with mild or severe deficits. Secondarily, we also investigated whether imaging markers of collateral circulation were different between severity groups. METHODS Registry data from two large Australian thrombectomy centers were used to identify all directly presenting and secondarily transferred LVO patients undergoing thrombectomy, divided into those with lower (NIHSS < 10) and higher (NIHSS ⩾ 10) baseline deficits. The primary outcome was the functional independence or return to baseline defined as modified Rankin Scale 0-2 or baseline at 90 days. Patients with complete baseline CT-perfusion data were analyzed for imaging markers of collateral circulation by baseline severity group. RESULTS A total of 1210 LVO patients undergoing thrombectomy were included, of which 273 (22.6%) had lower baseline severity. Despite similar thrombolysis and recanalization rates, transferred patients had lower odds of achieving the primary outcome compared to the primary presentation to a thrombectomy center, where baseline severity was higher (adjusted odds ratio (aOR) 0.759 (95% CI 0.576-0.999)), but not when severity was lower (aOR 1.357 (95% CI 0.764-2.409), p-interaction = 0.122). In the imaging analysis of 436 patients, those with milder severity showed smaller median ischemic core volumes (12.6 (IQR 0.0-17.9) vs 27.5 (IQR 6.5-37.1) mL, p < 0.001)), higher median perfusion mismatch ratio (10.8 (IQR 4.8-54.5) vs 6.6 (IQR 3.5-16.5), p < 0.001), and lower median hypoperfusion intensity ratio (0.25 (IQR 0.18-0.38) vs 0.40 (IQR 0.22-0.57), p < 0.001). DISCUSSION Patients receiving secondary inter-hospital transfer for thrombectomy had poorer outcomes compared to those presenting directly to a thrombectomy center if baseline deficits were severe, but this difference was not observed when baseline deficits were milder. This result may potentially be due to our secondary findings of significantly improved collateral circulation markers in lower-severity LVO patients. As such, failure of pre-hospital screening tools to detect lower-severity LVO patients for pre-hospital bypass to a thrombectomy center may not necessarily deleteriously affect outcome. DATA ACCESS STATEMENT Anonymized data not published within this article will be made available on request from any qualified investigator.
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Affiliation(s)
- Hannah Rowling
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dominic Italiano
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Logesh Palanikumar
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jackson Harvey
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Parsons
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, NSW, Australia
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter Mitchell
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen Davis
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Nyika Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bruce Campbell
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Henry Zhao
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
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Lee VH. Small Step or Giant Leap? Expanding the Acute Stroke Thrombolysis Window to 24 Hours. N Engl J Med 2024; 391:273-275. [PMID: 38884321 DOI: 10.1056/nejme2405846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Affiliation(s)
- Vivien H Lee
- From the Department of Neurology, Ohio State University Wexner Medical Center, Columbus
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Matsukawa H, Crosa R, Cunningham C, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Shaban A, Goyal N, Yoshimura S, Cuellar H, Howard B, Alawieh A, Alaraj A, Ezzeldin M, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Siddiqui F, Osbun J, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Williamson R, Navia P, Kan P, Leacy RD, Chowdhry S, Spiotta AM. Earlier Endovascular Thrombectomy and Mortality in Patients with Anterior Circulation Large Vessel Occlusion: A Propensity-Matched Analysis of the Stroke Thrombectomy and Aneurysm Registry. World Neurosurg 2024:S1878-8750(24)01041-6. [PMID: 38908685 DOI: 10.1016/j.wneu.2024.06.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/16/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND The definitive impact of onset to arterial puncture time (OPT) on 90-day mortality after endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) caused by anterior circulation large vessel occlusion (LVO) remains unknown. The present study aimed to evaluate the influence of OPT on 90-day mortality in anterior circulation AIS-LVO patients who underwent EVT. METHODS Data from 33 international centers were retrospectively analyzed. The receiver operating characteristic curve analysis was used to identify a cutoff for OPT. A propensity score-matched analysis was performed. The primary outcome was 90-day mortality (modified Rankin Scale [mRS] 6). Secondary outcomes included mortality at discharge, 90-day good outcome (mRS 0-2), 90-day poor outcome (mRS 5-6), successful recanalization (defined as postprocedure modified Thrombolysis in Cerebral Infarction scale ≥2b), and intracranial hemorrhage. RESULTS A total of 2842 AIS-LVO patients with EVT were included. The cutoff for OPT for 90-day mortality was 180 min. Of these 378 patients had OPT <180 min and 378 patients had OPT ≥180 min in the propensity score-matched cohort (n = 756). Patients with OPT <180 min were less likely to have 90-day mortality (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.51-0.96) and poor outcome (OR 0.71, 95% CI 0.53-0.96), and more likely to have 90-day good outcome (OR 1.55, 95% CI 1.16-2.08). Other outcomes showed no significant differences. CONCLUSIONS This study showed that OPT <180 min was less related to 90-day mortality and poor outcome, and more to 90-day good outcome in AIS-LVO patients who underwent EVT.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA; Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay.
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Stacey Quintero Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown, Virginia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Health System, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of interventional and diagnostical Neuroradiology, University of Basel, Basel, Switzerland
| | - Amir Shaban
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Nitin Goyal
- Department of Neurosurgery, University of Tennessee Health Science Center/Semmes Murphey Foundation, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hugo Cuellar
- Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Brian Howard
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, Houston, Texas, USA
| | - Daniele G Romano
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School, UNL, Lisbon, Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Fazeel Siddiqui
- Department of Neuroscience, University of Michigan Health West, Wyoming, Michigan, USA
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St Louis, Missouri, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Mark Moss
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, Arkansas, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurological Surgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Shakeel Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Victor P, Bian E, Mamdouh H, Mohamed GA, Nour HA, Miller K, Singh K, Patel S, Segovis C, Nahab F. Upfront vascular imaging in acute stroke: Impact on thrombectomy transfer time at a primary stroke center. J Stroke Cerebrovasc Dis 2024; 33:107815. [PMID: 38878844 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 05/17/2024] [Accepted: 06/10/2024] [Indexed: 06/24/2024] Open
Abstract
OBJECTIVES Early cerebral arterial imaging is currently only recommended in the subgroup of acute ischemic stroke (AIS) patients suspected of having large vessel occlusion (LVO). There is limited data on the impact of early cerebrovascular imaging in all suspected AIS patients presenting within 24 h of symptom onset and the impact on door in-door out (DIDO) time. MATERIALS AND METHODS In January 2020, our Primary Stroke Center implemented a protocol to perform upfront head and neck CT angiography (CTA) with initial non-contrast CT head for all suspected ischemic stroke patients screening positive for BE-FAST stroke symptoms within 24 h from last known normal time. We retrospectively reviewed IV alteplase and thrombectomy-eligible patients before (January 1-December 31, 2019) and after protocol implementation (January 1, 2020-June 30, 2022). RESULTS Of 86 patients meeting study criteria, up-front CTA was associated with significant reductions in door-to-CTA start (median 37 vs 15 min, p = 0.003), door-to-CTA result (median 83 vs 52 min, p = 0.023) and DIDO times (median 150 vs 106 min, p = 0.023). There was no significant difference in door-to-needle time before and after protocol implementation (median 48 vs 43 min, p = 0.450). CONCLUSION Up-front cerebrovascular imaging with CTA in suspected AIS patients presenting within 24 h resulted in shorter DIDO times without delaying door-to-needle times. Primary Stroke Centers should consider this approach to detect LVO early and expedite patient transport to thrombectomy capable centers.
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Affiliation(s)
- Patricia Victor
- Emory Healthcare, 1365 Clifton Road NE, Clinic B, Suite 2200, Atlanta, GA 30322, Georgia
| | | | | | - Ghada A Mohamed
- Medical University of South Carolina, Charleston, South Carolina
| | - Hassan Aboul Nour
- Departments of Neurology and Neurosurgery, University of Kentucky College of Medicine, Lexington, KY
| | | | | | | | | | - Fadi Nahab
- Emory Healthcare, 1365 Clifton Road NE, Clinic B, Suite 2200, Atlanta, GA 30322, Georgia; Emory University, Atlanta, Georgia.
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Abou Loukoul W, Richard S, Mione G, Finitsis S, Derelle AL, Zhu F, Liao L, Anxionnat R, Douarinou M, Humbertjean L, Gory B. Outcome of stroke patients eligible to mechanical thrombectomy managed by spoke center, primary stroke center or comprehensive stroke center in the East of France. Rev Neurol (Paris) 2024; 180:517-523. [PMID: 38036405 DOI: 10.1016/j.neurol.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/20/2023] [Accepted: 08/25/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND AND PURPOSE Patients with suspected stroke are referred to the nearest hospital and are managed either in a spoke center (SC), a primary stroke center (PSC), or a comprehensive stroke center (CSC) in order to benefit from early intravenous thrombolysis (IVT). In case of large vessel occlusion (LVO), mechanical thrombectomy (MT) is only performed in the CSC, whereas the effectiveness of MT is highly time-dependent. There is a debate about the best management model of patients with suspected LVO. Therefore, we aimed to compare functional and safety outcomes of LVO patients eligible for MT managed through our regional telestroke system. METHOD We performed a retrospective analysis of our observational prospective clinical registry in all consecutive subjects with LVO within six hours of onset who were admitted to the SC, PSC, or CSC in the east of France between October 2017 and November 2022. The primary endpoint was the functional independence defined as modified Rankin scale (mRS) score 0 to 2 at 90 days. Secondary endpoints were functional outcome, early neurological improvement, symptomatic intracranial hemorrhage and 90-day mortality. RESULTS Among the 794 included patients with LVO who underwent MT, 122 (15.4%) were managed by a SC, 403 (50.8%) were first admitted to a PSC, and 269 (33.9%) were first admitted to the CSC. The overall median NIHSS and ASPECTS score were 16 and 8, respectively. Multivariate analysis did not find any significant difference for the primary endpoint between patients managed by PSC versus CSC (OR 1.06 [95% CI 0.64;1.76], P=0.82) and between patient managed by SC versus CSC (OR 0.69 [0.34;1.40], P=0.30). No difference between the three groups was found except for the parenchymal hematoma rate between PSC and CSC (15.7 versus 7.4%, OR 2.25 [1.07;4.74], P=0.032). CONCLUSIONS Compared with a first admission to a CSC, the clinical outcomes of stroke patients with LVO eligible for MT first admitted to a SC or a PSC are similar.
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Affiliation(s)
- W Abou Loukoul
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - S Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France; Université de Lorraine, Inserm U1116, Nancy, France
| | - G Mione
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France
| | - S Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - A-L Derelle
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - F Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France; Université de Lorraine, Inserm U1254, Nancy, France
| | - L Liao
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - R Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France; Université de Lorraine, Inserm U1254, Nancy, France
| | - M Douarinou
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France
| | - L Humbertjean
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France; Université de Lorraine, Inserm U1254, Nancy, France.
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Seners P, Wouters A, Ter Schiphorst A, Yuen N, Mlynash M, Arquizan C, Heit JJ, Kemp S, Christensen S, Sablot D, Wacongne A, Lalu T, Costalat V, Lansberg MG, Albers GW. Arterial Recanalization During Interhospital Transfer for Thrombectomy. Stroke 2024; 55:1525-1534. [PMID: 38752736 DOI: 10.1161/strokeaha.124.046694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Patients with acute ischemic stroke harboring a large vessel occlusion admitted to nonendovascular-capable centers often require interhospital transfer for thrombectomy. We evaluated the incidence and predictors of arterial recanalization during transfer, as well as the relationship between interhospital recanalization and clinical outcomes. METHODS We analyzed data from 2 cohorts of patients with an anterior circulation large vessel occlusion transferred for consideration of thrombectomy to a comprehensive center, with arterial imaging at the referring hospital and on comprehensive stroke center arrival. Interhospital recanalization was determined by comparison of the baseline and posttransfer arterial imaging and was defined as revised arterial occlusive lesion (rAOL) score 2b to 3. Pretransfer variables independently associated with interhospital recanalization were studied using multivariable logistic regression analysis. RESULTS Of the 520 included patients (Montpellier, France, n=237; Stanford, United States, n=283), 111 (21%) experienced interhospital recanalization (partial [rAOL=2b] in 77% and complete [rAOL=3] in 23%). Pretransfer variables independently associated with recanalization were intravenous thrombolysis (adjusted odds ratio, 6.8 [95% CI, 4.0-11.6]), more distal occlusions (intracranial carotid occlusion as reference: adjusted odds ratio, 2.0 [95% CI, 0.9-4.5] for proximal first segment of the middle cerebral artery, 5.1 [95% CI, 2.3-11.5] for distal first segment of the middle cerebral artery, and 5.0 [95% CI, 2.1-11.8] for second segment of the middle cerebral artery), and smaller clot burden (clot burden score 0-4 as reference: adjusted odds ratio, 3.4 [95% CI, 1.5-7.6] for 5-7 and 5.6 [95% CI, 2.4-12.7] for 8-9). Recanalization on arrival at the comprehensive center was associated with less interhospital infarct growth (rAOL, 0-2a: 11.6 mL; rAOL, 2b: 2.2 mL; rAOL, 3: 0.6 mL; Ptrend<0.001) and greater interhospital National Institutes of Health Stroke Scale score improvement (0 versus -5 versus -6; Ptrend<0.001). Interhospital recanalization was associated with reduced 3-month disability (adjusted common odds ratio, 2.51 [95% CI, 1.68-3.77]) with greater benefit from complete than partial recanalization. CONCLUSIONS Recanalization is frequently observed during interhospital transfer for thrombectomy and is strongly associated with favorable outcomes, even when partial. Broadening thrombolysis indications in primary centers, and developing therapies that increase recanalization during transfer, will likely improve clinical outcomes.
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Affiliation(s)
- Pierre Seners
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
- Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France (P.S.)
- Institut de Psychiatrie et Neurosciences de Paris, U1266, INSERM, Paris, France (P.S., C.A.)
| | - Anke Wouters
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
- Division of Experimental Neurology, Department of Neurosciences, KU Leuven, Belgium (A.W.)
| | | | - Nicole Yuen
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
| | - Michael Mlynash
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
| | - Caroline Arquizan
- Institut de Psychiatrie et Neurosciences de Paris, U1266, INSERM, Paris, France (P.S., C.A.)
- Neurology Department (A.T.S., C.A.), CHRU Gui de Chauliac, Montpellier, France
| | - Jeremy J Heit
- Radiology Department, Stanford University, Palo Alto, CA (J.J.H.)
| | - Stephanie Kemp
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
| | - Soren Christensen
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
| | - Denis Sablot
- Neurology Department, CH Perpignan, Perpignan, France (D.S.)
| | | | | | - Vincent Costalat
- Neuroradiology Department (V.C.), CHRU Gui de Chauliac, Montpellier, France
| | - Maarten G Lansberg
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
| | - Gregory W Albers
- Stanford Stroke Center, Palo Alto, CA (P.S., A.W., N.Y., M.M., S.K., S.C., M.G.L., G.W.A.)
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Shen H, Huasen BB, Killingsworth MC, Bhaskar SMM. Introducing the Futile Recanalization Prediction Score (FRPS): A Novel Approach to Predict and Mitigate Ineffective Recanalization after Endovascular Treatment of Acute Ischemic Stroke. Neurol Int 2024; 16:605-619. [PMID: 38921949 PMCID: PMC11206671 DOI: 10.3390/neurolint16030045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
Objective: This study aims to develop and validate the Futile Recanalization Prediction Score (FRPS), a novel tool designed to predict the severity risk of FR and aid in pre- and post-EVT risk assessments. Methods: The FRPS was developed using a rigorous process involving the selection of predictor variables based on clinical relevance and potential impact. Initial equations were derived from previous meta-analyses and refined using various statistical techniques. We employed machine learning algorithms, specifically random forest regression, to capture nonlinear relationships and enhance model performance. Cross-validation with five folds was used to assess generalizability and model fit. Results: The final FRPS model included variables such as age, sex, atrial fibrillation (AF), hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, cognitive impairment, pre-stroke modified Rankin Scale (mRS), systolic blood pressure (SBP), onset-to-puncture time, sICH, and NIHSS score. The random forest model achieved a mean R-squared value of approximately 0.992. Severity ranges for FRPS scores were defined as mild (FRPS < 66), moderate (FRPS 66-80), and severe (FRPS > 80). Conclusions: The FRPS provides valuable insights for treatment planning and patient management by predicting the severity risk of FR. This tool may improve the identification of candidates most likely to benefit from EVT and enhance prognostic accuracy post-EVT. Further clinical validation in diverse settings is warranted to assess its effectiveness and reliability.
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Affiliation(s)
- Helen Shen
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
| | - Bella B. Huasen
- Department of Interventional Neuroradiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR2 9HT, UK
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Murray C. Killingsworth
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Cell-Based Disease Intervention Group, Clinical Sciences Stream, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Western Sydney University, Liverpool, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Cell-Based Disease Intervention Group, Clinical Sciences Stream, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South West Sydney Local Health District, Liverpool, NSW 2170, Australia
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10
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van der Meulen M, Wijnenga MMJ. Education and training in neurology: developments and future challenges. Eur J Neurol 2024:e16332. [PMID: 38773718 DOI: 10.1111/ene.16332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/17/2024] [Accepted: 04/24/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND AND PURPOSE Training and education is essential for best practice medicine and is especially important in a rapidly evolving field such as neurology. Due to improved imaging techniques and laboratory testing, there is a better understanding of the pathophysiology of diseases. As a result more treatments have become available. The most important developments in neurology over the last two decades and their effect on training and education are described. In addition, how future training should be aware of the challenges ahead of us is described. METHODS This is a narrative review describing developments and challenges based on personal experience and the literature. RESULTS Due to major developments in radiological and immunological testing, major changes have been seen in different subspecialties of neurology, including but not limited to, the treatment of ischaemic stroke, the development of new entities in the field of demyelinating diseases and auto-immune encephalitis, and diffuse glioma. These developments challenge the education and training in neurology with, ahead of us, technological developments, an aging population, and potentially more superspecialization. CONCLUSION Although there are differences in the training curricula between European countries, the developments and future challenges within the field of neurology are very similar. In the development of future curricula it is important to face these developments and challenges and to adapt to them.
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Lee M, Rafiq Sayyed D, Kim H, Sanchez JC, Sik Hong S, Choi S, Kim H, Han E, Won Kang H, Min Kim J, Joan M, Kim H, Chae H, Park JM. A comprehensive Exdia TRF-LFIA for simultaneous quantification of GFAP and NT-proBNP in distinguishing ischemic and hemorrhagic stroke. Clin Chim Acta 2024; 557:117872. [PMID: 38471630 DOI: 10.1016/j.cca.2024.117872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/23/2024] [Accepted: 03/09/2024] [Indexed: 03/14/2024]
Abstract
The goal of this study is to create a highly sensitive time-resolved fluorescence lateral flow immunoassay (TRF-LFIA) capable of concurrently measuring glial fibrillary acidic protein (GFAP) and the N-terminal fragment of B-type natriuretic peptide precursor (NT-proBNP). This assay is designed as a diagnostic tool and aims to provide an algorithm for stroke management, specifically for distinguishing between Ischemic stroke (IS) and Hemorrhagic stroke (HS). However, LFIA to quantify simultaneous serum NT-proBNP and GFAP are not yet available. We have developed and validated a novel TRF-LFIA for the simultaneous quantitative detection of NT-proBNP and GFAP. The sensitivity and reproducibility of the immunoassay were significantly improved by employing specific monoclonal antibodies linked to europium nanoparticles (EuNPs) that specifically target NT-proBNP and GFAP. The detection area on the nitrocellulose membrane featured sandwich-style complexes containing two test lines for NT-proBNP and GFAP, and one Control line. The fluorescence intensity of these test lines and control line was measured using an in-house developed Exdia TRF-Plus analyzer. As proof-of-concept, we enrolled patients suspected of having a stroke who were admitted within a specific time frame (6 h). A small amount of clinical specimen (serum) was used. To optimize the LFIA, an EuNPs conjugated antibodies were investigated to improve the detection sensitivity and decrease the background signal as well shorten the detection time. The Exdia TRF-LFIA cartridge offers a wide linear dynamic detection range, rapid detection, high sensitivity, and specificity. The limit of detection was determined to be 98 pg/mL for NT-proBNP and 68 pg/mL for GFAP, with minimal cross-reactivity. There were 200 clinical human serum samples that were used to evaluate this platform with high correlation. By combining the results of NT-proBNP and GFAP, we formulated an algorithm for the clinical assessment of Ischemic Stroke (IS) and Hemorrhagic Stroke (HS). According to our proposed algorithm, the combination of GFAP and NT-proBNP emerged as the most effective biomarker combination for distinguishing between IS and HS. Exdia TRF-LFIA shows great potential as a supplemental method for in vitro diagnostics in the laboratory or in other point-of-care testing (POCT) applications. Its development substantially decreases the diagnosis time for IS and HS. The proposed algorithm not only minimizes treatment delays but also lowers medical costs for patients.
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Affiliation(s)
- Minki Lee
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | | | - Hyejeong Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | | | - Sung Sik Hong
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | - Sehee Choi
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | - Hyunghoon Kim
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | - Eunhee Han
- Department of Laboratory Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hye Won Kang
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | - Jeong Min Kim
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | - Montaner Joan
- ABCDx, Avenue de Sécheron 15, 1202 Geneva, Switzerland
| | - Hanshin Kim
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea
| | - Hyojin Chae
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jong-Myeon Park
- Precision Biosensor, 306, Techno 2-ro, Yuseong-gu, Daejeon 34036, South Korea.
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12
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del Toro-Pérez C, Amaya-Pascasio L, Arjona-Padillo A, Martínez-Sánchez P. Impact of Direct Transport to Thrombectomy-Capable Center vs. Nearby/Distant Local Stroke Centers on Stroke Outcome in Patients Undergoing Thrombectomy: A Real-Life Study. J Pers Med 2024; 14:395. [PMID: 38673022 PMCID: PMC11050859 DOI: 10.3390/jpm14040395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Our aim was to compare the stroke outcomes of a direct transfer (DT) to a thrombectomy-capable center vs. initial care at two local stroke centers: a nearby hospital (NH, 36 km) and a distant hospital (DH, 113 km). Patients who underwent a mechanical thrombectomy were analyzed (February 2017-October 2021), and the outcome was considered favorable if the modified Rankin scale (mRS) score was ≤ 2 at three months. A total of 300 patients were included, 55 of which were transferred from the NH and 58 from the DH. There was a difference in the median (IQR) transfer time of 39 min between the hospitals (149 min for the NH vs. 188 min for the DH, p = 0.003). After adjusting for confounding variables, a secondary transfer from the DH, compared to a DT, was associated with a lower functional independence: mRS score ≤ 2 (OR = 0.37, 95% CI = 0.14-0.97, p = 0.043), without significant differences in the mortality between the groups. These differences were not observed in patients from the NH. Conclusions: A secondary transfer from a distant hospital was associated with a poorer functional outcome at 3 months. This unfavorable outcome was not observed among patients transferred from a nearby hospital. These findings highlight the importance of categorizing the suitability of one transfer model over another based on the proximity of hospitals to the thrombectomy center, but also in accordance with organizational and geographic characteristics that vary within each health region.
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Affiliation(s)
- Cristina del Toro-Pérez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Laura Amaya-Pascasio
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Antonio Arjona-Padillo
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Patricia Martínez-Sánchez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
- Faculty of Health Sciences, CEINSA (Center of Health Research), University of Almería, 04120 Almería, Spain
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13
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Masouris I, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Trumm C, Liebig T, Kellert L, Schöberl F. Basilar artery occlusion: drip-and-ship versus direct-to-center for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria (NEVAS). J Neurol 2024; 271:1885-1892. [PMID: 38095722 DOI: 10.1007/s00415-023-12126-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Recent clinical trials revealed a substantial clinical benefit for mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO). While urban areas are sufficiently covered with comprehensive stroke centers and MT expertise, rural areas lack such resources. Structured telemedical stroke networks offer rural hospitals instant consultation by stroke experts, enabling swift administration of intravenous thrombolysis (IVT) on-site and transportation for MT. For BAO patients, data on performance and clinical outcomes in telemedical stroke networks are lacking. METHODS We retrospectively analyzed data from patients with acute BAO eligible for MT: those treated directly in our comprehensive stroke center (direct-to-center/DC) and those treated in rural hospitals that were telemedically consulted by the Neurovascular Network of Southwest Bavaria (NEVAS) and transferred to our center for MT (drip-and-ship, DS). Key time intervals, stroke management performance and functional outcome after 90 days were compared. RESULTS Baseline characteristics, including premorbid status and stroke severity, were comparable. Time from symptom onset to IVT was identical in both groups (118 min). There was a delay of 180 min until recanalization in DS patients, mainly due to patient transport for MT. Procedural treatment time intervals, success of recanalization and complications were comparable. Clinical outcome at 3 months follow-up of DS patients was not inferior to DC patients. CONCLUSION We show for the first time that patients with BAO in rural areas benefit from a structured telemedicine network such as NEVAS, regarding both on-site processing and drip-and-ship for MT. Clinical outcomes are comparable among DS and DC patients.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | - J Wischmann
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Schniepp
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - L Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - G F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - C Trumm
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - T Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - L Kellert
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - F Schöberl
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
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Baser Y, Zarei H, Gharin P, Baradaran HR, Sarveazad A, Roshdi Dizaji S, Yousefifard M. Cincinnati Prehospital Stroke Scale (CPSS) as a Screening Tool for Early Identification of Cerebral Large Vessel Occlusions; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2024; 12:e38. [PMID: 38737135 PMCID: PMC11088790 DOI: 10.22037/aaem.v12i1.2242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Introduction Large vessel occlusion (LVO) strokes are associated with worse functional outcomes and higher mortality rates. In the present systematic review and meta-analysis, we evaluated the diagnostic yield of the Cincinnati Prehospital Stroke Scale (CPSS) in detecting LVO. Methods We performed an extensive systematic search among online databases including Medline, Embase, Web of Science, and Scopus, until July 31st, 2023. We also conducted a manual search on Google and Google scholar, along with citation tracking to supplement the systematic search in retrieving all studies that evaluated the diagnostic accuracy of the CPSS in detecting LVO among patients suspected to stroke. Results Fourteen studies were included in the present meta-analysis. CPSS showed the sensitivity of 97% (95% CI: 87%-99%) and the specificity of 17% (95% CI: 4%-54%) at the cut-off point of ≥1. The optimal threshold was determined to be ≥2, with a sensitivity of 82% (95% CI: 74%-88%) and specificity of 62% (95% CI: 48%-74%) in detecting LVO. At the highest cut-off point of ≥3, the CPSS had the lowest sensitivity of 60% (95% CI: 51%-69%) and the highest specificity of 81% (95% CI: 71%-88%). Sensitivity analyses showed the robustness of the results regardless of study population, inclusion of hemorrhagic stroke patients, pre-hospital or in-hospital settings, and the definition of LVO. Conclusion A very low level of evidence demonstrated that CPSS, with a threshold set at ≥2, is a useful tool for identifying LVO stroke and directing patients to CSCs, both in prehospital and in-hospital settings.
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Affiliation(s)
- Yazdan Baser
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
- Both authors contributed equally to this work
| | - Hamed Zarei
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
- Both authors contributed equally to this work
| | - Pantea Gharin
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Baradaran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shayan Roshdi Dizaji
- Men’s Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
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15
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Favilla CG, Baird GL, Grama K, Konecky S, Carter S, Smith W, Gitlevich R, Lebron-Cruz A, Yodh AG, McTaggart RA. Portable cerebral blood flow monitor to detect large vessel occlusion in patients with suspected stroke. J Neurointerv Surg 2024:jnis-2024-021536. [PMID: 38514189 DOI: 10.1136/jnis-2024-021536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Early detection of large vessel occlusion (LVO) facilitates triage to an appropriate stroke center to reduce treatment times and improve outcomes. Prehospital stroke scales are not sufficiently sensitive, so we investigated the ability of the portable Openwater optical blood flow monitor to detect LVO. METHODS Patients were prospectively enrolled at two comprehensive stroke centers during stroke alert evaluation within 24 hours of onset with National Institutes of Health Stroke Scale (NIHSS) score ≥2. A 70 s bedside optical blood flow scan generated cerebral blood flow waveforms based on relative changes in speckle contrast. Anterior circulation LVO was determined by CT angiography. A deep learning model trained on all patient data using fivefold cross-validation and learned discriminative representations from the raw speckle contrast waveform data. Receiver operating characteristic (ROC) analysis compared the Openwater diagnostic performance (ie, LVO detection) with prehospital stroke scales. RESULTS Among 135 patients, 52 (39%) had an anterior circulation LVO. The median NIHSS score was 8 (IQR 4-14). The Openwater instrument had 79% sensitivity and 84% specificity for the detection of LVO. The rapid arterial occlusion evaluation (RACE) scale had 60% sensitivity and 81% specificity and the Los Angeles motor scale (LAMS) had 50% sensitivity and 81% specificity. The binary Openwater classification (high-likelihood vs low-likelihood) had an area under the ROC (AUROC) of 0.82 (95% CI 0.75 to 0.88), which outperformed RACE (AUC 0.70; 95% CI 0.62 to 0.78; P=0.04) and LAMS (AUC 0.65; 95% CI 0.57 to 0.73; P=0.002). CONCLUSIONS The Openwater optical blood flow monitor outperformed prehospital stroke scales for the detection of LVO in patients undergoing acute stroke evaluation in the emergency department. These encouraging findings need to be validated in an independent test set and the prehospital environment.
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Affiliation(s)
- Christopher G Favilla
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Grayson L Baird
- Department of Interventional Radiology, Brown University, Providence, Rhode Island, USA
| | | | | | - Sarah Carter
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wendy Smith
- Department of Diagnostic Imaging, Lifespan Health System, Providence, Rhode Island, USA
| | - Rebecca Gitlevich
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexa Lebron-Cruz
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan A McTaggart
- Department of Interventional Radiology, Brown University, Providence, Rhode Island, USA
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16
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Lam TJR, Liu Z, Tan BYQ, Ng YY, Tan CK, Wong XY, Venketasubramanian N, Yeo LLL, Ho AFW, Ong MEH. Prehospital stroke care in Singapore. Singapore Med J 2024:00077293-990000000-00102. [PMID: 38449072 DOI: 10.4103/singaporemedj.smj-2023-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/03/2023] [Indexed: 03/08/2024]
Abstract
ABSTRACT Due to the narrow window of opportunity for stroke therapeutics to be employed, effectiveness of stroke care systems is predicated on the efficiency of prehospital stroke systems. A robust prehospital stroke system of care that provides a rapid and well-coordinated response maximises favourable poststroke outcomes, but achieving this presents a unique set of challenges dependent on demographic and geographical circumstances. Set in the context of a highly urbanised first-world nation with a rising burden of stroke, Singapore's prehospital stroke system has evolved to reflect the environment in which it operates. This review aims to characterise the current state of prehospital stroke care in Singapore, covering prehospital aspects of the stroke survival chain from symptom onset till arrival at the emergency department. We identify areas for improvement and innovation, as well as provide insights into the possible future of prehospital stroke care in Singapore.
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Affiliation(s)
| | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Yih Ying Ng
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore
- Ministry of Home Affairs, Singapore Civil Defence Force, Singapore
| | - Colin Kaihui Tan
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | - Xiang Yi Wong
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | | | | | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
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Kaesmacher J, Cavalcante F, Kappelhof M, Treurniet KM, Rinkel L, Liu J, Yan B, Zi W, Kimura K, Eker OF, Zhang Y, Piechowiak EI, van Zwam W, Liu S, Strbian D, Uyttenboogaart M, Dobrocky T, Miao Z, Suzuki K, Zhang L, van Oostenbrugge R, Meinel TR, Guo C, Seiffge D, Yin C, Bütikofer L, Lingsma H, Nieboer D, Yang P, Mitchell P, Majoie C, Fischer U, Roos Y, Gralla J. Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA 2024; 331:764-777. [PMID: 38324409 PMCID: PMC10851137 DOI: 10.1001/jama.2024.0589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy. Objective To determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset. Design, Setting, and Participants Individual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313). Exposure Interval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone. Main Outcomes and Measures The primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT. Results In 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, -3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes. Conclusions and Relevance In patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Kilian M. Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Omer F. Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People’s Hospital of Nanjing Medical University, Nanjing, China
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Congguo Yin
- Department of Neurology, Hangzhou First People’s Hospital of Zhejiang University, Hangzhou, China
| | | | - Hester Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Sarraj A, Hill MD, Hussain MS, Abraham MG, Ortega-Gutierrez S, Chen M, Kasner SE, Churilov L, Pujara DK, Johns H, Blackburn S, Sundararajan S, Hu YC, Herial NA, Budzik RF, Hicks WJ, Arenillas JF, Tsai JP, Kozak O, Cordato DJ, Hanel RA, Wu TY, Portela PC, Gandhi CD, Al-Mufti F, Maali L, Gibson D, Pérez de la Ossa N, Schaafsma JD, Blasco J, Sangha N, Warach S, Kleinig TJ, Shaker F, Sitton CW, Nguyen T, Fifi JT, Jabbour P, Furlan A, Lansberg MG, Tsivgoulis G, Sila C, Bambakidis N, Davis S, Wechsler L, Albers GW, Grotta JC, Ribo M, Campbell BC, Hassan AE. Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes: A Prespecified Analysis of the SELECT2 Trial. JAMA Neurol 2024:2815043. [PMID: 38363872 PMCID: PMC10853865 DOI: 10.1001/jamaneurol.2024.0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/11/2024] [Indexed: 02/18/2024]
Abstract
Importance Patients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT). Objective To assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes. Design, Setting, and Participants This prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024. Interventions EVT vs MM. Main Outcomes and Measures Functional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication. Results A total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80). Conclusions and Relevance Both directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport. Trial Registration ClinicalTrials.gov Identifier: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Michael D. Hill
- Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
| | - M. Shazam Hussain
- Cerebrovascular Center, Neurology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Michael Chen
- Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | | | - Leonid Churilov
- Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Deep K. Pujara
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Hannah Johns
- Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Spiros Blackburn
- Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Sophia Sundararajan
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Yin C. Hu
- Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nabeel A. Herial
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ronald F. Budzik
- Neuro-Interventional Radiology, OhioHealth, Riverside Methodist Hospital, Columbus
| | | | - Juan F. Arenillas
- Internal Medicine, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain
| | | | - Osman Kozak
- Neurosurgery, Abington Jefferson Health, Abington, Pennsylvania
| | | | - Ricardo A. Hanel
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida
| | - Teddy Y. Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Chirag D. Gandhi
- Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York
| | - Fawaz Al-Mufti
- Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York
| | - Laith Maali
- Neurology, University of Kansas Medical Center, Kansas City
| | - Daniel Gibson
- Neurointerventional Surgery, Ascension Columbia St Mary’s Hospital, Milwaukee, Wisconsin
| | | | | | - Jordi Blasco
- Stroke Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Navdeep Sangha
- Neurology, Kaiser Permanente Southern California, Los Angeles
| | - Steven Warach
- Neurology, Dell Medical School at The University of Texas at Austin, Ascension Texas, Austin
| | | | - Faris Shaker
- Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Clark W. Sitton
- Interventioal and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, Texas
| | - Thanh Nguyen
- Neurology, Boston Medical Center, Boston, Massachusetts
| | - Johanna T. Fifi
- Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anthony Furlan
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Cathy Sila
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nicholas Bambakidis
- Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Stephen Davis
- Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | | | | | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Houston, Texas
| | - Marc Ribo
- Neurology, Hospital Vall d’Hebrón, Sabadell, Spain
| | - Bruce C. Campbell
- Medicine and Neurology, The Royal Melbourne Hospital, The Florey Institute for Neuroscience and Mental Health, Melbourne, Australia
| | - Ameer E. Hassan
- Neuroscience, Valley Baptist Medical Center, Harlingen, Texas
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Leitner MA, Hubert GJ, Paternoster L, Leitner MI, Rémi JM, Trumm C, Haberl RL, Hubert ND. Clinical outcome of rural in-hospital-stroke patients after interhospital transfer for endovascular therapy within a telemedical stroke network in Germany: a registry-based observational study. BMJ Open 2024; 14:e071975. [PMID: 38238050 PMCID: PMC10806718 DOI: 10.1136/bmjopen-2023-071975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 11/08/2023] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVES Little is known about in-hospital-stroke (IHS) patients with large vessel occlusion and subsequent transfer to referral centres for endovascular therapy (EVT). However, this subgroup is highly relevant given the substantial amount of IHS, the ongoing trend towards greater use of EVT and lack of EVT possibilities in rural hospitals. The study objective is to explore the clinical outcomes of this vulnerable patient group, given that both IHS and interhospital transfer are associated with worse clinical outcomes due to a higher proportion of pre-existing conditions and substantial time delays during transfer. DESIGN AND SETTING Prospectively collected data of patients receiving EVT after interhospital transfer from 14 rural hospitals of the Telemedical Stroke Network in Southeast Bavaria (TEMPiS) between February 2018 and July 2020 was analysed. PARTICIPANTS 49 IHS and 274 out-of-hospital-stroke (OHS) patients were included. OUTCOME MEASURES Baseline characteristics, treatment times and outcomes were compared between IHS and OHS. The primary endpoint was a 3-month modified Rankin Scale (mRS). RESULTS In IHS patients, atrial fibrillation (55.3% vs 35.9%, p=0.012), diabetes (36.2% vs 21.1%, p=0.024) and use of oral anticoagulants (44.7% vs 20.8%, p<0.001) were more frequent. Stroke severity was similar in both groups. Treatment times from symptom onset to first brain imaging, therapy decision or EVT were shorter for IHS patients. IHS patients displayed worse clinical outcomes: 59.2% of IHS patients died within 3 months compared with 28.5% of OHS patients (p<0.001). They were less likely to achieve moderate outcomes (mRS 0-3) 3 months after stroke (20.4% vs 39.8%, p=0.010). After controlling for possible confounding variables, IHS was associated with worse clinical outcomes (adjusted OR 3.04 (95% CI 1.57 to 6.04), p<0.001). CONCLUSIONS The mortality of IHS patients after interhospital transfer and EVT was high and functional outcomes were worse compared with those of OHS patients. Further research is needed to ascertain whether IHS patients benefit from this therapeutic approach. A more careful selection of IHS patients for transfer and means to enable faster treatment should be considered. TRIAL REGISTRATION NUMBER NCT04270513; Post-results.
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Affiliation(s)
- Miriam Antonia Leitner
- Department of Medicine, Ludwig Maximilian University, Munich, Germany
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Laura Paternoster
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Moritz Immanuel Leitner
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Jan Martin Rémi
- Department of Neurology, LMU University Hospital, Munich, Germany
| | - Christoph Trumm
- Institute of Neuroradiology, LMU University Hospital, Munich, Germany
| | - Roman Ludwig Haberl
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Nikolai Dominik Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
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Flores A, Garcia-Tornel A, Seró L, Ustrell X, Requena M, Pellisé A, Rodriguez P, Monterde A, Lara L, Gonzalez-de-Echavarri JM, Molina CA, Doncel-Moriano A, Dorado L, Cardona P, Cánovas D, Krupinski J, Más N, Purroy F, Zaragoza-Brunet J, Palomeras E, Cocho D, Garcia J, Colom C, Silva Y, Gomez-Cocho M, Jiménez X, Ros-Roig J, Abilleira S, Pérez de la Ossa N, Ribo M. Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis. J Neurointerv Surg 2024; 16:143-150. [PMID: 37068936 DOI: 10.1136/jnis-2023-020125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND The influence of vascular imaging acquisition on workflows at local stroke centers (LSCs) not capable of performing thrombectomy in patients with a suspected large vessel occlusion (LVO) stroke remains uncertain. We analyzed the impact of performing vascular imaging (VI+) or not (VI- at LSC arrival on variables related to workflows using data from the RACECAT Trial. OBJECTIVE To compare workflows at the LSC among patients enrolled in the RACECAT Trial with or without VI acquisition. METHODS We included patients with a diagnosis of ischemic stroke who were enrolled in the RACECAT Trial, a cluster-randomized trial that compared drip-n-ship versus mothership triage paradigms in patients with suspected acute LVO stroke allocated at the LSC. Outcome measures included time metrics related to workflows and the rate of interhospital transfers and thrombectomy among transferred patients. RESULTS Among 467 patients allocated to a LSC, vascular imaging was acquired in 277 patients (59%), of whom 198 (71%) had a LVO. As compared with patients without vascular imaging, patients in the VI+ group were transferred less frequently as thrombectomy candidates to a thrombectomy-capable center (58% vs 74%, P=0.004), without significant differences in door-indoor-out time at the LSC (median minutes, VI+ 78 (IQR 69-96) vs VI- 76 (IQR 59-98), P=0.6). Among transferred patients, the VI+ group had higher rate of thrombectomy (69% vs 55%, P=0.016) and shorter door to puncture time (median minutes, VI+ 41 (IQR 26-53) vs VI- 54 (IQR 40-70), P<0.001). CONCLUSION Among patients with a suspected LVO stroke initially evaluated at a LSC, vascular imaging acquisition might improve workflow times at thrombectomy-capable centers and reduce the rate of futile interhospital transfers. These results deserve further evaluation and should be replicated in other settings and geographies.
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Affiliation(s)
- Alan Flores
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | | | - Laia Seró
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Xavier Ustrell
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Anna Pellisé
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Paula Rodriguez
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Angela Monterde
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Lidia Lara
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Jose María Gonzalez-de-Echavarri
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Antonio Doncel-Moriano
- Stroke Unit, Department of Neurology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Laura Dorado
- Stroke Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Catalunya, Spain
| | - Pedro Cardona
- Bellvitge University Hospital, L'Hospitalet de Llobregat, Catalunya, Spain
| | - David Cánovas
- Department of Neurology, Consorci Sanitari Parc Taulí, Barcelona, Spain
| | | | - Natalia Más
- Department of Neurology, Hospital Althaia, Manresa, Manresa, Catalunya, Spain
| | | | - Jose Zaragoza-Brunet
- Stroke Unit, Department of Neurology, Hospital Verge de la Cinta, Tortosa, Catalunya, Spain
| | - Ernesto Palomeras
- Department of Neurology, Hospital de Mataró, Mataro, Catalunya, Spain
| | - Dolores Cocho
- Department of Neurology, Hospital General de Granollers, Granollers, Catalunya, Spain
| | - Jessica Garcia
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedes, Catalunya, Spain
| | - Carla Colom
- Department of Neurology, Hospital Universitario de Igualada, Igualada, Catalunya, Spain
| | - Yolanda Silva
- Neurology Department, Stroke Unit, Doctor Josep Trueta University Hospital of Girona, Girona, Catalunya, Spain
| | - Manuel Gomez-Cocho
- Department of Neurology, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
| | - Xavier Jiménez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Josep Ros-Roig
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sonia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain
- Catalan Stroke Program, Barcelona, Spain
| | - Marc Ribo
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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21
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Pardo K, Naftali J, Barnea R, Findler M, Perlow A, Brauner R, Auriel E, Raphaeli G. Effect of time delay in inter-hospital transfer on outcomes of endovascular treatment of acute ischemic stroke. Front Neurol 2023; 14:1303061. [PMID: 38187154 PMCID: PMC10766796 DOI: 10.3389/fneur.2023.1303061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
Background Endovascular treatment (EVT) with mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke (AIS). The most common approach today is to perform EVT in a comprehensive stroke center (CSC) and transfer relevant patients for EVT from a primary stroke center (PSC). Rapid and efficient treatment of LVO is a key factor in achieving a good clinical outcome. Methods We present our retrospective cohort of patients who underwent EVT between 2018 and 2021, including direct admissions and patients transferred from PSC. Primary endpoints were time intervals (door-to-puncture, onset-to-puncture, door-to-door) and favorable outcome (mRS ≤ 2) at 90 days. Secondary outcomes were successful recanalization, mortality rate, and symptomatic intracranial hemorrhage (sICH). Additional analysis was performed for transferred patients not treated with EVT; endpoints were time intervals, favorable outcomes, and reason for exclusion of EVT. Results Among a total of 405 patients, 272 were admitted directly to our EVT center and 133 were transferred; there was no significant difference between groups in the occluded vascular territory, baseline NIHSS, wake-up strokes, or thrombolysis rate. Directly admitted patients had a shorter door-to-puncture time than transferred patients (190 min vs. 293 min, p < 0.001). The median door-to-door shift time was 204 min. We found no significant difference in functional independence, successful recanalization rates, or sICH rates. The most common reason to exclude transferred patients from EVT was clinical or angiographic improvement (55.6% of patients). Conclusion Our results show that transferring patients to the EVT center does not affect clinical outcomes, despite the expected delay in EVT. Reassessment of patients upon arrival at the CSC is crucial, and patient selection should be done based on both time and tissue window.
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Affiliation(s)
- Keshet Pardo
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Michael Findler
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Alain Perlow
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
| | - Ran Brauner
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
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22
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Raychev R, Sun JL, Schwamm L, Smith EE, Fonarow GC, Messé SR, Xian Y, Chiswell K, Blanco R, Mac Grory B, Saver JL. Performance of Thrombectomy-Capable, Comprehensive, and Primary Stroke Centers in Reperfusion Therapies for Acute Ischemic Stroke: Report From the Get With The Guidelines-Stroke Registry. Circulation 2023; 148:2019-2028. [PMID: 37855118 DOI: 10.1161/circulationaha.123.066114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The thrombectomy-capable stroke center (TSC) is a recently introduced intermediate tier of accreditation for hospitals at which patients with acute ischemic stroke receive care. The comparative quality and clinical outcomes of reperfusion therapies at TSCs, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs) have not been well delineated. METHODS We conducted a retrospective, observational, cohort study from 2018 to 2020 that included patients with acute ischemic stroke who received endovascular thrombectomy (EVT) and intravenous thrombolysis reperfusion therapies at CSCs, TSCs, or PSCs. Participants were recruited from Get With The Guidelines-Stroke registry. Study end points included timeliness of intravenous thrombolysis and EVT, successful reperfusion, discharge destination, discharge mortality, and functional independence at discharge. RESULTS Among 84 903 patients, 48 682 received EVT, of whom 73% were treated at CSCs, 22% at PSCs, and 4% at TSCs. The median annual EVT volume was 76 for CSCs, 55 for TSCs, and 32 for PSCs. Patient differences by center status included higher National Institutes of Health Stroke Scale score, longer onset-to-arrival time, and higher transfer-in rates for CSCs, TSCs, and PSCs, respectively. In adjusted analyses, the likelihood of achieving the goal door-to-needle time was higher in CSCs compared with PSCs (odds ratio [OR], 1.39 [95% CI, 1.17-1.66]) and in TSCs compared with PSCs (OR, 1.45 [95% CI, 1.08-1.96]). Likewise, the odds of achieving the goal door-to-puncture time were higher in CSCs compared with PSCs (OR, 1.58 [95% CI, 1.13-2.21]). CSCs and TSCs also demonstrated better clinical efficacy outcomes compared with PSCs. The odds of discharge to home or rehabilitation were higher in CSCs compared with PSCs (OR, 1.18 [95% CI, 1.06-1.31]), whereas the odds of in-hospital mortality or discharge to hospice were lower in both CSCs compared with PSCs (OR, 0.87 [95% CI, 0.81-0.94]) and TSCs compared with PSCs (OR, 0.86 [95% CI, 0.75-0.98]). There were no significant differences in any of the quality-of-care metrics and clinical outcomes between TSCs and CSCs. CONCLUSIONS In this study representing national US practice, CSCs and TSCs exceeded PSCs in key quality-of-care reperfusion metrics and outcomes, whereas TSCs and CSCs demonstrated a similar performance. With more than one-fifth of all EVT procedures during the study period conducted at PSCs, it may be desirable to explore national initiatives aimed at facilitating the elevation of eligible PSCs to a higher certification status.
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Affiliation(s)
- Radoslav Raychev
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
- Duke University School of Medicine, Durham, NC (J.-L.S.)
| | - Lee Schwamm
- Yale School of Medicine, New Haven, CT (L.S.)
| | | | - Gregg C Fonarow
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
| | | | - Ying Xian
- University of Texas, Southwestern Medical Center, Dallas (Y.X.)
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
| | | | | | - Jeffrey L Saver
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
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23
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van Stigt MN, Groenendijk EA, van Meenen LCC, van de Munckhof AAGA, Theunissen M, Franschman G, Smeekes MD, van Grondelle JAF, Geuzebroek G, Siegers A, Visser MC, van Schaik SM, Halkes PHA, Majoie CBLM, Roos YBWEM, Koelman JHTM, Koopman MS, Marquering HA, Potters WV, Coutinho JM. Prehospital Detection of Large Vessel Occlusion Stroke With EEG. Neurology 2023; 101:e2522-e2532. [PMID: 37848336 PMCID: PMC10791060 DOI: 10.1212/wnl.0000000000207831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) is standard treatment for anterior large vessel occlusion stroke (LVO-a stroke). Prehospital diagnosis of LVO-a stroke would reduce time to EVT by allowing direct transportation to an EVT-capable hospital. We aim to evaluate the diagnostic accuracy of dry electrode EEG for the detection of LVO-a stroke in the prehospital setting. METHODS ELECTRA-STROKE was an investigator-initiated, prospective, multicenter, diagnostic study, performed in the prehospital setting. Adult patients were eligible if they had suspected stroke (as assessed by the attending ambulance nurse) and symptom onset <24 hours. A single dry electrode EEG recording (8 electrodes) was performed by ambulance personnel. Primary endpoint was the diagnostic accuracy of the theta/alpha frequency ratio for LVO-a stroke (intracranial ICA, A1, M1, or proximal M2 occlusion) detection among patients with EEG data of sufficient quality, expressed as the area under the receiver operating characteristic curve (AUC). Secondary endpoints were diagnostic accuracies of other EEG features quantifying frequency band power and the pairwise derived Brain Symmetry Index. Neuroimaging was assessed by a neuroradiologist blinded to EEG results. RESULTS Between August 2020 and September 2022, 311 patients were included. The median EEG duration time was 151 (interquartile range [IQR] 151-152) seconds. For 212/311 (68%) patients, EEG data were of sufficient quality for analysis. The median age was 74 (IQR 66-81) years, 90/212 (42%) were women, and the median baseline NIH Stroke Scale was 1 (IQR 0-4). Six (3%) patients had an LVO-a stroke, 109/212 (51%) had a non-LVO-a ischemic stroke, 32/212 (15%) had a transient ischemic attack, 8/212 (4%) had a hemorrhagic stroke, and 57/212 (27%) had a stroke mimic. AUC of the theta/alpha ratio was 0.80 (95% CI 0.58-1.00). Of the secondary endpoints, the pairwise derived Brain Symmetry Index in the delta frequency band had the highest diagnostic accuracy (AUC 0.91 [95% CI 0.73-1.00], sensitivity 80% [95% CI 38%-96%], specificity 93% [95% CI 88%-96%], positive likelihood ratio 11.0 [95% CI 5.5-21.7]). DISCUSSION The data from this study suggest that dry electrode EEG has the potential to detect LVO-a stroke among patients with suspected stroke in the prehospital setting. Toward future implementation of EEG in prehospital stroke care, EEG data quality needs to be improved. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov identifier: NCT03699397. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that prehospital dry electrode scalp EEG accurately detects LVO-a stroke among patients with suspected acute stroke.
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Affiliation(s)
- Maritta N van Stigt
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Eva A Groenendijk
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Laura C C van Meenen
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Anita A G A van de Munckhof
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Monique Theunissen
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Gaby Franschman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Martin D Smeekes
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Joffry A F van Grondelle
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Geertje Geuzebroek
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Arjen Siegers
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Marieke C Visser
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Sander M van Schaik
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Patricia H A Halkes
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Charles B L M Majoie
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Yvo B W E M Roos
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Johannes H T M Koelman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Miou S Koopman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Henk A Marquering
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Wouter V Potters
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Jonathan M Coutinho
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
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Feick J, Pham M, März AG, Vogt ML, Strinitz M, Stoll G, Schuhmann MK, Kollikowski AM. Distinct Alterations in Oxygenation, Ion Composition and Acid-Base Balance in Cerebral Collaterals During Large-Vessel Occlusion Stroke. Clin Neuroradiol 2023; 33:973-984. [PMID: 37284875 PMCID: PMC10654170 DOI: 10.1007/s00062-023-01296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE Disturbances of blood gas and ion homeostasis including regional hypoxia and massive sodium (Na+)/potassium (K+) shifts are a hallmark of experimental cerebral ischemia but have not been sufficiently investigated for their relevance in stroke patients. METHODS We report a prospective observational study on 366 stroke patients who underwent endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) of the anterior circulation (18 December 2018-31 August 2020). Intraprocedural blood gas samples (1 ml) from within cerebral collateral arteries (ischemic) and matched systemic control samples were obtained according to a prespecified protocol in 51 patients. RESULTS We observed a significant reduction in cerebral oxygen partial pressure (-4.29%, paO2ischemic = 185.3 mm Hg vs. paO2systemic = 193.6 mm Hg; p = 0.035) and K+ concentrations (-5.49%, K+ischemic = 3.44 mmol/L vs. K+systemic = 3.64 mmol/L; p = 0.0083). The cerebral Na+:K+ ratio was significantly increased and negatively correlated with baseline tissue integrity (r = -0.32, p = 0.031). Correspondingly, cerebral Na+ concentrations were most strongly correlated with infarct progression after recanalization (r = 0.42, p = 0.0033). We found more alkaline cerebral pH values (+0.14%, pHischemic = 7.38 vs. pHsystemic = 7.37; p = 0.0019), with a time-dependent shift towards more acidotic conditions (r = -0.36, p = 0.055). CONCLUSION These findings suggest that stroke-induced changes in oxygen supply, ion composition and acid-base balance occur and dynamically progress within penumbral areas during human cerebral ischemia and are related to acute tissue damage.
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Affiliation(s)
- Jörn Feick
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Alexander G März
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Marius L Vogt
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Marc Strinitz
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Guido Stoll
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Alexander M Kollikowski
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
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25
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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26
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Baumann AA, Shelton RC, Kumanyika S, Haire‐Joshu D. Advancing healthcare equity through dissemination and implementation science. Health Serv Res 2023; 58 Suppl 3:327-344. [PMID: 37219339 PMCID: PMC10684051 DOI: 10.1111/1475-6773.14175] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity. DATA SOURCES AND STUDY SETTING This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees. STUDY DESIGN This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees. DATA COLLECTION/EXTRACTION METHODS We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations. PRINCIPAL FINDINGS We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers. CONCLUSIONS Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.
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Affiliation(s)
- Ana A. Baumann
- Division of Public Health Sciences, Department of SurgeryWashington University School of MedicineSt. LouisMissouriUSA
| | - Rachel C. Shelton
- Department of Sociomedical SciencesColumbia University, Mailman School of Public HealthNew YorkNew YorkUSA
| | - Shiriki Kumanyika
- Drexel Dornsife School of Public HealthDrexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Debra Haire‐Joshu
- Brown School of Public Health and School of MedicineWashington University in St. LouisSt. LouisMissouriUSA
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Groenendijk EA, van Stigt MN, van de Munckhof AAGA, Koelman JHTM, Koopman MS, Marquering HA, Potters WV, Coutinho JM. Subhairline Electroencephalography for the Detection of Large Vessel Occlusion Stroke. J Am Heart Assoc 2023; 12:e031929. [PMID: 37982212 PMCID: PMC10727307 DOI: 10.1161/jaha.123.031929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/28/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Endovascular thrombectomy is standard treatment for patients with anterior circulation large vessel occlusion stroke (LVO-a). Prehospital identification of these patients would enable direct routing to an endovascular thrombectomy-capable hospital and consequently reduce time-to-endovascular thrombectomy. Electroencephalography (EEG) has previously proven to be promising for LVO-a stroke detection. Fast and reliable electrode application, however, can remain a challenge. A potential alternative is subhairline EEG. We evaluated the diagnostic accuracy of subhairline EEG for LVO-a stroke detection. METHODS AND RESULTS We included adult patients with a suspected stroke or known LVO-a stroke and symptom onset time <24 hours. A single 3-minute EEG recording was performed at the emergency department, before endovascular thrombectomy, using 9 self-adhesive electrodes placed on the forehead and behind the ears. We evaluated the diagnostic accuracies of EEG features quantifying frequency band power and brain symmetry (pairwise derived Brain Symmetry Index) for LVO-a stroke detection using receiver operating characteristic analysis. EEG data were of sufficient quality for analysis in 51/52 (98%) included patients. Of these patients, 16 (31%) had an LVO-a stroke, 16 (31%) a non-LVO-a ischemic stroke, 5 (10%) a transient ischemic attack, and 14 (27%) a stroke mimic. Median symptom-onset-to-EEG-time was 266 (interquartile range 130-709) minutes. The highest diagnostic accuracy for LVO-a stroke detection was reached by the pairwise derived Brain Symmetry Index in the theta frequency band (area under the receiver operating characteristic curve 0.90; sensitivity 86%; specificity 83%). CONCLUSIONS Subhairline EEG could detect LVO-a stroke with high diagnostic accuracy and had high data reliability. These data suggest that subhairline EEG is potentially suitable as a prehospital stroke triage instrument.
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Affiliation(s)
- Eva A. Groenendijk
- Department of Clinical NeurophysiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
- Department of NeurologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Maritta N. van Stigt
- Department of Clinical NeurophysiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
- Department of NeurologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Johannes H. T. M. Koelman
- Department of Clinical NeurophysiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Miou S. Koopman
- Department of Radiology and Nuclear MedicineAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear MedicineAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
- Department of Biomedical Engineering and PhysicsAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Jonathan M. Coutinho
- Department of NeurologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
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28
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Gude MF, Valentin JB, Christensen HC, Mikkelsen S, Søvsø MB, Andersen G, Kirkegaard H, Johnsen SP. Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. Intern Emerg Med 2023; 18:2355-2365. [PMID: 37369888 PMCID: PMC10635938 DOI: 10.1007/s11739-023-03349-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
To investigate the association between the Emergency Medical Service dispatcher's initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017-2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1-76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was - 33.2 min (95% CI - 44.4; - 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI - 18.9; - 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.
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Affiliation(s)
- Martin F Gude
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark.
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Central Denmark Region, Aarhus, Denmark.
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helle C Christensen
- Copenhagen Emergency Medical Services, Capital Region of Denmark, Copenhagen, Denmark
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Morten B Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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29
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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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30
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Guo X, Dye J. Modern Prehospital Screening Technology for Emergent Neurovascular Disorders. Adv Biol (Weinh) 2023; 7:e2300174. [PMID: 37357150 DOI: 10.1002/adbi.202300174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/14/2023] [Indexed: 06/27/2023]
Abstract
Stroke is a serious neurological disease and a significant contributor to disability worldwide. Traditional in-hospital imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) remain the standard modalities for diagnosing stroke. The development of prehospital stroke detection devices may facilitate earlier diagnosis, initiation of stroke care, and ultimately better patient outcomes. In this review, the authors summarize the features of eight stroke detection devices using noninvasive brain scanning technology. The review summarizes the features of stroke detection devices including portable CT, MRI, transcranial Doppler ultrasound , microwave tomographic imaging, electroencephalography, near-infrared spectroscopy, volumetric impedance phaseshift spectroscopy, and cranial accelerometry. The technologies utilized, the indications for application, the environments indicated for application, the physical features of the eight stroke detection devices, and current commercial products are discussed. As technology advances, multiple portable stroke detection instruments exhibit the promising potential to expedite the diagnosis of stroke and enhance the time taken for treatment, ultimately aiding in prehospital stroke triage.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurology, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, CA, 92354, USA
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Ye J, Shan Y, Zhou X, Tian T, Gao W. Identification of Novel Circular RNA Targets in Key Penumbra Region of Rats After Cerebral Ischemia-Reperfusion Injury. J Mol Neurosci 2023; 73:751-762. [PMID: 37684515 PMCID: PMC10694113 DOI: 10.1007/s12031-023-02153-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023]
Abstract
Circular RNAs (circRNAs) are abundantly and stably expressed in the brain of mammals and humans. Some circRNAs are implicated in ischemic stroke. Therefore, we aimed to detect how circRNAs change in the key penumbra area during cerebral ischemia-reperfusion (CI/R) injury. Rats were subjected to transient middle cerebral artery occlusion (tMCAO), during which the permanent blocking period was 2 h and reperfusion time was 24 or 72 h. Then modified neurologic severity score (mNSS), triphenyl tetrazolium chloride (TTC) staining and HE staining were used to exhibiting damage between rats in different groups. The penumbra regions of all rats were dissected and total RNA was further processed for high-throughput sequencing. CircRNA expression profiles were screened and bioinformatics analyses were conducted to investigate these differentially expressed circRNAs. Some of them were verified by reverse transcription-quantitative polymerase chain reaction (RT-qPCR), followed by the establishment of a circRNA-miRNA-mRNA network and the detection of their downstream molecules. A total of 99 and 98 circRNAs were differentially expressed at CI/R 24 h and CI/R 72 h, respectively. Notably, 21 circRNAs significantly changed at both reperfusion points. Three circRNAs, namely circ.7225, circ.5415, and circ.20623 were found to be associated with CI/R injury and might be preferred targets. Common downstream miR-298-5p and Bcl-3 were found to make up the circRNA-miRNA-mRNA network. Novel circRNA targets came to light in the penumbra of rats during CI/R injury and might establish the circRNA-miRNA-mRNA relationship, thus serving as potential biomarkers for ischemic stroke treatment.
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Affiliation(s)
- Jiabei Ye
- Hebei Key Laboratory of Chinese Medicine Research on Cardio-Cerebrovascular Disease, Hebei University of Chinese Medicine, 326 South Xinshi Road, 050091, Shijiazhuang, Hebei Province, China
- Department of Acupuncture and Moxibustion, Hebei Province Hospital of Chinese Medicine, 050011, Shijiazhuang, Hebei, China
| | - Yudong Shan
- Hebei Key Laboratory of Chinese Medicine Research on Cardio-Cerebrovascular Disease, Hebei University of Chinese Medicine, 326 South Xinshi Road, 050091, Shijiazhuang, Hebei Province, China
- Hebei Cangzhou Hospital of Integrated Traditional and Western Medicine, Cangzhou, 061012, China
| | - Xiaohong Zhou
- Hebei Key Laboratory of Chinese Medicine Research on Cardio-Cerebrovascular Disease, Hebei University of Chinese Medicine, 326 South Xinshi Road, 050091, Shijiazhuang, Hebei Province, China
| | - Tian Tian
- Hebei Key Laboratory of Chinese Medicine Research on Cardio-Cerebrovascular Disease, Hebei University of Chinese Medicine, 326 South Xinshi Road, 050091, Shijiazhuang, Hebei Province, China
| | - Weijuan Gao
- Hebei Key Laboratory of Chinese Medicine Research on Cardio-Cerebrovascular Disease, Hebei University of Chinese Medicine, 326 South Xinshi Road, 050091, Shijiazhuang, Hebei Province, China.
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van Stigt MN, Groenendijk EA, van de Munckhof AAGA, Marquering HA, Koopman MS, Majoie CBLM, Roos YBWEM, Koelman JHTM, Potters WV, Coutinho JM. Correlation between EEG spectral power and cerebral perfusion in patients with acute ischemic stroke. J Clin Neurosci 2023; 116:81-86. [PMID: 37657169 DOI: 10.1016/j.jocn.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/08/2023] [Accepted: 08/23/2023] [Indexed: 09/03/2023]
Abstract
Dry electrode electroencephalography (EEG) has the potential to diagnose ischemic stroke in the acute phase. In the current study we determined the correlation between EEG spectral power and ischemic stroke size and location as determined by computed tomography perfusion (CTP). Dry electrode EEG recordings were performed in patients with acute ischemic stroke in the emergency room. CTP preceded the EEG recordings as part of standard imaging protocol. Infarct core volume, total hypoperfused volume and local cerebral blood flow (CBF) were estimated with CTP. Additionally, global and local EEG spectral power were determined. We used Spearman's correlation coefficients to evaluate the correlation between variables. We included 27 patients (median age 72 [IQR:69-80] years, 15/27 [56%] men). Median CTP-to-EEG time was 32 (range:8-138) minutes. Hypoperfused volumes were estimated for 12/27 (44%) patients. Infarct core volume correlated best with global delta power (ρ = 0.76, p < 0.01), total hypoperfused volume with global alpha power (ρ = -0.58, p = 0.05), and local CBF with local alpha power (ρ = 0.43, p < 0.01). We conclude that dry electrode EEG signals slow down with increasing hypoperfused volume, which could potentially be used to discriminate between small and large ischemic strokes.
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Affiliation(s)
- M N van Stigt
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| | - E A Groenendijk
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - A A G A van de Munckhof
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - H A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - M S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - C B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - J H T M Koelman
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - W V Potters
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; TrianecT, Padualaan 8, Utrecht, the Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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Nogueira RG, Haussen DC, Smith EE, Sun JL, Xian Y, Alhanti B, Blanco R, Mac Grory B, Doheim MF, Bhatt DL, Fonarow GC, Hassan AE, Joundi RA, Mocco J, Frankel MR, Schwamm LH. Higher Procedural Volumes Are Associated with Faster Treatment Times, Better Functional Outcomes, and Lower Mortality in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke. Ann Neurol 2023. [PMID: 37731004 DOI: 10.1002/ana.26803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE We aimed to characterize the association of hospital procedural volumes with outcomes among acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). METHODS This was a retrospective, observational cohort study using data prospectively collected from January 1, 2016 to December 31, 2019 in the Get with the Guidelines-Stroke registry. Participants were derived from a cohort of 60,727 AIS patients treated with EVT within 24 hours at 626 hospitals. The primary cohort excluded patients with pretreatment National Institutes of Health Stroke Scale (NIHSS) < 6, onset-to-treatment time > 6 hours, and interhospital transfers. There were 2 secondary cohorts: (1) the EVT metrics cohort excluded patients with missing data on time from door to arterial puncture and (2) the intravenous thrombolysis (IVT) metrics cohort only included patients receiving IVT ≤4.5 hours after onset. RESULTS The primary cohort (mean ± standard deviation age = 70.7 ± 14.8 years; 51.2% female; median [interquartile range] baseline NIHSS = 18.0 [13-22]; IVT use, 70.2%) comprised 21,209 patients across 595 hospitals. The EVT metrics cohort and IVT metrics cohort comprised 47,262 and 16,889 patients across 408 and 601 hospitals, respectively. Higher procedural volumes were significantly associated with higher odds (expressed as adjusted odds ratio [95% confidence interval] for every 10-case increase in volume) of discharge to home (1.03 [1.02-1.04]), functional independence at discharge (1.02 [1.01-1.04]), and lower rates of in-hospital mortality (0.96 [0.95-0.98]). All secondary measures were also associated with procedural volumes. INTERPRETATION Among AIS patients primarily presenting to EVT-capable hospitals (excluding those transferred from one facility to another and those suffering in-hospital strokes), EVT at hospitals with higher procedural volumes was associated with faster treatment times, better discharge outcomes, and lower rates of in-hospital mortality. ANN NEUROL 2023.
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Affiliation(s)
- Raul G Nogueira
- Departments of Neurology and Neurosurgery, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Diogo C Haussen
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ameer E Hassan
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | - Raed A Joundi
- Division of Neurology, Hamilton Health Sciences, McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael R Frankel
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Majoie CB, Cavalcante F, Gralla J, Yang P, Kaesmacher J, Treurniet KM, Kappelhof M, Yan B, Suzuki K, Zhang Y, Li F, Morimoto M, Zhang L, Miao Z, Rinkel LA, Huang J, Otsuka T, Wang S, Davis S, Cognard C, Hong B, Coutinho JM, Song J, Chen W, Emmer BJ, Eker O, Zhang L, Dobrocky T, Nguyen HT, Bush S, Peng Y, LeCouffe NE, Takeuchi M, Han H, Matsumaru Y, Strbian D, Lingsma HF, Nieboer D, Yang Q, Meinel T, Mitchell P, Kimura K, Zi W, Nogueira RG, Liu J, Roos YB, Fischer U. Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials. Lancet 2023; 402:965-974. [PMID: 37640037 DOI: 10.1016/s0140-6736(23)01142-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/18/2023] [Accepted: 06/02/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Intravenous thrombolysis is recommended before endovascular treatment, but its value has been questioned in patients who are admitted directly to centres capable of endovascular treatment. Existing randomised controlled trials have indicated non-inferiority of endovascular treatment alone or have been statistically inconclusive. We formed the Improving Reperfusion Strategies in Acute Ischaemic Stroke collaboration to assess non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. METHODS We conducted a systematic review and individual participant data meta-analysis to establish non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. We searched PubMed and MEDLINE with the terms "stroke", "endovascular treatment", "intravenous thrombolysis", and synonyms for articles published from database inception to March 9, 2023. We included randomised controlled trials on the topic of interest, without language restrictions. Authors of the identified trials agreed to take part, and individual participant data were provided by the principal investigators of the respective trials and collated centrally by the collaborators. Our primary outcome was the 90-day modified Rankin Scale (mRS) score. Non-inferiority of endovascular treatment alone was assessed using a lower boundary of 0·82 for the 95% CI around the adjusted common odds ratio (acOR) for shift towards improved outcome (analogous to 5% absolute difference in functional independence) with ordinal regression. We used mixed-effects models for all analyses. This study is registered with PROSPERO, CRD42023411986. FINDINGS We identified 1081 studies, and six studies (n=2313; 1153 participants randomly assigned to receive endovascular treatment alone and 1160 randomly assigned to receive intravenous thrombolysis and endovascular treatment) were eligible for analysis. The risk of bias of the included studies was low to moderate. Variability between studies was small, and mainly related to the choice and dose of the thrombolytic drug and country of execution. The median mRS score at 90 days was 3 (IQR 1-5) for participants who received endovascular treatment alone and 2 (1-4) for participants who received intravenous thrombolysis plus endovascular treatment (acOR 0·89, 95% CI 0·76-1·04). Any intracranial haemorrhage (0·82, 0·68-0·99) occurred less frequently with endovascular treatment alone than with intravenous thrombolysis plus endovascular treatment. Symptomatic intracranial haemorrhage and mortality rates did not differ significantly. INTERPRETATION We did not establish non-inferiority of endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment in patients presenting directly at endovascular treatment centres. Further research could focus on cost-effectiveness analysis and on individualised decisions when patient characteristics, medication shortages, or delays are expected to offset a potential benefit of administering intravenous thrombolysis before endovascular treatment. FUNDING Stryker and Amsterdam University Medical Centers, University of Amsterdam.
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Affiliation(s)
- Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China; Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Kilian M Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands; Department of Radiology, Haaglanden Medical Center, The Hague, Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Leon A Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | - Shouchun Wang
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Stephen Davis
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Bo Hong
- Department of Neurovascular Intervention, Clinical Center of Neuroscience, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Omer Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital of Shandong First Medical University, Liaocheng, China
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | | | - Steven Bush
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Ya Peng
- Department of Neurology, Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Natalie E LeCouffe
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | | | - Hongxing Han
- Department of Neurology, Linyi People's Hospital of Qingdao University, Linyi, China
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Thomas Meinel
- Department of Neurology, University Hospital of Bern, University of Bern, Stroke Research Center Bern, Bern, Switzerland
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Raul G Nogueira
- UPMC Stroke Institute, Department of Neurology and Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China; Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Yvo B Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital of Bern, University of Bern, Stroke Research Center Bern, Bern, Switzerland; Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
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van de Wijdeven RM, Duvekot MHC, van der Geest PJ, Moudrous W, Dorresteijn KRIS, Wijnhoud AD, Mulder LJMM, Alblas KCL, Asahaad N, Kerkhoff H, Dippel DWJ, Roozenbeek B. Determinants of door-in-door-out time in patients with ischaemic stroke transferred for endovascular thrombectomy. Eur Stroke J 2023; 8:667-674. [PMID: 37248995 PMCID: PMC10472962 DOI: 10.1177/23969873231177768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Long door-in-door-out (DIDO) times are an important cause of treatment delay in patients transferred for endovascular thrombectomy (EVT) from primary stroke centres (PSC) to an intervention centre. Insight in causes of prolonged DIDO times may facilitate process improvement interventions. We aimed to quantify different components of DIDO time and to identify determinants of DIDO time. METHODS We performed a retrospective cohort study in a Dutch ambulance region consisting of six PSCs and one intervention centre. We included consecutive adult patients with anterior circulation large vessel occlusion, transferred from a PSC for EVT between October 1, 2019 and November 31, 2020. We subdivided DIDO into several time components and quantified contribution of these components to DIDO time. We used univariable and multivariable linear regression models to explore associations between potential determinants and DIDO time. RESULTS We included 133 patients. Median (IQR) DIDO time was 66 (52-83) min. The longest component was CTA-to-ambulance notification time with a median (IQR) of 24 (16-37) min. DIDO time increased with age (6 min per 10 years, 95% CI: 2-9), onset-to-door time outside 6 h (20 min, 95% CI: 5-35), M2-segment occlusion (15 min, 95% CI: 4-26) and right-sided ischaemia (12 min, 95% CI: 2-21). CONCLUSIONS The CTA-to-ambulance notification time is the largest contributor to DIDO time. Higher age, onset-to-door time longer than 6 h, M2-segment occlusion and right-sided occlusions are independently associated with a longer DIDO time. Future interventions that aim to decrease DIDO time should take these findings into account.
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Affiliation(s)
| | - Martijne HC Duvekot
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Annemarie D Wijnhoud
- Department of Neurology, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Laus JMM Mulder
- Department of Neurology, Ikazia Hospital, Rotterdam, the Netherlands
| | - Kees CL Alblas
- Department of Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Nabil Asahaad
- Department of Neurology, Van Weel-Bethesda Hospital, Dirksland, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Jayaraman MV, Baird G, Oueidat K, Paolucci G, Haas RA, Torabi R, Moldovan K, Rhodes J, Potvin J, Alexander-Scott N, Yaghi S, Madsen T, Furie K, McTaggart RA. Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion. J Neurointerv Surg 2023; 15:e86-e92. [PMID: 35896319 DOI: 10.1136/jnis-2022-019250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between two adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC). METHODS During the study period, one of the two states implemented severity-based triage for suspected emergent large vessel occlusion, while in the other state, patients were transported to the closest hospital regardless of severity. We compared times to treatment and clinical outcomes between these two states. We also performed a matched pairs analysis, matching on date treated and distance from field to CSC. RESULTS 639 patients met the inclusion criteria, 407 in State 1 (with field triage) and 232 in State 2 (without field triage). In State 1, scene to EVT decreased 6% (or 8.13 min, p=0.0004) every year but no decrease was observed for State 2 (<1%, p=0.94). Cumulatively over 5.5 years, there was a reduction of 43 min in time to EVT in State 1, but no change in State 2. Lower rates of disability were seen in State 1, both for the entire cohort (all OR 1.22, 95% CI 1.07 to 1.40, p=0.0032) and for those independent at baseline (1.36, 95% CI 1.15 to 1.59, p=0.0003). CONCLUSIONS Comparing adjacent states over time, the implementation of severity-based field triage significantly reduced time to EVT.
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Affiliation(s)
- Mahesh V Jayaraman
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Grayson Baird
- Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Karim Oueidat
- Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Gino Paolucci
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Richard A Haas
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Radmehr Torabi
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurosurgery and Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Krisztina Moldovan
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurosurgery, Brown University, Providence, Rhode Island, USA
| | - Jason Rhodes
- Department of Health, State of Rhode Island, Providence, Rhode Island, USA
| | - John Potvin
- Division of Emergency Medical Services, City of East Providence, East Providence, Rhode Island, USA
| | | | - Shadi Yaghi
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurology, Brown University, Providence, Rhode Island, USA
| | - Tracy Madsen
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Emergency Medicine, Brown University, Providence, Rhode Island, USA
| | - Karen Furie
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurology, Brown University, Providence, Rhode Island, USA
| | - Ryan A McTaggart
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
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Jiang F, Yin W, Jia J, Zhong H, Yang H, Huang J, Wang Y, Liu Y, Liu H. Clinical outcomes after endovascular thrombectomy in different triage methods. Heliyon 2023; 9:e19113. [PMID: 37636373 PMCID: PMC10457447 DOI: 10.1016/j.heliyon.2023.e19113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/23/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023] Open
Abstract
Objective The purpose of this study was to evaluate the effectiveness and safety of drip and ship (DS) for acute ischemic stroke (AIS) by comparing three treatment strategies: 1) patients seen at a primary stroke center, started on emergency intravenous thrombolysis and then transported to a comprehensive stroke center (drip and ship, DS); 2) patients immediately transferred to comprehensive stroke center without starting intravenous thrombolysis, for mechanical thrombectomy (non-drip and ship, non-DS); and 3) patients admitted directly to the comprehensive stroke center for assessment and subsequent bridging thrombolysis (mothership, MS). Methods We retrospectively reviewed the data of patients that underwent mechanical thrombectomy for AIS from November 2020 to May 2022 at our institution. Patients were divided into three groups: DS, non-DS, and MS. Time course, multimodal CT features and clinical results were compared among the three groups. Results The study included 62 patients, with 19, 18, and 25 patients in DS, non-DS, and MS groups, respectively. Baseline characteristics did not differ among the three groups. The DS group had a significantly longer median onset to groin time than the MS group (395 min vs 244 min; P < 0.001), a significantly shorter onset to primary stroke center time than the non-DS group (90 min vs 463 min; P < 0.001), and a longer primary stroke center to groin puncture time than the non-DS group (277 min vs 162 min; P = 0.002). The onset to needle time was longer in the MS group than the DS group (151.2 min vs 111.8 min; P = 0.041). The intravenous thrombolysis to puncture time was shorter in the MS group compared with DS (56 min vs 278 min; P < 0.001). No significant differences were present among groups in post-operative variables measured. Conclusions DS is a safe and effective method, with no increased risk of postoperative complications or death compared to non-DS and MS methods. The study provides a reference for the selection of transport modes for AIS patients.
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Affiliation(s)
- Fucheng Jiang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Interventional Radiology and Vascular Surgery, Peking University International Hospital, Beijing, China
| | - Wenpeng Yin
- Department of Emergency, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jianwen Jia
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hongliang Zhong
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hongchao Yang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jvmei Huang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yunpeng Liu
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - He Liu
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Maas WJ, van der Zee DJ, Buskens E, Uyttenboogaart M, Lahr MM. Simulation modelling to study the impact of adding comprehensive stroke centres. Can we deliver endovascular thrombectomy sooner? BMJ Open 2023; 13:e068749. [PMID: 37487678 PMCID: PMC10373665 DOI: 10.1136/bmjopen-2022-068749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES Regional accessibility and distribution of endovascular thrombectomy (EVT) capable facilities, that is, comprehensive stroke centres (CSCs), may significantly influence time to treatment. We analysed the impact of adding CSCs in the north of the Netherlands, a region with roughly 1.7 million inhabitants currently served by one CSC and eight primary stroke centres (PSCs). DESIGN Monte Carlo simulation modelling was used to establish new CSCs in our region by hypothetically upgrading existing PSCs to CSCs and ensuing adjustments in health services set-up. SETTING One CSC and eight PSCs in the north of the Netherlands. PARTICIPANTS 165 patients with acute stroke treated with EVT and underwent interhospital transfer between PSC and CSC (drip and ship patients). PRIMARY AND SECONDARY OUTCOMES Time from onset to groin (OTG) puncture and predicted probability of favourable outcome (modified Rankin Scale 0-2) after 90 days. Sensitivity analyses were performed to assess uncertainty in workflow efficiency of CSCs. RESULTS Adding one or two CSCs would reduce the OTG time up to approximately 17 min and increases the predicted probability of favourable outcome by approximately 2%. Sensitivity analyses revealed that 'slow-acting' CSCs may reduce OTG by 3-5 min compared with 24-32 min for 'fast-acting' CSCs. CONCLUSIONS This study suggests that adding one or two CSCs in the north of the Netherlands would have modest impact. Improving workflow efficiencies seems to be more potent when aiming to improve existing acute stroke care systems.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten Mh Lahr
- Health Technology Assessment, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
- Aletta Jacobs School of Public Health, University of Groningen, Groningen, The Netherlands
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Maas WJ, van der Zee DJ, Lahr MMH, Bouma M, Buskens E, Uyttenboogaart M. 'Drive the doctor' for endovascular thrombectomy in a rural area: a simulation study. BMC Health Serv Res 2023; 23:778. [PMID: 37475023 PMCID: PMC10360278 DOI: 10.1186/s12913-023-09672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 06/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Patients who present in a primary stroke center (PSC) with ischemic stroke are usually transferred to a comprehensive stroke center (CSC) in case of a large vessel occlusion (LVO) for endovascular thrombectomy (EVT) treatment, the so-called 'drip-and-ship' (DS) model. The 'drive-the-doctor' (DD) model modifies the DS model by allowing mobile interventionalists (MIs) to transfer to an upgraded PSC acting as a thrombectomy capable stroke center (TSC), instead of transferring patients to a CSC. Using simulation we estimated time savings and impact on clinical outcome of DD in a rural region. METHODS Data from EVT patients in northern Netherlands was prospectively collected in the MR CLEAN Registry between July 2014 - November 2017. A Monte Carlo simulation model of DS patients served as baseline model. Scenarios included regional spread of TSCs, pre-hospital patient routing to 'the nearest PSC' or 'nearest TSC', MI's notification after LVO confirmation or earlier prehospital, and MI's transport modalities. Primary outcomes are onset to groin puncture (OTG) and predicted probability of favorable outcome (PPFO) (mRS 0-2). RESULTS Combining all scenarios OTG would be reduced by 28-58 min and PPFO would be increased by 3.4-7.1%. Best performing and acceptable scenario was a combination of 3 TSCs, prehospital patient routing based on the RACE scale, MI notification after LVO confirmation and MI's transfer by ambulance. OTG would reduce by 48 min and PPFO would increase by 5.9%. CONCLUSIONS A DD model is a feasible scenario to optimize acute stroke services for EVT eligible patients in rural regions. Key design decisions in implementing the DD model for a specific region are regional spread of TSCs, patient routing strategy, and MI's notification moment and transport modality.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands.
| | - Maarten M H Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc Bouma
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Tariq MB, Ali I, Salazar-Marioni S, Iyyangar AS, Azeem HM, Khose S, Lopez V, Abdelkhaleq R, McCullough LD, Sheth SA, Kim Y. Women With Large Vessel Occlusion Acute Ischemic Stroke Are Less Likely to Be Routed to Comprehensive Stroke Centers. J Am Heart Assoc 2023; 12:e029830. [PMID: 37462071 PMCID: PMC10382091 DOI: 10.1161/jaha.123.029830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/15/2023] [Indexed: 07/20/2023]
Abstract
Background Prehospital routing of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) to centers capable of performing endovascular therapy may improve clinical outcomes. Here, we explore whether distance to comprehensive stroke centers (CSCs), stroke severity, and sex are associated with direct-to-CSC prehospital routing in patients with LVO AIS. Methods and Results In this cross-sectional study, we identified consecutive patients with LVO AIS from a prospectively collected multihospital registry throughout the greater Houston area from January 2019 to June 2020. Primary outcome was prehospital routing to CSC and was compared between men and women using modified Poisson regression including age, sex, race or ethnicity, first in-hospital National Institutes of Health Stroke Scale score, travel time, and distances to the closest primary stroke center and CSC. Among 503 patients with LVO AIS, 413 (82%) were routed to CSCs, and women comprised 46% of the study participants. Women with LVO AIS compared with men were older (73 versus 65, P<0.01) and presented with greater National Institutes of Health Stroke Scale score (14 versus 12, P=0.01). In modified Poisson regression, women were 9% less likely to be routed to CSCs compared with men (adjusted relative risk [aRR], 0.91 [0.84-0.99], P=0.024) and distance to nearest CSC ≤10 miles was associated with 38% increased chance of routing to CSC (aRR, 1.38 [1.26-1.52], P<0.001). Conclusions Despite presenting with more significant stroke syndromes and living within comparable distance to CSCs, women with LVO AIS were less likely to be routed to CSCs compared with men. Further study of the mechanisms behind this disparity is needed.
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Affiliation(s)
- Muhammad Bilal Tariq
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Iman Ali
- Department of Neurology UTHealth McGovern Medical School Houston TX
| | | | | | - Hussain M Azeem
- Department of Neurology UTHealth McGovern Medical School Houston TX
| | - Swapnil Khose
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Victor Lopez
- Department of Neurosurgery Boston Medical Center Boston MA
| | | | - Louise D McCullough
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Sunil A Sheth
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Youngran Kim
- Department of Management, Policy and Community Health UTHealth School of Public Health Houston TX
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Raychev R, Sun JL, Schwamm L, Smith EE, Fonarow GC, Messé SR, Xian Y, Chiswell K, Blanco R, Grory BM, Saver JL. Performance of Thrombectomy-Capable, Comprehensive, and Primary Stroke Centers in Reperfusion Therapies for Acute Ischemic Stroke: Report from the Get With The Guidelines Stroke Registry: Stroke Outcomes Per Hospital Certification Status. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.05.23292270. [PMID: 37461517 PMCID: PMC10350146 DOI: 10.1101/2023.07.05.23292270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Background The thrombectomy-capable stroke center (TSC) is a recently introduced intermediate tier of accreditation for hospitals caring for patients with acute ischemic stroke (AIS). The comparative quality and clinical outcomes of reperfusion therapies at TSCs, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs) has not been well delineated. Methods We conducted a retrospective, observational, cohort study from 2018-2020 that included patients with AIS who received endovascular (EVT) and/or intravenous (IVT) reperfusion therapies at CSC, TSC, or PSC. Participants were recruited from Get With The Guidelines-Stroke registry. Study endpoints included timeliness of IVT and EVT, successful reperfusion, discharge destination, discharge mortality, and functional independence at discharge. Results Among 84,903 included patients, 48,682 received EVT, of whom 73% were treated at CSCs, 22% at PSCs, and 4% at TSCs. The median annual EVT volume was 76 for CSCs, 55 for TSCs, and 32 for PSCs. Patient differences by center status included higher NIHSS, longer onset-to-arrival time, and higher transfer-in rates for CSC/TSC/PSC, respectively. In adjusted analyses, the likelihood of achieving the goal door-to-needle time was higher in CSCs compared to PSCs (OR 1.39; 95% CI 1.17-1.66) and in TSCs compared to PSCs (OR 1.45; 95% CI 1.08-1.96). Similarly, the odds of achieving the goal door-to-puncture time were higher in CSCs compared to PSCs (OR 1.58; 95% CI 1.13-2.21). CSCs and TSCs also demonstrated better clinical efficacy outcomes compared to PSCs. The odds of discharge to home or rehabilitation were higher in CSCs compared to PSCs (OR 1.18; 95% CI 1.06-1.31), while the odds of in-hospital mortality/discharge to hospice were lower in both CSCs compared to PSCs (OR 0.87; 95% CI 0.81-0.94) and TSCs compared to PSCs (OR 0.86; 95% CI 0.75-0.98). There were no significant differences in any of the quality-of-care metrics and clinical outcomes between TSCs and CSCs. Conclusions In this study representing national US practice, CSCs and TSCs exceeded PSCs in key quality-of-care reperfusion metrics and outcomes, whereas TSCs and CSCs demonstrated similar performance. Considering that over one-fifth of all EVT procedures during the study period were conducted at PSCs, it may be desirable to explore national initiatives aimed at facilitating the elevation of eligible PSCs to a higher certification status.
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42
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Nazar E, Esmaily H, Yousefi R, Jamali J, Ghandehari K, Hashtarkhani S, Jafari Z, Shakeri MT. A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran. ARCHIVES OF IRANIAN MEDICINE 2023; 26:300-309. [PMID: 38310430 PMCID: PMC10685828 DOI: 10.34172/aim.2023.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 05/01/2022] [Indexed: 02/05/2024]
Abstract
BACKGROUND Despite significant advances in the quality and delivery of specialized stroke care, there still persist remarkable spatial variations in emergency medical services (EMS) transport delays, stroke incidence, and its outcomes. Therefore, it is very important to investigate the possible geographical variations of in-hospital stroke mortality and to identify its associated factors. METHODS This historical cohort study included suspected stroke cases transferred to Ghaem Hospital of Mashhad by the EMS from March 2018 to March 2019. Using emergency mission IDs, the pre-hospital emergency data were integrated with the patient medical records in the hospital. We used the Bayesian approach for estimating the model parameters. RESULTS Out of 301 patients (142 (47.2%) females vs. 159 (52.8%) males) with a final diagnosis of stroke, 61 (20.3%) cases had in-hospital mortality. Results from Bayesian spatial log-logistic proportional odds (PO) model showed that age (PO=1.07), access rate to EMS (PO=0.78), arrival time (evening shift vs. day shift, PO=0.09), and sequelae variables (PO=9.20) had a significant association with the odds of in-hospital stroke mortality (P<0.05). Furthermore, the odds of in-hospital stroke mortality were higher in central urban areas compared to suburban areas. CONCLUSION Marked regional variations were found in the odds of in-hospital stroke mortality in Mashhad. There was a direct association between age and odds of in-hospital stroke mortality. Hence, the prognosis of in-hospital stroke mortality could be improved by better control of hypertension, prevention of the occurrence of sequelae, increasing the access rate to EMS, and optimizing shift work schedule.
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Affiliation(s)
- Eisa Nazar
- Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Mazandaran, Iran
- Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Habibollah Esmaily
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Razieh Yousefi
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Jamshid Jamali
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kavian Ghandehari
- Neurocognitive Research Center, Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soheil Hashtarkhani
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, USA
| | - Zahra Jafari
- Clinical Research Development Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Taghi Shakeri
- Department of Biostatistics, School of Public Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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43
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Zheng M, Li L, Chen L, Li B, Feng C. Mechanical thrombectomy combined with intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analyses. Sci Rep 2023; 13:8597. [PMID: 37237159 DOI: 10.1038/s41598-023-35532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
To assess the clinical value of mechanical thrombectomy (MT) combined with intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) by comparing it with the MT alone. In this study, we conducted a comprehensive meta-analysis of both observational and randomized controlled studies (RCTs) to investigate various outcomes. Our search for relevant studies was conducted between January 2011 and June 2022 in four major databases: PubMed, Embase, WOS, and Cochrane Library. We collected data on several outcomes, including functional independence (FI; defined as modified Rankin Scale score of 0 to 2), excellent outcomes (mRS 0-1), successful recanalization (SR), symptomatic intracerebral hemorrhage (sICH), any intracerebral hemorrhage (aICH), and mortality at three months or discharge. The primary efficacy outcome and safety outcome were FI and sICH, respectively, whereas excellent outcomes and SR were considered secondary efficacy outcomes. Additionally, mortality and aICH were analyzed as secondary safety outcomes. We employed the Mantel-Haenszel fixed-effects model for RCTs when I2 < 50%, otherwise the random-effects model was utilized. For observational studies and subgroup analyses, we used the random-effects model to minimize potential bias. A total of 55 eligible studies (nine RCTs and 46 observational studies) were included. For RCTs, the MT + IVT group was superior in FI (OR: 1.27, 95% CI: 1.11-1.46), excellent outcomes (OR: 1.21, 95% CI: 1.03-1.43), SR (OR: 1.23, 95% CI: 1.05-1.45), mortality (OR: 0.72, 95% CI: 0.54-0.97) in crude analyses. In adjusted analyses, the MT + IVT group reduced the risk of mortality (OR: 0.65, 95% CI: 0.49-0.88). However, the difference in FI between the MT + IVT group and the MT alone group was not significant (OR: 1.17, 95% CI: 0.99-1.38, Fig. 3a). For observational studies, the results of FI (OR: 1.34, 95% CI: 1.16-1.33), excellent outcomes (OR: 1.30, 95% CI: 1.09-1.54), SR (OR: 1.23, 95% CI: 1.05-1.44), mortality (OR: 0.70, 95% CI: 0.64-0.77) in the MT + IVT group were better. Additionally, the MT + IVT group increased the risk of hemorrhagic transformation (HT) including sICH (OR: 1.16, 95% CI: 1.11-1.21) and aICH (OR: 1.24, 95% CI: 1.05-1.46) in crude analyses. In adjusted analyses, significant better outcomes were seen in the MT + IVT group on FI (OR: 1.36, 95% CI: 1.21-1.52), excellent outcomes (OR: 1.49, 95% CI: 1.26-1.75), and mortality (OR: 0.73, 95% CI: 0.56-0.94). The MT + IVT therapy did improve the prognosis for AIS patients and did not increase the risk of HT compared with MT alone therapy.
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Affiliation(s)
- Meiling Zheng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, People's Republic of China
| | - Li Li
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan Province, People's Republic of China.
| | - Lizhou Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Bin Li
- Department of Geriatrics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, People's Republic of China.
| | - Cuiling Feng
- Peking University People's Hospital, Beijing, 100000, People's Republic of China.
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Faizy TD, Broocks G, Heit JJ, Kniep H, Flottmann F, Meyer L, Sporns P, Hanning U, Kaesmacher J, Deb-Chatterji M, Vollmuth P, Lansberg MG, Albers GW, Fischer U, Wintermark M, Thomalla G, Fiehler J, Winkelmeier L. Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion. JAMA Netw Open 2023; 6:e2310213. [PMID: 37126350 PMCID: PMC10152307 DOI: 10.1001/jamanetworkopen.2023.10213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. Objective To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Design, Setting, and Participants Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Interventions Mechanical thrombectomy with or without IVT. Main Outcomes and Measures Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. Results After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). Conclusions and Relevance These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Gregory W Albers
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Urs Fischer
- Department of Neurology, University Medical Center Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Nakamoto CH, Wilcock AD, Schwamm LH, Zachrison KS, Uscher-Pines L, Mehrotra A. Variation in patterns of telestroke usage during the COVID-19 pandemic. J Stroke Cerebrovasc Dis 2023; 32:107036. [PMID: 36791674 PMCID: PMC9899774 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVES Early in the pandemic, there was a substantial increase in telestroke uptake among hospitals. The motivations for using telestroke during the pandemic might have been different than for hospitals that adopted telestroke previously. We compared stroke care at hospitals that adopted telestroke prior to the pandemic to care at hospitals that adopted telestroke during the pandemic. MATERIALS AND METHODS Stroke episodes and telestroke use were identified in Medicare Fee-for-Service Data. Hospital and episode characteristics were compared between pre-pandemic (Jan. 2019-Mar. 2020) and pandemic (Apr. 2020-Dec. 2020) adopters. RESULTS Hospital bed counts, critical access statuses, stroke volumes, clinical operating margins, shares of stroke care via telestroke, and vascular neurology consult rates did not differ significantly between pre-pandemic and pandemic-adopting hospitals. Hospitals that never adopted telestroke during the study period were more likely to be small critical access hospitals with low clinical operating margins. CONCLUSIONS Compared to hospitals that adopted telestroke before the pandemic, hospitals that adopted telestroke during the pandemic were similar in characteristics and how they used telestroke.
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Affiliation(s)
- Carter H. Nakamoto
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | | | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States; Beth Israel Deaconess Medical Center, Boston, MA, United States.
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Pajor MJ, Adeoye OM. Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era. Neurotherapeutics 2023; 20:655-663. [PMID: 36977818 PMCID: PMC10047478 DOI: 10.1007/s13311-023-01371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Thrombectomy became the gold-standard treatment of acute ischemic stroke caused by large-vessel occlusions (LVO) in 2015 after five clinical trials published that year demonstrated significantly improved patient outcomes. In subsequent years, advances in stroke systems of care have centered around improving access to and expanding patient eligibility for thrombectomy. The prehospital and acute stroke treatment settings have had the greatest emphasis. Numerous prehospital stroke scales now provide emergency medical services with focused physical exams to identify LVOs, and many devices to non-invasively detect LVO are undergoing clinical testing. Mobile stroke units deployed throughout Western Europe and the USA also show promising results by bringing elements of acute stroke care directly to the patient. Numerous clinical trials since 2015 have aimed to increase candidates for thrombectomy by expanding indications and the eligibility time window. Further optimizations of thrombectomy treatment have focused on the role of thrombolytics and other adjunctive therapies that may promote neuroprotection and neurorecovery. While many of these approaches require further clinical investigation, the next decade shows significant potential for further advances in stroke care.
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Affiliation(s)
- Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
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47
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Farooqui M, Ikram A, Suriya S, Qeadan F, Bzdyra P, Quadri SA, Zafar A. Patterns of Care in Patients with Basilar Artery Occlusion (BAO): A Population-Based Study. Life (Basel) 2023; 13:life13030829. [PMID: 36983984 PMCID: PMC10053211 DOI: 10.3390/life13030829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Basilar artery occlusion (BAO) is associated with high morbidity and mortality. Endovascular therapy (EVT) has been shown to be beneficial in acute BAO patients. This retrospective observational study used the National Inpatient Sample (NIS) database to identify BAO patients using the International Classification of Diseases (ICD). Multivariable models were used to evaluate the association of risk factors, comorbidities, length of stay (LOS) in hospital, total cost, disposition, and transfer status. A total of 1120 (447 females, 39.95%) patients were identified, with a higher proportion of White individuals (66.8% vs. 57.6%), atrial fibrillation (31.5% vs. 17.2%; p < 0.0001), and peripheral vascular disease (21.2% vs. 13.7%; p = 0.009). A lower proportion of individuals with diabetes mellitus (32.1% vs. 39.5%; p = 0.05) was found in the EVT group. Majority of the patients (924/1120, 82.5%) were treated at the urban teaching facility, which also performed most of the EVT procedures (164, 89.13%), followed by non-academic urban (166, 14.8%) and rural (30, 2.7%) hospitals. Most patients (19/30, 63%) admitted to rural hospitals were transferred to other facilities. Urban academic hospitals also had the highest median LOS (8.9 days), cost of hospitalization (USD 117,261), and disposition to home (32.6%). This study observed distinct patterns and geographical disparities in the acute treatment of BAO patients. There is a need for national- and state-level strategies to improve access to stroke care.
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Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Asad Ikram
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Sajid Suriya
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM 87106, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Piotr Bzdyra
- Department of Neurology, St. Bernardine Medical Center, San Bernadino, CA 92404, USA
| | - Syed A Quadri
- Department of Neurology, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Atif Zafar
- Department of Neurology, St. Michael Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
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48
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Chung I, Bae HJ, Kim BJ, Kim JY, Han MK, Kim J, Jung C, Kang J. Interactive Direct Interhospital Transfer Network System for Acute Stroke in South Korea. J Clin Neurol 2023; 19:125-130. [PMID: 36647229 PMCID: PMC9982181 DOI: 10.3988/jcn.2022.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/30/2022] [Accepted: 07/30/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Interhospital transfer is an essential practical component of regional stroke care systems. To establish an effective stroke transfer network in South Korea, an interactive transfer system was constructed, and its workflow metrics were observed. METHODS In March 2019, a direct transfer system between primary stroke hospitals (PSHs) and comprehensive regional stroke centers (CSCs) was established to standardize the clinical pathway of imaging, recanalization therapy, transfer decisions, and exclusive transfer linkage systems in the two types of centers. In an active case, the time metrics from arrival at PSH ("door") to imaging was measured, and intravenous thrombolysis (IVT) and endovascular treatment (EVT) were used to assess the differences in clinical situations. RESULTS The direct transfer system was used by 27 patients. They stayed at the PSH for a median duration of 72 min (interquartile range [IQR], 38-114 min), with a median times of 15 and 58 min for imaging and subsequent processing, respectively. The door-to-needle median times of subjects treated with IVT at PSHs (n=5) and CSCs (n=2) were 21 min (IQR, 20.0-22.0 min) and 137.5 min (IQR, 125.3-149.8 min), respectively. EVT was performed on seven subjects (25.9%) at CSCs, which took a median duration of 175 min; 77 min at the PSH, 48 min for transportation, and 50 min at the CSC. Before EVT, bridging IVT at the PSH did not significantly affect the door-to-puncture time (127 min vs. 143.5 min, p=0.86). CONCLUSIONS The direct and interactive transfer system is feasible in real-world practice in South Korea and presents merits in reducing the treatment delay by sharing information during transfer.
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Affiliation(s)
- Inyoung Chung
- Department of Neurology, H PLUS YANGJI Hospital, Seoul, Korea.,Department of Neurology, Gyeonggi Provincial Medical Center Icheon Hospital, Icheon, Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
| | - Jun Yup Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea
| | - Jinhwi Kim
- Department of Emergency Medicine, Gyeonggi Provincial Medical Center Icheon Hospital, Icheon, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University, Seongnam, Korea.
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García-Tornel Á, Flores A, Terceño M, Cardona P, Amaro S, Gomis M, Zaragoza J, Krupinski J, Gómez-Choco M, Mas N, Cocho D, Catena E, Purroy F, Deck M, Rubiera M, Pagola J, Rodriguez-Luna D, Juega J, Rodríguez-Villatoro N, Molina CA, Soro C, Jimenez X, Salvat-Plana M, Dávalos A, Jovin TG, Abilleira S, Pérez de la Ossa N, Ribó M. Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia. Stroke 2023; 54:770-780. [PMID: 36848432 DOI: 10.1161/strokeaha.122.041013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. METHODS We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am-8:59 pm) and nighttime (9:00 pm-7:59 am). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. RESULTS We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020-2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680-1.163]; P
interaction=0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548-1.072]; nighttime, acOR, 1.785 [95% CI, 1.024-3.112] ; P
interaction<0.01); no heterogeneity was observed for other stroke subtypes (P
interaction>0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. CONCLUSIONS Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02795962.
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Alan Flores
- Department of Neurology, Hospital Universitari Joan XXIII, Tarragona, Spain (A.F.)
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T.)
| | - Pedro Cardona
- Stroke Unit, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Spain (P.C.)
| | - Sergi Amaro
- Stroke Unit, Hospital Clínic, Barcelona, Spain (S.A.)
| | - Meritxell Gomis
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Josep Zaragoza
- Department of Neurology, Hospital Verge de la Cinta, Tortosa, Spain (J.Z.)
| | - Jerzy Krupinski
- Department of Neurology, Hospital Mútua Terrassa, Spain (J.K.)
| | - Manuel Gómez-Choco
- Department of Neurology, Hospital Moisés Broggi, Sant Joan Despí, Spain (M.G.-C.)
| | - Natalia Mas
- Department of Neurology, Hospital Sant Joan de Déu - Fundació Althaia, Manresa, Spain (N.M.)
| | - Dolores Cocho
- Department of Neurology, Hospital General Granollers, Spain (D.C.)
| | - Esther Catena
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Spain (E.C.)
| | - Francesc Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P.)
| | - Matias Deck
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Cristina Soro
- Sistema d'Emergències Mèdiques, Barcelona, Spain (C.S., X.J.)
| | - Xavier Jimenez
- Sistema d'Emergències Mèdiques, Barcelona, Spain (C.S., X.J.)
| | - Mercè Salvat-Plana
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (M.S.-P., S.A.)
| | - Antoni Dávalos
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Tudor G Jovin
- Neurological Institute, Cooper University Hospital, Camden, NJ (T.G.J.)
| | - Sonia Abilleira
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (M.S.-P., S.A.)
| | - Natalia Pérez de la Ossa
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
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50
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Matsoukas S, Stein LK, Fifi J. Artificial Intelligence-Assisted Software Significantly Decreases All Workflow Metrics for Large Vessel Occlusion Transfer Patients, within a Large Spoke and Hub System. Cerebrovasc Dis Extra 2023; 13:41-46. [PMID: 36787716 PMCID: PMC9999083 DOI: 10.1159/000529077] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/19/2022] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Artificial intelligence (AI) software is increasingly applied in stroke diagnostics. Viz LVO (large vessel occlusion) is an AI-based software that is FDA-approved for LVO detection in CT angiography (CTA) scans. We sought to investigate differences in transfer times (from peripheral [spoke] to central [hub] hospitals) for LVO patients between spoke hospitals that utilize Viz LVO and those that do not. METHODS In this retrospective cohort study, we used our institutional database to identify all suspected/confirmed LVO-transferred patients from spokes (peripheral hospitals) within and outside of our healthcare system, from January 2020 to December 2021. The "Viz-transfers" group includes all LVO transfers from spokes within our system where Viz LVO is readily available, while the "Non-Viz-transfers" group (control group) is comprised of all LVO transfers from spokes outside our system, without Viz LVO. Primary outcome included all available time metrics from peripheral CTA commencement. RESULTS In total, 78 patients required a transfer. Despite comparable peripheral hospital door to peripheral hospital CTA times (20.5 [24.3] vs. 32 [45] min, p = 0.28) and transfer (spoke to hub) time (23 [18] vs. 26 [13.5], p = 0.763), all workflow metrics were statistically significantly shorter in the Viz-transfers group. Peripheral CTA to interventional neuroradiology team notification was 12 (16.8) versus 58 (59.5), p < 0.001, and peripheral CTA to peripheral departure was 91.5 (37) versus 122.5 (68.5), p < 0.001. Peripheral arrival to peripheral departure was 116.5 (75.5) versus 169 (126.8), p = 0.002, and peripheral arrival to central arrival was 145 (62.5) versus 207 (97.8), p < 0.001. In addition, peripheral CTA to angiosuite arrival was 121 (41) versus 207 (92.5), p < 0.001, peripheral CTA to arterial puncture was 146 (53) versus 234 (99.8), p < 0.001, and peripheral CTA to recanalization was 198 (25) versus 253.5 (86), p < 0.001. CONCLUSION Within our spoke and hub system, Viz LVO significantly decreased all workflow metrics for patients who were transferred from spokes with versus without Viz.
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Affiliation(s)
- Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura K. Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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