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Lo BM, Carpenter CR, Ducey S, Gottlieb M, Kaji A, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med 2023; 82:e17-e64. [PMID: 37479410 DOI: 10.1016/j.annemergmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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Matossian V, Starkman S, Sanossian N, Stratton S, Eckstein M, Conwit R, Liebeskind DS, Sharma L, Tenser MK, Saver JL. Quantifying the amount of greater brain ischemia protection time with pre-hospital vs. in-hospital neuroprotective agent start. Front Neurol 2022; 13:990339. [PMID: 36176566 PMCID: PMC9514007 DOI: 10.3389/fneur.2022.990339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
The objective of this study is to quantify the increase in brain-under-protection time that may be achieved with pre-hospital compared with the post-arrival start of neuroprotective therapy among patients undergoing endovascular thrombectomy. In order to do this, a comparative analysis was performed of two randomized trials of neuroprotective agents: (1) pre-hospital strategy: Field administration of stroke therapy-magnesium (FAST-MAG) Trial; (2) in-hospital strategy: Efficacy and safety of nerinetide for the treatment of acute ischemic stroke (ESCAPE-NA1) Trial. In the FAST-MAG trial, among 1,041 acute ischemic stroke patients, 44 were treated with endovascular reperfusion therapy (ERT), including 32 treated with both intravenous thrombolysis and ERT and 12 treated with ERT alone. In the ESCAPE-NA1 trial, among 1,105 acute ischemic stroke patients, 659 were treated with both intravenous thrombolysis and ERT, and 446 were treated with ERT alone. The start of the neuroprotective agent was sooner after onset with pre-hospital vs. in-hospital start: 45 m (IQR 38-56) vs. 122 m. The neuroprotective agent in FAST-MAG was started 8 min prior to ED arrival compared with 64 min after arrival in ESCAPE-NA1. Projecting modern endovascular workflows to FAST-MAG, the total time of "brain under protection" (neuroprotective agent start to reperfusion) was greater with pre-hospital than in-hospital start: 94 m (IQR 90-98) vs. 22 m. Initiating a neuroprotective agent in the pre-hospital setting enables a faster treatment start, yielding 72 min additional brain protection time for patients with acute ischemic stroke. These findings provide support for the increased performance of ambulance-based, pre-hospital treatment trials in the development of neuroprotective stroke therapies.
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Affiliation(s)
- Vartan Matossian
- MSTAR Program, Department of Geriatrics, University of California, Los Angeles, Los Angeles, CA, United States,*Correspondence: Vartan Matossian
| | - Sidney Starkman
- Stroke Center and Department of Emergency Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nerses Sanossian
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | - Samuel Stratton
- Department of Emergency Medicine, University Harbor-UCLA Medical Center, Los Angeles, CA, United States
| | - Marc Eckstein
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, United States
| | - Robin Conwit
- Division of Extramural Research, National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - David S. Liebeskind
- Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Latisha Sharma
- Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - May-Kim Tenser
- Department of Neurology, University of Southern California, Los Angeles, CA, United States
| | - Jeffrey L. Saver
- Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
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Commentary on "Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians". J Vasc Interv Radiol 2022; 33:627-630. [PMID: 35636832 DOI: 10.1016/j.jvir.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/16/2022] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
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