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Inoa V, Goyal N. Role of Stroke Scales and Scores in Cerebrovascular Disease. Neurol Clin 2024; 42:753-765. [PMID: 38937040 DOI: 10.1016/j.ncl.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
This article provides a comprehensive review of widely utilized stroke scales in both routine clinical settings and research. These scales are crucial for planning treatment, predicting outcomes, and helping stroke patients recover. They also play a pivotal role in planning, executing, and comprehending stroke clinical trials. Each scale presents distinct advantages and limitations, and the authors explore these aspects within the article. The authors' intention is to provide the reader with practical insights for a clear understanding of these scales, and their effective use in their clinical practice.
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Affiliation(s)
- Violiza Inoa
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nitin Goyal
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Makharia A, Agarwal A, Garg D, Vishnu VY, Srivastava MVP. The Pitfalls of NIHSS: Time for a New Clinical Acute Stroke Severity Scoring System in the Emergency? Ann Indian Acad Neurol 2024; 27:15-18. [PMID: 38495237 PMCID: PMC10941908 DOI: 10.4103/aian.aian_842_23] [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: 09/21/2023] [Revised: 11/02/2023] [Accepted: 11/24/2023] [Indexed: 03/19/2024] Open
Abstract
Stroke is the second leading cause of death and a major cause of disability worldwide. Stroke severity scales serve as reliable means to track a patient's neurological deficit, predict outcome, and guide treatment decisions in clinical practice. The National Institute of Health Stroke Scale (NIHSS) was introduced over 30 years ago, marking a significant milestone in the field of stroke. Over the years, there have been notable advancements in acute stroke care. Despite several modifications made to NIHSS, none has yet succeeded in effectively capturing all the complex effects of a stroke. This review focuses on the pitfalls of NIHSS and emphasizes the need for a quick and comprehensive clinical and upgraded version of the stroke severity rating scale.
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Affiliation(s)
- Archita Makharia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Divyani Garg
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Keenan KJ, Smith WS, Jadhav AP, Haussen DC, Budzik RF, Bonafé A, Bhuva P, Yavagal DR, Ribò M, Cognard C, Hanel RA, Hassan AE, Sila CA, Saver JL, Liebeskind DS, Jovin TG, Nogueira RG. Large vessel occlusion prediction scale thresholds that are sensitive for DAWN Trial patients. Interv Neuroradiol 2023:15910199231203266. [PMID: 37915142 DOI: 10.1177/15910199231203266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Large vessel occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6-to-24-h time window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right-sided LVOs. METHODS LVO prediction scale scores were retrospectively calculated using the National Institutes of Health Stroke Scale (NIHSS) scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 and 24 h, NIHSS scores ≥ 10, intracranial internal carotid artery or proximal middle cerebral artery occlusions, and mismatches between their clinical severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified, along with scores ≥ 5% more sensitive for left or right-sided LVOs. Specificities could not be calculated because all patients had LVOs. RESULTS A total of 201 out of 206 patients had the required NIHSS subitem scores. CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 were the highest thresholds that were still 85% sensitive for DAWN Trial LVO stroke patients. RACE ≥ 5 was the only typically used score threshold more sensitive for right-sided LVOs, though similar small differences were seen for other scales at higher thresholds. CONCLUSIONS Our findings likely represent the maximum sensitivities of the LVO prediction scales tested for ideal thrombectomy candidates in the 6-to-24-h time window because NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Patients with NIHSS scores < 10 or more distal LVOs would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.
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Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, CA, USA
| | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Ashutosh P Jadhav
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Diogo C Haussen
- Department of Neurology and Radiology, Emory University School of Medicine at Grady Memorial Hospital, Atlanta, GA, USA
| | - Ronald F Budzik
- Department of Radiology, OhioHealth/Riverside Methodist Hospital, Columbus, OH, USA
| | - Alain Bonafé
- Department of Neuroradiology, University Hospital of Montpellier, Hop Gui de Chauliac, Montpellier, France
| | - Parita Bhuva
- Texas Stroke Institute at HCA North Texas, Plano, TX, USA
| | - Dileep R Yavagal
- Department of Neurology, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Marc Ribò
- Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Neurology, Vall d'Hebron University Hospital, Stroke Unit, Barcelona, Spain
| | - Christophe Cognard
- Department of Neuroradiology, Hospital Purpan, Toulouse, Midi-Pyrénées, France
| | - Ricardo A Hanel
- Baptist Medical Center Jacksonville/Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center - Harlingen, TX, USA
| | - Cathy A Sila
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles, CA, USA
| | | | - Tudor G Jovin
- Cooper Hospital University Medical Center, Camden, NJ, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Ramos-Pachón A, Rodríguez-Luna D, Martí-Fàbregas J, Millán M, Bustamante A, Martínez-Sánchez M, Serena J, Terceño M, Vera-Cáceres C, Camps-Renom P, Prats-Sánchez L, Rodríguez-Villatoro N, Cardona-Portela P, Urra X, Solà S, del Mar Escudero M, Salvat-Plana M, Ribó M, Abilleira S, Pérez de la Ossa N, Silva Y. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol 2023; 80:1028-1036. [PMID: 37603325 PMCID: PMC10442788 DOI: 10.1001/jamaneurol.2023.2754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/05/2023] [Indexed: 08/22/2023]
Abstract
Importance Prehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown. Objective To determine the effect of direct transport to an endovascular treatment (EVT)-capable stroke center vs transport to the nearest local stroke center. Design, Setting, and Participants This was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field >4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022. Intervention Direct transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165). Main Outcomes and Measures The primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5. Results Of 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group. Conclusions and Relevance In this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH. Trial Registration ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Anna Ramos-Pachón
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Mònica Millán
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Marina Martínez-Sánchez
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | | | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Luis Prats-Sánchez
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Pere Cardona-Portela
- Stroke Unit, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Xabier Urra
- Stroke Unit, Hospital Clínic, and August Pi i Sunyer Biomedical Research Institute Barcelona, Barcelona, Spain
| | - Silvia Solà
- Sistema d’Emergències Mèdiques, Barcelona, Spain
| | | | - Mercè Salvat-Plana
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sònia Abilleira
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Yolanda Silva
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
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Rafiemanesh H, Barikro N, Karimi S, Sotoodehnia M, Jalali A, Baratloo A. The Rapid Arterial oCclusion Evaluation (RACE) scale accuracy for diagnosis of acute ischemic stroke in emergency department - A multicenter study. BMC Emerg Med 2023; 23:51. [PMID: 37226097 DOI: 10.1186/s12873-023-00825-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 05/17/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE It seems that the available data on performance of the Rapid Arterial oCclusion Evaluation (RACE) as a prehospital stroke scale for differentiating all AIS cases, not only large vessel occlusion (LVO), from the stroke mimics is lacking. As a result, we intend to evaluate the accuracy of the RACE criteria in diagnosing of AIS in patients transferred to the emergency department (ED). METHOD The present study was a diagnostic accuracy cross-sectional study during 2021 in Iran. The study population consist of all suspected acute ischemic stroke (AIS) patients who transferred to the ED by emergency medical services (EMS). A 3-part checklist consisting of the basic and demographic information of the patients, items related to the RACE scale, and the final diagnosis of the patients based on interpretation of patients' brain MRI was used for data collection. All data were entered in Stata 14 software. We used the ROC analysis to evaluate the diagnostic power of the test. RESULT In this study, data from 805 patients with the mean age of 66.9 ± 13.9 years were studied of whom 57.5% were males. Of all the patients suspected of stroke who transferred to the ED, 562 (69.8%) had a definite final diagnosis of AIS. The sensitivity and specificity of the RACE scale for the recommended cut-off point (score ≥ 5) were 50.18% and 92.18%, respectively. According to the Youden J index, the best cut-off point for this tool for differentiating AIS cases was a score > 2, at which sensitivity and specificity were 74.73% and 87.65%, respectively. CONCLUSION It seems that, the RACE scale is an accurate diagnostic tool to detect and screen AIS patients in ED, Of course, not at the previously suggested cut-off point (score ≥ 5), but at the score > 2.
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Affiliation(s)
- Hosein Rafiemanesh
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Alborz University of Medical Sciences, Karaj, Iran
| | - Negin Barikro
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Karimi
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Sotoodehnia
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Jalali
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Baratloo
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Almqvist T, Falk Delgado A, Sjöstrand C, Ahmed N, Berglund A, Eriksson E, Mazya MV. Impact of prehospital stroke triage implementation on patients with intracerebral hemorrhage. Ther Adv Neurol Disord 2023; 16:17562864231168278. [PMID: 37187462 PMCID: PMC10176564 DOI: 10.1177/17562864231168278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/18/2023] [Indexed: 05/17/2023] Open
Abstract
Background Little is known about how prehospital triage using large vessel occlusion (LVO) stroke prediction scales affects patients with intracerebral hemorrhage (ICH). Objectives We aimed to investigate whether the Stockholm Stroke Triage System (SSTS) implemented in 2017 has affected timing and outcomes of acute ICH neurosurgery, and to assess system triage accuracy for ICH with a neurosurgical indication or LVO thrombectomy. Design Observational cohort study. Methods In the Stockholm Region, we compared surgical timing, functional outcome, and death at 3 months in patients transported by code-stroke ground ambulance who had ICH neurosurgery, 2 years before versus 2 years after SSTS implementation. We also calculated triage precision metrics for treatment with either ICH neurosurgery or thrombectomy. Results A total of 36 patients undergoing ICH neurosurgery were included before SSTS implementation and 30 after. No significant difference was found in timing of neurosurgery [median 7.5 (4.9-20.7) versus 9.1 (6.1-12.5) h after onset], distribution of functional outcomes (median 4 versus 4), and death at 3 months [3/29 (9%) versus 5/35 (17%)] before versus after implementation, respectively. The SSTS routed a larger proportion of patients subsequently undergoing ICH neurosurgery directly to the comprehensive stroke center: 13/36 (36%) before versus 18/30 (60%) after implementation. Overall system triage accuracy for ICH neurosurgery or thrombectomy was high at 90%, with 92% specificity and 65% sensitivity. Conclusion The SSTS, initially designed for prehospital LVO stroke triage, routed more patients with neurosurgical indication for ICH directly to the comprehensive stroke center. This did not significantly affect surgical timing or outcomes.
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Affiliation(s)
- Tove Almqvist
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital,
Stockholm, Sweden
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neuroradiology, Karolinska
University Hospital, University Hospital
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital,
Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Annika Berglund
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Einar Eriksson
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Michael V. Mazya
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
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Worthmann H, Winzer S, Schuppner R, Gumbinger C, Barlinn J. Telestroke networks for area-wide access to endovascular stroke treatment. Neurol Res Pract 2023; 5:9. [PMID: 36864498 PMCID: PMC9983226 DOI: 10.1186/s42466-023-00237-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. MAIN BODY Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. CONCLUSION The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.
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Affiliation(s)
- Hans Worthmann
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany.
| | - S. Winzer
- grid.412282.f0000 0001 1091 2917Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
| | - R. Schuppner
- grid.10423.340000 0000 9529 9877Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623 Hannover, Germany
| | - C. Gumbinger
- grid.5253.10000 0001 0328 4908Klinik Für Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - J. Barlinn
- grid.412282.f0000 0001 1091 2917Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
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Glober NK, Fulks T, Supples M, Panagos P, Kim D. Factors Predicting Misidentification of Acute Ischemic Stroke and Large Vessel Occlusion by Paramedics. Crit Pathw Cardiol 2022; 21:172-175. [PMID: 36413394 PMCID: PMC9678438 DOI: 10.1097/hpc.0000000000000307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The emergence of thrombectomy for large vessel occlusions has increased the importance of accurate prehospital identification and triage of acute ischemic stroke (AIS). Despite available clinical scores, prehospital identification is suboptimal. Our objective was to improve the sensitivity of prehospital AIS identification by combining dispatch information with paramedic impression. We performed a retrospective cohort review of emergency medical services and hospital records of all patients for whom a stroke alert was activated in 1 urban, academic emergency department from January 1, 2018, to December 31, 2019. Using admission diagnosis of acute stroke as outcome, we calculated the sensitivity and specificity of dispatch and paramedic impression in identifying AIS and large vessel occlusion. We identified factors that, when included together, would improve the sensitivity of prehospital AIS identification. Two-hundred twenty-six stroke alerts were activated by emergency department physicians after transport by Indianapolis emergency medical services. Forty-four percent (99/226) were female, median age was 58 years (interquartile range, 50-67 years), and median National Institutes of Health Stroke Scale was 6 (interquartile range, 2-12). Paramedics demonstrated superior sensitivity (59% vs. 48%) but inferior specificity (56% vs. 73%) for detection of stroke as compared with dispatch. A strategy incorporating dispatch code of stroke, or paramedic impression of altered mental status or weakness in addition to stroke, would be 84% sensitive and 27% specific for identification of stroke. To optimize rapid and sensitive stroke detection, prehospital systems should consider inclusion of patients with dispatch code of stroke and provider impression of altered mental status or generalized weakness.
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Affiliation(s)
- Nancy K. Glober
- From the Department of Emergency Medicine, Indiana University, Indianapolis, IN
| | - Tyler Fulks
- Department of Emergency Medicine, Southern Illinois University, Springfield, IL
| | - Michael Supples
- From the Department of Emergency Medicine, Indiana University, Indianapolis, IN
| | - Peter Panagos
- Department of Emergency Medicine, Washington University at St. Louis, St. Louis, MO
| | - David Kim
- Department of Emergency Medicine, Stanford University, Palo Alto, CA
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Gao L, Moodie M, Yassi N, Davis SM, Bladin CF, Smith K, Bernard S, Stephenson M, Churilov L, Campbell BCV, Zhao H. Long-Term Cost-Effectiveness of Severity-Based Triaging for Large Vessel Occlusion Stroke. Front Neurol 2022; 13:871999. [PMID: 35645977 PMCID: PMC9136079 DOI: 10.3389/fneur.2022.871999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose:Pre-hospital severity-based triaging using the Ambulance Clinical Triage For Acute Stroke Treatment (ACT-FAST) algorithm has been demonstrated to substantially reduce time to endovascular thrombectomy in Melbourne, Australia. We aimed to model the cost-effectiveness of an ACT-FAST bypass system from the healthcare system perspective.MethodsA simulation model was developed to estimate the long-term costs and health benefits associated with diagnostic accuracy of the ACT-FAST algorithm. Three-month post stroke functional outcome was projected to the lifetime horizon to estimate the long-term cost-effectiveness between two strategies (ACT-FAST vs. standard care pathways). For ACT-FAST screened true positives (i.e., screened positive and eligible for EVT), a 52 mins time saving was applied unanimously to the onset to arterial time for EVT, while 10 mins delay in thrombolysis was applied for false-positive (i.e., screened positive but was ineligible for EVT) thrombolysis-eligible infarction. Quality-adjusted life year (QALY) was employed as the outcome measure to calculate the incremental cost-effectiveness ratio (ICER) between the ACT-FAST algorithm and the current standard care pathway.ResultsOver the lifetime, ACT-FAST was associated with lower costs (–$45) and greater QALY gains (0.006) compared to the current standard care pathway, resulting in it being the dominant strategy (less costly but more health benefits). Implementing ACT-FAST triaging led to higher proportion of patients received EVT procedure (30 more additional EVT performed per 10,000 patients). The total Net Monetary Benefit from ACT-FAST care estimated at A$0.76 million based on its implementation for a single year.ConclusionsAn ACT-FAST severity-triaging strategy is associated with cost-saving and increased benefits when compared to standard care pathways. Implementing ACT-FAST triaging increased the proportion of patients who received EVT procedure due to more patients arriving at EVT-capable hospitals within the 6-h time window (when imaging selection is less rigorous).
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
- *Correspondence: Lan Gao
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Christopher F. Bladin
- Ambulance Victoria, Melbourne, VIC, Australia
- Department of Neurology, Faculty of Medicine, Nursing and Health Sciences, Eastern Health and Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, VIC, Australia
| | | | | | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Bruce C. V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
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10
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Pérez de la Ossa N, Abilleira S, Jovin TG, García-Tornel Á, Jimenez X, Urra X, Cardona P, Cocho D, Purroy F, Serena J, San Román Manzanera L, Vivanco-Hidalgo RM, Salvat-Plana M, Chamorro A, Gallofré M, Molina CA, Cobo E, Davalos A, Ribo M. Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial. JAMA 2022; 327:1782-1794. [PMID: 35510397 PMCID: PMC9073661 DOI: 10.1001/jama.2022.4404] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. OBJECTIVE To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURES The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTS Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR, 65-83] years; median National Institutes of Health Stroke Scale score, 17 [IQR, 11-21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCE In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Natalia Pérez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sònia Abilleira
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Tudor G. Jovin
- Neurological Institute, Cooper University Hospital, Camden, New Jersey
| | - Álvaro García-Tornel
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Xavier Jimenez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Pere Cardona
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Dolores Cocho
- Neurology Department, Hospital Granollers, Granollers, Spain
| | - Francisco Purroy
- Department of Neurology, Stroke Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | - Joaquin Serena
- Department of Neurology, Stroke Unit, Hospital Josep Trueta, Girona, Spain
| | | | - Rosa Maria Vivanco-Hidalgo
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Mercè Salvat-Plana
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Angel Chamorro
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Miquel Gallofré
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Carlos A. Molina
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Erik Cobo
- Statistics and Operational Research, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Antoni Davalos
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marc Ribo
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
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11
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Gude MF, Blauenfeldt RA, Behrndtz AB, Nielsen CN, Speiser L, Simonsen CZ, Johnsen SP, Kirkegaard H, Andersen G. The Prehospital Stroke Score and telephone conference: A prospective validation. Acta Neurol Scand 2022; 145:541-550. [PMID: 35023151 DOI: 10.1111/ane.13580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 12/08/2021] [Accepted: 12/26/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The main aim of the study is to investigate the performance of a two-part stroke scale for screening and subsequent severity assessment combined with a telephone conference (teleconference). MATERIALS AND METHODS During a 6-month period, we prospectively tested the Prehospital Stroke Score (PreSS). PreSS part 1 is designed to identify stroke or TIA in a prehospital setting. PreSS part 2 is a stroke severity scale designed to identify large-vessel occlusion (LVO). PreSS was performed by emergency medical service (EMS) providers prior to a teleconference with a stroke neurologist. RESULTS Combined teleconference and PreSS part 1 were performed on 79.3% of all patients diagnosed with stroke/TIA, and 99.1% of the patients with positive scores were subsequently PreSS part 2 scored. PreSS part 1 and teleconference had a sensitivity to identify stroke/TIA of 89.3% (95% CI 85.7-92.2), specificity of 64.5% (95% CI 59.3-69.5), and an area under the curve (AUC) of 0.80 (95% CI 0.77-0.83). Regarding LVO, PreSS part 1 with teleconference recognized 96.7% (95% CI 88.7-99.6) of all cases as stroke. PreSS part 2 had a sensitivity of 55.7% (95% CI 42.4-68.5), specificity of 91.5% (95% CI 89.0-93.6), and AUC of 0.86 (95% CI 0.82-0.90) for identification of LVO. CONCLUSIONS PreSS was feasible and the sensitivity for stroke/TIA and LVO was high to moderate providing an overall high precision. Almost all LVO cases were ensured acute stroke admission. The high specificity for LVO could be useful for determining transfers strategies. CLASSIFICATION OF EVIDENCE This study provides Class I evidence when evaluating PreSS combined with teleconference.
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Affiliation(s)
- Martin F. Gude
- Department of Research and Development Prehospital Emergency Medical Services Central Denmark Region and Aarhus University Aarhus Denmark
| | - Rolf A. Blauenfeldt
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
| | - Anne B. Behrndtz
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
| | - Casper N. Nielsen
- Department of Research and Development Prehospital Emergency Medical Services Central Denmark Region and Aarhus University Aarhus Denmark
| | - Lasse Speiser
- Department of Radiology Aarhus University Hospital Aarhus Denmark
| | - Claus Z. Simonsen
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Services Research Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Hans Kirkegaard
- Department of Research and Development Prehospital Emergency Medical Services Central Denmark Region and Aarhus University Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Grethe Andersen
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
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12
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Bhaumik S, Hannun M, Dymond C, DeSanto K, Barrett W, Wallis LA, Mould-Millman NK. Prehospital triage tools across the world: a scoping review of the published literature. Scand J Trauma Resusc Emerg Med 2022; 30:32. [PMID: 35477474 PMCID: PMC9044621 DOI: 10.1186/s13049-022-01019-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 01/15/2023] Open
Abstract
Background Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. Methods A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. Results Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. Conclusions The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01019-z.
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Affiliation(s)
- Smitha Bhaumik
- Department of Emergency Medicine, Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA.,Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Merhej Hannun
- Department of Family Medicine, Reading Hospital - Tower Health, 420 South 5th Avenue, West Reading, PA, 19611, USA
| | - Chelsea Dymond
- Department of Emergency Medicine, Providence St Joseph Hospital, 2700 Dolbeer St, Eureka, CA, 95501, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, School of Medicine, University of Colorado Anschutz Medical Campus, 12950 E. Montview Blvd., Mail Stop A003, Aurora, CO, 80045, USA
| | - Whitney Barrett
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, 1 University of New Mexico, MSC11 6025, Albuquerque, NM, 87131, USA
| | - Lee A Wallis
- Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA. .,Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa.
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13
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Brehm A, Tsogkas I, Ospel JM, Appenzeller-Herzog C, Aoki J, Kimura K, Pfaff JA, Möhlenbruch MA, Requena M, Ribo MJ, Sarraj A, Spiotta AM, Sporns P, Psychogios MN. Direct to angiography suite approaches for the triage of suspected acute stroke patients: a systematic review and meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864221078177. [PMID: 35251309 PMCID: PMC8894963 DOI: 10.1177/17562864221078177] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/18/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Increasing evidence suggests improved time metrics leading to better clinical outcomes when stroke patients with suspected large vessel occlusion (LVO) are transferred directly to the angiography suite (DTAS) compared with cross-sectional imaging followed by transfer to the angiography suite. We performed a systematic review and meta-analysis on the efficacy and safety of DTAS approaches. Methods: We searched Embase, Medline, Scopus, and clinicaltrials.gov for studies comparing outcomes of DTAS and conventional triage. Eligible studies were assessed for risk of bias. We performed a random-effects meta-analysis on the differences of median door-to-groin and door-to-reperfusion times between intervention and control group. Secondary outcomes included good outcome at 90 days (modified Rankin Scale ⩽ 2) rate of symptomatic intracranial hemorrhage (sICH) and mortality within 90 days. Results: Eight studies (one randomized, one cluster-randomized trial and six observational studies) with 1938 patients were included. Door-to-groin and door-to-reperfusion times in the intervention group were on median 29.0 min [95% confidence interval (CI): 14.3–43.6; p < 0.001] and 32.1 min (95% CI: 15.1–49.1; p < 0.001) shorter compared with controls. Prespecified subgroup analyses for transfer (n = 1753) and mothership patients (n = 185) showed similar reductions of the door-to-groin and door-to-reperfusion times in response to the intervention. The odds of good outcome did not differ significantly between both groups but were numerically higher in the intervention group (odds ratio: 1.38, 95% CI: 0.97–1.95; p = 0.07). There was no significant difference for mortality and sICH between the groups. Conclusion: DTAS approaches for the triage of suspected LVO patients led to a significant reduction in door-to-groin and door-to-reperfusion times but an effect on functional outcome was not detected. The subgroup analysis showed similar results for transfer and mothership patients. Registration: This study was registered in PROSPERO (CRD42020213621).
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Affiliation(s)
- Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Ioannis Tsogkas
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Johanna M. Ospel
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | | | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Johannes A.R. Pfaff
- Department of Neuroradiology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | | | - Manuel Requena
- Department of Neurology, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Marc J. Ribo
- Department of Neurology, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Amrou Sarraj
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Peter Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, SwitzerlandDepartment of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
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14
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Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145:265-272. [PMID: 34882786 DOI: 10.1111/ane.13565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/20/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prehospital identification of large vessel occlusion (LVO) holds significant potential to decrease the onset-to-treatment time. Several prehospital scales have been developed to identify LVO but data on their comparison has been limited. The aim of this study was to review the currently available prehospital LVO scales and compare their performance using prehospital data. METHODS All patients transported by ambulance using stroke code on a six-month period were enrolled into the study. The prehospital patient reports were retrospectively evaluated by two investigators using sixteen LVO scales identified by literature search and expert opinion. After the evaluation, the computed tomography angiography results were reviewed by a neuroradiologist to confirm or exclude LVO. RESULTS Sixteen different LVO scales met the predetermined study criteria and were selected for further comparison. Using them, a total of 610 evaluations were registered. The sensitivity of the scales varied between 8%-73%, specificity between 71%-97% and overall accuracy between 71%-87%. The areas under curve (AUC) varied between 0.61-0.80 for the whole scale range and 0.53%-0.74 for the scales' binary cut-offs. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was the only scale with AUC > 0.8. Regarding scales' binary cut-offs, The FAST-ED (0.70), Gaze - Face Arm Speech Time (G-FAST) (0.74) and Emergency Medical Stroke Assessment (EMSA) (0.72) were the only scales with AUC > 0.7. CONCLUSIONS In a comparison of 16 different LVO scales, the FAST-ED, G-FAST and EMSA achieved the highest overall performance.
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Affiliation(s)
- Tuukka Puolakka
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
- Department of Anaesthesiology & Intensive Care Medicine Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Pekka Virtanen
- Department of Radiology Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Markku Kuisma
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Daniel Strbian
- Department of Neurology Helsinki University Hospital and University of Helsinki Helsinki Finland
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15
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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16
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Ter Schiphorst A, Duflos C, Mourand I, Gaillard N, Dargazanli C, Corti L, Prin P, Lippi A, Ayrignac X, Charif M, Wacongne A, Bouly S, Lalu T, Sablot D, Blanchet-Fourcade G, Landragin N, Jacob F, Sayad C, Derraz I, Cagnazzo F, Lefevre PH, Gascou G, Beaufils O, Costalat V, Arquizan C. A regional strategy to decrease the time to thrombectomy in patients with low probability of treatment by thrombolysis. Rev Neurol (Paris) 2021; 178:558-568. [PMID: 34903351 DOI: 10.1016/j.neurol.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE The best transportation strategy for patients with suspected large vessel occlusion (LVO) is unknown. Here, we evaluated a new regional strategy of direct transportation to a Comprehensive Stroke Center (CSC) for patients with suspected LVO and low probability of receiving intravenous thrombolysis (IVT) at the nearest Primary Stroke Center (PSC). METHODS Patients could be directly transported to the CSC (bypass group) if they met our pre-hospital bypass criteria: high LVO probability (i.e., severe hemiplegia) with low IVT probability (contraindications) and/or travel time difference between CSC and PSC<15 minutes. The other patients were transported to the PSC according to a "drip-and-ship" strategy. Treatment time metrics were compared in patients with pre-hospital bypass criteria and confirmed LVO in the bypass and drip-and-ship groups. RESULTS In the bypass group (n=79), 54/79 (68.3%) patients met the bypass criteria and 29 (36.7%) had confirmed LVO. The positive predictive value of the hemiplegia criterion for LVO detection was 0.49. In the drip-and-ship group (n=457), 92/457 (20.1%) patients with confirmed LVO met our bypass criteria. Among the 121 patients with bypass criteria and confirmed LVO, direct routing decreased the time between symptom discovery and groin puncture by 55 minutes compared with the drip-and-ship strategy (325 vs. 229 minutes, P<0.001), without significantly increasing the time to IVT (P=0.19). CONCLUSIONS Our regional strategy led to the correct identification of LVO and a significant decrease of the time to mechanical thrombectomy, without increasing the time to IVT, and could be easily implemented in other territories.
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Affiliation(s)
- A Ter Schiphorst
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - C Duflos
- Clinical Research and Epidemiology Unit, CHU Montpellier, University Montpellier, Montpellier, France
| | - I Mourand
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - N Gaillard
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - C Dargazanli
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - L Corti
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - P Prin
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - A Lippi
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - X Ayrignac
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - M Charif
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - A Wacongne
- Department of Neurology, CHRU Carémeau, Nîmes, France
| | - S Bouly
- Department of Neurology, CHRU Carémeau, Nîmes, France
| | - T Lalu
- Department of Neurology, CH de Béziers, Béziers, France
| | - D Sablot
- Department of Neurology, CH de Perpignan, Perpignan, France
| | | | - N Landragin
- Department of Neurology, Clinique du Millénaire, Montpellier, France
| | - F Jacob
- Emergency Department, CH de Millau, Millau, France
| | - C Sayad
- Emergency Department, CH de Mende, Mende, France
| | - I Derraz
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - F Cagnazzo
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - P-H Lefevre
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - G Gascou
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - O Beaufils
- Emergency Department, CHRU Gui de Chauliac, Montpellier, France
| | - V Costalat
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - C Arquizan
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France.
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17
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Frank B, Fabian F, Brune B, Bozkurt B, Deuschl C, Nogueira RG, Kleinschnitz C, Köhrmann M. Validation of a shortened FAST-ED algorithm for smartphone app guided stroke triage. Ther Adv Neurol Disord 2021; 14:17562864211057639. [PMID: 34840607 PMCID: PMC8613889 DOI: 10.1177/17562864211057639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose: Large vessel occlusion (LVO) recognition scales were developed to identify patients with LVO-related acute ischemic stroke (AIS) on the scene of emergency. Thus, they may enable direct transport to a comprehensive stroke centre (CSC). In this study, we aim to validate a smartphone app-based stroke triage with a shortened form of the Field Assessment Stroke Triage for Emergency Destination (FAST-ED). Methods: This retrospective validation study included 2815 patients with confirmed acute stroke and suspected acute stroke but final diagnosis other than stroke (stroke mimics) who were admitted by emergency medical service (EMS) to the CSC of the Neurological University Hospital Essen, Germany. We analysed the predictive accuracy of a shortened digital app-based FAST-ED ( ‘FAST-ED App’) for LVO-related AIS and yield comparison to various other LVO recognition scales. Results: The shortened FAST-ED App had comparable test quality (Area under ROC = 0.887) to predict LVO-related AIS to the original FAST-ED (0.889) and RACE (0.883) and was superior to Cincinnati Prehospital Stroke Severity (CPSS), 3-Item Stroke Scale (3-ISS) and National Institute of Health Stroke Scale (NIHSS). A FAST-ED App ⩾ 4 revealed very good accuracy to detect LVO related AIS (sensitivity of 77% and a specificity 87%) with an area under the curve c-statistics of 0.89 (95% CI: 0.87–0.90). In a hypothetical triage model, the number needed to screen in order to avoid one secondary transportation in an urban setting would be five. Conclusion: This validation study of a shortened FAST-ED assessment for a smartphone-app guided stroke triage yields good quality to identify patients with LVO.
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Affiliation(s)
- Benedikt Frank
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Felix Fabian
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Bastian Brune
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Bessime Bozkurt
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, School of Medicine, Emory University, Atlanta, GA, USA
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
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18
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Frank B, Lembeck T, Toppe N, Brune B, Bozkurt B, Deuschl C, Nogueira RG, Dudda M, Risse J, Kill C, Forsting M, Kleinschnitz C, Köhrmann M. FAST-ED scale smartphone app-based prediction of large vessel occlusion in suspected stroke by emergency medical service. Ther Adv Neurol Disord 2021; 14:17562864211054962. [PMID: 34804205 PMCID: PMC8597063 DOI: 10.1177/17562864211054962] [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: 09/02/2021] [Accepted: 10/04/2021] [Indexed: 12/25/2022] Open
Abstract
Background and Purpose: Considering the highly time-dependent therapeutic effect of endovascular treatment in patients with large vessel occlusion–associated acute ischemic stroke, prehospital identification of large vessel occlusion and subsequent triage for direct transport to a comprehensive stroke center offers an intriguing option for optimizing patient pathways. Methods: This prospective in-field validation study included 200 patients with suspected acute ischemic stroke who were admitted by emergency medical service to a comprehensive stroke center. Ambulances were equipped with smartphones running an app-based Field Assessment Stroke Triage for Emergency Destination scale for transmission prior to admission. The primary measure was the predictive accuracy of the transmitted Field Assessment Stroke Triage for Emergency Destination for large vessel occlusion and the secondary measure the predictive accuracy for endovascular treatment. Results: A Field Assessment Stroke Triage for Emergency Destination ⩾4 revealed very good accuracy to detect large vessel occlusion–related acute ischemic stroke with a sensitivity of 82.4% (95% confidence interval = 65.5–93.2), specificity of 78.3% (95% confidence interval = 71.3–84.3), and an area under the curve c-statistics of 0.89 (95% confidence interval = 0.85–0.94). Field Assessment Stroke Triage for Emergency Destination ⩾4 correctly identified 84% of patients who received endovascular treatment [73.5% specificity (95% confidence interval = 66.4–79.8)] with an area under the curve c-statistics of 0.82 (95% confidence interval = 0.74–0.89). In a hypothetical triage model of an urban setting, one secondary transportation would be avoided with every fifth patient screened. Conclusion: A smartphone app-based stroke triage completed by emergency medical service personnel showed adequate quality for the Field Assessment Stroke Triage for Emergency Destination to identify large vessel occlusion–associated acute ischemic stroke. We demonstrate feasibility of the use of a medical messaging service in prehospital stroke care. Based on these first results, a randomized trial evaluating the clinical benefit of such a triage system in an urban setting is currently in preparation. Clinical Trial Registration: https://clinicaltrials.gov Unique identifier: NCT04404504.
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Affiliation(s)
- Benedikt Frank
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Thomas Lembeck
- Fire Department Essen (Feuerwehr der Stadt Essen), Essen, Germany
| | - Nina Toppe
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Bastian Brune
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Bessime Bozkurt
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Joachim Risse
- Center of Emergency Medicine, University Hospital Essen, Essen, Germany
| | - Clemens Kill
- Center of Emergency Medicine, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
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19
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Ramos A, Guerrero WR, Pérez de la Ossa N. Prehospital Stroke Triage. Neurology 2021; 97:S25-S33. [PMID: 34785601 DOI: 10.1212/wnl.0000000000012792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center ("drip and ship"), direct transfer of the patient to an endovascular center ("mothership"), transfer of the neurointerventional team to a local primary center ("drip and drive"), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed. RECENT FINDINGS Local observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol. SUMMARY Prehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.
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Affiliation(s)
- Anna Ramos
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa
| | - Waldo R Guerrero
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa
| | - Natalia Pérez de la Ossa
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa.
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20
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Flores A, Seró L, Gomez-Choco M, Ustrell X, Pellisé A, Viñas J, Rodriguez P, Monterde A, Castilho G, Rubiera M, Amaro S, Padrós MAF, Cardona P, Marti-Fabregas J, Molina CA, Serena J, Jimenez-Fábrega FX, Purroy F, Zaragoza-Brunet J, Cocho D, Palomeras E, Kuprinski J, Más N, Hernández-Perez M, Sanjurjo E, Carrión D, Costa X, Barceló M, Monedero J, Catena E, Rybyeba M, Díaz G, de la Ossa NP, Ribó M. The Role of Vascular Imaging atReferral Centers in the Drip and Ship Paradigm. J Stroke Cerebrovasc Dis 2021; 31:106209. [PMID: 34794029 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND In drip-and-ship protocols, non-invasive vascular imaging (NIVI) at Referral Centers (RC), although recommended, is not consistently performed and its value is uncertain. We evaluated the role of NIVI at RC, comparing patients with (VI+) and without (VI-) vascular imaging in several outcomes. METHODS Observational, multicenter study from a prospective government-mandated population-based registry of code stroke patients. We selected acute ischemic stroke patients, initially assessed at RC from January-2016 to June-2020. We compared and analyzed the rates of patients transferred to a Comprehensive Stroke Center (CSC) for Endovascular Treatment (EVT), rates of EVT and workflow times between VI+ and VI- patients. RESULTS From 5128 ischemic code stroke patients admitted at RC; 3067 (59.8%) were VI+, 1822 (35.5%) were secondarily transferred to a CSC and 600 (11.7%) received EVT. Among all patients with severe stroke (NIHSS ≥16) at RC, a multivariate analysis showed that lower age, thrombolytic treatment, and VI+ (OR:1.479, CI95%: 1.117-1.960, p=0.006) were independent factors associated to EVT. The rate of secondary transfer to a CSC was lower in VI+ group (24.6% vs. 51.6%, p<0.001). Among transferred patients, EVT was more frequent in VI+ than VI- (48.6% vs. 21.7%, p<0.001). Interval times as door-in door-out (median-minutes 83.5 vs. 82, p= 0.13) and RC-Door to puncture (median-minutes 189 vs. 178, p= 0.47) did not show differences between both groups. CONCLUSION In the present study, NIVI at RC improves selection for EVT, and is associated with receiving EVT in severe stroke patients. Time-metrics related to drip-and-ship model were not affected by NIVI.
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Affiliation(s)
- Alan Flores
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain.
| | - Laia Seró
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | - Xavier Ustrell
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Anna Pellisé
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Jaume Viñas
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Paula Rodriguez
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Angela Monterde
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Gislaine Castilho
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Marta Rubiera
- Stroke Unit, Neurology Department, Hospital Universitari Vall D' Hebron, Barcelona, Spain
| | - Sergi Amaro
- Stroke Unit, Neurology Department, Hospital Clinic, Barcelona, Spain
| | | | - Pedro Cardona
- Stroke Unit, Neurology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | | | - Carlos A Molina
- Stroke Unit, Neurology Department, Hospital Universitari Vall D' Hebron, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Neurology Department, Hospital Universitari Josep Trueta, Girona, Spain
| | | | - Francisco Purroy
- Stroke Unit, Neurology Department, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - Dolores Cocho
- Neurology Department, Hospital de Granollers, Granollers, Spain
| | | | - Jurek Kuprinski
- Neurology Department, Hospital Mutua Terrasa, Barcelona, Spain
| | - Natalia Más
- Neurology Department, Hospital Althaia, Manresa, Spain
| | - Maria Hernández-Perez
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | | | | | | | | | | | | | - Natalia Perez de la Ossa
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Neurology Department, Hospital Universitari Vall D' Hebron, Barcelona, Spain
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21
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Duvekot MH, Venema E, Lingsma HF, Coutinho JM, van der Worp HB, Hofmeijer J, Bokkers RP, van Es AC, van der Lugt A, Kerkhoff H, Dippel DW, Roozenbeek B. Sensitivity of prehospital stroke scales for different intracranial large vessel occlusion locations. Eur Stroke J 2021; 6:194-204. [PMID: 34414295 PMCID: PMC8370085 DOI: 10.1177/23969873211015861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/14/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Prehospital stroke scales have been proposed to identify stroke patients with a large vessel occlusion to allow direct transport to an intervention centre capable of endovascular treatment (EVT). It is unclear whether these scales are able to detect not only proximal, but also more distal treatable occlusions. Our aim was to assess the sensitivity of prehospital stroke scales for different EVT-eligible occlusion locations in the anterior circulation. Patients and methods The MR CLEAN Registry is a prospective, observational study in all centres that perform EVT in the Netherlands. We included adult patients with an anterior circulation stroke treated between March 2014 and November 2017. We used National Institutes of Health Stroke Scale scores at admission to reconstruct previously published prehospital stroke scales. We compared the sensitivity of each scale for different occlusion locations. Occlusions were assessed with CT angiography by an imaging core laboratory blinded to clinical findings. Results We included 3021 patients for the analysis of 14 scales. All scales had the highest sensitivity to detect internal carotid artery terminus occlusions (ranging from 0.21 to 0.97) and lowest for occlusions of the M2 segment (0.08 to 0.84, p-values < 0.001).Discussion and conclusion: Although prehospital stroke scales are generally sensitive for proximal large vessel occlusions, they are less sensitive to detect more distal occlusions.
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Affiliation(s)
- Martijne Hc Duvekot
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands.,Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Esmee Venema
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht, the Netherlands
| | | | - Reinoud Ph Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Adriaan Cgm van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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22
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Kass-Hout T, Lee J, Tataris K, Richards CT, Markul E, Weber J, Mendelson S, O'Neill K, Sednew RM, Prabhakaran S. Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke. JAMA Neurol 2021; 78:1220-1227. [PMID: 34369969 DOI: 10.1001/jamaneurol.2021.2485] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain. Objective To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT. Design, Setting, and Participants This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019. Interventions Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers. Main Outcomes and Measures Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset. Results Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window. Conclusions and Relevance Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.
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Affiliation(s)
- Tareq Kass-Hout
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Jungwha Lee
- Department of Preventive Medicine (Biostatistics), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katie Tataris
- Section of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois.,Chicago EMS System, Chicago, Illinois
| | - Christopher T Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eddie Markul
- Chicago EMS System, Chicago, Illinois.,Department of Emergency Medicine, University of lllinois College of Medicine, Advocate Illinois Masonic Hospital, Chicago, Illinois
| | - Joseph Weber
- Chicago EMS System, Chicago, Illinois.,Department of Emergency Medicine, Cook County Health, Chicago, Illinois
| | - Scott Mendelson
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | | | - Renee M Sednew
- American Heart Association, Midwest Region, Chicago, Illinois
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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23
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Daly M, Cummings C, Kittell M, Dubuque A, Plante L, Linares G, Wolfson D. Validation of field assessment stroke triage for emergency destination for prehospital use in a rural EMS system. Am J Emerg Med 2021; 50:178-182. [PMID: 34371326 DOI: 10.1016/j.ajem.2021.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a simple and accurate prehospital stroke severity scale that has been shown to have comparable accuracy to the gold standard National Institutes of Health Stroke Scale (NIHSS) but requires further field validation for use by emergency medical services (EMS), particularly in rural systems. FAST-ED scores ≥4 are considered high probability for large vessel occlusion (LVO) strokes, while scores <4 are low to moderate probability for LVO. The objective of this study was to assess inter-rater reliability of the EMS FAST-ED (EMS) score to the emergency department FAST-ED (ED-MD) scores. METHODS EMS calculated FAST-ED scores prior to transport to the emergency department (ED) on patients with a positive prehospital stroke screen. EDMD calculated FAST-ED scores for the same patients upon arrival to the ED. Interrater reliability and test characteristics were calculated. RESULTS A total of 95 patients were included in this study and 14 were subsequently diagnosed with an LVO. EMS assigned 34 patients (35.8%) a FAST-ED score of ≥4. EDMD assigned 25 patients (26.3%) a FAST-ED score of ≥4. Using the clinical cut-points of FAST-ED scores <4 and ≥ 4, a linearly weighted Cohen's kappa coefficient showed moderate interrater reliability when comparing EMS and EDMD scores (kw 0.44, 95% CI 0.25-0.63). At ≥4, EMS FAST-ED scores had a sensitivity 0.48, specificity 0.75, PPV 0.62, NPV 0.62 for predicting an LVO, while EDMD FAST-ED scores had a sensitivity 0.36, specificity 0.82, PPV 0.64, NPV 0.60. Comparable receiver operator curve area under the curve values were obtained. CONCLUSIONS EMS and EDMD FAST-ED scores were moderately comparable in a rural EMS system. Similar NPVs compared to EDMD suggest the use of FAST-ED as an appropriate screening tool for EMS to predict the probability of LVO in the prehospital setting and make destination determinations regarding primary transport to a thrombectomy-capable stroke center.
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Affiliation(s)
- Madison Daly
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America.
| | - Cori Cummings
- Medical University of South Carolina, Department of Neurology, Charleston, SC, United States of America
| | - Miles Kittell
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Amy Dubuque
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Laurel Plante
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Guillermo Linares
- Saint Louis University School of Medicine, Department of Neurology, Saint Louis, MO, United States of America
| | - Daniel Wolfson
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
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24
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Kägi G, Schurter D, Niederhäuser J, De Marchis GM, Engelter S, Arni P, Nyenhuis O, Imboden P, Bonvin C, Luft A, Renaud S, Nedeltchev K, Carrera E, Cereda C, Fischer U, Arnold M, Michel P. Swiss guidelines for the prehospital phase in suspected acute stroke. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x21999230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.
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Affiliation(s)
- Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - David Schurter
- Protection & Rescue Zurich, Ambulance, Zurich, Switzerland
| | | | - Gian Marco De Marchis
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
- Neurorehabilitation Felix Platter, University of Basel, Basel, Switzerland
| | - Patrick Arni
- Protection and Rescue Bern, Medical Police, Bern, Switzerland
| | | | - Paul Imboden
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Kantonsspital St. Gallen, Switzerland
| | - Christophe Bonvin
- Division of Neurology and Stroke Unit, Hôpital du Valais, Sion, Switzerland
| | - Andreas Luft
- Department of Neurology, University Hospital Zurich and Cereneo, Vitznau, Switzerland
| | - Susanne Renaud
- Division of Neurology, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, University Hospitals of Geneva, Geneva, Switzerland
| | - Carlo Cereda
- Department of Neurology, Neurocentro della Svizzera Italiana, Lugano Civic Hospital, Lugano, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Nehme A, Rivet S, Choisi TJ, Dallaire M, de Montigny L, Deschaintre Y, Daneault N, Jacquin G, Legault C, Levy JP, Neves Briard J, Odier C, Poppe AY, Segal E, Stapf C, Gioia LC. Prospective Evaluation of a Two-Scale Protocol for Prehospital Large Vessel Occlusion Detection. PREHOSP EMERG CARE 2021; 26:348-354. [PMID: 33689555 DOI: 10.1080/10903127.2021.1901164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background and purposes: Stroke severity scales may expedite prehospital large vessel occlusion (LVO) stroke detection, but few are validated for paramedic use. We evaluated the feasibility of introducing the Cincinnati Stroke Triage Assessment Tool (C-STAT) in the field and its capacity to detect LVO stroke.Methods: We performed a prospective paramedic-based study assessing C-STAT in the field on patients currently redirected to two comprehensive stroke centers (CSC), based on a Cincinnati Prehospital Stroke Scale (CPSS) score of 3/3. C-STAT was administered by on-site paramedics with telephone guidance from trained centralized clinical support paramedics.Results: Between October 2018 and November 2019, C-STAT scores were obtained in 188/218 (86.2%) patients, among which 118/188 (62.8%) were positive. Paramedics reported performing the C-STAT in less than 5 minutes on 170/188 (90.4%) patients and noted no difficulties administering the scale in 151/188 (80.3%). A positive C-STAT identified 51/68 (75%) LVO strokes in the cohort, demonstrating a 43% (95% CI: 38%-48%) positive and 76% (95% CI: 66%-83%) negative predictive value for LVO stroke diagnosis. In a cohort of 100 patients with CPSS 3/3, requiring a positive C-STAT for redirection would decrease CSC patient volume by 37 but miss 9 of 36 LVO strokes.Conclusion: Prehospital administration of the C-STAT was feasible, using a model of minimal paramedic training and real-time telephone guidance. A protocol based on both a CPSS 3/3 and a positive C-STAT would decrease CSC redirected patient volume by one-third but would miss one-quarter of LVO strokes when compared to a CPSS-based protocol.
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26
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Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, Lingsma HF, Maasland L, Wijnhoud AD, Mulder LJMM, Alblas KCL, van Eijkelenburg RPJ, Buijck BI, Bakker J, Plaisier AS, Hensen JH, Lycklama à Nijeholt GJ, van Doormaal PJ, van Es ACGM, van der Lugt A, Kerkhoff H, Dippel DWJ, Roozenbeek B, Dippel DW, Roozenbeek B, Kerkhoff H, Lingsma HF, van der Lugt A, van Es AC, Rozeman AD, Moudrous W, Vermeij FH, Venema E, Duvekot MH, Alblas KC, Mulder LJ, Wijnhoud AD, Maasland L, van Eijkelenburg RP, Biekart M, Willeboer ML, Buijck B, van Doormaal PJ, Bakker J, Hensen JH, Plaisier A, Lycklama à Nijeholt G, Hoek A, Oskam E, van der Zon MM, Zwets ED, Kuiper JW, van Moll BJ, Woudenberg M, de Leeuw AM, Noordam-Reijm A, Bevelander T, Chalos V, Wiegers EJ, Wolff L, van Kalkeren DC, van den Biggelaar J. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20:213-221. [DOI: 10.1016/s1474-4422(20)30439-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022]
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Almqvist T, Berglund A, Sjöstrand C, Eriksson E, Mazya MV. Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset. Stroke 2021; 52:1441-1445. [PMID: 33641383 DOI: 10.1161/strokeaha.120.033676] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE The Stockholm Stroke Triage System, implemented in 2017, identifies patients with high likelihood of large vessel occlusion (LVO) stroke. A previous report has shown Stockholm Stroke Triage System notably reduced time to endovascular thrombectomy (EVT). As the indication for EVT now includes patients up to 24 hours, we aimed to assess Stockholm Stroke Triage System triage accuracy for LVO stroke and EVT treatment for patients presenting late (within 6-24 hours or with an unknown onset), put in contrast to triage accuracy within 0 to 6 hours. METHODS Between October 2017 and October 2018, we included 2905 patients with suspected stroke, transported by priority 1 ground ambulance to a Stockholm Region hospital. Patients assessed 6 to 24 hours from last known well or with unknown onset were defined as late-presenting; those within <6 hours as early-presenting. Triage positivity was defined as transport to comprehensive stroke center because of suspected stroke, hemiparesis and high likelihood of EVT-eligible LVO per teleconsultation. RESULTS Overall triage accuracy was high in late-presenting patients (90.9% for LVO, 93.9% for EVT), with high specificity (95.7% for LVO, 94.5% for EVT), and low to moderate sensitivity (34.3% for LVO, 64.7% for EVT), with similar findings in the early-presenting group. CONCLUSIONS Our results may support using the Stockholm Stroke Triage System for primary stroke center bypass in patients assessed by ambulance up to 24 hours from time of last known well.
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Affiliation(s)
- Tove Almqvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
| | - Annika Berglund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.)
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
| | - Einar Eriksson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
| | - Michael V Mazya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
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28
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Mazya MV, Berglund A, Ahmed N, von Euler M, Holmin S, Laska AC, Mathé JM, Sjöstrand C, Eriksson EE. Implementation of a Prehospital Stroke Triage System Using Symptom Severity and Teleconsultation in the Stockholm Stroke Triage Study. JAMA Neurol 2021; 77:691-699. [PMID: 32250423 DOI: 10.1001/jamaneurol.2020.0319] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance To our knowledge, it is unknown whether a prehospital stroke triage system combining symptom severity and teleconsultation could accurately select patients for primary stroke center bypass and hasten delivery of endovascular thrombectomy (EVT) without delaying intravenous thrombolysis (IVT). Objective To evaluate the predictive performance of the newly implemented Stockholm Stroke Triage System (SSTS) for large-artery occlusion (LAO) stroke and EVT initiation. Secondary objectives included evaluating whether the Stockholm Stroke Triage System shortened onset-to-puncture time for EVT and onset-to-needle time (ONT) for IVT. Design, Setting, and Participants This population-based prospective cohort study conducted from October 2017 to October 2018 across the Stockholm region (Sweden) included patients transported by first-priority ("code stroke") ambulance to the hospital for acute stroke suspected by an ambulance nurse and historical controls (October 2016-October 2017). Exclusion criteria were in-hospital stroke and helicopter or private transport. Of 2909 eligible patients, 4 (0.14%) declined participation. Exposures Patients were assessed by ambulance nurses with positive the face-arm-speech-time test or other stroke suspicion and were evaluated for moderate-to-severe hemiparesis (≥2 National Institutes of Health stroke scale points each on the ipsilateral arm and leg [A2L2 test]). If present, the comprehensive stroke center (CSC) stroke physician was teleconsulted by phone for confirmation of stroke suspicion, assessment of EVT eligibility, and direction to CSC or the nearest primary stroke center. If absent, the nearest hospital was prenotified. Main Outcomes and Measures Primary outcome: LAO stroke. Secondary outcomes: EVT initiation, onset-to-puncture time, and ONT. Predictive performance measures included sensitivity, specificity, positive and negative predictive values, the overall accuracy for LAO stroke, and EVT initiation. Results We recorded 2905 patients with code-stroke transports (1420 women [49%]), and of these, 323 (11%) had A2L2+ teleconsultation positive results and were triaged for direct transport to CSC (median age, 73 years [interquartile range (IQR), 64-82 years]; 55 women [48%]). Accuracy for LAO stroke was 87% (positive predictive value, 41%; negative predictive value, 93%) and 91% for EVT initiation (positive predictive value, 26%; negative predictive value, 99%). Endovascular thrombectomy was performed for 84 of 323 patients (26%) with triage-positive results and 35 of 2582 patients (1.4%) with triage-negative results. In EVT cases with a known onset time (77 [3%]), the median OPT was 137 minutes (IQR, 118-180; previous year, 206 minutes [IQR, 160-280]; n = 75) (P < .001). The regional median ONT (337 [12%]) was unchanged at 115 minutes (IQR, 83-164; previous year, 115 minutes [IQR, 85-161]; n = 360) (P = .79). The median CSC IVT door-to-needle time was 13 minutes (IQR, 10-18; 116 [4%]) (previous year, 31 minutes [IQR, 19-38]; n = 45) (P < .001). Conclusions and Relevance The Stockholm Stroke Triage System, which combines symptom severity and teleconsultation, results in markedly faster EVT delivery without delaying IVT.
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Affiliation(s)
- Michael V Mazya
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Berglund
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Clinical Pharmacology Unit, Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jan M Mathé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Capio St Göran Hospital, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Einar E Eriksson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, Duijndam D, Koster GT, de Schryver ELLM, Kloos LMH, de Laat KF, Aerden LAM, Zylicz SA, Wermer MJH, Kruyt ND. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78:157-164. [PMID: 33252631 DOI: 10.1001/jamaneurol.2020.4418] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. Objective To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. Design, Setting, and Participants This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Exposures Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Main Outcomes and Measures Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Results Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. Conclusions and Relevance This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.
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Affiliation(s)
- T Truc My Nguyen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
| | - Jan Bosch
- Emergency Medical Services Hollands-Midden, Leiden, the Netherlands
| | - Eduard van Belle
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Dion Duijndam
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Gaia T Koster
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands
| | | | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis Hospital, Delft, the Netherlands
| | - Stas A Zylicz
- Department of Neurology, Langeland Hospital, Zoetermeer, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
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30
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Abstract
BACKGROUND AND PURPOSE Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. METHODS Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. RESULTS Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0-61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. CONCLUSIONS The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.
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Simonsen CZ, Schönenberger S, Hendén PL, Yoo AJ, Uhlmann L, Rentzos A, Bösel J, Valentin J, Rasmussen M. Patients Requiring Conversion to General Anesthesia during Endovascular Therapy Have Worse Outcomes: A Post Hoc Analysis of Data from the SAGA Collaboration. AJNR Am J Neuroradiol 2020; 41:2298-2302. [PMID: 33093133 DOI: 10.3174/ajnr.a6823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy for acute ischemic stroke is often performed with the patient under conscious sedation. Emergent conversion from conscious sedation to general anesthesia is sometimes necessary. The aim of this study was to assess the functional outcome in converted patients compared with patients who remained in conscious sedation and to identify predictors associated with the risk of conversion. MATERIALS AND METHODS Data from 368 patients, included in 3 trials randomizing between conscious sedation and general anesthesia before endovascular therapy (SIESTA, ANSTROKE, and GOLIATH) constituted the study cohort. Twenty-one (11%) of 185 patients randomized to conscious sedation were emergently converted to general anesthesia. RESULTS Absence of hyperlipidemia seemed to be the strongest predictor of conversion to general anesthesia, albeit a weak predictor (area under curve = 0.62). Sex, hypertension, diabetes, smoking status, atrial fibrillation, blood pressure, size of the infarct, and level and side of the occlusion were not significantly associated with conversion to general anesthesia. Neither age (mean age, 71.3 ± 13.8 years for conscious sedation versus 71.6 ± 12.3 years for converters, P = .58) nor severity of stroke (mean NIHSS score, 17 ± 4 versus 18 ± 4, respectively, P = .27) were significantly different between converters and those who tolerated conscious sedation. The converters had significantly worse outcome with a common odds ratio of 2.67 (P = .015) for a shift toward a higher mRS score compared with the patients remaining in the conscious sedation group. CONCLUSIONS Patients undergoing conversion had significantly worse outcome compared with patients remaining in conscious sedation. No factor was identified that predicted conversion from conscious sedation to general anesthesia.
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Affiliation(s)
| | - S Schönenberger
- Department of Neurology (S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - P L Hendén
- Department of Anesthesiology and Intensive Care Medicine (P.L.H.)
| | - A J Yoo
- Division of Neurointervention (A.J.Y.), Texas Stroke Institute, Dallas-Fort Worth, Texas
| | - L Uhlmann
- Institute of Medical Biometry and Informatics (L.U.), University of Heidelberg, Heidelberg, Germany
| | - A Rentzos
- Radiology (A.R.), Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J Bösel
- Department of Neurology (J.B.), Klinikum Kassel, Kassel, Germany
| | - J Valentin
- Department of Clinical Medicine, (J.V.), Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, North Denmark Region, Denmark
| | - M Rasmussen
- Anesthesia (M.R.), Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
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The Neurological Examination Improves Cranial Accelerometry Large Vessel Occlusion Prediction Accuracy. Neurocrit Care 2020; 35:103-112. [PMID: 33215393 DOI: 10.1007/s12028-020-01144-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVE We combined cranial accelerometry, a device-based approach to large vessel occlusion (LVO) prediction, with neurological examination findings to determine if this improves diagnostic accuracy compared to either alone. METHODS Cranial accelerometry recordings and NIHSS scores were obtained during stroke codes and thrombectomy transfers at an academic medical center using convenience sampling. The reference standard was discharge diagnosis of LVO stroke. We compared accuracy statistics between machine learning models trained using cranial accelerometry alone, with asymmetric arm weakness added, with NIHSS scores added, and retrospective examination only LVO prediction scales. An exploratory analysis required asymmetric arm weakness prior to model training or scale testing. RESULTS Of 68 patients, there were 23 LVO strokes. Cranial accelerometry was 65% sensitive (95% CI 43-84%) and 87% specific (95% CI 73-95%). Adding asymmetric arm weakness increased specificity to 91% (95% CI 79-98%). Adding asymmetric arm weakness and the NIHSS increased sensitivity to 74% (95% CI 52-90%) and decreased specificity to 89% (95% CI 76-96%). LVO prediction scales had wide sensitivity and specificity ranges. The exploratory analysis improved sensitivity to 91% (95% CI 72-99%) and specificity to 93% (95% CI 92-99%) with only three false positives and two false negatives. CONCLUSIONS Cranial accelerometry models are improved by various additions of asymmetric arm weakness and the NIHSS. An exploratory analysis requiring asymmetric arm weakness prior to cranial accelerometry model training minimized false positives and negatives.
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Flores A, Ustrell X, Seró L, Pellisé A, Rodriguez P, Viñas J, Ribó M, Krupinski J, Más N, Garcia S, Palomeras Soler E, Cocho D, Canovas D, Purroy F, Serena J, Zaragoza-Brunet J, Obach V, Perez de la Ossa N, Cardona P, Molina CA, Abilleira S, Rubiera M. Vascular Occlusion Evolution in Endovascular Reperfusion Candidates Transferred from Primary to Comprehensive Stroke Centers. Cerebrovasc Dis 2020; 49:550-555. [PMID: 33091908 DOI: 10.1159/000511063] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The evolution of the symptomatic intracranial occlusion during transfers from primary stroke centers (PSCs) to comprehensive stroke centers (CSCs) for endovascular treatment (EVT) is not widely known. Our aim was to identify factors related to partial or complete recanalization (REC) at CSC arrival in patients with a documented large vessel occlusion (LVO) in PSC transferred for EVT evaluation to better define the workflow at CSC of this group of patients. METHODS We conducted an observational, multicenter study from a prospective, government-mandated, population-based registry of stroke patients with documented LVO at PSC transferred to CSC for EVT from January 2017 to June 2019. The primary end point was defined as partial or complete REC that precluded EVT at CSC arrival (REC). We evaluated the association between baseline, treatment variables and time intervals with the presence of REC. RESULTS From 589 patients, the rate of REC at CSC was 10.5% in all LVO patients transferred from PSC to CSC for EVT evaluation. On univariate analysis, lower PSC-NIHSS (median 12vs.16, p = 0.001), tPA treatment at PSC (13.7 vs. 5.0%; p = 0.001), presence of M2 occlusion on PSC (16.8 vs. 9%; p = 0.023), and clinical improvement at CSC arrival (21.7 vs. 9.6% p = 0.001) were associated with REC at CSC. On multivariate analysis, clinical improvement at CSC arrival (p < 0.001, OR: 5.96 95% CI: 2.5-13.9) and PSC tPA treatment predicted REC (p = 0.003, OR: 4.65, 95% CI: 1.73-12.4). CONCLUSION REC at CSC arrival occurs exceptionally in patients with a documented LVO on PSC. Repeating a second vascular study before EVT would not be necessary in most patients. Despite its modest effect, tPA treatment at PSC was an independent predictor of REC.
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Affiliation(s)
- Alan Flores
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain,
| | - Xavier Ustrell
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Laia Seró
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Anna Pellisé
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Paula Rodriguez
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Jaume Viñas
- Stroke Unit, Neurology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Marc Ribó
- Stroke Unit, Neurology Department, Hospital Universitari Vall D' Hebron, Barcelona, Spain
| | | | - Natalia Más
- Neurology Department, Hospital Mutua Terrasa, Barcelona, Spain
| | - Sonia Garcia
- Neurology Department, Hospital Moises Broggi, Barcelona, Spain
| | | | - Dolores Cocho
- Neurology Department, Hospital de Granollers, Granollers, Spain
| | - David Canovas
- Neurology Department, Hospital Parc Tauli, Sabadell, Spain
| | - Francisco Purroy
- Stroke Unit, Neurology Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - Joaquim Serena
- Stroke Unit, Neurology Department, Hospital Univri Josep Trueta, Girona, Spain
| | | | - Victor Obach
- Stroke Unit, Neurology Department, Hospital Clinic, Barcelona, Spain
| | - Natalia Perez de la Ossa
- Stroke Unit, Neurology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Pere Cardona
- Stroke Unit, Neurology Department, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Neurology Department, Hospital Universitari Vall D' Hebron, Barcelona, Spain
| | - Sonia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Neurology Department, Hospital Universitari Vall D' Hebron, Barcelona, Spain
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Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke 2020; 51:3310-3319. [PMID: 33023425 PMCID: PMC7587242 DOI: 10.1161/strokeaha.120.031144] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose: Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States. Methods: We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies: (1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Rankin Scale score of >2). Results: Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 [65%]), followed by the algorithm with <60 minutes delay (n=10 [20%]). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31). Conclusions: Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.
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Affiliation(s)
- Esmee Venema
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, MI (J.F.B.)
| | - Bob Roozenbeek
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (B.R.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
| | - Hester F Lingsma
- Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
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Birnbaum L, Wampler D, Shadman A, de Leonni Stanonik M, Patterson M, Kidd E, Tovar J, Garza A, Blanchard B, Slesnick L, Blanchette A, Miramontes D. Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke. J Neurointerv Surg 2020; 13:505-508. [PMID: 32611621 DOI: 10.1136/neurintsurg-2020-016054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Numerous stroke severity scales have been published, but few have been studied with emergency medical services (EMS) in the prehospital setting. We studied the Vision, Aphasia, Neglect (VAN) stroke assessment scale in the prehospital setting for its simplicity to both teach and perform. This prospective prehospital cohort study was designed to validate the use and efficacy of VAN within our stroke systems of care, which includes multiple comprehensive stroke centers (CSCs) and EMS agencies. METHODS The performances of VAN and the National Institutes of Health Stroke Scale (NIHSS) ≥6 for the presence of both emergent large vessel occlusion (ELVO) alone and ELVO or any intracranial hemorrhage (ICH) combined were reported with positive predictive value, sensitivity, negative predictive value, specificity, and overall accuracy. For subjects with intraparenchymal hemorrhage, volume was calculated based on the ABC/2 formula and the presence of intraventricular hemorrhage was recorded. RESULTS Both VAN and NIHSS ≥6 were significantly associated with ELVO alone and with ELVO or any ICH combined using χ2 analysis. Overall, hospital NIHSS ≥6 performed better than prehospital VAN based on statistical measures. Of the 34 cases of intraparenchymal hemorrhage, mean±SD hemorrhage volumes were 2.5±4.0 mL for the five VAN-negative cases and 17.5±14.2 mL for the 29 VAN-positive cases. CONCLUSIONS Our VAN study adds to the published evidence that prehospital EMS scales can be effectively taught and implemented in stroke systems with multiple EMS agencies and CSCs. In addition to ELVO, prehospital scales such as VAN may also serve as an effective ICH bypass tool.
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Affiliation(s)
- Lee Birnbaum
- Neurosurgery, UTHSC at San Antonio, San Antonio, Texas, USA
| | - David Wampler
- Emergency Health Sciences, UTHSC at San Antonio, San Antonio, Texas, USA
| | - Arash Shadman
- Neurology, UTHSC at San Antonio, San Antonio, Texas, USA
| | | | - Michele Patterson
- Clinical Services, Saint Luke's Baptist Hospital, San Antonio, Texas, USA
| | - Emily Kidd
- Acadian Ambulance Service, San Antonio, Texas, USA
| | - Jeanette Tovar
- Neurosciences, University Hospital, San Antonio, Texas, USA
| | - Ashley Garza
- Neurosciences, University Hospital, San Antonio, Texas, USA
| | - Bonnie Blanchard
- Methodist Healthcare System of San Antonio Ltd, San Antonio, Texas, USA
| | - Lara Slesnick
- School of Medicine, UTHSC at San Antonio, San Antonio, Texas, USA
| | - Adam Blanchette
- Methodist Healthcare System of San Antonio Ltd, San Antonio, Texas, USA
| | - David Miramontes
- Emergency Health Sciences, UTHSC at San Antonio, San Antonio, Texas, USA
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Hackett CT, Rahangdale R, Protetch J, Saleemi MA, Rana SS, Wright DG, Fishman R, Noah P, Tayal AH. Rapid Arterial Occlusion Evaluation Scale Agreement between Emergency Medical Services Technicians and Neurologists. J Stroke Cerebrovasc Dis 2020; 29:104745. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022] Open
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Brandler ES, Thode H, Fiorella D. The Los Angeles Motor Scale as a predictor of angiographically determined large vessel occlusion. Intern Emerg Med 2020; 15:695-700. [PMID: 31927683 DOI: 10.1007/s11739-019-02272-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
Recent advances in time-sensitive mechanical thrombectomy for the treatment of emergent large vessel occlusion (ELVO) have changed the role of prehospital providers from simply identifying a stroke to identifying the likely presence of ELVO. No one method for identifying ELVO in the field has been demonstrated to be superior. We sought to describe how this might be best accomplished using the Los Angeles Motor Scale (LAMS) in concert with other physical exam findings by paramedics and emergency medical technicians (EMTs). We had paramedics and EMTs examine patients with suspected stroke in the hospital. We compared their exams to the standard neurologist exams and to the results of angiography. We performed multiple analyses to identify the exam elements that would best identify large vessel occlusions. Using LAMS with a threshold score of 4, sensitivity for stroke and ELVO, respectively, was 27% (95% CI 20-36%) and 42% (95% CI 30-55%). When a LAMS of 3 was used in concert with speech abnormality, sensitivity improved to 36% (95% CI 28-45%) and 61% (95% CI 48-73%). Specificity of this model was 70%, (95% CI 64-75%). Most striking was the negative predictive value of this model for ELVO: 90% (95% CI 85-93%) The LAMS or LAMS plus speech can be used to decrease the number of missed large vessel occlusions and to route suspected large vessel occlusions to thrombectomy-capable centers. Other, more complicated scales may have little additional benefit. This derivation data set is the first to use paramedics and EMTs as examiners prospectively and supports prehospital protocol change underway in New York City.
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Affiliation(s)
- Ethan Samuel Brandler
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, USA.
| | - Henry Thode
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, USA
| | - David Fiorella
- Department of Neurological Surgery, State University of New York at Stony Brook, Stony Brook, USA
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Schlemm L, Endres M, Nolte CH. Bypassing the Closest Stroke Center for Thrombectomy Candidates. Stroke 2020; 51:867-875. [DOI: 10.1161/strokeaha.119.027512] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
Patients with acute ischemic stroke who have large vessel occlusion benefit from direct transport to a comprehensive stroke center (CSC) capable of endovascular therapy. To avoid harm for patients without large vessel occlusion from delayed access to intravenous thrombolysis (IVT), it has been suggested to only redirect patients with high likelihood of large vessel occlusion for whom the additional delay to intravenous thrombolysis (IVT) caused by transport to the CSC is below a certain threshold. However, which threshold achieves the greatest clinical benefit is unknown.
Methods—
We used mathematical modeling to calculate additional-delay-to-IVT thresholds associated with the greatest reduction in disability-adjusted life years in abstracted 2-stroke center and multiple-stroke center scenarios. Model parameters were extracted from recent meta-analyses or large prospective cohort studies. Uncertainty was quantified in probabilistic and 2-way univariate sensitivity analyses.
Results—
Assuming ideal treatment time performance metrics, transport to the nearest CSC was the preferred strategy irrespective of additional delay-to-IVT when the transfer time between primary stroke center and CSC was <40 minutes (95% credible interval: 25–66 minutes); otherwise, the optimal additional delay-to-IVT-threshold ranged from 28 to 139 minutes. In multiple-stroke center scenarios, optimal additional-delay-to-IVT thresholds were 30 to 54 minutes in urban and 49 to 141 minutes in rural settings; use of optimal thresholds as compared with a 15 minute-threshold saved 0 to 0.11 and 0 to 0.37 disability-adjusted life years per triage case, respectively. Assuming slower treatment times at primary stroke centers and CSCs yielded longer permissible additional delays.
Conclusions—
Our results suggest that patients with acute ischemic stroke with suspected large vessel occlusion should be redirected to a CSC if the additional delay to IVT is <30 minutes in urban and 50 minutes in rural settings.
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Affiliation(s)
- Ludwig Schlemm
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
| | - Matthias Endres
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Christian H. Nolte
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
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Rodríguez-Pardo J, Riera-López N, Fuentes B, Alonso de Leciñana M, Secades-García S, Álvarez-Fraga J, Busca-Ostolaza P, Carneado-Ruiz J, Díaz-Guzmán J, Egido-Herrero J, Gil-Núñez A, Masjuan-Vallejo J, Real-Martínez V, Vivancos-Mora J, Díez-Tejedor E. Prehospital selection of thrombectomy candidates beyond large vessel occlusion. Neurology 2020; 94:e851-e860. [DOI: 10.1212/wnl.0000000000008998] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 09/02/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveCurrent prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C.MethodsIn this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort).ResultsThe M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts.ConclusionsThe M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.
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Keigher KM. Large Vessel Occlusion in the Acute Stroke Patient: Identification, Treatment, and Management. Crit Care Nurs Clin North Am 2019; 32:21-36. [PMID: 32014159 DOI: 10.1016/j.cnc.2019.11.007] [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] [Indexed: 11/26/2022]
Abstract
Acute ischemic stroke is a major cause of death and disability in the United States. Historically, acute stroke patients were treated with intravenous (IV) thrombolysis. Patients with large vessel occlusions (LVOs) should be offered mechanical thrombectomy, with or without IV thrombolysis, in an extended window up to 24 hours of last known well. Both treatment options are the standard of care for a patient with an LVO. It is critical that the intensive care unit nurse understand new treatment indications for LVO strokes, and the priorities of nursing care with medical and endovascular intervention.
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Affiliation(s)
- Kiffon M Keigher
- Neurosurgery & Neuroendovascular, Advocate Lutheran General Hospital, Chicago, IL, USA; Advocate Aurora Health, Chicago, IL, USA.
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42
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Jumaa MA, Castonguay AC, Salahuddin H, Shawver J, Saju L, Burgess R, Kung V, Slawski DE, Tietjen G, Lindstrom D, Parquette B, Korsnack A, Cole K, Afreen E, Bafna K, Zaidi SF. Long-term implementation of a prehospital severity scale for EMS triage of acute stroke: a real-world experience. J Neurointerv Surg 2019; 12:19-24. [PMID: 31266858 PMCID: PMC6996096 DOI: 10.1136/neurintsurg-2019-014997] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 12/30/2022]
Abstract
Background Data on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA. Objective To report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score. Methods Our prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score <5, taken to the nearest hospital as stroke-alerts (SA). Baseline demographics, RACE score, time metrics, final diagnosis, treatments, and clinical and angiographic outcomes were captured. The sensitivity and specificity for patients with a RACE score ≥5 with LVO, eligible for mechanical thrombectomy (MT), were calculated. Results Between July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; p<0.0001). Median times from onset-to-ECC arrival (74 vs 167 min, p=0.03) and dispatch-to-ECC arrival (31 vs 46 min, p=0.0002) were shorter in the RA-MT than in the SA-MT cohort. A RACE cut-off point ≥5 showed a sensitivity and specificity of 0.77 and 0.75 for detection of patients with LVO eligible for MT, respectively. Conclusions We have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.
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Affiliation(s)
- Mouhammad A Jumaa
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA.,Neurology, Promedica Toledo Hospital, Toledo, Ohio, USA
| | | | | | - Julie Shawver
- Neurology, Promedica Toledo Hospital, Toledo, Ohio, USA
| | - Linda Saju
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Richard Burgess
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Vieh Kung
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Diana E Slawski
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Gretchen Tietjen
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | | | | | - Andrea Korsnack
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Kimberly Cole
- University of Toledo Medical Center, Toledo, Ohio, USA
| | - Ehad Afreen
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Kunaal Bafna
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Syed F Zaidi
- Neurology, University of Toledo Medical Center, Toledo, Ohio, USA.,Neurology, Promedica Toledo Hospital, Toledo, Ohio, USA
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Martinez-Gutierrez JC, Chandra RV, Hirsch JA, Leslie-Mazwi T. Technological innovation for prehospital stroke triage: ripe for disruption. J Neurointerv Surg 2019; 11:1085-1090. [DOI: 10.1136/neurintsurg-2019-014902] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
BackgroundWith the benefit of mechanical thrombectomy firmly established, the focus has shifted to improved delivery of care. Reducing time from symptom onset to reperfusion is a primary goal. Technology promises tremendous opportunities in the prehospital space to achieve this goal.MethodsThis review explores existing, fledgling, and potential future technologies for application in the prehospital space.ResultsThe opportunity for technology to improve stroke care resides in the detection, evaluation, triage, and transport of patients to an appropriate healthcare facility. Most prehospital technology remains in the early stages of design and implementation.ConclusionThe major challenges to tackle for future improvement in prehospital stroke care are that of public awareness, emergency medical service detection, and triage, and improved systems of stroke care. Thoughtfully applied technology will transform all these areas.
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Schlemm L, Endres M, Scheitz JF, Ernst M, Nolte CH, Schlemm E. Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke. J Am Heart Assoc 2019; 8:e012665. [PMID: 31189395 PMCID: PMC6645624 DOI: 10.1161/jaha.119.012665] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.
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Affiliation(s)
- Ludwig Schlemm
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
| | - Matthias Endres
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
- DZNE (German Center for Neurodegenerative Diseases)BerlinGermany
| | - Jan F. Scheitz
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
| | - Marielle Ernst
- Medizinische FakultätUniversität HamburgGermany
- Abteilung für diagnostische und interventionelle NeuroradiologieUniversitätsklinikum Hamburg‐EppendorfHamburgGermany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für NeurologieCharité—Universitätsmedizin BerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinGermany
- Berlin Institute of Health (BIH)BerlinGermany
- DZHK (German Center for Cardiovascular Research)BerlinGermany
- DZNE (German Center for Neurodegenerative Diseases)BerlinGermany
| | - Eckhard Schlemm
- Medizinische FakultätUniversität HamburgGermany
- Klinik und Poliklinik für Neurologie, Kopf‐ und NeurozentrumUniversitätsklinikum Hamburg‐EppendorfHamburgGermany
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