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Hagrass AI, Elsayed SM, Doheim MF, Mostafa MA, Elfil M, Al-Kafarna M, Almaghary BK, Fayoud AM, Hamdallah A, Hasan MT, Ragab KM, Nourelden AZ, Zaazouee MS, Medicherla C, Lerario M, Czap AL, Chong J, Nour M, Al-Mufti F. Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 "T Letter" Domains. Cardiol Rev 2024; 32:297-313. [PMID: 38602410 DOI: 10.1097/crd.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.
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Affiliation(s)
| | | | - Mohamed Fahmy Doheim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | | | | | | | | | | | - Mackenzie Lerario
- Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Alexandra L Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY
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Gunda ST, Yip JHY, Ng VTK, Chen Z, Han X, Chen X, Pang MYC, Ying MTC. The Diagnostic Accuracy of Transcranial Color-Coded Doppler Ultrasound Technique in Stratifying Intracranial Cerebral Artery Stenoses in Cerebrovascular Disease Patients: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:1507. [PMID: 38592335 PMCID: PMC10934108 DOI: 10.3390/jcm13051507] [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: 12/27/2023] [Revised: 02/17/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024] Open
Abstract
The early and accurate stratification of intracranial cerebral artery stenosis (ICAS) is critical to inform treatment management and enhance the prognostic outcomes in patients with cerebrovascular disease (CVD). Digital subtraction angiography (DSA) is an invasive and expensive procedure but is the gold standard for the diagnosis of ICAS. Over recent years, transcranial color-coded Doppler ultrasound (TCCD) has been suggested to be a useful imaging method for accurately diagnosing ICAS. However, the diagnostic accuracy of TCCD in stratifying ICASs among patients with CVD remains unclear. Therefore, this systematic review and meta-analysis aimed at evaluating the diagnostic accuracy of TCCD in the stratification of intracranial steno-occlusions among CVD patients. A total of six databases-Embase, CINAHL, Medline, PubMed, Google Scholar, and Web of Science (core collection)-were searched for studies that assessed the diagnostic accuracy of TCCD in stratifying ICASs. The meta-analysis was performed using Meta-DiSc 1.4. The Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Eighteen studies met all of the eligibility criteria. TCCD exhibited a high pooled diagnostic accuracy in stratifying intracranial steno-occlusions in patients presenting with CVD when compared to DSA as a reference standard (sensitivity = 90%; specificity = 87%; AUC = 97%). Additionally, the ultrasound parameters peak systolic velocity (PSV) and mean flow velocity (MFV) yielded a comparable diagnostic accuracy of "AUC = 0.96". In conclusion, TCCD could be a noble, safe, and accurate alternative imaging technique to DSA that can provide useful diagnostic information in stratifying intracranial steno-occlusions in patients presenting with CVD. TCCD should be considered in clinical cases where access to DSA is limited.
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Affiliation(s)
- Simon Takadiyi Gunda
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Jerica Hiu-Yui Yip
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Veronica Tsam-Kit Ng
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Ziman Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Xinyang Han
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Xiangyan Chen
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
| | - Marco Yiu-Chung Pang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China;
| | - Michael Tin-Cheung Ying
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China; (S.T.G.); (J.H.-Y.Y.); (V.T.-K.N.); (Z.C.); (X.H.); (X.C.)
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Walter U. Novel ultrasonic imaging of the brain and its vasculature: the long way to clinical guideline recommendation. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:460-466. [PMID: 37832533 DOI: 10.1055/a-2143-7233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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4
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Fladt J, Ospel JM, Singh N, Saver JL, Fisher M, Goyal M. Optimizing Patient-Centered Stroke Care and Research in the Prehospital Setting. Stroke 2023; 54:2453-2460. [PMID: 37548010 DOI: 10.1161/strokeaha.123.044169] [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: 08/08/2023]
Abstract
Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (J.F.)
| | - Johanna M Ospel
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, Canada (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
| | - Mayank Goyal
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
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Habib P, Dimitrov I, Pinho J, Schürmann K, Bach JP, Wiesmann M, Schulz JB, Reich A, Nikoubashman O. Point-of-Care Ultrasound to Detect Acute Large Vessel Occlusions in Stroke Patients: A Proof-of-Concept Study. Can J Neurol Sci 2023; 50:656-661. [PMID: 35872570 DOI: 10.1017/cjn.2022.275] [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: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A primary admission of patients with suspected acute ischemic stroke and large vessel occlusion (LVO) to centers capable of providing endovascular stroke therapy (EVT) may induce shorter time to treatment and better functional outcomes. One of the limitations in this strategy is the need for accurately identifying LVO patients in the prehospital setting. We aimed to study the feasibility and diagnostic performance of point-of-care ultrasound (POCUS) for the detection of LVO in patients with acute stroke. METHODS We conducted a proof-of-concept study and selected 15 acute ischemic stroke patients with angiographically confirmed LVO and 15 patients without LVO. Duplex ultrasonography (DUS) of the common carotid arteries was performed, and flow profiles compatible with LVO were scored independently by one experienced and one junior neurologist. RESULTS Among the 15 patients with LVO, 6 patients presented with an occlusion of the carotid-T and 9 patients presented with an M1 occlusion. Interobserver agreement between the junior and the experienced neurologist was excellent (kappa = 0.813, p < 0.001). Flow profiles of the CAA allowed the detection of LVO with a sensitivity of 73%, a positive predictive value of 92 and 100%, and a c-statistics of 0.83 (95%CI = 0.65-0.94) and 0.87 (95%CI = 0.69-0.94) (experienced neurologist and junior neurologist, respectively). In comparison with clinical stroke scales, DUS was associated with better trade-off between sensitivity and specificity. CONCLUSION POCUS in acute stroke setting is feasible, it may serve as a complementary tool for the detection of LVO and is potentially applicable in the prehospital phase.
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Affiliation(s)
- Pardes Habib
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Ivaylo Dimitrov
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Kolja Schürmann
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Jan Philipp Bach
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
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von Foerster N, Radomski MA, Martin-Gill C. Prehospital Ultrasound: A Narrative Review. PREHOSP EMERG CARE 2022; 28:1-13. [PMID: 36194192 DOI: 10.1080/10903127.2022.2132332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 10/31/2022]
Abstract
Background: Point-of-care ultrasound is rapidly becoming more prevalent in the prehospital environment. Though considered a relatively new intervention in this setting, there is growing literature that aims to explore the use of prehospital ultrasound by EMS personnel.Methods: To better understand and report the state of the science on prehospital ultrasound, we conducted a narrative review of the literature.Results: Following a keyword search of MEDLINE in Ovid from inception to August 2, 2022, 2,564 records were identified and screened. Based on review of abstracts and full texts, with addition of seven articles via bibliography review, 193 records were included. Many included studies detail usage in air medical and other critical care transport environments. Clinicians performing prehospital ultrasound are often physicians or other advanced practice personnel who have previous ultrasound experience, which facilitates implementation in the prehospital setting. Emerging literature details training programs for prehospital personnel who are novices to ultrasound, and implementation for some study types appears feasible without prior experience. Unique use scenarios that show promise include during critical care transport, for triage in austere settings, and for thoracic evaluation of patients at risk of life-threatening pathology.Conclusion: There is a growing mostly observational body of literature describing the use of ultrasound by prehospital personnel. Prehospital ultrasound has demonstrated feasibility for specific conditions, yet interventional studies evaluating benefit to patient outcomes are absent.
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Affiliation(s)
- Nicholas von Foerster
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marek A Radomski
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Mozaffarzadeh M, Verschuur DJE, Verweij MD, de Jong N, Renaud G. Accelerated 2-D Real-Time Refraction-Corrected Transcranial Ultrasound Imaging. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2022; 69:2599-2610. [PMID: 35797321 DOI: 10.1109/tuffc.2022.3189600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In a recent study, we proposed a technique to correct aberration caused by the skull and reconstruct a transcranial B-mode image with a refraction-corrected synthetic aperture imaging (SAI) scheme. Given a sound speed map, the arrival times were calculated using a fast marching technique (FMT), which solves the Eikonal equation and, therefore, is computationally expensive for real-time imaging. In this article, we introduce a two-point ray tracing method, based on Fermat's principle, for fast calculation of the travel times in the presence of a layered aberrator in front of the ultrasound probe. The ray tracing method along with the reconstruction technique is implemented on a graphical processing unite (GPU). The point spread function (PSF) in a wire phantom image reconstructed with the FMT and the GPU implementation was studied with numerical synthetic data and experiments with a bone-mimicking plate and a sagittally cut human skull. The numerical analysis showed that the error on travel times is less than 10% of the ultrasound temporal period at 2.5 MHz. As a result, the lateral resolution was not significantly degraded compared with images reconstructed with FMT-calculated travel times. The results using the synthetic, bone-mimicking plate, and skull dataset showed that the GPU implementation causes a lateral/axial localization error of 0.10/0.20, 0.15/0.13, and 0.26/0.32 mm compared with a reference measurement (no aberrator in front of the ultrasound probe), respectively. For an imaging depth of 70 mm, the proposed GPU implementation allows reconstructing 19 frames/s with full synthetic aperture (96 transmission events) and 32 frames/s with multiangle plane wave imaging schemes (with 11 steering angles) for a pixel size of [Formula: see text]. Finally, refraction-corrected power Doppler imaging is demonstrated with a string phantom and a bone-mimicking plate placed between the probe and the moving string. The proposed approach achieves a suitable frame rate for clinical scanning while maintaining the image quality.
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Chennareddy S, Kalagara R, Smith C, Matsoukas S, Bhimani A, Liang J, Shapiro S, De Leacy R, Mokin M, Fifi JT, Mocco J, Kellner CP. Portable stroke detection devices: a systematic scoping review of prehospital applications. BMC Emerg Med 2022; 22:111. [PMID: 35710360 PMCID: PMC9204948 DOI: 10.1186/s12873-022-00663-z] [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: 02/08/2022] [Accepted: 05/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The worldwide burden of stroke remains high, with increasing time-to-treatment correlated with worse outcomes. Yet stroke subtype determination, most importantly between stroke/non-stroke and ischemic/hemorrhagic stroke, is not confirmed until hospital CT diagnosis, resulting in suboptimal prehospital triage and delayed treatment. In this study, we survey portable, non-invasive diagnostic technologies that could streamline triage by making this initial determination of stroke type, thereby reducing time-to-treatment. METHODS Following PRISMA guidelines, we performed a scoping review of portable stroke diagnostic devices. The search was executed in PubMed and Scopus, and all studies testing technology for the detection of stroke or intracranial hemorrhage were eligible for inclusion. Extracted data included type of technology, location, feasibility, time to results, and diagnostic accuracy. RESULTS After a screening of 296 studies, 16 papers were selected for inclusion. Studied devices utilized various types of diagnostic technology, including near-infrared spectroscopy (6), ultrasound (4), electroencephalography (4), microwave technology (1), and volumetric impedance spectroscopy (1). Three devices were tested prior to hospital arrival, 6 were tested in the emergency department, and 7 were tested in unspecified hospital settings. Median measurement time was 3 minutes (IQR: 3 minutes to 5.6 minutes). Several technologies showed high diagnostic accuracy in severe stroke and intracranial hematoma detection. CONCLUSION Numerous emerging portable technologies have been reported to detect and stratify stroke to potentially improve prehospital triage. However, the majority of these current technologies are still in development and utilize a variety of accuracy metrics, making inter-technology comparisons difficult. Standardizing evaluation of diagnostic accuracy may be helpful in further optimizing portable stroke detection technology for clinical use.
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Affiliation(s)
- Susmita Chennareddy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA.
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Abhiraj Bhimani
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Steven Shapiro
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 8th Floor, New York, NY, 10029, USA
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Kilic M, Wendl C, Wilfling S, Olmes D, Linker RA, Schlachetzki F. Acute Middle Cerebral Artery Occlusion Detection Using Mobile Non-Imaging Brain Perfusion Ultrasound-First Case. J Clin Med 2022; 11:jcm11123384. [PMID: 35743454 PMCID: PMC9225458 DOI: 10.3390/jcm11123384] [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: 05/13/2022] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 12/02/2022] Open
Abstract
Mobile brain perfusion ultrasound (BPU) is a novel non-imaging technique creating only hemispheric perfusion curves following ultrasound contrast injection and has been specifically designed for early prehospital large vessel occlusion (LVO) stroke identification. We report on the first patient investigated with the SONAS® system, a portable point-of-care ultrasound system for BPU. This patient was admitted into our stroke unit about 12 h following onset of a fluctuating motor aphasia, dysarthria and facial weakness resulting in an NIHSS of 3 to 8. Occlusion of the left middle cerebral artery occlusion was diagnosed by computed tomography angiography. BPU was performed in conjunction with injection of echo-contrast agent to generate hemispheric perfusion curves and in parallel, conventional color-coded sonography (TCCS) assessing MCAO. Both assessments confirmed the results of angiography. Emergency mechanical thrombectomy (MT) achieved complete recanalization (TICI 3) and post-interventional NIHSS of 2 the next day. Telephone follow-up after 2 years found the patient fully active in professional life. Point-of-care BPU is a non-invasive technique especially suitable for prehospital stroke diagnosis for LVO. BPU in conjunction with prehospital stroke scales may enable goal-directed stroke patient placement, i.e., directly to comprehensive stroke centers aiming for MT. Further results of the ongoing phase II study are needed to confirm this finding.
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Affiliation(s)
- Mustafa Kilic
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - Christina Wendl
- Center for Neuroradiology, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany;
| | - Sibylle Wilfling
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - David Olmes
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - Ralf Andreas Linker
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
| | - Felix Schlachetzki
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, University Hospital Regensburg, Medbo Bezirksklinikum Regensburg, Universitaetsstr. 84, 93053 Regensburg, Germany; (M.K.); (S.W.); (D.O.); (R.A.L.)
- Correspondence: ; Tel.: +49-941-941-3502; Fax: +49-941-941-3095
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Kilic M, Scalzo F, Lyle C, Baldaranov D, Dirnbacher M, Honda T, Liebeskind DS, Schlachetzki F. A mobile battery-powered brain perfusion ultrasound (BPU) device designed for prehospital stroke diagnosis: correlation to perfusion MRI in healthy volunteers. Neurol Res Pract 2022; 4:13. [PMID: 35399083 PMCID: PMC8996400 DOI: 10.1186/s42466-022-00179-8] [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: 01/06/2022] [Accepted: 03/11/2022] [Indexed: 12/07/2022] Open
Abstract
Background Early prehospital stroke identification is crucial for goal directed hospital admission especially in rural areas. However, clinical prehospital stroke scales are designed to identify any stroke but cannot sufficiently differentiate hemorrhagic from ischemic stroke, including large vessel occlusion (LVO) amenable to mechanical thrombectomy. We report on a novel small, portable and battery driven point-of-care ultrasound system (SONAS®) specifically developed for mobile non-invasive brain perfusion ultrasound (BPU) measurement after bolus injection of an echo-enhancing agent suitable for the use in prehospital stroke diagnosis filling a current, unmet and critical need for LVO identification.
Methods In a phase I study of healthy volunteers we performed comparative perfusion-weighted magnetic resonance imaging (PWI) and BPU measurements, including safety analysis. Results Twelve volunteers (n = 7 females, n = 5 males, age ranging between 19 and 55 years) tolerated the measurement extremely well including analysis of blood–brain barrier integrity, and the correlation coefficient between the generated time kinetic curves after contrast agent bolus between PWI and BPU transducers ranged between 0.89 and 0.76. Conclusions Mobile BPU using the SONAS® device is feasible and safe with results comparable to PWI. When applied in conjunction with prehospital stroke scales this may lead to a more accurate stroke diagnosis and patients bypassing regular stroke units to comprehensive stroke centers. Further studies are needed in acute stroke patients and in the prehospital phase including assessment of immediate and long-term morbidity and mortality in stroke. Trial registration: Clinical trials.gov, registered 28.Sep.2017, Identifier: NCT03296852.
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Affiliation(s)
- Mustafa Kilic
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, medbo Bezirksklinikum Regensburg, Universitaetsstr.84, 93053, Regensburg, Germany
| | - Fabien Scalzo
- Department of Neurology, UCLA Stroke Center and Brain Research Institute, 635 Charles E Young Drive South, Suite 116, Los Angeles, CA, 90095, USA
| | - Chandler Lyle
- BURL Concepts, Inc., 4901 Morena Boulevard Suite 703, San Diego, CA, 92117, USA
| | - Dobri Baldaranov
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, medbo Bezirksklinikum Regensburg, Universitaetsstr.84, 93053, Regensburg, Germany.,Alzheimer's Therapeutic Research Institute, Keck School of Medicine, University of Southern California, 9860 Mesa Rim Road, San Diego, CA, 92121, USA
| | | | - Tristan Honda
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles, Ronald Reagan UCLA Medical Center, 300 Medical Plaza Driveway B200, Los Angeles, CA, 90095, USA
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles, Ronald Reagan UCLA Medical Center, 300 Medical Plaza Driveway B200, Los Angeles, CA, 90095, USA
| | - Felix Schlachetzki
- Department of Neurology, Center for Vascular Neurology and Intensive Care, University of Regensburg, medbo Bezirksklinikum Regensburg, Universitaetsstr.84, 93053, Regensburg, Germany.
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11
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Mozaffarzadeh M, Verschuur E, Verweij MD, Daeichin V, De Jong N, Renaud G. Refraction-Corrected Transcranial Ultrasound Imaging Through the Human Temporal Window Using a Single Probe. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2022; 69:1191-1203. [PMID: 35100111 DOI: 10.1109/tuffc.2022.3148121] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Transcranial ultrasound imaging (TUI) is a diagnostic modality with numerous applications, but unfortunately, it is hindered by phase aberration caused by the skull. In this article, we propose to reconstruct a transcranial B-mode image with a refraction-corrected synthetic aperture imaging (SAI) scheme. First, the compressional sound velocity of the aberrator (i.e., the skull) is estimated using the bidirectional headwave technique. The medium is described with four layers (i.e., lens, water, skull, and water), and a fast marching method calculates the travel times between individual array elements and image pixels. Finally, a delay-and-sum algorithm is used for image reconstruction with coherent compounding. The point spread function (PSF) in a wire phantom image and reconstructed with the conventional technique (using a constant sound speed throughout the medium), and the proposed method was quantified with numerical synthetic data and experiments with a bone-mimicking plate and a human skull, compared with the PSF achieved in a ground truth image of the medium without the aberrator (i.e., the bone plate or skull). A phased-array transducer (P4-1, ATL/Philips, 2.5 MHz, 96 elements, pitch = 0.295 mm) was used for the experiments. The results with the synthetic signals, the bone-mimicking plate, and the skull indicated that the proposed method reconstructs the scatterers with an average lateral/axial localization error of 0.06/0.14 mm, 0.11/0.13 mm, and 1.0/0.32 mm, respectively. With the human skull, an average contrast ratio (CR) and full-width-half-maximum (FWHM) of 37.1 dB and 1.75 mm were obtained with the proposed approach, respectively. This corresponds to an improvement of CR and FWHM by 7.1 dB and 36% compared with the conventional method, respectively. These numbers were 12.7 dB and 41% with the bone-mimicking plate.
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12
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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13
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Dinsmore M, Venkatraghavan L. Clinical applications of point‐of‐care ultrasound in brain injury: a narrative review. Anaesthesia 2022; 77 Suppl 1:69-77. [DOI: 10.1111/anae.15604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/01/2021] [Indexed: 12/24/2022]
Affiliation(s)
- M. Dinsmore
- Department of Anaesthesia and Pain Management Toronto Western Hospital University Health Network University of Toronto Toronto ON Canada
| | - L. Venkatraghavan
- Department of Anaesthesia and Pain Management Toronto Western Hospital University Health Network University of Toronto Toronto ON Canada
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14
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Akbarzadeh MA, Sanaie S, Kuchaki Rafsanjani M, Hosseini MS. Role of imaging in early diagnosis of acute ischemic stroke: a literature review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00432-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
AbstractStroke is a serious health condition that is responsible for more than 5% of total deaths. Near 20% of patients experiencing stroke die every year, resulting in the stroke being at the top of the list of preventable causes of death. Once an acute stroke is suspected, a golden hour of less than an hour is available to prevent the undesirable consequences. Since neuroimaging is mandatory in the diagnosis of stroke, the proper use of neuroimaging could help saving time and planning the right treatment for the patient. Some of the available imaging methods help us with rapid results, while others benefit us from a more accurate diagnosis. Hereby, we aim to provide a clinical review of the advantages and disadvantages of different available neuroimaging methods in approaching acute stroke to help clinicians choose the best method according to the settings.
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15
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Requena M, Ren Z, Ribo M. Direct Transfer to Angiosuite in Acute Stroke: Why, When, and How? Neurology 2021; 97:S34-S41. [PMID: 34785602 DOI: 10.1212/wnl.0000000000012799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023] Open
Abstract
Time to reperfusion is one of the strongest predictors of functional outcome in acute stroke due to a large vessel occlusion (LVO). Direct transfer to angiography suite (DTAS) protocols have shown encouraging results in reducing in-hospital delays. DTAS allows bypassing of conventional imaging in the emergency room by ruling out an intracranial hemorrhage or a large established infarct with imaging performed before transfer to the thrombectomy-capable center in the angiography suite using flat-panel CT (FP-CT). The rate of patients with stroke code primarily admitted to a comprehensive stroke center with a large ischemic established lesion is <10% within 6 hours from onset and remains <20% among patients with LVO or transferred from a primary stroke center. At the same time, stroke severity is an acceptable predictor of LVO. Therefore, ideal DTAS candidates are patients admitted in the early window with severe symptoms. The main difference between protocols adopted in different centers is the inclusion of FP-CT angiography to confirm an LVO before femoral puncture. While some centers advocate for FP-CT angiography, others favor additional time saving by directly assessing the presence of LVO with an angiogram. The latter, however, leads to unnecessary arterial punctures in patients with no LVO (3%-22% depending on selection criteria). Independently of these different imaging protocols, DTAS has been shown to be effective and safe in improving in-hospital workflow, achieving a reduction of door-to-puncture time as low as 16 minutes without safety concerns. The impact of DTAS on long-term functional outcomes varies between published studies, and randomized controlled trials are warranted to examine the benefit of DTAS.
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Affiliation(s)
- Manuel Requena
- From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D'Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston
| | - Zeguang Ren
- From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D'Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston
| | - Marc Ribo
- From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D'Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston.
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16
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Jing B, Lindsey BD. Effect of Skull Porous Trabecular Structure on Transcranial Ultrasound Imaging in the Presence of Elastic Wave Mode Conversion at Varying Incidence Angle. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2734-2748. [PMID: 34140169 DOI: 10.1016/j.ultrasmedbio.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 06/12/2023]
Abstract
With the advancement of aberration correction techniques, transcranial ultrasound imaging has exhibited great potential in applications such as imaging neurological function and guiding therapeutic ultrasound. However, the feasibility of transcranial imaging varies among individuals because of the differences in skull acoustic properties. To better understand the fundamental mechanisms underlying the variation in imaging performance, the effect of the structure of the porous trabecular bone on transcranial imaging performance (i.e., target localization errors and resolution) was investigated for the first time through the use of elastic wave simulations and experiments. Simulation studies using high-resolution computed tomography data from ex vivo skull samples revealed that imaging at large incidence angles reduced the target localization error for skulls having low porosity; however, as skull porosity increased, large angles of incidence resulted in degradation of resolution and increased target localization errors. Experimental results indicate that imaging at normal incidence introduced a localization error of 1.85 ± 0.10 mm, while imaging at a large incidence angle (40°) resulted in an increased localization error of 6.54 ± 1.33 mm and caused a single point target to no longer appear as a single, coherent target in the resulting image, which is consistent with simulation results. This first investigation of the effects of skull microstructure on transcranial ultrasound imaging indicates that imaging performance is highly dependent on the porosity of the skull, particularly at non-normal angles of incidence.
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Affiliation(s)
- Bowen Jing
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Brooks D Lindsey
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA; School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA.
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17
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Shahrestani S, Wishart D, Han SMJ, Strickland BA, Bakhsheshian J, Mack WJ, Toga AW, Sanossian N, Tai YC, Zada G. A systematic review of next-generation point-of-care stroke diagnostic technologies. Neurosurg Focus 2021; 51:E11. [PMID: 34198255 DOI: 10.3171/2021.4.focus21122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stroke is a leading cause of morbidity and mortality. Current diagnostic modalities include CT and MRI. Over the last decade, novel technologies to facilitate stroke diagnosis, with the hope of shortening time to treatment and reducing rates of morbidity and mortality, have been developed. The authors conducted a systematic review to identify studies reporting on next-generation point-of-care stroke diagnostic technologies described within the last decade. METHODS A systematic review was performed according to PRISMA guidelines to identify studies reporting noninvasive stroke diagnostics. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool was utilized to assess risk of bias. PubMed, Web of Science, and Scopus databases were utilized. Primary outcomes assessed included accuracy and timing compared with standard imaging, potential risks or complications, potential limitations, cost of the technology, size/portability, and range/size of detection. RESULTS Of the 2646 reviewed articles, 19 studies met the inclusion criteria and included the following modalities of noninvasive stoke detection: microwave technology (6 studies, 31.6%), electroencephalography (EEG; 4 studies, 21.1%), ultrasonography (3 studies, 15.8%), near-infrared spectroscopy (NIRS; 2 studies, 10.5%), portable MRI devices (2 studies, 10.5%), volumetric impedance phase-shift spectroscopy (VIPS; 1 study, 5.3%), and eddy current damping (1 study, 5.3%). Notable medical devices that accurately predicted stroke in this review were EEG-based diagnosis, with a maximum sensitivity of 91.7% for predicting a stroke, microwave-based diagnosis, with an area under the receiver operating characteristic curve (AUC) of 0.88 for differentiating ischemic stroke and intracerebral hemorrhage (ICH), ultrasound with an AUC of 0.92, VIPS with an AUC of 0.93, and portable MRI with a diagnostic accuracy similar to that of traditional MRI. NIRS offers significant potential for more superficially located hemorrhage but is limited in detecting deep-seated ICH (2.5-cm scanning depth). CONCLUSIONS As technology and computational resources have advanced, several novel point-of-care medical devices show promise in facilitating rapid stroke diagnosis, with the potential for improving time to treatment and informing prehospital stroke triage.
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Affiliation(s)
- Shane Shahrestani
- Departments of1Neurological Surgery and.,2Department of Medical Engineering, California Institute of Technology, Pasadena; and
| | | | | | | | | | | | - Arthur W Toga
- 3Laboratory of NeuroImaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nerses Sanossian
- 4Neurology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Yu-Chong Tai
- 2Department of Medical Engineering, California Institute of Technology, Pasadena; and
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18
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The use of transcranial ultrasound and clinical assessment to diagnose ischaemic stroke due to large vessel occlusion in remote and rural areas. PLoS One 2020; 15:e0239653. [PMID: 33007053 PMCID: PMC7531787 DOI: 10.1371/journal.pone.0239653] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Rapid endovascular thrombectomy, which can only be delivered in specialist centres, is the most effective treatment for acute ischaemic stroke due to large vessel occlusion (LVO). Pre-hospital selection of these patients is challenging, especially in remote and rural areas due to long transport times and limited access to specialist clinicians and diagnostic facilities. We investigated whether combined transcranial ultrasound and clinical assessment (“TUCA” model) could accurately triage these patients and improve access to thrombectomy. We recruited consecutive patients within 72 hours of suspected stroke, and performed non-contrast transcranial colour-coded ultrasonography within 24 hours of brain computed tomography. We retrospectively collected clinical information, and used hospital discharge diagnosis as the “gold standard”. We used binary regression for diagnosis of haemorrhagic stroke, and an ordinal regression model for acute ischaemic stroke with probable LVO, without LVO, transient ischaemic attacks (TIA) and stroke mimics. We calculated sensitivity, specificity, positive and negative predictive values and performed a sensitivity analysis. We recruited 107 patients with suspected stroke from July 2017 to December 2019 at two study sites: 13/107 (12%) with probable LVO, 50/107 (47%) with acute ischaemic stroke without LVO, 18/107 (17%) with haemorrhagic stroke, and 26/107 (24%) with stroke mimics or TIA. The model identified 55% of cases with probable LVO who would have correctly been selected for thrombectomy and 97% of cases who would not have required this treatment (sensitivity 55%, specificity 97%, positive and negative predictive values 75% and 93%, respectively). Diagnostic accuracy of the proposed model was superior to the clinical assessment alone. These data suggest that our model might be a useful tool to identify pre-hospital patients requiring mechanical thrombectomy, however a larger sample is required with the use of CT angiogram as a reference test.
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19
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Baracchini C, Pieroni A, Kneihsl M, Azevedo E, Diomedi M, Pascazio L, Wojczal J, Lucas C, Bartels E, Bornstein NM, Csiba L, Valdueza J, Tsivgoulis G, Malojcic B. Practice recommendations for neurovascular ultrasound investigations of acute stroke patients in the setting of the COVID-19 pandemic: an expert consensus from the European Society of Neurosonology and Cerebral Hemodynamics. Eur J Neurol 2020; 27:1776-1780. [PMID: 32426890 PMCID: PMC7276863 DOI: 10.1111/ene.14334] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Background and purpose Patients with acute ischemic stroke are at high‐risk for contracting COVID‐19 infection. Additionally, healthcare professionals including neurovascular ultrasound providers are also at risk of being infected by SARS‐CoV‐2 virus. Yet, preparedness to continue to guarantee hyperacute treatment is vital for patients outcome. In light of this situation, the European Society of Neurosonology and Cerebral Hemodynamic (ESNCH) appointed a task force to provide consensus recommendations for the performance of neurovascular ultrasound investigations in acute ischemic stroke during the COVID‐19 pandemic with the aim of protecting both patients and ultrasound providers. Methods The “ultrasound in acute stroke working group” of the ESNCH examined literature articles and reviews using the following key words: “corona virus” or “COVID‐19” or “SARS‐CoV‐2 virus”, and “acute stroke” or “cerebrovascular disease”, and “ultrasound”. Thereafter, a thorough discussion was conducted with the “education and guidelines working group” of the ESNCH. Results We propose rapid up‐to‐date recommendations for healthcare personnel involved in the pre‐hospital and intra‐hospital assessment of stroke patients, with a particular attention to neurovascular ultrasound performance. Conclusion The ESNCH provides a guidance summary for the performance of neurovascular ultrasound investigations in acute ischemic stroke in the time of COVID‐19.
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Affiliation(s)
- C Baracchini
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - A Pieroni
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - M Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - E Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - M Diomedi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - L Pascazio
- Stroke Unit, Neurology I, University of Bari, Bari, Italy
| | - J Wojczal
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - C Lucas
- Neurology Department, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - E Bartels
- Center for Neurological Vascular Diagnostics, München, Germany
| | | | - L Csiba
- Department of Neurology, Debrecen University, Debrecen, Hungary
| | - J Valdueza
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - G Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - B Malojcic
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
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20
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Antipova D, Eadie L, Macaden AS, Wilson P. Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review. Ultrasound J 2019; 11:29. [PMID: 31641895 PMCID: PMC6805840 DOI: 10.1186/s13089-019-0143-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/04/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.
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Affiliation(s)
- Daria Antipova
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK.
| | - Leila Eadie
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK
| | - Ashish Stephen Macaden
- Department of Stroke and Rehabilitation Medicine, Raigmore Hospital, NHS Highland, Inverness, IV2 3UJ, UK
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Old Perth Road, Inverness, IV2 3JH, UK
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21
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Connolly F, Röhl JE, Guthke C, Wengert O, Valdueza JM, Schreiber SJ. Emergency Room Use of "Fast-Track" Ultrasound in Acute Stroke: An Observational Study. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1103-1111. [PMID: 30773376 DOI: 10.1016/j.ultrasmedbio.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/01/2019] [Accepted: 01/04/2019] [Indexed: 06/09/2023]
Abstract
Early information on vascular status in acute stroke is essential. We analyzed whether duplex ultrasound (DUS) using a fast-track protocol provides this information without relevant delay. One hundred forty-six patients were prospectively enrolled. DUS was performed by sonographers with two levels of experience. The carotid and vertebral arteries, as well as all basal cerebral arteries, were bilaterally analyzed. Criteria for vessel analysis were (i) normal or stenosis <50%, (ii) stenosis ≥50% and (iii) occlusion. The mean duration of the ultrasound investigation was 6:07 ± 2:06 min with a significant difference between more and less experienced investigators (p < 0.0001). Insonation times decreased during the study in both groups. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound findings in comparison with computed tomography angiography were 73%, 99%, 84% and 98%, respectively. Our data suggest that "fast track" DUS is feasible and reliable. The time required for DUS assessment depends on the sonographer´s experience.
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Affiliation(s)
- Florian Connolly
- Department of Neurology, Charité, Universitätsmedizin Berlin, Berlin, Germany.
| | - Jens-Eric Röhl
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Carolin Guthke
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Oliver Wengert
- Department of Neurology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - José M Valdueza
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Stephan J Schreiber
- Department of Neurology, Asklepios Fachklinikum Brandenburg, Brandenburg an der Havel, Germany
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22
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Houzé-Cerfon CH, Bounes V, Guemon J, Le Gourrierec T, Geeraerts T. Quality And Feasibility of Sonographic Measurement of the Optic Nerve Sheath Diameter to Estimate the Risk of Raised Intracranial Pressure After Traumatic Brain Injury in Prehospital Setting. PREHOSP EMERG CARE 2018; 23:277-283. [PMID: 30118380 DOI: 10.1080/10903127.2018.1501444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE In patients with traumatic brain injury (TBI), early detection and subsequent prompt treatment of elevated intracranial pressure (ICP) is a challenge in the prehospital setting, because physical examination is limited in comatose patients and invasive device placement is not possible. The aim of this study was to evaluate the quality and feasibility of optic nerve sheath diameter (ONSD) measurements obtained during the prehospital management of patients with TBI. METHODS This study was a prospective, observational study of 23 patients with moderate and severe TBI during prehospital medical care. The primary endpoint was the quality of ONSD measurements expressed as the percentage of ONSD validated by the experts. Secondary endpoints included the feasibility of ONSD measurements as the percentage of ONSD performed and assessment by operators of ease and duration to perform. RESULTS Ultrasound ONSD was performed in 19 (82%) patients and 80% of ONSD measurements were validated by the experts. The ONSD measurements were possible in 15 (79%) cases. The physicians have assessed the ease of use at 8 (interquartile range [IQR] = 2.5-8) on 10 for and the median time to obtain ONSD measurement was 4 min (IQR = 3-5). ONSD measurement was performed in 12 (63%) cases during the transport and in 7 (37%) cases on scene, with 58% (n = 7) and 71% (n = 5) validated ONSD, respectively. The success rate in the helicopter was 43% compared to 80% in the ambulance. CONCLUSION This study shows that it is feasible to obtain high-quality ONSD measurements in the management of patients with TBI in a prehospital setting. A randomized study evaluating the usefulness of ONSD to guide management of TBI in the prehospital phase may be of great interest.
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23
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Ketelaars R, Reijnders G, van Geffen GJ, Scheffer GJ, Hoogerwerf N. ABCDE of prehospital ultrasonography: a narrative review. Crit Ultrasound J 2018; 10:17. [PMID: 30088160 PMCID: PMC6081492 DOI: 10.1186/s13089-018-0099-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023] Open
Abstract
Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.
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Affiliation(s)
- Rein Ketelaars
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Gabby Reijnders
- Department of Intensive Care, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Geert-Jan van Geffen
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nico Hoogerwerf
- Radboud Institute for Health Sciences, Department of Anesthesiology, Pain, and Palliative Medicine, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Helicopter Emergency Medical Service Lifeliner 3, Radboud university medical center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
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van Gaal S, Demchuk A. Clinical and Technological Approaches to the Prehospital Diagnosis of Large Vessel Occlusion. Stroke 2018. [PMID: 29540610 DOI: 10.1161/strokeaha.117.017947] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen van Gaal
- From the Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada (S.v.G.); and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (A.D.).
| | - Andrew Demchuk
- From the Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada (S.v.G.); and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (A.D.)
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Schlemm L, Schlemm E. Clinical benefit of improved Prehospital stroke scales to detect stroke patients with large vessel occlusions: results from a conditional probabilistic model. BMC Neurol 2018; 18:16. [PMID: 29427993 PMCID: PMC5807751 DOI: 10.1186/s12883-018-1021-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/02/2018] [Indexed: 11/18/2022] Open
Abstract
Background Clinical scales to detect large vessel occlusion (LVO) may help to determine the optimal transport destination for patients with suspected acute ischemic stroke (AIS). The clinical benefit associated with improved diagnostic accuracy of these scales has not been quantified. Methods We used a previously reported conditional model to estimate the probability of good outcome (modified Rankin scale sore ≤2) for patients with AIS and unknown vessel status occurring in regions with greater proximity to a primary than to a comprehensive stroke center. Optimal rapid arterial occlusion evaluation (RACE) scale cutoff scores were calculated based on time-dependent effect-size estimates from recent randomized controlled trials. Probabilities of good outcome were compared between a triage strategy based on these cutoffs and a strategy based on a hypothetical perfect LVO detection tool with 100% diagnostic accuracy. Results In our model, the additional benefit of a perfect LVO detection tool as compared to optimal transport-time dependent RACE cutoff scores ranges from 0 to 5%. It is largest for patients with medium stroke symptom severity (RACE score 5) and in geographic environments with longer transfer time between the primary and comprehensive stroke center. Conclusion Based on a probabilistic conditional model, the results of our simulation indicate that more accurate prehospital clinical LVO detections scales may be associated with only modest improvements in the expected probability of good outcome for patients with suspected acute ischemic stroke and unknown vessel status. Electronic supplementary material The online version of this article (10.1186/s12883-018-1021-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ludwig Schlemm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany. .,London School of Economics and Political Science, London, UK.
| | - Eckhard Schlemm
- Universität Hamburg, Medizinische Fakultät, Hamburg, Germany.,Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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26
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Peultier AC, Redekop K, Coche E, Severens JL. What are the images used to diagnose and assess suspected strokes?: A systematic literature review of care in four European countries. Expert Rev Pharmacoecon Outcomes Res 2018; 18:177-189. [PMID: 29400089 DOI: 10.1080/14737167.2018.1429270] [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: 10/18/2022]
Abstract
INTRODUCTION The cost-effectiveness of clinical interventions is often assessed using current care as comparator. However, evidence suggests practice variation in stroke imaging across countries. For the purpose of feeding into cost-effectiveness analysis, this research aims to describe the patterns of stroke imaging, examine practice variations across countries and, as such, obtain results reflecting current care. AREAS COVERED A systematic literature review was conducted to identify original studies reporting the imaging workup used in acute stroke care in clinical practice in Hungary, Germany, Sweden and the UK. Information regarding the type and frequency of stroke imaging was analysed. Computed Tomography (CT) was reported as the main diagnostic imaging modality used in stroke care (78-98% across patient profiles and time periods). This review revealed patterns that were not observed in individual studies. Comparisons of UK studies revealed considerable variations in the proportion of scanned patients and timing of imaging. EXPERT COMMENTARY While the evidence about thrombectomy is difficult to translate in clinical practice, the evidence regarding the optimal imaging approach to diagnose stroke patients is lacking. The heterogeneity in stroke imaging reinforces the need to compare the quality of stroke care within and between countries.
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Affiliation(s)
- Anne-Claire Peultier
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Ken Redekop
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands.,b Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Emmanuel Coche
- c Department of Radiology , Cliniques Universitaires St-Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Johan L Severens
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands.,b Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
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27
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Yan Q, Jin G, Ma K, Qin M, Zhuang W, Sun J. Magnetic inductive phase shift: a new method to differentiate hemorrhagic stroke from ischemic stroke on rabbit. Biomed Eng Online 2017; 16:63. [PMID: 28558773 PMCID: PMC5450218 DOI: 10.1186/s12938-017-0354-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/22/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The major therapy for ischemic stroke is thrombolytic treatment, but severe consequences occur when this method is used to treat hemorrhagic stroke. Currently, computed tomography and magnetic resonance imaging are used to differentiate between two types of stroke, but these two methods are ineffective for pre-hospital care. METHODS We developed a new brain diagnostic device for rabbits based on electromagnetic induction to non-invasively differentiate two types of stroke. The device includes two coils and a phase difference measurement system that detects the magnetic inductive phase shift (MIPS) value to reflect the tissue's condition. The hemorrhage model was established through the injection of autologous blood into the internal capsule of a rabbit's brain. Ischemia was induced in the brain of a rabbit by bilateral carotid artery occlusion. Two types of animal models were measured with our device. RESULTS The MIPS value gradually decreased with increasing injected blood and increased with ischemia time. The MIPS changes induced by the two types of strokes were exact opposites, and the absolute values of MIPS variation in the hemorrhagic and the ischemic groups were significantly larger than those of the normal control group (P < 0.05). CONCLUSIONS The tested technique can differentiate ischemic stroke from hemorrhagic stroke on rabbit brain in a non-invasive, continuous, and bulk monitoring manner by using a simple and inexpensive apparatus.
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Affiliation(s)
- Qingguang Yan
- College of Biomedical Engineering, Third Military Medical University, Chongqing, 400030 China
| | - Gui Jin
- College of Biomedical Engineering, Third Military Medical University, Chongqing, 400030 China
| | - Ke Ma
- College of Biomedical Engineering, Third Military Medical University, Chongqing, 400030 China
| | - Mingxin Qin
- College of Biomedical Engineering, Third Military Medical University, Chongqing, 400030 China
| | - Wei Zhuang
- College of Biomedical Engineering, Third Military Medical University, Chongqing, 400030 China
| | - Jian Sun
- College of Biomedical Engineering, Third Military Medical University, Chongqing, 400030 China
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28
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Vecchiato A. Can we imagine a survival chain also for ischemic stroke? Am J Emerg Med 2017; 35:1961. [PMID: 28587953 DOI: 10.1016/j.ajem.2017.05.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 05/28/2017] [Accepted: 05/28/2017] [Indexed: 01/31/2023] Open
Affiliation(s)
- Aurora Vecchiato
- Emergency Medicine Residency Program, University of Sassari, Italy.
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29
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Fassbender K, Grotta JC, Walter S, Grunwald IQ, Ragoschke-Schumm A, Saver JL. Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol 2017; 16:227-237. [PMID: 28229894 DOI: 10.1016/s1474-4422(17)30008-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/02/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.
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Affiliation(s)
- Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.
| | - James C Grotta
- Department of Neurology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Iris Q Grunwald
- Neuroscience and Vascular Simulation Unit, Faculty of Medical Science, PMI, Anglia Ruskin University, Chelmsford, UK; Department of Stroke Medicine, Southend University Hospital, Southend, UK
| | | | - Jeffrey L Saver
- Stroke Center, University of California Los Angeles, Los Angeles, CA, USA
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McCallum J, Vu E, Sweet D, Kanji HD. Assessment of Paramedic Ultrasound Curricula: A Systematic Review. Air Med J 2016; 34:360-8. [PMID: 26611224 DOI: 10.1016/j.amj.2015.07.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/10/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prehospital ultrasound is being applied in the field. The purpose of this systematic review is to describe evidence pertaining to ultrasound curricula for paramedics specifically, including content, duration, setting, design, evaluation, and application. METHODS Electronic searches of MEDLINE, Embase, CINAHL, and the Cochrane Center Register of Controlled Trials were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary literature describing acute care ultrasound curricula for paramedics were included. Two authors independently extracted data and assessed quality using 2 validated tools. RESULTS Twelve studies with 187 paramedics were included. Curricula duration varied, with effective curricula teaching focused assessment with sonography for trauma (FAST) in 6 to 8 hours and pleural ultrasound in 25 minutes. FAST, pleural, and fracture-detection ultrasound are being applied in the field by paramedics; however, no literature exists describing application to detect cardiac standstill. Curricula combined didactic and hands-on components including simulation and evaluated competency using sensitivity and specificity of paramedic-performed ultrasound. CONCLUSIONS Paramedic ultrasound curricula in FAST and pleural ultrasound is feasible and time effective with successful application. Although fracture detection ultrasound is being used by the special operations forces, no comprehensive curriculum was described. Curricula designed to detect cardiac standstill have been too short, and successful application by paramedics has not been shown.
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Affiliation(s)
- Jessica McCallum
- Student, University of British Columbia MD Undergraduate Program, Vancouver, BC, Canada
| | - Erik Vu
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Emergency Health Services, Provincial AirEvac & Critical Care Operations, Vancouver, BC, Canada; Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - David Sweet
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
| | - Hussein D Kanji
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
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Paschoal Jr FM, Nogueira RC, Ronconi KDAL, de Lima Oliveira M, Teixeira MJ, Bor-Seng-Shu E. Multimodal brain monitoring in fulminant hepatic failure. World J Hepatol 2016; 8:915-923. [PMID: 27574545 PMCID: PMC4976210 DOI: 10.4254/wjh.v8.i22.915] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/22/2016] [Accepted: 06/16/2016] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure, also known as fulminant hepatic failure (FHF), embraces a spectrum of clinical entities characterized by acute liver injury, severe hepatocellular dysfunction, and hepatic encephalopathy. Cerebral edema and intracranial hypertension are common causes of mortality in patients with FHF. The management of patients who present acute liver failure starts with determining the cause and an initial evaluation of prognosis. Regardless of whether or not patients are listed for liver transplantation, they should still be monitored for recovery, death, or transplantation. In the past, neuromonitoring was restricted to serial clinical neurologic examination and, in some cases, intracranial pressure monitoring. Over the years, this monitoring has proven insufficient, as brain abnormalities were detected at late and irreversible stages. The need for real-time monitoring of brain functions to favor prompt treatment and avert irreversible brain injuries led to the concepts of multimodal monitoring and neurophysiological decision support. New monitoring techniques, such as brain tissue oxygen tension, continuous electroencephalogram, transcranial Doppler, and cerebral microdialysis, have been developed. These techniques enable early diagnosis of brain hemodynamic, electrical, and biochemical changes, allow brain anatomical and physiological monitoring-guided therapy, and have improved patient survival rates. The purpose of this review is to discuss the multimodality methods available for monitoring patients with FHF in the neurocritical care setting.
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32
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Mort A, Eadie L, Regan L, Macaden A, Heaney D, Bouamrane MM, Rushworth G, Wilson P. Combining transcranial ultrasound with intelligent communication methods to enhance the remote assessment and management of stroke patients: Framework for a technology demonstrator. Health Informatics J 2016; 22:691-701. [DOI: 10.1177/1460458215580353] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With over 150,000 strokes in the United Kingdom every year, and more than 1 million living survivors, stroke is the third most common cause of death and the leading cause of severe physical disability among adults. A major challenge in administering timely treatment is determining whether the stroke is due to vascular blockage (ischaemic) or haemorrhage. For patients with ischaemic stroke, thrombolysis (i.e. pharmacological ‘clot-busting’) can improve outcomes when delivered swiftly after onset, and current National Health Service Quality Improvement Scotland guidelines are for thrombolytic therapy to be provided to at least 80 per cent of eligible patients within 60 min of arrival at hospital. Thrombolysis in haemorrhagic stroke could severely compound the brain damage, so administration of thrombolytic therapy currently requires near-immediate care in a hospital, rapid consultation with a physician and access to imaging services (X-ray computed tomography or magnetic resonance imaging) and intensive care services. This is near impossible in remote and rural areas, and stroke mortality rates in Scotland are 50 per cent higher than in London. We here describe our current project developing a technology demonstrator with ultrasound imaging linked to an intelligent, multi-channel communication device − connecting to multiple 2G/3G/4G networks and/or satellites − in order to stream live ultrasound images, video and two-way audio streams to hospital-based specialists who can guide and advise ambulance clinicians regarding diagnosis. With portable ultrasound machines located in ambulances or general practices, use of such technology is not confined to stroke, although this is our current focus. Ultrasound assessment is useful in many other immediate care situations, suggesting potential wider applicability for this remote support system. Although our research programme is driven by rural need, the ideas are potentially applicable to urban areas where access to imaging and definitive treatment can be restricted by a range of operational factors.
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Affiliation(s)
| | - Leila Eadie
- University of Aberdeen, Centre for Rural Health, UK
| | - Luke Regan
- University of Aberdeen, Highland Medical Education Centre, UK; NHS Highland, UK
| | | | - David Heaney
- University of Aberdeen, Centre for Rural Health, UK
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Weber J, Ebinger M, Audebert HJ. Prehospital stroke care: telemedicine, thrombolysis and neuroprotection. Expert Rev Neurother 2016; 15:753-61. [PMID: 26109228 DOI: 10.1586/14737175.2015.1051967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last 15 years, new approaches regarding neuroprotective and thrombolytic strategies in stroke management have been evaluated in the prehospital setting. These efforts have provided exciting new potentials of hyperacute stroke care. Trials have shown that the use of specialized stroke ambulances increases the proportion of patients receiving intravenous thrombolysis and shortens alarm-to-treatment time by approximately half an hour compared to standard care. Intravenous thrombolysis within the ultra-early time window of the 'golden hour' has become a realistic scenario. However, direct effects of prehospital stroke care on functional outcome have yet to be shown and other approaches such as neuroprotective treatments could not demonstrate clinical benefit so far. There is a clear need for systematic research in the prehospital field to test the clinical effectiveness and cost-effectiveness of new therapeutic strategies. It will be necessary to test various components of prehospital stroke care alone and in combination.
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Affiliation(s)
- Joachim Weber
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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34
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Sun J, Guo Y, Wang X, Zeng Q. mHealth For Aging China: Opportunities and Challenges. Aging Dis 2016; 7:53-67. [PMID: 26816664 DOI: 10.14336/ad.2015.1011] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/11/2015] [Indexed: 12/17/2022] Open
Abstract
The aging population with chronic and age-related diseases has become a global issue and exerted heavy burdens on the healthcare system and society. Neurological diseases are the leading chronic diseases in the geriatric population, and stroke is the leading cause of death in China. However, the uneven distribution of caregivers and critical healthcare workforce shortages are major obstacles to improving disease outcome. With the advancement of wearable health devices, cloud computing, mobile technologies and Internet of Things, mobile health (mHealth) is rapidly developing and shows a promising future in the management of chronic diseases. Its advantages include its ability to improve the quality of care, reduce the costs of care, and improve treatment outcomes by transferring in-hospital treatment to patient-centered medical treatment at home. mHealth could also enhance the international cooperation of medical providers in different time zones and the sharing of high-quality medical service resources between developed and developing countries. In this review, we focus on trends in mHealth and its clinical applications for the prevention and treatment of diseases, especially aging-related neurological diseases, and on the opportunities and challenges of mHealth in China. Operating models of mHealth in disease management are proposed; these models may benefit those who work within the mHealth system in developing countries and developed countries.
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Affiliation(s)
- Jing Sun
- 1Department of International Inpatient, Chinese PLA General Hospital, Beijing 100853, China
| | - Yutao Guo
- 2Department of Geriatric Cardiology, Institute of Health Management, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiaoning Wang
- 3The State Key Laboratory and Normal Aging, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiang Zeng
- 1Department of International Inpatient, Chinese PLA General Hospital, Beijing 100853, China
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Barlinn K, Tsivgoulis G, Barreto AD, Alleman J, Molina CA, Mikulik R, Saqqur M, Demchuk AM, Schellinger PD, Howard G, Alexandrov AV. Outcomes following sonothrombolysis in severe acute ischemic stroke: subgroup analysis of the CLOTBUST trial. Int J Stroke 2014; 9:1006-10. [PMID: 25079049 PMCID: PMC4227933 DOI: 10.1111/ijs.12340] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 05/20/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sonothrombolysis is safe and may increase the likelihood of early recanalization in acute ischemic stroke patients. AIMS In preparation of a phase III clinical trial, we contrast the likelihood of achieving a sustained recanalization and functional independence in a post hoc subgroup analysis of patients randomized to transcranial Doppler monitoring plus intravenous tissue plasminogen activator (sonothrombolysis) compared with intravenous tissue plasminogen activator alone in the CLOTBUST trial. METHODS We analyzed the data from all randomized acute ischemic stroke patients with pretreatment National Institutes of Health Stroke Scale scores ≥ 10 points and proximal intracranial occlusions in the CLOTBUST trial. We compared sustained complete recanalization rate (Thrombolysis in Brain Ischemia flow grades 4-5) and functional independence (modified Rankin Scale 0-1) at 90 days. Safety was evaluated by the rate of symptomatic intracranial hemorrhage within 72 h of stroke onset. RESULTS Of 126 patients, a total of 85 acute ischemic stroke patients met our inclusion criteria: mean age 71 ± 11years, 56% men, median National Institutes of Health Stroke Scale 17 (interquartile range 14-20). Of these patients, 41 (48%) and 44 (52%) were randomized to intravenous tissue plasminogen activator alone and sonothrombolysis, respectively. More patients achieved sustained complete recanalization in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (38·6% vs. 17·1%; P = 0·032). Functional independence at 90 days was more frequently achieved in the sonothrombolysis than in the intravenous tissue plasminogen activator alone group (37·2% vs. 15·8%; P = 0·045). Symptomatic intracranial hemorrhage rate was similar in both groups (4·9% vs. 4·6%; P = 1·00). CONCLUSIONS Our results point to a signal of efficacy and provide information to guide the subsequent phase III randomized trial of sonothrombolysis in patients with severe ischemic strokes.
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Affiliation(s)
- Kristian Barlinn
- Dresden University Stroke Center,Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Georgios Tsivgoulis
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
- Second Department of Neurology,School of Medicine, Attikon Hospital, University of Athens, Greece
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | | | | | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Robert Mikulik
- International Clinical Research Centre,Neurology department, St. Anne's University Hospital in Brno and Masaryk University, Czech Republic
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew M Demchuk
- University of Calgary, Department of Clinical Neurosciences, Calgary Stroke Program, Canada
| | | | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, USA
| | - Andrei V. Alexandrov
- Department of Neurology,The University of Tennessee Health Science Center, Memphis, TN, USA
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Microwave-Based Stroke Diagnosis Making Global Prehospital Thrombolytic Treatment Possible. IEEE Trans Biomed Eng 2014; 61:2806-17. [DOI: 10.1109/tbme.2014.2330554] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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37
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Yperzeele L, Van Hooff RJ, De Smedt A, Valenzuela Espinoza A, Van de Casseye R, Hubloue I, De Keyser J, Brouns R. Prehospital stroke care: limitations of current interventions and focus on new developments. Cerebrovasc Dis 2014; 38:1-9. [PMID: 25116305 DOI: 10.1159/000363617] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 05/15/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The global burden of stroke is immense, both in medical and economic terms. With the aging population and the ongoing industrialization of the third world, stroke prevalence is expected to increase and will have a major effect on national health expenditures. Currently, the medical treatment for acute ischemic stroke is limited to intravenous recombinant tissue plasminogen activator (IV r-tPA), but its time dependency leads to low utilization rates in routine clinical practice. Prehospital delay contributes significantly to delayed or missed treatment opportunities in acute stroke. State-of-the-art acute stroke care, starting in the prehospital phase, could thereby reduce the disease burden and its enormous financial costs. SUMMARY The first part of this review focuses on current education measures for the general public, the emergency medical services (EMS) dispatchers and paramedics. Although much has been expected of these measures to improve stroke care, no major effects on prehospital delay or missed treatment opportunities have been demonstrated over the years. Most interventional studies showed little or no effect on the onset-to-door time, IV r-tPA utilization rates or outcome, except for prenotification of the receiving hospital by the EMS. No data are currently available on the cost-effectiveness of these commonly used measures. In the second part, we discuss new developments for the improvement of prehospital stroke diagnosis and treatment which could open new perspectives in the nearby future. These include the implementation of prehospital telestroke and the deployment of mobile stroke units. These approaches may improve patient care and could serve as a platform for prehospital clinical trials. Other opportunities include the implementation of noninvasive diagnostics (like transcranial ultrasound and blood-borne biomarkers) and the reevaluation of neuroprotective strategies in the prehospital phase. Key Messages: Timely initiation of treatment can effectively reduce the medical and economic burden of stroke and should begin with optimal prehospital stroke care. For this, prehospital telemedicine is a particularly attractive approach because it is a scalable solution that has the potential to rapidly optimize acute stroke care at limited cost.
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Affiliation(s)
- Laetitia Yperzeele
- Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Lindsey BD, Nicoletto HA, Bennett ER, Laskowitz DT, Smith SW. 3-D transcranial ultrasound imaging with bilateral phase aberration correction of multiple isoplanatic patches: a pilot human study with microbubble contrast enhancement. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:90-101. [PMID: 24239360 PMCID: PMC3849324 DOI: 10.1016/j.ultrasmedbio.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 08/20/2013] [Accepted: 09/01/2013] [Indexed: 05/03/2023]
Abstract
With stroke currently the second-leading cause of death globally, and 87% of all strokes classified as ischemic, the development of a fast, accessible, cost-effective approach for imaging occlusive stroke could have a significant impact on health care outcomes and costs. Although clinical examination and standard computed tomography alone do not provide adequate information for understanding the complex temporal events that occur during an ischemic stroke, ultrasound imaging is well suited to the task of examining blood flow dynamics in real time and may allow for localization of a clot. A prototype bilateral 3-D ultrasound imaging system using two matrix array probes on either side of the head allows for correction of skull-induced aberration throughout two entire phased array imaging volumes. We investigated the feasibility of applying this custom correction technique in five healthy volunteers with Definity microbubble contrast enhancement. Subjects were scanned simultaneously via both temporal acoustic windows in 3-D color flow mode. The number of color flow voxels above a common threshold increased as a result of aberration correction in five of five subjects, with a mean increase of 33.9%. The percentage of large arteries visualized by 3-D color Doppler imaging increased from 46% without aberration correction to 60% with aberration correction.
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Affiliation(s)
- Brooks D Lindsey
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA; Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina, USA.
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39
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Abstract
We present the first correction of refraction in three-dimensional (3D) ultrasound imaging using an iterative approach that traces propagation paths through a two-layer planar tissue model, applying Snell's law in 3D. This approach is applied to real-time 3D transcranial ultrasound imaging by precomputing delays offline for several skull thicknesses, allowing the user to switch between three sets of delays for phased array imaging at the push of a button. Simulations indicate that refraction correction may be expected to increase sensitivity, reduce beam steering errors, and partially restore lost spatial resolution, with the greatest improvements occurring at the largest steering angles. Distorted images of cylindrical lesions were created by imaging through an acrylic plate in a tissue-mimicking phantom. As a result of correcting for refraction, lesions were restored to 93.6% of their original diameter in the lateral direction and 98.1% of their original shape along the long axis of the cylinders. In imaging two healthy volunteers, the mean brightness increased by 8.3% and showed no spatial dependency.
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Affiliation(s)
- Brooks D. Lindsey
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Stephen W. Smith
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
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40
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Backhaus R, Boy S, Fuchs K, Ulrich B, Schuierer G, Schlachetzki F. Hyperperfusion syndrome after MCA embolectomy - a rare complication? AMERICAN JOURNAL OF CASE REPORTS 2013; 14:513-7. [PMID: 24340127 PMCID: PMC3858203 DOI: 10.12659/ajcr.889672] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/11/2013] [Indexed: 12/11/2022]
Abstract
Patient: Female, 78 Final Diagnosis: Cerebral hyperperfusion syndrome Symptoms: — Medication: — Clinical Procedure: Endovascular embolectomy Specialty: Neurology
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Affiliation(s)
- Roland Backhaus
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Regensburg, Germany
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41
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Lapchak PA. Fast neuroprotection (fast-NPRX) for acute ischemic stroke victims: the time for treatment is now. Transl Stroke Res 2013; 4:704-9. [PMID: 24323424 DOI: 10.1007/s12975-013-0303-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 10/23/2013] [Indexed: 01/25/2023]
Affiliation(s)
- Paul A Lapchak
- Department of Neurology and Neurosurgery, Cedars-Sinai Medical Center, Advanced Health Sciences Pavilion, Rm 8305, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA,
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42
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Rudolph SS, Sørensen MK, Svane C, Hesselfeldt R, Steinmetz J. Effect of prehospital ultrasound on clinical outcomes of non-trauma patients--a systematic review. Resuscitation 2013; 85:21-30. [PMID: 24056394 DOI: 10.1016/j.resuscitation.2013.09.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/18/2013] [Accepted: 09/15/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Advances in technology have made prehospital ultrasound (US) examination available. Whether US in the prehospital setting can lead to improvement in clinical outcomes is yet unclear. OBJECTIVE The aim of this systematic review was to assess whether prehospital US improves clinical outcomes for non-trauma patients. METHOD We conducted a systematic review on non-trauma patients who had an US examination performed in the prehospital setting. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the ISI Web of Science and the references of the included studies for additional relevant studies. We then performed a risk of bias analysis and descriptive data analysis. RESULTS We identified 1707 unique citations and included ten studies with a total of 1068 patients undergoing prehospital US examination. Included publications ranged from case series to non-randomized, descriptive studies, and all showed a high risk of bias. The large heterogeneity between the different studies made further statistical analysis impossible. CONCLUSION There are currently no randomized, controlled studies on the use of US for non-trauma patients in the prehospital setting. The included studies were of large heterogeneity and all showed a high risk of bias. We were thus unable to assess the effect of prehospital US on clinical outcomes. However, consistent reports suggested that US may improve patient management with respect to diagnosis, treatment, and hospital referral.
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Affiliation(s)
- Søren Steemann Rudolph
- The Emergency Medical Services in Copenhagen, Denmark; Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark.
| | | | - Christian Svane
- The Emergency Medical Services in Copenhagen, Denmark; Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
| | - Rasmus Hesselfeldt
- Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
| | - Jacob Steinmetz
- The Emergency Medical Services in Copenhagen, Denmark; Centre of Head and Orthopaedics, Department of Anaesthesia, Rigshospitalet, Denmark
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43
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Prehospital emergency ultrasound: a review of current clinical applications, challenges, and future implications. Emerg Med Int 2013; 2013:531674. [PMID: 24171113 PMCID: PMC3792527 DOI: 10.1155/2013/531674] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 08/22/2013] [Indexed: 12/19/2022] Open
Abstract
Imaging modalities in the prehospital setting are helpful in the evaluation and management of time-sensitive emergency conditions. Ultrasound is the main modality that has been applied by emergency medical services (EMS) providers in the field. This paper examines the clinical applications of ultrasound in the prehospital setting. Specific focus is on applications that provide essential information to guide triage and management of critical patients. Challenges of this modality are also described in terms of cost impact on EMS agencies, provider training, and skill maintenance in addition to challenges related to the technical aspect of ultrasound.
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Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Prehospital stroke care: new prospects for treatment and clinical research. Neurology 2013; 81:501-8. [PMID: 23897876 PMCID: PMC3776535 DOI: 10.1212/wnl.0b013e31829e0fdd] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/16/2013] [Indexed: 01/03/2023] Open
Abstract
Brain cells die rapidly after stroke and any effective treatment must start as early as possible. In clinical routine, the tight time-outcome relationship continues to be the major limitation of therapeutic approaches: thrombolysis rates remain low across many countries, with most patients being treated at the late end of the therapeutic window. In addition, there is no neuroprotective therapy available, but some maintain that this concept may be valid if administered very early after stroke. Recent innovations have opened new perspectives for stroke diagnosis and treatment before the patient arrives at the hospital. These include stroke recognition by dispatchers and paramedics, mobile telemedicine for remote clinical examination and imaging, and integration of CT scanners and point-of-care laboratories in ambulances. Several clinical trials are now being performed in the prehospital setting testing prehospital delivery of neuroprotective, antihypertensive, and thrombolytic therapy. We hypothesize that these new approaches in prehospital stroke care will not only shorten time to treatment and improve outcome but will also facilitate hyperacute stroke research by increasing the number of study participants within an ultra-early time window. The potentials, pitfalls, and promises of advanced prehospital stroke care and research are discussed in this review.
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Affiliation(s)
- Heinrich J Audebert
- Department of Neurology, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.
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45
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Fassbender K, Balucani C, Walter S, Levine SR, Haass A, Grotta J. Streamlining of prehospital stroke management: the golden hour. Lancet Neurol 2013; 12:585-96. [DOI: 10.1016/s1474-4422(13)70100-5] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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46
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Saqqur M, Tsivgoulis G, Nicoli F, Skoloudik D, Sharma VK, Larrue V, Eggers J, Perren F, Charalampidis P, Storie D, Shuaib A, Alexandrov AV. The role of sonolysis and sonothrombolysis in acute ischemic stroke: a systematic review and meta-analysis of randomized controlled trials and case-control studies. J Neuroimaging 2013; 24:209-20. [PMID: 23607713 DOI: 10.1111/jon.12026] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 03/05/2013] [Accepted: 03/11/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To assess the evidence on the safety and efficacy of sonothrombolysis in acute stroke. SEARCH METHODS Electronic databases and grey literature were searched under different MeSH terms from 1970 to present. SELECTION CRITERIA Randomized control trials (RCTs) and case control studies (CCSs) on sonolysis and sonothrombolysis alone or with microsphere in acute stroke patients (>18 old). Outcome measures included complete recanalization (CR) at 1-2 and 24 hours, 3 months modified Rankin Scale (mRS), and symptomatic intracerebral hemorrhage (sICH). Data was extracted to Review Manager software. RESULTS Fifty-seven studies were retrieved and analyzed. Ten studies (7 RCTs and 3 CCSs) were included in our meta-analysis, which revealed that sonolysis and sonothrombolysis are safe (OR of sICH: 1.14; 95% confidence interval (CI): 0.56- 2.34;P=0.71) and effective (OR of CR at 1-2 hours: 2.95;95% CI: 1.81-4.81;P<0.00001) and have more than two-fold higher likelihood of favourable long-term outcome (3-month mRS 0-2; OR: 2.20; CI:1.52-3.19;P<0.0001). Further subgroup analysis based on the presence of microsphere revealed that it is safe (OR of sICH: 1.18; CI:0.433.24;P=0.75) and effective (OR of CR: 2.61; CI: 1.36-4.99;P=0.004). Subgroup analysis based on sonolysis revealed to be safe and effective. CONCLUSIONS This novel treatment appears safe and effective. The evidence of microsphere as an enhancement of sonothrombolysis is evolving.
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Affiliation(s)
- Maher Saqqur
- From the Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
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Lindsey BD, Nicoletto HA, Bennett ER, Laskowitz DT, Smith SW. Simultaneous bilateral real-time 3-d transcranial ultrasound imaging at 1 MHz through poor acoustic windows. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:721-34. [PMID: 23415287 PMCID: PMC3764922 DOI: 10.1016/j.ultrasmedbio.2012.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 05/19/2023]
Abstract
Ultrasound imaging has been proposed as a rapid, portable alternative imaging modality to examine stroke patients in pre-hospital or emergency room settings. However, in performing transcranial ultrasound examinations, 8%-29% of patients in a general population may present with window failure, in which case it is not possible to acquire clinically useful sonographic information through the temporal bone acoustic window. In this work, we describe the technical considerations, design and fabrication of low-frequency (1.2 MHz), large aperture (25.3 mm) sparse matrix array transducers for 3-D imaging in the event of window failure. These transducers are integrated into a system for real-time 3-D bilateral transcranial imaging-the ultrasound brain helmet-and color flow imaging capabilities at 1.2 MHz are directly compared with arrays operating at 1.8 MHz in a flow phantom with attenuation comparable to the in vivo case. Contrast-enhanced imaging allowed visualization of arteries of the Circle of Willis in 5 of 5 subjects and 8 of 10 sides of the head despite probe placement outside of the acoustic window. Results suggest that this type of transducer may allow acquisition of useful images either in individuals with poor windows or outside of the temporal acoustic window in the field.
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Affiliation(s)
- Brooks D Lindsey
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.
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Hölscher T, Dunford JV, Schlachetzki F, Boy S, Hemmen T, Meyer BC, Serra J, Powers J, Voie A. Prehospital stroke diagnosis and treatment in ambulances and helicopters-a concept paper. Am J Emerg Med 2013; 31:743-7. [PMID: 23415600 DOI: 10.1016/j.ajem.2012.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 12/18/2012] [Accepted: 12/28/2012] [Indexed: 01/25/2023] Open
Abstract
Stroke is the second common cause of death and the primary cause of early invalidity worldwide. Different from other diseases is the time sensitivity related to stroke. In case of an ischemic event occluding a brain artery, 2000000 neurons die every minute. Stroke diagnosis and treatment should be initiated at the earliest time point possible, preferably at the site or during patient transport. Portable ultrasound has been used for prehospital diagnosis for applications other than stroke, and its acceptance as a valuable diagnostic tool "in the field" is growing. The intrahospital use of transcranial ultrasound for stroke diagnosis has been described extensively in the literature. Beyond its diagnostic use, first clinical trials as well as numerous preclinical work demonstrate that ultrasound can be used to accelerate clot lysis (sonothrombolysis) in presence as well as in absence of tissue plasminogen activator. Hence, the use of transcranial ultrasound for diagnosis and possibly treatment of stroke bares the potential to add to current stroke care paradigms significantly. The purpose of this concept article is to describe the opportunities presented by recent advances in transcranial ultrasound to diagnose and potentially treat large vessel embolic stroke in the prehospital environment.
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Affiliation(s)
- Thilo Hölscher
- Department of Radiology, Brain Ultrasound Research Laboratory (BURL), University of California, San Diego, CA, USA.
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Topcuoglu MA. Transcranial Doppler ultrasound in neurovascular diseases: diagnostic and therapeutic aspects. J Neurochem 2012; 123 Suppl 2:39-51. [PMID: 23050641 DOI: 10.1111/j.1471-4159.2012.07942.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Albeit no direct anatomical information can be obtained, neurosonological methods provide real-time determination of velocity, and spectral waveform of blood flow in basal intracranial arteries adds significant benefit to the care of the patients with neurovascular diseases. Several features, such as relative simplicity in terms of interpretation and performance, significantly low cost, totally non-invasiveness, portability, and excellent temporal resolution, make neurosonology increasingly popular tool for evaluation, planning, and monitoring of treatment, and for determining prognosis in various neurovascular diseases. Usefulness of transcranial Doppler in diagnosing/monitoring subarachnoid hemorrhage related vasospasm and sickle cell vasculopathy is already well known. Utility in diagnosis of intracranial arterial stenosis, acute occlusion and recanalization, intracranial hemodynamic effect of the cervical arterial pathologies, intracranial pressure increase, and cerebral circulatory arrest are also well established. Neurosonological determination of vasomotor reactivity, cerebral autoregulation, neurovascular coupling, and micro-embolic signals detection are useful in the assessment of stroke risk, diagnosis of right-to-left shunting, and monitoring during surgery and interventional procedures. Transcranial Doppler is also an evolving ultrasound method with a therapeutic potential such as augmentation of clot lysis and cerebral delivery of thrombolytic or neuroprotective agent loaded nanobubbles in neurovascular diseases. The aim of this study is to give an overview of current usage of the different ultrasound modalities in different neurovascular diseases.
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Affiliation(s)
- M Akif Topcuoglu
- Hacettepe University Hospitals, Department of Neurology, Neurosonology Laboratory, Neurological Intensive Care Unit, Ankara, Turkey.
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50
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Lossius HM, Lund CG. Pre-hospital treatment of stroke--time is brain. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:1848-9. [PMID: 22986968 DOI: 10.4045/tidsskr.12.0832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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