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Lopez-Rivera V, Salazar-Marioni S, Abdelkhaleq R, Savitz SI, Czap A, Alderazi Y, Chen PR, Grotta JC, Blackburn S, Jones W, Spiegel G, Dannenbaum MJ, Wu TC, Cochran J, Kim DH, Day AL, Farquhar G, McCullough LD, Sheth SA. Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes. Stroke 2021; 52:1022-1029. [PMID: 33535778 PMCID: PMC7902449 DOI: 10.1161/strokeaha.120.032710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. METHODS We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. RESULTS Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. CONCLUSIONS In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.
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Affiliation(s)
| | | | - Rania Abdelkhaleq
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Sean I. Savitz
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| | - Alexandra Czap
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Yazan Alderazi
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Peng R. Chen
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Spiros Blackburn
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Wesley Jones
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Gary Spiegel
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Mark J. Dannenbaum
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Tzu-Ching Wu
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Joseph Cochran
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Dong H. Kim
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Arthur L. Day
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | | | | | - Sunil A. Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
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152
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Abstract
PURPOSE Endovascular thrombectomy (EVT) significantly improves outcomes for acute ischemic stroke patients with large vessel occlusion (LVO) who present in a time sensitive manner. Prolonged EVT access times may reduce benefits for eligible patients. We evaluated the efficiency of EVT services including EVT rates, onset-to-CTA time and onset-to-groin puncture time in our province. MATERIALS AND METHODS Three areas were defined: zone I- urban region, zone II-areas within 1 h drive distance from the Comprehensive Stroke Center (CSC); and zone III-areas more than 1hr drive distance from the CSC. In this retrospective cohort study, EVT rate, onset-to-groin puncture time and onset-to-CTA time were compared among the three groups using Krustal-Wallis and Wilcoxon tests. RESULTS The EVT rate per 100,000 inhabitants for urban zone I was 8.6 as compared to 5.1 in zone II, and 7.5 in zone III. Compared to zone I (114 min; 95% CI (96, 132); n = 128), mean onset-to-CTA time was 19 min longer in zone II (133 min; 95% CI (77, 189); n = 23; p = 0.0459) and 103 min longer in zone III (217 min, 95% CI (162, 272); n = 44; p < 0.0001). Compared to zone I (209 min, 95% CI (181, 238)), mean onset-to-groin puncture time was 22 min longer in zone II (231 min, 95% CI (174, 288); p = 0.046) but 163 min longer in zone III (372 min, 95% CI (312, 432); p < 0.0001). CONCLUSION EVT access in rural areas is considerably reduced with significantly longer onset-to-groin puncture times and onset-to-CTA times when compared to our urban area. This may help in modifying the patient transfer policy for EVT referral.
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153
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Mazya MV, Berglund A, Ahmed N, von Euler M, Holmin S, Laska AC, Mathé JM, Sjöstrand C, Eriksson EE. Implementation of a Prehospital Stroke Triage System Using Symptom Severity and Teleconsultation in the Stockholm Stroke Triage Study. JAMA Neurol 2021; 77:691-699. [PMID: 32250423 DOI: 10.1001/jamaneurol.2020.0319] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance To our knowledge, it is unknown whether a prehospital stroke triage system combining symptom severity and teleconsultation could accurately select patients for primary stroke center bypass and hasten delivery of endovascular thrombectomy (EVT) without delaying intravenous thrombolysis (IVT). Objective To evaluate the predictive performance of the newly implemented Stockholm Stroke Triage System (SSTS) for large-artery occlusion (LAO) stroke and EVT initiation. Secondary objectives included evaluating whether the Stockholm Stroke Triage System shortened onset-to-puncture time for EVT and onset-to-needle time (ONT) for IVT. Design, Setting, and Participants This population-based prospective cohort study conducted from October 2017 to October 2018 across the Stockholm region (Sweden) included patients transported by first-priority ("code stroke") ambulance to the hospital for acute stroke suspected by an ambulance nurse and historical controls (October 2016-October 2017). Exclusion criteria were in-hospital stroke and helicopter or private transport. Of 2909 eligible patients, 4 (0.14%) declined participation. Exposures Patients were assessed by ambulance nurses with positive the face-arm-speech-time test or other stroke suspicion and were evaluated for moderate-to-severe hemiparesis (≥2 National Institutes of Health stroke scale points each on the ipsilateral arm and leg [A2L2 test]). If present, the comprehensive stroke center (CSC) stroke physician was teleconsulted by phone for confirmation of stroke suspicion, assessment of EVT eligibility, and direction to CSC or the nearest primary stroke center. If absent, the nearest hospital was prenotified. Main Outcomes and Measures Primary outcome: LAO stroke. Secondary outcomes: EVT initiation, onset-to-puncture time, and ONT. Predictive performance measures included sensitivity, specificity, positive and negative predictive values, the overall accuracy for LAO stroke, and EVT initiation. Results We recorded 2905 patients with code-stroke transports (1420 women [49%]), and of these, 323 (11%) had A2L2+ teleconsultation positive results and were triaged for direct transport to CSC (median age, 73 years [interquartile range (IQR), 64-82 years]; 55 women [48%]). Accuracy for LAO stroke was 87% (positive predictive value, 41%; negative predictive value, 93%) and 91% for EVT initiation (positive predictive value, 26%; negative predictive value, 99%). Endovascular thrombectomy was performed for 84 of 323 patients (26%) with triage-positive results and 35 of 2582 patients (1.4%) with triage-negative results. In EVT cases with a known onset time (77 [3%]), the median OPT was 137 minutes (IQR, 118-180; previous year, 206 minutes [IQR, 160-280]; n = 75) (P < .001). The regional median ONT (337 [12%]) was unchanged at 115 minutes (IQR, 83-164; previous year, 115 minutes [IQR, 85-161]; n = 360) (P = .79). The median CSC IVT door-to-needle time was 13 minutes (IQR, 10-18; 116 [4%]) (previous year, 31 minutes [IQR, 19-38]; n = 45) (P < .001). Conclusions and Relevance The Stockholm Stroke Triage System, which combines symptom severity and teleconsultation, results in markedly faster EVT delivery without delaying IVT.
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Affiliation(s)
- Michael V Mazya
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Berglund
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Clinical Pharmacology Unit, Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jan M Mathé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Capio St Göran Hospital, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Einar E Eriksson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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154
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Aldstadt J, Waqas M, Yasumiishi M, Mokin M, Tutino VM, Rai HH, Chin F, Levy BR, Rai AT, Mocco J, Snyder KV, Davies JM, Levy EI, Siddiqui AH. Mapping access to endovascular stroke care in the USA and implications for transport models. J Neurointerv Surg 2021; 14:neurintsurg-2020-016942. [PMID: 33593798 DOI: 10.1136/neurintsurg-2020-016942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive. METHODS Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated. RESULTS Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive. CONCLUSION Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.
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Affiliation(s)
- Jared Aldstadt
- National Center for Geographic Information and Analysis and Department of Geography, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Muhammad Waqas
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Misa Yasumiishi
- National Center for Geographic Information and Analysis and Department of Geography, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Maxim Mokin
- Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.,Neurosciences Center, Tampa General Hospital, Tampa, Florida, USA
| | - Vincent M Tutino
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,University at Buffalo Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Hamid H Rai
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Felix Chin
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Bennett R Levy
- (Medical school student), The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth V Snyder
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jason M Davies
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Bioinformatics and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Elad I Levy
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA .,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
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155
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Alexandrov AW, Fassbender K. Triage Based on Preclinical Scores-Low-Cost Strategy for Accelerating Time to Thrombectomy. JAMA Neurol 2021; 77:681-682. [PMID: 32250425 DOI: 10.1001/jamaneurol.2020.0113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anne W Alexandrov
- Mobile Stroke Unit, The University of Tennessee Health Science Center, Memphis
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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156
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Dagonnier M, Donnan GA, Davis SM, Dewey HM, Howells DW. Acute Stroke Biomarkers: Are We There Yet? Front Neurol 2021; 12:619721. [PMID: 33633673 PMCID: PMC7902038 DOI: 10.3389/fneur.2021.619721] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Distinguishing between stroke subtypes and knowing the time of stroke onset are critical in clinical practice. Thrombolysis and thrombectomy are very effective treatments in selected patients with acute ischemic stroke. Neuroimaging helps decide who should be treated and how they should be treated but is expensive, not always available and can have contraindications. These limitations contribute to the under use of these reperfusion therapies. Aim: An alternative approach in acute stroke diagnosis is to identify blood biomarkers which reflect the body's response to the damage caused by the different types of stroke. Specific blood biomarkers capable of differentiating ischemic from hemorrhagic stroke and mimics, identifying large vessel occlusion and capable of predicting stroke onset time would expedite diagnosis and increase eligibility for reperfusion therapies. Summary of Review: To date, measurements of candidate biomarkers have usually occurred beyond the time window for thrombolysis. Nevertheless, some candidate markers of brain tissue damage, particularly the highly abundant glial structural proteins like GFAP and S100β and the matrix protein MMP-9 offer promising results. Grouping of biomarkers in panels can offer additional specificity and sensitivity for ischemic stroke diagnosis. Unbiased “omics” approaches have great potential for biomarker identification because of greater gene, protein, and metabolite coverage but seem unlikely to be the detection methodology of choice because of their inherent cost. Conclusion: To date, despite the evolution of the techniques used in their evaluation, no individual candidate or multimarker panel has proven to have adequate performance for use in an acute clinical setting where decisions about an individual patient are being made. Timing of biomarker measurement, particularly early when decision making is most important, requires urgent and systematic study.
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Affiliation(s)
- Marie Dagonnier
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Department of Neurology, Ambroise Paré Hospital, Mons, Belgium
| | - Geoffrey A Donnan
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Helen M Dewey
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - David W Howells
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Faculty of Health, School of Medicine, University of Tasmania, Hobart, TAS, Australia
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157
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Yu AT, Regenhardt RW, Whitney C, Schwamm LH, Patel AB, Stapleton CJ, Viswanathan A, Hirsch JA, Lev M, Leslie-Mazwi TM. CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals. AJNR Am J Neuroradiol 2021; 42:435-440. [PMID: 33541900 DOI: 10.3174/ajnr.a6950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/03/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns. MATERIALS AND METHODS A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy. RESULTS There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011). CONCLUSIONS Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.
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Affiliation(s)
- A T Yu
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - R W Regenhardt
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - C Whitney
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - L H Schwamm
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - A B Patel
- Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
| | | | - A Viswanathan
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - J A Hirsch
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - M Lev
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - T M Leslie-Mazwi
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.).,Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
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158
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Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, Duijndam D, Koster GT, de Schryver ELLM, Kloos LMH, de Laat KF, Aerden LAM, Zylicz SA, Wermer MJH, Kruyt ND. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78:157-164. [PMID: 33252631 DOI: 10.1001/jamaneurol.2020.4418] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. Objective To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. Design, Setting, and Participants This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Exposures Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Main Outcomes and Measures Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Results Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. Conclusions and Relevance This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.
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Affiliation(s)
- T Truc My Nguyen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
| | - Jan Bosch
- Emergency Medical Services Hollands-Midden, Leiden, the Netherlands
| | - Eduard van Belle
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Dion Duijndam
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Gaia T Koster
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands
| | | | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis Hospital, Delft, the Netherlands
| | - Stas A Zylicz
- Department of Neurology, Langeland Hospital, Zoetermeer, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
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159
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Hiu T, Morimoto S, Matsuo A, Satoh K, Otsuka H, Kutsuna F, Ozono K, Hirayama K, Nakamichi C, Yamasaki K, Ogawa Y, Shiozaki E, Morofuji Y, Kawahara I, Horie N, Tateishi Y, Ono T, Haraguchi W, Izumo T, Tsujino A, Matsuo T, Tsutsumi K. Current status of a helicopter transportation system on remote islands for patients undergoing mechanical thrombectomy. PLoS One 2021; 16:e0245082. [PMID: 33465116 PMCID: PMC7815141 DOI: 10.1371/journal.pone.0245082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is standard treatment for acute ischemic stroke (AIS) with large-vessel occlusion within 6 h of symptom onset to treatment initiation (OTP). Recent trials have extended the therapeutic time window for MT to within 24 h. However, MT treatment remains low in remote areas. Nagasaki Prefecture, Japan has many inhabited islands with no neurointerventionalists. Our hospital on the mainland is a regional hub for eight island hospitals. We evaluated clinical outcomes of MT for patients with AIS on these islands versus on the mainland. METHODS During 2014-2019, we reviewed consecutive patients with AIS who received MT at our hospital. Patients comprised the Islands group and Mainland group. Patient characteristics and clinical outcomes were compared between groups. RESULTS We included 91 patients (Islands group: 15 patients, Mainland group: 76 patients). Seven patients (46.7%) in the Islands group versus 43 (56.6%) in the Mainland group achieved favorable outcomes. Successful recanalization was obtained in 11 patients (73.3%) on the islands and 67 (88.2%) on the mainland. The median OTP time in the Islands was 365 min. In both the Islands and Mainland groups, the OTP time and successful recanalization were associated with functional outcome. The modified Rankin Scale (mRS) score at 90 days ≤2 was obtained in two patients and mRS = 3 in four patients among eight patients with OTP time >6 h. CONCLUSIONS Few patients with AIS on remote islands have received MT. Although patients who underwent MT on the islands had longer OTP, the clinical outcomes were acceptable. OTP time on remote islands must be shortened, as this is related to functional outcome. In some cases with successful recanalization, a favorable outcome can still be obtained even after 6 h. Even if OTP exceeds 6 h, it is desirable to appropriately select patients and actively perform MT.
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Affiliation(s)
- Takeshi Hiu
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- * E-mail:
| | - Shimpei Morimoto
- Innovation Platform & Office for Precision Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Ayaka Matsuo
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kei Satoh
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Hiroaki Otsuka
- Department of Neurology, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Fumiya Kutsuna
- Department of Neurology, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Keisuke Ozono
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kosuke Hirayama
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Chikaaki Nakamichi
- Department of Emergency, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kazumi Yamasaki
- Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Yuka Ogawa
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Eri Shiozaki
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Ichiro Kawahara
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yohei Tateishi
- Department of Neurology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomonori Ono
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Wataru Haraguchi
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akira Tsujino
- Department of Neurology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Keisuke Tsutsumi
- Department of Neurosurgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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160
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Boltyenkov AT, Wang JJ, Malhotra A, Katz JM, Martinez G, Sanelli PC. Early Thrombectomy Outcomes in Transfer Patients. Air Med J 2021; 40:102-107. [PMID: 33637271 DOI: 10.1016/j.amj.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/15/2020] [Accepted: 12/30/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The optimal patient transportation destination of acute ischemic stroke (AIS) patients remains uncertain. The purpose of this study was to evaluate the predictive variables that determine stroke outcomes depending on the patient transportation destination. METHODS We performed a retrospective study using an AIS database consisting of patients who underwent thrombectomy admitted to our institution from November 1, 2011, through October 1, 2018. RESULTS A total of 171 patients were included in the statistical analysis; 42.1% (72/171) of patients were in the mothership group (directly admitted) and 57.9% (99/171) in the drip-and-ship group (transferred). Multivariable logistic regression revealed the predictive factors for favorable outcomes were driving distance (expressed in miles) between the patient's home and a comprehensive stroke center (CSC) (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.90-0.99; P = .035), absence of diabetes mellitus (OR = 3.60; 95% CI, 1.20-10.82; P = .022), lower National Institutes of Health Stroke Scale score at admission (OR = 0.91; 95% CI, 0.85-0.97; P = .003), and shorter symptom onset to CSC arrival time (expressed in hours) (OR = 0.84; 95% CI, 0.72-0.99; P = .038). CONCLUSIONS Our study revealed that a shorter driving distance between the patient's home and CSC, absence of diabetes, lower National Institutes of Health Stroke Scale score, and shorter onset to hospital arrival time positively impacted the outcomes of endovascularly treated AIS patients.
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Affiliation(s)
- Artem T Boltyenkov
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Siemens Medical Solutions USA Inc., Malvern, PA.
| | - Jason J Wang
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Siemens Medical Solutions USA Inc., Malvern, PA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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161
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Wu TC, Ankrom C, Joseph M, Trevino A, Zhu L, Warach S, Novakovic RR, Goldberg MP, Birnbaum LA, Mir O, Rodriguez GJ, Alderazi YJ, Hassan AE, Savitz SI. IAT-TiMeS: Intra-Arterial Thrombectomy Transfer Metric Study in Texas. J Stroke Cerebrovasc Dis 2021; 30:105602. [PMID: 33461026 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE We aim to report intra-arterial thrombectomy transfer metrics for ischemic stroke patients that were transferred to hub hospitals for possible intra-arterial thrombectomy in multiple geographic regions throughout the state of Texas and to identify potential barriers and delays in the intra-arterial thrombectomy transfer process. METHOD We prospectively collected data from 8 participating Texas comprehensive stroke/thrombectomy capable centers from 7 major regions in the State of Texas. We collected baseline clinical and imaging data related to the pre-transfer evaluation, transfer metrics, and post-transfer clinical and imaging data. RESULTS A total of 103 acute ischemic stroke patients suspected/confirmed to have large vessel occlusions between December 2016 to May 2019 that were transferred to hubs as possible intra-arterial thrombectomy candidates were enrolled. A total of 56 (54%) patients were sent from the spoke to the hub via ground ambulance with 47 (46%) patients traveling via air ambulance. The median spoke arrival to hub arrival time was 174 min, median spoke arrival to departure from spoke was 131 min, and median travel time was 39 min. The spoke arrival time to transfer initiation was 68 min. CT-perfusion obtained at the spoke and earlier initiation of transfer were statistically associated with shorter transfer times. CONCLUSION Transfer of intra-arterial thrombectomy patients in Texas may take over 4 h from spoke arrival to hub arrival. This time may be shortened by earlier transfer initiation and acceptance.
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Affiliation(s)
- Tzu-Ching Wu
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Christy Ankrom
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Michele Joseph
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Alyssa Trevino
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Liang Zhu
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Steven Warach
- Dell Medical School, The University of Texas at Austin, Austin, Texas, USA.
| | - Roberta R Novakovic
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas, USA.
| | - Mark P Goldberg
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas, USA.
| | - Lee A Birnbaum
- Department of Neurology, The University of Texas Health Science Center at San Antonio, Texas, USA.
| | - Osman Mir
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Science Center, El Paso, Texas, USA.
| | - Yazan J Alderazi
- Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
| | - Ameer E Hassan
- Department of Neuroscience, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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162
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Goyal M, Ospel JM. Adapting pre-hospital stroke triage systems to expanding thrombectomy indications. Neuroradiology 2021; 63:161-166. [PMID: 33439296 DOI: 10.1007/s00234-021-02638-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada. .,Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.
| | - Johanna M Ospel
- , Calgary, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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163
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Mano Y, Suzuki I, Ishikawa S, Katsuki M, Suzuki R, Ichikawa T, Kato Y, Sato R, Toyoshima M, Kato K, Narikawa K, Oikawa T, Tominaga T. Rapid Treatment of Acute Ischemic Stroke Using a Computed Tomography-Based Reperfusion Protocol: The Reality of a Local Community Hospital with Limited Resources. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:525-532. [PMID: 37502760 PMCID: PMC10370583 DOI: 10.5797/jnet.oa.2020-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/08/2020] [Indexed: 07/29/2023]
Abstract
Objective In patients with acute ischemic stroke (AIS), prognosis strongly depends on the onset-to-recanalization time. The Ishinomaki protocol for rapid recanalization has been used since October 2017. This protocol determines the indication for reperfusion therapy based on computed tomography (CT)/three-dimensional CT angiography (3DCTA) findings and intends to reduce the onset-to-recanalization time. We aimed to compare the outcomes before and after protocol introduction. Methods Our hospital is the only thrombectomy-capable center in Ishinomaki, Tome, and Kesennuma medical area. Before protocol introduction (April 2014-June 2016), both CT and magnetic resonance imaging were performed to determine the indications for intravenous (IV) recombinant tissue-plasminogen activator (rt-PA) or mechanical thrombectomy within 6 hours of disease onset. However, after protocol introduction (from October 2017), plain CT and 3DCTA were used. We collected data on patients who underwent mechanical thrombectomy and/or IV rt-PA before (n = 13) and after (n = 34) the protocol introduction. The required time from onset to door (OTD), door to needle (DTN), needle to puncture (NTP), puncture to recanalization (PTR), and door to recanalization (DTR) were compared before and after protocol introduction. Furthermore, thrombolysis in cerebral infarction (TICI) grades and modified Rankin scale (mRS) scores at discharge were compared. Results The outcomes before and after protocol introduction were as follows: OTD: 105 ± 73.8 (mean ± standard deviation) vs. 120 ± 68.1 min (p = 0.376, Mann-Whitney U test); DTN: 62.9 ± 15.9 vs. 41 ± 17 min (p <0.01); NTP: 112 ± 69.8 vs. 39.9 ± 33.7 min (p <0.01); PTR: 87.9 ± 45.4 vs. 52.5 ± 27.9 min (p <0.01); and DTR, 230 ± 69.9 vs. 110 ± 40.3 min (p <0.0001). Before and after protocol introduction, the proportion of patients with TICI grade 2b-3, mRS score of 0-2 at discharge, and mRS score of 5-6 were 54% vs. 50% (p = 0.815, Fisher's exact test), 23% vs. 21% (p = 0.854), and 15% vs. 50% (p = 0.046), respectively. Conclusion The Ishinomaki protocol reduced the mean DTR time by 120 min. The reduction in treatment time was due to the change in CT-based recanalization and collaboration with emergency physicians and paramedics. There was no increase in good outcomes, but there was a significant increase in poor outcomes at discharge. Patients who could not be salvaged were indicated for reperfusion therapy as CT and 3DCTA cannot detect the ischemic core.
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Affiliation(s)
- Yui Mano
- Department of Neurosurgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Ichiro Suzuki
- Department of Neurosurgery, Hachinohe City Hospital, Hachinohe, Aomori, Japan
| | - Syuichi Ishikawa
- Department of Neurosurgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Masahito Katsuki
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Ryutaro Suzuki
- Department of Neurosurgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Takaki Ichikawa
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Yuji Kato
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Ryosuke Sato
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Masaya Toyoshima
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Kazuhiro Kato
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Koichi Narikawa
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Takanori Oikawa
- Department of Neurology, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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164
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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165
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Scheving WL, Froehler M, Hart K, McNaughton CD, Ward MJ. Inter-facility transfer for patients with acute large vessel occlusion stroke receiving mechanical thrombectomy. Am J Emerg Med 2021; 39:132-136. [PMID: 33039216 PMCID: PMC7736132 DOI: 10.1016/j.ajem.2020.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/29/2020] [Accepted: 09/16/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the preferred treatment for large vessel occlusion (LVO) ischemic stroke, and neurological outcome improves with earlier treatment. Patients with LVO frequently require inter-facility transfer to access MT but delays at transferring EDs may worsen neurological outcomes. METHODS We conducted a retrospective observational study to evaluate the association of time spent and transferring EDs with 90-day neurological outcomes among patients who were transferred from an outside ED to the Comprehensive Stroke Center and received MT. Time intervals at transferring EDs were examined descriptively, and multivariable logistic regression modeling was used to examine the association of time spent in the ED with 90-day neurologic outcome (modified Rankin Scale; good ≤2, poor ≥3). RESULTS Among 111 patients transferred to a stroke center for MT between 2013 and 2017, the time between CT scan and the stroke center transfer request was 44 (IQR 27,65) minutes, or 47% of transferring ED total duration. Duration at the transferring ED was not significantly associated with 90-day outcome. Only NIH Stroke Scale at the time of arrival to the stroke center was associated with good 90-day neurological outcome (aOR 0.84, 95%CI 0.77, 0.92, p < 0.0001). CONCLUSIONS Among LVO patients transferred for MT, the total time spent at transferring EDs was not associated with 90-day neurologic outcome in patients with LVO. As therapies and their associated effectiveness improves over time, future investigations should further characterize the time between CT and transfer request to identify targets for process improvement and clinical outcomes.
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Affiliation(s)
- William L Scheving
- University of California at Los Angeles School of Medicine, Department of Emergency Medicine, Los Angeles, CA, USA.
| | - Michael Froehler
- Vanderbilt University Medical Center, Department of Neurology, Nashville, TN, USA.
| | - Kimberly Hart
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN, USA.
| | - Candace D McNaughton
- Vanderbilt University Medical Center, Department of Emergency Medicine. Geriatric Research Education and Clinical Centers (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Michael J Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine. VA Tennessee Valley Healthcare System, 1313 21st Ave. S. Nashville, TN 37232, USA.
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166
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Triage and systems of care in stroke. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:401-407. [PMID: 33272408 DOI: 10.1016/b978-0-444-64034-5.00018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There has been increasing adoption of endovascular stroke treatment in the United States following multiple clinical trials demonstrating superior efficacy. Next steps in enhancing this treatment include an analysis and development of stroke systems of care geared toward efficient delivery of endovascular and comprehensive stroke care. The chapter presents epidemiological data and an overview of the current state of stroke delivery and potential improvements for the future in the light of clinical data.
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167
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Abstract
BACKGROUND AND PURPOSE Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. METHODS Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. RESULTS Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0-61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. CONCLUSIONS The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.
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168
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Deeds SI, Barreto A, Elm J, Derdeyn CP, Berry S, Khatri P, Moy C, Janis S, Broderick J, Grotta J, Adeoye O. The multiarm optimization of stroke thrombolysis phase 3 acute stroke randomized clinical trial: Rationale and methods. Int J Stroke 2020; 16:873-880. [PMID: 33297893 DOI: 10.1177/1747493020978345] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator is the only proven effective medication for the treatment of acute ischemic stroke. Two approaches that may augment recombinant tissue plasminogen activator thrombolysis and prevent arterial reocclusion are direct thrombin inhibition with argatroban and inhibition of the glycoprotein 2b/3a receptor with eptifibatide. AIM The multi-arm optimization of stroke thrombolysis trial aims to determine the safety and efficacy of intravenous therapy with argatroban or eptifibatide as compared with placebo in acute ischemic stroke patients treated with intravenous recombinant tissue plasminogen activator within 3 h of symptom onset. SAMPLE SIZE ESTIMATE A maximum of 1200 randomized subjects to test the superiority of argatroban or eptifibatide to placebo in improving 90-day modified Rankin scores. METHODS AND DESIGN Multiarm optimization of stroke thrombolysis is a multicenter, multiarm, adaptive, single blind, randomized controlled phase 3 clinical trial conducted within the National Institutes of Health StrokeNet clinical trial network. Patients treated with 0.9 mg/kg intravenous recombinant tissue plasminogen activator within 3 h of stroke symptom onset are randomized to receive intravenous argatroban (100 µg/kg bolus followed by 3 µg/kg/min for 12 h), intravenous eptifibatide (135 µg/kg bolus followed by 0.75 µg/kg/min infusion for 2 h) or IV placebo. Patients may receive endovascular thrombectomy per usual care. STUDY OUTCOMES The primary efficacy outcome is improved modified Rankin score assessed at 90 days post-randomization. DISCUSSION Multiarm optimization of stroke thrombolysis is an innovative and collaborative project that is the culmination of many years of dedicated efforts to improve outcomes for stroke patients.
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Affiliation(s)
- S Iris Deeds
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Andrew Barreto
- Department of Neurology, University of Texas Health Science Center, Houston, TX, USA
| | - Jordan Elm
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA
| | - Claudia Moy
- 35046National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Scott Janis
- 35046National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Joseph Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA.,UC Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - James Grotta
- Memorial Hermann Hospital - Texas Medical Center, Houston, TX, USA
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
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169
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Abstract
PURPOSE OF REVIEW Abrupt blood pressure (BP) rise is the most common clinical symptom of acute ischemic stroke (AIS). However, BP alterations during AIS reflect many diverse mechanisms, both stroke-related and nonspecific epiphenomena, which change over time and across patients. While extremes of BP as well as high BP variability have been related with worse outcomes in observational studies, optimal BP management after AIS remains challenging. RECENT FINDINGS This review discusses the complexity of the factors linking BP changes to the clinical outcomes of patients with AIS, depending on the treatment strategy and local vessel status and, in particular, the degree of reperfusion achieved. The evidence for possible additional clinical markers, including the presence of arterial hypertension, and comorbid organ dysfunction in individuals with AIS, as informative and helpful factors in therapeutic decision-making concerning BP will be reviewed, as well as recent data on neurovascular monitoring targeting person-specific local cerebral perfusion and metabolic demand, instead of the global traditional parameters (BP among others) alone. The individualization of BP management protocols based on a complex evaluation of the homeostatic response to focal cerebral ischemia, including but not limited to BP changes, may be a valuable novel goal proposed in AIS, but further trials are warranted.
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Affiliation(s)
- Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland.
| | - Mariusz Kwarciany
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
| | - Kamil Kowalczyk
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
| | - Bartosz Karaszewski
- Department of Adult Neurology, Medical University of Gdańsk, ul, Dębinki 7, 80-952, Gdańsk, Poland
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170
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Morey JR, Oxley TJ, Wei D, Kellner CP, Dangayach NS, Stein L, Hom D, Wheelwright D, Rubenstein L, Skliut M, Shoirah H, De Leacy RA, Singh IP, Zhang X, Persaud S, Tuhrim S, Dhamoon M, Bederson J, Mocco J, Fifi JT, Boniece IR, Brockington CD, Fara M, Hao Q, Horowitz DR, Lay C, Liang J, Nasrallah EJ, Roche T, Sheinart KF, Paul Singh I, Tegtmeyer C, Weinberger J. Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke. Stroke 2020; 51:3495-3503. [DOI: 10.1161/strokeaha.120.030248] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose:
Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models.
Methods:
This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months.
Results:
MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes (
P
<0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively (
P
=0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%;
P
<0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS (
P
=0.10).
Conclusions:
MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03048292.
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Affiliation(s)
- Jacob R. Morey
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Thomas J. Oxley
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Daniel Wei
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Christopher P. Kellner
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Neha S. Dangayach
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Laura Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Danny Hom
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Danielle Wheelwright
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Liorah Rubenstein
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Maryna Skliut
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Hazem Shoirah
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Reade A. De Leacy
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - I. Paul Singh
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Xiangnan Zhang
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Steven Persaud
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Joshua Bederson
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - J Mocco
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Johanna T. Fifi
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
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171
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Kircher C, Humphries A, Kleindorfer D, Alwell K, Sucharew H, Moomaw CJ, Mackey J, De Los Rios La Rosa F, Kissela B, Adeoye O. Can non-contrast head CT and stroke severity be used for stroke triage? A population-based study. Am J Emerg Med 2020; 38:2650-2652. [PMID: 33041149 DOI: 10.1016/j.ajem.2020.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/19/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke (AIS) patients may benefit from endovascular thrombectomy (EVT) up to 24 h since last known normal (LKN). Advanced imaging is required for patient selection. Small or rural hospitals may not have sufficient CT technician and radiology support to rapidly acquire and interpret images. We estimated transfer rates using non-contrast head CT and stroke severity to select patients to be transferred to larger centers for evaluation. METHODS We identified all AIS among residents of the study region in 2010. Only cases age ≥ 18 with baseline mRS 0-2 that presented to an ED were included. Among cases that presented between 6 and 24 h from LKN, those without evidence of acute infarct on head CT and with initial NIHSS ≥6 or ≥ 10 were identified. RESULTS Of 1359 AIS cases, 448 (33.0%) presented between 6 and 24 h, of which 383 (85.5%) showed no evidence of acute infarct on CT. Of cases with no acute infarct on CT, 89/383 (23.2%) had NIHSS ≥6, of which 66 (74.2%) initially presented to a hospital without thrombectomy capabilities; and 51/383 (13.3%) had NIHSS ≥10, of which 40 (78.4%) presented to a non-thrombectomy hospital. CONCLUSIONS In our population, 40-66 AIS patients annually (0.8-1.3/week, or 3-5 patients/100,000 persons/year) may present to non-thrombectomy hospitals and need to be transferred using non-contrast CT and stroke severity as screening tools. Such an approach may sufficiently mitigate the impact of delays in treatment on outcomes, without overburdening the referring nor accepting hospitals.
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Affiliation(s)
- Charles Kircher
- University of Cincinnati (UC) Gardner Neuroscience Institute, Division of Neurocritical Care, Cincinnati OH, United States of America; UC Department of Emergency Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45229, United States of America.
| | - Amanda Humphries
- University of New Mexico School of Medicine, Department of Emergency Medicine, Albuquerque, NM, United States of America
| | - Dawn Kleindorfer
- University of Michigan Department of Neurology, Ann Arbor, MI, United States of America
| | - Kathleen Alwell
- UC Gardner Neuroscience Institute, Department of Neurology and Rehabilitation Medicine, United States of America
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 5041, Cincinnati, OH 45229-3039, United States of America; Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Charles J Moomaw
- UC Gardner Neuroscience Institute, Department of Neurology and Rehabilitation Medicine, United States of America
| | - Jason Mackey
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Felipe De Los Rios La Rosa
- UC Gardner Neuroscience Institute, Department of Neurology and Rehabilitation Medicine, United States of America; Baptist Health Neuroscience Center, Miami, FL, United States of America
| | - Brett Kissela
- UC Gardner Neuroscience Institute, Department of Neurology and Rehabilitation Medicine, United States of America
| | - Opeolu Adeoye
- University of Cincinnati (UC) Gardner Neuroscience Institute, Division of Neurocritical Care, Cincinnati OH, United States of America; UC Department of Emergency Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45229, United States of America
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172
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Ngiam NJH, Tan BYQ, Sia CH, Chan BPL, Anil G, Cunli Y, Holmin S, Anderssen T, Poh KK, Yeo LLL, Sharma VK. Significant aortic stenosis associated with poorer functional outcomes in patients with acute ischaemic stroke undergoing endovascular therapy. Interv Neuroradiol 2020; 26:793-799. [PMID: 32340516 PMCID: PMC7724604 DOI: 10.1177/1591019920920988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/15/2020] [Accepted: 03/30/2020] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND AND AIM Bi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke. METHODS Consecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm2) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months. RESULTS We identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68-84) vs. 67 (interquartile range 56-75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1-7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation. CONCLUSION In acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.
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Affiliation(s)
- Nicholas JH Ngiam
- Division of Neurology, Department of Medicine, National
University Health System, Singapore, Singapore
| | - Benjamin YQ Tan
- Division of Neurology, Department of Medicine, National
University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of
Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of
Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre
Singapore, National University Health System, Singapore, Singapore
| | - Bernard PL Chan
- Division of Neurology, Department of Medicine, National
University Health System, Singapore, Singapore
| | - Gopinathan Anil
- Yong Loo Lin School of Medicine, National University of
Singapore, Singapore, Singapore
- Division of Interventional Radiology, Department of Diagnostic
Imaging, National University Health System, Singapore, Singapore
| | - Yang Cunli
- Division of Interventional Radiology, Department of Diagnostic
Imaging, National University Health System, Singapore, Singapore
| | - Staffan Holmin
- Deparment of Neuroradiology, Karolinska University Hospital and
Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tommy Anderssen
- Deparment of Neuroradiology, Karolinska University Hospital and
Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kian-Keong Poh
- Yong Loo Lin School of Medicine, National University of
Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre
Singapore, National University Health System, Singapore, Singapore
| | - Leonard LL Yeo
- Division of Neurology, Department of Medicine, National
University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of
Singapore, Singapore, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National
University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of
Singapore, Singapore, Singapore
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173
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Coughlan D, McMeekin P, Flynn D, Ford GA, Lumley H, Burgess D, Balami J, Mawson A, Craig D, Rice S, White P. Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations. Emerg Med J 2020; 38:33-39. [PMID: 33172878 PMCID: PMC7788185 DOI: 10.1136/emermed-2019-209039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 08/16/2020] [Accepted: 08/27/2020] [Indexed: 11/22/2022]
Abstract
Background Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services (HEMS) compared with ground emergency medical services (GEMS) of rural patients eligible for MT in England. Methods The model consisted of (1) a short-run decision tree with two branches, representing secondary transfer transportation strategies and (2) a long-run Markov model for a theoretical population of rural patients with a confirmed ischaemic stroke. Strategies were compared by lifetime costs: quality-adjusted life years (QALYs), incremental cost per QALY gained and net monetary benefit. Sensitivity and scenario analyses explored uncertainty around parameter values. Results We used the base case of early-presenting (<6 hours to arterial puncture) patient aged 75 years who had stroke to compare HEMS and GEMS. This produced an incremental cost-effectiveness ratio (ICER) of £28 027 when a 60 min reduction in travel time was assumed. Scenario analyses showed the importance of the reduction in travel time and futile transfers in lowering ICERs. For late presenting (>6 hours to arterial puncture), ground transportation is the dominant strategy. Conclusion Our model indicates that using HEMS to transfer patients who had stroke eligible for MT from remote hospitals in England may be cost-effective when: travel time is reduced by at least 60 min compared with GEMS, and a £30 000/QALY threshold is used for decision-making. However, several other logistic considerations may impact on the use of air transportation.
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Affiliation(s)
- Diarmuid Coughlan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK.,Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Hannah Lumley
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - David Burgess
- North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK
| | - Joyce Balami
- Kellogg College, University of Oxford, Oxford, UK
| | - Andrew Mawson
- Great North Air Ambulance, Northumberland Wing, The Imperial Centre, Darlington, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
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174
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Kang J, Kim SE, Park HK, Cho YJ, Kim JY, Lee KJ, Park JM, Park KY, Lee KB, Lee SJ, Lee JS, Lee J, Yang KH, Choi AR, Kang MY, Choi NC, Gorelick PB, Bae HJ. Routing to Endovascular Treatment of Ischemic Stroke in Korea: Recognition of Need for Process Improvement. J Korean Med Sci 2020; 35:e347. [PMID: 33107228 PMCID: PMC7590651 DOI: 10.3346/jkms.2020.35.e347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/19/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To track triage, routing, and treatment status regarding access to endovascular treatment (EVT) after acute ischemic stroke (AIS) at a national level. METHODS From national stroke audit data, potential candidates for EVT arriving within 6 hours with National Institute of Health Stroke Scale score of ≥ 7 were identified. Acute care hospitals were classified as thrombectomy-capable hospitals (TCHs, ≥ 15 EVT cases/year) or primary stroke hospital (PSH, < 15 cases/year), and patients' initial routes and subsequent inter-hospital transfer were described. Impact of initial routing to TCHs vs. PSHs on EVT and clinical outcomes were analyzed using multilevel generalized mixed effect models. RESULTS Out of 14,902 AIS patients, 2,180 (14.6%) were EVT candidates. Eighty-one percent of EVT candidates were transported by ambulance, but only one-third were taken initially to TCHs. Initial routing to TCHs was associated with greater chances of receiving EVT compared to initial routing to PSHs (33.3% vs 12.1%, P < 0.001; adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.59-2.92) and favorable outcome (38.5% vs. 28.2%, P < 0.001; aOR, 1.52; 95% CI, 1.16-2.00). Inter-hospital transfers to TCHs occurred in 17.4% of those initially routed to a PSH and was associated with the greater chance of EVT compared to remaining at PSHs (34.8% vs. 7.5%, P < 0.001), but not with better outcomes. CONCLUSION Two-thirds of EVT candidates were initially routed to PSHs despite greater chance of receiving EVT and having favorable outcomes if routed to a TCH in Korea. Process improvement is needed to direct appropriate patients to TCHs.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Seong Eun Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hong Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Yong Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Jun Yup Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Keon Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ah Rum Choi
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Mi Yeon Kang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Nack Cheon Choi
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea.
| | - Philip B Gorelick
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hee Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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175
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Wang J, Zhang W, Ma B, Zhang H, Fan Z, Li M, Li X. A novel biscoumarin derivative dephosphorylates ERK and alleviates apoptosis induced by mitochondrial oxidative damage in ischemic stroke mice. Life Sci 2020; 264:118499. [PMID: 33141045 DOI: 10.1016/j.lfs.2020.118499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022]
Abstract
AIM We previously reported the protective effects of biscoumarin derivatives against oxidative stress, but effects of the derivative on mitochondrial oxidative damage induced apoptosis in ischemic stroke remains unknown. METHODS Primary neurons were subjected to oxygen and glucose deprivation (OGD) for the in vitro simulation of ischemic stroke, and an ischemic stroke model was established in mice by operation of middle cerebral artery occlusion (MCAO). RESULTS The results indicated that the nontoxic concentration range of biscoumarin derivative Comp. B in neurons was from 0 to 30 μg/ml and the optimal protective concentration was 20 μg/ml. Treatment with Comp. B increased the cell survival rate and alleviated mitochondrial oxidative damage and apoptosis in OGD-treated neurons. Comp. B reduced the ratio of Bax/Bcl-2, inhibited the phosphorylation of ERK, and thus alleviated apoptosis in OGD-treated neurons. Further research demonstrated that the dephosphorylation effect on ERK of Comp. B is a key factor in alleviating apoptosis in neurons induced by OGD injury. Furthermore, Comp. B reduced the infarct volume, improved neurobehavioural score, and alleviated morphological changes and brain apoptosis in MCAO mice. CONCLUSION The novel biscoumarin derivative Comp. B alleviates mitochondrial oxidative damage and apoptosis in ischemic stroke mice. These findings might provide new insights that will aid in elucidating the effect of biscoumarin derivative against cerebral ischemic reperfusion injury and support the new development of Comp. B as a potential treatment for ischemic stroke.
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Affiliation(s)
- Jun Wang
- Department of Digestive Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Wentong Zhang
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Bo Ma
- Department of Pharmacology, The Fourth Military Medical University, Xi'an, China
| | - Hongchen Zhang
- Department of Neurosurgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhaoyang Fan
- Department of Pharmacology, The Fourth Military Medical University, Xi'an, China
| | - Mingkai Li
- Department of Pharmacology, The Fourth Military Medical University, Xi'an, China.
| | - Xia Li
- Department of Neurosurgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
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176
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Maas WJ, Lahr MMH, Buskens E, van der Zee DJ, Uyttenboogaart M. Pathway Design for Acute Stroke Care in the Era of Endovascular Thrombectomy: A Critical Overview of Optimization Efforts. Stroke 2020; 51:3452-3460. [PMID: 33070713 DOI: 10.1161/strokeaha.120.030392] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The efficacy of intravenous thrombolysis and endovascular thrombectomy (EVT) for acute ischemic stroke is highly time dependent. Optimal organization of acute stroke care is therefore important to reduce treatment delays but has become more complex after the introduction of EVT as regular treatment for large vessel occlusions. There is no singular optimal organizational model that can be generalized to different geographic regions worldwide. Current dominant organizational models for EVT include the drip-and-ship- and mothership model. Guidelines recommend routing of suspected patients with stroke to the nearest intravenous thrombolysis capable facility; however, the choice of routing to a certain model should depend on regional stroke service organization and individual patient characteristics. In general, design approaches for organizing stroke care are required, in which 2 key strategies could be considered. The first entails the identification of interventions within existing organizational models for optimizing timely delivery of intravenous thrombolysis and/or EVT. This includes adaptive patient routing toward a comprehensive stroke center, which focuses particularly on prehospital triage tools; bringing intravenous thrombolysis or EVT to the location of the patient; and expediting services and processes along the stroke pathway. The second strategy is to develop analytical or simulation model-based approaches enabling the design and evaluation of organizational models before their implementation. Organizational models for acute stroke care need to take regional and patient characteristics into account and can most efficiently be assessed and optimized through the application of model-based approaches.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Maarten Uyttenboogaart
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands
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177
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Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke 2020; 51:3310-3319. [PMID: 33023425 PMCID: PMC7587242 DOI: 10.1161/strokeaha.120.031144] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose: Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States. Methods: We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies: (1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Rankin Scale score of >2). Results: Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 [65%]), followed by the algorithm with <60 minutes delay (n=10 [20%]). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31). Conclusions: Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.
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Affiliation(s)
- Esmee Venema
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, MI (J.F.B.)
| | - Bob Roozenbeek
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (B.R.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
| | - Hester F Lingsma
- Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
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178
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Lee MK, Yih Y, Griffin PM. Quantifying the Impact of Acute Stroke System of Care Transfer Protocols on Patient Outcomes. Med Decis Making 2020; 40:873-884. [PMID: 33000686 DOI: 10.1177/0272989x20946694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We quantify the impact of implementing a stroke system of care requiring transport of individuals believed to have stroke to a primary stroke center, in rural and urban settings, based on time from symptom recognition to treatment, probability of receiving treatment within 3 hours of stroke onset, and probability of overcrowding. We use Indiana as an example. METHODS We used discrete-event simulation to estimate outcomes for 2 scenarios: stroke system of care with enabling technology (mobile stroke unit, stroke team expansion) and stroke system of care with no enabling technology, as compared with the status quo. We considered patient flow from symptom recognition to treatment. Patient locations and stroke events were generated for the 92 Indiana counties in Indiana, subdivided into 1009 locations. We considered time from emergency medical service (EMS) arrival at onset to treatment, probability of tissue plasminogen activator administered within 3 h of onset, and percentage of patients admitted beyond the occupancy level at the comprehensive stroke center. RESULTS Results varied by urbanicity. Under no enabling technology, having a stroke system of care improved outcomes for individuals in urban and suburban settings. However, in rural settings, the implementation of stroke system of care guidelines decreased the average rate of treatment within 3 h of stroke onset and increased the EMS arrival to treatment times compared with sending the individual to the closest provider. Enabling technologies improved outcomes regardless of setting. DISCUSSION Geographic disparities tend to increase the number of transfers, decrease the rate of treatment within 3 h of onset, and increase transit time. This could be overcome through federal and state initiatives to reduce quality gaps in stroke care in rural settings and promote care with dedicated stroke wards.
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Affiliation(s)
- Min K Lee
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA
| | - Yuehwern Yih
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA.,Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
| | - Paul M Griffin
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA.,Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
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179
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Man S, Tang AS, Schold JD, Kolikonda MK, Uchino K. The Patterns and Outcomes of Inter-Hospital Transfer Among Medicare Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:105331. [PMID: 32992204 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/03/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND PURPOSE Inter-hospital transfer for ischemic stroke is an essential part of stroke system of care. This study aimed to understand the national patterns and outcomes of ischemic stroke transfer. METHODS AND RESULTS This retrospective study examined Medicare beneficiaries aged ≥65 years undergoing inter-hospital transfer for ischemic stroke in 2012. Cox proportional hazards model was used to compare 30-day and one-year mortality between transferred patients and direct admissions from the emergency department (ED admissions). Among 312,367 ischemic stroke admissions, 5.7% underwent inter-hospital transfer. Using this value as cut-off, the hospitals were classified into receiving (n = 411), sending (n = 559), and low-transfer (n = 1863) hospitals. Receiving hospitals were larger than low-transfer and sending hospitals as demonstrated by the median bed number (371, 189, and 88, respectively, p < 0.001); more frequently to be certified stroke centers (75%, 47%, and 16%, respectively, p < 0.001); and less commonly located in the rural area (2%, 7%, and 24%, respectively, p < 0.001). For receiving hospitals, transfer-in patients and ED admissions had comparable mortality at 30 days (10% vs 10%; adjusted HR [aHR]=1.07; 95% CI, 0.99-1.14) and 1 year (23% vs 24%; aHR=1.03; 95% CI, 0.99-1.08). For sending hospitals, transfer-out patients, compared to ED admissions, had higher mortality at 30 days (14% vs 11%; aHR=1.63; 95% CI, 1.39-1.91) and 1 year (30% vs 27%; aHR=1.33; 95% CI, 1.20-1.48). For low-transfer hospitals, overall transfer-in and transfer-out patients, compared to ED admissions, had higher mortality at 30 days (13% vs 10%; aHR=1.46; 95% CI, 1.33-1.60) and 1 year (28% vs 25%; aHR=1.27; 95% CI, 1.19-1.36). CONCLUSIONS Hospitals in the US, based on their transfer patterns, could be classified into 3 groups that shared distinct characteristics including hospital size, rural vs urban location, and stroke certification. Transferred patients at sending and low-transfer hospitals had worse outcomes than their ED admission counterpart.
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Affiliation(s)
- Shumei Man
- Department of Neurology & Cerebrovascular Center, Neurological Institute, Cleveland Clinic, United States
| | - Anne S Tang
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Jesse D Schold
- Center for Populations Health Research, Department of Quantitative Health Sciences, Cleveland Clinic, United States
| | - Murali K Kolikonda
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue/S80, Cleveland, OH, United States
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue/S80, Cleveland, OH, United States.
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180
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Romoli M, Paciaroni M, Tsivgoulis G, Agostoni EC, Vidale S. Mothership versus Drip-and-Ship Model for Mechanical Thrombectomy in Acute Stroke: A Systematic Review and Meta-Analysis for Clinical and Radiological Outcomes. J Stroke 2020; 22:317-323. [PMID: 33053947 PMCID: PMC7568974 DOI: 10.5853/jos.2020.01767] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/25/2020] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Substantial uncertainty exists on the benefit of organizational paradigms in stroke networks. Here we systematically reviewed and meta-analyzed data from studies comparing functional outcome between the mothership (MS) and the drip and ship (DS) models.
Methods The meta-analysis protocol was registered international prospective register of systematic reviews (PROSPERO) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Central databases were searched for randomized-controlled clinical trials (RCTs), retrospective and prospective studies comparing MS versus DS. Primary endpoints were functional independence at 90 days (modified Rankin Scale <3) and successful recanalization (Thrombolysis in Cerebral Infarction Scale [TICI] >2a); secondary endpoints were 3-month mortality and symptomatic intracranial haemorrhage (sICH). Odds ratios for endpoints were pooled using the random effects model and were compared between the two organizational models.
Results Overall, 18 studies (n=7,017) were included in quantitative synthesis. MS paradigm was superior to DS model for functional independence (odds ratio, 1.34; 95% confidence interval, 1.16 to 1.55; I<sup>2</sup>=30%). Meta-regression analysis revealed association between onset-to-needle time and good functional outcome, with longer onset-to-needle time being detrimental. Similar rates of recanalization, sICH and mortality at 90 days were documented between MS and DS.
Conclusions Patients with acute ischemic stroke eligible for reperfusion strategies might benefit more from MS paradigm as compared to DS. RCTs are needed to further refine best management taking into account logistics, facilities and resources.
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Affiliation(s)
- Michele Romoli
- Neurology Unit, Rimini "Infermi" Hospital, AUSL Romagna, Rimini, Italy.,Neurology Clinic, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Simone Vidale
- Neurology Unit, Rimini "Infermi" Hospital, AUSL Romagna, Rimini, Italy
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181
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Schuhmann MK, Stoll G, Bieber M, Vögtle T, Hofmann S, Klaus V, Kraft P, Seyhan M, Kollikowski AM, Papp L, Heuschmann PU, Pham M, Nieswandt B, Stegner D. CD84 Links T Cell and Platelet Activity in Cerebral Thrombo-Inflammation in Acute Stroke. Circ Res 2020; 127:1023-1035. [PMID: 32762491 PMCID: PMC7508294 DOI: 10.1161/circresaha.120.316655] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 01/01/2023]
Abstract
RATIONALE Ischemic stroke is a leading cause of morbidity and mortality worldwide. Recanalization of the occluded vessel is essential but not sufficient to guarantee brain salvage. Experimental and clinical data suggest that infarcts often develop further due to a thromboinflammatory process critically involving platelets and T cells, but the underlying mechanisms are unknown. OBJECTIVE We aimed to determine the role of CD (cluster of differentiation)-84 in acute ischemic stroke after recanalization and to dissect the underlying molecular thromboinflammatory mechanisms. METHODS AND RESULTS Here, we show that mice lacking CD84-a homophilic immunoreceptor of the SLAM (signaling lymphocyte activation molecule) family-on either platelets or T cells displayed reduced cerebral CD4+ T-cell infiltration and thrombotic activity following experimental stroke resulting in reduced neurological damage. In vitro, platelet-derived soluble CD84 enhanced motility of wild-type but not of Cd84-/- CD4+ T cells suggesting homophilic CD84 interactions to drive this process. Clinically, human arterial blood directly sampled from the ischemic cerebral circulation indicated local shedding of platelet CD84. Moreover, high platelet CD84 expression levels were associated with poor outcome in patients with stroke. CONCLUSIONS These results establish CD84 as a critical pathogenic effector and thus a potential pharmacological target in ischemic stroke.
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Affiliation(s)
- Michael K. Schuhmann
- From the Department of Neurology (M.K.S., G.S., M.B., P.K., L.P.), University Hospital Würzburg, Germany
| | - Guido Stoll
- From the Department of Neurology (M.K.S., G.S., M.B., P.K., L.P.), University Hospital Würzburg, Germany
| | - Michael Bieber
- From the Department of Neurology (M.K.S., G.S., M.B., P.K., L.P.), University Hospital Würzburg, Germany
| | - Timo Vögtle
- Department I, Institute of Experimental Biomedicine (T.V., S.H., V.K., B.N., D.S.), University Hospital Würzburg, Germany
- Rudolf Virchow Center for Integrative and Translational Bioimaging (T.V., S.H., B.N., D.S.), University of Würzburg, Germany
| | - Sebastian Hofmann
- Department I, Institute of Experimental Biomedicine (T.V., S.H., V.K., B.N., D.S.), University Hospital Würzburg, Germany
| | - Vanessa Klaus
- Department I, Institute of Experimental Biomedicine (T.V., S.H., V.K., B.N., D.S.), University Hospital Würzburg, Germany
| | - Peter Kraft
- From the Department of Neurology (M.K.S., G.S., M.B., P.K., L.P.), University Hospital Würzburg, Germany
- Department of Neurology, Klinikum Main-Spessart, Lohr, Germany (P.K.)
| | - Mert Seyhan
- Institute of Clinical Epidemiology and Biometry (M.S., P.U.H.), University of Würzburg, Germany
| | | | - Lena Papp
- From the Department of Neurology (M.K.S., G.S., M.B., P.K., L.P.), University Hospital Würzburg, Germany
| | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and Biometry (M.S., P.U.H.), University of Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology (A.M.K., M.P.), University Hospital Würzburg, Germany
| | - Bernhard Nieswandt
- Rudolf Virchow Center for Integrative and Translational Bioimaging (T.V., S.H., B.N., D.S.), University of Würzburg, Germany
| | - David Stegner
- Department I, Institute of Experimental Biomedicine (T.V., S.H., V.K., B.N., D.S.), University Hospital Würzburg, Germany
- Rudolf Virchow Center for Integrative and Translational Bioimaging (T.V., S.H., B.N., D.S.), University of Würzburg, Germany
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182
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Kunz WG, Hunink MG, Almekhlafi MA, Menon BK, Saver JL, Dippel DWJ, Majoie CBLM, Jovin TG, Davalos A, Bracard S, Guillemin F, Campbell BCV, Mitchell PJ, White P, Muir KW, Brown S, Demchuk AM, Hill MD, Goyal M. Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology 2020; 95:e2465-e2475. [PMID: 32943483 DOI: 10.1212/wnl.0000000000010867] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 06/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine public health and cost consequences of time delays to endovascular thrombectomy (EVT) for patients, health care systems, and society, we estimated quality-adjusted life-years (QALYs) of EVT-treated patients and associated costs based on times to treatment. METHODS The Markov model analysis was performed from US health care and societal perspectives over a lifetime horizon. Contemporary data from 7 trials within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration served as data source. Aside from cumulative lifetime costs, we calculated the net monetary benefit (NMB) to determine the economic value of care. We used a contemporary willingness-to-pay threshold of $100,000 per QALY for NMB calculations. RESULTS Every 10 minutes of earlier treatment resulted in an average gain of 39 days (95% prediction interval 23-53 days) of disability-free life. Overall, the cumulative lifetime costs for patients with earlier or later treatment were similar. Patients with later treatment had higher morbidity-related costs but over a shorter time span due to their shorter life expectancy, resulting in similar lifetime costs as in patients with early treatment. Regarding the economic value of care, every 10 minutes of earlier treatment increased the NMB by $10,593 (95% prediction interval $5,549-$14,847) and by $10,915 (95% prediction interval $5,928-$15,356) taking health care and societal perspectives, respectively. CONCLUSIONS Any time delay to EVT reduces QALYs and decreases the economic value of care provided by this intervention. Health care policies to implement efficient prehospital triage and to accelerate in-hospital workflow are urgently needed.
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Affiliation(s)
- Wolfgang G Kunz
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Myriam G Hunink
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Mohammed A Almekhlafi
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Bijoy K Menon
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Jeffrey L Saver
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Diederik W J Dippel
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Charles B L M Majoie
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Tudor G Jovin
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Antoni Davalos
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Serge Bracard
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Francis Guillemin
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Bruce C V Campbell
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Peter J Mitchell
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Philip White
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Keith W Muir
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Scott Brown
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Andrew M Demchuk
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Michael D Hill
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Mayank Goyal
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN.
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Rao RR, Desai SM, Tonetti DA, Manners J, Gross BA, Jankowitz B, Jovin TG, Jadhav AP. Thrombectomy after in-house stroke in the transfer population. J Stroke Cerebrovasc Dis 2020; 29:105049. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022] Open
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Alkhouli M, Alqahtani F, Hopkins LN, Harris AH, Hohmann SF, Tarabishy A, Holmes DR. Clinical Outcomes of On-Site Versus Off-Site Endovascular Stroke Interventions. JACC Cardiovasc Interv 2020; 13:2159-2166. [PMID: 32861630 DOI: 10.1016/j.jcin.2020.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/14/2020] [Accepted: 05/12/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to assess whether offering local endovascular stroke therapy (EST) rather than transferring patients off-site to receive EST would improve outcomes. BACKGROUND There are limited data to determine whether offering EST on-site rather than transferring patients to receive EST off-site improves clinical outcomes. METHODS A large academic consortium database was queried to identify patients with acute ischemic stroke who received EST between October 2015 and September 2019. Primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints were major complications, length of stay, and cost. Baseline characteristics were adjusted for using propensity score matching and multivariate risk adjustment. RESULTS A total of 22,193 patients with acute ischemic stroke who underwent EST (50.8% on-site, 49.2% off-site) were included. Mean ages were 67.9 ± 15.5 years and 68.4 ± 15.5 years, respectively (p = 0.03). In the propensity score matching analysis, mortality and poor functional outcomes were higher in the off-site EST group (14.7% vs. 11.2% and 40.7% vs. 35.9%, respectively; p < 0.001). In the risk-adjusted analyses with different models, in-hospital mortality and poor functional outcomes remained significantly higher in the off-site EST group. In the most comprehensive model (adjusting for age, sex, demographics, risk factors, tissue plasminogen activator use, and institutional EST volume), in-hospital mortality and poor functional outcomes were significantly higher in the off-site EST group, with odds ratios of 1.38 (95% confidence interval: 1.26 to 1.51) and 1.26 (95% confidence interval: 1.18 to 1.34), respectively (p < 0.001). The incidence of intracranial hemorrhage and mechanical ventilation was higher in the off-site group, but cost was higher in the on-site group in both the propensity score matching and risk-adjusted analyses. CONCLUSIONS In contemporary U.S. practice, patients with acute ischemic stroke treated with EST on-site had lower in-hospital mortality and better functional outcomes compared with those transferred off-site for EST.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota.
| | - Fahad Alqahtani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - L Nelson Hopkins
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Alyssa H Harris
- Center for Advanced Analytics and Informatics, Chicago, Illinois
| | - Samuel F Hohmann
- Center for Advanced Analytics and Informatics, Chicago, Illinois; Department of Health Systems Management, Rush University, Chicago, Illinois
| | - Abdul Tarabishy
- Division of Neuroradiology, West Virginia University, Morgantown, West Virginia
| | - David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota
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185
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Hassan AE, Ringheanu VM, Rabah RR, Preston L, Tekle WG, Qureshi AI. Early experience utilizing artificial intelligence shows significant reduction in transfer times and length of stay in a hub and spoke model. Interv Neuroradiol 2020; 26:615-622. [PMID: 32847449 DOI: 10.1177/1591019920953055] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Recently approved artificial intelligence (AI) software utilizes AI powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. We performed this analysis to determine if utilization of AI software and workflow platform can reduce the transfer time (time interval between CTA at a primary stroke center (PSC) to door-in at a comprehensive stroke center (CSC)). METHODS We compared the transfer time for all LVO transfer patients from a single spoke PSC to our CSC prior to and after incorporating AI Software (Viz.ai LVO). Using a prospectively collected stroke database at a CSC, demographics, mRS at discharge, mortality rate at discharge, length of stay (LOS) in hospital and neurological-ICU were examined. RESULTS There were a total of 43 patients during the study period (median age 72.0 ± 12.54 yrs., 51.16% women). Analysis of 28 patients from the pre-AI software (median age 73.5 ± 12.28 yrs., 46.4% women), and 15 patients from the post-AI software (median age 70.0 ± 13.29 yrs., 60.00% women). Following implementation of AI software, median CTA time at PSC to door-in at CSC was significantly reduced by an average of 22.5 min. (132.5 min versus 110 min; p = 0.0470). CONCLUSIONS The incorporation of AI software was associated with an improvement in transfer times for LVO patients as well as a reduction in the overall hospital LOS and LOS in the neurological-ICU. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.
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Affiliation(s)
- Ameer E Hassan
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA.,Department of Neurology, UTRGV School of Medicine, Edinburg, TX, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Texas, USA
| | - Victor M Ringheanu
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Rani R Rabah
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Laurie Preston
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Wondwossen G Tekle
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, USA.,Department of Neurology, UTRGV School of Medicine, Edinburg, TX, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Texas, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.,Department of Neurology, University of Missouri, Columbia, MO, USA
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186
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Grunwald IQ, Phillips DJ, Sexby D, Wagner V, Lesmeister M, Bachhuber M, Mathur S, Guyler P, Fisher J, Perera S, Helwig SA, Schottek A, Ewart I, Menon N, Inam Ul Haq M, Grün D, Merzou F, Howard C, Mapplebeck S, Dommett D, Alam S, Chakrabarti A, Gerry S, Wiltshire C, Bailey M, Bertsch T, Foster T, Davis T, Reith W, Fassbender K, Walter S. Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions. Cerebrovasc Dis 2020; 49:388-395. [PMID: 32846413 DOI: 10.1159/000508910] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. OBJECTIVE The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. METHODS Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. RESULTS In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40-60). CONCLUSION This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.
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Affiliation(s)
- Iris Q Grunwald
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom.,Department of Neuroscience, Medical School, Anglia Ruskin University, Chelmsford, United Kingdom.,Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Daniel J Phillips
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - David Sexby
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Viola Wagner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Monika Bachhuber
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Shrey Mathur
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom.,Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Paul Guyler
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - James Fisher
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Saman Perera
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Stefan A Helwig
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Andrea Schottek
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Ian Ewart
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Nisha Menon
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Muhammad Inam Ul Haq
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Daniel Grün
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Fatma Merzou
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Caroline Howard
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Sarah Mapplebeck
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - David Dommett
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Sajid Alam
- East Suffolk and North Essex NHS Foundation Trust, Ipswich, United Kingdom
| | - Annie Chakrabarti
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
| | - Stephen Gerry
- Institute of Medical Statistics, University of Oxford, Oxford, United Kingdom
| | - Chris Wiltshire
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Marcus Bailey
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Tom Davis
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany,
| | - Silke Walter
- Department of Neuroscience, Medical School, Anglia Ruskin University, Chelmsford, United Kingdom.,Department of Neurology, Saarland University Medical Center, Homburg, Germany
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Reidler P, Puhr-Westerheide D, Rotkopf L, Fabritius MP, Feil K, Kellert L, Tiedt S, Rémi J, Liebig T, Kunz WG. Cerebral attenuation on single-phase CT angiography source images: Automated ischemia detection and morphologic outcome prediction after thrombectomy in patients with ischemic stroke. PLoS One 2020; 15:e0236956. [PMID: 32790766 PMCID: PMC7425881 DOI: 10.1371/journal.pone.0236956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/16/2020] [Indexed: 11/26/2022] Open
Abstract
Objectives Stroke triage using CT perfusion (CTP) or MRI gained importance after successful application in recent trials on late-window thrombectomy but is often unavailable and time-consuming. We tested the clinical value of software-based analysis of cerebral attenuation on Single-phase CT angiography source images (CTASI) as CTP surrogate in stroke patients. Methods Software-based automated segmentation and Hounsfield unit (HU) measurements for all regions of the Alberta Stroke Program Early CT Score (ASPECTS) on CTASI were performed in patients with large vessel occlusion stroke who underwent thrombectomy. To normalize values, we calculated relative HU (rHU) as ratio of affected to unaffected hemisphere. Ischemic regions, regional ischemic core and final infarction were determined on simultaneously acquired CTP and follow-up imaging as ground truth. Receiver operating characteristics analysis was performed to calculate the area-under-the-curve (AUC). Resulting cut-off values were used for comparison with visual analysis and to calculate an 11-point automated CTASI ASPECTS. Results Seventy-nine patients were included. rHU values enabled significant classification of ischemic involvement on CTP in all ten regions of the ASPECTS (each p<0.001, except M4-cortex p = 0.002). Classification of ischemic core and prediction of final infarction had best results in subcortical regions but produced lower AUC values with significant classification for all regions except M1, M3 and M5. Relative total hemispheric attenuation provided strong linear correlation with CTP total ischemic volume. Automated classification of regional ischemia on CTASI was significantly more accurate in most regions and provided better agreement with CTP cerebral blood flow ASPECTS than visual assessment. Conclusions Automated attenuation measurements on CTASI provide excellent performance in detecting acute ischemia as identified on CTP with improved accuracy compared to visual analysis. However, value for the approximation of ischemic core and morphologic outcome in large vessel occlusion stroke after thrombectomy was regionally dependent and limited. This technique has the potential to facilitate stroke imaging as sensitive surrogate for CTP-based ischemia.
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Affiliation(s)
- Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- * E-mail:
| | | | - Lukas Rotkopf
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Katharina Feil
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, LMU Munich, Munich, Germany
| | - Jan Rémi
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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Ernst M, Psychogios MN, Schlemm E, Holodinsky JK, Kamal N, Rodt T, Henningsen H, Kraemer C, Thomalla G, Fiehler J, Brekenfeld C. Modeling the Optimal Transportation for Acute Stroke Treatment : Impact of Diurnal Variations in Traffic Rate. Clin Neuroradiol 2020; 31:729-736. [PMID: 32676698 PMCID: PMC8463378 DOI: 10.1007/s00062-020-00933-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 11/26/2022]
Abstract
Purpose Prolonged transfer times between the primary stroke center (PSC) and the comprehensive stroke center (CSC) are one of the major causes of treatment delay for endovascular stroke treatment. We aimed to analyze the effect of the diurnal variations in traffic rates at weekdays and weekends on the catchment area size of three transportation paradigms, i.e. mothership, drip-and-ship (DS) and drip-and-drive (DD). Methods A conditional probability model that predicts the probability of good outcome for patients with suspected large vessel occlusion was used to analyze the prehospital stroke triage in northwest Germany and produce catchment area maps. Transportation times were calculated during each hour of a weekday and a Sunday using Google Maps. For comparison, real DD transportation times from our CSC in Hamburg-Eppendorf (blinded for review) to a PSC in Lüneburg were prospectively recorded. Result On weekdays, the mothership catchment area was the largest (≥40,000 km2, 63%) except for a decrease during morning rush hours, when the DD catchment area was highest (30,879 km2, 48%). The DS catchment area was higher than the DD catchment area during the afternoon rush hours both during the week as well as on Sundays. Conclusion Our study showed a considerable impact of the diurnal variations in traffic rate and direction of travel on optimal stroke transportation. Stroke systems of care should take real time traffic information into account. Electronic supplementary material The online version of this article (10.1007/s00062-020-00933-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany.
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada
| | - Thomas Rodt
- Department of Diagnostic and Interventional Radiology, Klinikum Lüneburg, Lüneburg, Germany
| | | | | | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany
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Abstract
Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital and The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
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190
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Rodríguez-Pardo J, Secades-García S, Riera-López N, Alonso de Leciñana M, Real-Martínez V, Carneado-Ruiz J, Díaz-Guzmán J, Díez-Tejedor E, Egido-Herrero J, Gil-Núñez A, Matute-Lozano MC, Trillo S, Vera-Lechuga R, Vivancos-Mora J, Ximénez-Carrillo Á, Fuentes B. Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates. Eur J Neurol 2020; 27:2439-2445. [PMID: 32638466 DOI: 10.1111/ene.14429] [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: 06/08/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.
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Affiliation(s)
- J Rodríguez-Pardo
- Department of Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - S Secades-García
- Department of Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - N Riera-López
- Stroke Code Coordination Center, Servicio de Emergencias Médicas SUMMA-112, Madrid, Spain
| | - M Alonso de Leciñana
- Department of Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - V Real-Martínez
- Stroke Code Coordination Center, Servicio de Emergencias Médicas SUMMA-112, Madrid, Spain
| | - J Carneado-Ruiz
- Department of Neurology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | - J Díaz-Guzmán
- Department of Neurology, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - E Díez-Tejedor
- Department of Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - J Egido-Herrero
- Department of Neurology, Hospital Universitario Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - A Gil-Núñez
- Department of Neurology, Hospital Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - M C Matute-Lozano
- Department of Neurology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Spain
| | - S Trillo
- Department of Neurology, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - R Vera-Lechuga
- Department of Neurology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Spain
| | - J Vivancos-Mora
- Department of Neurology, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Á Ximénez-Carrillo
- Department of Neurology, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - B Fuentes
- Department of Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
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191
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Ota T, Shigeta K, Inoue M, Matsumaru Y, Shiokawa Y, Hirano T. Long-Term Outcomes of Acute Endovascular Thrombectomy: Tokyo/tama-Registry of Acute Endovascular Thrombectomy (TREAT). World Neurosurg 2020; 142:e271-e277. [PMID: 32622064 DOI: 10.1016/j.wneu.2020.06.209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Mechanical thrombectomy (MT) is the recommended treatment for patients with acute ischemic stroke due to large cerebral vessel occlusion (LVO). However, few studies have investigated long-term outcomes after MT. The aim of this study was to investigate functional outcomes at long-term follow-up (1 year after MT) in patients undergoing MT for anterior circulation LVO in real-world clinical practice. METHODS This was a retrospective and prospective observational study using data from TREAT (Tokyo/tama-Registry of Acute Endovascular Thrombectomy), a multicenter registry of MT for acute LVO in the Tokyo metropolitan area. All subjects emergently transferred and treated with MT from January 2015 to December 2018 were selected. Patients' baseline characteristics and stroke-related parameters were evaluated. The primary outcome was the modified Rankin Scale (mRS) score 1 year after MT. The secondary outcomes were risk factors for long-term good outcomes (mRS score 0-2); transfer system (stroke bypass vs. secondary transfer) was also evaluated as a potential factor associated with good long-term outcomes. RESULTS A total of 162 cases (mean age 73.0 years, age range 30-97 years; 59.9% male) whose mRS scores at 1 year were obtained were analyzed. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 17. Overall, 42.6% of the patients achieved functional independence at 1-year follow-up. Lower initial NIHSS score and mRS score 0-2 at 90 days were the independent predictors for good long-term outcomes. Stroke bypass was associated with a higher initial NIHSS score and mRS score 0 at 1 year. CONCLUSIONS A significant number of patients experience a good long-term outcome after MT.
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Affiliation(s)
- Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan.
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Japan
| | - Masato Inoue
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Shinjuku, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Ibaraki, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
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192
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Prehospital stroke management in the thrombectomy era. Lancet Neurol 2020; 19:601-610. [DOI: 10.1016/s1474-4422(20)30102-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/06/2020] [Accepted: 03/10/2020] [Indexed: 11/19/2022]
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193
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Affiliation(s)
- Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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194
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Siegler JE, Jovin TG. Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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195
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McTaggart RA, Holodinsky JK, Ospel JM, Cheung AK, Manning NW, Wenderoth JD, Phan TG, Beare R, Lane K, Haas RA, Kamal N, Goyal M, Jayaraman MV. Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy. Stroke 2020; 51:1951-1960. [PMID: 32568640 DOI: 10.1161/strokeaha.119.026735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan A McTaggart
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K.H.)
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Andrew K Cheung
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.)
| | - Nathan W Manning
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Jason D Wenderoth
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Thanh G Phan
- Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P.)
| | - Richard Beare
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and Murdoch Children's Research Institute Melbourne Australia (R.B.)
| | - Kendall Lane
- Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Richard A Haas
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
| | - Mahesh V Jayaraman
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
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196
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Tokunaga K, Inoue S, Suruga Y, Nagase T, Takagi Y, Watanabe K, Kiriyama H, Deguchi S, Deguchi K, Matsumoto K. Practical Use of a Communication Application on Mobile Devices by Our Stroke Team. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:339-344. [PMID: 37501671 PMCID: PMC10370912 DOI: 10.5797/jnet.oa.2020-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/23/2020] [Indexed: 07/29/2023]
Abstract
Objective To describe our 1-year experience of the practical use of a mobile communication application by our stroke team. Methods The mobile Join application (Allm Inc., Tokyo, Japan) was introduced into our stroke team for the purpose of immediate sharing of the patient information. We analyzed the usage situation for 1 year after the introduction of Join, particularly its efficacy in improving the door-to-puncture time (D2P) for thrombectomy cases, and reported our inter-hospital collaboration with the use of Join. Results The total number of events notified by Join was 337, and they included acute stroke potentially leading to reperfusion therapy in 23% (76 events), head trauma in 14%, brain hemorrhage in 12%, other infarction in 10%, subarachnoid hemorrhage in 8%, and the others in 34%. The information of the patients was shared among the team members before arrival to our hospital in 42% of acute stroke cases. Of 31 patients undergoing mechanical thrombectomy, the median interval between arrival and groin puncture for the directly transported patients with/without pre-hospital information was 77.5 min/87 min, respectively, whereas that of the patients transferred from primary hospitals with/without pre-hospital information was 19 min/71 min (p <0.0001), respectively, demonstrating the efficacy of information sharing in advance through Join in improving the timing of endovascular therapy. For inter-hospital collaboration using the telestroke system, we concluded the partnership agreement with three local primary hospitals by communication via Join at a reasonable cost. Conclusion Active and effective utilization of the mobile Join application for communication by our stroke team was demonstrated, and it is expected to promote inter-hospital collaboration in stroke treatment.
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Affiliation(s)
- Koji Tokunaga
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Satoshi Inoue
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Yasuki Suruga
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Takayuki Nagase
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Yuji Takagi
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Kyoichi Watanabe
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Hideki Kiriyama
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Shoko Deguchi
- Department of Neurology, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Kentaro Deguchi
- Department of Neurology, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
| | - Kengo Matsumoto
- Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Okayama, Japan
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197
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Zhao W, Ma P, Chen J, Yue X. Direct admission versus secondary transfer for acute ischemic stroke patients treated with thrombectomy: a systematic review and meta-analysis. J Neurol 2020; 268:3601-3609. [PMID: 32494852 DOI: 10.1007/s00415-020-09877-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials have demonstrated that mechanical thrombectomy (MT) could provide more benefit than standard medical care for acute ischemic stroke (AIS) patients due to emergent large vessel occlusion. However, most primary stroke centers (PSCs) are unable to perform MT, and MT can only be performed in comprehensive stroke centers (CSCs) with on-site interventional neuroradiologic services. Therefore, there is an ongoing debate regarding whether patients with suspected AIS should be directly admitted to CSCs or secondarily transferred to CSCs from PSCs. This meta-analysis was aimed to investigate the two transportation paradigms of direct admission and secondary transfer, which one could provide more benefit for AIS patients treated with MT. METHODS We conducted a systematic review and meta-analysis through searching PubMed, Embase and the Cochrane Library database up to March 2020. Primary outcomes are as follows: symptomatic intracerebral hemorrhage (sICH) within 7 days; favorable functional outcome at 3 months; mortality in hospital; mortality at 3 months; and successful recanalization rate. RESULTS Our pooled results showed that patients directly admitted to CSCs had higher chances of achieving a favorable functional outcome at 3 months than those secondarily transferred to CSCs (OR = 1.26; 95% CI, 1.12-1.42; P < 0.001). In addition, no significant difference was found between the two transportation paradigms in the rate of sICH (OR = 0.86; 95% CI, 0.62-1.18; P = 0.35), mortality in hospital (OR = 0.84; 95% CI, 0.51-1.39; P = 0.51), mortality at 3 months (OR = 1.01; 95% CI, 0.85-1.21; P = 0.91), and successful recanalization (OR = 1.03; 95% CI, 0.88-1.20; P = 0.74). However, in the 100% bridging thrombolysis usage rate subgroup, our subgroup analysis indicated that no difference was found in any outcome between the two transportation paradigms. CONCLUSION Patients with AIS directly admitted to CSCs for MT may be a feasible transportation paradigm for AIS patients. However, more large-scale randomized prospective trials are required to further investigate this issue.
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Affiliation(s)
- Weisong Zhao
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, 453000, Henan, China
| | - Pengju Ma
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453000, Henan, China
| | - Jinbao Chen
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, 453000, Henan, China
| | - Xuejing Yue
- School of Basic Medicine, Xinxiang Medical University, No.601 Jinsui Avenue, Xinxiang, 453000, China.
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198
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Mueller-Kronast N, Froehler MT, Jahan R, Zaidat O, Liebeskind D, Saver JL. Impact of EMS bypass to endovascular capable hospitals: geospatial modeling analysis of the US STRATIS registry. J Neurointerv Surg 2020; 12:1058-1063. [PMID: 32385089 PMCID: PMC7569363 DOI: 10.1136/neurintsurg-2019-015593] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Routing patients directly to endovascular capable centers (ECCs) would decrease time to mechanical thrombectomy (MT), but may delay intravenous thrombolysis (IVT). OBJECTIVE To study the clinical outcomes of patients with a stroke transferred directly to ECCs compared with those transferred to ECCs from non-endovascular capable centers (nECCs). METHODS Data from the STRATIS registry were analyzed to evaluate process and clinical outcomes under five routing policies: (1) transport to nearest nECC; (2) transport to STRATIS ECC over any distance or (3) within 20 miles; (4) transport to ideal ECC (iECC), over any distance or (5) within 20 miles. RESULTS Among 236 patients, 117 (49.6%) were transferred by ground, of whom 62 (53%) were transferred within 20 miles. Median MT start time was accelerated in all direct transport models. IVT start was prolonged with direct transport across all distances, but accelerated with direct transport to iECC ≤20 miles. With bypass limited to ≤20 miles, the median modeled EMS arrival to IVT interval decreased for both iECCs and ECCs (by 12 min and 6 min, respectively), and median EMS arrival to puncture time decreased by up to 94 min. In this cohort, no patient would have become ineligible for IVT. Bypass to iECC modeling under 20 miles showed a significant reduction in the level of disability at 3 months, with freedom from disability (modified Rankin Scale score 0-1) at 3 months increased by 12%. CONCLUSIONS Direct routing of patients with a large vessel occlusion to ECCs, especially when within 20 miles, may lead to better clinical outcomes by accelerating the start of MT without any delay of IVT. CLINICAL TRIAL REGISTRATION NUMBER http://www.clinicaltrials.gov. Unique identifier: NCT02239640.
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Affiliation(s)
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Reza Jahan
- Department of Radiology, University of California Los Angeles, Los Angeles, California, USA
| | | | - David Liebeskind
- Neurovascular Imaging Core and UCLA Stroke Center, Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
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199
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Qureshi AI, Abd-Allah F, Al-Senani F, Aytac E, Borhani-Haghighi A, Ciccone A, Gomez CR, Gurkas E, Hsu CY, Jani V, Jiao L, Kobayashi A, Lee J, Liaqat J, Mazighi M, Parthasarathy R, Steiner T, Suri MFK, Toyoda K, Ribo M, Gongora-Rivera F, Oliveira-Filho J, Uzun G, Wang Y. Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel. Int J Stroke 2020; 15:540-554. [DOI: 10.1177/1747493020923234] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Foad Abd-Allah
- Department of Neurology, Kasralainy school of Medicine, Cairo University, Cairo, Egypt
| | - Fahmi Al-Senani
- Neurology Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Emrah Aytac
- Department of Neurology, University of FIRAT, Elazig Turkey
| | | | - Alfonso Ciccone
- Department of Neurosciences, Hospital Carlo Poma, ASST di Mantova, Mantua, Italy
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, MO, USA
| | - Erdem Gurkas
- Stroke Center, Department of Neurology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Vishal Jani
- Department of Neurology, Creighton University Medical Center/CHI Health, Omaha, NE, USA
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Adam Kobayashi
- Department of Neurology and Interventional Stroke Treatment Centre, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Jahanzeb Liaqat
- Pakistan Emirates Military Hospital (J.L.), Rawalpindi, Pakistan
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | | | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain
| | - Fernando Gongora-Rivera
- Servicio de Neurología, Hospital Universitario José Eleuterio González de la Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México; Instituto de Neurología y Neurocirugía, Hospital Zambrano Hellion, Tecnológico de Monterrey, San Pedro, Nuevo León, México
| | | | - Guven Uzun
- Beverly Hills Pain Institute and Neurology, Beverly Hills, CA, USA
| | - Yongjun Wang
- Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University Beijing, China
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Yaeger KA, Shoirah H, Kellner CP, Fifi J, Mocco J. Emerging Technologies in Optimizing Pre-Intervention Workflow for Acute Stroke. Neurosurgery 2020; 85:S9-S17. [PMID: 31197335 DOI: 10.1093/neuros/nyz058] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 02/20/2019] [Indexed: 01/08/2023] Open
Abstract
Over the last several years, thrombectomy for large vessel occlusions (LVOs) has emerged as a standard of care for acute stroke patients. Furthermore, the time to reperfusion has been identified as a predictor of overall patient outcomes, and much effort has been made to identify potential areas to target in enhancing preintervention workflow. As medical technology and stroke devices improve, nearly all time points can be affected, from field stroke triage to automated imaging interpretation to mass mobile stroke code communications. In this article, we review the preintervention stroke workflow with specific regard to emerging technologies in improving time to reperfusion and overall patient outcomes.
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Affiliation(s)
- Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York
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