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Hagrass AI, Elsayed SM, Doheim MF, Mostafa MA, Elfil M, Al-Kafarna M, Almaghary BK, Fayoud AM, Hamdallah A, Hasan MT, Ragab KM, Nourelden AZ, Zaazouee MS, Medicherla C, Lerario M, Czap AL, Chong J, Nour M, Al-Mufti F. Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 "T Letter" Domains. Cardiol Rev 2024; 32:297-313. [PMID: 38602410 DOI: 10.1097/crd.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.
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Affiliation(s)
| | | | - Mohamed Fahmy Doheim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | | | | | | | | | | | - Mackenzie Lerario
- Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Alexandra L Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY
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Billot L, Chen C, Song L, Lin Y, Liu F, Chen X, Arima H, Bath PM, Ford GA, Robinson TG, Sandset EC, Saver JL, Sprigg N, van der Worp HB, Yang J, Li G, Anderson CS. Statistical Analysis Plan for the INTEnsive Ambulance-Delivered Blood Pressure Reduction in Hyper-ACute Stroke Trial. Cerebrovasc Dis 2024:1-4. [PMID: 38815572 DOI: 10.1159/000539503] [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: 11/09/2023] [Accepted: 05/22/2024] [Indexed: 06/01/2024] Open
Abstract
INTRODUCTION Recruitment is complete in the fourth INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4), a multicenter, prospective, randomized, open-label, blinded endpoint assessed trial of prehospital blood pressure (BP) lowering initiated in the ambulance for patients with a suspected acute stroke and elevated BP in China. According to the registered and published trial protocol and developed by the blinded trial Steering Committee and Operations team, this manuscript outlines a detailed statistical analysis plan for the trial prior to database lock. METHODS Patients were randomized (1:1) to intensive (target systolic BP 130-140 mm Hg within 30 min) or guideline-recommended BP management (BP lowering only considered if systolic BP >220 mm Hg) group. Primary outcome is an ordinal analysis of the full range of scores on the modified Rankin scale at 90 days. A modified sample size of 2,320 was estimated to provide 90% power to detect a 22% reduction in the odds (common odds ratio of 0.78) of a worse functional outcome using ordinal logistic regression, on the assumption of 5% patients with missing outcome and 6% patients with a stroke mimic. CONCLUSION The statistical analysis plan for the trial has been developed to ensure transparent, verifiable, and prespecified analysis and to avoid potential bias in the evaluation of the trial intervention.
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Affiliation(s)
- Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia,
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China,
- The George Institute for Global Health, Beijing, China,
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
- The George Institute for Global Health, Beijing, China
| | - Yapeng Lin
- Department of Neurology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- International Clinical Research Centre, Chengdu Medical College, Chengdu, China
| | - Feifeng Liu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
| | - Hisatomi Arima
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Thompson G Robinson
- College of Life Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | | | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Chengdu, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, New South Wales, Australia
- The George Institute for Global Health, Beijing, China
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Bluhm S, Schramm P, Spreen-Ledebur Y, Bluhm S, Münte TF, Eiersted MR, Wolfram F, van Hooff RJR, Wienecke T, Royl G. Potential effects of a mobile stroke unit on time to treatment and outcome in patients treated with thrombectomy or thrombolysis: A Danish-German cross-border analysis. Eur J Neurol 2024:e16298. [PMID: 38682808 DOI: 10.1111/ene.16298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND PURPOSE A mobile stroke unit (MSU) reduces delays in stroke treatment by allowing thrombolysis on board and avoiding secondary transports. Due to the beneficial effect in comparison to conventional emergency medical services, current guidelines recommend regional evaluation of MSU implementation. METHODS In a descriptive study, current pathways of patients requiring a secondary transport for mechanical thrombectomy were reconstructed from individual patient records within a Danish (n = 122) and an adjacent German region (n = 80). Relevant timestamps included arrival times (on site, primary hospital, thrombectomy centre) as well as the initiation of acute therapy. An optimal MSU location for each region was determined. The resulting time saving was translated into averted disability-adjusted life years (DALYs). RESULTS For each region, the optimal MSU location required a median driving time of 35 min to a stroke patient. Time savings in the German region (median [Q1; Q3]) were 7 min (-15; 31) for thrombolysis and 35 min (15; 61) for thrombectomy. In the Danish region, the corresponding time savings were 20 min (8; 30) and 43 min (25; 66). Assuming 28 thrombectomy cases and 52 thrombolysis cases this would translate to 9.4 averted DALYs per year justifying an annual net MSU budget of $0.8M purchasing power parity dollars (PPP-$) in the German region. In the Danish region, the MSU would avert 17.7 DALYs, justifying an annual net budget of PPP-$1.7M. CONCLUSION The effects of an MSU can be calculated from individual patient pathways and reflect differences in the hospital infrastructure between Denmark and Germany.
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Affiliation(s)
- Susanna Bluhm
- Department of Neurology, University of Lübeck, Lübeck, Germany
- St Vinzenz-Hospital, Köln, Germany
| | - Peter Schramm
- Department of Neuroradiology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | | | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | - Frauke Wolfram
- Department of Radiology, Zealand University Hospital, Roskilde, Denmark
| | - Robbert-Jan Roderick van Hooff
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Troels Wienecke
- Department of Neurology, Zealand University Hospital, Roskilde, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Georg Royl
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Neurovascular Center, University Hospital Schleswig-Holstein, Lübeck, Germany
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Wen R, Wang M, Bian W, Zhu H, Xiao Y, Zeng J, He Q, Wang Y, Liu X, Shi Y, Hong Z, Xu B. Effectiveness of the acute stroke care map program in reducing in-hospital delay for acute ischemic stroke in a Chinese urban area: an interrupted time series analysis. Front Neurol 2024; 15:1364952. [PMID: 38699054 PMCID: PMC11063247 DOI: 10.3389/fneur.2024.1364952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Background Timely intravenous thrombolysis (IVT) is crucial for improving outcomes in acute ischemic stroke (AIS) patients. This study evaluates the effectiveness of the Acute Stroke Care Map (ASCaM) initiative in Shenyang, aimed at reducing door-to-needle times (DNT) and thus improving the timeliness of care for AIS patients. Methods An retrospective cohort study was conducted from April 2019 to December 2021 in 30 hospitals participating in the ASCaM initiative in Shenyang. The ASCaM bundle included strategies such as EMS prenotification, rapid stroke triage, on-call stroke neurologists, immediate neuroimaging interpretation, and the innovative Pre-hospital Emergency Call and Location Identification feature. An interrupted time series analysis (ITSA) was used to assess the impact of ASCaM on DNT, comparing 9 months pre-intervention with 24 months post-intervention. Results Data from 9,680 IVT-treated ischemic stroke patients were analyzed, including 2,401 in the pre-intervention phase and 7,279 post-intervention. The ITSA revealed a significant reduction in monthly DNT by -1.12 min and a level change of -5.727 min post-ASCaM implementation. Conclusion The ASCaM initiative significantly reduced in-hospital delays for AIS patients, demonstrating its effectiveness as a comprehensive stroke care improvement strategy in urban settings. These findings highlight the potential of coordinated care interventions to enhance timely access to reperfusion therapies and overall stroke prognosis.
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Affiliation(s)
- Rui Wen
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Miaoran Wang
- Affiliated Central Hospital of Shenyang Medical College, Shenyang Medical College, Shenyang, China
| | - Wei Bian
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Haoyue Zhu
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Ying Xiao
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Jing Zeng
- ChongQing Medical University, ChongQing, China
| | - Qian He
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yu Wang
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Xiaoqing Liu
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Yangdi Shi
- Shenyang Tenth People’s Hospital, Shenyang, China
| | - Zhe Hong
- Shenyang First People’s Hospital, Shenyang Medical College, Shenyang, China
| | - Bing Xu
- Shenyang Tenth People’s Hospital, Shenyang, China
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Mohamed A, Elsherif S, Legere B, Fatima N, Shuaib A, Saqqur M. Is telestroke more effective than conventional treatment for acute ischemic stroke? A systematic review and meta-analysis of patient outcomes and thrombolysis rates. Int J Stroke 2024; 19:280-292. [PMID: 37752674 PMCID: PMC10903130 DOI: 10.1177/17474930231206066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Telestroke systems operate through remote communication, providing distant stroke evaluation through expert healthcare providers. The aim of this study was to assess whether the implementation of a telestroke system influenced stroke treatment outcomes in acute ischemic stroke (AIS) patients compared with conventional in-person treatment. AIMS The study group evaluated multiple studies from electronic databases, comparing telemedicine (TM) and non-telemedicine (NTM) AIS patients between 1999 and 2022. We aimed to evaluate baseline characteristics, critical treatment times, and clinical outcomes. SUMMARY OF REVIEW A total of 12,540 AIS patients were included in our study with 7936 (63.9%) thrombolyzed patients. Of the thrombolyzed patients, 4150 (51.7%) were treated with TM, while 3873 (48.3%) were not. The mean age of TM and NTM cohorts was 70.45 ± 4.68 and 70.42 ± 4.63, respectively (p > 0.05). Mean National Institute of Health Stroke Scale scores were comparable, with the TM group reporting a non-significantly higher mean (11.89 ± 3.29.6 vs. 11.13 ± 3.65, p > 0.05). No significant difference in outcomes was found for symptoms onset-to-intravenous tissue plasminogen activator (ivtPA) times (144.09 ± 18.87 vs. 147.18 ± 25.97, p = 0.632) and door-to-needle times (73.03 ± 20.04 vs. 65.91 ± 25.96, p = 0.321). Modified Rankin scale scores (0-2) were evaluated, and no significant difference was detected between cohorts (odds ratio (OR): 1.06, 95% confidence interval (CI): 0.89-1.29, p = 0.500). Outcomes did not indicate any significance between both cohorts for 90-day mortality (OR: 1.16, 95% CI: 0.94-1.43, p = 0.17) or symptomatic intracranial hemorrhage (OR: 0.99, 95% CI: 0.73-1.34, p = 0.93). Results between groups were also non-significant when analyzing the rate of thrombolysis with ivtPA (30.86%± 30.7 vs. 20.5%± 18.6, p = 0.372) and endovascular mechanical thrombectomy (11.8%± 11.7 vs. 18.7%± 18.9, p = 0.508). CONCLUSION The use of telestroke in the treatment of AIS patients is safe with minimal non-significant differences in long-term outcomes and rates of thrombolysis compared with face-to-face treatment. Further studies comparing the different methods of TM are needed to assess the efficacy of TM in stroke treatment.
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Affiliation(s)
- Ahmed Mohamed
- Biology Department (Physiology), McMaster University, Hamilton, ON, Canada
| | - Salah Elsherif
- Department of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Brittney Legere
- Department of Applied Sciences, University of Guelph, Guelph, ON, Canada
| | - Nida Fatima
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ashfaq Shuaib
- Department of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Maher Saqqur
- Department of Neurology, University of Toronto, Mississauga, ON, Canada
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Rink JS, Tollens F, Tschalzev A, Bartelt C, Heinzl A, Hoffmann J, Schoenberg SO, Marzina A, Sandikci V, Wiegand C, Hoyer C, Szabo K. Establishing an MSU service in a medium-sized German urban area-clinical and economic considerations. Front Neurol 2024; 15:1358145. [PMID: 38487327 PMCID: PMC10938346 DOI: 10.3389/fneur.2024.1358145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Background and purpose Mobile stroke units (MSU) have been demonstrated to improve prehospital stroke care in metropolitan and rural regions. Due to geographical, social and structural idiosyncrasies of the German city of Mannheim, concepts of established MSU services are not directly applicable to the Mannheim initiative. The aim of the present analysis was to identify major determinants that need to be considered when initially setting up a local MSU service. Methods Local stroke statistics from 2015 to 2021 were analyzed and circadian distribution of strokes and local incidence rates were calculated. MSU patient numbers and total program costs were estimated for varying operating modes, daytime coverage models, staffing configurations which included several resource sharing models with the hospital. Additional case-number simulations for expanded catchment areas were performed. Results Median time of symptom onset of ischemic stroke patients was 1:00 p.m. 54.3% of all stroke patients were admitted during a 10-h time window on weekdays. Assuming that MSU is able to reach 53% of stroke patients, the average expected number of ischemic stroke patients admitted to MSU would be 0.64 in a 10-h shift each day, which could potentially be increased by expanding the MSU catchment area. Total estimated MSU costs amounted to € 815,087 per annum. Teleneurological assessment reduced overall costs by 11.7%. Conclusion This analysis provides a framework of determinants and considerations to be addressed during the design process of a novel MSU program in order to balance stroke care improvements with the sustainable use of scarce resources.
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Affiliation(s)
- Johann S. Rink
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Fabian Tollens
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Andrej Tschalzev
- Institute for Enterprise Systems, University of Mannheim, Mannheim, Germany
| | - Christian Bartelt
- Institute for Enterprise Systems, University of Mannheim, Mannheim, Germany
| | | | - Jens Hoffmann
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Stefan O. Schoenberg
- Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Annika Marzina
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Vesile Sandikci
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Carla Wiegand
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Carolin Hoyer
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim, Mannheim University Medical Centre, Heidelberg University, Mannheim, Germany
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Kaffes M, Bondi F, Geisler F, Grittner U, Haacke L, Ihl T, Lorenz M, Schehadat MS, Schwabauer E, Wendt M, Zuber M, Kübler-Weller D, Lorenz-Meyer I, Sanchez JC, Montaner J, Audebert HJ, Weber JE. Optimization of sensitivity and specificity of a biomarker-based blood test (LVOCheck-Opti): A protocol for a multicenter prospective observational study of patients suspected of having a stroke. Front Neurol 2024; 14:1327348. [PMID: 38371304 PMCID: PMC10870936 DOI: 10.3389/fneur.2023.1327348] [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: 10/24/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction Acute ischemic stroke (AIS) is a time-critical medical emergency. For patients with large-vessel occlusions (LVO), mechanical thrombectomy (MT) is the gold-standard treatment. Mobile Stroke Units (MSUs) provide on-site diagnostic capabilities via computed tomography (CT) and have been shown to improve functional outcomes in stroke patients, but are cost-efficient only in urban areas. Blood biomarkers have recently emerged as possible alternative to cerebral imaging for LVO diagnosis. Prehospital LVO diagnosis offers the potential to transport patients directly to centers that have MT treatment available. In this study, we assess the accuracy of combining two biomarkers, HFABP and NT-proBNP, with clinical indicators to detect LVO using ultra-early prehospital blood samples. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00030399). Methods and analysis We plan a multicenter prospective observational study with 800 patients with suspected stroke enrolled within 24 h of symptom onset. Study participants will be recruited at three sites (MSUs) in Berlin, Germany. Blood-samples will be taken pre-hospitally at the scene and tested for HFABP and NT-proBNP levels. Additional clinical data and information on final diagnosis will be collected and documented in an electronic case report form (eCRF). Sensitivity and specificity of the combination will be calculated through iterative permutation-response calculations. Discussion This study aims to evaluate the diagnostic capabilities of a combination of the biomarkers HFABP and NT-proBNP in LVO prediction. In contrast to most other biomarker studies to date, by employing MSUs as study centers, ultra-early levels of biomarkers can be analyzed. Point-of-care LVO detection in suspected stroke could lead to faster treatment in both urban and rural settings and thus improve functional outcomes on a broader scale. Clinical trial registration Deutsches Register klinischer Studien https://drks.de/search/de/trial/DRKS00030399, DRKS00030399.
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Affiliation(s)
- Maximilian Kaffes
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fulvio Bondi
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Frederik Geisler
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa Haacke
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Ihl
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maren Lorenz
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc S. Schehadat
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Martina Zuber
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dorothee Kübler-Weller
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jean-Charles Sanchez
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joan Montaner
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
- Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Heinrich J. Audebert
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim E. Weber
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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8
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Dixon M, Appleton JP, Siriwardena AN, Williams J, Bath PM. A systematic review of ambulance service-based randomised controlled trials in stroke. Neurol Sci 2023; 44:4363-4378. [PMID: 37405524 PMCID: PMC10641071 DOI: 10.1007/s10072-023-06910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Treatment for stroke is time-dependent, and ambulance services play a vital role in the early recognition, assessment and transportation of stroke patients. Innovations which begin in ambulance services to expedite delivery of treatments for stroke are developing. However, research delivery in ambulance services is novel, developing and not fully understood. AIMS To synthesise literature encompassing ambulance service-based randomised controlled interventions for acute stroke with consideration to the characteristics of the type of intervention, consent modality, time intervals and issues unique to research delivery in ambulance services. Online searches of MEDLINE, EMBASE, Web of Science, CENTRAL and WHO IRCTP databases and hand searches identified 15 eligible studies from 538. Articles were heterogeneous in nature and meta-analysis was partially available as 13 studies reported key time intervals, but terminology varied. Randomised interventions were evident across all points of contact with ambulance services: identification of stroke during the call for help, higher dispatch priority assigned to stroke, on-scene assessment and clinical interventions, direct referral to comprehensive stroke centres and definitive care delivery at scene. Consent methods ranged between informed patient, waiver and proxy modalities with country-specific variation. Challenges unique to the prehospital setting comprise the geographical distribution of ambulance resources, low recruitment rates, prolonged recruitment phases, management of investigational medicinal product and incomplete datasets. CONCLUSION Research opportunities exist across all points of contact between stroke patients and ambulance services, but randomisation and consent remain novel. Early collaboration and engagement between trialists and ambulance services will alleviate some of the complexities reported. REGISTRATION NUMBER PROSPERO 2018CRD42018075803.
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Affiliation(s)
- Mark Dixon
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Julia Williams
- Department of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Queens Medical Centre Campus, Nottingham, NG7 2UH, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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9
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Kaźmierski R. Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield-General concept and medical aspects. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1598-1606. [PMID: 37702254 DOI: 10.1002/jcu.23545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/14/2023]
Abstract
To present the concept of a portable ultrasound tomography device for diagnosing traumatic and vascular brain lesions. The device consisting of multiple transcranial ultrasound probes placed on the surface of the head, specifically but not exclusively in natural acoustic windows. An integral part of the mobile diagnostic system (MDS) is a decision support system based on artificial intelligence algorithms utilizing information from: head images, laboratory data, and assessment of the patient's clinical condition. The MDS can significantly reduce the time from stroke onset to rtPA therapy in civilian medical services and support therapeutic and evacuation strategies in instances of brain and skull trauma on the battlefield.
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Affiliation(s)
- Radosław Kaźmierski
- Department of Neurology, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
- Department for Neurology, Poznan University of Medical Sciences, Poznan, Poland
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10
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Zheng B, Li Y, Gu G, Yang J, Jiang J, Chen Z, Fan Y, Wang S, Pei H, Wang J. Comparing 5G mobile stroke unit and emergency medical service in patients acute ischemic stroke eligible for t-PA treatment: A prospective, single-center clinical trial in Ya'an, China. Brain Behav 2023; 13:e3231. [PMID: 37632149 PMCID: PMC10636411 DOI: 10.1002/brb3.3231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/12/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND This study aims to assess and compare the functional outcomes of patients with acute ischemic stroke (AIS) eligible for tissue plasminogen activator (t-PA) treatment who received care from either a fifth-generation(5G) mobile stroke unit (MSU) or traditional emergency medical service (EMS). METHOD The study recruited patients between February 2020 and January 2022, with the final 90-day follow-up concluded in April 2022. Prior to enrollment, patients were assigned to either EMS or MSU care based on predetermined rules. The primary outcome measure was the Modified Rankin Scale (mRS) score at 90 days, with secondary outcome measures including time metrics, mRS and National Institutes of Health Stroke Scale scores at 7-day follow-up, and hospitalization costs. RESULTS Of the 2281 enrolled patients, 207 were eligible for t-PA treatment, with 101 allocated to MSU care and 106 to EMS care. The percentage of patients achieving a favorable mRS score (0-2) at 90 days was 82.2% in the MSU group compared to 72.6% in the EMS group (p < .05). Median times from symptom onset to thrombolysis were 146 min in the MSU group and 204 min in the EMS group, while median times from ambulance alert to computed tomography (CT) completion were 53 and 128 min, respectively. Hospitalization charges averaged approximately $3592 in the MSU group and $4800 in the EMS group. CONCLUSIONS Our findings indicate that 5G MSU care significantly reduces the time from symptom onset to stroke diagnosis and intravenous thrombolysis in patients with AIS, resulting in improved functional outcomes compared to EMS care. As China continues its deployment of 5G technology and other digital infrastructures, the adoption of 5G MSU care on a broader scale may eventually supplant traditional stroke treatment approaches.
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Affiliation(s)
- Bo Zheng
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Yan Li
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Gangfeng Gu
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Jian Yang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Junyao Jiang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Zhao Chen
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Yang Fan
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Sheng Wang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Han Pei
- Department of NeurologyYa'an Peoples HospitalYa'anChina
| | - Jian Wang
- Department of NeurologyYa'an Peoples HospitalYa'anChina
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11
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Guo X, Dye J. Modern Prehospital Screening Technology for Emergent Neurovascular Disorders. Adv Biol (Weinh) 2023; 7:e2300174. [PMID: 37357150 DOI: 10.1002/adbi.202300174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/14/2023] [Indexed: 06/27/2023]
Abstract
Stroke is a serious neurological disease and a significant contributor to disability worldwide. Traditional in-hospital imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) remain the standard modalities for diagnosing stroke. The development of prehospital stroke detection devices may facilitate earlier diagnosis, initiation of stroke care, and ultimately better patient outcomes. In this review, the authors summarize the features of eight stroke detection devices using noninvasive brain scanning technology. The review summarizes the features of stroke detection devices including portable CT, MRI, transcranial Doppler ultrasound , microwave tomographic imaging, electroencephalography, near-infrared spectroscopy, volumetric impedance phaseshift spectroscopy, and cranial accelerometry. The technologies utilized, the indications for application, the environments indicated for application, the physical features of the eight stroke detection devices, and current commercial products are discussed. As technology advances, multiple portable stroke detection instruments exhibit the promising potential to expedite the diagnosis of stroke and enhance the time taken for treatment, ultimately aiding in prehospital stroke triage.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurology, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, CA, 92354, USA
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12
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Geisler F, Haacke L, Lorenz M, Schwabauer E, Wendt M, Bernhardt L, Dashti E, Freitag E, Kunz A, Hofmann-Shen C, Zuber M, Waldschmidt C, Kandil FI, Kappert K, Dang-Heine C, Lorenz-Meyer I, Audebert HJ, Weber JE. Prospective collection of blood plasma samples to identify potential biomarkers for the prehospital stroke diagnosis (ProGrEss-Bio): study protocol for a multicenter prospective observational study. Front Neurol 2023; 14:1201130. [PMID: 37483444 PMCID: PMC10359480 DOI: 10.3389/fneur.2023.1201130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/09/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are well-established, evidence-based, time-critical therapies that reduce morbidity and mortality in acute ischemic stroke (AIS) patients. The exclusion of intracerebral hemorrhage (ICH) is mandatory and has been performed by cerebral imaging to date. Mobile stroke units (MSUs) have been shown to improve functional outcomes by bringing cerebral imaging and IVT directly to the patient, but they have limited coverage. Blood biomarkers clearly distinguishing between AIS, ICH, and stroke mimics (SM) could provide an alternative to cerebral imaging if concentration changes are detectable in the hyperacute phase after stroke with high diagnostic accuracy. In this study, we will take blood samples in a prehospital setting to evaluate potential biomarkers. The study was registered in the German Clinical Trials Register (https://drks.de/search/de) with the identifier DRKS00023063. Methods and analysis We plan a prospective, observational study involving 300 patients with suspected stroke and symptom onset of ≤4.5 h before the collection of biomarkers. Study participants will be recruited from three sites in Berlin, Germany during MSU deployments. The focus of the study is the collection of blood samples from participants at the prehospital scene and from participants with AIS or ICH at a second-time point. All samples will be analyzed using targeted and untargeted analytical approaches. Study-related information about participants, including medical information and discharge diagnoses from the subsequent treating hospital, will be collected and documented in an electronic case report form (eCRF). Discussion This study will evaluate whether a single blood biomarker or a combination of biomarkers can distinguish patients with AIS and ICH from patients with stroke and SM in the early phase after symptom onset in the prehospital setting. In addition, the kinetics of blood biomarkers in AIS and ICH patients will be investigated. Our goal is to evaluate new ways to reliably diagnose stroke in the prehospital setting and thus accelerate the application of evidence-based therapies to stroke patients.
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Affiliation(s)
- Frederik Geisler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa Haacke
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maren Lorenz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Lydia Bernhardt
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Eman Dashti
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erik Freitag
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kunz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christina Hofmann-Shen
- Kliniken Beelitz, Teaching Hospital of Brandenburg Medical School Theodor Fontane, Beelitz-Heilstätten, Germany
| | - Martina Zuber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Farid I. Kandil
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kai Kappert
- Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chantip Dang-Heine
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim E. Weber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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13
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Parody-Rua E, Bustamante A, Montaner J, Rubio-Valera M, Serrano D, Pérez-Sánchez S, Sánchez-Viñas A, Guevara-Cuellar C, Serrano-Blanco A. Modeling the potential efficiency of a blood biomarker-based tool to guide pre-hospital thrombolytic therapy in stroke patients. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:621-632. [PMID: 35896861 PMCID: PMC10175459 DOI: 10.1007/s10198-022-01495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/21/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Stroke treatment with intravenous tissue-type plasminogen activator (tPA) is effective and efficient, but as its benefits are highly time dependent, it is essential to treat the patient promptly after symptom onset. This study evaluates the cost-effectiveness of a blood biomarker test to differentiate ischemic and hemorrhagic stroke to guide pre-hospital treatment with tPA in patients with suspected stroke, compared with standard hospital management. The standard care for patients suffering stroke consists mainly in diagnosis, treatment, hospitalization and monitoring. METHODS A Markov model was built with four health states according to the modified Rankin scale, in adult patients with suspected moderate to severe stroke (NIHSS 4-22) within 4.5 hours after symptom onset. A Spanish Health System perspective was used. The time horizon was 15 years. Quality-adjusted life-years (QALYs) and life-years gained (LYGs) were used as a measure of effectiveness. Short- and long-term direct health costs were included. Costs were expressed in Euros (2022). A discount rate of 3% was used. Probabilistic sensitivity analysis and several one-way sensitivity analyses were conducted. RESULTS The use of a blood-test biomarker compared with standard care was associated with more QALYs (4.87 vs. 4.77), more LYGs (7.18 vs. 7.07), and greater costs (12,807€ vs. 12,713€). The ICER was 881€/QALY. Probabilistic sensitivity analysis showed that the biomarker test was cost-effective in 82% of iterations using a threshold of 24,000€/QALY. CONCLUSIONS The use of a blood biomarker test to guide pre-hospital thrombolysis is cost-effective compared with standard hospital care in patients with ischemic stroke.
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Affiliation(s)
- Elizabeth Parody-Rua
- Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- Primary Care Prevention and Health Promotion Network (redIAPP), Barcelona, Spain
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville and Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Maria Rubio-Valera
- Head of Quality and Patient Safety, Parc Sanitari Sant Joan de Déu. Institut de Recerca Sant Joan de Déu, Sant Boi de Llobregat, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | | | - Soledad Pérez-Sánchez
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville and Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alba Sánchez-Viñas
- Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | | | - Antoni Serrano-Blanco
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.
- Parc Sanitari Sant Joan de Déu. Institut de Recerca Sant Joan de Déu, Mental Health Directorate, C/Camí Vell de la Colònia, 25, 08830, Sant Boi de Llobregat, Barcelona, Spain.
- Departament de Medicina. Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.
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14
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Bösel J, Hubert GJ, Jesser J, Möhlenbruch MA, Ringleb PA. Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion. Neurol Res Pract 2023; 5:19. [PMID: 37198694 DOI: 10.1186/s42466-023-00245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for. AIM This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO. METHOD The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels. RESULTS This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care. CONCLUSIONS The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Gordian J Hubert
- TEMPiS Telestroke Center, Department of Neurology, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Munich, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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15
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Bagot KL, Purvis T, Hancock S, Zhao H, Coote S, Easton D, Campbell BCV, Davis SM, Donnan GA, Foster S, Langenberg F, Smith K, Stephenson M, Bernard S, McGowan S, Yan B, Mitchell P, Middleton S, Cadilhac DA. Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation. J Eval Clin Pract 2023; 29:495-512. [PMID: 36648226 DOI: 10.1111/jep.13803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. AIM To identify successes and challenges in the pre- and initial operations of the first Australian MSU service from an interdisciplinary perspective. METHODS Process evaluation of the Melbourne MSU with a mixed-methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June-September 2019) and semistructured interviews (October-November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. RESULTS Participants representing executive/program operations, MSU clinicians and hospital-based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. CONCLUSIONS Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.
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Affiliation(s)
- Kathleen L Bagot
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Shaun Hancock
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Skye Coote
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Damien Easton
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia.,Stroke Foundation, Melbourne, Victoria, Australia
| | - Steve M Davis
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff A Donnan
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Shane Foster
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Francesca Langenberg
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Michael Stephenson
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | | | - Bernard Yan
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Mitchell
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Sandy Middleton
- St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Nursing Research Institute, Australian Catholic University, Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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16
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Pajor MJ, Adeoye OM. Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era. Neurotherapeutics 2023; 20:655-663. [PMID: 36977818 PMCID: PMC10047478 DOI: 10.1007/s13311-023-01371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Thrombectomy became the gold-standard treatment of acute ischemic stroke caused by large-vessel occlusions (LVO) in 2015 after five clinical trials published that year demonstrated significantly improved patient outcomes. In subsequent years, advances in stroke systems of care have centered around improving access to and expanding patient eligibility for thrombectomy. The prehospital and acute stroke treatment settings have had the greatest emphasis. Numerous prehospital stroke scales now provide emergency medical services with focused physical exams to identify LVOs, and many devices to non-invasively detect LVO are undergoing clinical testing. Mobile stroke units deployed throughout Western Europe and the USA also show promising results by bringing elements of acute stroke care directly to the patient. Numerous clinical trials since 2015 have aimed to increase candidates for thrombectomy by expanding indications and the eligibility time window. Further optimizations of thrombectomy treatment have focused on the role of thrombolytics and other adjunctive therapies that may promote neuroprotection and neurorecovery. While many of these approaches require further clinical investigation, the next decade shows significant potential for further advances in stroke care.
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Affiliation(s)
- Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
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17
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Grotta JC. Intravenous Thrombolysis for Acute Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:425-442. [PMID: 37039403 DOI: 10.1212/con.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the "time is brain" versus "tissue clock" approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions. LATEST DEVELOPMENTS The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the "time is brain" concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose "tissue clock" is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the "drip and ship" versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis. ESSENTIAL POINTS IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.
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18
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Fu C, Wang D, Wang L, Zhu L, Li Z, Chen T, Feng H, Li F. Diffuse optical detection of global cerebral ischemia in an adult porcine model. JOURNAL OF BIOPHOTONICS 2023; 16:e202200168. [PMID: 36397661 DOI: 10.1002/jbio.202200168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
Rapid screening for ischemic strokes in prehospital settings may improve patient outcomes by allowing early deployment of vascular recanalization therapies. However, there are no low-cost and convenient methods that can assess ischemic strokes in such a setting. Diffuse correlation spectroscopy (DCS) is a promising method for continuous, noninvasive transcranial monitoring of cerebral blood flow. In this study, we used a DCS system to detect cerebral hemodynamics before and after acute ischemic stroke in pigs. Seven adult porcines were chosen to establish ischemic stroke models via bilateral common carotid artery ligation (n = 5) or air emboli (n = 2). The results showed a significant difference in blood flow index (BFI) between the normal and ischemic groups. Relative blood flow index (rBFI) exhibited excellent results. Therefore, the diffuse optical method can assess the hemodynamic changes in acute cerebral ischemic stroke onset in pigs, and rBFI may be a promising biomarker for identifying cerebral ischemic stroke.
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Affiliation(s)
- Chuhua Fu
- Department of Neurosurgery of Southwest Hospital, Army Medical University, Chong Qing, People's Republic of China
- Department of Neurosurgery, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, People's Republic of China
| | - Detian Wang
- Department of Neurosurgery of Southwest Hospital, Army Medical University, Chong Qing, People's Republic of China
- Institute of Fluid Physics, China Academy of Engineering Physics, Mianyang, Sichuan, People's Republic of China
| | - Long Wang
- Department of Neurosurgery of Southwest Hospital, Army Medical University, Chong Qing, People's Republic of China
| | - Liguo Zhu
- Institute of Fluid Physics, China Academy of Engineering Physics, Mianyang, Sichuan, People's Republic of China
| | - Zeren Li
- Institute of Fluid Physics, China Academy of Engineering Physics, Mianyang, Sichuan, People's Republic of China
| | - Tunan Chen
- Department of Neurosurgery of Southwest Hospital, Army Medical University, Chong Qing, People's Republic of China
| | - Hua Feng
- Department of Neurosurgery of Southwest Hospital, Army Medical University, Chong Qing, People's Republic of China
| | - Fei Li
- Department of Neurosurgery of Southwest Hospital, Army Medical University, Chong Qing, People's Republic of China
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19
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Gao L, Parsons M, Churilov L, Zhao H, Campbell BCV, Yan B, Mitchell P, Coote S, Langenberg F, Smith K, Anderson D, Stephenson M, Davis SM, Donnan G, Easton D, Bivard A. Cost-effectiveness of tenecteplase versus alteplase for stroke thrombolysis evaluation trial in the ambulance. Eur Stroke J 2023; 8:448-455. [DOI: 10.1177/23969873231165086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: Tenecteplase administered to patients with ischaemic stroke in a mobile stroke unit (MSU) has been shown to reduce the perfusion lesion volumes and result in ultra-early recovery. We now seek to assess the cost-effectiveness of tenecteplase in the MSU. Methods: A within-trial (TASTE-A) economic analysis and a model-based long-term cost-effectiveness analysis were performed. This post hoc within-trial economic analysis utilised the patient-level data (intention to treat, ITT) prospectively collected over the trial to calculate the difference in both healthcare costs and quality-adjusted life years (QALYs, estimated from modified Rankin scale score). A Markov microsimulation model was developed to simulate the long-term costs and benefits. Results: In total, there were 104 patients with ischaemic stroke randomised to tenecteplase ( n = 55) or alteplase ( n = 49) treatment groups, respectively in the TASTE-A trial. The ITT-based analysis showed that treatment with tenecteplase was associated with non-signficantly lower costs (A$28,903 vs A$40,150 ( p = 0.056)) and greater benefits (0.171 vs 0.158 ( p = 0.457)) than that for the alteplase group over the first 90 days post the index stroke. The long-term model showed that tenecteplase led to greater savings in costs (−A$18,610) and more health benefits (0.47 QALY or 0.31 LY gains). Tenecteplase-treated patients had reduced costs for rehospitalisation (−A$1464), nursing home care (−A$16,767) and nonmedical care (−A$620) per patient. Conclusions: Treatment of ischaemic stroke patients with tenecteplase appeared to be cost-effective and improve QALYs in the MSU setting based on Phase II data. The reduced total cost from tenecteplase was driven by savings from acute hospitalisation and reduce need for nursing home care.
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20
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Al-Ajlan FS, Gladstone DJ, Song D, Thorpe KE, Swartz RH, Butcher KS, Del Campo M, Dowlatshahi D, Gensicke H, Lee GJ, Flaherty ML, Hill MD, Aviv RI, Demchuk AM. Time Course of Early Hematoma Expansion in Acute Spot-Sign Positive Intracerebral Hemorrhage: Prespecified Analysis of the SPOTLIGHT Randomized Clinical Trial. Stroke 2023; 54:715-721. [PMID: 36756899 DOI: 10.1161/strokeaha.121.038475] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 μg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. METHODS Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. RESULTS Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2-2.6). Median time from baseline CT to study drug was 62.5 (55-80) minutes, and from study drug to early post-dose CT was 19 (14.5-30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (-0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8-8.3) in the placebo arm (P=0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (-2.6 to 8.3) in the rFVIIa arm and 0.7 mL (-1.6 to 2.1) in the placebo arm (P=0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71-1.43]; P=0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994-1.003]; P=0.50; Table 3). CONCLUSIONS In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01359202.
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Affiliation(s)
- Fahad S Al-Ajlan
- Department of Neurosciences (Neurology), King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - David J Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dongbeom Song
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Canada (K.E.T.)
| | - Rick H Swartz
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, AustraliaDepartment of Medicine (Neurology), University of Alberta, Edmonton, Canada (K.S.B.)
| | - Martin Del Campo
- Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Henrik Gensicke
- Stroke Center and Neurology, University Hospital Basel, Switzerland (H.G.)
| | - Gloria Jooyoung Lee
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Richard I Aviv
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
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21
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Tanaka K, Reeves MJ. Mobile Stroke Units and Pursuit of Intravenous Tissue-Type Plasminogen Activator Treatment in the Golden Hour. Stroke 2023; 54:426-429. [PMID: 36689589 DOI: 10.1161/strokeaha.122.041391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
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22
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Rohmann JL, Piccininni M, Ebinger M, Wendt M, Weber JE, Schwabauer E, Geisler F, Freitag E, Harmel P, Lorenz-Meyer I, Rohrpasser-Napierkowski I, Nolte CH, Nabavi DG, Schmehl I, Ekkernkamp A, Endres M, Audebert HJ. Effect of Mobile Stroke Unit Dispatch in all Patients with Acute Stroke or TIA. Ann Neurol 2023; 93:50-63. [PMID: 36309933 DOI: 10.1002/ana.26541] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the effect of additional mobile stroke unit (MSU) dispatch on functional outcomes among the full spectrum of stroke patients, regardless of subtype or potential contraindications to reperfusion therapies. METHODS We used data from the nonrandomized Berlin-based B_PROUD study (02/2017 to 05/2019), in which MSUs were dispatched based solely on availability, and the linked B-SPATIAL stroke registry. All patients with final stroke or transient ischemic attack (TIA) diagnoses were eligible. The intervention under study was the additional dispatch of an MSU, an emergency physician-staffed ambulance equipped to provide prehospital imaging and thrombolytic treatment, compared to conventional ambulance alone. The primary outcome was the 3-month modified Rankin Scale (mRS) score, and the co-primary outcome was a 3-tiered disability scale. We identified confounders using directed acyclic graphs and obtained adjusted effect estimates using inverse probability of treatment weighting. RESULTS MSUs were dispatched to 1,125 patients (mean age: 74 years, 46.5% female), while for 1,141 patients only conventional ambulances were dispatched (75 years, 49.9% female). After confounding adjustment, MSU dispatch was associated with more favorable 3-month mRS scores (common odds ratio [cOR] = 0.82; 95% confidence interval [CI]: 0.71-0.94). No statistically significant association was found with the co-primary outcome (cOR = 0.86; 9% CI: 0.72-1.01) or 7-day mortality (OR = 0.94; 95% CI: 0.59-1.48). INTERPRETATION When considering the entire population of stroke/TIA patients, MSU dispatch improved 3-month functional outcomes without evidence of compromised safety. Our results are relevant for decision-makers since stroke subtype and treatment eligibility are unknown at time of dispatch. ANN NEUROL 2023;93:50-63.
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Affiliation(s)
- Jessica L Rohmann
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin (MPB) Humboldtmühle, Berlin, Germany
| | - Matthias Wendt
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Joachim E Weber
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Freitag
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Darius G Nabavi
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Ingo Schmehl
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Berlin, Germany
| | | | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,NeuroCure Cluster of Excellence, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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23
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Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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24
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Leys D, Mas JL. Quelles pistes d’avenir pour le traitement de l’infarctus cérébral aigu ? BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2023. [DOI: 10.1016/j.banm.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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25
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Deng L, Li ZQ, Yang WS, Li R, Lv XN, Li YL, Wang ZJ, Hu X, Zhao LB, Lv FJ, Yao ST, Cao F, Xie P, Li Q. Prehospital Ultra-Early Neurological Deterioration in Intracerebral Hemorrhage: Definition, Prevalence, and Association with Outcomes. Cerebrovasc Dis 2022; 52:471-479. [PMID: 36509082 DOI: 10.1159/000527545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The objective of this study was to define prehospital ultra-early neurological deterioration (UND) and to investigate the association with functional outcomes in patients with intracerebral hemorrhage (ICH). METHODS We conducted a prospective cohort study of consecutive acute ICH patients. The stroke severity at onset and hospital admission was assessed using the Chongqing Stroke Scale (CQSS), and prehospital UND was defined as a CQSS increase of ≥2 points between symptoms onset and admission. Early neurological deterioration (END) was defined as the increase of ≥4 points in NIHSS score within the first 24 h after admission. Poor outcome was defined as a modified Rankin Scale (mRS) of 4-6 at 3 months. RESULTS Prehospital UND occurred in 29 of 169 patients (17.2%). Patients with prehospital UND had a median admission NIHSS score of 17.0 as opposed to those without prehospital UND with a median NIHSS score of 8.5. There were three patterns of neurological deterioration: prehospital UND only in 21 of 169 patients (12.4%), END but without prehospital UND in 20 of 169 patients (11.8%), and continuous neurological deterioration in both phases in 8 patients (4.7%). Prehospital UND was associated with worse 3-month outcomes (median mRS score, 4.0 vs. 2.0, p = 0.002). After adjusting for age, time from onset to admission, END, and systolic blood pressure, prehospital UND was an independent predictor of poor outcome (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.26-8.48, p = 0.015). CONCLUSION Prehospital UND occurs in approximately 1 in 7 patients between symptom onset and admission and is associated with poor functional outcome in patients with ICH. Further research is needed to investigate the prehospital UND in the prehospital phase in the triage of patients with ICH.
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Affiliation(s)
- Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zuo-Qiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen-Song Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin-Ni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-Lun Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-Jie Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li-Bo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Fa-Jin Lv
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sheng-Tao Yao
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fang Cao
- Department of Neurosurgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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26
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Shownkeen H, Richards CT, Buffo K, Graham S, Iacob T, Mohajer-Esfahani M, Lindstrom A, Garg A, Gutti P, Sachdeva K, Shrivastava A, Williams J, Crumlett H, Huml J. Outcomes of Patients Receiving Thrombolysis in a Mobile Stroke Unit: a 4-Year Retrospective, Observational, Single-Center Study. PREHOSP EMERG CARE 2022:1-7. [DOI: 10.1080/10903127.2022.2142991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Harish Shownkeen
- Northwestern Medicine Central DuPage Hospital, Mobile Stroke Unit, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Christopher T. Richards
- Northwestern Medicine Central DuPage Hospital, Neuro - Interventional, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Keely Buffo
- University of Cincinnati, Emergency Medicine, 231 Albert Sabin Way, PO Box 670769, ML: 0769, Cincinnati, 45221 United States
| | - Stephen Graham
- Northwestern Medicine Central DuPage Hospital, Emergency Medicine, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Tudor Iacob
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Mehr Mohajer-Esfahani
- Northwestern Medicine Huntley Hospital, Cardiac Telemetry, 10400 Haligus Rd, Huntley, 60142-9553 United States
| | - Anne Lindstrom
- Marianjoy Rehabilitation Hospital, Rehabilitation, 26W171 Roosevelt Rd, Wheaton, 60189-0795 United States
| | - Anjali Garg
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Padmaja Gutti
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Kapil Sachdeva
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Archana Shrivastava
- Northwestern Medicine Central DuPage Hospital, Neurology, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Justin Williams
- Northwestern Medicine Central DuPage Hospital, Emergency Medical Services, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Hillary Crumlett
- Northwestern Medicine Central DuPage Hospital, Inpatient Nursing and Emergency Department, 25 N Winfield Rd, Winfield, 60190-1379 United States
| | - Jeffrey Huml
- Northwestern Medicine Central DuPage Hospital, Critical Care, 25 N Winfield Rd, Winfield, 60190-1379 United States
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27
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Al Saiegh F, Velagapudi L, Khanna O, Baldassari MP, Mouchtouris N, Hafazalla K, Roussis J, DePrince M, Tjoumakaris S, Gooch MR, Herial N, Rosenwasser RH, Jabbour P. Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via a Mobile Stroke Unit. World Neurosurg 2022; 166:e546-e550. [PMID: 35863651 DOI: 10.1016/j.wneu.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally. METHODS A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means. RESULTS Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 minutes ±77.53 vs. 483.51 minutes ±322.66, P = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86 ± 1.35 vs. 3.57 ± 1.88, P = 0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed. CONCLUSIONS Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
| | - Lohit Velagapudi
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karim Hafazalla
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Roussis
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maureen DePrince
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Napierkowski I, Lorenz-Meyer I, Hille A, Ebinger M, Freitag E, Harmel P, Endres M, Hagemann G, Koennecke HC, Mackert BM, Siegerink B, Audebert HJ. Follow-up of Patients With Stroke, Based on Opt-Out Choice Potential Approach for Acute Care Quality Registries or Observational Studies. Neurology 2022; 99:e1335-e1344. [PMID: 35918161 DOI: 10.1212/wnl.0000000000200916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 05/17/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Restricting follow-up assessment of both interventional and observational studies to patients who provide informed consent introduces relevant selection bias - particularly by underrepresenting patients with neurological communication deficits and impaired capacity to consent. Many patients who are initially unable to give consent may be willing to do so after recovery. Informing patients on study purposes and procedures with offering them the option of non-participation but not requesting explicit consent is called 'opt-out' approach. We investigated whether an opt-out strategy yields meaningful follow-up rates in an acute stroke registry with embedded controlled study. METHODS The citywide Berlin-Specific Acute Treatment in Ischemic or hAemorrhagic stroke with Long-term follow-up (B_SPATiAL) registry was designed to provide reliable information on process indicators and outcomes of specific acute stroke treatments in order to inform health care providers about quality of care and best-practice strategies including the effects of a Mobile Stroke Unit implementation. Because this information was regarded of high public interest, Berlin data protection authorities permitted data sampling without prior informed consent, employing instead follow-up assessment on "opt-out" basis. Patients were included if they had neurological symptoms at ambulance or hospital arrival within 6h of onset and had a final diagnosis of stroke or TIA. Information on data collection and outcome assessment was sent by letter to patients one month before follow-up. RESULTS From 1st Feb 2017 to 31st Jan 2020, a total of 10,597 patients were assessed. Thirty-one (0.3%) patients declined any data use, while 578 (5.5%) opted out of follow-up assessment. Of those not opting-out (n=9,988), functional outcome (modified Rankin Scale) was collected in 8,330 patients (83.4%) and vital status in 9,741 patients (97.5%). We received no complaints regarding data collection procedures. DISCUSSION Opt-out based follow-up collection offers a way to achieve high follow-up rates along with respecting patients' preferences.
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Affiliation(s)
- Ira Napierkowski
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Irina Lorenz-Meyer
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Annegret Hille
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, An der Mühle 2-9, 13507 Berlin, Germany
| | - Erik Freitag
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Harmel
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg Hagemann
- Helios Klinikum Berlin Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Hans-Christian Koennecke
- Klinik für Neurologie mit Stroke Unit; Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Bruno-Marcel Mackert
- Klinik für Neurologie mit Stroke Unit, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157 Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,Department of clinical epidemiology, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Charitéplatz 1, 10117 Berlin, Germany
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29
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Lund UH, Stoinska-Schneider A, Larsen K, Bache KG, Robberstad B. Cost-Effectiveness of Mobile Stroke Unit Care in Norway. Stroke 2022; 53:3173-3181. [PMID: 35862205 PMCID: PMC9508956 DOI: 10.1161/strokeaha.121.037491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project).
METHODS:
We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway.
RESULTS:
MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated.
CONCLUSIONS:
MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.
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Affiliation(s)
- Ulrikke Højslev Lund
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Anna Stoinska-Schneider
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
| | - Kristi G. Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
- Research and Dissemination, Østfold University College, Halden, Norway (K.G.B.)
| | - Bjarne Robberstad
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
- Department of Global Public Health and Primary Care, University of Bergen, Norway (B.R.)
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Hubert GJ, Hubert ND, Maegerlein C, Kraus F, Wiestler H, Müller-Barna P, Gerdsmeier-Petz W, Degenhart C, Hohenbichler K, Dietrich D, Witton-Davies T, Regler A, Paternoster L, Leitner M, Zeman F, Koller M, Linker RA, Bath PM, Audebert HJ, Haberl RL. Association Between Use of a Flying Intervention Team vs Patient Interhospital Transfer and Time to Endovascular Thrombectomy Among Patients With Acute Ischemic Stroke in Nonurban Germany. JAMA 2022; 327:1795-1805. [PMID: 35510389 PMCID: PMC9092197 DOI: 10.1001/jama.2022.5948] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke is highly time-dependent, and it is challenging to expedite treatment for patients in remote areas. OBJECTIVE To determine whether deployment of a flying intervention team, compared with patient interhospital transfer, is associated with a shorter time to endovascular thrombectomy and improved clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This was a nonrandomized controlled intervention study comparing 2 systems of care in alternating weeks. The study was conducted in a nonurban region in Germany including 13 primary telemedicine-assisted stroke centers within a telestroke network. A total of 157 patients with acute ischemic stroke for whom decision to pursue thrombectomy had been made and deployment of flying intervention team or patient interhospital transfer was initiated were enrolled between February 1, 2018, and October 24, 2019. The date of final follow-up was January 31, 2020. EXPOSURES Deployment of a flying intervention team for EVT in a primary stroke center vs patient interhospital transfer for EVT to a referral center. MAIN OUTCOMES AND MEASURES The primary outcome was time delay from decision to pursue thrombectomy to start of the procedure in minutes. Secondary outcomes included functional outcome after 3 months, determined by the distribution of the modified Rankin Scale score (a disability score ranging from 0 [no deficit] to 6 [death]). RESULTS Among the 157 patients included (median [IQR] age, 75 [66-80] y; 80 [51%] women), 72 received flying team care and 85 were transferred. EVT was performed in 60 patients (83%) in the flying team group vs 57 (67%) in the transfer group. Median (IQR) time from decision to pursue EVT to start of the procedure was 58 (51-71) minutes in the flying team group and 148 (124-177) minutes in the transfer group (difference, 90 minutes [95% CI, 75-103]; P < .001). There was no significant difference in modified Rankin Scale score after 3 months between patients in the flying team (n = 59) and transfer (n = 57) groups who received EVT (median [IQR] score, 3 [2-6] vs 3 [2-5]; adjusted common odds ratio for less disability, 1.91 [95% CI, 0.96-3.88]; P = .07). CONCLUSIONS AND RELEVANCE In a nonurban stroke network in Germany, deployment of a flying intervention team to local stroke centers, compared with patient interhospital transfer to referral centers, was significantly associated with shorter time to EVT for patients with acute ischemic stroke. The findings may support consideration of a flying intervention team for some stroke systems of care, although further research is needed to confirm long-term clinical outcomes and to understand applicability to other geographic settings.
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Affiliation(s)
- Gordian J. Hubert
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nikolai D. Hubert
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Frank Kraus
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Hanni Wiestler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Peter Müller-Barna
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | | | - Christoph Degenhart
- Department of Diagnostic and Interventional Radiology, München Klinik, Munich, Germany
| | - Katharina Hohenbichler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Dennis Dietrich
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Witton-Davies
- Department of Diagnostic and Interventional Radiology, München Klinik, Munich, Germany
| | - Angelika Regler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Laura Paternoster
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Miriam Leitner
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Ralf A. Linker
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Philip M. Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Heinrich J. Audebert
- Department of Neurology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Roman L. Haberl
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
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Ellens NR, Schartz D, Rahmani R, Akkipeddi SMK, Kelly AG, Benesch CG, Parker SA, Burgett JL, Proper D, Pilcher WH, Mattingly TK, Grotta JC, Bhalla T, Bender MT. Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis. Front Neurol 2022; 13:868051. [PMID: 35614916 PMCID: PMC9124821 DOI: 10.3389/fneur.2022.868051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance. Methods Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day. Results Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I2 = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I2 = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I2 = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I2 = 91%). Conclusions In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Sajal Medha K. Akkipeddi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Adam G. Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Curtis G. Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Stephanie A. Parker
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, United States
| | - Jason L. Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Webster H. Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital—Texas Medical Center, Houston, TX, United States
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
- *Correspondence: Matthew T. Bender
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Bivard A, Zhao H, Coote S, Campbell B, Churilov L, Yassi N, Yan B, Valente M, Sharobeam A, Balabanski A, Dos Santos A, Ng F, Langenberg F, Stephenson M, Smith K, Bernard S, Thijs V, Cloud G, Choi P, Ma H, Wijeratne T, Chen C, Olenko L, Davis SM, Donnan GA, Parsons M. Tenecteplase versus Alteplase for Stroke Thrombolysis Evaluation Trial in the Ambulance (Mobile Stroke Unit-TASTE-A): protocol for a prospective randomised, open-label, blinded endpoint, phase II superiority trial of tenecteplase versus alteplase for ischaemic stroke patients presenting within 4.5 hours of symptom onset to the mobile stroke unit. BMJ Open 2022; 12:e056573. [PMID: 35487712 PMCID: PMC9058803 DOI: 10.1136/bmjopen-2021-056573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mobile stroke units (MSUs) equipped with a CT scanner are increasingly being used to assess and treat stroke patients' prehospital with thrombolysis and transfer them to the most appropriate hospital for ongoing stroke care and thrombectomy when indicated. The effect of MSUs in both reducing the time to reperfusion treatment and improving patient outcomes is now established. There is now an opportunity to improve the efficacy of treatment provided by the MSU. Tenecteplase is a potent plasminogen activator, which may have benefits over the standard of care stroke lytic alteplase. Specifically, in the MSU environment tenecteplase presents practical benefits since it is given as a single bolus and does not require an infusion over an hour like alteplase. OBJECTIVE In this trial, we seek to investigate if tenecteplase, given to patients with acute ischaemic stroke as diagnosed on the MSU, improves the rate of early reperfusion. METHODS AND ANALYSIS TASTE-A is a prospective, randomised, open-label, blinded endpoint (PROBE) phase II trial of patients who had an ischaemic stroke assessed in an MSU within 4.5 hours of symptom onset. The primary endpoint is early reperfusion measured by the post-lysis volume of the CT perfusion lesion performed immediately after hospital arrival. ETHICS AND DISSEMINATION The study was approved by the Royal Melbourne Hospital Human Ethics committee. The findings will be published in peer-reviewed journals, presented at academic conferences and disseminated among consumer and healthcare professional audiences. TRIAL REGISTRATION NUMBER NCT04071613.
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Affiliation(s)
- Andrew Bivard
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Skye Coote
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Valente
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Angelos Sharobeam
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Anna Balabanski
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Angela Dos Santos
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Felix Ng
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Francesca Langenberg
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | | | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Stroke Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neurology, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, Footscray, Victoria, Australia
| | - Chushuang Chen
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liudmyla Olenko
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark Parsons
- School of Medicine and Public Health, Department of Neurology Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
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Effect of the COVID-19 Pandemic in the Prehospital Management of Patients with Suspected Acute Stroke: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084769. [PMID: 35457634 PMCID: PMC9029874 DOI: 10.3390/ijerph19084769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
Acute Ischemic Stroke (AIS) can be successfully handled if it is noticed early in the prehospital setting and immediately diagnosed in the emergency department (ED). The coronavirus pandemic has altered the way health care is delivered and has had a profound impact on healthcare delivery. The effects could include prioritizing the prevention of COVID-19 spread, which could result in the discontinuation or deferral of non-COVID-19 care. We used the National Emergency Medical Service Command Support System, a register of medical interventions performed by emergency medical services (EMS) in Poland, to assess the impact of the COVID-19 epidemic across the Masovian Voivodeship on suspected stroke patients’ baseline characteristics, prehospital vital parameters, clinical and neurological status, emergency procedures performed on the prehospital phase and EMS processing times. Between 1 April 2019 and 30 April 2021, the study population included 18,922 adult suspected stroke patients who were treated by EMS teams, with 18,641 admitted to the emergency departments. The overall number of suspected stroke patients treated by EMS remained unchanged during COVID-19 compared to the pre-COVID-19 period; however, the average time from call to hospital admission increased by 15 min.
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Navi BB, Audebert HJ, Alexandrov AW, Cadilhac DA, Grotta JC. Mobile Stroke Units: Evidence, Gaps, and Next Steps. Stroke 2022; 53:2103-2113. [PMID: 35331008 DOI: 10.1161/strokeaha.121.037376] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mobile stroke units (MSUs) are specialized ambulances equipped with the personnel, equipment, and imaging capability to diagnose and treat acute stroke in the prehospital setting. Over the past decade, MSUs have proliferated throughout the world, particularly in European and US cities, culminating in the formation of an international consortium. Randomized trials have demonstrated that MSUs increase stroke thrombolysis rates and reduce onset-to-treatment times but until recently it was uncertain if these advantages would translate into better patient outcomes. In 2021, 2 pivotal, large, controlled clinical trials, B_PROUD and BEST-MSU, demonstrated that as compared with conventional emergency care, treatment aboard MSUs was safe and led to improved functional outcomes in patients with stroke. Further, the observed benefit of MSUs appeared to be primarily driven by the higher frequency of ultra-early thrombolysis within the golden hour. Nevertheless, questions remain regarding the cost-effectiveness of MSUs, their utility in nonurban settings, and optimal infrastructure. In addition, in much of the world, MSUs are currently not reimbursed by insurers nor accepted as standard care by regulatory bodies. As MSUs are now established as one of the few proven acute stroke interventions with an effect size that is comparable to that of intravenous thrombolysis and stroke units, stroke leaders and organizations should work with emergency medical services, governments, and community stakeholders to determine how MSUs might benefit individual communities, and their optimal organization and financing. Future research to explore the effect of MSUs on intracranial hemorrhage and thrombectomy outcomes, cost-effectiveness, and novel models including the use of rendezvous transports, helicopters, and advanced neuroimaging is ongoing. Recommended next steps for MSUs include reimbursement by insurers, integration with ambulance networks, recognition by program accreditors, and inclusion in registries that monitor care quality.
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Affiliation(s)
- Babak B Navi
- Department of Neurology and Brain and Mind Research Institute, Weill Cornell Medicine and NewYork-Presbyterian Hospital' New York (B.B.N.)
| | - Heinrich J Audebert
- Department of Neurology, Center for Stroke Research, Charite-Universitatsmedizin, Berlin, Germany (H.J.A.)
| | | | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia (D.A.C.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston
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Chen J, Lin X, Cai Y, Huang R, Yang S, Zhang G. A Systematic Review of Mobile Stroke Unit Among Acute Stroke Patients: Time Metrics, Adverse Events, Functional Result and Cost-Effectiveness. Front Neurol 2022; 13:803162. [PMID: 35356455 PMCID: PMC8959845 DOI: 10.3389/fneur.2022.803162] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 12/23/2022] Open
Abstract
BackgroundMobile stroke unit (MSU) is deployed to shorten the duration of ischemic stroke recognition to thrombolysis treatment, thus reducing disability, mortality after an acute stroke attack, and related economic burden. Therefore, we conducted a comprehensive systematic review of the clinical trial and economic literature focusing on various outcomes of MSU compared with conventional emergency medical services (EMS).MethodsAn electronic search was conducted in four databases (PubMed, OVID Medline, Embase, and the Cochrane Controlled Register of Trials) from 1990 to 2021. In these trials, patients with acute stroke were assigned to receive either MSU or EMS, with clinical and economic outcomes. First, we extracted interested data in the pooled population and conducted a subgroup analysis to examine related heterogeneity. We then implemented a descriptive analysis of economic outcomes. All analyses were performed with R 4.0.1 software.ResultsA total of 22,766 patients from 16 publications were included. In total 7,682 (n = 33.8%) were treated in the MSU and 15,084 (n = 66.2%) in the conventional EMS. Economic analysis were available in four studies, of which two were based on trial data and the others on model simulations. The pooled analysis of time metrics indicated a mean reduction of 32.64 min (95% confidence interval: 23.38–41.89, p < 0.01) and 28.26 minutes (95% CI: 16.11–40.41, p < 0.01) in the time-to-therapy and time-to-CT completion, respectively in the MSU. However, there was no significant difference on stroke-related neurological events (OR = 0.94, 95% CI: 0.70–1.27, p = 0.69) and in-hospital mortality (OR = 1.11, 95% CI: 0.83–1.50, p = 0.48) between the MSU and EMS. The proportion of patients with modified Ranking scale (mRS) of 0–2 at 90 days from onset was higher in the MSU than EMS (p < 0.05). MSU displayed favorable benefit-cost ratios (2.16–6.85) and incremental cost-effectiveness ratio ($31,911 /QALY and $38,731 per DALY) comparing to EMS in multiple economic publications. Total cost data based on 2014 USD showed that the MSU has the highest cost in Australia ($1,410,708) and the lowest cost in the USA ($783,463).ConclusionA comprehensive analysis of current research suggests that MUS, compared with conventional EMS, has a better performance in terms of time metrics, safety, long-term medical benefits, and cost-effectiveness.
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Affiliation(s)
- Jieyun Chen
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
- *Correspondence: Jieyun Chen
| | - Xiaoying Lin
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Yali Cai
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Risheng Huang
- Quanzhou First Hospital, Fujian Medical University, Fujian, China
| | - Songyu Yang
- Department of Radiology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
| | - Gaofeng Zhang
- Department of Radiology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Turc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, Yamal JM, Bowry R, Katsanos AH, Zhao H, Donnan G, Davis SM, Hussain MS, Uchino K, Helwig SA, Johns H, Weber JE, Nolte CH, Kunz A, Steiner T, Sacco S, Ebinger M, Tsivgoulis G, Faßbender K, Audebert HJ. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:281-290. [PMID: 35129584 PMCID: PMC8822443 DOI: 10.1001/jamaneurol.2021.5321] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care. OBJECTIVE To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS). DATA SOURCES MEDLINE, Cochrane Library, and Embase from 1960 to 2021. STUDY SELECTION Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies. DATA EXTRACTION AND SYNTHESIS Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days). RESULTS Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT. CONCLUSIONS AND RELEVANCE Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France,Université de Paris, Paris, France,INSERM U1266, Paris, France,FHU Neurovasc, Paris, France
| | | | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Leonid Churilov
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital–Texas Medical Center, Houston
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health, Houston
| | - Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University Population Health Research Institute, Hamilton, Ontario, Canada,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Geoffrey Donnan
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Stephen M. Davis
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Muhammad S. Hussain
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Hannah Johns
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
| | - Alexander Kunz
- Klinik für Neurologie, Neurologische Intensivmedizin, Zentrum für Hirngefäßerkrankungen, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Martin Ebinger
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany,Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Klaus Faßbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
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Hariharan P, Tariq MB, Grotta JC, Czap AL. Mobile Stroke Units: Current Evidence and Impact. Curr Neurol Neurosci Rep 2022; 22:71-81. [PMID: 35129761 DOI: 10.1007/s11910-022-01170-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Several approaches have been developed to optimize prehospital systems for acute stroke given poor access and significant delays to timely treatment. Specially equipped ambulances that directly initiate treatment, known as Mobile Stroke Units (MSUs), have rapidly proliferated across the world. This review provides a comprehensive summary on the efficacy of MSUs in acute stroke, its various applications beyond thrombolysis, as well as the establishment, optimal setting and cost-effectiveness of incorporating an MSU into healthcare systems. RECENT FINDINGS MSUs speed stroke treatment into the first "golden hour" when better outcomes from thrombolysis are achieved. While evidence for the positive impact of MSUs on outcomes was previously unavailable, two recent landmark controlled trials, B_PROUD and BEST-MSU, show that MSUs result in significantly lesser disability compared to conventional ambulance care. Emerging literature prove the significant impact of MSUs. Adaptability however remains limited by significant upfront financial investment, challenges with reimbursements and pending evidence on their cost-effectiveness.
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Affiliation(s)
- Praveen Hariharan
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - Muhammad Bilal Tariq
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA.
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El Khoury C, Aboa‐Eboule C, Fraticelli L, Claustre C, Bischoff M, Blanc‐Lasserre K, Buisson M, Cakmak S, Cho T, Ferroud‐Plattet B, Guerrier O, Philippeau F, Serre P, Mechtouff L, Nighoghossian N, Ruzteroltz T, Vallet A, Ong E, Derex L. Temporal trends in reperfusion therapy for patients with acute ischemic stroke. J Am Coll Emerg Physicians Open 2022; 3:e12654. [PMID: 35079735 PMCID: PMC8769069 DOI: 10.1002/emp2.12654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/25/2021] [Accepted: 12/28/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To analyze the temporal trends in thrombolysis rates after implementation of a regional emergency network for acute ischemic stroke (AIS). METHODS We conducted a retrospective study based on a prospective multicenter observational registry. The AIS benefited from reperfusion therapy included in 1 of the 5 primary stroke units or 1 comprehensive stroke center and 37 emergency departments were included using a standardized case report form. The population covers 3 million inhabitants. RESULTS In total, 32,319 AIS was reported in the regional hospitalization database of which 2215 thrombolyzed AIS patients were included in the registry and enrolled in this study. The annual incidence rate of thrombolysis continuously and significantly increased from 2010 to 2018 (10.2% to 17.3%, P-trend = 0.0013). The follow-up of the onset-to-door and the door-to-needle delays over the study period showed stable rates, as did the all-cause mortality rate at 3-months (13.2%). CONCLUSION Although access to stroke thrombolysis has increased linearly since 2010, the 3-month functional outcome has not evolved as favorably. Further efforts must focus on reducing hospital delays.
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Affiliation(s)
- Carlos El Khoury
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
- Clinical Research Unit and Emergency DepartmentMédipôle Hôpital MutualisteLyonFrance
| | | | - Laurie Fraticelli
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
- Health, Systemic, ProcessEA 4129 Research UnitUniversity Claude Bernard Lyon 1LyonFrance
| | | | - Magali Bischoff
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
| | | | - Marielle Buisson
- Hospices Civils de LyonCardiologic Hospital Louis PradelLyonFrance
| | | | - Tee‐hi Cho
- Stroke UnitPierre Wertheimer HospitalLyonFrance
| | | | | | | | - Patrice Serre
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
- Department of Emergency MedicineBourg‐en‐Bresse HospitalBourg‐en‐BresseFrance
| | - Laura Mechtouff
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
| | | | | | | | - Elodie Ong
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
| | - Laurent Derex
- Auvergne Rhône‐Alpes Agency for HealthRESCUe NetworkLyonFrance
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Pre-hospital transdermal glyceryl trinitrate in patients with stroke mimics: data from the RIGHT-2 randomised-controlled ambulance trial. BMC Emerg Med 2022; 22:2. [PMID: 35012462 PMCID: PMC8744321 DOI: 10.1186/s12873-021-00560-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prehospital stroke trials will inevitably recruit patients with non-stroke conditions, so called stroke mimics. We undertook a pre-specified analysis to determine outcomes in patients with mimics in the second Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2). METHODS RIGHT-2 was a prospective, multicentre, paramedic-delivered, ambulance-based, sham-controlled, participant-and outcome-blinded, randomised-controlled trial of transdermal glyceryl trinitrate (GTN) in adults with ultra-acute presumed stroke in the UK. Final diagnosis (intracerebral haemorrhage, ischaemic stroke, transient ischaemic attack, mimic) was determined by the hospital investigator. This pre-specified subgroup analysis assessed the safety and efficacy of transdermal GTN (5 mg daily for 4 days) versus sham patch among stroke mimic patients. The primary outcome was the 7-level modified Rankin Scale (mRS) at 90 days. RESULTS Among 1149 participants in RIGHT-2, 297 (26%) had a final diagnosis of mimic (GTN 134, sham 163). The mimic group were younger, mean age 67 (SD: 18) vs 75 (SD: 13) years, had a longer interval from symptom onset to randomisation, median 75 [95% CI: 47,126] vs 70 [95% CI:45,108] minutes, less atrial fibrillation and a lower systolic blood pressure and Face-Arm-Speech-Time tool score than the stroke group. The three most common mimic diagnoses were seizure (17%), migraine or primary headache disorder (17%) and functional disorders (14%). At 90 days, the GTN group had a better mRS score as compared to the sham group (adjusted common odds ratio 0.54; 95% confidence intervals 0.34, 0.85; p = 0.008), a difference that persisted at 365 days. There was no difference in the proportion of patients who died in hospital, were discharged to a residential care facility, or suffered a serious adverse event. CONCLUSIONS One-quarter of patients suspected by paramedics to have an ultra-acute stroke were subsequently diagnosed with a non-stroke condition. GTN was associated with unexplained improved functional outcome observed at 90 days and one year, a finding that may represent an undetected baseline imbalance, chance, or real efficacy. GTN was not associated with harm. TRIAL REGISTRATION This trial is registered with International Standard Randomised Controlled Trials Number ISRCTN 26986053 .
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Osuegbu OI, Adeniji FO, Owhonda GC, Kanee RB, Aigbogun EO. Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580211067939. [PMID: 35049398 PMCID: PMC8785286 DOI: 10.1177/00469580211067939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.
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Affiliation(s)
- Osborne Ikechuckwu Osuegbu
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | - Foluke Olukemi Adeniji
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | | | - Rogers Bariture Kanee
- Institute of Geo-Science and Space Technology, 108005Rivers State University, Oroworukwo, Nigeria
| | - Eric Osamudiamwen Aigbogun
- Department of Public Health, Faculty of Sciences and Technology, 248428Cavendish University Uganda, Kampala, Uganda
- Center for Occupational Health and Safety, Institute of Petroleum Studies, 327041University of Port Harcourt, Choba, Nigeria
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Czap AL, Harmel P, Audebert H, Grotta JC. Stroke Systems of Care and Impact on Acute Stroke Treatment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Design of Stroke-Related Clinical Trials. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Bender MT, Mattingly TK, Rahmani R, Proper D, Burnett WA, Burgett JL, LEsperance J, Cushman JT, Pilcher WH, Benesch CG, Kelly AG, Bhalla T. Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy. Stroke Vasc Neurol 2021; 7:209-214. [PMID: 34952889 PMCID: PMC9240459 DOI: 10.1136/svn-2021-001119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes. OBJECTIVE Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes. RESULTS Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable. CONCLUSIONS Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Walter A Burnett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason L Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Joshua LEsperance
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Webster H Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Cook D, Brown H, Widanapathirana I, Shah D, Walsham J, Trakic A, Zhu G, Zamani A, Guo L, Brankovic A, Al-Saffar A, Stancombe A, Bialkowski A, Nguyen P, Bialkowski K, Crozier S, Abbosh A. Case Report: Preliminary Images From an Electromagnetic Portable Brain Scanner for Diagnosis and Monitoring of Acute Stroke. Front Neurol 2021; 12:765412. [PMID: 34777233 PMCID: PMC8589013 DOI: 10.3389/fneur.2021.765412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Electromagnetic imaging is an emerging technology which promises to provide a mobile, and rapid neuroimaging modality for pre-hospital and bedside evaluation of stroke patients based on the dielectric properties of the tissue. It is now possible due to technological advancements in materials, antennae design and manufacture, rapid portable computing power and network analyses and development of processing algorithms for image reconstruction. The purpose of this report is to introduce images from a novel, portable electromagnetic scanner being trialed for bedside and mobile imaging of ischaemic and haemorrhagic stroke. Methods: A prospective convenience study enrolled patients (January 2020 to August 2020) with known stroke to have brain electromagnetic imaging, in addition to usual imaging and medical care. The images are obtained by processing signals from encircling transceiver antennae which emit and detect low energy signals in the microwave frequency spectrum between 0.5 and 2.0 GHz. The purpose of the study was to refine the imaging algorithms. Results: Examples are presented of haemorrhagic and ischaemic stroke and comparison is made with CT, perfusion and MRI T2 FAIR sequence images. Conclusion: Due to speed of imaging, size and mobility of the device and negligible environmental risks, development of electromagnetic scanning scanner provides a promising additional modality for mobile and bedside neuroimaging.
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Affiliation(s)
- David Cook
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Helen Brown
- Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | | | - Darshan Shah
- Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - James Walsham
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Adnan Trakic
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Guohun Zhu
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Ali Zamani
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Lei Guo
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Aida Brankovic
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Ahmed Al-Saffar
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Anthony Stancombe
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Alina Bialkowski
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Phong Nguyen
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Konstanty Bialkowski
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Stuart Crozier
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Amin Abbosh
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
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Demel SL, Stanton R, Aziz YN, Adeoye O, Khatri P. Reflection on the Past, Present, and Future of Thrombolytic Therapy for Acute Ischemic Stroke. Neurology 2021; 97:S170-S177. [PMID: 34785615 DOI: 10.1212/wnl.0000000000012806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 05/26/2021] [Indexed: 11/15/2022] Open
Abstract
More than 25 years have passed since the US Food and Drug Administration approved IV recombinant tissue plasminogen activator (alteplase) for the treatment of acute ischemic stroke. This landmark decision brought a previously untreatable disease into a new therapeutic landscape, providing inspiration for clinicians and hope to patients. Since that time, the use of alteplase in the clinical setting has become standard of care, continually improving with quality measures such as door-to-needle times and other metrics of specialized stroke unit care. The past decade has seen more widespread use of alteplase in the prehospital setting with mobile stroke units and telestroke and beyond initial time windows via the use of CT perfusion or MRI. Simultaneously, the position of alteplase is being challenged by new lytics and by the concept of its bypass altogether in the era of endovascular therapy. We provide an overview of alteplase, including its earliest trials and how they have shaped the current therapeutic landscape of ischemic stroke treatment, and touch on new frontiers for thrombolytic therapy. We highlight the critical role of thrombolytic therapy in the past, present, and future of ischemic stroke care.
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Affiliation(s)
- Stacie L Demel
- From the Department of Neurology (S.L.D., R.S., Y.N.A., P.K.), University of Cincinnati, OH; and Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO.
| | - Robert Stanton
- From the Department of Neurology (S.L.D., R.S., Y.N.A., P.K.), University of Cincinnati, OH; and Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO
| | - Yasmin N Aziz
- From the Department of Neurology (S.L.D., R.S., Y.N.A., P.K.), University of Cincinnati, OH; and Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO
| | - Opeolu Adeoye
- From the Department of Neurology (S.L.D., R.S., Y.N.A., P.K.), University of Cincinnati, OH; and Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO
| | - Pooja Khatri
- From the Department of Neurology (S.L.D., R.S., Y.N.A., P.K.), University of Cincinnati, OH; and Department of Emergency Medicine (O.A.), Washington University, St. Louis, MO
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Richter D, Eyding J, Weber R, Bartig D, Misselwitz B, Grau A, Krogias C. The level of urbanization influences acute ischemic stroke care: A nationwide ecological study from Germany. J Neurol Sci 2021; 430:119983. [PMID: 34534884 DOI: 10.1016/j.jns.2021.119983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Regional differences in acute ischemic stroke (AIS) care are still reported for Germany but not fully understood. We aimed to analyze the impact of the level of urbanization on the application of proved treatment procedures and the incidence of hospitalized AIS cases in Germany. METHODS The level of urbanization of the 401 districts and district-free cities in Germany was defined according to the Federal Institute for Building, Urban Affairs and Spatial Research classification. Using nationwide administrative data, the application of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and the incidence of hospitalizations for AIS, were analyzed according to the place of residence of the patients. Data included all patients hospitalized for AIS in 2019 (n = 224,274) and sociodemographic information of 83,019,213 residents in Germany. RESULTS Sparsely populated districts had a significantly higher incidence of hospitalizations for AIS than cities (age-standardized: 271.8 versus 242.3 per 100,000 inhabitants, P < 0.001), but a lower use of MT (5.7% versus 8.4%, P < 0.001). In the adjusted negative binomial regression model, rurality remained an independent predictor for MT use and the incidence of AIS hospitalizations. The proportion of IVT did not significantly differ between sparsely populated districts and cities (15.6% versus 17.2%, P = 0.021). CONCLUSIONS Although there is a dense network of stroke units in Germany, the level of urbanization still influences AIS care, as we found a lower proportion of MT and a higher incidence of AIS hospitalizations in Germany's rural areas.
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Affiliation(s)
- Daniel Richter
- Department of Neurology, St. Josef-Hospital Bochum, Ruhr University Bochum, Germany
| | - Jens Eyding
- Medical Faculty, Ruhr University Bochum, Germany; Department of Neurology, Gemeinschaftskrankenhaus Herdecke, Germany
| | - Ralph Weber
- Medical Faculty, Ruhr University Bochum, Germany; Department of Neurology, Alfried Krupp Krankenhaus Essen, Germany
| | - Dirk Bartig
- Department of Neurology, St. Josef-Hospital Bochum, Ruhr University Bochum, Germany
| | | | - Armin Grau
- Department of Neurology, Klinikum der Stadt Ludwigshafen a.Rh., Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital Bochum, Ruhr University Bochum, Germany; Medical Faculty, Ruhr University Bochum, Germany.
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Davis SM, Donnan GA. Ischemic Penumbra: A Personal View. Cerebrovasc Dis 2021; 50:656-665. [PMID: 34736251 DOI: 10.1159/000519730] [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: 08/09/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
The concept of the ischemic penumbra was defined over 40 years ago by Lindsay Symon and his group and is now an established principle of all acute ischemic stroke therapies. These reperfusion treatments rescue threatened, critically hypoperfused brain tissue and have been proven to improve clinical outcomes. We have been fortunate to have observed and played a small part in the penumbral story from its beginnings in the 1970s to its pivotal position today. Over this period, we have witnessed penumbral imaging evolve from positron emission tomography through to magnetic resonance imaging and now predominantly computed tomography perfusion, with the advent of automated imaging facilitating case selection for reperfusion therapies. We and others have conducted clinical trials using penumbral imaging to extend the time window for intravenous thrombolysis and select patients for thrombectomy. Together with the concept of fast- and slow-growing ischemic infarct patterns, this embeds the penumbral principle in everyday clinical management. The opportunity now exists to make penumbral imaging even more portable, affordable, and more widely available using mobile platforms, novel imaging techniques, digital linkage, and artificial intelligence.
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Affiliation(s)
- Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Victoria, Victoria, Australia
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Victoria, Victoria, Australia
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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