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Agrawal D, Dhillon P, Siow I, Lee KS, Spooner O, Yeo L, Bhogal P. Prehospital technologies for early stroke detection - A review. Interv Neuroradiol 2023:15910199231152372. [PMID: 36654460 DOI: 10.1177/15910199231152372] [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: 01/20/2023] Open
Abstract
The rate of neural circuitry loss in a typical large vessel occlusion well emphasizes that 'Time is Brain'. Every untreated minute in a large vessel ischaemic stroke results in loss of 1.9 million neurons and 13.8 billion synapses. As such, it is essential to optimize the flow-limiting steps in delivering the current standard of care. The current diagnostic model involves recognition of symptoms by patients, followed by access to Emergency Medical Services and subsequent physical examination and neuroimaging in the Emergency Department. With more than 50% of stroke patients using Emergency Medical Services as the first point of care contact, it can be deduced that the outcome of the 'stroke chain of survival' can be improved by addressing the bottleneck of prehospital stroke diagnosis. Here we present a review of the existing technologies.
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Affiliation(s)
- Deepsha Agrawal
- Department of Radiology, 6397Oxford University Hospitals NHS Trust, Oxford, UK
| | - Permesh Dhillon
- Department of Interventional Neuroradiology, 105590Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Isabel Siow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Oliver Spooner
- Department of Stroke Medicine, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Leonard Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
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52
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Rohmann JL, Huerta-Gutierrez R, Audebert HJ, Kurth T, Piccininni M. Adjusted horizontal stacked bar graphs (“Grotta bars”) for consistent presentation of observational stroke study results. Eur Stroke J 2023; 8:370-379. [PMID: 37021164 PMCID: PMC10069225 DOI: 10.1177/23969873221149464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Modified Rankin Scale (mRS) scores are used to measure functional outcomes after stroke. Researchers create horizontal stacked bar graphs (nicknamed “Grotta bars”) to illustrate distributional differences in scores between groups. In well-conducted randomized controlled trials, Grotta bars have a causal interpretation. However, the common practice of exclusively presenting unadjusted Grotta bars in observational studies can be misleading in the presence of confounding. We demonstrated this problem and a possible solution using an empirical comparison of 3-month mRS scores among stroke/TIA patients discharged home versus elsewhere after hospitalization. Patients and methods: Using data from the Berlin-based B-SPATIAL registry, we estimated the probability of being discharged home conditional on prespecified measured confounding factors and generated stabilized inverse probability of treatment (IPT) weights for each patient. We visualized mRS distributions by group with Grotta bars for the IPT-weighted population in which measured confounding was removed. We then used ordinal logistic regression to quantify unadjusted and adjusted associations between being discharged home and the 3-month mRS score. Results: Of 3184 eligible patients, 2537 (79.7%) were discharged home. In the unadjusted analyses, those discharged home had considerably lower mRS compared with patients discharged elsewhere (common odds ratio, cOR = 0.13, 95% CI: 0.11–0.15). After removing measured confounding, we obtained substantially different mRS distributions, visually apparent in the adjusted Grotta bars. No statistically significant association was found after confounding adjustment (cOR = 0.82, 95% CI: 0.60–1.12). Discussion and conclusion: The practice of presenting only unadjusted stacked bar graphs for mRS scores together with adjusted effect estimates in observational studies can be misleading. IPT weighting can be implemented to create Grotta bars that account for measured confounding, which are more consistent with the presentation of adjusted results in observational studies.
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Affiliation(s)
- Jessica L Rohmann
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Rodrigo Huerta-Gutierrez
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
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53
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Oliveira Gonçalves AS, Rohmann JL, Piccininni M, Kurth T, Ebinger M, Endres M, Freitag E, Harmel P, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Busse R, Audebert HJ. Economic Evaluation of a Mobile Stroke Unit Service in Germany. Ann Neurol 2023; 93:942-951. [PMID: 36637359 DOI: 10.1002/ana.26602] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Lower global disability and higher quality of life among ischemic stroke patients was found to be associated with the dispatch of mobile stroke units (MSUs) among patients eligible for recanalizing treatments in the Berlin_Prehospital Or Usual Delivery of stroke care (B_PROUD) study. The current study assessed the cost-utility and cost-effectiveness of additional MSU dispatch using data from this prospective, controlled, intervention study. METHODS Outcomes considered in the economic evaluation included quality-adjusted life years (QALYs) derived from the 3-level version of EQ-5D (EQ-5D-3L) and modified Rankin Scale (mRS) scores for functional outcomes 3-months after stroke. Costs were prospectively collected during the study by the MSU provider (Berlin Fire Brigade) and the B_PROUD research team. We focus our results on the societal perspective. As we aimed to determine the economic consequences of the intervention beyond the study's follow-up period, both care costs and QALYs were extrapolated over 5 years. RESULTS The additional MSU dispatch resulted in an incremental €40,984 per QALY. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €24,470.76 and €61,690.88 per QALY. In the cost-effectiveness analysis, MSU dispatch resulted in incremental costs of €81,491 per survival without disability. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €44,455.30 and €116,491.15 per survival without disability. INTERPRETATION Among patients eligible for recanalizing treatments in ischemic stroke, MSU dispatch was associated with both higher QALYs and higher costs and is cost-effective when considering internationally accepted thresholds ranging from an additional €40,000 to €80,000 per QALY. ANN NEUROL 2023.
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Affiliation(s)
- Ana Sofia Oliveira Gonçalves
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Jessica L Rohmann
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Marco Piccininni
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Erik Freitag
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Ira Rohrpasser-Napierkowski
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Berlin University of Technology, Berlin, Germany.,European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt Universität zu Berlin, Berlin, Germany
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Jensen M, Sehner S, Cheng B, Schlemm E, Quandt F, Barow E, Wegscheider K, Boutitie F, Ebinger M, Endres M, Fiebach JB, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Thomalla G, Gerloff C. Patient-Reported Quality of Life After Intravenous Alteplase for Stroke in the WAKE-UP Trial. Neurology 2023; 100:e154-e162. [PMID: 36302662 DOI: 10.1212/wnl.0000000000201375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intravenous alteplase improves functional outcome after acute ischemic stroke. However, little is known about the effects on self-reported health-related quality of life (HRQoL). METHODS WAKE-UP was a multicenter, randomized, placebo-controlled trial of MRI-guided intravenous alteplase in stroke with unknown onset time. HRQoL was assessed using the EuroQol five-dimensional questionnaire (EQ-5D) at 90 days, comprising the EQ-5D index and the EQ visual analogue scale (VAS). Functional outcome was assessed by the modified Rankin Scale (mRS). We calculated the effect of treatment on EQ-5D index and EQ VAS using multiple linear regression models. Mediation analysis was performed on stroke survivors to explore the extent to which the effect of alteplase on HRQoL was mediated by functional outcome. RESULTS Among 490 stroke survivors, the EQ-5D index was available for 452 (92.2%), of whom 226 (50%) were assigned to treatment with alteplase and 226 (50%) to placebo. At 90 days, mean EQ-5D index was higher, reflecting a better health state, in patients randomized to treatment with alteplase than with placebo (0.75 vs 0.67) with an adjusted mean difference of 0.07 (95% CI 0.02-0.12, p = 0.005). In addition, mean EQ VAS was higher with alteplase than with placebo (72.6 vs 64.9), with an adjusted mean difference of 7.6 (95% CI 3.9-11.8, p < 0.001). Eighty-five percent of the total treatment effect of alteplase on the EQ-5D index was mediated using the mRS score while there was no significant direct effect. By contrast, the treatment effect on the EQ VAS was mainly through the direct pathway (60%), whereas 40% was mediated by the mRS. DISCUSSION Assessment of patient-reported outcome measures reveals a potential benefit of intravenous alteplase for HRQoL beyond improvement of functional outcome. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov number, NCT01525290; EudraCT number, 2011-005906-32.
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Affiliation(s)
- Märit Jensen
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark.
| | - Susanne Sehner
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Bastian Cheng
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Eckhard Schlemm
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Fanny Quandt
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Ewgenia Barow
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Karl Wegscheider
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Florent Boutitie
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Martin Ebinger
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Matthias Endres
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Jochen B Fiebach
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Vincent Thijs
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Robin Lemmens
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Keith W Muir
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Norbert Nighoghossian
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Salvador Pedraza
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Claus Z Simonsen
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Götz Thomalla
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
| | - Christian Gerloff
- From the Klinik und Poliklinik für Neurologie (M.J., B.C., E.S., F.Q., E.B., G.T., C.G.), Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf; Institut für Medizinische Biometrie und Epidemiologie (S.S., K.W.), Zentrum für Experimentelle Medizin, Universitätsklinikum Hamburg-Eppendorf, Germany; Hospices Civils de Lyon (F.B.), Service de Biostatistique; Université Lyon 1 (F.B.), Villeurbanne; and CNRS (F.B.), UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Centrum für Schlaganfallforschung Berlin (CSB) (M. Ebinger, M. Endres, J.F.) and Klinik und Hochschulambulanz für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin; Neurologie (M. Ebinger), Medical Park Berlin Humboldtmühle; German Center for Neurodegenerative Disease (DZNE) (M. Endres), Partner Site Berlin; German Center for Cardiovascular Research (DZHK) (M. Endres), Partner Site Berlin; Excellence Cluster NeuroCure (M. Endres), Berlin, Germany; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Heidelberg, Victoria Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Department of Neurology (R.L.), University Hospitals Leuven; Department of Neurosciences (R.L.), KU Leuven, University of Leuven, Experimental Neurology; VIB (R.L.), Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium; School of Psychology & Neuroscience (K.M.), University of Glasgow, United Kingdom; Department of Stroke Medicine (N.N.), Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA; Hospices Civils de Lyon (N.N.), France; Department of Radiology (S.P.), Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut dInvestigació Biomèdica de Girona (IDIBGI), Girona, Spain; and Department of Neurology (C.Z.S.), Aarhus University Hospital, Denmark
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Rohmann JL, Piccininni M, Ebinger M, Wendt M, Weber JE, Schwabauer E, Geisler F, Freitag E, Harmel P, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Nolte CH, Nabavi DG, Schmehl I, Ekkernkamp A, Endres M, Audebert HJ. Effect of Mobile Stroke Unit Dispatch in all Patients with Acute Stroke or TIA. Ann Neurol 2023; 93:50-63. [PMID: 36309933 DOI: 10.1002/ana.26541] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the effect of additional mobile stroke unit (MSU) dispatch on functional outcomes among the full spectrum of stroke patients, regardless of subtype or potential contraindications to reperfusion therapies. METHODS We used data from the nonrandomized Berlin-based B_PROUD study (02/2017 to 05/2019), in which MSUs were dispatched based solely on availability, and the linked B-SPATIAL stroke registry. All patients with final stroke or transient ischemic attack (TIA) diagnoses were eligible. The intervention under study was the additional dispatch of an MSU, an emergency physician-staffed ambulance equipped to provide prehospital imaging and thrombolytic treatment, compared to conventional ambulance alone. The primary outcome was the 3-month modified Rankin Scale (mRS) score, and the co-primary outcome was a 3-tiered disability scale. We identified confounders using directed acyclic graphs and obtained adjusted effect estimates using inverse probability of treatment weighting. RESULTS MSUs were dispatched to 1,125 patients (mean age: 74 years, 46.5% female), while for 1,141 patients only conventional ambulances were dispatched (75 years, 49.9% female). After confounding adjustment, MSU dispatch was associated with more favorable 3-month mRS scores (common odds ratio [cOR] = 0.82; 95% confidence interval [CI]: 0.71-0.94). No statistically significant association was found with the co-primary outcome (cOR = 0.86; 9% CI: 0.72-1.01) or 7-day mortality (OR = 0.94; 95% CI: 0.59-1.48). INTERPRETATION When considering the entire population of stroke/TIA patients, MSU dispatch improved 3-month functional outcomes without evidence of compromised safety. Our results are relevant for decision-makers since stroke subtype and treatment eligibility are unknown at time of dispatch. ANN NEUROL 2023;93:50-63.
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Affiliation(s)
- Jessica L Rohmann
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin (MPB) Humboldtmühle, Berlin, Germany
| | - Matthias Wendt
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Joachim E Weber
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Freitag
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Darius G Nabavi
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Ingo Schmehl
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Berlin, Germany
| | | | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,NeuroCure Cluster of Excellence, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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Beauchamp NJ, Bryan RN, Bui MM, Krestin GP, McGinty GB, Meltzer CC, Neumaier M. Integrative Diagnostics: The Time Is Now-A Report From the International Society for Strategic Studies in Radiology. J Am Coll Radiol 2022; 20:455-466. [PMID: 36565973 DOI: 10.1016/j.jacr.2022.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
Enormous recent progress in diagnostic testing can enable more accurate diagnosis and improved clinical outcomes. Yet these tests are increasingly challenging and frustrating; the volume and diversity of results may overwhelm the diagnostic acumen of even the most dedicated and experienced clinician. Because they are gathered and processed within the "silo" of each diagnostic discipline, diagnostic data are fragmented, and the electronic health record does little to synthesize new and existing data into usable information. Therefore, despite great promise, diagnoses may still be incorrect, delayed, or never made. Integrative diagnostics represents a vision for the future, wherein diagnostic data, together with clinical data from the electronic health record, are aggregated and contextualized by informatics tools to direct clinical action. Integrative diagnostics has the potential to identify correct therapies more quickly, modify treatment when appropriate, and terminate treatment when not effective, ultimately decreasing morbidity, improving outcomes, and avoiding unnecessary costs. Radiology, laboratory medicine, and pathology already play major roles in medical diagnostics. Our specialties can increase the value of our examinations by taking a holistic approach to their selection, interpretation, and application to the patient's care pathway. We have the means and rationale to incorporate integrative diagnostics into our specialties and guide its implementation in clinical practice.
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Affiliation(s)
- Norman J Beauchamp
- Executive Vice President for Health Sciences, Michigan State University, East Lansing, Michigan
| | - R Nick Bryan
- University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Marilyn M Bui
- Moffitt Cancer Center and Research Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Gabriel P Krestin
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Geraldine B McGinty
- Senior Associate Dean for Clinical Affairs, Weill Cornell Medicine, New York, New York
| | - Carolyn C Meltzer
- Dean, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Neumaier
- Chairman of Clinical Chemistry, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Takahashi EA, Schwamm LH, Adeoye OM, Alabi O, Jahangir E, Misra S, Still CH. An Overview of Telehealth in the Management of Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e558-e568. [PMID: 36373541 DOI: 10.1161/cir.0000000000001107] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Telehealth enables the remote delivery of health care through telecommunication technologies and has substantially affected the evolving medical landscape. The COVID-19 pandemic accelerated the utilization of telehealth as health care professionals were forced to limit face-to-face in-person visits. It has been shown that information delivery, diagnosis, disease monitoring, and follow-up care can be conducted remotely, resulting in considerable changes specific to cardiovascular disease management. Despite increasing telehealth utilization, several factors such as technological infrastructure, reimbursement, and limited patient digital literacy can hinder the adoption of remote care. This scientific statement reviews definitions pertinent to telehealth discussions, summarizes the effect of telehealth utilization on cardiovascular and peripheral vascular disease care, and identifies obstacles to the adoption of telehealth that need to be addressed to improve health care accessibility and equity.
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Rink JS, Froelich MF, Nour M, Saver JL, Szabo K, Hoyer C, Fassbender KC, Schoenberg SO, Tollens F. Lifetime economic potential of mobile stroke units in acute stroke care: A model-based analysis of the drivers of cost-effectiveness. J Telemed Telecare 2022:1357633X221140951. [PMID: 36484406 DOI: 10.1177/1357633x221140951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND PURPOSE To simulate patient-level costs, analyze the economic potential of telemedicine-based mobile stroke units for acute prehospital stroke care, and identify major determinants of cost-effectiveness, based on two recent prospective trials from the United States and Germany. METHODS A Markov decision model was developed to simulate lifetime costs and outcomes of mobile stroke unit. The model compares diagnostic and therapeutic pathways of ischemic stroke, hemorrhagic stroke, and stroke mimic patients by conventional care or by mobile stroke units. The treatment outcomes were derived from the B_PROUD and the BEST-mobile stroke unit trials and further input parameters were derived from recent literature. Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. A lifetime horizon based on the US healthcare system was adopted to evaluate different cost thresholds for mobile stroke unit and the resulting cost-effectiveness. Willingness-to-pay thresholds were set at 1x and 3x gross domestic product per capita, as recommended by the World Health Organization. RESULTS In the base case scenario, mobile stroke unit care yielded an incremental gain of 0.591 quality-adjusted life years per dispatch. Mobile stroke unit was highly cost-effective up to a maximum average cost of 43,067 US dollars per patient. Sensitivity analyses revealed that MSU cost-effectiveness is mainly affected by reduction of long-term disability costs. Also, among other parameters, the rate of stroke mimics patients diagnosed by MSU plays an important role. CONCLUSION This study demonstrated that mobile stroke unit can possibly be operated on an excellent level of cost-effectiveness in urban areas in North America with number of stroke mimic patients and long-term stroke survivor costs as major determinants of lifetime cost-effectiveness.
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Affiliation(s)
- Johann S Rink
- Department of Radiology and Nuclear Medicine, 36642University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
| | - Matthias F Froelich
- Department of Radiology and Nuclear Medicine, 36642University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
| | - May Nour
- Departments of Neurology and Radiology, 21767Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kristina Szabo
- Department of Neurology, 36642University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany, Mannheim, BW, Germany
| | - Carolin Hoyer
- Department of Neurology, 36642University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany, Mannheim, BW, Germany
| | - Klaus C Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Stefan O Schoenberg
- Department of Radiology and Nuclear Medicine, 36642University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
| | - Fabian Tollens
- Department of Radiology and Nuclear Medicine, 36642University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
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Muacevic A, Adler JR, Alves M, Papoila AL, Nunes AP. Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region. Cureus 2022; 14:e32659. [PMID: 36660499 PMCID: PMC9844243 DOI: 10.7759/cureus.32659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Endovascular treatment (EVT) with mechanical thrombectomy and acute carotid stenting has become an integral part of the treatment of acute ischemic stroke with large vessel occlusion. Despite being included in the most recent stroke guidelines, only comprehensive centers can offer EVT and thus patients frequently need to be transferred from primary hospitals. We aimed to assess which pre-hospital model of care - direct admission to a comprehensive stroke center (mothership) or transfer to a comprehensive stroke center after the first admission to the nearest hospital (drip-and-ship) - had the most benefit in stroke patients in a Portuguese urban region. Methods We selected patients admitted to a comprehensive stroke center who underwent EVTs between January 2018 and December 2020, in Lisbon, Portugal. We used data from the Safe Implementation of Treatments in Stroke (SITS) International registry on stroke severity, previous modified Rankin Scale (mRS), time from symptom onset to the first admission, time from symptom onset to the procedure, and mRS three months post stroke. We defined an unfavorable outcome as having an mRS >2 at three months post stroke. For patients with previous mRS >2, an unfavorable outcome was defined as any increase in mRS at three months post stroke. Results We analyzed the data of 1154 patients, of which 407 were admitted through a mothership approach and 747 through a drip-and-ship approach. Both groups were similar regarding sociodemographic characteristics, stroke risk factors, previous disability, and stroke severity. Median onset-to-door time was higher (126 vs 110 minutes, p-value=0.002) but onset-to-procedure time was lower (199 vs 339 minutes, p-value<0.001) in the mothership group. The mothership group had a higher proportion of patients with mRS <3 at three months post stroke than the drip-and-ship group (41.3% vs 34.9%, p-value=0.035). Mortality was similar in both groups. A multivariate logistic regression model confirmed a lower probability of unfavorable outcomes with the mothership approach (OR = 0.677, 95% CI 0.514-0.892, p-value=0.006). Surprisingly, onset-to-procedure time did not have an impact on functional outcomes. Conclusion Our findings show that the mothership model results in better functional outcomes for patients with acute ischemic stroke with large vessel occlusion. Further studies are needed to better define patient selection for this strategy and the impact of a mothership model in comprehensive stroke centers.
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Advancements in Hydrogel Application for Ischemic Stroke Therapy. Gels 2022; 8:gels8120777. [PMID: 36547301 PMCID: PMC9778209 DOI: 10.3390/gels8120777] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Ischemic stroke is a major cause of death and disability worldwide. There is almost no effective treatment for this disease. Therefore, developing effective treatment for ischemic stroke is urgently needed. Efficient delivery of therapeutic drugs to ischemic sites remained a great challenge for improved treatment of strokes. In recent years, hydrogel-based strategies have been widely investigated for new and improved therapies. They have the advantage of delivering therapeutics in a controlled manner to the poststroke sites, aiming to enhance the intrinsic repair and regeneration. In this review, we discuss the pathophysiology of stroke and the development of injectable hydrogels in the application of both stroke treatment and neural tissue engineering. We also discuss the prospect and the challenges of hydrogels in the treatment of ischemic strokes.
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Shownkeen H, Richards CT, Buffo K, Graham S, Iacob T, Mohajer-Esfahani M, Lindstrom A, Garg A, Gutti P, Sachdeva K, Shrivastava A, Williams J, Crumlett H, Huml J. Outcomes of Patients Receiving Thrombolysis in a Mobile Stroke Unit: a 4-Year Retrospective, Observational, Single-Center Study. PREHOSP EMERG CARE 2022:1-7. [DOI: 10.1080/10903127.2022.2142991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Harish Shownkeen
- Northwestern Medicine Central DuPage Hospital, Mobile Stroke Unit, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Christopher T. Richards
- Northwestern Medicine Central DuPage Hospital, Neuro - Interventional, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Keely Buffo
- University of Cincinnati, Emergency Medicine, 231 Albert Sabin Way, PO Box 670769, ML: 0769, Cincinnati, 45221 United States
| | - Stephen Graham
- Northwestern Medicine Central DuPage Hospital, Emergency Medicine, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Tudor Iacob
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Mehr Mohajer-Esfahani
- Northwestern Medicine Huntley Hospital, Cardiac Telemetry, 10400 Haligus Rd, Huntley, 60142-9553 United States
| | - Anne Lindstrom
- Marianjoy Rehabilitation Hospital, Rehabilitation, 26W171 Roosevelt Rd, Wheaton, 60189-0795 United States
| | - Anjali Garg
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Padmaja Gutti
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Kapil Sachdeva
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Archana Shrivastava
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Justin Williams
- Northwestern Medicine Central DuPage Hospital, Emergency Medical Services, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Hillary Crumlett
- Northwestern Medicine Central DuPage Hospital, Inpatient Nursing and Emergency Department, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Jeffrey Huml
- Northwestern Medicine Central DuPage Hospital, Critical Care, 25 N Winfield Rd, Winfield, 60190-1379 United States
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Fang M, Xu C, Ma L, Sun Y, Zhou X, Deng J, Liu X. No sex difference was found in the safety and efficacy of intravenous alteplase before endovascular therapy. Front Neurol 2022; 13:989166. [DOI: 10.3389/fneur.2022.989166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022] Open
Abstract
Background and purposePrior studies on sex disparities were post-hoc analyses, had limited treatment modalities, and had controversial findings. Our study aimed to examine whether sex difference modifies the effect of intravenous alteplase before endovascular therapy.MethodsWe conducted a multicenter prospective cohort study of 850 eligible patients with acute ischemic stroke who underwent endovascular therapy. A propensity score was utilized as a covariate to achieve approximate randomization of alteplase pretreatment. The baseline characteristics of women and men were compared. Logistic regression with interaction terms, adjusted for potential confounders, was used to investigate the effect of sex on the prognosis of bridging therapy.ResultsIn comparison to men, women were older [78.00 (70.00–84.00) vs. 67 (61.00–74.00), P < 0.001], had more atrial fibrillation (61.4 vs. 35.2%, P < 0.001), had a lower ASPECTS [10.00 (8.00–10.00) vs. 10 (9.00–10.00), P = 0.0047], and had a higher NIHSS score [17.00 (14.00–20.00) vs. 16 (13.00–19.00), P = 0.005]. Women tended to receive less bridging therapy (26.3 vs. 33%, P = 0.043) and more retrieval attempts [2.00 (1.00–2.00) vs. 1 (1.00–2.00), P = 0.026]. There was no sex difference in functional independence at 90 days after bridging therapy (OR 0.968, 95% CI 0.575–1.63), whereas men benefited more after EVT alone (OR 0.654, 95% CI 0.456–0.937). There were no sex-treatment interactions observed regardless of the location of the occlusion. There were no significant sex differences in all safety outcomes.ConclusionOur study could not confirm that sex modifies the treatment effect of intravenous alteplase before endovascular therapy. At the same time, we advocate for women to seek timely medical treatment.
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Melaika K, Sveikata L, Vilionskis A, Wiśniewski A, Jurjans K, Klimašauskas A, Jatužis D, Masiliūnas R. Prehospital Stroke Care, Paramedic Training Needs, and Hospital-Directed Feedback in Lithuania. Healthcare (Basel) 2022; 10:healthcare10101958. [PMID: 36292405 PMCID: PMC9601945 DOI: 10.3390/healthcare10101958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Emergency medical services (EMS) are the first health care contact for the majority of stroke patients. However, there is a lack of data on the current paramedics’ hospital-directed feedback and training needs across different health care settings. We aimed to evaluate paramedics’ prehospital stroke care knowledge, training needs, and current status of feedback on suspected stroke patients. Methods: We surveyed paramedics from the Vilnius region from September to November 2019 and compared the answers between the city and the district agencies. The questionnaire content included questions on paramedics’ demographic characteristics, prehospital stroke care self-assessment, knowledge on stroke mimics, stroke training needs, and the importance of hospital-directed feedback on suspected stroke patients. Results: A total number of 161 paramedics (or 49.4% of all paramedics from our stroke care network) were surveyed, with more district paramedics rating their prehospital stroke care knowledge as inadequate (44.8% (95% confidence interval (CI) 32.8−57.6) vs. 28.1% (95% CI 20.1−27.8), p = 0.028). In addition, more district paramedics indicated a need for additional stroke training (83.1% (95% CI 71.5−90.5) vs. 69.8% (60.0−78.1), p = 0.043). However, respondents reported being the most confident while dealing with stroke (71.3%, 95% CI 63.8−77.7) compared to other time-critical conditions (p < 0.001). Vertigo (60.8%, 95% CI 53.0−68.0), brain tumors (56.3%, 95% CI 48.5−63.8), and seizures (54.4%, 95% CI 46.7−62.0) were indicated as the most common stroke mimics. Only 6.2% (95% CI 3.4−11.1) of respondents received formal feedback on the outcome of suspected stroke patients brought to the emergency department. Conclusions: A high proportion of paramedics self-perceive having inadequate stroke knowledge and an urgent need for further stroke training. The EMS staff indicate receiving insufficient feedback on suspected stroke patients, even though its usefulness is perceived as paramount.
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Affiliation(s)
| | - Lukas Sveikata
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, 1205 Geneva, Switzerland
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Aleksandras Vilionskis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Vilnius University, 08661 Vilnius, Lithuania
| | - Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-067 Bydgoszcz, Poland
| | - Kristaps Jurjans
- Department of Neurology and Neurosurgery, Riga Stradins University, 1002 Riga, Latvia
- Department of Neurology, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia
| | - Andrius Klimašauskas
- Center of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University, 08661 Vilnius, Lithuania
| | - Dalius Jatužis
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania
| | - Rytis Masiliūnas
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania
- Correspondence: ; Tel.: +370-688-62356; Fax: +370-688-62728
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van Stigt MN, van de Munckhof AAGA, van Meenen LCC, Groenendijk EA, Theunissen M, Franschman G, Smeekes MD, van Grondelle JAF, Geuzebroek G, Siegers A, Marquering HA, Majoie CBLM, Roos YBWEM, Koelman JHTM, Potters WV, Coutinho JM. ELECTRA-STROKE: Electroencephalography controlled triage in the ambulance for acute ischemic stroke—Study protocol for a diagnostic trial. Front Neurol 2022; 13:1018493. [PMID: 36262832 PMCID: PMC9576201 DOI: 10.3389/fneur.2022.1018493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Endovascular thrombectomy (EVT) is the standard treatment for large vessel occlusion stroke of the anterior circulation (LVO-a stroke). Approximately half of EVT-eligible patients are initially presented to hospitals that do not offer EVT. Subsequent inter-hospital transfer delays treatment, which negatively affects patients' prognosis. Prehospital identification of patients with LVO-a stroke would allow direct transportation of these patients to an EVT-capable center. Electroencephalography (EEG) may be suitable for this purpose because of its sensitivity to cerebral ischemia. The hypothesis of ELECTRA-STROKE is that dry electrode EEG is feasible for prehospital detection of LVO-a stroke. Methods ELECTRA-STROKE is an investigator-initiated, diagnostic study. EEG recordings will be performed in patients with a suspected stroke in the ambulance. The primary endpoint is the diagnostic accuracy of the theta/alpha ratio for the diagnosis of LVO-a stroke, expressed by the area under the receiver operating characteristic (ROC) curve. EEG recordings will be performed in 386 patients. Discussion If EEG can be used to identify LVO-a stroke patients with sufficiently high diagnostic accuracy, it may enable direct routing of these patients to an EVT-capable center, thereby reducing time-to-treatment and improving patient outcomes. Clinical trial registration ClinicalTrials.gov, identifier: NCT03699397.
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Affiliation(s)
- Maritta N. van Stigt
- Department of Clinical Neurophysiology, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Anita A. G. A. van de Munckhof
- Department of Clinical Neurophysiology, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Laura C. C. van Meenen
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Eva A. Groenendijk
- Department of Clinical Neurophysiology, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | | | | | | | | | | | | | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Johannes H. T. M. Koelman
- Department of Clinical Neurophysiology, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
| | - Wouter V. Potters
- Department of Clinical Neurophysiology, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Jonathan M. Coutinho
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Tan S, Stephens K, Gao L, Tan E, Frost T, Choi PMC. Practical utility of the ACT-FAST triage algorithm from a primary stroke centre perspective. BMJ Neurol Open 2022; 4:e000325. [PMID: 36110929 PMCID: PMC9462081 DOI: 10.1136/bmjno-2022-000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Rapid reperfusion in ischaemic stroke with emergent large vessel occlusion (ELVO) reduces morbidity and mortality. Limited distribution of endovascular clot retrieval (ECR) capable comprehensive stroke centres (CSCs) necessitates development of pre-hospital models of care to provide equitable and economical access to reperfusion therapy. We examine the time metrics of the traditional secondary transfer strategy in comparison to the direct bypass strategy and the potential utility of the ACT-FAST prehospital triage algorithm on a large volume Melbourne primary stroke centre (PSC). Method: Retrospective analysis of consecutive patients presenting to a PSC from 1 January 2020 to 31 December 2020. Clinical records were interrogated for ACT-FAST positive patients. Time metrics were established using Google Maps traffic modelling and local/published door-to-needle, door-in-door out and door-to-groin data. Results: 88 patients during the study period were ACT-FAST positive. Of these, 49/88 (56%) cases had ELVO ischaemic strokes, 24/88 (27%) cases had intracranial haemorrhages and the remaining 15/88 (17%) had non ELVO ischaemic strokes or mimics (seizure, complex migraine, etc). 28/88 (32%) cases met indication for and were subsequently transferred to a CSC for consideration of ECR. The modelled median scene to groin time for the direct bypass strategy is 94 min whereas the median scene to groin time for the secondary transfer strategy is 109 min, giving a difference of 15 min. Conclusion: Time savings to groin puncture for the direct bypass strategy is substantially less than previous estimates and suggests that the secondary transfer strategy continues to be a viable pathway for a high efficiency PSC.
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Affiliation(s)
- Shuangyue Tan
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Karen Stephens
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Lan Gao
- Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Elise Tan
- Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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Hoenning A, Lemcke J, Rot S, Stengel D, Hoppe B, Zappel K, Schuss P, Mutze S, Goelz L. Middle Meningeal Artery Embolization Minimizes Burdensome Recurrence Rates After Newly Diagnosed Chronic Subdural Hematoma Evacuation (MEMBRANE): study protocol for a randomized controlled trial. Trials 2022; 23:703. [PMID: 35996195 PMCID: PMC9396835 DOI: 10.1186/s13063-022-06506-3] [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: 04/20/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Chronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial. Methods MEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O’Brien-Fleming approach with a planned interim analysis halfway. Discussion The MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH. Trial registration German Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021. ClinicalTrials.gov NCT05327933. Registered on 13 Apr 2022.
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Affiliation(s)
- Alexander Hoenning
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Johannes Lemcke
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Sergej Rot
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Dirk Stengel
- BG Kliniken - Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Germany
| | - Berthold Hoppe
- Institute of Laboratory Medicine, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Kristina Zappel
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Patrick Schuss
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Sven Mutze
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Leonie Goelz
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
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Harahsheh E, English SW, Hrdlicka CM, Demaerschalk B. Telestroke’s Role Through the COVID-19 Pandemic and Beyond. Curr Treat Options Neurol 2022; 24:589-603. [PMID: 35999901 PMCID: PMC9388966 DOI: 10.1007/s11940-022-00737-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 11/25/2022]
Abstract
Purpose of review The goal of this paper is to discuss the role and utilization of telestroke services through the COVID-19 pandemic and to suggest future directions to sustain and increase patients’ access to stroke expertise. Recent findings Telestroke is an innovative and effective tool that has been shown to improve access, quality of care, and outcomes of patients with acute stroke syndromes in resource-limited areas for the last two decades. The COVID-19 pandemic posed a significant challenge and strained healthcare systems worldwide, but it created novel and unique opportunities to expand and increase the utilization of telehealth and telestroke services to deliver personalized healthcare across the continuum of stroke care outside of traditional settings. This rapid and widespread increase in telestroke use was facilitated by the removal of many legislative and regulatory barriers which have limited patients’ access to stroke expertise for many years. Summary As the public health emergency ends, there exists a unique opportunity to optimize and expand upon the pandemic-related rapid growth of telestroke care. Optimal utilization of telehealth and telestroke services will depend on maintaining and improving required infrastructure, laws, and regulations, particularly those governing reimbursement and licensing.
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Affiliation(s)
- Ehab Harahsheh
- Department of Neurology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ 85259 USA
| | | | - Courtney M. Hrdlicka
- Department of Neurology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ 85259 USA
| | - Bart Demaerschalk
- Department of Neurology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ 85259 USA
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Wei C, Shen T, Tang X, Gao Y, Yu X, Chen X. Cerebral small vessel disease combined with cerebral collaterals to predict the prognosis of patients with acute large artery atherosclerotic stroke. Front Neurol 2022; 13:969637. [PMID: 36034278 PMCID: PMC9403757 DOI: 10.3389/fneur.2022.969637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Besides cerebral collaterals, few studies have examined other additional factors affecting the prognosis of patients with large artery atherosclerotic (LAA) stroke. Our study aims to explore the effect of the cerebral small vessel disease (SVD) and the effects of its interaction with cerebral collaterals on the prognosis of patients with acute LAA stroke. Method Patients aged 18 years or older with LAA stroke within 24 h after stroke onset were consecutively enrolled. The functional outcome was determined using the modified Rankin Scale (mRS) at 3 months after stroke onset. Logistic multivariate analyses were used to identify the risk factors for stroke prognosis. Receiver operating characteristic (ROC) curves were constructed to compare the effects of cerebral collaterals and SVD on predicting the prognosis. Results Of the 274 enrolled patients, 174 (63.50%) were identified as having a favorable prognosis, and 100 (36.50%) were identified as having an unfavorable prognosis. After adjusting for covariates, the logistic regression analysis identified that unfavorable prognosis was related to the total SVD score (Model 1, adjusted odds ratio = 1.73, 95% CI: 1.15–2.61, P < 0.01; Model 2, adjusted odds ratio = 1.85, 95% CI: 1.23–2.79, P < 0.01) and Tan score (Model 1, adjusted odds ratio = 0.38, 95% CI: 0.23–0.64, P < 0.01; Model 2, adjusted odds ratio = 0.52, 95% CI: 0.33–0.82, P < 0.01). Compared with cerebral collaterals (AUC = 0.59; 95% CI: 0.52–0.67; P < 0.01) or SVD (AUC = 0.62; 95% CI: 0.56–0.69; P < 0.01) alone, the combination of collaterals and SVD (AUC = 0.66; 95% CI: 0.59–0.73; P < 0.01) had higher diagnostic value for an unfavorable prognosis, and the optimal sensitivity and specificity were 77.01 and 53.00%, respectively. Conclusions The total SVD burden was related to the prognosis of patients with LAA stroke. Compared with cerebral collaterals or SVD alone, cerebral collaterals combined with total SVD burden are better at predicting the prognosis of patients with acute LAA stroke.
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Affiliation(s)
- Cunsheng Wei
- Department of Neurology, The Affiliated Jiangning Hospital With Nanjing Medical University, Nanjing, China
| | - Tingwen Shen
- The Health Promotion Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xuelian Tang
- Department of Neurology, The Affiliated Jiangning Hospital With Nanjing Medical University, Nanjing, China
| | - Yuanyuan Gao
- Department of General Practice, The Affiliated Jiangning Hospital With Nanjing Medical University, Nanjing, China
| | - Xiaorong Yu
- Department of Neurology, The Affiliated Jiangning Hospital With Nanjing Medical University, Nanjing, China
| | - Xuemei Chen
- Department of Neurology, The Affiliated Jiangning Hospital With Nanjing Medical University, Nanjing, China
- *Correspondence: Xuemei Chen
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Napierkowski I, Lorenz-Meyer I, Hille A, Ebinger M, Freitag E, Harmel P, Endres M, Hagemann G, Koennecke HC, Mackert BM, Siegerink B, Audebert HJ. Follow-up of Patients With Stroke, Based on Opt-Out Choice Potential Approach for Acute Care Quality Registries or Observational Studies. Neurology 2022; 99:e1335-e1344. [PMID: 35918161 DOI: 10.1212/wnl.0000000000200916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 05/17/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Restricting follow-up assessment of both interventional and observational studies to patients who provide informed consent introduces relevant selection bias - particularly by underrepresenting patients with neurological communication deficits and impaired capacity to consent. Many patients who are initially unable to give consent may be willing to do so after recovery. Informing patients on study purposes and procedures with offering them the option of non-participation but not requesting explicit consent is called 'opt-out' approach. We investigated whether an opt-out strategy yields meaningful follow-up rates in an acute stroke registry with embedded controlled study. METHODS The citywide Berlin-Specific Acute Treatment in Ischemic or hAemorrhagic stroke with Long-term follow-up (B_SPATiAL) registry was designed to provide reliable information on process indicators and outcomes of specific acute stroke treatments in order to inform health care providers about quality of care and best-practice strategies including the effects of a Mobile Stroke Unit implementation. Because this information was regarded of high public interest, Berlin data protection authorities permitted data sampling without prior informed consent, employing instead follow-up assessment on "opt-out" basis. Patients were included if they had neurological symptoms at ambulance or hospital arrival within 6h of onset and had a final diagnosis of stroke or TIA. Information on data collection and outcome assessment was sent by letter to patients one month before follow-up. RESULTS From 1st Feb 2017 to 31st Jan 2020, a total of 10,597 patients were assessed. Thirty-one (0.3%) patients declined any data use, while 578 (5.5%) opted out of follow-up assessment. Of those not opting-out (n=9,988), functional outcome (modified Rankin Scale) was collected in 8,330 patients (83.4%) and vital status in 9,741 patients (97.5%). We received no complaints regarding data collection procedures. DISCUSSION Opt-out based follow-up collection offers a way to achieve high follow-up rates along with respecting patients' preferences.
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Affiliation(s)
- Ira Napierkowski
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Irina Lorenz-Meyer
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Annegret Hille
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, An der Mühle 2-9, 13507 Berlin, Germany
| | - Erik Freitag
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Harmel
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg Hagemann
- Helios Klinikum Berlin Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Hans-Christian Koennecke
- Klinik für Neurologie mit Stroke Unit; Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Bruno-Marcel Mackert
- Klinik für Neurologie mit Stroke Unit, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157 Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of clinical epidemiology, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Naidech AM, Grotta J, Elm J, Janis S, Dowlatshahi D, Toyoda K, Steiner T, Mayer SA, Khanolkar P, Denlinger J, Audebert HJ, Molina C, Khatri P, Sprigg N, Vagal A, Broderick JP. Recombinant factor VIIa for hemorrhagic stroke treatment at earliest possible time (FASTEST): Protocol for a phase III, double-blind, randomized, placebo-controlled trial. Int J Stroke 2022; 17:806-809. [PMID: 34427473 PMCID: PMC9933458 DOI: 10.1177/17474930211042700] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage is the deadliest form of stroke. Hematoma expansion, growth of the hematoma between the baseline computed tomography scan and a follow-up computed tomography scan at 24 ± 6 h, predicts long-term disability or death. Recombinant factor VIIa (rFVIIa) has reduced hematoma expansion in previous clinical trials with a variable effect on clinical outcomes, with the greatest impact on hematoma expansion and potential benefit when administered within 2 h of symptom onset. METHODS Factor VIIa for Hemorrhagic Stroke Treatment at Earliest Possible Time (FASTEST, NCT03496883) is a randomized controlled trial that will enroll 860 patients at ∼100 emergency departments and mobile stroke units in five countries. Patients are eligible for enrollment if they have acute intracerebral hemorrhage within 2 h of symptom onset confirmed by computed tomography, a hematoma volume of 2 to 60 mL, no or small volumes of intraventricular hemorrhage, do not take anticoagulant medications or concurrent heparin/heparinoids (antiplatelet medications are permissible), and are not deeply comatose. Enrolled patients will receive rFVIIa 80 µg/kg or placebo intravenously over 2 min. The primary outcome measure is the distribution of the ordinal modified Rankin Scale at 180 days. FASTEST is monitored by a Data Safety Monitoring Board. Safety endpoints include thrombotic events (e.g. myocardial infarction). Human subjects research is monitored by an external Institutional Review Board in participating countries. DISCUSSION In the US, FASTEST will be first NIH StrokeNet Trial with an Exception from Informed Consent which allows enrollment of non-communicative patients without an immediately identifiable proxy.
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Affiliation(s)
| | | | - Jordan Elm
- Medical University of South Carolina, Charleston, SC, USA
| | - Scott Janis
- National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Thorsten Steiner
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Richards CT. Strengthening the stroke chain of survival in community emergency departments. J Am Coll Emerg Physicians Open 2022; 3:e12763. [PMID: 35898235 PMCID: PMC9307289 DOI: 10.1002/emp2.12763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/29/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Christopher T. Richards
- Division of Emergency Medical Services Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA
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Application of Multimodal Magnetic Resonance Imaging in Green Channel of Acute and Hyperacute Ischemic Stroke. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2452282. [PMID: 35935321 PMCID: PMC9337922 DOI: 10.1155/2022/2452282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/24/2022] [Accepted: 07/04/2022] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to observe the effects of multimodal magnetic resonance imaging (MRI) in the green channel of acute and hyperacute ischemic strokes, in order to better guide clinical treatment. The clinical data of 126 patients with acute and hyperacute ischemic stroke who received interventional treatment in the emergency green channel was collected retrospectively. The patients who received multimodal computed tomography (CT) were included in the CT group. Patients who underwent multimodal MRI examinations were included in the MRI group, and the door-to-needle time (DNT), neurological function, and prognosis of the two groups were compared. The result turned out that among the 126 patients included, 40 patients underwent CT examination (CT group) and 86 patients underwent MRI examination (MRI group). A comparison of general data between the CT group and the MRI group showed
. The MRI group’s DNT time (61.23 ± 9.32) min was shorter than that of the CT group (87.22 ± 14.26) min,
. Through comparison, the
values of mRS scores and NIHSS scores in both groups were greater than 0.05. After treatment, the mRS score and NIHSS score of the MRI group was lower, with
. According to the results of this study, it can be concluded that emergency multimodal MRI could shorten the DNT time of patients with acute and hyperacute ischemic stroke, reduce the degree of neurological impairment, and improve the prognosis.
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Lund UH, Stoinska-Schneider A, Larsen K, Bache KG, Robberstad B. Cost-Effectiveness of Mobile Stroke Unit Care in Norway. Stroke 2022; 53:3173-3181. [PMID: 35862205 PMCID: PMC9508956 DOI: 10.1161/strokeaha.121.037491] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project).
METHODS:
We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway.
RESULTS:
MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated.
CONCLUSIONS:
MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.
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Affiliation(s)
- Ulrikke Højslev Lund
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Anna Stoinska-Schneider
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
| | - Kristi G. Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
- Research and Dissemination, Østfold University College, Halden, Norway (K.G.B.)
| | - Bjarne Robberstad
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
- Department of Global Public Health and Primary Care, University of Bergen, Norway (B.R.)
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Value of 4D CT Angiography Combined with Whole Brain CT Perfusion Imaging Feature Analysis under Deep Learning in Imaging Examination of Acute Ischemic Stroke. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:2286413. [PMID: 35733580 PMCID: PMC9208916 DOI: 10.1155/2022/2286413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/06/2022] [Accepted: 05/16/2022] [Indexed: 12/30/2022]
Abstract
This study was aimed at investigating the application of deep learning 4D computed tomography angiography (CTA) combined with whole brain CT perfusion (CTP) imaging in acute ischemic stroke (AIS). A total of 46 patients with ischemic stroke were selected from the hospital as the research objects. Image quality was analyzed after the 4D CTA images were obtained by perfusion imaging. The results showed that whole brain perfusion imaging based on FCN can achieve automatic segmentation. FCN segmentation results took a short time, an average of 2-3 seconds, and the Dice similarity coefficient (DSC) and mean absolute distance (MAD) were lower than those of other algorithms. FCN segmentation distance was 17.87. The parameters of the central area, the peripheral area, and the mirror area of the perfusion map were compared, and the mean transit time (MTT) and time to peak (TTP) of the lesion were prolonged compared with the mirror area. Moreover, the peripheral CBV was increased, and the differences between the parameters were significant (P < 0.05). In conclusion, using the deep learning FCN network, 4D CTA combined with whole brain CTP imaging technology can effectively analyze the perfusion state and achieve clinically personalized treatment.
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Mobile Stroke Units verbessern das Outcome von Schlaganfallpatienten. NOTARZT 2022. [DOI: 10.1055/a-1690-3162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
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Abstract
Intravenous thrombolytics and endovascular thrombectomy for ischemic stroke have evolved in parallel. However, the best approach to combine these reperfusion therapies in patients eligible for both strategies remains uncertain. Initial randomized trials of endovascular thrombectomy included administration of intravenous thrombolytics to all eligible patients. However, whether that is of net benefit has been questioned and parallels drawn with treatment of ST-segment-elevation myocardial infarction, where intravenous thrombolytics are only given if first medical contact to percutaneous intervention is expected to be >90 minutes. Six randomized trials of a direct thrombectomy approach versus intravenous thrombolytics followed by endovascular thrombectomy have now reported their results. With exception of a minority of patients in one trial, the trials all used alteplase rather than potentially more effective tenecteplase. This review examines the current state of evidence and implications for clinical practice. Importantly, these trials only apply to patients who present to a hospital with immediate access to endovascular thrombectomy and are not relevant to patients who receive thrombolytic and are then transferred to an endovascular-capable hospital. Although 2 of the 6 randomized trials met their prespecified noninferiority margin, these margins were large compared with the absolute benefit of alteplase. Overall, functional outcome was similar, with slight trends favoring bridging thrombolytics and a significant increase in final reperfusion. Symptomatic hemorrhage was increased by ≈1.8% in the bridging group but death was nonsignificantly lower. The workflow in direct thrombectomy trials involved delaying thrombolytic administration until eligibility for thrombectomy and the trials was established and randomization completed. This reduced the time available for thrombolytics to occur prethrombectomy compared with standard practice. We conclude that, pending individual-patient data meta-analyses, intravenous thrombolytics retain an important role alongside endovascular thrombectomy. Further efforts to accelerate and enhance reperfusion with thrombolytics and perform individual patient-level pooled subgroup analyses are warranted.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C.), University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health (B.C.V.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands (M.K.)
| | - Urs Fischer
- Department of Neurology, Universitätsspital Basel, Switzerland (U.F.)
- Department of Neurology, University Hospital Bern, University of Bern, Switzerland (U.F.)
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Zheng Y, Guo Z, Zhang Y, Shang J, Yu L, Fu P, Liu Y, Li X, Wang H, Ren L, Zhang W, Hou H, Tan X, Wang W. Rapid triage for ischemic stroke: a machine learning-driven approach in the context of predictive, preventive and personalised medicine. EPMA J 2022; 13:285-298. [PMID: 35719136 PMCID: PMC9203613 DOI: 10.1007/s13167-022-00283-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recognising the early signs of ischemic stroke (IS) in emergency settings has been challenging. Machine learning (ML), a robust tool for predictive, preventive and personalised medicine (PPPM/3PM), presents a possible solution for this issue and produces accurate predictions for real-time data processing. METHODS This investigation evaluated 4999 IS patients among a total of 10,476 adults included in the initial dataset, and 1076 IS subjects among 3935 participants in the external validation dataset. Six ML-based models for the prediction of IS were trained on the initial dataset of 10,476 participants (split participants into a training set [80%] and an internal validation set [20%]). Selected clinical laboratory features routinely assessed at admission were used to inform the models. Model performance was mainly evaluated by the area under the receiver operating characteristic (AUC) curve. Additional techniques-permutation feature importance (PFI), local interpretable model-agnostic explanations (LIME), and SHapley Additive exPlanations (SHAP)-were applied for explaining the black-box ML models. RESULTS Fifteen routine haematological and biochemical features were selected to establish ML-based models for the prediction of IS. The XGBoost-based model achieved the highest predictive performance, reaching AUCs of 0.91 (0.90-0.92) and 0.92 (0.91-0.93) in the internal and external datasets respectively. PFI globally revealed that demographic feature age, routine haematological parameters, haemoglobin and neutrophil count, and biochemical analytes total protein and high-density lipoprotein cholesterol were more influential on the model's prediction. LIME and SHAP showed similar local feature attribution explanations. CONCLUSION In the context of PPPM/3PM, we used the selected predictors obtained from the results of common blood tests to develop and validate ML-based models for the diagnosis of IS. The XGBoost-based model offers the most accurate prediction. By incorporating the individualised patient profile, this prediction tool is simple and quick to administer. This is promising to support subjective decision making in resource-limited settings or primary care, thereby shortening the time window for the treatment, and improving outcomes after IS. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s13167-022-00283-4.
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Affiliation(s)
- Yulu Zheng
- Centre for Precision Health, Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027 Western
Australia Australia
| | - Zheng Guo
- Centre for Precision Health, Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027 Western
Australia Australia
| | - Yanbo Zhang
- The Second Affiliated Hospital of Shandong First Medical University, Tai’an, Shandong China
| | | | - Leilei Yu
- Tai’an City Central Hospital, Tai’an, Shandong China
| | - Ping Fu
- Ti’men Township Central Hospital, Tai’an, Shandong China
| | - Yizhi Liu
- School of Public Health, Shandong First Medical University & Shandong Academy of Medical Sciences, 619 Changcheng Road, Tai’an, 271016 Shandong China
| | - Xingang Li
- Centre for Precision Health, Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027 Western
Australia Australia
| | - Hao Wang
- Department of Clinical Epidemiology and Evidence-Based Medicine, National Clinical Research Centre for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
| | - Ling Ren
- Beijing United Family Hospital, No.2 Jiangtai Road, Chaoyang District, Beijing, China
| | - Wei Zhang
- Centre for Cognitive Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haifeng Hou
- Centre for Precision Health, Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027 Western
Australia Australia
- The Second Affiliated Hospital of Shandong First Medical University, Tai’an, Shandong China
- School of Public Health, Shandong First Medical University &
- Shandong Academy of Medical Sciences, 619 Changcheng Road, Tai’an, 271016 Shandong China
| | - Xuerui Tan
- The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong China
| | - Wei Wang
- Centre for Precision Health, Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027 Western
Australia Australia
- School of Public Health, Shandong First Medical University &
- Shandong Academy of Medical Sciences, 619 Changcheng Road, Tai’an, 271016 Shandong China
- Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
- The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong China
- Institute for Nutrition Research, Edith Cowan University, Joondalup, WA Australia
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Hubert GJ, Hubert ND, Maegerlein C, Kraus F, Wiestler H, Müller-Barna P, Gerdsmeier-Petz W, Degenhart C, Hohenbichler K, Dietrich D, Witton-Davies T, Regler A, Paternoster L, Leitner M, Zeman F, Koller M, Linker RA, Bath PM, Audebert HJ, Haberl RL. Association Between Use of a Flying Intervention Team vs Patient Interhospital Transfer and Time to Endovascular Thrombectomy Among Patients With Acute Ischemic Stroke in Nonurban Germany. JAMA 2022; 327:1795-1805. [PMID: 35510389 PMCID: PMC9092197 DOI: 10.1001/jama.2022.5948] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke is highly time-dependent, and it is challenging to expedite treatment for patients in remote areas. OBJECTIVE To determine whether deployment of a flying intervention team, compared with patient interhospital transfer, is associated with a shorter time to endovascular thrombectomy and improved clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This was a nonrandomized controlled intervention study comparing 2 systems of care in alternating weeks. The study was conducted in a nonurban region in Germany including 13 primary telemedicine-assisted stroke centers within a telestroke network. A total of 157 patients with acute ischemic stroke for whom decision to pursue thrombectomy had been made and deployment of flying intervention team or patient interhospital transfer was initiated were enrolled between February 1, 2018, and October 24, 2019. The date of final follow-up was January 31, 2020. EXPOSURES Deployment of a flying intervention team for EVT in a primary stroke center vs patient interhospital transfer for EVT to a referral center. MAIN OUTCOMES AND MEASURES The primary outcome was time delay from decision to pursue thrombectomy to start of the procedure in minutes. Secondary outcomes included functional outcome after 3 months, determined by the distribution of the modified Rankin Scale score (a disability score ranging from 0 [no deficit] to 6 [death]). RESULTS Among the 157 patients included (median [IQR] age, 75 [66-80] y; 80 [51%] women), 72 received flying team care and 85 were transferred. EVT was performed in 60 patients (83%) in the flying team group vs 57 (67%) in the transfer group. Median (IQR) time from decision to pursue EVT to start of the procedure was 58 (51-71) minutes in the flying team group and 148 (124-177) minutes in the transfer group (difference, 90 minutes [95% CI, 75-103]; P < .001). There was no significant difference in modified Rankin Scale score after 3 months between patients in the flying team (n = 59) and transfer (n = 57) groups who received EVT (median [IQR] score, 3 [2-6] vs 3 [2-5]; adjusted common odds ratio for less disability, 1.91 [95% CI, 0.96-3.88]; P = .07). CONCLUSIONS AND RELEVANCE In a nonurban stroke network in Germany, deployment of a flying intervention team to local stroke centers, compared with patient interhospital transfer to referral centers, was significantly associated with shorter time to EVT for patients with acute ischemic stroke. The findings may support consideration of a flying intervention team for some stroke systems of care, although further research is needed to confirm long-term clinical outcomes and to understand applicability to other geographic settings.
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Affiliation(s)
- Gordian J. Hubert
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nikolai D. Hubert
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Frank Kraus
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Hanni Wiestler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Peter Müller-Barna
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | | | - Christoph Degenhart
- Department of Diagnostic and Interventional Radiology, München Klinik, Munich, Germany
| | - Katharina Hohenbichler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Dennis Dietrich
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Witton-Davies
- Department of Diagnostic and Interventional Radiology, München Klinik, Munich, Germany
| | - Angelika Regler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Laura Paternoster
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Miriam Leitner
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Ralf A. Linker
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Philip M. Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Heinrich J. Audebert
- Department of Neurology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Roman L. Haberl
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
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Ellens NR, Schartz D, Rahmani R, Akkipeddi SMK, Kelly AG, Benesch CG, Parker SA, Burgett JL, Proper D, Pilcher WH, Mattingly TK, Grotta JC, Bhalla T, Bender MT. Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis. Front Neurol 2022; 13:868051. [PMID: 35614916 PMCID: PMC9124821 DOI: 10.3389/fneur.2022.868051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance. Methods Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day. Results Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I2 = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I2 = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I2 = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I2 = 91%). Conclusions In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Sajal Medha K. Akkipeddi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Adam G. Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Curtis G. Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Stephanie A. Parker
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, United States
| | - Jason L. Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Webster H. Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital—Texas Medical Center, Houston, TX, United States
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
- *Correspondence: Matthew T. Bender
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81
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Bivard A, Zhao H, Churilov L, Campbell BCV, Coote S, Yassi N, Yan B, Valente M, Sharobeam A, Balabanski AH, Dos Santos A, Ng JL, Yogendrakumar V, Ng F, Langenberg F, Easton D, Warwick A, Mackey E, MacDonald A, Sharma G, Stephenson M, Smith K, Anderson D, Choi P, Thijs V, Ma H, Cloud GC, Wijeratne T, Olenko L, Italiano D, Davis SM, Donnan GA, Parsons MW. Comparison of tenecteplase with alteplase for the early treatment of ischaemic stroke in the Melbourne Mobile Stroke Unit (TASTE-A): a phase 2, randomised, open-label trial. Lancet Neurol 2022; 21:520-527. [DOI: 10.1016/s1474-4422(22)00171-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 12/19/2022]
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Bivard A, Zhao H, Coote S, Campbell B, Churilov L, Yassi N, Yan B, Valente M, Sharobeam A, Balabanski A, Dos Santos A, Ng F, Langenberg F, Stephenson M, Smith K, Bernard S, Thijs V, Cloud G, Choi P, Ma H, Wijeratne T, Chen C, Olenko L, Davis SM, Donnan GA, Parsons M. Tenecteplase versus Alteplase for Stroke Thrombolysis Evaluation Trial in the Ambulance (Mobile Stroke Unit-TASTE-A): protocol for a prospective randomised, open-label, blinded endpoint, phase II superiority trial of tenecteplase versus alteplase for ischaemic stroke patients presenting within 4.5 hours of symptom onset to the mobile stroke unit. BMJ Open 2022; 12:e056573. [PMID: 35487712 PMCID: PMC9058803 DOI: 10.1136/bmjopen-2021-056573] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mobile stroke units (MSUs) equipped with a CT scanner are increasingly being used to assess and treat stroke patients' prehospital with thrombolysis and transfer them to the most appropriate hospital for ongoing stroke care and thrombectomy when indicated. The effect of MSUs in both reducing the time to reperfusion treatment and improving patient outcomes is now established. There is now an opportunity to improve the efficacy of treatment provided by the MSU. Tenecteplase is a potent plasminogen activator, which may have benefits over the standard of care stroke lytic alteplase. Specifically, in the MSU environment tenecteplase presents practical benefits since it is given as a single bolus and does not require an infusion over an hour like alteplase. OBJECTIVE In this trial, we seek to investigate if tenecteplase, given to patients with acute ischaemic stroke as diagnosed on the MSU, improves the rate of early reperfusion. METHODS AND ANALYSIS TASTE-A is a prospective, randomised, open-label, blinded endpoint (PROBE) phase II trial of patients who had an ischaemic stroke assessed in an MSU within 4.5 hours of symptom onset. The primary endpoint is early reperfusion measured by the post-lysis volume of the CT perfusion lesion performed immediately after hospital arrival. ETHICS AND DISSEMINATION The study was approved by the Royal Melbourne Hospital Human Ethics committee. The findings will be published in peer-reviewed journals, presented at academic conferences and disseminated among consumer and healthcare professional audiences. TRIAL REGISTRATION NUMBER NCT04071613.
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Affiliation(s)
- Andrew Bivard
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Skye Coote
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Valente
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Angelos Sharobeam
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Anna Balabanski
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Angela Dos Santos
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Felix Ng
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Francesca Langenberg
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | | | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Stroke Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neurology, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, Footscray, Victoria, Australia
| | - Chushuang Chen
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liudmyla Olenko
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark Parsons
- School of Medicine and Public Health, Department of Neurology Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
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Abstract
The treatment of acute ischemic stroke continues to advance. The mainstay of treatment remains intravenous thrombolysis with alteplase. Recent studies demonstrated that later treatment with alteplase is beneficial in patients selected with advanced imaging techniques. Tenecteplase has been evaluated as an alternative thrombolytic drug and evidence suggests that it is as least as effective as alteplase and may lyse large vessel clots more effectively. Endovascular therapy with mechanical thrombectomy has now been shown to be beneficial up to 24 hours after stroke onset in carefully selected patients with proximal, large vessel occlusions. Ongoing studies are evaluating the effectiveness of thrombectomy in patients with more distal vessel occlusions and patients with proximal large vessel occlusions with larger ischemic core volumes and also in patients with milder neurological deficits. Cytoprotection is another potential acute stroke therapy that has not demonstrated efficacy in prior clinical trials. It should be reconsidered as an adjunct to reperfusion and a variety of new clinical trials can be envisioned to evaluate the potential benefits of cytoprotection in patients before and after reperfusion.
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Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.X.).,Chinese Institute of Brain Research (Y.X.)
| | - Ajay K Wakhloo
- Department of Neurointerventional Radiology Beth Israel Lahey Health Medical Center, Tufts University School of Medicine, Burlington' MA (A.K.W.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School' Boston' MA (M.F.)
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Coote S, Mackey E, Alexandrov AW, Cadilhac DA, Alexandrov AV, Easton D, Zhao H, Langenberg F, Bivard A, Stephenson M, Parsons MW, Campbell BCV, Donnan GA, Davis SM, Middleton S. The Mobile Stroke Unit Nurse: An International Exploration of Their Scope of Practice, Education, and Training. J Neurosci Nurs 2022; 54:61-67. [PMID: 35245919 DOI: 10.1097/jnn.0000000000000632] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Mobile stroke units (MSUs) are ambulance-based prehospital stroke care services. Through immediate roadside assessment and onboard brain imaging, MSUs provide faster stroke management with improved patient outcomes. Mobile stroke units have enabled the development of expanded scope of practice for stroke nurses; however, there is limited published evidence about these evolving prehospital acute nursing roles. AIMS: The aim of this study was to explore the expanded scope of practice of nurses working on MSUs by identifying MSUs with onboard nurses; describing the roles and responsibilities, training, and experience of MSU nurses, through a search of the literature; and describing 2 international MSU services incorporating nurses from Memphis, Tennessee, and Melbourne, Australia. METHODS: We searched PubMed, CINAHL, and the Joanna Briggs Institute Evidence-Based Practice database using the terms "mobile stroke unit" and "nurse." Existing MSUs were identified through the PRE-hospital Stroke Treatment Organization to determine models that involved nurses. We describe 2 MSUs involving nurses: one in Memphis and one in Melbourne, led by 2 of our authors. RESULTS: Ninety articles were found describing 15 MSUs; however, staffing details were lacking, and it is unknown how many employ nurses. Nine articles described the role of the nurse, but role specifics, training, and expertise were largely undocumented. The MSU in Memphis, the only unit to be staffed exclusively by onboard nurse practitioners, is supported by a neurologist who consults via telephone. The Melbourne MSU plans to trial a nurse-led telemedicine model in the near future. CONCLUSION: We lack information on how many MSUs employ nurses, and the nurses' scope of practice, training, and expertise. Expert stroke nurse practitioners can safely perform many of the tasks undertaken by the onboard neurologist, making a nurse-led telemedicine model an effective and potentially cost-effective model that should be considered for all MSUs.
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85
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Navi BB, Audebert HJ, Alexandrov AW, Cadilhac DA, Grotta JC. Mobile Stroke Units: Evidence, Gaps, and Next Steps. Stroke 2022; 53:2103-2113. [PMID: 35331008 DOI: 10.1161/strokeaha.121.037376] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mobile stroke units (MSUs) are specialized ambulances equipped with the personnel, equipment, and imaging capability to diagnose and treat acute stroke in the prehospital setting. Over the past decade, MSUs have proliferated throughout the world, particularly in European and US cities, culminating in the formation of an international consortium. Randomized trials have demonstrated that MSUs increase stroke thrombolysis rates and reduce onset-to-treatment times but until recently it was uncertain if these advantages would translate into better patient outcomes. In 2021, 2 pivotal, large, controlled clinical trials, B_PROUD and BEST-MSU, demonstrated that as compared with conventional emergency care, treatment aboard MSUs was safe and led to improved functional outcomes in patients with stroke. Further, the observed benefit of MSUs appeared to be primarily driven by the higher frequency of ultra-early thrombolysis within the golden hour. Nevertheless, questions remain regarding the cost-effectiveness of MSUs, their utility in nonurban settings, and optimal infrastructure. In addition, in much of the world, MSUs are currently not reimbursed by insurers nor accepted as standard care by regulatory bodies. As MSUs are now established as one of the few proven acute stroke interventions with an effect size that is comparable to that of intravenous thrombolysis and stroke units, stroke leaders and organizations should work with emergency medical services, governments, and community stakeholders to determine how MSUs might benefit individual communities, and their optimal organization and financing. Future research to explore the effect of MSUs on intracranial hemorrhage and thrombectomy outcomes, cost-effectiveness, and novel models including the use of rendezvous transports, helicopters, and advanced neuroimaging is ongoing. Recommended next steps for MSUs include reimbursement by insurers, integration with ambulance networks, recognition by program accreditors, and inclusion in registries that monitor care quality.
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Affiliation(s)
- Babak B Navi
- Department of Neurology and Brain and Mind Research Institute, Weill Cornell Medicine and NewYork-Presbyterian Hospital' New York (B.B.N.)
| | - Heinrich J Audebert
- Department of Neurology, Center for Stroke Research, Charite-Universitatsmedizin, Berlin, Germany (H.J.A.)
| | | | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia (D.A.C.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston
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86
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Chen J, Lin X, Cai Y, Huang R, Yang S, Zhang G. A Systematic Review of Mobile Stroke Unit Among Acute Stroke Patients: Time Metrics, Adverse Events, Functional Result and Cost-Effectiveness. Front Neurol 2022; 13:803162. [PMID: 35356455 PMCID: PMC8959845 DOI: 10.3389/fneur.2022.803162] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 12/23/2022] Open
Abstract
BackgroundMobile stroke unit (MSU) is deployed to shorten the duration of ischemic stroke recognition to thrombolysis treatment, thus reducing disability, mortality after an acute stroke attack, and related economic burden. Therefore, we conducted a comprehensive systematic review of the clinical trial and economic literature focusing on various outcomes of MSU compared with conventional emergency medical services (EMS).MethodsAn electronic search was conducted in four databases (PubMed, OVID Medline, Embase, and the Cochrane Controlled Register of Trials) from 1990 to 2021. In these trials, patients with acute stroke were assigned to receive either MSU or EMS, with clinical and economic outcomes. First, we extracted interested data in the pooled population and conducted a subgroup analysis to examine related heterogeneity. We then implemented a descriptive analysis of economic outcomes. All analyses were performed with R 4.0.1 software.ResultsA total of 22,766 patients from 16 publications were included. In total 7,682 (n = 33.8%) were treated in the MSU and 15,084 (n = 66.2%) in the conventional EMS. Economic analysis were available in four studies, of which two were based on trial data and the others on model simulations. The pooled analysis of time metrics indicated a mean reduction of 32.64 min (95% confidence interval: 23.38–41.89, p < 0.01) and 28.26 minutes (95% CI: 16.11–40.41, p < 0.01) in the time-to-therapy and time-to-CT completion, respectively in the MSU. However, there was no significant difference on stroke-related neurological events (OR = 0.94, 95% CI: 0.70–1.27, p = 0.69) and in-hospital mortality (OR = 1.11, 95% CI: 0.83–1.50, p = 0.48) between the MSU and EMS. The proportion of patients with modified Ranking scale (mRS) of 0–2 at 90 days from onset was higher in the MSU than EMS (p < 0.05). MSU displayed favorable benefit-cost ratios (2.16–6.85) and incremental cost-effectiveness ratio ($31,911 /QALY and $38,731 per DALY) comparing to EMS in multiple economic publications. Total cost data based on 2014 USD showed that the MSU has the highest cost in Australia ($1,410,708) and the lowest cost in the USA ($783,463).ConclusionA comprehensive analysis of current research suggests that MUS, compared with conventional EMS, has a better performance in terms of time metrics, safety, long-term medical benefits, and cost-effectiveness.
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Affiliation(s)
- Jieyun Chen
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
- *Correspondence: Jieyun Chen
| | - Xiaoying Lin
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Yali Cai
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Risheng Huang
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Songyu Yang
- Department of Radiology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
| | - Gaofeng Zhang
- Department of Radiology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
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87
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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88
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Broderick JP, Hill MJ. Advances in Stroke: Treatments-Acute. Stroke 2022; 53:999-1003. [PMID: 35176877 DOI: 10.1161/strokeaha.122.036976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Michael J Hill
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (M.J.H.)
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89
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Zhang Y, Tu E, Yao C, Liu J, Lei Q, Lu W. Validation of the Clinical Assessment Scale in Autoimmune Encephalitis in Chinese Patients. Front Immunol 2022; 12:796965. [PMID: 34975905 PMCID: PMC8718556 DOI: 10.3389/fimmu.2021.796965] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background and Objectives The Clinical Assessment Scale in Autoimmune Encephalitis (CASE) is a scale for assessing severity in autoimmune encephalitis. We aimed to validate the CASE score in a Chinese population and evaluate its clinical significance. Methods Patients diagnosed with autoimmune encephalitis were recruited between June 2014 and May 2019 from two hospitals. CASE and modified Rankin Scale (mRS) scores were obtained. Data regarding clinical features, treatment, and available information were gathered from the hospital information system. Results Of the 176 patients with autoimmune encephalitis, 11 died and 14 had tumors. Ten patients received second-line treatment. The CASE scores of patients receiving second-line treatment were significantly higher (median CASE: 15) than in those receiving first-line treatment (median CASE: 8) (p<0.001). Twenty-two patients had poor functional status (mRS>2). Areas under the curve of CASE on whether functional status was poor at 1 year were 0.89 (p<0.001). Sixty patients were admitted to the intensive care unit (ICU), and the CASE scores were positively correlated with days in the ICU (r=0.58, p<0.001). There was no statistically significant association between the CASE scores and relapse (p=0.39>0.05). Additionally, the CASE scores were positively associated with the mRS scores (r=0.85 p<0.001). Conclusions The CASE score is suitable for the comprehensive assessment of Chinese patients with autoimmune encephalitis, which may help clinicians to select the appropriate intervention and estimate the disease severity and prognosis.
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Affiliation(s)
- Yingchi Zhang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ewen Tu
- Department of Neurology, The Second Hospital of Hunan Province, Hunan University of Chinese Medicine, Changsha, China
| | - Chenxiao Yao
- Department of Neurology, The Second Hospital of Hunan Province, Hunan University of Chinese Medicine, Changsha, China
| | - Jia Liu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiang Lei
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
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90
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Turc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, Yamal JM, Bowry R, Katsanos AH, Zhao H, Donnan G, Davis SM, Hussain MS, Uchino K, Helwig SA, Johns H, Weber JE, Nolte CH, Kunz A, Steiner T, Sacco S, Ebinger M, Tsivgoulis G, Faßbender K, Audebert HJ. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:281-290. [PMID: 35129584 PMCID: PMC8822443 DOI: 10.1001/jamaneurol.2021.5321] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care. OBJECTIVE To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS). DATA SOURCES MEDLINE, Cochrane Library, and Embase from 1960 to 2021. STUDY SELECTION Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies. DATA EXTRACTION AND SYNTHESIS Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days). RESULTS Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT. CONCLUSIONS AND RELEVANCE Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France,Université de Paris, Paris, France,INSERM U1266, Paris, France,FHU Neurovasc, Paris, France
| | | | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Leonid Churilov
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital–Texas Medical Center, Houston
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health, Houston
| | - Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University Population Health Research Institute, Hamilton, Ontario, Canada,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Geoffrey Donnan
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Stephen M. Davis
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Muhammad S. Hussain
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Hannah Johns
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
| | - Alexander Kunz
- Klinik für Neurologie, Neurologische Intensivmedizin, Zentrum für Hirngefäßerkrankungen, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Martin Ebinger
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany,Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Klaus Faßbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
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91
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Hariharan P, Tariq MB, Grotta JC, Czap AL. Mobile Stroke Units: Current Evidence and Impact. Curr Neurol Neurosci Rep 2022; 22:71-81. [PMID: 35129761 DOI: 10.1007/s11910-022-01170-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Several approaches have been developed to optimize prehospital systems for acute stroke given poor access and significant delays to timely treatment. Specially equipped ambulances that directly initiate treatment, known as Mobile Stroke Units (MSUs), have rapidly proliferated across the world. This review provides a comprehensive summary on the efficacy of MSUs in acute stroke, its various applications beyond thrombolysis, as well as the establishment, optimal setting and cost-effectiveness of incorporating an MSU into healthcare systems. RECENT FINDINGS MSUs speed stroke treatment into the first "golden hour" when better outcomes from thrombolysis are achieved. While evidence for the positive impact of MSUs on outcomes was previously unavailable, two recent landmark controlled trials, B_PROUD and BEST-MSU, show that MSUs result in significantly lesser disability compared to conventional ambulance care. Emerging literature prove the significant impact of MSUs. Adaptability however remains limited by significant upfront financial investment, challenges with reimbursements and pending evidence on their cost-effectiveness.
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Affiliation(s)
- Praveen Hariharan
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - Muhammad Bilal Tariq
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA.
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92
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Ricci S, Toni D, Silvestrini M. Mobile stroke unit is not a stroke unit. Eur J Intern Med 2022; 96:121. [PMID: 34776329 DOI: 10.1016/j.ejim.2021.10.032] [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] [Received: 10/21/2021] [Accepted: 10/29/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Stefano Ricci
- Scientific Committee of the Italian Stroke Association.
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93
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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94
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Pharmacological brain cytoprotection in acute ischaemic stroke — renewed hope in the reperfusion era. Nat Rev Neurol 2022; 18:193-202. [PMID: 35079135 PMCID: PMC8788909 DOI: 10.1038/s41582-021-00605-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/08/2022]
Abstract
For over 40 years, attempts to develop treatments that protect neurons and other brain cells against the cellular and biochemical consequences of cerebral ischaemia in acute ischaemic stroke (AIS) have been unsuccessful. However, the advent of intravenous thrombolysis and endovascular thrombectomy has taken us into a new era of treatment for AIS in which highly effective reperfusion therapy is widely available. In this context, cytoprotective treatments should be revisited as adjunctive treatment to reperfusion therapy. Renewed efforts should focus on developing new drugs that target multiple aspects of the ischaemic cascade, and previously developed drugs should be reconsidered if they produced robust cytoprotective effects in preclinical models and their safety profiles were reasonable in previous clinical trials. Several development pathways for cytoprotection as an adjunct to reperfusion can be envisioned. In this Review, we outline the targets for cytoprotective therapy and discuss considerations for future drug development, highlighting the recent ESCAPE-NA1 trial of nerinetide, which produced the most promising results to date. We review new types of clinical trial to evaluate whether cytoprotective drugs can slow infarct growth prior to reperfusion and/or ameliorate the consequences of reperfusion, such as haemorrhagic transformation. We also highlight how advanced brain imaging can help to identify patients with salvageable ischaemic tissue who are likely to benefit from cytoprotective therapy. In this Review, Fisher and Savitz consider how the era of reperfusion therapy in ischaemic stroke provides new hope for the development of cytoprotective therapies to further improve outcomes, highlighting how promising recent findings can be built on to benefit patients. Highly successful reperfusion therapy with intravenous thrombolysis and endovascular thrombectomy is now widely available for the treatment of acute ischaemic stroke, making cytoprotective therapy a viable additional treatment approach. Previous attempts to develop cytoprotective therapy have been unsuccessful, but this approach should now be reconsidered as an adjunctive therapy to thrombolysis and thrombectomy. New cytoprotective drugs should be developed to target multiple aspects of the ischaemic cascade, and previously developed drugs should be reconsidered. Trials should be conducted to evaluate the effects of cytoprotective drugs when administered before or after reperfusion therapy or both. Advanced brain imaging should be used to select patients who are most likely to benefit from cytoprotective treatment for enrolment in new trials.
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Torlén Wennlund K, Kurland L, Olanders K, Castrén M, Bohm K. A registry-based observational study comparing emergency calls assessed by emergency medical dispatchers with and without support by registered nurses. SCANDINAVIAN JOURNAL OF TRAUMA, RESUSCITATION AND EMERGENCY MEDICINE 2022; 30:1. [PMID: 35012595 PMCID: PMC8744325 DOI: 10.1186/s13049-021-00987-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 12/10/2021] [Indexed: 12/05/2022]
Abstract
Background The requirement concerning formal education for emergency medical dispatcher (EMD) is debated and varies, both nationally and internationally. There are few studies on the outcomes of emergency medical dispatching in relation to professional background. This study aimed to compare calls handled by an EMD with and without support by a registered nurse (RN), with respect to priority level, accuracy, and medical condition. Methods A retrospective observational study, performed on registry data from specific regions during 2015. The ambulance personnel’s first assessment of the priority level and medical condition was used as the reference standard. Outcomes were: the proportion of calls dispatched with a priority in concordance with the ambulance personnel’s assessment; over- and undertriage; the proportion of most adverse over- and undertriage; sensitivity, specificity and predictive values for each of the ambulance priorities; proportion of calls dispatched with a medical condition in concordance with the ambulance personnel’s assessment. Proportions were reported with 95% confidence intervals. χ2-test was used for comparisons. P-levels < 0.05 were regarded as significant. Results A total of 25,025 calls were included (EMD n = 23,723, EMD + RN n = 1302). Analyses relating to priority and medical condition were performed on 23,503 and 21,881 calls, respectively. A dispatched priority in concordance with the ambulance personnel’s assessment were: EMD n = 11,319 (50.7%) and EMD + RN n = 481 (41.5%) (p < 0.01). The proportion of overtriage was equal for both groups: EMD n = 5904, EMD + RN n = 306, (26.4%) p = 0.25). The proportion of undertriage for each group was: EMD n = 5122 (22.9%) and EMD + RN n = 371 (32.0%) (p < 0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD + RN (p < 0.01), and specificity was 67.3% and 84.8% (p < 0.01) respectively. A dispatched medical condition in concordance with the ambulance personnel’s assessment were: EMD n = 13,785 (66.4%) and EMD + RN n = 697 (62.2%) (p = 0.01). Conclusions A higher precision of emergency medical dispatching was not observed when the EMD was supported by an RN. How patient safety is affected by the observed divergence in dispatched priorities is an area for future research. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00987-y.
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Affiliation(s)
- Klara Torlén Wennlund
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83, Stockholm, Sweden.
| | - Lisa Kurland
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83, Stockholm, Sweden.,Department of Medical Sciences and Department of Emergency Medicine, Örebro University, 70181, Örebro, Sweden
| | - Knut Olanders
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Maaret Castrén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83, Stockholm, Sweden.,Department of Emergency Medicine, Helsinki University, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Katarina Bohm
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83, Stockholm, Sweden.,Emergency Department, Södersjukhuset, Stockholm, Sweden
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96
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Digitale Systeme zur Unterstützung von präklinischen Notfalleinsätzen. Anaesthesist 2022; 71:518-525. [DOI: 10.1007/s00101-021-01085-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/23/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
Abstract
Zusammenfassung
Hintergrund und Fragestellung
Steigende Anforderungen an Dokumentation und sektorenübergreifende Kommunikation führen zu vermehrtem organisatorischem Aufwand im Notarzt- und Rettungsdienst. Die Verwendung digitaler Informationssysteme im präklinischen Einsatz kann sowohl dazu beitragen, Einsatzkräfte bei diesen Aufgaben zu unterstützen als auch neue Behandlungsmöglichkeiten für Patienten eröffnen. Die Arbeit versucht, ein möglichst umfassendes Bild der derzeitigen Verbreitung und Nutzung von Informations- und Kommunikationssystemen zur Einsatzunterstützung in Deutschland zu erstellen.
Material und Methoden
Die Querschnittsstudie wurde als deutschlandweite, explorative Online-Befragung unter Notärzten und Rettungsdienstfachpersonal von Juli bis August 2020 durchgeführt. Die anschließende Datenanalyse erfolgte durch deskriptive Statistikmethoden. Betrachtet wurden u. a. Lösungen für die digitale Dokumentation und Krankenhausvoranmeldung, für den Versorgungsnachweis und Telenotarztdienst sowie der Digitalfunk.
Ergebnisse
Es wurden 821 Antwortbogen von 481 Rettungswachen aus insgesamt 382 Städten in der Auswertung berücksichtigt. Die Verfügbarkeit von 16 untersuchten Systemen variiert deutschlandweit je nach Bundesland und Anwendungsbereich. Befragte Einsatzkräfte zeigen sich gegenüber neuen Technologien und Möglichkeiten grundsätzlich offen, wenngleich die aktuelle Umsetzung als nicht zufriedenstellend bewertet wird. Herausforderungen zeigen sich v. a. hinsichtlich Verlässlichkeit, Hardware, Benutzerfreundlichkeit und Interoperabilität.
Diskussion
Eine weitreichende Digitalisierung der präklinischen Notfallmedizin wurde in Deutschland bislang nicht erreicht. Die ganzheitliche Betrachtung und vernetzte Implementierung aller am Einsatz beteiligten Systeme und Prozesse kann dazu beitragen, digitale Lösungen für die Präklinik zu verbessern und weiter zu verbreiten.
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97
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Li G, Wang C, Wang S, Xiong Y, Zhao X. Tenecteplase in Ischemic Stroke: Challenge and Opportunity. Neuropsychiatr Dis Treat 2022; 18:1013-1026. [PMID: 35586365 PMCID: PMC9109727 DOI: 10.2147/ndt.s360967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE OF REVIEW Intravenous thrombolysis is the first-line therapy for ischemic stroke, and alteplase has been used as an intravenous thrombolysis drug for over 20 years. However, considering its low rate of recanalization and risk of intracerebral hemorrhage, alteplase may not be the optimal thrombolytic drug of choice for ischemic stroke. Tenecteplase (TNK) is a genetically engineered, mutant, tissue plasminogen activator that is a potential substitute to alteplase in ischemic stroke. The pharmacokinetic advantages of TNK include greater fibrin selectivity than alteplase and prolonged half-life time. In this review, we have summarized the clinical trials of TNK in ischemic stroke. RECENT FINDINGS Clinical trials showed a higher recanalization rate of TNK over alteplase without increasing the rate of intracerebral hemorrhage. However, not all clinical trials showed superiority of TNK over alteplase in functional outcomes and early neurological improvement. TNK was superior to alteplase in terms of recanalization in patients who fulfilled the imaging mismatch criteria and in those planning to undergo mechanical thrombectomy. SUMMARY TNK has the potential to substitute alteplase for ischemic stroke therapy. Future TNK clinical trials that target functional outcomes are warranted.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chuanying Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shang Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Chinese Institute of Brain Research, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
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98
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Heidet M, Tazarourte K, Mermet É, Freyssenge J, Mellouk A, Khellaf M, Lecarpentier É. Accessibilité aux soins en situation d’urgence : des déterminants complexes, un besoin d’outils novateurs. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Les délais d’accès aux soins sont directement associés au pronostic de nombreuses situations et pathologies urgentes telles que l’arrêt cardiaque extrahospitalier, l’accident vasculaire cérébral, l’infarctus du myocarde ou le traumatisme grave. Ils représentent ainsi un critère de qualité et d’efficacité du système préhospitalier. Or, les déterminants de l’accessibilité aux soins urgents, donc des délais de prise en charge préhospitalière jusqu’au soin définitif, sont multiples, intriquant notamment des dimensions organisationnelles, géographiques et socioéconomiques, captées par différentes définitions de l’accessibilité aux soins. La mesure de l’accessibilité aux soins urgents est donc complexe et nécessite l’emploi de méthodes spécifiques. Ses déterminants sont sujets à d’importantes disparités territoriales, tant sur le plan national que local, qui conduisent à de fortes inégalités de santé en situation urgente. L’organisation du système de soins préhospitaliers doit ainsi prendre en compte l’ensemble des définitions de l’accessibilité en vie réelle, afin de répondre à des objectifs de performance ajustés aux enjeux particuliers des pathologies traceuses les plus urgentes. Les prochaines évolutions organisationnelles et technologiques en médecine d’urgence devraient permettre de mieux appréhender les déterminants de l’accessibilité à toutes les phases de la prise en charge préhospitalière, vers un rééquilibrage de l’inadéquation entre les besoins réels et l’offre possible de soins urgents.
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99
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Osuegbu OI, Adeniji FO, Owhonda GC, Kanee RB, Aigbogun EO. Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580211067939. [PMID: 35049398 PMCID: PMC8785286 DOI: 10.1177/00469580211067939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.
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Affiliation(s)
- Osborne Ikechuckwu Osuegbu
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | - Foluke Olukemi Adeniji
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | | | - Rogers Bariture Kanee
- Institute of Geo-Science and Space Technology, 108005Rivers State University, Oroworukwo, Nigeria
| | - Eric Osamudiamwen Aigbogun
- Department of Public Health, Faculty of Sciences and Technology, 248428Cavendish University Uganda, Kampala, Uganda
- Center for Occupational Health and Safety, Institute of Petroleum Studies, 327041University of Port Harcourt, Choba, Nigeria
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100
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Bender MT, Mattingly TK, Rahmani R, Proper D, Burnett WA, Burgett JL, LEsperance J, Cushman JT, Pilcher WH, Benesch CG, Kelly AG, Bhalla T. Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy. Stroke Vasc Neurol 2021; 7:209-214. [PMID: 34952889 PMCID: PMC9240459 DOI: 10.1136/svn-2021-001119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes. OBJECTIVE Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes. RESULTS Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable. CONCLUSIONS Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Walter A Burnett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason L Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Joshua LEsperance
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Webster H Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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