Prehospital Imaging-Based Triage of Head Trauma with a Mobile Stroke Unit: First Evidence and Literature Review

Assessing the Awareness on Symptoms and Risk Factors of Stroke amongst Rural Community in Central Region of Malaysia: A Cross-Sectional Survey

Background

As the third leading cause of mortality in Malaysia, stroke is recognised as a medical emergency which requires urgent medical attention within a limited timeframe to prevent exacerbation of the brain damage and death in patients. Recent report revealed a high prevalence of pre-hospital delay amongst the stroke patients due to the lack of awareness on symptoms and risk factors of stroke, as well as poor understanding on appropriate action towards stroke. A number of studies had assessed stroke awareness amongst urban population residing in central region of Malaysia but yet amongst rural population.

Methods

A cross-sectional survey was conducted amongst individuals residing in rural districts of Selangor by using a set of questionnaires assessing the sociodemographic characteristics, as well as the awareness and action towards stroke symptoms and risk factors.

Results

All 343 respondents were able to recognise at least one modifiable risk factor for stroke. Meanwhile, only 36.44% were able to identify all the stroke symptoms. Despite majority of them were familiar with the stroke term, less than half of the respondents were aware of calling the emergency medical service as the appropriate action towards stroke symptoms.

Conclusion

The present study indicated a poor level of awareness and action towards stroke symptoms and risk factors amongst rural population residing in Selangor.

Disparities in spatial access to neurological care in Appalachia: a cross-sectional health services analysis

Background

Appalachia is rural and socioeconomically deprived with a heavy burden of neurological disorders and poor access to healthcare providers. Rates of neurological disorders are increasing over time without equal increases in providers, indicating that Appalachian disparities are likely to worsen. Spatial access to neurological care has not been robustly explored for U.S. areas, so we aimed to examine disparities in the vulnerable Appalachian region.

Methods

Using 2022 CMS Care Compare physician data, we conducted a cross-sectional health services analysis, where we computed spatial accessibility of neurologists for all census tracts in the 13 states with Appalachian counties. We stratified access ratios by state, area deprivation, and rural-urban commuting area (RUCA) codes then utilized Welch two-sample t-tests to compare Appalachian tracts with non-Appalachian tracts. Using stratified results, we identified Appalachian areas where interventions would have the largest impact.

Findings

Appalachian tracts (n = 6169) had neurologist spatial access ratios between 25% and 35% lower than non-Appalachian tracts (n = 18,441; p < 0.001). When stratified by rurality and deprivation, three-step floating catchment area spatial access ratios for Appalachian tracts remained significantly lower in the most urban (RUCA = 1 [p < 0.0001) and most rural tracts (RUCA = 9 [p = 0.0093]; RUCA = 10 [p = 0.0227]). We identified 937 Appalachian census tracts where interventions can be targeted.

Interpretation

After stratifying by rural status and deprivation, significant disparities in spatial access to neurologists remained for Appalachian areas, indicating both poorer access in Appalachia and that neurologist accessibility cannot be determined solely by remoteness and socioeconomic status. These findings and our identified disparity areas have broad implications for policymaking and intervention targeting in Appalachia.

Funding

R.B.B. was supported by NIH Award Number T32CA094186. M.P.M. was supported by NIH-NCATS Award Number KL2TR002547.

A proposed novel traumatic brain injury classification system - an overview and inter-rater reliability validation on behalf of the Society of British Neurological Surgeons

INTRODUCTION

The measurement of traumatic brain injury (TBI) 'severity' has traditionally been based on the earliest Glasgow Coma Score (GCS) recorded, however, the underlying parenchymal pathology is highly heterogonous. This heterogeneity renders prediction of outcome on an individual patient level inaccurate and makes comparison between patients both in clinical practice and research difficult. The complexity of this heterogeneity has resulted in generic all encompassing 'traumatic brain injury protocols'. Early management and studies of neuro-protectants are often done irrespective of TBI type, yet it may well be that a specific treatment may be beneficial in a subset of TBI pathologies.

METHODS

A simple CT-based classification system rating the recognised types of blunt TBI (extradural, subdural, subarachnoid haemorrhage, contusions/intracerebral haematoma and diffuse axonal injury) as mild (1), moderate (2) or severe (3) is proposed. Hypoxic brain injury, a common secondary injury following TBI, is also included. Scores can be combined to reflect concomitant types of TBI and predominant location of injury is also recorded. To assess interrater reliability, 50 patient CT images were assessed by 5 independent clinicians of varying experience. Interrater reliability was calculated using overall agreement through Cronbach's alpha including confidence intervals for intra-class coefficients.

RESULTS

Interrater reliability scores showed strong agreement for same score and same injury for TBIs with blood on CT and Cronbach's alpha co-efficient (range 0.87-0.93) demonstrated excellent correlation between raters. Cronbach's alpha was not affected when individual raters were removed.

CONCLUSIONS

The proposed simple CT classification system has good inter-rater reliability and hence potentially could enable better individual prognostication and targeted treatments to be compared while also accounting for multiple intracranial injury types. Further studies are proposed and underway.

Mobile Stroke Units: Current Evidence and Impact

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.

Impact of mobile stroke units

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

Neuroimaging of Acute Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for 10% to 20% of all strokes worldwide and is associated with high morbidity and mortality. Neuroimaging is clinically important for the rapid diagnosis of ICH and underlying etiologies, but also for identification of ICH expansion, often as-sociated with an increased risk for poor outcome. In this context, rapid assessment of early hema-toma expansion risk is both an opportunity for therapeutic intervention and a potential hazard for hematoma evacuation surgery. In this review, we provide an overview of the current literature surrounding the use of multimodal neuroimaging of ICH for etiological diagnosis, prediction of early hematoma expansion, and prognostication of neurological outcome. Specifically, we discuss standard imaging using computed tomography, the value of different vascular imaging modalities to identify underlying causes and present recent advances in magnetic resonance imaging and computed tomography perfusion.

Pre-hospital triage of suspected acute stroke patients in a mobile stroke unit in the rural Alberta

Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

Mobile Stroke Units: Current and Future Impact on Stroke Care

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.

The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties

INTRODUCTION

The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties.

MATERIALS AND METHODS

A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase.

RESULTS

The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers.

CONCLUSION

The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review

BACKGROUND

Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs.

METHODS

A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions.

CONCLUSIONS

There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs.

A review of mobile stroke units

PURPOSE OF REVIEW

Mobile stroke units (MSUs) for prehospital treatment and management of patients with acute stroke have been developed more than a decade ago and is currently spreading worldwide. This review discusses the history of MSU and current operations and research.

RECENT FINDINGS

Multiple studies have shown that MSU can significantly reduce treatment time with a tenfold increase of patients treated within the first 60 min of symptom onset. Recent preliminary results from the Berlin Prehospital or Usual Delivery of Acute Stroke Care trial (B-PROUD) showed a positive shift in modified Rankin Scale (mRS) scores at 3 months for patients treated in MSUs. Two German studies indicate that the MSU model is cost effective by reducing disability and improving adjusted quality-life years after stroke. The MSU model for prehospital management of acute stroke is spreading worldwide. More research is needed, however, to establish cost-effectiveness, efficacy and best setting for prehospital stroke management.

An experimental study on the early diagnosis of traumatic brain injury in rabbits based on a noncontact and portable system

Closed cerebral hemorrhage (CCH) is a common symptom in traumatic brain injury (TBI) patients who suffer intracranial hemorrhage with the dura mater remaining intact. The diagnosis of CCH patients prior to hospitalization and in the early stage of the disease can help patients get earlier treatments that improve outcomes. In this study, a noncontact, portable system for early TBI-induced CCH detection was constructed that measures the magnetic induction phase shift (MIPS), which is associated with the mean brain conductivity caused by the ratio between the liquid (blood/CSF and the intracranial tissues) change. To evaluate the performance of this system, a rabbit CCH model with two severity levels was established based on the horizontal biological impactor BIM-II, whose feasibility was verified by computed tomography images of three sections and three serial slices. There were two groups involved in the experiments (group 1 with 10 TBI rabbits were simulated by hammer hit with air pressure of 600 kPa by BIM-II and group 2 with 10 TBI rabbits were simulated with 650 kPa). The MIPS values of the two groups were obtained within 30 min before and after injury. In group 1, the MIPS values showed a constant downward trend with a minimum value of −11.17 ± 2.91° at the 30th min after 600 kPa impact by BIM-II. After the 650 kPa impact, the MIPS values in group 2 showed a constant downward trend until the 25th min, with a minimum value of −16.81 ± 2.10°. Unlike group 1, the MIPS values showed an upward trend after that point. Before the injury, the MIPS values in both group 1 and group 2 did not obviously change within the 30 min measurement. Using a support vector machine at the same time point after injury, the classification accuracy of the two types of severity was shown to be beyond 90%. Combined with CCH pathological mechanisms, this system can not only achieve the detection of early functional changes in CCH but can also distinguish different severities of CCH.

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

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.

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

Mobile stroke unit triage of patients with a suspected stroke: a novel solution to reducing suspected stroke admissions in busy emergency departments

Background

Evaluation of patients with a suspected stroke is one of the most common neurological emergencies requiring rapid, comprehensive assessment by the stroke service to determine patient eligibility for timely reperfusion therapies. Prehospital evaluation may help to improve patient selection and reduce avoidable admissions to overcapacity emergency departments.

Methods and results

We report on our early experience of prehospital triage of patients with a suspected stroke using a mobile stroke unit (MSU) equipped with CT scanner in rural Alberta. During the initial 4 months of operation, 28 patients were evaluated by the team in the MSU. Eight patients were within the time window of thrombolysis and were treated with intravenous tissue plasminogen activator in the MSU. No patients suffered haemorrhage or any other complications. Fourteen patients with multiple aetiologies (stroke mimics 6, transient ischaemic attacks 2, subacute stroke outside thrombolysis window 2, intracranial haemorrhage 3 and cerebral contusion 1) were assessed in the field and transferred to the tertiary hospital. Six patients after assessment and imaging were repatriated back to the local hospital as they were deemed stroke mimics or were outside of the reperfusion window.

Conclusions

The MSU offers a novel approach to performing timely evaluation and treatment of patients with a suspected stroke in rural settings and may help reduce admissions to overcapacity tertiary care facilities.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

The PRE-hospital Stroke Treatment Organization

Background

The PRE-hospital Stroke Treatment Organization was formed in 2016 as an international consortium of medical practitioners involved in pre-hospital treatment of patients with acute stroke.

Aims

PRE-hospital Stroke Treatment Organization’s mission is to improve stroke outcomes by supporting research and advocacy for pre-hospital stroke treatment in Mobile Stroke Units. PRE-hospital Stroke Treatment Organization will provide a platform to enhance collaborative research across the spectrum of acute stroke management in the pre-hospital setting. PRE-hospital Stroke Treatment Organization will also facilitate the appropriate proliferation and distribution of Mobile Stroke Units by providing a forum for professional communication, resource for public education, and stimulus for government, industry, and philanthropic support.

Summary of review

In this “white paper”, we describe the evidence supporting pre-hospital stroke treatment, progress to date, practical issues such as application in various environments and staffing, planned research initiatives, and organizational structure.

Conclusions

PRE-hospital Stroke Treatment Organization is not-for-profit, with membership open to anyone involved (or hoping to become involved) in pre-hospital stroke care. PRE-hospital Stroke Treatment Organization has a Steering Committee comprised of members from Europe, U.S., Canada, Australia, and other regions having a Mobile Stroke Unit in operation. PRE-hospital Stroke Treatment Organization convenes satellite meetings for membership at the International Stroke Conference and European Stroke Congress each year to address the PRE-hospital Stroke Treatment Organization mission. The first research collaborations agreed upon are to: (1) develop a list of common data elements to be collected by all Mobile Stroke Unit programs and entered into a common research database, and (2) develop a protocol for investigating the natural history of hyper-acute Intracerebral Hemorrhage.

Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges

In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.