151
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Wu P, Stayman JW, Mow M, Zbijewski W, Sisniega A, Aygun N, Stevens R, Foos D, Wang X, Siewerdsen JH. Reconstruction-of-difference (RoD) imaging for cone-beam CT neuro-angiography. Phys Med Biol 2018; 63:115004. [PMID: 29722296 DOI: 10.1088/1361-6560/aac225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Timely evaluation of neurovasculature via CT angiography (CTA) is critical to the detection of pathology such as ischemic stroke. Cone-beam CTA (CBCT-A) systems provide potential advantages in the timely use at the point-of-care, although challenges of a relatively slow gantry rotation speed introduce tradeoffs among image quality, data consistency and data sparsity. This work describes and evaluates a new reconstruction-of-difference (RoD) approach that is robust to such challenges. A fast digital simulation framework was developed to test the performance of the RoD over standard reference reconstruction methods such as filtered back-projection (FBP) and penalized likelihood (PL) over a broad range of imaging conditions, grouped into three scenarios to test the trade-off between data consistency, data sparsity and peak contrast. Two experiments were also conducted using a CBCT prototype and an anthropomorphic neurovascular phantom to test the simulation findings in real data. Performance was evaluated primarily in terms of normalized root mean square error (NRMSE) in comparison to truth, with reconstruction parameters chosen to optimize performance in each case to ensure fair comparison. The RoD approach reduced NRMSE in reconstructed images by up to 50%-53% compared to FBP and up to 29%-31% compared to PL for each scenario. Scan protocols well suited to the RoD approach were identified that balance tradeoffs among data consistency, sparsity and peak contrast-for example, a CBCT-A scan with 128 projections acquired in 8.5 s over a 180° + fan angle half-scan for a time attenuation curve with ~8.5 s time-to-peak and 600 HU peak contrast. With imaging conditions such as the simulation scenarios of fixed data sparsity (i.e. varying levels of data consistency and peak contrast), the experiments confirmed the reduction of NRMSE by 34% and 17% compared to FBP and PL, respectively. The RoD approach demonstrated superior performance in 3D angiography compared to FBP and PL in all simulation and physical experiments, suggesting the possibility of CBCT-A on low-cost, mobile imaging platforms suitable to the point-of-care. The algorithm demonstrated accurate reconstruction with a high degree of robustness against data sparsity and inconsistency.
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Affiliation(s)
- P Wu
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, 21205, United States of America
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152
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Lin E, Calderon V, Goins-Whitmore J, Bansal V, Zaidat O. World's First 24/7 Mobile Stroke Unit: Initial 6-Month Experience at Mercy Health in Toledo, Ohio. Front Neurol 2018; 9:283. [PMID: 29867711 PMCID: PMC5966532 DOI: 10.3389/fneur.2018.00283] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 04/10/2018] [Indexed: 01/12/2023] Open
Abstract
Background and purpose As the fourth mobile stroke unit (MSU) in the nation, and the first 24/7 unit worldwide, we review our initial experience with the Mercy Health MSU and institutional protocols implemented to facilitate rapid treatment of acute stroke patients and field triage for patients suffering other time-sensitive, acute neurologic emergencies in Lucas County, Ohio, and the greater Toledo metropolitan area. Methods Data was prospectively collected for all patients transported and treated by the MSU during the first 6 months of service. Data was abstracted from documentation of on-scene emergency medical services (EMS) personnel, critical care nurses, and onboard physicians, who participated through telemedicine. Results The MSU was dispatched 248 times and transported 105 patients after on-scene examination with imaging. Intravenous (IV) tissue plasminogen activator (tPA) was administered to 10 patients; 8 patients underwent successful endovascular therapy after a large vessel occlusion was identified using CT performed within the MSU without post treatment symptomatic hemorrhage. Moreover, 14 patients were treated with IV anti-epileptics for status epilepticus, and 19 patients received IV anti-hypertensive agents for malignant hypertension. MSU alarm to on-scene times and treatment times were 34.7 min (25–49) and 50.6 min (44.4–56.8), respectively. Conclusion The world’s first 24/7 MSU has been successfully implemented with IV-tPA administration rates and times comparable to other MSUs nation-wide, while demonstrating rapid triage and treatment in the field for neurologic emergencies, including status epilepticus. With the rising number of MSUs worldwide, further data will drive standardized protocols that can be adopted nationwide by EMS.
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Affiliation(s)
- Eugene Lin
- Neuroscience Institute, Mercy Health-St. Vincent Medical Center, Toledo, OH, United States
| | - Victoria Calderon
- Neuroscience Institute, Mercy Health-St. Vincent Medical Center, Toledo, OH, United States
| | - Julie Goins-Whitmore
- Neuroscience Institute, Mercy Health-St. Vincent Medical Center, Toledo, OH, United States
| | - Vibhav Bansal
- Neuroscience Institute, Mercy Health-St. Rita's Medical Center, Lima, OH, United States
| | - Osama Zaidat
- Neuroscience Institute, Mercy Health-St. Vincent Medical Center, Toledo, OH, United States
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153
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Bowry R, Parker SA, Yamal JM, Hwang H, Appana S, Rangel-Gutierrez N, Wu TC, Rajan SS, Grotta JC. Time to Decision and Treatment With tPA (Tissue-Type Plasminogen Activator) Using Telemedicine Versus an Onboard Neurologist on a Mobile Stroke Unit. Stroke 2018; 49:1528-1530. [PMID: 29720439 DOI: 10.1161/strokeaha.117.020585] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/13/2018] [Accepted: 04/03/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Mobile stroke units (MSUs) can speed treatment with intravenous tPA (tissue-type plasminogen activator). We previously showed substantial agreement between a telemedicine-based vascular neurologist (TM-VN) and an onboard vascular neurologist (OB-VN) for the evaluation of patients with stroke for tPA eligibility on an MSU. However, the time efficiency of the telemedicine-based evaluation remained uncertain. In this study, we examined the speed of decision and treatment from MSU arrival for the TM-VN compared with an OB-VN. METHODS In 50 consecutive situations, the TM-VN served as the primary decision maker. Times from MSU arrival to tPA decision and tPA bolus were compared with the same metrics for when the OB-VN served as the primary decision maker. RESULTS Time to tPA decision for the TM-VN was 21 minutes (interquartile range, 16.25-26) versus 18 minutes (interquartile range, 14-22) for the OB-VN (P=0.01). Initiation of tPA bolus was 24 minutes (interquartile range, 19.75-30) for the TM-VN versus 24 minutes (interquartile range, 19-27.75) for the OB-VN (P=0.5). CONCLUSIONS Assessment by a TM-VN is comparable with an OB-VN in making decisions about tPA administration on an MSU and does not lead to treatment delays. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02190500.
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Affiliation(s)
- Ritvij Bowry
- From the Department of Neurology, McGovern Medical School (R.B., S.A.P., J.-M.Y., N.R.-G., T.-C.W.)
| | - Stephanie A Parker
- From the Department of Neurology, McGovern Medical School (R.B., S.A.P., J.-M.Y., N.R.-G., T.-C.W.)
| | - Jose-Miguel Yamal
- From the Department of Neurology, McGovern Medical School (R.B., S.A.P., J.-M.Y., N.R.-G., T.-C.W.).,School of Public Heath, Department of Biostatistics (J.-M.Y., H.H., S.A.)
| | - Hyunsoo Hwang
- School of Public Heath, Department of Biostatistics (J.-M.Y., H.H., S.A.)
| | - Savitri Appana
- School of Public Heath, Department of Biostatistics (J.-M.Y., H.H., S.A.)
| | - Nicole Rangel-Gutierrez
- From the Department of Neurology, McGovern Medical School (R.B., S.A.P., J.-M.Y., N.R.-G., T.-C.W.)
| | - Tzu-Ching Wu
- From the Department of Neurology, McGovern Medical School (R.B., S.A.P., J.-M.Y., N.R.-G., T.-C.W.)
| | - Suja S Rajan
- Department of Management Policy and Community Health (S.S.R.), University of Texas Health Science Center, Houston
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.).
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154
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Xiong XY, Liu L, Yang QW. Refocusing Neuroprotection in Cerebral Reperfusion Era: New Challenges and Strategies. Front Neurol 2018; 9:249. [PMID: 29740385 PMCID: PMC5926527 DOI: 10.3389/fneur.2018.00249] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/28/2018] [Indexed: 12/27/2022] Open
Abstract
Pathophysiological processes of stroke have revealed that the damaged brain should be considered as an integral structure to be protected. However, promising neuroprotective drugs have failed when translated to clinical trials. In this review, we evaluated previous studies of neuroprotection and found that unsound patient selection and evaluation methods, single-target treatments, etc., without cerebral revascularization may be major reasons of failed neuroprotective strategies. Fortunately, this may be reversed by recent advances that provide increased revascularization with increased availability of endovascular procedures. However, the current improved effects of endovascular therapy are not able to match to the higher rate of revascularization, which may be ascribed to cerebral ischemia/reperfusion injury and lacking of neuroprotection. Accordingly, we suggest various research strategies to improve the lower therapeutic efficacy for ischemic stroke treatment: (1) multitarget neuroprotectant combinative therapy (cocktail therapy) should be investigated and performed based on revascularization; (2) and more efforts should be dedicated to shifting research emphasis to establish recirculation, increasing functional collateral circulation and elucidating brain–blood barrier damage mechanisms to reduce hemorrhagic transformation. Therefore, we propose that a comprehensive neuroprotective strategy before and after the endovascular treatment may speed progress toward improving neuroprotection after stroke to protect against brain injury.
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Affiliation(s)
- Xiao-Yi Xiong
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
| | - Liang Liu
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
| | - Qing-Wu Yang
- Department of Neurology, Xinqiao Hospital, The Army Medical University (Third Military Medical University), Chongqing, China
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155
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Abstract
Neurological disorders are the leading cause of global disability. However, for most people around the world, current neurological care is poor. In low-income countries, most individuals lack access to proper neurological care, and in high-income countries, distance and disability limit access. With the global proliferation of smartphones, teleneurology - the use of technology to provide neurological care and education remotely - has the potential to improve and increase access to care for billions of people. Telestroke has already fulfilled this promise, but teleneurology applications for chronic conditions are still in their infancy. Similarly, few studies have explored the capabilities of mobile technologies such as smartphones and wearable sensors, which can guide care by providing objective, frequent, real-world assessments of patients. In low-income settings, teleneurology can increase the capacity of local care systems through professional development, diagnostic support and consultative services. In high-income settings, teleneurology is likely to promote the expansion and migration of neurological care away from institutions, incorporate systems of asynchronous communication (such as e-mail), integrate clinicians with diverse skill sets and reach new populations. Inertia, outdated policies and social barriers - especially the digital divide - will slow this progress at considerable cost. However, a future increasingly will be possible in which neurological care can be accessed by anyone, anywhere. Here, we examine the emerging evidence regarding the benefits of teleneurology for chronic conditions, its role and risks in low-income countries and the promise of mobile technologies to measure disease status and deliver care. We conclude by discussing the future trends, barriers and timing for the adoption of teleneurology.
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156
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Hasan TF, Rabinstein AA, Middlebrooks EH, Haranhalli N, Silliman SL, Meschia JF, Tawk RG. Diagnosis and Management of Acute Ischemic Stroke. Mayo Clin Proc 2018; 93:523-538. [PMID: 29622098 DOI: 10.1016/j.mayocp.2018.02.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/25/2018] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
Acute ischemic stroke (AIS) is among the leading causes of death and long-term disability. Intravenous tissue plasminogen activator has been the mainstay of acute therapy. Recently, several prospective randomized trials documented the value of endovascular revascularization in selected patients with large-vessel occlusion within the anterior circulation. This finding has led to a paradigm shift in the management of AIS, including wide adoption of noninvasive neuroimaging to assess vessel patency and tissue viability, with the supplemental and independent use of intravenous tissue plasminogen activator to improve clinical outcomes. In this article, we review the landmark studies on management of AIS and the current position on the diagnosis and management of AIS. The review also highlights the importance of early stabilization and prompt initiation of therapeutic interventions before, during, and after the diagnosis of AIS within and outside of the hospital.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Neil Haranhalli
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Scott L Silliman
- Department of Neurology, University of Florida Health Science Center, Jacksonville, FL
| | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
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157
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English SW, Rabinstein AA, Mandrekar J, Klaas JP. Rethinking Prehospital Stroke Notification: Assessing Utility of Emergency Medical Services Impression and Cincinnati Prehospital Stroke Scale. J Stroke Cerebrovasc Dis 2018; 27:919-925. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/20/2017] [Accepted: 10/29/2017] [Indexed: 01/19/2023] Open
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158
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Nolte CH, Ebinger M, Scheitz JF, Kunz A, Erdur H, Geisler F, Braemswig TB, Rozanski M, Weber JE, Wendt M, Zieschang K, Fiebach JB, Villringer K, Grittner U, Kaczmarek S, Endres M, Audebert HJ. Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Stroke 2018; 49:646-651. [DOI: 10.1161/strokeaha.117.019060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/13/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily –independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency.
Methods—
This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression.
Results—
Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69–159; STEMO) and 135 (interquartile range, 98–184; CC;
P
<0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%;
P
=0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive (
P
=0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02–3.87;
P
=0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95–3.16;
P
=0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%;
P
=0.167).
Conclusions—
The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT02358772.
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Affiliation(s)
- Christian H. Nolte
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Martin Ebinger
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Jan F. Scheitz
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Alexander Kunz
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Hebun Erdur
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Frederik Geisler
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Tim Bastian Braemswig
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Michal Rozanski
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Joachim E. Weber
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Matthias Wendt
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Katja Zieschang
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Jochen B. Fiebach
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Kersten Villringer
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Ulrike Grittner
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Sabina Kaczmarek
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Matthias Endres
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Heinrich J. Audebert
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
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Bache KG, Hov MR, Larsen K, Solyga VM, Lund CG. Prehospital Advanced Diagnostics and Treatment of Acute Stroke: Protocol for a Controlled Intervention Study. JMIR Res Protoc 2018; 7:e53. [PMID: 29490898 PMCID: PMC6283254 DOI: 10.2196/resprot.8110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/07/2017] [Accepted: 08/09/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a medical emergency. The outcome is closely linked to the time elapsing from symptom onset to treatment, and seemingly small delays can mean the difference between full recovery and physical and cognitive dysfunction. Recanalization to allow blood to reenter the affected area is most efficient immediately after symptoms occur, and intravenous thrombolysis must be initiated no later than 4.5 hours after the symptom onset. A liable diagnosis is mandatory to administer the appropriate treatment. Prehospital diagnosis and, in cases where contraindications are ruled out, prehospital initiation of intravenous thrombolysis have been shown to significantly decrease the time from alarm to the treatment. OBJECTIVE The objective of this paper is to investigate the effectiveness of prehospital thrombolysis as measured by (1) time spent from symptom onset to treatment and (2) the number of patients treated within 4.5 hours. In addition, we want to conduct explorative studies. These will include (1) the use of biomarkers for diagnostic and prognostic use where we will collect blood samples from various time points, including the hyperacute phase and (2) the study of magnetic resonance imaging (MRI) images at day 1 to determine the infarct volume and if the time to thrombolysis has an influence on this. METHODS This is a prospective controlled intervention study. The intervention will involve a computed tomography (CT) and thrombolysis in a physician-manned ambulance called a mobile stroke unit (MSU). The control will be the conventional pathway where the patient is transported to the hospital for CT, and thrombolysis as per current procedure. RESULTS Patient inclusion has started and a total of 37 patients are enrolled (control and intervention combined). The estimated time to completed inclusion is 36 months, starting from May 2017. The results of this study will be analyzed and published at the end of the trial. CONCLUSIONS This trial aims to document the feasibility of saving time for all stroke patients by providing prehospital diagnostics and treatment, as well as transport to appropriate level of care, in a safe environment provided by anesthesiologists trained in prehospital critical care. TRIAL REGISTRATION ClinicalTrials.gov NCT03158259; https://clinicaltrials.gov/show/NCT03158259 (Archived by WebCite at http://www.webcitation.org/6wxNEUMUD).
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Affiliation(s)
- Kristi G Bache
- Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maren Ranhoff Hov
- Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Karianne Larsen
- Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
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160
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Kummer BR, Lerario MP, Navi BB, Ganzman AC, Ribaudo D, Mir SA, Pishanidar S, Lekic T, Williams O, Kamel H, Marshall RS, Hripcsak G, Elkind MSV, Fink ME. Clinical Information Systems Integration in New York City's First Mobile Stroke Unit. Appl Clin Inform 2018; 9:89-98. [PMID: 29415308 DOI: 10.1055/s-0037-1621704] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU operations are understudied. OBJECTIVE The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts. METHODS NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction. RESULTS Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field. CONCLUSION The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts.
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Affiliation(s)
- Benjamin R Kummer
- Department of Biomedical Informatics, Columbia University, New York, United States.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - Michael P Lerario
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States.,Department of Neurology, New York-Presbyterian Queens, Flushing, New York, United States
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Adam C Ganzman
- Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Daniel Ribaudo
- Department of Emergency Medical Services, New York Presbyterian Hospital, New York, United States
| | - Saad A Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Sammy Pishanidar
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Tim Lekic
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - Olajide Williams
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States.,Department of Neurology, Weill Cornell Medicine, New York, United States
| | - Randolph S Marshall
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, United States
| | - Mitchell S V Elkind
- Department of Neurology, Columbia College of Physicians and Surgeons, New York, United States.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, United States
| | - Matthew E Fink
- Department of Neurology, Weill Cornell Medicine, New York, United States
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161
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Shuaib A, Amlani S, Kalashyan H, Morrison L, Khan K, Jickling G, Buck B, Butcher K, Saqqur M, Jeerakathil T. Mobile stroke unit triage of patients with a suspected stroke: a novel solution to reducing suspected stroke admissions in busy emergency departments. ACTA ACUST UNITED AC 2018. [DOI: 10.1136/bmjinnov-2017-000240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundEvaluation of patients with a suspected stroke is one of the most common neurological emergencies requiring rapid, comprehensive assessment by the stroke service to determine patient eligibility for timely reperfusion therapies. Prehospital evaluation may help to improve patient selection and reduce avoidable admissions to overcapacity emergency departments.Methods and resultsWe report on our early experience of prehospital triage of patients with a suspected stroke using a mobile stroke unit (MSU) equipped with CT scanner in rural Alberta. During the initial 4 months of operation, 28 patients were evaluated by the team in the MSU. Eight patients were within the time window of thrombolysis and were treated with intravenous tissue plasminogen activator in the MSU. No patients suffered haemorrhage or any other complications. Fourteen patients with multiple aetiologies (stroke mimics 6, transient ischaemic attacks 2, subacute stroke outside thrombolysis window 2, intracranial haemorrhage 3 and cerebral contusion 1) were assessed in the field and transferred to the tertiary hospital. Six patients after assessment and imaging were repatriated back to the local hospital as they were deemed stroke mimics or were outside of the reperfusion window.ConclusionsThe MSU offers a novel approach to performing timely evaluation and treatment of patients with a suspected stroke in rural settings and may help reduce admissions to overcapacity tertiary care facilities.
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162
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Baratloo A, Rahimpour L, Abushouk AI, Safari S, Lee CW, Abdalvand A. Effects of Telestroke on Thrombolysis Times and Outcomes: A Meta-analysis. PREHOSP EMERG CARE 2018; 22:472-484. [PMID: 29345529 DOI: 10.1080/10903127.2017.1408728] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Telestroke systems are tools, used to provide an advanced stroke care in regions without sufficient neurologic services. We performed this meta-analysis to assess the effects of telemedicine on treatment times and clinical outcomes of acute stroke care. METHODS A literature search of PubMed, SCOPUS, and Cochrane CENTRAL was conducted for original studies investigating telemedicine applications in acute stroke care. Dichotomous data on treatment outcomes were pooled as odds ratios (ORs), while continuous data on thrombolysis times were pooled as mean differences (MDs) with 95% confidence interval (CI), using RevMan software (version 5.3). RESULTS Pooling data from 26 studies (6605 thrombolysed patients) showed no significant differences between the telestroke and control groups in terms of in-hospital mortality (OR = 1.21, 95% CI [0.98, 1.49]), 90-day mortality (OR = 1.08, 95% CI [0.85, 1.37]), symptomatic intracranial hemorrhage (sICH) (OR = 1.10, 95% CI [0.79, 1.53]), and favorable clinical outcome at discharge (OR = 1.03, 95% CI [0.69, 1.53]) and 90 days later (OR = 0.99, 95% CI [0.82, 1.18]). The onset-to-door (OTD) duration (MD = -10.4 minutes, 95% CI [-14.79, -.01]) and length of hospital stay (MD = -0.55 days, 95% CI [-1.02, -0.07]) were significantly shorter in the telestroke group, compared to the control group. Although the overall effect estimate (under the fixed-effect model) showed a significant decrease in the onset-to-treatment (OTT) duration in the telestroke group (MD = -5.83 minutes, 95% CI [-8.57, -3.09]), employing the random-effects model for between-study heterogeneity abolished this significance (MD = -5.90 minutes, 95% CI [-13.23, 1.42]). CONCLUSION Telestroke significantly reduced OTD and hospital stay durations in stroke patients without increasing the risk of mortality or sICH. Therefore, telemedicine can improve stroke care in regional areas with minor experience in thrombolysis. Further randomized controlled trials are needed to assess the benefits of telestroke systems, especially in terms of cost-effectiveness and quality of life outcomes.
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163
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Kobayashi A, Czlonkowska A, Ford GA, Fonseca AC, Luijckx GJ, Korv J, de la Ossa NP, Price C, Russell D, Tsiskaridze A, Messmer-Wullen M, De Keyser J. European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke. Eur J Neurol 2018; 25:425-433. [PMID: 29218822 DOI: 10.1111/ene.13539] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/01/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE The reduction of delay between onset and hospital arrival and adequate pre-hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence-based practices for the management of patients with suspected stroke in the pre-hospital setting. METHODS The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations. RESULTS Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre-hospital 'code stroke' including highest priority dispatch, pre-hospital notification and rapid transfer to the closest 'stroke-ready' centre. Insufficient evidence was found to recommend a pre-hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre-hospital telemedicine during ambulance transport. CONCLUSIONS These guidelines inform on the contemporary approach to patients with suspected stroke in the pre-hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.
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Affiliation(s)
- A Kobayashi
- Institute of Psychiatry and Neurology, Interventional Stroke and Cerebrovascular Diseases Treatment Centre, Warsaw, Poland.,Department of Neuroradiology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - A Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - G A Ford
- Division of Medical Sciences, Oxford University, Oxford, UK
| | - A C Fonseca
- Department of Neurology, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - G J Luijckx
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J Korv
- Department of Neurology, Estonia Department of Neurology and Neurosurgery, Neurology Clinic, Tartu University Hospital, University of Tartu, Tartu, Estonia
| | - N Pérez de la Ossa
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - C Price
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - D Russell
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - A Tsiskaridze
- Department of Neurology, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
| | - M Messmer-Wullen
- Austrian Stroke Selfhelp Association, Lochau, Austria.,European Federation of Neurological Associations (EFNA) and Stroke Alliance for Europe (SAFE), Brussels, Belgium
| | - J De Keyser
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Neurology, Centre for Neurosciences, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Gusev EI, Martynov MY, Yasamanova AN, Nikonov AA, Markin SS, Semenov AM. Thrombolytic therapy of ischemic stroke. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:4-14. [DOI: 10.17116/jnevro20181181224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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165
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Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2017; 49:439-446. [PMID: 29284734 DOI: 10.1161/strokeaha.117.019431] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/21/2017] [Accepted: 12/05/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Prehospital stroke severity scales may help to triage acute ischemic stroke patients with large vessel occlusion (LVO) for direct transportation to a comprehensive stroke center. The impact on resource use and time to reperfusion treatment for patients with and without LVO is unknown. METHODS Based on empirical distributions of stroke symptom severity, prehospital delay times, and stroke symptom severity-dependent likelihood of LVO, we simulate prehospital incidents of stroke-like symptoms in abstract geographical environments to estimate the impact of prehospital triage strategies based on different cutoffs of the rapid arterial occlusion evaluation scale. RESULTS Compared with transporting each patient to the nearest stroke center, implementation of a prehospital triage strategy based on a rapid arterial occlusion evaluation scale cutoff score ≥5 is associated with more patients with suspected acute stroke at comprehensive stroke centers and less patients at primary stroke centers (+11.7% [95% confidence interval: +8.1% to +15.3%] and -18.4% [-19.1% to -17.7%], respectively). Mean time to groin puncture is reduced by 29.6 minutes (-35.2 to -24.7 minutes) while mean time to thrombolysis does not change significantly (±0.0 minutes [-0.3 to +0.3 minutes]). The total number of secondary transfers is reduced by 60.9% (-62.8% to -59.0%); mean time of ambulance use per patient is unchanged. Results are robust with regards to variation in model parameters. CONCLUSIONS Implementation of prehospital triage based on stroke severity scales would have strong impact on patient flow and distribution. The benefit of earlier thrombectomy for patients with LVO may outweigh the harm associated with delayed access to thrombolysis for some patients without LVO. Randomized trials using clinical stroke severity scales as a triage tool are needed to confirm our findings.
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Affiliation(s)
- Ludwig Schlemm
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres).
| | - Martin Ebinger
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres)
| | - Christian H Nolte
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres)
| | - Matthias Endres
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres)
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Valenzuela Espinoza A, Devos S, van Hooff RJ, Fobelets M, Dupont A, Moens M, Hubloue I, Lauwaert D, Cornu P, Brouns R, Putman K. Time Gain Needed for In-Ambulance Telemedicine: Cost-Utility Model. JMIR Mhealth Uhealth 2017; 5:e175. [PMID: 29175808 PMCID: PMC5722977 DOI: 10.2196/mhealth.8288] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/27/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022] Open
Abstract
Background Stroke is a very time-sensitive pathology, and many new solutions target the optimization of prehospital stroke care to improve the stroke management process. In-ambulance telemedicine, defined by live bidirectional audio-video between a patient and a neurologist in a moving ambulance and the automated transfer of vital parameters, is a promising new approach to speed up and improve the quality of acute stroke care. Currently, no evidence exists on the cost effectiveness of in-ambulance telemedicine. Objective We aim to develop a first cost effectiveness model for in-ambulance telemedicine and use this model to estimate the time savings needed before in-ambulance telemedicine becomes cost effective. Methods Current standard stroke care is compared with current standard stroke care supplemented with in-ambulance telemedicine using a cost-utility model measuring costs and quality-adjusted life-years (QALYs) from a health care perspective. We combine a decision tree with a Markov model. Data from the UZ Brussel Stroke Registry (2282 stroke patients) and linked hospital claims data at individual level are combined with literature data to populate the model. A 2-way sensitivity analysis varying both implementation costs and time gain is performed to map the different cost-effective combinations and identify the time gain needed for cost effectiveness and dominance. For several modeled time gains, the cost-effectiveness acceptability curve is calculated and mapped in 1 figure. Results Under the base-case scenario (implementation cost of US $159,425) and taking a lifetime horizon into account, in-ambulance telemedicine is a cost-effective strategy compared to standard stroke care alone starting from a time gain of 6 minutes. After 12 minutes, in-ambulance telemedicine becomes dominant, and this results in a mean decrease of costs by US –$30 (95% CI –$32 to –$29) per patient with 0.00456 (95% CI 0.00448 to 0.00463) QALYs on average gained per patient. In over 82% of all probabilistic simulations, in-ambulance telemedicine remains under the cost-effectiveness threshold of US $47,747. Conclusions Our model suggests that in-ambulance telemedicine can be cost effective starting from a time gain of 6 minutes and becomes a dominant strategy after approximately 15 minutes. This indicates that in-ambulance telemedicine has the potential to become a cost-effective intervention assuming time gains in clinical implementations are realized in the future.
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Affiliation(s)
| | - Stefanie Devos
- Interuniversity Center for Health Economics Research, Vrije Universiteit Brussel, Brussels, Belgium
| | - Robbert-Jan van Hooff
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Neurovascular Center, Department of Neurology, Zealand University Hospital, Roskilde, Denmark
| | - Maaike Fobelets
- Interuniversity Center for Health Economics Research, Vrije Universiteit Brussel, Brussels, Belgium
| | - Alain Dupont
- Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - Door Lauwaert
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Research Group on Emergency and Disaster Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pieter Cornu
- Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Raf Brouns
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Neurology, ZorgSaam Hospital, Terneuzen, Netherlands
| | - Koen Putman
- Interuniversity Center for Health Economics Research, Vrije Universiteit Brussel, Brussels, Belgium
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Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
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Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
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168
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Kettner M, Helwig SA, Ragoschke-Schumm A, Schwindling L, Roumia S, Keller I, Martens D, Kulikovski J, Manitz M, Lesmeister M, Walter S, Grunwald IQ, Schlechtriemen T, Reith W, Fassbender K. Prehospital Computed Tomography Angiography in Acute Stroke Management. Cerebrovasc Dis 2017; 44:338-343. [PMID: 29130951 DOI: 10.1159/000484097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. METHODS Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. RESULTS Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. CONCLUSION Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.
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Affiliation(s)
- Michael Kettner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany.,Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | | | | | - Lenka Schwindling
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Safwan Roumia
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Isabel Keller
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Daniel Martens
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Matthias Manitz
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Iris Quasar Grunwald
- Department of Neuroscience, Anglia Ruskin University, Chelmsford, United Kingdom
| | | | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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169
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Abstract
PURPOSE OF REVIEW Acute ischemic stroke (AIS) care is rapidly evolving. This review discusses current diagnostic, therapeutic, and process models that can expedite stroke treatment to achieve best outcomes. RECENT FINDINGS Use of stent retrievers after selection via advanced imaging is safe and effective, and is an important option for AIS patients with large vessel occlusion (LVO). Significant time delays occur before and during patient transfers, and upon comprehensive stroke center (CSC) arrival, and have deleterious effects on functional outcome. Removing obstacles, enhancing inter-facility communication, and creating acute stroke management processes and protocols are paramount strategies to enhance network efficiency. Inter-departmental CSC collaboration can significantly reduce door-to-treatment times. Streamlined stroke systems of care may result in higher treatment rates and better functional outcomes for AIS patients, simultaneously conserving healthcare dollars. Stroke systems of care should be structured regionally to minimize time to treatment. A proactive approach must be employed; a management plan incorporating stroke team prenotification and parallel processes between departments can save valuable time, maximize brain salvage, and reduce disability from stroke.
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170
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Nolte CH, Audebert HJ. [Prehospital care for stroke patients]. Med Klin Intensivmed Notfmed 2017; 112:668-673. [PMID: 28900664 DOI: 10.1007/s00063-017-0348-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022]
Abstract
The effectiveness of thrombolysis or mechanical recanalization for acute stroke is higher, the sooner these therapies are started. Therefore, acute stroke patients need to be evaluated by qualified staff for these therapies as soon as possible. Lay persons need to identify the typical symptoms of stroke as an emergency and act accordingly by calling the emergency medical system (EMS). The EMS team reassesses the symptoms and prompts cerebral imaging. Cerebral imaging is performed ideally in hospitals with a stroke unit where subsequent (stroke) treatments occur. On the way, the emergency team will measure and stabilize vital functions and obtain further important clinical information. Telemedicine allows communicating exact time of onset and severity of symptoms, as well as comorbidities and medication of the patient to the respective hospital. Thereby, the intrahospital workload will be disencumbered and accelerated. Some EMS vehicles now carry point-of-care laboratories and may measure lab values en route (glucose and INR [International Normalized Ratio] for example). Some ambulances are not only equipped with qualified staff, telemedicine technique, and point-of-care labs but even computer tomography (CT) to perform imaging. Such mobile stroke emergency mobiles (STEMO) or mobile stroke units may perform thrombolysis prehospitally. Prehospital thrombolysis has been proven to be initiated faster and is safe. Preliminary results even suggest superiority to intrahospital thrombolysis with respect to clinical outcome. Moreover, STEMO may perform CT-angiography and assess intracranial large-vessel status. If intracranial large-vessel occlusion is present, patients will be brought directly to hospitals able to perform mechanical recanalization. Thus, secondary transports are no longer required.
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Affiliation(s)
- C H Nolte
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland. .,Klinik und Hochschulambulanz für Neurologie, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland. .,Berlin Institute of Health (BIH), Berlin, Deutschland.
| | - H J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Klinik und Hochschulambulanz für Neurologie, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland
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171
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Audebert H, Fassbender K, Hussain MS, Ebinger M, Turc G, Uchino K, Davis S, Alexandrov A, Grotta J. The PRE-hospital Stroke Treatment Organization. Int J Stroke 2017; 12:932-940. [DOI: 10.1177/1747493017729268] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The PRE-hospital Stroke Treatment Organization was formed in 2016 as an international consortium of medical practitioners involved in pre-hospital treatment of patients with acute stroke. Aims PRE-hospital Stroke Treatment Organization’s mission is to improve stroke outcomes by supporting research and advocacy for pre-hospital stroke treatment in Mobile Stroke Units. PRE-hospital Stroke Treatment Organization will provide a platform to enhance collaborative research across the spectrum of acute stroke management in the pre-hospital setting. PRE-hospital Stroke Treatment Organization will also facilitate the appropriate proliferation and distribution of Mobile Stroke Units by providing a forum for professional communication, resource for public education, and stimulus for government, industry, and philanthropic support. Summary of review In this “white paper”, we describe the evidence supporting pre-hospital stroke treatment, progress to date, practical issues such as application in various environments and staffing, planned research initiatives, and organizational structure. Conclusions PRE-hospital Stroke Treatment Organization is not-for-profit, with membership open to anyone involved (or hoping to become involved) in pre-hospital stroke care. PRE-hospital Stroke Treatment Organization has a Steering Committee comprised of members from Europe, U.S., Canada, Australia, and other regions having a Mobile Stroke Unit in operation. PRE-hospital Stroke Treatment Organization convenes satellite meetings for membership at the International Stroke Conference and European Stroke Congress each year to address the PRE-hospital Stroke Treatment Organization mission. The first research collaborations agreed upon are to: (1) develop a list of common data elements to be collected by all Mobile Stroke Unit programs and entered into a common research database, and (2) develop a protocol for investigating the natural history of hyper-acute Intracerebral Hemorrhage.
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Affiliation(s)
- Heinrich Audebert
- Department of Neurology, Charite-Universitaetsmedizin, Berlin, Germany
| | - Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | | | - Martin Ebinger
- Department of Neurology, Charite-Universitaetsmedizin, Berlin, Germany
- Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Guillaume Turc
- Department of Neurology, Charite-Universitaetsmedizin, Berlin, Germany
- Department of Neurology, Hopital Sainte-Anne, Paris, France
| | | | - Stephen Davis
- The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Anne Alexandrov
- College of Nursing and College of Medicine Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
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172
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Klingner CM, Herdtle S, Brodoehl S, Hohenstein C, Wild T, Behringer W, Witte OW, Günther A. Mit Notarzt schneller zur Lyse. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0335-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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173
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Venema E, Boodt N, Berkhemer OA, Rood PPM, van Zwam WH, van Oostenbrugge RJ, van der Lugt A, Roos YBWEM, Majoie CBLM, Lingsma HF, Dippel DWJ. Workflow and factors associated with delay in the delivery of intra-arterial treatment for acute ischemic stroke in the MR CLEAN trial. J Neurointerv Surg 2017; 10:424-428. [DOI: 10.1136/neurintsurg-2017-013198] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/23/2017] [Accepted: 07/30/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveThe effect of intra-arterial treatment (IAT) for acute ischemic stroke is highly time-dependent. We investigated the delay of IAT and factors associated with such delay.MethodsMR CLEAN was a randomized trial of IAT plus usual care versus usual care alone (n=500). With multivariable linear regression, we analyzed the effect of intravenous treatment, general anesthesia, off-hours and inter-hospital transfer on time to admission to the emergency department (ED) of the intervention center and time to treatment. Furthermore, we assessed compliance with a target of 75 min for time from ED to treatment, and calculated the potential absolute increase in the number of patients with a good outcome (modified Rankin Scale score ≤2) if this target had been achieved in all treated patients.ResultsInter-hospital transfer prolonged time to ED by 140 min (95% CI 129 to 150) but reduced time from ED to treatment by 77 min (95% CI 64 to 91). Time from ED to treatment was increased by 19 min by general anesthesia (95% CI 5 to 33) and total time was increased by 23 min during off-hours (95% CI 6 to 40). The in-hospital target was achieved in 11.5% (22/192) of patients. Full compliance with the target time of 75 min from ED to treatment would have increased the proportion of patients with a good outcome by 7.6% (95% CI 6.7% to 8.5%).ConclusionInter-hospital transfer is an important cause of delay in the delivery of IAT and every effort should be made to avoid transfers and reduce transfer-related delay. Furthermore, in-hospital workflow should be optimized to improve functional outcome after IAT.
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174
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Weber JE, Audebert HJ. [Appropriate treatment of acute stroke at all times and in all places : Organizational concepts and new approaches]. Internist (Berl) 2017; 58:1213-1219. [PMID: 28840255 DOI: 10.1007/s00108-017-0305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Stroke is one of the most common neurological diseases in acute care. The introduction of new organizational concepts in the rescue chain and in acute inpatient services can significantly reduce time to treatment and patients can receive specific therapeutic options that have been shown to improve acute stroke prognosis. This review provides an overview of organizational structures that lead to improved medical care and outlines the evidence-based therapeutic options. This is intended to give the reader a decision support on provision of specific treatment in acute ischemic stroke. The almost simultaneous proof of effectiveness of mechanical thrombectomy for targeted patient populations in five randomized trials has challenged the organization of stroke care. This provides a good example of how an optimized interplay within the rescue chain from emergency services via community hospitals to referral centers with intervention facilities can ensure access to this novel treatment for as many patients as possible. For the limited time span between onset of symptoms and start of treatment, creative but nevertheless well-standardized concepts have emerged that lead to measurable therapeutic success. It has become an urgent challenge to create sustainable regional infrastructures that allow access to appropriate treatment for all patients.
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Affiliation(s)
- J E Weber
- Klinik für Neurologie mit experimenteller Neurologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.
| | - H J Audebert
- Klinik für Neurologie mit experimenteller Neurologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Centrum für Schlaganfallforschung Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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175
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Alotaibi NM, Sarzetto F, Guha D, Lu M, Bodo A, Gupta S, Dyer E, Howard P, da Costa L, Swartz RH, Boyle K, Nathens AB, Yang VXD. Impact of Smartphone Applications on Timing of Endovascular Therapy for Ischemic Stroke: A Preliminary Study. World Neurosurg 2017; 107:678-683. [PMID: 28823672 DOI: 10.1016/j.wneu.2017.08.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/05/2017] [Accepted: 08/08/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND The metrics of imaging-to-puncture and imaging-to-reperfusion were recently found to be associated with the clinical outcomes of endovascular thrombectomy for acute ischemic stroke. However, measures for improving workflow within hospitals to achieve better timing results are largely unexplored for endovascular therapy. The aim of this study was to examine our experience with a novel smartphone application developed in house to improve our timing metrics for endovascular treatment. METHODS We developed an encrypted smartphone application connecting all stroke team members to expedite conversations and to provide synchronized real-time updates on the time window from stroke onset to imaging and to puncture. The effects of the application on the timing of endovascular therapy were evaluated with a secondary analysis of our single-center cohort. Our primary outcome was imaging-to-puncture time. We assessed the outcomes with nonparametric tests of statistical significance. RESULTS Forty-five patients met our criteria for analysis among 66 consecutive patients with acute ischemic stroke who received endovascular therapy at our institution. After the implementation of the smartphone application, imaging-to-puncture time was significantly reduced (preapplication median time, 127 minutes; postapplication time, 69 minutes; P < 0.001). Puncture-to-reperfusion time was not affected by the application use (42 minutes vs. 36 minutes). CONCLUSION The use of smartphone applications may reduce treatment times for endovascular therapy in acute ischemic stroke. Further studies are needed to confirm our findings.
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Affiliation(s)
- Naif M Alotaibi
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Francesca Sarzetto
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Daipayan Guha
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael Lu
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andre Bodo
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erin Dyer
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter Howard
- Department of Radiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard H Swartz
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Karl Boyle
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Victor X D Yang
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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176
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Abstract
This review discusses modern therapeutic interventions for acute ischemic stroke with a focus on endovascular therapy. In 2015, the American Heart Association made major changes to the guidelines for the endovascular treatment of acute ischemic stroke. The Class IA indications for endovascular therapy of stroke patients include symptom onset within 6 h, proven large vessel occlusion of an artery in the anterior circulation, and the use of a stent retriever as part of the mechanical thrombectomy. Advanced perfusion imaging helps identify patients with a low ratio of ischemic core to salvageable penumbra. Equally important to overall clinical outcome is the organization of comprehensive stroke centers and the recent advent of the mobile stroke unit. Future clinical endovascular stroke trials will help us to better understand the role of endovascular interventions.
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177
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Schlemm E, Ebinger M, Nolte CH, Endres M, Schlemm L. Optimal Transport Destination for Ischemic Stroke Patients With Unknown Vessel Status. Stroke 2017; 48:2184-2191. [PMID: 28655816 DOI: 10.1161/strokeaha.117.017281] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/28/2017] [Accepted: 06/02/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Eckhard Schlemm
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Martin Ebinger
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Christian H. Nolte
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Matthias Endres
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
| | - Ludwig Schlemm
- From the University of Glasgow, School of Life Sciences, United Kingdom (E.S.); Queen Elizabeth University Hospital Glasgow, NHS Greater Glasgow and Clyde, United Kingdom (E.S.); Universität Hamburg, Medizinische Fakultät, Germany (E.S.); Department of Neurology (M. Ebinger, C.H.N., M. Endres, L.S.) and Center for Stroke Research Berlin (CSB) (M. Ebinger, C.H.N., M. Endres, L.S.), Charité—Universitätsmedizin, Germany; Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger)
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178
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Hov MR, Zakariassen E, Lindner T, Nome T, Bache KG, Røislien J, Gleditsch J, Solyga V, Russell D, Lund CG. Interpretation of Brain CT Scans in the Field by Critical Care Physicians in a Mobile Stroke Unit. J Neuroimaging 2017; 28:106-111. [PMID: 28766306 PMCID: PMC5811888 DOI: 10.1111/jon.12458] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/23/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute stroke, thromboembolism or spontaneous hemorrhage abruptly reduces blood flow to a part of the brain. To limit necrosis, rapid radiological identification of the pathological mechanism must be conducted to allow the initiation of targeted treatment. The aim of the Norwegian Acute Stroke Prehospital Project is to determine if anesthesiologists, trained in prehospital critical care, may accurately assess cerebral computed tomography (CT) scans in a mobile stroke unit (MSU). METHODS In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on‐call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter‐rater agreement between the pre‐ and in‐hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter‐rater agreement was analyzed with Cohen's kappa. RESULTS Fifty‐one cerebral CT scans from the MSU were included. Inter‐rater agreement between prehospital anesthesiologists and the in‐hospital on‐call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital. CONCLUSION This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.
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Affiliation(s)
- Maren Ranhoff Hov
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Zakariassen
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
| | - Thomas Lindner
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,The Regional Centre for Emergency Medical Research and Development, Stavanger, Norway
| | - Terje Nome
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Kristi G Bache
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Jo Røislien
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway
| | | | - Volker Solyga
- Department of Neurology, Østfold Hospital, Kalnes, Norway
| | - David Russell
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christian G Lund
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway
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179
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Schlemm L, Turc G, Audebert HJ, Ebinger M. Access to Thrombolysis for Non-Resident and Resident Stroke Patients-A Registry-Based Comparative Study from Berlin. Front Neurol 2017; 8:319. [PMID: 28713330 PMCID: PMC5491940 DOI: 10.3389/fneur.2017.00319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/19/2017] [Indexed: 11/20/2022] Open
Abstract
Objectives Stroke can happen to people away from home. It is unknown whether non-resident and resident stroke patients have equal access to thrombolysis. Materials and methods Consecutive patients cared for by the Stroke Emergency Mobile between 2011 and 2016 after prompting suspicion of acute stroke during the emergency call were included in our registry. Patients were categorized as residents or non-residents based on their main address. Clinical characteristics, thrombolysis rates, and time intervals from symptom onset/last seen well to alarm and to thrombolysis were compared between groups adjusting for age, pre-stroke modified Rankin Scale (mRS) score, and National Institutes of Health Stroke Scale (NIHSS) score. Results Of 4,254 patients for whom a stroke dispatch was activated, 2,451 had ischemic or hemorrhagic strokes, including 73 non-residents. Non-resident stroke patients were younger (median 69.4 vs. 76.6 years, p < 0.001), had less pre-stroke disability (mRS ≥ 2:17.8 vs. 47.5%, p < 0.001) and less severe strokes (median NIHSS 4 vs. 5, p = 0.02). Thrombolysis rates were higher in non-residents (30.9 vs. 22.0% of ischemic stroke patients, p = 0.04) and emergency calls were made faster (symptom onset/last-seen-well-to-alarm time 35 vs. 144 min, p = 0.04). A lower proportion of non-residents had unknown time of symptom onset (21.9 vs. 46.4%, p < 0.001). For patients with known time of symptom onset, thrombolysis rates, and prehospital delays were similar among non-residents and residents. Conclusion In this study, non-resident stroke patients had higher rates of thrombolysis than residents. This may be explained by a lower proportion of patients with unknown time of symptom onset.
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Affiliation(s)
- Ludwig Schlemm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,London School of Economics and Political Science, London, United Kingdom
| | - Guillaume Turc
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Department of Neurology, Hôpital Sainte-Anne, Paris, France.,INSERM U894, Paris, France
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany
| | - Martin Ebinger
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Berlin, Germany
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Bustamante A, López-Cancio E, Pich S, Penalba A, Giralt D, García-Berrocoso T, Ferrer-Costa C, Gasull T, Hernández-Pérez M, Millan M, Rubiera M, Cardona P, Cano L, Quesada H, Terceño M, Silva Y, Castellanos M, Garces M, Reverté S, Ustrell X, Marés R, Baiges JJ, Serena J, Rubio F, Salas E, Dávalos A, Montaner J. Blood Biomarkers for the Early Diagnosis of Stroke: The Stroke-Chip Study. Stroke 2017; 48:2419-2425. [PMID: 28716979 DOI: 10.1161/strokeaha.117.017076] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/23/2017] [Accepted: 06/27/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Stroke diagnosis could be challenging in the acute phase. We aimed to develop a blood-based diagnostic tool to differentiate between real strokes and stroke mimics and between ischemic and hemorrhagic strokes in the hyperacute phase. METHODS The Stroke-Chip was a prospective, observational, multicenter study, conducted at 6 Stroke Centers in Catalonia. Consecutive patients with suspected stroke were enrolled within the first 6 hours after symptom onset, and blood samples were drawn immediately after admission. A 21-biomarker panel selected among previous results and from the literature was measured by immunoassays. Outcomes were differentiation between real strokes and stroke mimics and between ischemic and hemorrhagic strokes. Predictive models were developed by combining biomarkers and clinical variables in logistic regression models. Accuracy was evaluated with receiver operating characteristic curves. RESULTS From August 2012 to December 2013, 1308 patients were included (71.9% ischemic, 14.8% stroke mimics, and 13.3% hemorrhagic). For stroke versus stroke mimics comparison, no biomarker resulted included in the logistic regression model, but it was only integrated by clinical variables, with a predictive accuracy of 80.8%. For ischemic versus hemorrhagic strokes comparison, NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) >4.9 (odds ratio, 2.40; 95% confidence interval, 1.55-3.71; P<0.0001) and endostatin >4.7 (odds ratio, 2.02; 95% confidence interval, 1.19-3.45; P=0.010), together with age, sex, blood pressure, stroke severity, atrial fibrillation, and hypertension, were included in the model. Predictive accuracy was 80.6%. CONCLUSIONS The studied biomarkers were not sufficient for an accurate differential diagnosis of stroke in the hyperacute setting. Additional discovery of new biomarkers and improvement on laboratory techniques seem necessary for achieving a molecular diagnosis of stroke.
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Affiliation(s)
- Alejandro Bustamante
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Elena López-Cancio
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Sara Pich
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Anna Penalba
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Dolors Giralt
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Teresa García-Berrocoso
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Carles Ferrer-Costa
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Teresa Gasull
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - María Hernández-Pérez
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Mónica Millan
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Marta Rubiera
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Pedro Cardona
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Luis Cano
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Helena Quesada
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Mikel Terceño
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Yolanda Silva
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Mar Castellanos
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Moisés Garces
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Silvia Reverté
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Xavier Ustrell
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Rafael Marés
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Joan Josep Baiges
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Joaquín Serena
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Francisco Rubio
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Eduardo Salas
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Antoni Dávalos
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.)
| | - Joan Montaner
- From the Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain (A.B., A.P., D.G., T.G.-B., J.M.); Stroke Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain (E.L.-C., M.H.-P., M.M., A.D.); Gendiag.exe, S.L., Barcelona, Spain (S.P., C.F.-C., E.S.); Cellular and Molecular Neurobiology Research Group, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain (T.G.); Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.R., J.M.); Stroke Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (P.C., L.C., H.Q., F.R.); Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T., Y.S., J.S.); Complejo Hospitalario Universitario A Coruña, Spain (M.C.); Stroke Unit, Hospital Universitari Verge de la Cinta de Tortosa, Spain (M.G., S.R., J.J.B.); and Stroke Unit, Hospital Universitari Joan XXIII, Tarragona, Spain (X.U., R.M.).
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181
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Mattila OS, Harve H, Pihlasviita S, Ritvonen J, Sibolt G, Pystynen M, Strbian D, Curtze S, Kuisma M, Tatlisumak T, Lindsberg PJ. Ultra-acute diagnostics for stroke: Large-scale implementation of prehospital biomarker sampling. Acta Neurol Scand 2017; 136:17-23. [PMID: 27642014 DOI: 10.1111/ane.12687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. To facilitate development of ultra-acute biomarkers, we set out to implement large-scale prehospital blood sampling and determine feasibility and diagnostic timesavings of this approach. MATERIALS AND METHODS Emergency medical services (EMS) personnel of the Helsinki metropolitan area were trained to collect prehospital blood samples from thrombolysis candidates using a cannula adapter technique. Time delays, sample quality, and logistics were investigated between May 20, 2013 and May 19, 2014. RESULTS Prehospital blood sampling and study recruiting were successfully performed for 430 thrombolysis candidates, of which 50% had ischemic stroke, 14.4% TIA, 13.5% hemorrhagic stroke, and 22.1% stroke mimics. A total of 66.3% of all samples were collected during non-office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than hospital admission blood sampling and 37 minutes (30-47) earlier than admission neuroimaging. Hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples. CONCLUSIONS Prehospital biomarker sampling can be implemented in all EMS units and provides a median timesaving of more than 30 minutes to first blood sample. Large prehospital sample sets will enable development of novel ambulance biomarkers to improve early differential diagnosis and treatment of thrombolysis candidates.
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Affiliation(s)
- O. S. Mattila
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
| | - H. Harve
- Emergency Medical Services; Department of Emergency Care; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - S. Pihlasviita
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
| | - J. Ritvonen
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
| | - G. Sibolt
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - M. Pystynen
- Emergency Medical Services; Department of Emergency Care; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - D. Strbian
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - S. Curtze
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - M. Kuisma
- Emergency Medical Services; Department of Emergency Care; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - T. Tatlisumak
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- The Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
- Department of Neurology; Sahlgrenska University Hospital; Gothenburg Sweden
| | - P. J. Lindsberg
- Neurology, Clinical Neurosciences; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Molecular Neurology; Research Programs Unit; University of Helsinki; Helsinki Finland
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182
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Richards CT, Wang B, Markul E, Albarran F, Rottman D, Aggarwal NT, Lindeman P, Stein-Spencer L, Weber JM, Pearlman KS, Tataris KL, Holl JL, Klabjan D, Prabhakaran S. Identifying Key Words in 9-1-1 Calls for Stroke: A Mixed Methods Approach. PREHOSP EMERG CARE 2017; 21:761-766. [PMID: 28661784 DOI: 10.1080/10903127.2017.1332124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Identifying stroke during a 9-1-1 call is critical to timely prehospital care. However, emergency medical dispatchers (EMDs) recognize stroke in less than half of 9-1-1 calls, potentially due to the words used by callers to communicate stroke signs and symptoms. We hypothesized that callers do not typically use words and phrases considered to be classical descriptors of stroke, such as focal neurologic deficits, but that a mixed-methods approach can identify words and phrases commonly used by 9-1-1 callers to describe acute stroke victims. METHODS We performed a mixed-method, retrospective study of 9-1-1 call audio recordings for adult patients with confirmed stroke who were transported by ambulance in a large urban city. Content analysis, a qualitative methodology, and computational linguistics, a quantitative methodology, were used to identify key words and phrases used by 9-1-1 callers to describe acute stroke victims. Because a caller's level of emotional distress contributes to the communication during a 9-1-1 call, the Emotional Content and Cooperation Score was scored by a multidisciplinary team. RESULTS A total of 110 9-1-1 calls, received between June and September 2013, were analyzed. EMDs recognized stroke in 48% of calls, and the emotional state of most callers (95%) was calm. In 77% of calls in which EMDs recognized stroke, callers specifically used the word "stroke"; however, the word "stroke" was used in only 38% of calls. Vague, non-specific words and phrases were used to describe stroke victims' symptoms in 55% of calls, and 45% of callers used distractor words and phrases suggestive of non-stroke emergencies. Focal neurologic symptoms were described in 39% of calls. Computational linguistics identified 9 key words that were more commonly used in calls where the EMD identified stroke. These words were concordant with terms identified through qualitative content analysis. CONCLUSIONS Most 9-1-1 callers used vague, non-specific, or distractor words and phrases and infrequently provide classic stroke descriptions during 9-1-1 calls for stroke. Both qualitative and quantitative methodologies identified similar key words and phrases associated with accurate EMD stroke recognition. This study suggests that tools incorporating commonly used words and phrases could potentially improve EMD stroke recognition.
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183
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Yu IC, Kuo PC, Yen JH, Paraiso HC, Curfman ET, Hong-Goka BC, Sweazey RD, Chang FL. A Combination of Three Repurposed Drugs Administered at Reperfusion as a Promising Therapy for Postischemic Brain Injury. Transl Stroke Res 2017. [PMID: 28624878 DOI: 10.1007/s12975-017-0543-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cerebral ischemia leads to multifaceted injury to the brain. A polytherapeutic drug that can be administered immediately after reperfusion may increase protection to the brain by simultaneously targeting multiple deleterious cascades. This study evaluated efficacy of the combination of three clinically approved drugs: lamotrigine, minocycline, and lovastatin, using two mouse models: global and focal cerebral ischemia induced by transient occlusion of the common carotid arteries or the middle cerebral artery, respectively. In vitro, the combination drug, but not single drug, protected neurons against oxygen-glucose deprivation (OGD)-induced cell death. The combination drug simultaneously targeted cell apoptosis and DNA damage induced by ischemia. Besides acting on neurons, the combination drug suppressed inflammatory processes in microglia and brain endothelial cells induced by ischemia. In a transient global ischemia model, the combination drug, but not single drug, suppressed microglial activation and inflammatory cytokine production, and reduced neuronal damage. In a transient focal ischemia model, the combination drug, but not single drug, attenuated brain infarction, suppressed infiltration of peripheral neutrophils, and reduced neurological deficits following ischemic stroke. In summary, the combination drug confers a broad-spectrum protection against ischemia/reperfusion (I/R) injury and could be a promising approach for early neuroprotection after out-of-hospital cardiac arrest or ischemic stroke.
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Affiliation(s)
- I-Chen Yu
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA.
| | - Ping-Chang Kuo
- Department of Microbiology and Immunology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Jui-Hung Yen
- Department of Microbiology and Immunology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Hallel C Paraiso
- Department of Biology, Indiana University-Purdue University Fort Wayne, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Eric T Curfman
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Benecia C Hong-Goka
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Robert D Sweazey
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA
| | - Fen-Lei Chang
- Department of Neurology, Indiana University School of Medicine, 2101 E. Coliseum Boulevard, Fort Wayne, IN, 46805, USA.
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184
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Dong Q, Dong Y, Liu L, Xu A, Zhang Y, Zheng H, Wang Y. The Chinese Stroke Association scientific statement: intravenous thrombolysis in acute ischaemic stroke. Stroke Vasc Neurol 2017; 2:147-159. [PMID: 28989804 PMCID: PMC5628383 DOI: 10.1136/svn-2017-000074] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 12/30/2022] Open
Abstract
The most effective medical treatment for acute ischaemic stroke (AIS) is to offer intravenous thrombolysis during the ultra-early period of time after the onset. Even based on the Consensus of Chinese Experts on Intravenous Thrombolysis for AIS in 2012 and 2014 Chinese Guidelines on the Diagnosis and Treatment of AIS, the rate of thrombolysis for AIS in China remained around 2.4%, and the rate of intravenous tissue plasminogen activator usage was only about 1.6% in real world. The indication of thrombolysis for AIS has been expanded, and contraindications have been reduced with recently published studies. In order to facilitate the standardisation of treating AIS, improve the rate of thrombolysis and benefit patients who had a stroke, Chinese Stroke Association has organised and developed this scientific statement.
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Affiliation(s)
- Qiang Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Anding Xu
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Yusheng Zhang
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
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185
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Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg 2017; 263:1051-9. [PMID: 26720428 DOI: 10.1097/sla.0000000000001608] [Citation(s) in RCA: 412] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) have become standard of care in the management of bleeding injured patients, yet strategies to guide them vary widely. We conducted a pragmatic, randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography (TEG) improves survival compared with an MTP guided by conventional coagulation assays (CCA). METHODS This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation. Upon MTP activation, patients were randomized to be managed either by an MTP goal directed by TEG or by CCA (ie, international normalized ratio, fibrinogen, platelet count). Primary outcome was 28-day survival. RESULTS One hundred eleven patients were included in an intent-to-treat analysis (TEG = 56, CCA = 55). Survival in the TEG group was significantly higher than the CCA group (log-rank P = 0.032, Wilcoxon P = 0.027); 20 deaths in the CCA group (36.4%) compared with 11 in the TEG group (19.6%) (P = 0.049). Most deaths occurred within the first 6 hours from arrival (21.8% CCA group vs 7.1% TEG group) (P = 0.032). CCA patients required similar number of red blood cell units as the TEG patients [CCA: 5.0 (2-11), TEG: 4.5 (2-8)] (P = 0.317), but more plasma units [CCA: 2.0 (0-4), TEG: 0.0 (0-3)] (P = 0.022), and more platelets units [CCA: 0.0 (0-1), TEG: 0.0 (0-0)] (P = 0.041) in the first 2 hours of resuscitation. CONCLUSIONS Utilization of a goal-directed, TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation.
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186
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Vuong SM, Carroll CP, Tackla RD, Jeong WJ, Ringer AJ. Application of emerging technologies to improve access to ischemic stroke care. Neurosurg Focus 2017; 42:E8. [DOI: 10.3171/2017.1.focus16520] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
During the past 20 years, the traditional supportive treatment for stroke has been radically transformed by advances in catheter technologies and a cohort of prominent randomized controlled trials that unequivocally demonstrated significant improvement in stroke outcomes with timely endovascular intervention. However, substantial limitations to treatment remain, among the most important being timely access to care. Nonetheless, stroke care has continued its evolution by incorporating technological advances from various fields that can further reduce patients' morbidity and mortality. In this paper the authors discuss the importance of emerging technologies—mobile stroke treatment units, telemedicine, and robotically assisted angiography—as future tools for expanding access to the diagnosis and treatment of acute ischemic stroke.
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Affiliation(s)
- Shawn M. Vuong
- 1Department of Neurosurgery, University of Cincinnati College of Medicine
- 2Comprehensive Stroke Center at University of Cincinnati Gardner Neuroscience Institute; and
| | - Christopher P. Carroll
- 1Department of Neurosurgery, University of Cincinnati College of Medicine
- 2Comprehensive Stroke Center at University of Cincinnati Gardner Neuroscience Institute; and
| | - Ryan D. Tackla
- 1Department of Neurosurgery, University of Cincinnati College of Medicine
- 2Comprehensive Stroke Center at University of Cincinnati Gardner Neuroscience Institute; and
| | - William J. Jeong
- 1Department of Neurosurgery, University of Cincinnati College of Medicine
- 2Comprehensive Stroke Center at University of Cincinnati Gardner Neuroscience Institute; and
| | - Andrew J. Ringer
- 1Department of Neurosurgery, University of Cincinnati College of Medicine
- 2Comprehensive Stroke Center at University of Cincinnati Gardner Neuroscience Institute; and
- 3Mayfield Clinic, Cincinnati, Ohio
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187
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Giardino A, Gupta S, Olson E, Sepulveda K, Lenchik L, Ivanidze J, Rakow-Penner R, Patel MJ, Subramaniam RM, Ganeshan D. Role of Imaging in the Era of Precision Medicine. Acad Radiol 2017; 24:639-649. [PMID: 28131497 DOI: 10.1016/j.acra.2016.11.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/07/2016] [Accepted: 11/29/2016] [Indexed: 12/17/2022]
Abstract
Precision medicine is an emerging approach for treating medical disorders, which takes into account individual variability in genetic and environmental factors. Preventive or therapeutic interventions can then be directed to those who will benefit most from targeted interventions, thereby maximizing benefits and minimizing costs and complications. Precision medicine is gaining increasing recognition by clinicians, healthcare systems, pharmaceutical companies, patients, and the government. Imaging plays a critical role in precision medicine including screening, early diagnosis, guiding treatment, evaluating response to therapy, and assessing likelihood of disease recurrence. The Association of University Radiologists Radiology Research Alliance Precision Imaging Task Force convened to explore the current and future role of imaging in the era of precision medicine and summarized its finding in this article. We review the increasingly important role of imaging in various oncological and non-oncological disorders. We also highlight the challenges for radiology in the era of precision medicine.
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Affiliation(s)
- Angela Giardino
- Department of Imaging, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Supriya Gupta
- Department of Radiology and Imaging, Medical College of Georgia, 1120 15th St, Augusta, GA 30912.
| | - Emmi Olson
- Radiology Resident, University of California San Diego, San Diego, California
| | | | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jana Ivanidze
- Department of Diagnostic Radiology, Weill Cornell Medicine, New York, New York
| | - Rebecca Rakow-Penner
- Department of Radiology, University of California San Diego, San Diego, California
| | - Midhir J Patel
- Department of Radiology, University of South Florida, Tampa, Florida
| | - Rathan M Subramaniam
- Cyclotron and Molecular Imaging Program, Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
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188
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El-Ghanem M, Al-Mufti F, Thulasi V, Singh IP, Gandhi C. Expanding the treatment window for ischemic stroke through the application of novel system-based technology. Neurosurg Focus 2017; 42:E7. [PMID: 28366056 DOI: 10.3171/2017.1.focus16515] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent randomized controlled trials have demonstrated the superiority of endovascular treatment (ET) over medical management in the treatment of acute ischemic stroke patients with anterior circulation emergent large vessel occlusions (ELVOs). Due to such accumulating evidence, expanding ET has become of paramount importance. Advancements in modern technology have enabled the use of mobile stroke units, telestroke networks, mobile neuroendovascular teams, and smartphone applications that shorten the time window to treatment and, thus, make patients more amenable to ET. Additionally, modifying stroke-screening tools to make them more accessible to first responders and the creation of stroke registries can provide further opportunities for ET.
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189
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Ebinger M, Harmel P, Nolte CH, Grittner U, Siegerink B, Audebert HJ. Berlin prehospital or usual delivery of acute stroke care - Study protocol. Int J Stroke 2017. [PMID: 28649936 DOI: 10.1177/1747493017700152] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Rationale Prehospital stroke care in specialized ambulances increases thrombolysis rates, reduces alarm-to-treatment times, and improves the prehospital triage. Preliminary analyses suggest cost-effectiveness. However, scientific proof of better functional outcome compared to usual care is still lacking. Aim To prove better functional outcomes after deployment of the Stroke Emergency Mobile compared to regular ambulances. Sample size estimates A sample size of 686 patients will be required in each arm (Stroke Emergency Mobile group vs. regular care) to detect a difference regarding the primary outcome with 80% power at a two-sided significance level of 0.05. Methods and design This is a pragmatic, prospective study with blinded outcome assessment. Primary outcome will be functional status as defined by modified Rankin Scale score three months after the incident event. We will include cerebral ischemia patients within a predefined catchment area in Berlin, Germany. The study population consists of patients who might be candidates for acute recanalizing treatments, with onset-to-alarm time ≤4 h, symptoms not resolved at time of ambulance arrival, and able to walk without assistance prior to the qualifying incident. About 45% of Stroke Emergency Mobile dispatches are expected to be handled by regular ambulances, since Stroke Emergency Mobile will be already in operation creating the control group. Primary outcome Functional outcome after three months measured by the modified Rankin Scale over the entire range. Discussion The results will inform decision makers on the effectiveness of Stroke Emergency Mobile.
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Affiliation(s)
- Martin Ebinger
- 1 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Department for Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- 1 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- 1 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Department for Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,3 Berlin Institute of Health (BIH), Berlin, Germany
| | - Ulrike Grittner
- 1 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,4 Department of Biostatistics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bob Siegerink
- 1 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- 1 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Department for Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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190
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Tahtali D, Bohmann F, Rostek P, Misselwitz B, Reihs A, Heringer F, Jahnke K, Steinmetz H, Pfeilschifter W. [Crew resource management and simulator training in acute stroke therapy]. DER NERVENARZT 2017; 87:1322-1331. [PMID: 27431675 DOI: 10.1007/s00115-016-0162-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Time is of critical importance in acute stroke management. The establishment of thrombectomy now adds to the complexity and interdisciplinarity of the initial phase. In non-medical high-fidelity situations, such as aviation, crew resource management (CRM) has proven to be highly efficient. It has therefore also been implemented in professional cardiovascular life support training. In a setting where every minute counts, CRM and regular training of the high-fidelity stroke team could offer ways to improve treatment of acute stroke patients. OBJECTIVES We evaluated the effects of a CRM-based stroke team with regular simulation training on the quality of care (e.g. door to needle time and thrombolysis rate) as well as on staff satisfaction and perceived patient safety in the emergency department of a tertiary care neurocenter. MATERIAL AND METHODS We implemented a dedicated stroke team consisting of 7 persons who are notified by a collective call via speed dial and conceived a simulator-based team training for all new stroke team members which we conduct at monthly intervals. We recorded door to needle times of all consecutive patients, staff satisfaction in the emergency room and the acceptance of this new learning format. RESULTS This approach led to a relevant and sustained reduction of the mean door to needle time to less than 30 min. It improved perceived patient safety in residents with professional experience of less than 2 years. There was a very high acceptance within the stroke team training and staff and its usefulness was judged to be very high. CONCLUSION Even though our data do not allow positive effects on patient outcomes to be inferred, the implementation of a CRM-based stroke team and simulator training has had multiple positive effects on the workflow and work satisfaction in the treatment of acute stroke patients.
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Affiliation(s)
- D Tahtali
- Klinik für Neurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - F Bohmann
- Klinik für Neurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - P Rostek
- Anästhesie und Intensivpflege NICU, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - B Misselwitz
- Geschäftsstelle Qualitätssicherung Hessen (GQH), Eschborn, Frankfurt, Deutschland
| | - A Reihs
- Geschäftsstelle Qualitätssicherung Hessen (GQH), Eschborn, Frankfurt, Deutschland
| | - F Heringer
- Frankfurter interdisziplinäre Einrichtung für Notfallmedizin und Simulationstraining (FINeST), Goethe-Universität Frankfurt/Main, Frankfurt/Main, Deutschland
| | - K Jahnke
- Klinik für Neurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - H Steinmetz
- Klinik für Neurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - W Pfeilschifter
- Klinik für Neurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
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191
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Tsivgoulis G, Katsanos AH, Kadlecová P, Czlonkowska A, Kobayashi A, Brozman M, Švigelj V, Csiba L, Fekete K, Kõrv J, Demarin V, Vilionskis A, Jatuzis D, Krespi Y, Liantinioti C, Giannopoulos S, Mikulik R. Intravenous thrombolysis for ischemic stroke in the golden hour: propensity-matched analysis from the SITS-EAST registry. J Neurol 2017; 264:912-920. [PMID: 28315960 DOI: 10.1007/s00415-017-8461-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/06/2017] [Accepted: 03/13/2017] [Indexed: 01/20/2023]
Abstract
As there are scarce data regarding the outcomes of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) within 60 min from symptom onset ("golden hour"), we sought to compare outcomes between AIS patients treated within [GH(+)] and outside [GH(-)] the "golden hour" by analyzing propensity score matched data from the SITS-EAST registry. Clinical recovery (CR) at 2 and 24 h was defined as a reduction of ≥10 points on NIHSS-score or a total NIHSS-score of ≤3 at 2 and 24 h, respectively. A relative reduction in NIHSS-score of ≥40% at 2 h was considered predictive of complete recanalization (CREC). Symptomatic intracranial hemorrhage (sICH) was defined using SITS-MOST criteria. Favorable functional outcome (FFO) was defined as a mRS-score of 0-1 at 3 months. Out of 19,077 IVT-treated AIS patients, 71 GH(+) patients were matched to 6882 GH(-) patients, with no differences in baseline characteristics (p > 0.1). GH(+) had higher rates of CR at 2 (31.0 vs. 12.4%; p < 0.001) and 24 h (41 vs. 27%; p = 0.010), CREC at 2 h (39 vs. 21%; p < 0.001) and FFO (46.5 vs. 34.0%; p = 0.028) at 3 months. The rates of sICH and 3-month mortality did not differ (p > 0.2) between the two groups. GH(+) was associated with 2-h CR (OR: 5.34; 95% CI 2.53-11.03) and CREC (OR: 2.38; 95% CI 1.38-4.09), 24-h CR (OR: 1.88; 95% CI 1.08-3.26) and 3-month FFO (OR: 2.02; 95% CI 1.15-3.54) in multivariable logistic regression models adjusting for potential confounders. In conclusion, AIS treated with IVT within the GH seems to have substantially higher odds of early neurological recovery, CREC, 3-month FFO and functional improvement.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece. .,International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic.
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece.,Department of Neurology, University of Ioannina, Ioannina, Greece
| | - Pavla Kadlecová
- International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic
| | - Anna Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Adam Kobayashi
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Miroslav Brozman
- Neurology Department, University Hospital Nitra, Nitra, Slovakia
| | - Viktor Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Laszlo Csiba
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Klara Fekete
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Vida Demarin
- Department of Neurology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Aleksandras Vilionskis
- Department of Neurology and Neurosurgery, Vilnius University and Republican Vilnius University Hospital, Vilnius, Lithuania
| | - Dalius Jatuzis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Yakup Krespi
- Neurology Department and Stroke Center, Memorial Şişli Hospital, Istanbul, Turkey
| | - Chrissoula Liantinioti
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece
| | | | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic.,Medical Faculty of Masaryk University, Brno, Czech Republic
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192
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Intravenous and Arterial Treatments for Acute Ischemic Stroke: Indications and the Role of Imaging. Top Magn Reson Imaging 2017; 26:127-132. [PMID: 28277463 DOI: 10.1097/rmr.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute ischemic stroke continues to be a leading cause of disability in adults and the fifth leading cause of mortality worldwide. In the past few years, acute ischemic stroke diagnosis and management has advanced by leaps and bounds, with the lengthening of the time window for intravenous tissue plasminogen activator and the establishment of endovascular stroke therapy. As a result of these changes, the focus today has shifted from proving efficacy to expanding indications and identifying all patients who may benefit from these therapies. In this pursuit, neuroimaging will continue to play a pivotal role, by shifting treatment paradigms from time-based to tissue-based. The quest to accurately determine the volume and function of salvageable brain has never been more important than now.
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193
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Taqui A, Cerejo R, Itrat A, Briggs FBS, Reimer AP, Winners S, Organek N, Buletko AB, Sheikhi L, Cho SM, Buttrick M, Donohue MM, Khawaja Z, Wisco D, Frontera JA, Russman AN, Hustey FM, Kralovic DM, Rasmussen P, Uchino K, Hussain MS. Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis. Neurology 2017; 88:1305-1312. [PMID: 28275084 DOI: 10.1212/wnl.0000000000003786] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 12/19/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. METHODS We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014-November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. RESULTS Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. CONCLUSION Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.
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Affiliation(s)
- Ather Taqui
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Russell Cerejo
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Ahmed Itrat
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Farren B S Briggs
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Andrew P Reimer
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Stacey Winners
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Natalie Organek
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Andrew B Buletko
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Lila Sheikhi
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Sung-Min Cho
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Maureen Buttrick
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Megan M Donohue
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Zeshaun Khawaja
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Dolora Wisco
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Jennifer A Frontera
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Andrew N Russman
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Fredric M Hustey
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Damon M Kralovic
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Peter Rasmussen
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Ken Uchino
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH
| | - Muhammad S Hussain
- From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH.
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Southerland AM, Brandler ES. The cost-efficiency of mobile stroke units: Where the rubber meets the road. Neurology 2017; 88:1300-1301. [PMID: 28275085 DOI: 10.1212/wnl.0000000000003833] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrew M Southerland
- From the Departments of Neurology and Public Health Sciences (A.M.S.), University of Virginia Health System, Charlottesville; and Department of Emergency Medicine (E.S.B.), SUNY Stony Brook Medicine, Stony Brook, NY.
| | - Ethan S Brandler
- From the Departments of Neurology and Public Health Sciences (A.M.S.), University of Virginia Health System, Charlottesville; and Department of Emergency Medicine (E.S.B.), SUNY Stony Brook Medicine, Stony Brook, NY
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195
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Feldman WB, Kim AS, Chiong W. Trends in Recruitment Rates for Acute Stroke Trials, 1990-2014. Stroke 2017; 48:799-801. [PMID: 28104835 PMCID: PMC5330837 DOI: 10.1161/strokeaha.116.014458] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/07/2016] [Accepted: 12/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Slow recruitment in acute stroke trials hampers the evaluation of new therapies and delays the adoption of effective therapies into clinical practice. This systematic review evaluates whether recruitment efficiency and rates have increased in acute stroke trials from 1990 to 2014. METHODS Acute stroke trials from 2010 to 2014 were identified by a search of PubMed, Medline, the Cochrane Database of Research in Stroke, and the Stroke Trials Registry. These trials were compared to a previously published data set of trials conducted from 1990 to 2004. RESULTS The median recruitment efficiency of trials from 1990 to 2004 was 0.41 participants/site/month compared with 0.26 participants/site/month from 2010 to 2014 (P=0.14). The median recruitment rate of trials from 1990 to 2004 was 26.8 participants/month compared with 19.0 participants/month from 2010 to 2014 (P=0.13). CONCLUSIONS For acute stroke trials, neither recruitment efficiency nor recruitment rates have increased over the past 25 years and, if anything, have declined.
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Affiliation(s)
- William B Feldman
- From the Department of Medicine, Brigham and Women's Hospital, Boston, MA (W.B.F.); Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco (A.S.K, W.C.); and the University of California, San Francisco Memory and Aging Center (W.C.).
| | - Anthony S Kim
- From the Department of Medicine, Brigham and Women's Hospital, Boston, MA (W.B.F.); Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco (A.S.K, W.C.); and the University of California, San Francisco Memory and Aging Center (W.C.)
| | - Winston Chiong
- From the Department of Medicine, Brigham and Women's Hospital, Boston, MA (W.B.F.); Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco (A.S.K, W.C.); and the University of California, San Francisco Memory and Aging Center (W.C.)
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196
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Hov MR, Ryen A, Finsnes K, Storflor J, Lindner T, Gleditsch J, Lund CG. Pre-hospital ct diagnosis of subarachnoid hemorrhage. Scand J Trauma Resusc Emerg Med 2017; 25:21. [PMID: 28245880 PMCID: PMC5331704 DOI: 10.1186/s13049-017-0365-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/15/2017] [Indexed: 11/29/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) is associated with higher mortality in the acute phase than other stroke types. There is a particular risk of early and devastating re-bleeding. Patients therefore need urgent assessment in a neurosurgical department, and the shorter the time from symptom onset to diagnosis the better. Case presentation The Norwegian Acute Stroke Pre-hospital Project (NASPP) has developed a Mobile Stroke Unit (MSU) model, which is staffed with anesthesiologists also trained in pre-hospital clinical assessment of acute stroke patients and interpretation of computerized tomography (CT). The MSU was operated on-call from the local dispatch center in a rural area 45–160 km away from a neurosurgical department. Two patients presented with clinical symptoms and signs compatible with SAH. In both cases, the CT examination confirmed the diagnosis of SAH. Both were transported directly from patient location to the regional neurosurgical department, saving at least 2–2.5 h of pre-neurosurgical time. Conclusion The Norwegian MSU model staffed with anesthesiologists can rapidly establish an exact diagnosis of SAH, which in a rural area significantly reduces time to neurosurgical care. Trial registration Study data are retrospectively registered in ClinicalTrail.gov. NCT03036020 Unique Protocol ID: NASPP-2 Brief Title: The Norwegian Acute Stroke Prehospital Project Overall Status: Completed Primary Completion Date: January 2016 [Actual] Verification Date: January 2017
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Affiliation(s)
- Maren Ranhoff Hov
- The Norwegian Air Ambulance Foundation, Holterveien 24, 1448, Drøbak, Norway.
| | - Annette Ryen
- Department of Anaesthesiology, Østfold Hospital, Sarpsborg, Norway.,Department of Neurology, Østfold Hospital, Sarpsborg, Norway
| | - Katrine Finsnes
- The Norwegian Air Ambulance Foundation, Holterveien 24, 1448, Drøbak, Norway.,Department of Neurology, Østfold Hospital, Sarpsborg, Norway
| | - Janne Storflor
- Department of Neurology, Østfold Hospital, Sarpsborg, Norway
| | - Thomas Lindner
- The Norwegian Air Ambulance Foundation, Holterveien 24, 1448, Drøbak, Norway
| | | | - Christian Georg Lund
- The Norwegian Air Ambulance Foundation, Holterveien 24, 1448, Drøbak, Norway.,Department of Neurology, Oslo University Hospital, Rikshospitalet, Norway
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197
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Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JL. Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol 2017; 16:227-237. [PMID: 28229894 DOI: 10.1016/s1474-4422(17)30008-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/02/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.
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Affiliation(s)
- Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.
| | - James C Grotta
- Department of Neurology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Iris Q Grunwald
- Neuroscience and Vascular Simulation Unit, Faculty of Medical Science, PMI, Anglia Ruskin University, Chelmsford, UK; Department of Stroke Medicine, Southend University Hospital, Southend, UK
| | | | - Jeffrey L Saver
- Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
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198
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Schwamm LH, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K, Suter R, Zavala M, Polsky D, Radhakrishnan K, Lacktman N, Horton K, Malcarney MB, Halamka J, Tiner AC. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation 2017; 135:e24-e44. [DOI: 10.1161/cir.0000000000000475] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.
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199
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Affiliation(s)
- Patrik Michel
- From the Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Switzerland
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200
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Kim JT, Chung PW, Starkman S, Sanossian N, Stratton SJ, Eckstein M, Pratt FD, Conwit R, Liebeskind DS, Sharma L, Restrepo L, Tenser MK, Valdes-Sueiras M, Gornbein J, Hamilton S, Saver JL. Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity. Stroke 2017; 48:298-306. [DOI: 10.1161/strokeaha.116.015247] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/21/2016] [Accepted: 12/02/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region.
Methods—
We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy–Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals.
Results—
Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20–50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119–180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120–180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were
r
=0.49 for the prehospital LAMS and
r
=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale,
r
=−0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74–0.78); EPA LAMS, 0.85 (95% confidence interval 0.83–0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85–0.88).
Conclusions—
In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.
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Affiliation(s)
- Joon-Tae Kim
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Pil-Wook Chung
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Sidney Starkman
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Nerses Sanossian
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Samuel J. Stratton
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Marc Eckstein
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Frank D. Pratt
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Robin Conwit
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - David S. Liebeskind
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Latisha Sharma
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Lucas Restrepo
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - May-Kim Tenser
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Miguel Valdes-Sueiras
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Jeffrey Gornbein
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Scott Hamilton
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Jeffrey L. Saver
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
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