Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy

Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience

BACKGROUND/PURPOSE

A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community.

METHODS

Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time.

RESULTS

We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001).

CONCLUSION

The prehospital bypass strategy with G-FAST showed benefits for stroke patients.

Distance Neurological Supervision Using Telestroke Does Not Increase Door-to-Needle Time in Acute Ischemic Stroke Management: The Experience of Two Regional Stroke Units

Background and Aims: Timely administration of recombinant tissue plasminogen activator (r-tPA) improves clinical outcomes in acute ischemic stroke patients. This study aims to explore the influence of the systematic presence on site of a neurologist compared with telestroke management on door-to-needle time in acute ischemic stroke outside of working hours (OWH).

Methods: This retrospective cohort study included all r-tPA-treated patients in the emergency rooms of two Swiss stroke units, Nyon Hospital [Groupement Hospitalier de l'Ouest Lémanique (GHOL)] and Fribourg Hospital [Hôpital de Fribourg (HFR)], between February 2014 and September 2018. Door-to-needle time was analyzed for patients admitted during working hours (WH' weekdays 08:00–18:00) and OWH (weekdays 18:00–08:00, weekends, and public holidays). The latter was compared between centers; OWH, every patient was evaluated prior to thrombolysis by a neurologist on site in GHOL, while HFR adopted distance neurological supervision with teleradiology, performed by telephone evaluation of relevant clinical information with online real-time access to brain imaging.

Results: Data were analyzed for 157 patients in HFR and 101 patients in GHOL. No statistically significant differences in baseline characteristics were found for the 258 r-tPA-treated acute ischemic stroke patients, in terms of age, gender, cardiovascular risk factors (hypertension, diabetes, and atrial fibrillation), and pre-Modified Rankin Scale (pre-mRs) between centers, with the exception of smoking and anticoagulation status. Patients in HFR presented with more severe strokes {median National Institutes of Health Stroke Scale (NIHSS) [6 (SD 6.88) (GHOL), 8 (SD 6.98) (HFR), p = 0.005]}. No significant differences in baseline characteristics were found as per admission time independently of the center. Door-to-needle time was significantly longer in the HFR cohort when compared with GHOL, irrespective of admission time. Both centers demonstrated significantly longer median door-to-needle time OWH. However, analysis of the door-to-needle time differences between WH and OWH showed no significant interaction using robust ANCOVA WRS2 analysis (p = 0.952) and a Bayesian model (BF01 = 3.97).

Conclusions: On-site systematic evaluation by a neurologist did not appear to influence door-to-needle time OWH, suggesting distance supervision may be time-efficient in thrombolysis. This supports existing prospective studies in hyperacute telestroke management. The relevance lies in optimizing resource use considering the increasing demand for emergency neurological management.