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Almubayyidh M, Parry-Jones AR, Jenkins DA. Development and internal validation of prehospital prediction models for identifying intracerebral haemorrhage in suspected stroke patients. BMJ Neurol Open 2024; 6:e000878. [PMID: 39493673 PMCID: PMC11529750 DOI: 10.1136/bmjno-2024-000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 09/29/2024] [Indexed: 11/05/2024] Open
Abstract
Introduction Distinguishing patients with intracerebral haemorrhage (ICH) from other suspected stroke cases in the prehospital setting is crucial for determining the appropriate level of care and minimising the onset-to-treatment time, thereby potentially improving outcomes. Therefore, we developed prehospital prediction models to identify patients with ICH among suspected stroke cases. Methods Data were obtained from the Field Administration of Stroke Therapy-Magnesium prehospital stroke trial, where paramedics evaluated multiple variables in suspected stroke cases within the first 2 hours from the last known well time. A total of 19 candidate predictors were included to minimise overfitting and were subsequently refined through the backward exclusion of non-significant predictors. We used logistic regression and eXtreme Gradient Boosting (XGBoost) models to evaluate the performance of the predictors. Model performance was assessed using the area under the receiver operating characteristic curve (AUC), confusion matrix metrics and calibration measures. Additionally, models were internally validated and corrected for optimism through bootstrapping. Furthermore, a nomogram was built to facilitate paramedics in estimating the probability of ICH. Results We analysed 1649 suspected stroke cases, of which 373 (23%) were finally diagnosed with ICH. From the 19 candidate predictors, 9 were identified as independently associated with ICH (p<0.05). Male sex, arm weakness, worsening neurological status and high systolic blood pressure were positively associated with ICH. Conversely, a history of hyperlipidaemia, atrial fibrillation, coronary artery disease, ischaemic stroke and improving neurological status were associated with other diagnoses. Both logistic regression and XGBoost demonstrated good calibration and predictive performance, with optimism-corrected sensitivities ranging from 47% to 49%, specificities from 89% to 90% and AUCs from 0.796 to 0.801. Conclusions Our models demonstrate good predictive performance in distinguishing patients with ICH from other diagnoses, making them potentially useful tools for prehospital ICH management.
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Affiliation(s)
- Mohammed Almubayyidh
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Department of Aviation and Marine, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Podlasek A, Walter S, Licenik R, Grunwald I. Professor Klaus Fassbender: The Father of Mobile Stroke Units. Cureus 2024; 16:e69050. [PMID: 39391442 PMCID: PMC11465001 DOI: 10.7759/cureus.69050] [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] [Accepted: 09/09/2024] [Indexed: 10/12/2024] Open
Abstract
Professor Klaus Fassbender is a distinguished neurologist from Germany, widely recognized for his groundbreaking contributions to the fields of neurology and neurodegenerative disease. His work has been pivotal in advancing our understanding of the pathophysiological mechanisms underlying neurodegenerative disorders, including Alzheimer's and Parkinson's disease, as well as in refining therapeutic strategies for their treatment. His studies in cerebrovascular disease have elucidated the complex molecular and cellular processes involved in ischemic and hemorrhagic stroke, leading to the development of novel therapeutic interventions, often bridging the gap between laboratory discoveries and their application in clinical settings. Professor Klaus Fassbender is "the father" of the mobile stroke unit (MSU). With the "time is brain" concept in mind, he proposed and developed the MSU concept for the first time, allowing prehospital stroke imaging, diagnosis, and treatment directly at the site of emergency. This concept reduced times between symptoms onset and treatment, resulting in an increased proportion of patients receiving treatment within "the golden hour" and leading to the improvement of functional outcomes at 90 days. Professor Fassbender's work has been instrumental in shaping contemporary approaches to diagnosing and managing stroke and neurodegenerative disease, making him a leading figure in modern neurology.
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Affiliation(s)
- Anna Podlasek
- Image Guided Therapy Research Facility (IGTRF), University of Dundee, Dundee, GBR
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, GBR
- Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, GBR
| | - Silke Walter
- Department of Neurology, Saarland University Clinic, Homburg, DEU
| | - Radim Licenik
- Acute Stroke Centre, North West Anglia NHS Foundation Trust, Peterborough, GBR
- Zlin Regional, Emergency Medical Services, Zlin, CZE
| | - Iris Grunwald
- Image Guided Therapy Research Facility (IGTRF), University of Dundee, Dundee, GBR
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, GBR
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Rink JS, Froelich MF, Nour M, Saver JL, Szabo K, Hoyer C, Fassbender KC, Schoenberg SO, Tollens F. Lifetime economic potential of mobile stroke units in acute stroke care: A model-based analysis of the drivers of cost-effectiveness. J Telemed Telecare 2024; 30:1335-1344. [PMID: 36484406 DOI: 10.1177/1357633x221140951] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND PURPOSE To simulate patient-level costs, analyze the economic potential of telemedicine-based mobile stroke units for acute prehospital stroke care, and identify major determinants of cost-effectiveness, based on two recent prospective trials from the United States and Germany. METHODS A Markov decision model was developed to simulate lifetime costs and outcomes of mobile stroke unit. The model compares diagnostic and therapeutic pathways of ischemic stroke, hemorrhagic stroke, and stroke mimic patients by conventional care or by mobile stroke units. The treatment outcomes were derived from the B_PROUD and the BEST-mobile stroke unit trials and further input parameters were derived from recent literature. Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. A lifetime horizon based on the US healthcare system was adopted to evaluate different cost thresholds for mobile stroke unit and the resulting cost-effectiveness. Willingness-to-pay thresholds were set at 1x and 3x gross domestic product per capita, as recommended by the World Health Organization. RESULTS In the base case scenario, mobile stroke unit care yielded an incremental gain of 0.591 quality-adjusted life years per dispatch. Mobile stroke unit was highly cost-effective up to a maximum average cost of 43,067 US dollars per patient. Sensitivity analyses revealed that MSU cost-effectiveness is mainly affected by reduction of long-term disability costs. Also, among other parameters, the rate of stroke mimics patients diagnosed by MSU plays an important role. CONCLUSION This study demonstrated that mobile stroke unit can possibly be operated on an excellent level of cost-effectiveness in urban areas in North America with number of stroke mimic patients and long-term stroke survivor costs as major determinants of lifetime cost-effectiveness.
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Affiliation(s)
- Johann S Rink
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
| | - Matthias F Froelich
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
| | - May Nour
- Departments of Neurology and Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kristina Szabo
- Department of Neurology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany, Mannheim, BW, Germany
| | - Carolin Hoyer
- Department of Neurology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany, Mannheim, BW, Germany
| | - Klaus C Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Stefan O Schoenberg
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
| | - Fabian Tollens
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Mannheim, BW, Germany
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Almubayyidh M, Alghamdi I, Parry-Jones AR, Jenkins D. Prehospital identification of intracerebral haemorrhage: a scoping review of early clinical features and portable devices. BMJ Open 2024; 14:e079316. [PMID: 38643005 PMCID: PMC11033659 DOI: 10.1136/bmjopen-2023-079316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 03/26/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Prehospital identification of intracerebral haemorrhage (ICH) in suspected stroke cases may enable the initiation of appropriate treatments and facilitate better-informed transport decisions. This scoping review aims to examine the literature to identify early clinical features and portable devices for the detection of ICH in the prehospital setting. METHODS Three databases were searched via Ovid (MEDLINE, EMBASE and CENTRAL) from inception to August 2022 using prespecified search strategies. One reviewer screened all titles, abstracts and full-text articles for eligibility, while a second reviewer independently screened 20% of the literature during each screening stage. Data extracted were tabulated to summarise the key findings. RESULTS A total of 6803 articles were screened for eligibility, of which 22 studies were included for analysis. Among them, 15 studies reported on early clinical features, while 7 considered portable devices. Associations between age, sex and comorbidities with the presence of ICH varied across studies. However, most studies reported that patients with ICH exhibited more severe neurological deficits (n=6) and higher blood pressure levels (n=11) at onset compared with other stroke and non-stroke diagnoses. Four technologies were identified for ICH detection: microwave imaging technology, volumetric impedance phase shift spectroscopy, transcranial ultrasound and electroencephalography. Microwave and ultrasound imaging techniques showed promise in distinguishing ICH from other diagnoses. CONCLUSION This scoping review has identified potential clinical features for the identification of ICH in suspected stroke patients. However, the considerable heterogeneity among the included studies precludes meta-analysis of available data. Moreover, we have explored portable devices to enhance ICH identification. While these devices have shown promise in detecting ICH, further technological development is required to distinguish between stroke subtypes (ICH vs ischaemic stroke) and non-stroke diagnoses.
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Affiliation(s)
- Mohammed Almubayyidh
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Aviation and Marine, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Alghamdi
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Emergency Medical Services, College of Applied Medical Sciences, Khamis Mushait Campus, King Khalid University, Abha, Saudi Arabia
| | - Adrian Robert Parry-Jones
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
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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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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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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: 2] [Impact Index Per Article: 1.0] [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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Choi J, Petrone A, Adcock A. A Case for the Non-Neurologist Telestroke Provider. Front Neurol 2021; 12:651519. [PMID: 34421782 PMCID: PMC8377720 DOI: 10.3389/fneur.2021.651519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations. Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test. Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group. Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.
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Affiliation(s)
- Justin Choi
- School of Medicine, West Virginia University, Morgantown, WV, United States
| | - Ashley Petrone
- Department of Neurology, West Virginia University Hospitals, Morgantown, WV, United States
| | - Amelia Adcock
- Department of Neurology, West Virginia University Hospitals, Morgantown, WV, United States.,Department of Neurology, Mayo Clinic, Phoenix, AZ, United States
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9
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Chowdhury SZ, Baskar PS, Bhaskar S. Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta-analysis. Acad Emerg Med 2021; 28:781-801. [PMID: 33387368 DOI: 10.1111/acem.14204] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. METHODS The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta-analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large-vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR] = 1.80, 95% confidence interval [CI] = 1.18 to 2.75); however, MSU did not (RR = 1.22, 95% CI = 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD] = -0.82, 95% CI = -1.32 to -0.32), LVO bypass (SMD = -0.80, 95% CI = -1.13 to -0.47), and MSU (SMD = -0.87, 95% CI = -1.57 to -0.17) were found to significantly reduce door-to-needle time for IVT. MSU was found to significantly reduce call-to-needle (SMD = -1.41, 95% CI = -1.94 to -0.88) and onset-to-needle (SMD = -1.15, 95% CI = -1.74 to -0.56) times for IVT. MSU additionally demonstrated significant reduction in door-to-perfusion (SMD = -0.72, 95% CI = -1.32 to -0.12) as well as call-to-perfusion (SMD = -0.73, 95% CI = -1.08 to -0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR = 1.04, 95% CI = 0.97 to 1.12) or mortality at 90 days (RR = 1.00, 95% CI = 0.76 to 1.31). CONCLUSIONS This systematic review and meta-analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often-neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis-à-vis PSWOs are warranted.
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Affiliation(s)
- Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Sonu Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
- Department of Neurology & Neurophysiology Liverpool Hospital & South West Sydney Local Health District (SWSLHD Sydney New South Wales Australia
- Stroke & Neurology Research Group Ingham Institute for Applied Medical Research Sydney New South Wales Australia
- NSW Brain Clot BankNSW Health Statewide Biobank and NSW Health Pathology Sydney New South Wales Australia
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10
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Advani R. Addressing the Stroke Triage Challenge. Front Neurol 2021; 12:670204. [PMID: 33935959 PMCID: PMC8081897 DOI: 10.3389/fneur.2021.670204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
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11
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Bustamante A, Penalba A, Orset C, Azurmendi L, Llombart V, Simats A, Pecharroman E, Ventura O, Ribó M, Vivien D, Sanchez JC, Montaner J. Blood Biomarkers to Differentiate Ischemic and Hemorrhagic Strokes. Neurology 2021; 96:e1928-e1939. [PMID: 33674361 DOI: 10.1212/wnl.0000000000011742] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 01/13/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To validate a panel of blood biomarkers to differentiate between ischemic stroke (IS) and intracerebral hemorrhage (ICH) in patients with suspected stroke. METHODS Patients with suspected stroke admitted within 4.5 hours after onset were enrolled. Blood samples were collected at hospital admission. Glial fibrillary acid protein (GFAP), retinol binding protein 4 (RBP-4), N-terminal proB-type natriuretic peptide (NT-proBNP), and endostatin were measured by immunoassays. Cutoff points were obtained for 100% specificity for IS. A high-sensitivity assay to measure GFAP and rapid point-of-care tests (POCTs) to measure RBP-4 and NT-proBNP were used in subsets of patients. Biomarker panels were evaluated in another cohort of 62 stroke mimics. RESULTS A total of 189 patients (154 IS and 35 ICH) were enrolled. Patients with IS had higher RBP-4, NT-proBNP, and endostatin and lower GFAP levels than patients with ICH. The best biomarker combination for the identification of IS was RBP-4+NT-proBNP, which was able to identify 29.7% of patients with IS with 100% specificity. In the subset of patients for whom GFAP was measured with the high-sensitivity assay, RBP-4, NT-proBNP, and GFAP identified 51.5% of patients with IS with 100% specificity. When stroke mimics were included, specificities were reduced to 98.4 and 96.8%, respectively. POCTs of RBP-4 and NT-proBNP showed results similar results to those of conventional ELISAs. CONCLUSIONS A biomarker panel including RBP-4, NT-proBNP, and GFAP provided moderate but potentially useful sensitivity rates at 100% specificity for IS diagnosis. If confirmed in future studies, this strategy might allow prehospital treatment in selected patients. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that a biomarker panel including RBP-4, NT-proBNP, and GFAP distinguishes IS from ICH with moderate accuracy.
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Affiliation(s)
- Alejandro Bustamante
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Anna Penalba
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Cyrille Orset
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Leire Azurmendi
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Víctor Llombart
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Alba Simats
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Emili Pecharroman
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Oriol Ventura
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Marc Ribó
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Denis Vivien
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Jean Charles Sanchez
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France
| | - Joan Montaner
- From the Neurovascular Research Laboratory (A.B., A.P., V.L., A.S., E.P., O.V., J.M.), Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona; Department of Neurology (A.B., M.R.), Hospital Universitari Vall d'Hebrón, Barcelona, Spain; Inserm (C.O., D.V.), Université Caen-Normandie, Inserm UMR-S U1237, Physiopathology and Imaging of Neurological Disorders, GIP Cyceron, Caen, France; Department of Specialities of Internal Medicine (L.A., J.C.S.), Faculty of Medicine, University of Geneva, Switzerland; and Department of Clinical Research (D.V.), Caen Normandie Hospital (CHU Caen), France.
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12
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Abstract
Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.
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Affiliation(s)
- Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center-Houston, Houston, Texas
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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13
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Geisler F, Wesirow M, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Audebert HJ. Probability assessment of intracerebral hemorrhage in prehospital emergency patients. Neurol Res Pract 2021; 3:1. [PMID: 33499926 PMCID: PMC7786495 DOI: 10.1186/s42466-020-00100-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Routing of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services particularly when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult. We aimed to develop a prehospital score - called prehospital-intracerebral hemorrhage score (ph-ICH score) - to assist in discriminating between both conditions. METHODS The ph-ICH score was developed with data from patients treated aboard a mobile stroke unit in Berlin, Germany, between 2011 and 2013 (derivation cohort) and in 2018 (validation cohort). Diagnosis of ICH or AIS was established using clinical data and neuroradiological cerebral imaging. Diagnostic accuracy was measured with significance testing, Cohen's d and receiver-operating-characteristics. RESULTS We analyzed 416 patients (32 ICH, 224 AIS, 41 transient ischemic attack, 119 stroke mimic) in the derivation cohort and 285 patients (33 ICH and 252 AIS) in the validation cohort. Systolic blood pressure, level of consciousness and severity of neurological deficits (i. e. certain items of the National Institutes of Health Stroke Scale) were used to calculate the ph-ICH score that showed higher values in the ICH compared to the AIS group (derivation cohort: 1.8 ± 1.2 vs. 1.0 ± 0.9 points; validation cohort: 1.8 ± 0.9 vs. 0.8 ± 0.7 points; d = 0.9 and 1.4, both p < 0.01). Receiver-operating-characteristics showed fair and good accuracy with an area under the curve of 0.71 for the derivation and 0.81 for the validation cohort. CONCLUSIONS The ph-ICH score can assist medical personnel in the field to assess the likelihood of ICH and AIS in emergency patients.
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Affiliation(s)
- Frederik Geisler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Medschid Wesirow
- Department of Neurology, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Martin Ebinger
- Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Alexander Kunz
- Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Michal Rozanski
- Department of Neurology, Auguste-Viktoria-Klinikum, Berlin, Germany
| | | | - Joachim E Weber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Benjamin Winter
- Department of Neurology, St. Josefs-Krankenhaus, Potsdam, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany
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14
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Lazarus G, Permana AP, Nugroho SW, Audrey J, Wijaya DN, Widyahening IS. Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis. Brain Behav 2020; 10:e01787. [PMID: 32812380 PMCID: PMC7559631 DOI: 10.1002/brb3.1787] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas. METHODS Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. RESULTS The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ≤3 hr (OR 2.15; 95% CI 1.37-3.40; I2 = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I2 = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I2 = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I2 = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I2 = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences. CONCLUSION Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.
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Affiliation(s)
- Gilbert Lazarus
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Affan Priyambodo Permana
- Department of Neurosurgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Setyo Widi Nugroho
- Department of Neurosurgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Jessica Audrey
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Indah Suci Widyahening
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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15
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Parker SA, Kus T, Bowry R, Gutierrez N, Cai C, Yamal JM, Rajan S, Wang M, Jacob AP, Souders C, Persse D, Grotta JC. Enhanced dispatch and rendezvous doubles the catchment area and number of patients treated on a mobile stroke unit. J Stroke Cerebrovasc Dis 2020; 29:104894. [PMID: 32689599 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104894] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/11/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Mobile Stroke Units (MSUs) deliver acute stroke treatment on-scene in coordination with Emergency Medical Services (EMS). One criticism of the MSU approach is the limited range of a single MSU. The Houston MSU is evaluating MSU implementation, and we developed a rendezvous approach as an innovative solution to expand the range and number of patients treated. METHODS In addition to direct 911 dispatch of our MSU to the scene within our 7-mile catchment area, we empowered more distant EMS units to activate the MSU. We also monitored EMS radio communications to identify possible patients. For these distant patients, the MSU met the EMS unit en route to the stroke center and treated the patient at that intermediate location. The distribution of the distance from MSU base station to site of stroke and time from 911 alert to tissue plasminogen activator (tPA) bolus were compared between patients treated on-scene and by rendezvous using Wilcoxon rank sum test. RESULTS Over 4 years, 338 acute ischemic stroke patients were treated with tPA on our MSU. Of these, 169 (50%) were treated on-scene after MSU dispatch at a median of 6.4 miles (IQR 6.4 miles) from MSU base station. 169 (50%) were treated by 'rendezvous' pathway with assessment and treatment of stroke a median of 12.4 miles from base (IQR 5.5 miles) (p< 0.0001). Time (min) from MSU alert to tPA bolus did not differ: 36.0 ± 10.0 for on-scene vs 37.0 ± 10.0 with rendezvous (p=0.65). 13% of patients alerted via direct 911 dispatch were treated vs 44% of rendezvous patients. CONCLUSION Adding a rendezvous approach to an MSU dispatch pathway doubles the range of operations and the number of patients treated by an MSU in an urban area, without incurring delay.
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Affiliation(s)
- Stephanie A Parker
- McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin St, Suite 1423, Houston, TX 77030, United States.
| | - Tessa Kus
- McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin St, Suite 1423, Houston, TX 77030, United States.
| | - Ritvij Bowry
- McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin St, Suite 1423, Houston, TX 77030, United States.
| | - Nicole Gutierrez
- McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin St, Suite 1423, Houston, TX 77030, United States.
| | - Chunyan Cai
- McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin St, Suite 1423, Houston, TX 77030, United States
| | - Jose-Miguel Yamal
- School of Public Health at the University of Texas Health Science Center, Houston, TX, United States.
| | - Suja Rajan
- School of Public Health at the University of Texas Health Science Center, Houston, TX, United States.
| | - Mengxi Wang
- School of Public Health at the University of Texas Health Science Center, Houston, TX, United States.
| | - Asha P Jacob
- School of Public Health at the University of Texas Health Science Center, Houston, TX, United States.
| | | | - David Persse
- Baylor College of Medicine, Houston, TX, United States.
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Turner AC, Schwamm LH, Etherton MR. Acute ischemic stroke: improving access to intravenous tissue plasminogen activator. Expert Rev Cardiovasc Ther 2020; 18:277-287. [PMID: 32323590 DOI: 10.1080/14779072.2020.1759422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Since approval by the United States Food and Drug Administration in 1996, alteplase utilization rates for acute ischemic stroke have increased. Despite its efficacy for improving stroke outcomes, however, the majority of ischemic stroke patients still do not receive alteplase. To address this issue, different methods for improving access to alteplase have been tested with varying degrees of success. AREAS COVERED This article gives an overview of the recent approaches pursued to improve access to alteplase for acute ischemic stroke patients. Utilization of stroke systems of care, quality metrics, and quality-improvement initiatives to improve alteplase treatment rates are discussed. The implementation of Telestroke networks to improve access and timely evaluation by a stroke specialist are also reviewed. Lastly, this review discusses the use of neuroimaging techniques to identify alteplase candidates in stroke of unknown symptom onset or beyond the 4.5-h treatment window. EXPERT COMMENTARY Expanding access to alteplase therapy for acute ischemic stroke is a multi-faceted approach. Specific considerations based on region, population, and health-care resources should be considered for each strategy. Neuroimaging approaches to identify alteplase-eligible patients beyond the 4.5-h treatment window are a recent development in acute stroke care that holds promise for increasing alteplase treatment rates.
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Affiliation(s)
- Ashby C Turner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
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Ohannessian R, Schott AM, Colin C, Nighoghossian N, Medeiros de Bustos E, Moulin T. Acute telestroke in France: A systematic review. Rev Neurol (Paris) 2020; 176:316-324. [PMID: 32147201 DOI: 10.1016/j.neurol.2019.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/12/2019] [Accepted: 11/18/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute telestroke is the use of telemedicine to improve acute stroke care. It has demonstrated to be a safe and effective medical practice. Since 2011, acute telestroke has been promoted by the Ministry of Health in France, and in 2018 many regions were in the process or completion of implementing telestroke. The objective of this study was to describe acute telestroke implementation in France. METHODS A systematic review was conducted using PubMed and ScienceDirect databases. Articles and abstracts in English and French, published between January 1st, 2000 to April 30th, 2018 were used. Studies conducted in France and that had presented an outcome evaluation of a regional acute telestroke activity were included. No meta-analysis was conducted. RESULTS A total of 24 studies (14 in French, 10 in English) were included, with 13 published articles (7 indexed on PubMed) and 11 abstracts. Among the 13 published articles, there were seven observational retrospective studies, one quasi-experimental before-after study, one experimental randomised controlled trial, and four medico-economic studies. All telestroke network models of care were drip-and-ship with hub and spoke organisation. The case-control studies did not show a difference with or without telemedicine. The territorial thrombolysis rate was measured in two regions, with an increase in Franche-Comté from 0.2% (2004) to 9.9% (2015), and a relative increase of 76% in Nord-Pas-de-Calais between 2009-2010 and 2012. CONCLUSION Implementation of acute telestroke in France had a positive clinical and public health impact but the evaluation remained limited and needs to be supported.
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Affiliation(s)
- R Ohannessian
- CIC-1431 Inserm département de Neurologie, EA 481 laboratoire de neurosciences intégratives et cliniques université de Franche-Comté, UBFC, CHRU de Besançon, Besançon, France; Télémédecine 360, TLM360, Paris, France.
| | - A-M Schott
- HESPER EA 7425, université Lyon, université Claude Bernard Lyon 1, 69008 Lyon, France; Pôle IMER, hospices civils de Lyon, 69003 Lyon, France
| | - C Colin
- HESPER EA 7425, université Lyon, université Claude Bernard Lyon 1, 69008 Lyon, France; Pôle IMER, hospices civils de Lyon, 69003 Lyon, France
| | - N Nighoghossian
- Unité neurovasculaire, hôpital Pierre-Wertheimer, hospices Civils de Lyon, 69677 Bron cedex, France
| | | | - T Moulin
- Department of Neurology, University Hospital of Besançon, Besançon, France; French Society of Telemedicine, Paris, France
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Abstract
PURPOSE OF REVIEW Mobile stroke units (MSUs) have revolutionized emergency stroke care by delivering pre-hospital thrombolysis faster than conventional ambulance transport and in-hospital treatment. This review discusses the history of MSUs technological development, current operations and research, cost-effectiveness, and future directions. RECENT FINDINGS Multiple prospective and retrospective studies have shown that MSUs deliver acute ischemic stroke treatment with intravenous recombinant tissue plasminogen activator (IV r-tPA) approximately 30 min faster than conventional care. The 90-day modified Rankin Scores for patients who received IV r-tPA on the MSU compared to conventional care were not statistically different in the PHANTOM-S study. Two German studies suggest that the MSU model is cost-effective by reducing disability and improving adjusted quality-life years post-stroke. The ongoing BEST-MSU trial will be the first multicenter, randomized controlled study that will shed light on MSUs' impact on long-term neurologic outcomes and cost-effectiveness. MSUs are effective in reducing treatment times in acute ischemic stroke without increasing adverse events. MSUs could potentially improve treatment times in large vessel occlusion and intracranial hemorrhage. Further studies are needed to assess functional outcomes and cost-effectiveness. Clinical trials are ongoing internationally.
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Tipton PW, D'Souza CE, Greenway MRF, Peel JB, Barrett KM, Eidelman BH, Meschia JF, Mauricio EA, Hattery WM, Siegel JL, Huang JF, TerKonda SP, Demaerschalk BM, Freeman WD. Incorporation of Telestroke into Neurology Residency Training: "Time Is Brain and Education". Telemed J E Health 2019; 26:1035-1042. [PMID: 31821116 DOI: 10.1089/tmj.2019.0184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: With increasing demand for neurologists, nontraditional health care delivery mechanisms have been developed to leverage this limited resource. Introduction: Telemedicine has emerged as an effective digital solution. Over the past three decades, telemedicine use has steadily grown; however, neurologists often learn on the job, rather than as part of their medical training. The current literature regarding telestroke training during neurology training is sparse, focusing on cerebrovascular fellowship curricula. We sought to enhance telestroke training in our neurology residency by incorporating real-life application. Materials and Methods: We implemented a formal educational model for neurology residents to use telemedicine for remote acquisition of the National Institutes of Health Stroke Scale (NIHSS) for patients with suspected acute ischemic stroke (AIS) before arrival at our comprehensive stroke center. This three-phase educational model involved multidisciplinary classroom didactics, simulation exercises, and real-world experience. Training and feedback were provided by neurologists experienced in telemedicine. Results: All residents completed formal training in telemedicine prehospital NIHSS acquisition and had the opportunity to participate in additional simulation exercises. Currently, residents are gaining additional experience by performing prehospital NIHSS acquisition for patients in whom AIS is suspected. Our preliminary data indicate that resident video encounters average 10.6 min in duration, thus saving time once patients arrive at our hospital. Discussion: To our knowledge, this is the first report of a telestroke-integrated neurology residency program in a comprehensive stroke center resulting in shortened time to treatment in patients with suspected AIS. Conclusions: We present a model that can be adopted by other neurology residency programs as it provides real-world telemedicine training critical to future neurologists.
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Affiliation(s)
- Philip W Tipton
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Jeffrey B Peel
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.,Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Kevin M Barrett
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Division of Speech-Language Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Wendy M Hattery
- Center for Connected Care, Mayo Clinic, Jacksonville, Florida, USA
| | - Jason L Siegel
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.,Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Josephine F Huang
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Sarvam P TerKonda
- Center for Connected Care, Mayo Clinic, Jacksonville, Florida, USA.,Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.,Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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20
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Phan TG, Beare R, Srikanth V, Ma H. Googling Location for Operating Base of Mobile Stroke Unit in Metropolitan Sydney. Front Neurol 2019; 10:810. [PMID: 31447755 PMCID: PMC6691052 DOI: 10.3389/fneur.2019.00810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/15/2019] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: The recent advances in stroke therapy have placed focus on delivering care within the first hour after stroke onset (golden hour), principally through the use of Mobile Stroke Unit (MSU) to bring the hospital to the patient. The aim of this project is to search the location of MSU hub in Sydney, Australia, optimizing for catchment, transport to nearest thrombolysis and endovascular clot retrieval (ECR)/thrombectomy capable hospital and population at risk. Methods: Traveling time was performed using ggmap package in R to interface with Google Maps application program interface (API). This analysis estimates the travel time from the centroids of each suburbs to five potential MSU hubs (Royal Prince Alfred, Prince of Wales, Royal North Shore, Liverpool, and Westmead hospitals) and eight thrombolysis capable hospitals. It is proposed that the MSU should be deployed at ECR hub to cover the suburbs, not well-covered by thrombolysis and ECR capable hospitals. This step was performed by assigning membership to hospitals within 30 min traveling time to the ECR hub. The base hub of the MSU was proposed as the closest hub (providing ECR) to the least well-served suburbs. The population serviceable by MSU was estimated using stroke incidence studies in Melbourne and Adelaide. Results: The largest population, serviceable by MSU within 30 min (4,606 cases), 45 min radius (8,918 cases), and 60 min (10,084 cases), was Royal North Shore followed by Royal Prince Alfred, Liverpool, Westmead, and Prince of Wales hospitals. Prince of Wales hospital has the smallest catchment within 30 min (3,078 cases), 45 min (7,721 cases), and 60 min (9,984 cases). Suburbs at the edge of metropolitan Sydney such as the Northern Suburbs are less well-served by thrombolysis and ECR capable hospitals. There are 10 suburbs within 30 min travel of one hospital. The remainders are within 30 min of two or more hospitals. Conclusions: Any of the five endovascular clot retrieval capable hospitals are capable of serving as a hub for MSU. We provide a method to identify the hub based on location of suburbs less well-served by other hospital.
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Affiliation(s)
- Thanh G Phan
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children Research Institute, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Henry Ma
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
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21
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Mathur S, Walter S, Grunwald IQ, Helwig SA, Lesmeister M, Fassbender K. Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units. Front Neurol 2019; 10:159. [PMID: 30881334 PMCID: PMC6407433 DOI: 10.3389/fneur.2019.00159] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/07/2019] [Indexed: 12/11/2022] Open
Abstract
In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.
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Affiliation(s)
- Shrey Mathur
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Iris Q. Grunwald
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
- Department of Medicine, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, United Kingdom
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
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22
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Cadilhac DA, Rajan SS, Kim J. In response to Mobile Stroke Units - Cost-Effective or Just an Expensive Hype? Curr Atheroscler Rep 2019; 21:5. [PMID: 30684083 DOI: 10.1007/s11883-019-0764-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D A Cadilhac
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia. .,Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Australia.
| | - S S Rajan
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - J Kim
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Australia
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