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Nag DS, Swain A, Sahu S, Sen B, Vatsala, Parween S. Stroke: Evolution of newer treatment modalities for acute ischemic stroke. World J Clin Cases 2024; 12:6137-6147. [DOI: 10.12998/wjcc.v12.i28.6137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/08/2024] [Accepted: 07/03/2024] [Indexed: 08/13/2024] Open
Abstract
Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes. However, there has been a paradigm shift in the management approach over the last decade, and with the emphasis currently directed toward including newer modalities such as neuroprotection, stem cell treatment, magnetic stimulation, anti-apoptotic drugs, delayed recanalization, and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
- Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831017, India
| | - Seelora Sahu
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
- Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831017, India
| | - Biswajit Sen
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Vatsala
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Sadiya Parween
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
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Psychogios MN, Ntoulias N, Fischer U, Luethi M, Sporns PB. Efficient Organization of a Stroke Center : Using Modern Communication Methods. Clin Neuroradiol 2024; 34:731-733. [PMID: 38324207 DOI: 10.1007/s00062-024-01386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024]
Affiliation(s)
| | - Nikos Ntoulias
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | | | - Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology and Neuroradiology, Stadtspital Zürich, Switzerland
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3
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Turón-Viñas E, Boronat S, Gich I, González Álvarez V, García-Puig M, Camós Carreras M, Rodriguez-Palmero A, Felipe-Rucián A, Aznar-Laín G, Jiménez-Fàbrega X, Pérez de la Ossa N. Design and Interrater Reliability of the Pediatric Version of the Race Scale: PedRACE. Stroke 2024; 55:2240-2246. [PMID: 39051112 DOI: 10.1161/strokeaha.124.046846] [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] [Received: 02/09/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Acute ischemic stroke is a leading cause of pediatric death and disability. A clinical scale adapted for children can ensure early detection of candidates for urgent acute ischemic stroke treatment. The Rapid Arterial Occlusion Evaluation (RACE) scale for adults, which scores 5 items (facial palsy 0-2; arm motor function 0-2; leg motor function 0-2; head/gaze deviation 0-1; and aphasia or agnosia 0-2), has good sensitivity and specificity in detecting large vessel occlusion. METHODS We adapted the previously validated RACE scale for use in children as the Pediatric RACE scale. This adapted scale was tested by prehospital/emergency room staff attending to patients covered by the Catalan Pediatric Stroke Code and child neurologists for its correlation with the Pediatric National Institutes of Health Stroke Scale and for interrater reliability. RESULTS The study included 50 children, 18 with confirmed strokes (7 acute ischemic strokes and 11 hemorrhagic strokes). Prehospital/emergency staff and child neurologists agreed fully regarding 82% of patients and 100% regarding head/gaze deviation and agnosia. The Pediatric RACE scale correlated strongly with the Pediatric National Institutes of Health Stroke Scale in evaluations by child neurologists (Spearman ρ, 0.852; P<0.001) and prehospital/emergency staff (Spearman ρ, 0.781; P<0.001). The median Pediatric RACE score was significantly higher in patients with large vessel occlusion (6.5; interquartile range, 6-7) than with other etiologies. CONCLUSIONS Pediatric RACE, showing good interrater reliability and correlation with the Pediatric National Institutes of Health Stroke Scale, is a simple scale to detect candidates for pediatric acute stroke treatment, designed for both prehospital and in-hospital use by non-neurologist medical staff.
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Affiliation(s)
- Eulàlia Turón-Viñas
- Department of Child Neurology, Pediatrics Service, Hospital Sant Pau, Barcelona, Spain (E.T.-V., S.B.)
- IIB Sant Pau Research Institute, Barcelona, Spain (E.T.-V., S.B., I.G.)
- Autonomous University of Barcelona, Spain (E.T.-V., S.B., I.G., A.R.-P., N.P.d.l.O. and A.F.-R.)
| | - Susana Boronat
- Department of Child Neurology, Pediatrics Service, Hospital Sant Pau, Barcelona, Spain (E.T.-V., S.B.)
- IIB Sant Pau Research Institute, Barcelona, Spain (E.T.-V., S.B., I.G.)
- Autonomous University of Barcelona, Spain (E.T.-V., S.B., I.G., A.R.-P., N.P.d.l.O. and A.F.-R.)
| | - Ignasi Gich
- IIB Sant Pau Research Institute, Barcelona, Spain (E.T.-V., S.B., I.G.)
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (I.G.)
- CIBER Epidemiology and Public Health, Instituto de Salud Carlos III, Madrid, Spain (I.G.)
- Autonomous University of Barcelona, Spain (E.T.-V., S.B., I.G., A.R.-P., N.P.d.l.O. and A.F.-R.)
| | | | | | - Maria Camós Carreras
- Department of Pediatrics, Dr Josep Trueta University Hospital, Girona, Spain (M.C.C.)
- Girona Biomedical Research Institute, Girona, Spain (M.C.C.)
| | - Agustí Rodriguez-Palmero
- Pediatric Neurology Unit, Department of Pediatrics, Germans Trias i Pujol University Hospital (A.R.-P.), Spain
- Autonomous University of Barcelona, Spain (E.T.-V., S.B., I.G., A.R.-P., N.P.d.l.O. and A.F.-R.)
| | - Ana Felipe-Rucián
- Autonomous University of Barcelona, Spain (E.T.-V., S.B., I.G., A.R.-P., N.P.d.l.O. and A.F.-R.)
- Child Neurology Section, Hospital Vall d'Hebron, Barcelona, Spain (A.F.-R.)
| | - Gemma Aznar-Laín
- Pediatric Neurology, Hospital del Mar, Barcelona, Spain (G.A.-L.)
- Program in Neurosciences, Hospital del Mar Research Institute, Barcelona, Spain (G.A.-L.)
| | | | - Natalia Pérez de la Ossa
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol (N.P.d.l.O.), Spain
- Autonomous University of Barcelona, Spain (E.T.-V., S.B., I.G., A.R.-P., N.P.d.l.O. and A.F.-R.)
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Peycheva M, Seiler A, Wagner F, Li L, Heldner MR. Journal Club: Prehospital Detection of Large Vessel Occlusion Stroke With Electroencephalography: Results of the ELECTRA-STROKE Study. Neurology 2024; 103:e209587. [PMID: 38870459 DOI: 10.1212/wnl.0000000000209587] [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: 06/15/2024] Open
Abstract
The ELECTRA-STROKE study investigated the potential of EEG for prehospital triage of patients with ischemic stroke due to large vessel occlusion (LVO), in which fast triage to stroke centers for endovascular treatment is crucial. The study was conducted in 4 phases, and this Journal Club article focuses on the fourth phase in the prehospital setting with suspected stroke patients. An EEG cap with dry electrodes was used to measure brain activity. The main focus was on the diagnostic accuracy of the theta/alpha ratio, which yielded an area under the receiver operator characteristic curve (AUC) of 0.80. Secondary endpoints, particularly the Brain Symmetry Index (a quantified EEG interhemispheric cortical power asymmetry index) in the delta frequency band, showed an AUC of 0.91. Despite the convenient study design and user-friendly EEG device, limitations include a single-arm design, a relatively small sample size, and exclusions due to data quality issues. The usefulness of EEG in the detection of neuronal changes based on brain ischemia was highlighted, but uncertainties remain regarding its use in certain patient groups. The improvements in the Brain Symmetry Index from phase 3 to 4 of the study indicate the potential for further refinement and investigation of combined methods to improve diagnostic accuracy. The study provides insight into the role of EEG in prehospital stroke detection, recognizing both the strengths and limitations. Overall, the study contributes to understanding the promise of EEG in optimizing LVO stroke triage and urges further refinement and exploration of complementary diagnostic approaches.
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Affiliation(s)
- Marieta Peycheva
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Andrea Seiler
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Franca Wagner
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Linxin Li
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Mirjam R Heldner
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
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Lucas L, Georget A, Rouxel L, Briau P, Couture M, Liegey JS, Debruxelles S, Poli M, Sagnier S, Renou P, Olindo S, Rouanet F, Maurin X, Benard A, Sibon I. Remote neurological evaluation reliably identifies patients eligible to endovascular therapy while non-eligible to intravenous thrombolysis. Rev Neurol (Paris) 2024:S0035-3787(24)00553-8. [PMID: 38918135 DOI: 10.1016/j.neurol.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/16/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION/BACKGROUND Early identification of suspected stroke patients who might be eligible for a reperfusion strategy is a daily challenge in the management of patient referrals. The aim of this study was to evaluate the performance of a remote medical assessment in identifying patients eligible for endovascular therapy (EVT) while not eligible for intravenous thrombolysis (IVT), compared with a decision based on bedside clinico-radiological data. METHODS Patients admitted to the emergency department for acute neurological symptoms lasting for less than 24h were prospectively included. Assessment of the clinical severity and medical history was performed simultaneously by two vascular neurologists (VNs), one remotely using a mobile telemedicine solution (NOMADEEC), the other at the bedside. RACE score was calculated from the NIHSS score. At the end of the evaluation, both VNs quoted their treatment convictions (IVT/EVT). Final therapeutic decision following brain and vascular imaging was recorded and compared to remote and bedside predictions. The performances of three different conditions were evaluated: complete medical evaluation (NIHSS+medical history), NIHSS score alone, and RACE score alone. Remote and bedside performances were also compared. Diagnostic accuracy parameters (sensitivity, specificity, positive and negative predictive values) of each condition were estimated, along with their two-sided 95% binomial confidence intervals. RESULTS Out of 215 enrolled patients, 186 had a complete evaluation, 91 (54.3%) were diagnosed with an ischemic stroke or transient ischemic attack and 46 (24.7%) had an intracranial occlusion. Considering the three conditions evaluated remotely, RACE score-based decision provided the best sensitivity 54.6% [95% CI 23.4; 83.2]/specificity 80.6% [73.9; 86.2] combination. However, the complete medical evaluation had the best specificity (88.6% [82.9; 92.9] compared to RACE scores alone (P=0.038). Remote and bedside performances did not differ (κ=0.68 [0.59; 0.77]). DISCUSSION/CONCLUSION This real-life study performed in the setting of emergency demonstrates that remote medical evaluations including recording of extensive medical information and NIHSS examination to address patient's eligibility to revascularization treatment is swiftly feasible and is as effective as bedside prediction to EVT and/or IVT. Remote standardized medical evaluation might improve the decision of patients' primary orientation and avoid overcrowding of comprehensive stroke centres.
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Affiliation(s)
- L Lucas
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - A Georget
- Bordeaux University Hospital, Methodology Department, Bordeaux, France.
| | - L Rouxel
- Enovacom-NOMADEEC, Bordeaux, France.
| | - P Briau
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - M Couture
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - J-S Liegey
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - S Debruxelles
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - M Poli
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - S Sagnier
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - P Renou
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - S Olindo
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - F Rouanet
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - X Maurin
- Enovacom-NOMADEEC, Bordeaux, France.
| | - A Benard
- Bordeaux University Hospital, Methodology Department, Bordeaux, France.
| | - I Sibon
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
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Arends G, Perry E, Sherman A, Flint J. A Review of an Interfacility Transport Program Pediatric Stroke Clinical Practice Guideline. Pediatr Emerg Care 2024; 40:382-385. [PMID: 38194682 DOI: 10.1097/pec.0000000000003095] [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: 01/11/2024]
Abstract
BACKGROUND Pediatric acute ischemic stroke is a rare diagnosis that requires timely recognition and definitive management to prevent morbidity and mortality. Children often present to primary care offices, urgent care clinics, and adult emergency departments for evaluation of symptoms that may be signs and symptoms of stroke. Currently, there are no published prehospital or transport protocols specific to pediatric acute ischemic stroke. The Children's Mercy Hospital Critical Care Transport Team (CMCCT) created a pediatric-specific clinical practice guideline (CPG) for suspected acute ischemic stroke. METHODS This retrospective, descriptive study reports pediatric patients aged younger than 18 years who met criteria for the pediatric stroke CPG and required interfacility transport by CMCCT over a 4- year period. Large vessel occlusion (LVO) scores used in adults were calculated retrospectively. RESULTS Seventeen patients met inclusion criteria. Four (24%) of 17 had radiographic evidence of acute thrombus, 3 of whom received alteplase and/or endovascular clot retrieval. Median age of confirmed stroke was 83 months (interquartile range, 65-148) compared with 177 months for nonstroke (interquartile range, 169-191), P = 0.126. The most common presenting symptom was hemiplegia in the confirmed stroke group. The confirmed stroke group scored significantly lower on the Glasgow Coma Scale (median of 8 vs 15, P = 0.014), significantly higher on the Los Angeles Motor Scale LVO score (median 4 vs 0, P = 0.021), and significantly higher on the Rapid Arterial Occlusion Evaluation LVO (median 4 vs 0, P = 0.036). CONCLUSIONS To our knowledge, the CMCCT CPG is the first pediatric transport protocol aimed at recognition and management of pediatric stroke described in the literature. Retrospective calculation of LVO scores show that they may be helpful in application to pediatric patients.
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Affiliation(s)
- Grace Arends
- From the Children's Mercy Hospital, Kansas City, MO
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Paxton JH, Keenan KJ, Wilburn JM, Wise SL, Klausner HA, Ball MT, Dunne RB, Kreitel KD, Morgan LF, Fales WD, Madhok D, Barazangi N, McLean ST, Cross K, Distenfield L, Sykes J, Lovoi P, Johnson B, Smith WS. Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. Acad Emerg Med 2024. [PMID: 38643419 DOI: 10.1111/acem.14919] [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: 12/22/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.
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Affiliation(s)
- James H Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, California, USA
| | - John M Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Stefanie L Wise
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Howard A Klausner
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Matthew T Ball
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - K Derek Kreitel
- Department of Radiology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Larry F Morgan
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - William D Fales
- Department of Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Debbie Madhok
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Nobl Barazangi
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | - Steven T McLean
- Department of Emergency Medicine, Ascension St. Mary's Hospital, Saginaw, Michigan, USA
| | - Katherine Cross
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | | | - Paul Lovoi
- MindRhythm, Inc., Cupertino, California, USA
| | | | - Wade S Smith
- Department of Neurology, University of California, Davis, Sacramento, California, USA
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Qiu K, Xie T, Wei K, Shi HB, Liu S. Validation of the prehospital stroke scales as a tool for in-hospital large vessel occlusion stroke: whether we satisfied? Acta Neurol Belg 2024; 124:467-474. [PMID: 37889423 DOI: 10.1007/s13760-023-02402-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/18/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Prehospital stroke severity scales have been widely used to identify whether community stroke patients presented with large vessel occlusion (LVO) or not. However, whether these scales are also applicable to in-hospital stroke patients remains unknown. PURPOSE We aim to validate and compare the predictive capability of these scales for these patients. MATERIAL AND METHODS From January 2016 to October 2020, a total of 243 patients who activated in-hospital stroke alerts, were included in this study. The area under the curve (AUC) was used to assess the predictive ability of five scales (Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Rapid Arterial Occlusion Evaluation [RACE], Los Angeles Motor Scale [LAMS], Cincinnati Prehospital Stroke Severity Scale [CPSSS], and Prehospital Acute Stroke Severity scale [PASS]) for LVO. In addition, multivariable logistic analysis was adopted to determine the predictors of LVO in our patients cohort. RESULTS Finally, 94 (38.7%) patients were confirmed presence of persistent LVO. The AUC for the FAST-ED, RACE, LAMS, CPSSS, and PASS scales to predict the presence of LVO in patients activating in-hospital stroke alerts were 0.82, 0.89, 0.86, 0.81, and 0.79, respectively. After multivariable analysis, baseline NIHSS (adjusted odds ratio [OR] = 1.160, 95% confidence interval [CI] = 1.110-1.212; P < 0.001) atrial fibrillation (adjusted OR = 2.940, 95% CI = 1.387-6.230; P = 0.005) and cardiac/pulmonary procedure (adjusted OR = 6.861, 95% CI = 2.437-19.315; P < 0.001) remained independent predictors of LVO. CONCLUSION The prehospital stroke scales also showed good predictive capabilities in discriminating LVO among inpatients who activated stroke alerts. However, given that inpatients' history is more readily available, a specifically designed in-hospital stroke scale that combines stroke severity and history is warranted.
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Affiliation(s)
- Kai Qiu
- Department of Interventional Radiology, The First Affiliated Hospital With Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Ting Xie
- Department of Radiology, Women's Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Ke Wei
- Department of Stroke Center, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital With Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China.
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital With Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China.
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9
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Mikolich B, Shank G, Thomas D. LifeFlight Case Studies: Lessons Learned From Notable Flights. Crit Care Nurs Q 2024; 47:126-142. [PMID: 38419176 DOI: 10.1097/cnq.0000000000000503] [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: 03/02/2024]
Abstract
Air medical providers are responsible for the care of an incredibly diverse patient population. When it is time to transport a patient, providers must be prepared for complex situations, each requiring different skills, medications, and critical thinking. Scene flights will have providers landing and providing care in the prehospital setting where an interfacility transport requires the patient to be taken from one hospital to another. Specialty flights require special equipment, personnel, and aircraft preparedness to be completed. The case studies provided within this article highlight the complexity and diversity that is encountered each shift at Allegheny LifeFlight.
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Affiliation(s)
- Brian Mikolich
- AHN LifeFlight, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Prasad S, Jones EM, Gebreyohanns M, Kwon Y, Olson DM, Anderson JA, Savitz SI, Cruz-Flores S, Warach SJ, Rhodes CE, Goldberg MP, Ifejika NL. Multicenter exploration of tenecteplase transition factors: A quantitative analysis. J Stroke Cerebrovasc Dis 2024; 33:107592. [PMID: 38266690 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107592] [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] [Received: 09/25/2023] [Revised: 01/02/2024] [Accepted: 01/20/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Tenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems. OBJECTIVE Identify barriers and facilitators of TNK implementation at acute care hospitals in Texas. METHODS This prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform. RESULTS The 40 hospitals had a median of 34 (IQR 24.5-49) emergency department beds and 42.5 (IQR 23.5-64.5) inpatient stroke beds with 506.5 (IQR 350-797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases. CONCLUSION Understanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.
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Affiliation(s)
- Sidarrth Prasad
- University of Texas Southwestern Medical Center, United States
| | - Erica M Jones
- University of Texas Southwestern Medical Center, United States
| | | | - Yoon Kwon
- University of Texas Southwestern Medical Center, United States
| | - DaiWai M Olson
- University of Texas Southwestern Medical Center, United States
| | | | - Sean I Savitz
- University of Texas Health Science Center at Houston, United States
| | | | - Steven J Warach
- Dell Medical School, The University of Texas at Austin, United States
| | - Charlotte E Rhodes
- The University of Texas Health Science Center at San Antonio, United States
| | - Mark P Goldberg
- The University of Texas Health Science Center at San Antonio, United States
| | - Nneka L Ifejika
- University of Texas Southwestern Medical Center, United States.
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11
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Menéndez Albarracín A, Valls Carbó A, Rabaneda Lombarte N, Yugueros Baena B, Carbonell Gisbert J, Flores-Pina B, Larrañaga De Bofarull MC, Martínez Sánchez M, Hernández-Pérez M, Bustamante Rangel A, Dorado Bouix L, Gomis Cortina M, Millán Tornè M, Pérez de la Ossa N. Time of the day and season distribution among stroke code subtypes: differences between ischemic stroke, intracranial hemorrhage, and stroke mimic. Front Neurol 2024; 15:1372324. [PMID: 38595853 PMCID: PMC11002223 DOI: 10.3389/fneur.2024.1372324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024] Open
Abstract
Background Circadian variations in the timing of the onset of stroke symptoms have been described, showing a morning excess of cardiovascular risk. To date, no differences have been found between stroke subtype and time distribution throughout the day. The present study aims to compare the seasonal and circadian rhythm of symptoms onset in ischemic, hemorrhagic, and stroke mimic patients. Methods This study was conducted prospectively at a hospital and involved a cohort of stroke alert patients from 2018 to 2021. Stroke subtypes were classified as ischemic stroke, intracerebral hemorrhage (ICH), transient ischemic attack (TIA), and stroke mimic. Clinical variables were recorded, and each patient was assigned to a 4-h interval of the day according to the time of onset of symptoms; unwitnessed stroke patients were analyzed separately. Seasonal changes in stroke distribution were analyzed at 3-month intervals. Results A total of 2,348 patients were included in this analysis (ischemic 67%, ICH 13%, mimic 16%, and TIA 3%). Regardless of stroke subtype, most of the patients were distributed between 08-12 h and 12-16 h. Significant differences were found in the time distribution depending on stroke subtype, with ICH predominating in the 4-8 h period (dawn), most of which were hypertensive, TIA in the 12-16 h period (afternoon), and stroke mimic in the 20 h period (evening). The ischemic stroke was evenly distributed throughout the different periods of the day. There were no differences in the seasonal pattern between different stroke subtypes, with winter being the one that accumulated the most cases. Conclusion The present study showed different circadian patterns of stroke subtypes, with a predominance of ICH at dawn and stroke mimic in the afternoon. The stroke circadian rhythm resembles previous studies, with a higher incidence in the morning and a second peak in the afternoon.
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12
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Kolls BJ, Ehrlich ME, Monk L, Shah S, Roettig M, Iversen E, Jollis JG, Granger CB, Graffagnino C. Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program. Am Heart J 2024; 269:72-83. [PMID: 38061683 DOI: 10.1016/j.ahj.2023.11.020] [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] [Received: 08/17/2023] [Revised: 11/18/2023] [Accepted: 11/28/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks. METHODS The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly. RESULTS Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59). CONCLUSIONS The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.
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Affiliation(s)
- Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Matthew E Ehrlich
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | | | - Edwin Iversen
- Department of Statistical Science, Duke University, Durham NC
| | - James G Jollis
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Carmelo Graffagnino
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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13
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Ali M, Dekker L, Daems JD, Ali M, van Zwet EW, Steyerberg EW, Duvekot MHC, Nguyen TTM, Moudrous W, van de Wijdeven RM, Visser MC, de Laat KF, Kerkhoff H, van den Wijngaard IR, Dippel DWJ, Roozenbeek B, Kruyt ND, Wermer MJH. Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke. Stroke 2024; 55:548-554. [PMID: 38299328 PMCID: PMC10896195 DOI: 10.1161/strokeaha.123.044898] [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] [Received: 08/18/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. METHODS We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. RESULTS Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94-0.96] to 0.98 [95% CI, 0.97-0.98] in women versus 0.94 [95% CI, 0.93-0.95] to 0.96 [95% CI, 0.94-0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43-0.63] to 0.76 [95% CI, 0.68-0.84] versus 0.49 [95% CI, 0.40-0.57] to 0.63 [95% CI, 0.55-0.73]), whereas specificity was lower (0.79 [95% CI, 0.76-0.81] to 0.87 [95% CI, 0.84-0.89] versus 0.82 [95% CI, 0.79-0.84] to 0.90 [95% CI, 0.88-0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. CONCLUSIONS aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Luuk Dekker
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands (W.M.)
| | - Ruben M van de Wijdeven
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke C Visser
- Department of Neurology (M.C.V.)
- Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (M.C.V.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, the Hague, the Netherlands (K.F.d.L.)
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - Ido R van den Wijngaard
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands (I.R.v.d.W.)
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Marieke J H Wermer
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Centre Groningen, University of Groningen, the Netherlands (M.J.H.W.)
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14
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Herrmann ML, Franck C, Schuchardt FF, Meier S, Henningsen M, Wimmesberger N, Rau D, Busch H, Taschner CA, Farin‐Glattacker E, Brich J. The non-paretic-hand-to-opposite-ear test: A simple test to detect aphasia and neglect and an indicator of large anterior vessel occlusion in patients with suspected acute stroke. Brain Behav 2024; 14:e3450. [PMID: 38450998 PMCID: PMC10918592 DOI: 10.1002/brb3.3450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/28/2024] [Accepted: 02/04/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Aphasia and neglect in combination with hemiparesis are reliable indicators of large anterior vessel occlusion (LAVO). Prehospital identification of these symptoms is generally considered difficult by emergency medical service (EMS) personnel. Therefore, we evaluated the simple non-paretic-hand-to-opposite-ear (NPE) test to identify aphasia and neglect with a single test. As the NPE test includes a test for arm paresis, we also evaluated the diagnostic ability of the NPE test to detect LAVO in patients with suspected stroke. METHODS In this prospective observational study, we performed the NPE test in 1042 patients with suspected acute stroke between May 2021 and May 2022. We analyzed the correlation between the NPE test and the aphasia/neglect items of the National Institutes of Health Stroke Scale. Additionally, the predictive values of the NPE test for LAVO detection were calculated. RESULTS The NPE test showed a strong, significant correlation with both aphasia and neglect. A positive NPE test result predicted LAVO with a sensitivity of 0.70, a specificity of 0.88, and an accuracy of 0.85. Logistic regression analysis showed an odds ratio of 16.14 (95% confidence interval 10.82-24.44) for predicting LAVO. CONCLUSION The NPE test is a simple test for the detection of both aphasia and neglect. With its predictive values for LAVO detection being comparable to the results of LAVO scores in the prehospital setting, this simple test might be a promising test for prehospital LAVO detection by EMS personnel. Further prospective prehospital validation is needed.
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Affiliation(s)
- Matthias L. Herrmann
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Clara Franck
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Florian F. Schuchardt
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Simone Meier
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Max Henningsen
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Nicole Wimmesberger
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Diana Rau
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Hans‐Jörg Busch
- Department of Emergency Medicine, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Christian A. Taschner
- Department of Neuroradiology, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Erik Farin‐Glattacker
- Section of Health Care Research and Rehabilitation Research (SEVERA), Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Jochen Brich
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
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15
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Sporns PB, Fischer U, Katan M, Ospel JM, Brehm A, Tsogkas I, Holodinsky JK, Kamal N, Fiehler J, Psychogios MN. Simulation of transportation of acute stroke patients in border regions. Sci Rep 2024; 14:1736. [PMID: 38242912 PMCID: PMC10798996 DOI: 10.1038/s41598-024-51959-y] [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] [Received: 05/22/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
Determining the optimal transportation for each stroke patient is critically important to achieve the best possible outcomes. In border regions the next comprehensive stroke center may be just across an international border, but bureaucratic and financial hurdles may prevent a simple transfer to the next stroke center. We hypothesized that in regions close to international borders, patients may benefit from an "open border, closed transfer scenario", meaning that patients in whom a large vessel occlusion (LVO) is detected in the primary stroke center will benefit from a transfer to the nearest stroke center offering endovascular thrombectomy-even if this may be across a national border. We used the Swiss-German-French trinational region as an example for a region with several international borders within close proximity to one another, and compared two feasible scenarios; (a) a "closed borders, open transfer" scenario, where the patient is transported to any center in the same country, (b) an "open border, closed transfer" scenario, where patients are always transported to the nearby primary stroke center first and then to the nearest comprehensive stroke center in either the same or a neighboring country and (c) and "open borders, open transfer" scenario. The outcome of interest was the predicted probability of acute ischemic stroke patients to achieve a good outcome using a conditional probability model which predicts the likelihood of excellent outcome (modified Rankin scale score of 0-1 at 90 days post-stroke) for patients with suspected LVO. Results were modeled in a virtual map from which the ideal transport concept emerged. For an exemplary LVO stroke patient in Germany, the probability of a good outcome was higher in an open border, closed transfer scenario than with closed borders, open transfer (33.1 vs. 30.1%). Moreover, time to EVT would decrease from 232 min in the first scenario to 169 min in an open border, closed transfer scenario. The catchment area of the University Hospital Basel was almost double the size in an open border, closed transfer scenario compared to closed borders (1674 km2 vs. 2897 km2) and would receive transfers from 3 primary stroke centers in other countries (2 in Germany and 1 in France). Stroke patients showed a higher likelihood of good outcome in the "open border" scenarios without transfer restrictions to a specific healthcare system. This probably has implications for stroke treatment in all border regions where EVT eligible stroke patients may benefit from transport to the closest EVT capable center whenever possible, regardless of whether this hospital is located in the same or a neighboring country/jurisdiction.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland.
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Urs Fischer
- Department of Neurology, University Hospital of Basel, 4031, Basel, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital of Basel, 4031, Basel, Switzerland
| | - Johanna M Ospel
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Ioannis Tsogkas
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Jessalyn K Holodinsky
- Department of Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
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16
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Flores A, Garcia-Tornel A, Seró L, Ustrell X, Requena M, Pellisé A, Rodriguez P, Monterde A, Lara L, Gonzalez-de-Echavarri JM, Molina CA, Doncel-Moriano A, Dorado L, Cardona P, Cánovas D, Krupinski J, Más N, Purroy F, Zaragoza-Brunet J, Palomeras E, Cocho D, Garcia J, Colom C, Silva Y, Gomez-Cocho M, Jiménez X, Ros-Roig J, Abilleira S, Pérez de la Ossa N, Ribo M. Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis. J Neurointerv Surg 2024; 16:143-150. [PMID: 37068936 DOI: 10.1136/jnis-2023-020125] [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] [Received: 01/25/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND The influence of vascular imaging acquisition on workflows at local stroke centers (LSCs) not capable of performing thrombectomy in patients with a suspected large vessel occlusion (LVO) stroke remains uncertain. We analyzed the impact of performing vascular imaging (VI+) or not (VI- at LSC arrival on variables related to workflows using data from the RACECAT Trial. OBJECTIVE To compare workflows at the LSC among patients enrolled in the RACECAT Trial with or without VI acquisition. METHODS We included patients with a diagnosis of ischemic stroke who were enrolled in the RACECAT Trial, a cluster-randomized trial that compared drip-n-ship versus mothership triage paradigms in patients with suspected acute LVO stroke allocated at the LSC. Outcome measures included time metrics related to workflows and the rate of interhospital transfers and thrombectomy among transferred patients. RESULTS Among 467 patients allocated to a LSC, vascular imaging was acquired in 277 patients (59%), of whom 198 (71%) had a LVO. As compared with patients without vascular imaging, patients in the VI+ group were transferred less frequently as thrombectomy candidates to a thrombectomy-capable center (58% vs 74%, P=0.004), without significant differences in door-indoor-out time at the LSC (median minutes, VI+ 78 (IQR 69-96) vs VI- 76 (IQR 59-98), P=0.6). Among transferred patients, the VI+ group had higher rate of thrombectomy (69% vs 55%, P=0.016) and shorter door to puncture time (median minutes, VI+ 41 (IQR 26-53) vs VI- 54 (IQR 40-70), P<0.001). CONCLUSION Among patients with a suspected LVO stroke initially evaluated at a LSC, vascular imaging acquisition might improve workflow times at thrombectomy-capable centers and reduce the rate of futile interhospital transfers. These results deserve further evaluation and should be replicated in other settings and geographies.
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Affiliation(s)
- Alan Flores
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | | | - Laia Seró
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Xavier Ustrell
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Anna Pellisé
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Paula Rodriguez
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Angela Monterde
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Lidia Lara
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Jose María Gonzalez-de-Echavarri
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Antonio Doncel-Moriano
- Stroke Unit, Department of Neurology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Laura Dorado
- Stroke Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Catalunya, Spain
| | - Pedro Cardona
- Bellvitge University Hospital, L'Hospitalet de Llobregat, Catalunya, Spain
| | - David Cánovas
- Department of Neurology, Consorci Sanitari Parc Taulí, Barcelona, Spain
| | | | - Natalia Más
- Department of Neurology, Hospital Althaia, Manresa, Manresa, Catalunya, Spain
| | | | - Jose Zaragoza-Brunet
- Stroke Unit, Department of Neurology, Hospital Verge de la Cinta, Tortosa, Catalunya, Spain
| | - Ernesto Palomeras
- Department of Neurology, Hospital de Mataró, Mataro, Catalunya, Spain
| | - Dolores Cocho
- Department of Neurology, Hospital General de Granollers, Granollers, Catalunya, Spain
| | - Jessica Garcia
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedes, Catalunya, Spain
| | - Carla Colom
- Department of Neurology, Hospital Universitario de Igualada, Igualada, Catalunya, Spain
| | - Yolanda Silva
- Neurology Department, Stroke Unit, Doctor Josep Trueta University Hospital of Girona, Girona, Catalunya, Spain
| | - Manuel Gomez-Cocho
- Department of Neurology, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
| | - Xavier Jiménez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Josep Ros-Roig
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sonia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain
- Catalan Stroke Program, Barcelona, Spain
| | - Marc Ribo
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Makharia A, Agarwal A, Garg D, Vishnu VY, Srivastava MVP. The Pitfalls of NIHSS: Time for a New Clinical Acute Stroke Severity Scoring System in the Emergency? Ann Indian Acad Neurol 2024; 27:15-18. [PMID: 38495237 PMCID: PMC10941908 DOI: 10.4103/aian.aian_842_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/02/2023] [Accepted: 11/24/2023] [Indexed: 03/19/2024] Open
Abstract
Stroke is the second leading cause of death and a major cause of disability worldwide. Stroke severity scales serve as reliable means to track a patient's neurological deficit, predict outcome, and guide treatment decisions in clinical practice. The National Institute of Health Stroke Scale (NIHSS) was introduced over 30 years ago, marking a significant milestone in the field of stroke. Over the years, there have been notable advancements in acute stroke care. Despite several modifications made to NIHSS, none has yet succeeded in effectively capturing all the complex effects of a stroke. This review focuses on the pitfalls of NIHSS and emphasizes the need for a quick and comprehensive clinical and upgraded version of the stroke severity rating scale.
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Affiliation(s)
- Archita Makharia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Divyani Garg
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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18
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Sallustio F, Mascolo AP, Marrama F, Lacidogna G, D'Agostino F, Rocco A, Gandini R, Morosetti D, Da Ros V, Nezzo M, Argirò R, Plocco M, Alemseged F, Diomedi M. Comparison between different referral strategies for acute ischemic stroke patients in a hub-spoke emergency stroke network: a real-world experience in south-east Lazio. Neurol Sci 2024; 45:203-211. [PMID: 37507617 DOI: 10.1007/s10072-023-06966-8] [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] [Received: 04/11/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
AIM To describe different referral strategies for acute ischemic stroke (AIS) patients in a Hub-Spoke emergency stroke network with their incidence, time metrics and related outcomes. METHODS Referral paradigms were defined as follows: primary transfer to the comprehensive stroke center (CSC) from a remote region, called mothership (MS); secondary transfer to the CSC from a primary stroke center where intravenous thrombolysis was available, called drip and ship (DS); secondary transfer to the CSC from a community hospital where no reperfusion therapy was available, called ship and drip (SD); primary transfer to the CSC from its catchment area, called direct CSC (dCSC). RESULTS Among 517 anterior circulation AIS patients treated with mechanical thrombectomy between 2015 and 2020, 16.6% of them were SD, in addition to the well-known referral paradigms of MS (21.8%) and DS (18.1%). This rate grew to 30% when only patients whose place of onset was outside the CSC catchment area were considered. In the SD group, onset to CSC and onset to groin were significantly longer (178±80 min vs. 102±60 min, p<0.001, and 277±77 min vs. 211±61 min, p<0.001, respectively), and the risk of any intracranial hemorrhage (ICH) was significantly higher (OR: 2.514; 95%CI: 1.18-5.35, p=0.017) compared to MS. CONCLUSION In this hub-spoke stroke network, a high proportion of SD paradigm was found, which was associated with longer times to treatment and higher rates of any ICH. A closer cooperation between hospital stroke physicians, national health system staff, and paramedics is warranted to identify the most appropriate referral strategy for each patient.
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Affiliation(s)
- F Sallustio
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy.
| | - A P Mascolo
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - F Marrama
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - G Lacidogna
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - F D'Agostino
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - A Rocco
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - R Gandini
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - D Morosetti
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - V Da Ros
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - M Nezzo
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - R Argirò
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - M Plocco
- Neurovascular Therapy Unit, F. Spaziani Hospital, Rome, Frosinone, Italy
| | - F Alemseged
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - M Diomedi
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
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19
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [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: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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20
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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [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: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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21
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Martinez-Gutierrez JC, Kim Y, Salazar-Marioni S, Tariq MB, Abdelkhaleq R, Niktabe A, Ballekere AN, Iyyangar AS, Le M, Azeem H, Miller CC, Tyson JE, Shaw S, Smith P, Cowan M, Gonzales I, McCullough LD, Barreto AD, Giancardo L, Sheth SA. Automated Large Vessel Occlusion Detection Software and Thrombectomy Treatment Times: A Cluster Randomized Clinical Trial. JAMA Neurol 2023; 80:1182-1190. [PMID: 37721738 PMCID: PMC10507590 DOI: 10.1001/jamaneurol.2023.3206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/21/2023] [Indexed: 09/19/2023]
Abstract
Importance The benefit of endovascular stroke therapy (EVT) in large vessel occlusion (LVO) ischemic stroke is highly time dependent. Process improvements to accelerate in-hospital workflows are critical. Objective To determine whether automated computed tomography (CT) angiogram interpretation coupled with secure group messaging can improve in-hospital EVT workflows. Design, Setting, and Participants This cluster randomized stepped-wedge clinical trial took place from January 1, 2021, through February 27, 2022, at 4 comprehensive stroke centers (CSCs) in the greater Houston, Texas, area. All 443 participants with LVO stroke who presented through the emergency department were treated with EVT at the 4 CSCs. Exclusion criteria included patients presenting as transfers from an outside hospital (n = 158), in-hospital stroke (n = 39), and patients treated with EVT through randomization in a large core clinical trial (n = 3). Intervention Artificial intelligence (AI)-enabled automated LVO detection from CT angiogram coupled with secure messaging was activated at the 4 CSCs in a random-stepped fashion. Once activated, clinicians and radiologists received real-time alerts to their mobile phones notifying them of possible LVO within minutes of CT imaging completion. Main Outcomes and Measures Primary outcome was the effect of AI-enabled LVO detection on door-to-groin (DTG) time and was measured using a mixed-effects linear regression model, which included a random effect for cluster (CSC) and a fixed effect for exposure status (pre-AI vs post-AI). Secondary outcomes included time from hospital arrival to intravenous tissue plasminogen activator (IV tPA) bolus in eligible patients, time from initiation of CT scan to start of EVT, and hospital length of stay. In exploratory analysis, the study team evaluated the impact of AI implementation on 90-day modified Rankin Scale disability outcomes. Results Among 243 patients who met inclusion criteria, 140 were treated during the unexposed period and 103 during the exposed period. Median age for the complete cohort was 70 (IQR, 58-79) years and 122 were female (50%). Median National Institutes of Health Stroke Scale score at presentation was 17 (IQR, 11-22) and the median DTG preexposure was 100 (IQR, 81-116) minutes. In mixed-effects linear regression, implementation of the AI algorithm was associated with a reduction in DTG time by 11.2 minutes (95% CI, -18.22 to -4.2). Time from CT scan initiation to EVT start fell by 9.8 minutes (95% CI, -16.9 to -2.6). There were no differences in IV tPA treatment times nor hospital length of stay. In multivariable logistic regression adjusted for age, National Institutes of Health Stroke scale score, and the Alberta Stroke Program Early CT Score, there was no difference in likelihood of functional independence (modified Rankin Scale score, 0-2; odds ratio, 1.3; 95% CI, 0.42-4.0). Conclusions and Relevance Automated LVO detection coupled with secure mobile phone application-based communication improved in-hospital acute ischemic stroke workflows. Software implementation was associated with clinically meaningful reductions in EVT treatment times. Trial Registration ClinicalTrials.gov Identifier: NCT05838456.
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Affiliation(s)
| | - Youngran Kim
- Center for Healthcare Data, School of Public Health, UTHealth, Houston, Texas
| | | | | | - Rania Abdelkhaleq
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Arash Niktabe
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Anjan N. Ballekere
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Ananya S. Iyyangar
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Mai Le
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Hussain Azeem
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Charles C. Miller
- Department of Cardiovascular and Thoracic Surgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at UTHealth Houston, Texas
| | - Sandi Shaw
- Memorial Herman Hospital, Houston, Texas
| | - Peri Smith
- Memorial Herman Hospital, Houston, Texas
| | | | | | | | - Andrew D. Barreto
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Luca Giancardo
- UTHealth School of Biomedical Informatics, Houston, Texas
| | - Sunil A. Sheth
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
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22
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Keenan KJ, Smith WS, Jadhav AP, Haussen DC, Budzik RF, Bonafé A, Bhuva P, Yavagal DR, Ribò M, Cognard C, Hanel RA, Hassan AE, Sila CA, Saver JL, Liebeskind DS, Jovin TG, Nogueira RG. Large vessel occlusion prediction scale thresholds that are sensitive for DAWN Trial patients. Interv Neuroradiol 2023:15910199231203266. [PMID: 37915142 DOI: 10.1177/15910199231203266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Large vessel occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6-to-24-h time window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right-sided LVOs. METHODS LVO prediction scale scores were retrospectively calculated using the National Institutes of Health Stroke Scale (NIHSS) scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 and 24 h, NIHSS scores ≥ 10, intracranial internal carotid artery or proximal middle cerebral artery occlusions, and mismatches between their clinical severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified, along with scores ≥ 5% more sensitive for left or right-sided LVOs. Specificities could not be calculated because all patients had LVOs. RESULTS A total of 201 out of 206 patients had the required NIHSS subitem scores. CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 were the highest thresholds that were still 85% sensitive for DAWN Trial LVO stroke patients. RACE ≥ 5 was the only typically used score threshold more sensitive for right-sided LVOs, though similar small differences were seen for other scales at higher thresholds. CONCLUSIONS Our findings likely represent the maximum sensitivities of the LVO prediction scales tested for ideal thrombectomy candidates in the 6-to-24-h time window because NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Patients with NIHSS scores < 10 or more distal LVOs would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.
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Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, CA, USA
| | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Ashutosh P Jadhav
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Diogo C Haussen
- Department of Neurology and Radiology, Emory University School of Medicine at Grady Memorial Hospital, Atlanta, GA, USA
| | - Ronald F Budzik
- Department of Radiology, OhioHealth/Riverside Methodist Hospital, Columbus, OH, USA
| | - Alain Bonafé
- Department of Neuroradiology, University Hospital of Montpellier, Hop Gui de Chauliac, Montpellier, France
| | - Parita Bhuva
- Texas Stroke Institute at HCA North Texas, Plano, TX, USA
| | - Dileep R Yavagal
- Department of Neurology, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Marc Ribò
- Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Neurology, Vall d'Hebron University Hospital, Stroke Unit, Barcelona, Spain
| | - Christophe Cognard
- Department of Neuroradiology, Hospital Purpan, Toulouse, Midi-Pyrénées, France
| | - Ricardo A Hanel
- Baptist Medical Center Jacksonville/Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center - Harlingen, TX, USA
| | - Cathy A Sila
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles, CA, USA
| | | | - Tudor G Jovin
- Cooper Hospital University Medical Center, Camden, NJ, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
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23
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English SW, Chhabra N, Hanus AE, Basharath R, Miller M, Butterfield RJ, Zhang N, Demaerschalk BM. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare 2023:1357633X231204066. [PMID: 37899587 DOI: 10.1177/1357633x231204066] [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: 10/31/2023]
Abstract
INTRODUCTION Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further. METHODS This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables. RESULTS A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection. DISCUSSION Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.
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Affiliation(s)
- Stephen W English
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Nikita Chhabra
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
| | - Abigail E Hanus
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Rida Basharath
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Monet Miller
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | - Bart M Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
- Center for Digital Health, Mayo Clinic, Rochester, MI, USA
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Thilemann S, Traenka CK, Schaub F, Nussbaum L, Bonati L, Peters N, Fladt J, Nickel C, Hunziker P, Luethy M, Schädelin S, Ernst A, Engelter S, De Marchis GM, Lyrer P. Real-time video analysis allows the identification of large vessel occlusion in patients with suspected stroke: feasibility trial of a "telestroke" pathway in Northwestern Switzerland. Front Neurol 2023; 14:1232401. [PMID: 37941577 PMCID: PMC10627858 DOI: 10.3389/fneur.2023.1232401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023] Open
Abstract
Background and aim Loss of time is a major obstacle to efficient stroke treatment. Our telestroke path intends to optimize prehospital triage using a video link connecting ambulance personnel and a stroke physician. The objectives were as follows: (1) To identify patients suffering a stroke and (2) in particular large vessel occlusion (LVO) strokes as candidates for endovascular treatment. We have chosen the Rapid Arterial Occlusion Evaluation (RACE) scale for this purpose. Methods This analysis aimed to verify the feasibility of prehospital stroke identification by video assessment. In this prospective telestroke cohort study, we included 97 subjects, in which the RACE score (items: facial palsy, arm and leg motor function, head and gaze deviation, and aphasia or agnosia) was applied, and the assessment videotaped by a trained member of the Emergency Medical Services (EMS) in the field using a mobile device. Each recorded patient video was independently assessed by three experienced stroke physicians from a certified stroke center and compared to the neuroimaging gold standard. Within this feasibility study, the stroke code was not altered by the outcome of the RACE assessment, and all patients underwent the standard procedures within the emergency unit. Results We analyzed 97 patients (median age 78 years, 53% women), of whom 51 (52.6%) suffered an acute stroke, 12 (23.5%) of which were due to an LVO and 46 patients had symptoms mimicking a stroke. The sensitivity of stroke identification was 77.8%, and specificity was 53.6%. In regard to the identification of an LVO, sensitivity was 69.4% and specificity was 84.3%. The inter-rater agreement in the RACE-score assessment was ICC = 0.82 (intraclass-correlation coefficient). Conclusion These results confirm our hypothesis that the local telestroke concept is feasible. It allows correct (i) stroke and (ii) LVO identification in the majority of the cases and thus has the potential to assist in efficient prehospital triage.
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Affiliation(s)
- Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christoph Kenan Traenka
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Fabian Schaub
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Nussbaum
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Nickel
- Department of Emergency, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Patrick Hunziker
- Medical Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Marc Luethy
- Anaesthesiology, University Hospital Basel, Switzerland and Emergency Medical Service (EMS) Basel, Basel, Switzerland
| | - Sabine Schädelin
- Clinical Trial Unit, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Axel Ernst
- ICT Service and Support, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital St Gallen, St. Gallen, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel, University of Basel, Basel, Switzerland
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Ramos-Pachón A, Rodríguez-Luna D, Martí-Fàbregas J, Millán M, Bustamante A, Martínez-Sánchez M, Serena J, Terceño M, Vera-Cáceres C, Camps-Renom P, Prats-Sánchez L, Rodríguez-Villatoro N, Cardona-Portela P, Urra X, Solà S, del Mar Escudero M, Salvat-Plana M, Ribó M, Abilleira S, Pérez de la Ossa N, Silva Y. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol 2023; 80:1028-1036. [PMID: 37603325 PMCID: PMC10442788 DOI: 10.1001/jamaneurol.2023.2754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/05/2023] [Indexed: 08/22/2023]
Abstract
Importance Prehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown. Objective To determine the effect of direct transport to an endovascular treatment (EVT)-capable stroke center vs transport to the nearest local stroke center. Design, Setting, and Participants This was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field >4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022. Intervention Direct transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165). Main Outcomes and Measures The primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5. Results Of 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group. Conclusions and Relevance In this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH. Trial Registration ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Anna Ramos-Pachón
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Mònica Millán
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Marina Martínez-Sánchez
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | | | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Luis Prats-Sánchez
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Pere Cardona-Portela
- Stroke Unit, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Xabier Urra
- Stroke Unit, Hospital Clínic, and August Pi i Sunyer Biomedical Research Institute Barcelona, Barcelona, Spain
| | - Silvia Solà
- Sistema d’Emergències Mèdiques, Barcelona, Spain
| | | | - Mercè Salvat-Plana
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sònia Abilleira
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Yolanda Silva
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
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Ren Z, Wangqin R, Demiraj F, Li W, Mokin M, Wang A, Miao Z, Wang Y, Burgin WS. Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion. J Neurointerv Surg 2023:jnis-2023-020871. [PMID: 37734930 DOI: 10.1136/jnis-2023-020871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/27/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Early endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency department or mobile stroke unit, incorporating rapidly available non-contrast CT (NCCT) information with examination findings may improve the accuracy of arterial occlusion prediction scales. For this purpose, we developed a rapid and straightforward IVO predictive instrument-the T3AM2PA1 scale. METHODS The T3AM2PA1 scale was retrospectively derived from our 'Get with the Guidelines' database. We included all patients with acute stroke alert between January 2017 and August 2018 with a National Institutes of Health Stroke Scale (NIHSS) score between 5 and 25 inclusive. Different pre-intervention variables were collected, including itemized NIHSS and NCCT information. The T3AM2PA1 scale was also compared with other commonly used scales and was validated in a separate sequential retrospective cohort of patients with a full range of NIHSS scores. RESULTS 574 eligible patients from 2115 acute stroke alerts were identified. The scale was established with five items (CT hyperdense sign, parenchymal hypodensity, lateralizing hemiparesis, gaze deviation, and language disturbance), with a total score of 9. To minimize unnecessary angiography, a cut-off of ≥5 for IVO detection yielded a sensitivity of 52%, a specificity of 90%, and a positive predictive value of 76%. CONCLUSIONS The T3AM2PA1 scale accurately predicts the presence of clinical IVO in patients with AIS. Adopting the T3AM2PA1 scale could reduce revascularization times, improve treatment outcomes, and potentially reduce disability.
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Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, the Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Runqi Wangqin
- Duke Clinical Research Institute, Duke Univeristy Medical Center, Durham, North Carolina, USA
| | - Francis Demiraj
- Department of Neurology, FAU Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Weizhe Li
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Maxim Mokin
- Department of Neurosurgery and Neurology, University of South Florida, Tampa, Florida, USA
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Neurological Intervention, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China
| | - W Scott Burgin
- Department of Neurology, University of South Florida, Tampa, Florida, USA
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Gude M, Kirkegaard H, Blauenfeldt R, Behrndtz A, Mainz J, Riddervold I, Simonsen CZ, Hjort N, Johnsen SP, Andersen G, Valentin JB. Inter-Rater Agreement on Cincinnati Prehospital Stroke Scale (CPSS) and Prehospital Acute Stroke Severity Scale (PASS) Between EMS Providers, Neurology Residents and Neurology Consultants. Clin Epidemiol 2023; 15:957-968. [PMID: 37700930 PMCID: PMC10494913 DOI: 10.2147/clep.s418253] [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: 04/23/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023] Open
Abstract
Objective To examine the agreement between emergency medical service (EMS) providers, neurology residents and neurology consultants, using the Cincinnati Prehospital Stroke Scale (CPSS) and the Prehospital Acute Stroke Severity Scale (PASS). Methods Patients with stroke, transient ischemic attack (TIA) and stroke mimic were included upon primary stroke admission or during rehabilitation. Patients were included from June 2018 to September 2019. Video recordings were made of patients being assessed with CPSS and PASS. The recordings were later presented to the healthcare professionals. To determine relative and absolute interrater reliability in terms of inter-rater agreement (IRA), we used generalisability theory. Group-level agreement was determined against a gold standard and presented as an area under the curve (AUC). The gold standard was a consensus agreement between two neurology consultants. Results A total of 120 patient recordings were assessed by 30 EMS providers, two neurology residents and two neurology consultants. Using the CPSS and the PASS, a total of 1,800 assessments were completed by EMS providers, 240 by neurology residents and 240 by neurology consultants. The overall relative and absolute IRA for all items combined from the CPSS and PASS score was 0.84 (95% CI 0.80; 0.87) and 0.81 (95% CI 0.77; 0.85), respectively. Using the CPSS, the agreement on a group-level resulted in AUCs of 0.83 (95% CI 0.78; 0.88) for the EMS providers and 0.86 (95% CI 0.82; 0.90) for the neurology residents when compared with the gold standard. Using the PASS, the AUC was 0.82 (95% CI 0.77; 0.87) for the EMS providers and 0.88 (95% CI 0.84; 0.93) for the neurology residents. Conclusion The high relative and absolute inter-rater agreement underpins a high robustness/generalisability of the two scales. A high agreement exists across individual raters and different groups of healthcare professionals supporting widespread applicability of the stroke scales.
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Affiliation(s)
- Martin Gude
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region; and Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region; and Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rolf Blauenfeldt
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Behrndtz
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Mainz
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Claus Z Simonsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Hjort
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Grethe Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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van de Wijdeven RM, Duvekot MHC, van der Geest PJ, Moudrous W, Dorresteijn KRIS, Wijnhoud AD, Mulder LJMM, Alblas KCL, Asahaad N, Kerkhoff H, Dippel DWJ, Roozenbeek B. Determinants of door-in-door-out time in patients with ischaemic stroke transferred for endovascular thrombectomy. Eur Stroke J 2023; 8:667-674. [PMID: 37248995 PMCID: PMC10472962 DOI: 10.1177/23969873231177768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Long door-in-door-out (DIDO) times are an important cause of treatment delay in patients transferred for endovascular thrombectomy (EVT) from primary stroke centres (PSC) to an intervention centre. Insight in causes of prolonged DIDO times may facilitate process improvement interventions. We aimed to quantify different components of DIDO time and to identify determinants of DIDO time. METHODS We performed a retrospective cohort study in a Dutch ambulance region consisting of six PSCs and one intervention centre. We included consecutive adult patients with anterior circulation large vessel occlusion, transferred from a PSC for EVT between October 1, 2019 and November 31, 2020. We subdivided DIDO into several time components and quantified contribution of these components to DIDO time. We used univariable and multivariable linear regression models to explore associations between potential determinants and DIDO time. RESULTS We included 133 patients. Median (IQR) DIDO time was 66 (52-83) min. The longest component was CTA-to-ambulance notification time with a median (IQR) of 24 (16-37) min. DIDO time increased with age (6 min per 10 years, 95% CI: 2-9), onset-to-door time outside 6 h (20 min, 95% CI: 5-35), M2-segment occlusion (15 min, 95% CI: 4-26) and right-sided ischaemia (12 min, 95% CI: 2-21). CONCLUSIONS The CTA-to-ambulance notification time is the largest contributor to DIDO time. Higher age, onset-to-door time longer than 6 h, M2-segment occlusion and right-sided occlusions are independently associated with a longer DIDO time. Future interventions that aim to decrease DIDO time should take these findings into account.
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Affiliation(s)
| | - Martijne HC Duvekot
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Annemarie D Wijnhoud
- Department of Neurology, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Laus JMM Mulder
- Department of Neurology, Ikazia Hospital, Rotterdam, the Netherlands
| | - Kees CL Alblas
- Department of Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Nabil Asahaad
- Department of Neurology, Van Weel-Bethesda Hospital, Dirksland, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Galecio-Castillo M, Vivanco-Suarez J, Zevallos CB, Dajles A, Weng J, Farooqui M, Ribo M, Jovin TG, Ortega-Gutierrez S. Direct to angiosuite strategy versus standard workflow triage for endovascular therapy: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e17-e25. [PMID: 35710313 DOI: 10.1136/neurintsurg-2022-018895] [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] [Received: 03/07/2022] [Accepted: 05/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Reducing stroke workflow times when performing endovascular thrombectomy is associated with improvement in clinical outcomes. We compared outcomes among large vessel occlusion (LVO) stroke patients following the direct to angiosuite (DTAS) strategy versus standard workflow (SW) when undergoing endovascular therapy. METHODS We conducted a systematic review and meta-analysis to compare rates of functional outcomes, reperfusion, symptomatic intracranial hemorrhage (sICH) and stroke workflow metrics. We included observational studies and clinical trials that compared the DTAS strategy versus SW, and at least one outcome of interest was assessed. Clinical, methodological and statistical heterogeneity were measured, and a random-effects model was used. RESULTS 12 studies were included in the systematic review and 8 in the meta-analysis (n=2890). The DTAS strategy was associated with significant higher odds of good functional outcome at 90 days (47.3% vs 34.9%; OR 1.58, 95% CI 1.16 to 2.14) and a significant average reduction of door-to-puncture (mean differences (MD) -35.09, 95% CI -49.76 to -20.41) and door-to-reperfusion times (MD -32.88, 95% CI -50.75 to -15.01). We found no differences in sICH (OR 0.80, 95% CI 0.53 to 1.20), mortality (OR 1.00, 95% CI 0.60 to 1.67) or successful reperfusion rates (OR 1.37, 95% CI 0.82 to 2.29). Moreover, the DTAS strategy was associated with greater odds of dramatic clinical improvement at 24 hours (OR 1.79, 95% CI 1.15 to 2.79). CONCLUSION Patients undergoing the DTAS strategy had a significant reduction in door-to-puncture and door-to-reperfusion times. This resulted in an increased rate of early neurological and 90-day functional recovery without compromising safety in LVO patients undergoing endovascular thrombectomy.
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Affiliation(s)
| | - Juan Vivanco-Suarez
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Andres Dajles
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Julie Weng
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Marc Ribo
- Stroke Unit. Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Schröter N, Weiller A, Rijntjes M, Harloff A, Urbach H, Kukolja J, Bardutzky J, Weiller C, Beume LA. Identifying large vessel occlusion at first glance in telemedicine. J Neurol 2023; 270:4318-4325. [PMID: 37202605 PMCID: PMC10421816 DOI: 10.1007/s00415-023-11775-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Telemedicine has rapidly emerged as an important tool in emergency neurology. In particular, reliable biomarkers of large vessel occlusions (LVOs) are critically necessary in order to identify the need for in-hospital mechanical thrombectomy (MT). Based on pathophysiological factors, we propose that the presence of head and/or gaze deviation alone signifies cortical hypoperfusion and is therefore a highly sensitive marker for the presence of LVO. METHODS We retrospectively analyzed a cohort of 160 patients, examined via telemedicine and suspected to have had an acute stroke; this included patients with ischemic or hemorrhagic stroke, transient ischemic attack, and stroke mimics. An assessment of head and gaze deviation and NIHSS score evaluation was performed. In a second analysis, patients who only had ischemia in the anterior circulation (n = 110) were evaluated. RESULTS Head and/or gaze deviation alone was found to be a reliable marker of LVO (sensitivity: 0.66/specificity: 0.92), as well as a sound indicator for MT (0.82/0.91), in patients with suspected ischemic stroke. The performance of this indicator further improved when patients with ischemia in the anterior circulation only were assessed (LVO: 0.70/0.93; MT: 0.86/0.90). In both analyses, head and/or gaze deviation served as a better indicator for LVO or MT compared to the prevalence of motor deficits or aphasia. Of note, in patients who had ischemia in the anterior circulation, head and/or gaze deviation performed better than the NIHSS score as an indicator for MT. CONCLUSION These findings confirm that the presence of head and/or gaze deviation serves as a reliable biomarker in stroke-based telemedicine for the diagnosis of LVO, as well as a strong indicator for MT. Furthermore, this marker is just as reliable as the NIHSS score but easier to assess. We therefore suggest that any stroke patient who displays head and/or gaze deviation should immediately be scheduled for vessel imaging and subsequently transported to a MT-competent center.
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Affiliation(s)
- Nils Schröter
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Antonia Weiller
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
- Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Michel Rijntjes
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Juraj Kukolja
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of Neurology and Clinical Neurophysiology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Jürgen Bardutzky
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Cornelius Weiller
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Lena-Alexandra Beume
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
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31
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Qiu K, Wei K, Jia ZY, Liu S. Design and Validation of a Novel Evaluation Scale to Predict Inpatient Large Vessel Occlusion Strokes: Clinical Assessment Stroke Severity for Inpatient Scale. J Comput Assist Tomogr 2023; 47:806-810. [PMID: 37707412 DOI: 10.1097/rct.0000000000001476] [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: 06/03/2023]
Abstract
OBJECTIVES A large quantity of ischemic stroke events occur in patients hospitalized for non-stroke-related reason. No scale has been developed to identify the large vessel occlusion (LVO) among inpatient stroke alerts. We aimed to develop a novel evaluation scale to predict LVO from in-hospital stroke alerts. METHODS Data from consecutive in-hospital stroke alerts were analyzed at a single high volume stroke center between January 2016 and October 2020. We developed a predictive scale based on the first half of patients (training group) using multivariate logistic regression and evaluated it in the remaining half of patients (validation group) adopting receiver operating curve. Receiver operating characteristics of the scale were analyzed to evaluate its value for the detection of LVO. RESULTS A total of 243 patients were enrolled for further study, among them, 94 (38.7%) had confirmed LVO. Three risk factors independently predicted the presence of LVO: recent cardiac or pulmonary procedure (1 point), neurological deficit scale (≥1: 2 points), and history of atrial fibrillation (1 point). The CAPS scale was generated based on predictive factors and demonstrated highly effective discrimination in identifying the presence of LVO in the training group (area under curve = 0.956) and the validation group (area under curve = 0.940). When the score ≥2, CAPS scale showed 97.9% sensitivity, 79.2% specificity, 74.8% positive predictive value, and 98.3% negative predictive value for discriminating LVO. CONCLUSIONS CAPS scale was developed for identifying LVO among inpatient stroke alerts with high sensitivity and specificity, which may help to quickly prompt responses by appropriate stroke teams.
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Affiliation(s)
- Kai Qiu
- From the Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Ke Wei
- Department of Stroke Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Zhen-Yu Jia
- From the Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Sheng Liu
- From the Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
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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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Dekker L, Daems JD, Duvekot MHC, Nguyen TTM, Venema E, van Es ACGM, Rozeman AD, Moudrous W, Dorresteijn KRIS, Hensen JHJ, Bosch J, van Zwet EW, de Schryver ELLM, Kloos LMH, de Laat KF, Aerden LAM, van den Wijngaard IR, Dippel DWJ, Kerkhoff H, Wermer MJH, Roozenbeek B, Kruyt ND. Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies. Stroke 2023; 54:2279-2285. [PMID: 37465998 DOI: 10.1161/strokeaha.123.042644] [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] [Received: 01/26/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians. METHODS We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (rs) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference. RESULTS We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (rs=0.70 [95% CI, 0.68-0.72]). Concerning individual items, prehospital assessment of arm (rs=0.68) and leg (rs=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (rs=0.31), abnormal speech (rs=0.50), and gaze deviation (rs=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%). CONCLUSIONS The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.
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Affiliation(s)
- Luuk Dekker
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D., E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Esmee Venema
- Department of Public Health (J.D.D., E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine (E.V.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands
| | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - Walid Moudrous
- Department of Neurology (W.M.), Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Jan-Hein J Hensen
- Department of Radiology (J.-H.J.H.), Maasstad Hospital, Rotterdam, the Netherlands
| | - Jan Bosch
- Emergency Medical Services Hollands-Midden, Leiden, the Netherlands (J.B.)
| | - Erik W van Zwet
- Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, the Netherlands
| | - Els L L M de Schryver
- Department of Neurology, Alrijne Hospital, Leiderdorp, the Netherlands (E.L.L.M.d.S.)
| | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands (L.M.H.K.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, The Hague, the Netherlands (K.F.d.L.)
| | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis Hospital, Delft, the Netherlands (L.A.M.A.)
| | - Ido R van den Wijngaard
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., A.D.R., H.K.)
| | - Marieke J H Wermer
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands (M.J.H.W.)
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (L.D., T.T.M.N., I.R.v.d.W., M.J.H.W., N.D.K.), Leiden University Medical Center, the Netherlands
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Raha O, Hall C, Malik A, D'Anna L, Lobotesis K, Kwan J, Banerjee S. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ MEDICINE 2023; 2:e000407. [PMID: 37577026 PMCID: PMC10414072 DOI: 10.1136/bmjmed-2022-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/15/2023]
Abstract
Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.
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Affiliation(s)
- Oishik Raha
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Hall
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Abid Malik
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Lucio D'Anna
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Joseph Kwan
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Soma Banerjee
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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Lo BM, Carpenter CR, Ducey S, Gottlieb M, Kaji A, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med 2023; 82:e17-e64. [PMID: 37479410 DOI: 10.1016/j.annemergmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Maas WJ, van der Zee DJ, Lahr MMH, Bouma M, Buskens E, Uyttenboogaart M. 'Drive the doctor' for endovascular thrombectomy in a rural area: a simulation study. BMC Health Serv Res 2023; 23:778. [PMID: 37475023 PMCID: PMC10360278 DOI: 10.1186/s12913-023-09672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 06/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Patients who present in a primary stroke center (PSC) with ischemic stroke are usually transferred to a comprehensive stroke center (CSC) in case of a large vessel occlusion (LVO) for endovascular thrombectomy (EVT) treatment, the so-called 'drip-and-ship' (DS) model. The 'drive-the-doctor' (DD) model modifies the DS model by allowing mobile interventionalists (MIs) to transfer to an upgraded PSC acting as a thrombectomy capable stroke center (TSC), instead of transferring patients to a CSC. Using simulation we estimated time savings and impact on clinical outcome of DD in a rural region. METHODS Data from EVT patients in northern Netherlands was prospectively collected in the MR CLEAN Registry between July 2014 - November 2017. A Monte Carlo simulation model of DS patients served as baseline model. Scenarios included regional spread of TSCs, pre-hospital patient routing to 'the nearest PSC' or 'nearest TSC', MI's notification after LVO confirmation or earlier prehospital, and MI's transport modalities. Primary outcomes are onset to groin puncture (OTG) and predicted probability of favorable outcome (PPFO) (mRS 0-2). RESULTS Combining all scenarios OTG would be reduced by 28-58 min and PPFO would be increased by 3.4-7.1%. Best performing and acceptable scenario was a combination of 3 TSCs, prehospital patient routing based on the RACE scale, MI notification after LVO confirmation and MI's transfer by ambulance. OTG would reduce by 48 min and PPFO would increase by 5.9%. CONCLUSIONS A DD model is a feasible scenario to optimize acute stroke services for EVT eligible patients in rural regions. Key design decisions in implementing the DD model for a specific region are regional spread of TSCs, patient routing strategy, and MI's notification moment and transport modality.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands.
| | - Maarten M H Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc Bouma
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Tariq MB, Ali I, Salazar-Marioni S, Iyyangar AS, Azeem HM, Khose S, Lopez V, Abdelkhaleq R, McCullough LD, Sheth SA, Kim Y. Women With Large Vessel Occlusion Acute Ischemic Stroke Are Less Likely to Be Routed to Comprehensive Stroke Centers. J Am Heart Assoc 2023; 12:e029830. [PMID: 37462071 PMCID: PMC10382091 DOI: 10.1161/jaha.123.029830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/15/2023] [Indexed: 07/20/2023]
Abstract
Background Prehospital routing of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) to centers capable of performing endovascular therapy may improve clinical outcomes. Here, we explore whether distance to comprehensive stroke centers (CSCs), stroke severity, and sex are associated with direct-to-CSC prehospital routing in patients with LVO AIS. Methods and Results In this cross-sectional study, we identified consecutive patients with LVO AIS from a prospectively collected multihospital registry throughout the greater Houston area from January 2019 to June 2020. Primary outcome was prehospital routing to CSC and was compared between men and women using modified Poisson regression including age, sex, race or ethnicity, first in-hospital National Institutes of Health Stroke Scale score, travel time, and distances to the closest primary stroke center and CSC. Among 503 patients with LVO AIS, 413 (82%) were routed to CSCs, and women comprised 46% of the study participants. Women with LVO AIS compared with men were older (73 versus 65, P<0.01) and presented with greater National Institutes of Health Stroke Scale score (14 versus 12, P=0.01). In modified Poisson regression, women were 9% less likely to be routed to CSCs compared with men (adjusted relative risk [aRR], 0.91 [0.84-0.99], P=0.024) and distance to nearest CSC ≤10 miles was associated with 38% increased chance of routing to CSC (aRR, 1.38 [1.26-1.52], P<0.001). Conclusions Despite presenting with more significant stroke syndromes and living within comparable distance to CSCs, women with LVO AIS were less likely to be routed to CSCs compared with men. Further study of the mechanisms behind this disparity is needed.
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Affiliation(s)
- Muhammad Bilal Tariq
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Iman Ali
- Department of Neurology UTHealth McGovern Medical School Houston TX
| | | | | | - Hussain M Azeem
- Department of Neurology UTHealth McGovern Medical School Houston TX
| | - Swapnil Khose
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Victor Lopez
- Department of Neurosurgery Boston Medical Center Boston MA
| | | | - Louise D McCullough
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Sunil A Sheth
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Youngran Kim
- Department of Management, Policy and Community Health UTHealth School of Public Health Houston TX
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Yoshida Y, Hayashi Y, Shimada T, Hattori N, Tomita K, Miura RE, Yamao Y, Tateishi S, Iwadate Y, Nakada TA. Prehospital stroke-scale machine-learning model predicts the need for surgical intervention. Sci Rep 2023; 13:9135. [PMID: 37277424 DOI: 10.1038/s41598-023-36004-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/27/2023] [Indexed: 06/07/2023] Open
Abstract
While the development of prehospital diagnosis scales has been reported in various regions, we have also developed a scale to predict stroke type using machine learning. In the present study, we aimed to assess for the first time a scale that predicts the need for surgical intervention across stroke types, including subarachnoid haemorrhage and intracerebral haemorrhage. A multicentre retrospective study was conducted within a secondary medical care area. Twenty-three items, including vitals and neurological symptoms, were analysed in adult patients suspected of having a stroke by paramedics. The primary outcome was a binary classification model for predicting surgical intervention based on eXtreme Gradient Boosting (XGBoost). Of the 1143 patients enrolled, 765 (70%) were used as the training cohort, and 378 (30%) were used as the test cohort. The XGBoost model predicted stroke requiring surgical intervention with high accuracy in the test cohort, with an area under the receiver operating characteristic curve of 0.802 (sensitivity 0.748, specificity 0.853). We found that simple survey items, such as the level of consciousness, vital signs, sudden headache, and speech abnormalities were the most significant variables for accurate prediction. This algorithm can be useful for prehospital stroke management, which is crucial for better patient outcomes.
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Affiliation(s)
- Yoichi Yoshida
- Department of Neurosurgery, Chiba Municipal Kaihin Hospital, Chiba, Japan
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Hayashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Tadanaga Shimada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Noriyuki Hattori
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Keisuke Tomita
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Rie E Miura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
- SMART119 Inc., 7th Floor, Chiba Chuo Twin Building No. 2, 2-5-1 Chuo, Chiba, Japan
| | - Yasuo Yamao
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
- SMART119 Inc., 7th Floor, Chiba Chuo Twin Building No. 2, 2-5-1 Chuo, Chiba, Japan
| | - Shino Tateishi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
- SMART119 Inc., 7th Floor, Chiba Chuo Twin Building No. 2, 2-5-1 Chuo, Chiba, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan.
- SMART119 Inc., 7th Floor, Chiba Chuo Twin Building No. 2, 2-5-1 Chuo, Chiba, Japan.
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Rafiemanesh H, Barikro N, Karimi S, Sotoodehnia M, Jalali A, Baratloo A. The Rapid Arterial oCclusion Evaluation (RACE) scale accuracy for diagnosis of acute ischemic stroke in emergency department - A multicenter study. BMC Emerg Med 2023; 23:51. [PMID: 37226097 DOI: 10.1186/s12873-023-00825-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 05/17/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE It seems that the available data on performance of the Rapid Arterial oCclusion Evaluation (RACE) as a prehospital stroke scale for differentiating all AIS cases, not only large vessel occlusion (LVO), from the stroke mimics is lacking. As a result, we intend to evaluate the accuracy of the RACE criteria in diagnosing of AIS in patients transferred to the emergency department (ED). METHOD The present study was a diagnostic accuracy cross-sectional study during 2021 in Iran. The study population consist of all suspected acute ischemic stroke (AIS) patients who transferred to the ED by emergency medical services (EMS). A 3-part checklist consisting of the basic and demographic information of the patients, items related to the RACE scale, and the final diagnosis of the patients based on interpretation of patients' brain MRI was used for data collection. All data were entered in Stata 14 software. We used the ROC analysis to evaluate the diagnostic power of the test. RESULT In this study, data from 805 patients with the mean age of 66.9 ± 13.9 years were studied of whom 57.5% were males. Of all the patients suspected of stroke who transferred to the ED, 562 (69.8%) had a definite final diagnosis of AIS. The sensitivity and specificity of the RACE scale for the recommended cut-off point (score ≥ 5) were 50.18% and 92.18%, respectively. According to the Youden J index, the best cut-off point for this tool for differentiating AIS cases was a score > 2, at which sensitivity and specificity were 74.73% and 87.65%, respectively. CONCLUSION It seems that, the RACE scale is an accurate diagnostic tool to detect and screen AIS patients in ED, Of course, not at the previously suggested cut-off point (score ≥ 5), but at the score > 2.
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Affiliation(s)
- Hosein Rafiemanesh
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Alborz University of Medical Sciences, Karaj, Iran
| | - Negin Barikro
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Karimi
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Sotoodehnia
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Jalali
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Baratloo
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Almqvist T, Falk Delgado A, Sjöstrand C, Ahmed N, Berglund A, Eriksson E, Mazya MV. Impact of prehospital stroke triage implementation on patients with intracerebral hemorrhage. Ther Adv Neurol Disord 2023; 16:17562864231168278. [PMID: 37187462 PMCID: PMC10176564 DOI: 10.1177/17562864231168278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/18/2023] [Indexed: 05/17/2023] Open
Abstract
Background Little is known about how prehospital triage using large vessel occlusion (LVO) stroke prediction scales affects patients with intracerebral hemorrhage (ICH). Objectives We aimed to investigate whether the Stockholm Stroke Triage System (SSTS) implemented in 2017 has affected timing and outcomes of acute ICH neurosurgery, and to assess system triage accuracy for ICH with a neurosurgical indication or LVO thrombectomy. Design Observational cohort study. Methods In the Stockholm Region, we compared surgical timing, functional outcome, and death at 3 months in patients transported by code-stroke ground ambulance who had ICH neurosurgery, 2 years before versus 2 years after SSTS implementation. We also calculated triage precision metrics for treatment with either ICH neurosurgery or thrombectomy. Results A total of 36 patients undergoing ICH neurosurgery were included before SSTS implementation and 30 after. No significant difference was found in timing of neurosurgery [median 7.5 (4.9-20.7) versus 9.1 (6.1-12.5) h after onset], distribution of functional outcomes (median 4 versus 4), and death at 3 months [3/29 (9%) versus 5/35 (17%)] before versus after implementation, respectively. The SSTS routed a larger proportion of patients subsequently undergoing ICH neurosurgery directly to the comprehensive stroke center: 13/36 (36%) before versus 18/30 (60%) after implementation. Overall system triage accuracy for ICH neurosurgery or thrombectomy was high at 90%, with 92% specificity and 65% sensitivity. Conclusion The SSTS, initially designed for prehospital LVO stroke triage, routed more patients with neurosurgical indication for ICH directly to the comprehensive stroke center. This did not significantly affect surgical timing or outcomes.
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Affiliation(s)
- Tove Almqvist
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital,
Stockholm, Sweden
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neuroradiology, Karolinska
University Hospital, University Hospital
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital,
Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Annika Berglund
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Einar Eriksson
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Michael V. Mazya
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
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Sanjuan E, Pancorbo O, Santana K, Miñarro O, Sala V, Muchada M, Boned S, Juega JM, Pagola J, García-Tornel Á, Requena M, Rodríguez-Villatoro N, Rodríguez-Luna D, Deck M, Ribo M, Molina CA, Meler P, Romero V, Dalmases G, Rodríguez-Samaniego MT, Calleja L, Gutierrez T, Peña L, Gallego JC, Lorenzo E, Gonzalez Y, Moreno R, Rubiera M. Management of acute stroke. Specific nursing care and treatments in the stroke unit. Neurologia 2023:S2173-5808(23)00022-6. [PMID: 37120108 DOI: 10.1016/j.nrleng.2020.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/29/2020] [Indexed: 05/01/2023] Open
Abstract
OBJECTIVE This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.
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Affiliation(s)
- E Sanjuan
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - O Pancorbo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - K Santana
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - O Miñarro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Sala
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Muchada
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - S Boned
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J M Juega
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J Pagola
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Á García-Tornel
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Requena
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - N Rodríguez-Villatoro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - D Rodríguez-Luna
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Deck
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Ribo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - C A Molina
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - P Meler
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Romero
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - G Dalmases
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M T Rodríguez-Samaniego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Calleja
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - T Gutierrez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Peña
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J C Gallego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - E Lorenzo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Y Gonzalez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - R Moreno
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Rubiera
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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Ollikainen J, Jolma P, Pienimäki JP, Vuorinen P, Oksala N, Kimpimäki M, Grönroos M, Haula TM, Janhunen H, Pauniaho SL. Less is more - The Finnish Prehospital Stroke Scale prospective validation. J Stroke Cerebrovasc Dis 2023; 32:106996. [PMID: 36801497 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106996] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVES The current bifurcation of the acute stroke care pathway requires prehospital separation of strokes caused by large vessel occlusion. The first four binary items of the Finnish Prehospital Stroke Scale (FPSS) identify stroke in general, while the fifth binary item alone identifies stroke due to large vessel occlusion. The straightforward design is both easy for paramedics and statistically beneficial. We implemented FPSS based Western Finland Stroke Triage Plan, including medical districts of a comprehensive stroke center and four primary stroke centers. PATIENTS AND METHODS The prospective study population was consecutive recanalization candidates transported to the comprehensive stroke center within the first six months of implementing the stroke triage plan. Cohort 1 consisted of n=302 thrombolysis- or endovascular treatment candidates transported from the comprehensive stroke center hospital district. Cohort 2 comprised ten endovascular treatment candidates transferred directly to the comprehensive stroke center from the medical districts of four primary stroke centers. RESULTS In Cohort 1, FPSS sensitivity for large vessel occlusion was 0.66, specificity 0.94, positive predictive value 0.70, and negative predictive value 0.93. Of the ten Cohort 2 patients, nine had large vessel occlusion, and one had an intracerebral hemorrhage. CONCLUSIONS FPSS is straightforward enough to be implemented in primary care services to identify candidates for endovascular treatment and thrombolysis. When used by paramedics, it predicted two-thirds of large vessel occlusions with the highest specificity and positive predictive value reported to date.
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Affiliation(s)
- Jyrki Ollikainen
- Department of Neuroscience and Rehabilitation, Tampere University Hospital and University of Tampere, Tampere, Finland.
| | - Pasi Jolma
- Department of Neuroscience and Rehabilitation, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Juha-Pekka Pienimäki
- Vascular Centre, Tampere University Hospital, Tampere University Hospital, and the University of Tampere, Tampere, Finland
| | - Pauli Vuorinen
- Emergency Care Service, Prehospital Emergency Care Centre, Department of Emergency Care, Anesthesia and Pain Medicine Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Niku Oksala
- Vascular Centre, Tampere University Hospital, Tampere University Hospital, and the University of Tampere, Tampere, Finland; Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
| | | | | | | | | | - Satu-Liisa Pauniaho
- Department of Adolescent Psychiatry, Tampere University Hospital and University of Tampere, Tampere, Finland; Emergency Department, Tampere University Hospital, Tampere, Finland
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Farooqui M, Ikram A, Suriya S, Qeadan F, Bzdyra P, Quadri SA, Zafar A. Patterns of Care in Patients with Basilar Artery Occlusion (BAO): A Population-Based Study. Life (Basel) 2023; 13:life13030829. [PMID: 36983984 PMCID: PMC10053211 DOI: 10.3390/life13030829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Basilar artery occlusion (BAO) is associated with high morbidity and mortality. Endovascular therapy (EVT) has been shown to be beneficial in acute BAO patients. This retrospective observational study used the National Inpatient Sample (NIS) database to identify BAO patients using the International Classification of Diseases (ICD). Multivariable models were used to evaluate the association of risk factors, comorbidities, length of stay (LOS) in hospital, total cost, disposition, and transfer status. A total of 1120 (447 females, 39.95%) patients were identified, with a higher proportion of White individuals (66.8% vs. 57.6%), atrial fibrillation (31.5% vs. 17.2%; p < 0.0001), and peripheral vascular disease (21.2% vs. 13.7%; p = 0.009). A lower proportion of individuals with diabetes mellitus (32.1% vs. 39.5%; p = 0.05) was found in the EVT group. Majority of the patients (924/1120, 82.5%) were treated at the urban teaching facility, which also performed most of the EVT procedures (164, 89.13%), followed by non-academic urban (166, 14.8%) and rural (30, 2.7%) hospitals. Most patients (19/30, 63%) admitted to rural hospitals were transferred to other facilities. Urban academic hospitals also had the highest median LOS (8.9 days), cost of hospitalization (USD 117,261), and disposition to home (32.6%). This study observed distinct patterns and geographical disparities in the acute treatment of BAO patients. There is a need for national- and state-level strategies to improve access to stroke care.
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Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Asad Ikram
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Sajid Suriya
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM 87106, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Piotr Bzdyra
- Department of Neurology, St. Bernardine Medical Center, San Bernadino, CA 92404, USA
| | - Syed A Quadri
- Department of Neurology, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Atif Zafar
- Department of Neurology, St. Michael Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
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Balucani C, Levine SR, Sanossian N, Starkman S, Liebeskind D, Gornbein JA, Shkirkova K, Stratton S, Eckstein M, Hamilton S, Conwit R, Sharma LK, Saver JL. Neurologic Improvement in Acute Cerebral Ischemia: Frequency, Magnitude, Predictors, and Clinical Outcomes. Neurology 2023; 100:e1038-e1047. [PMID: 36878722 PMCID: PMC9990857 DOI: 10.1212/wnl.0000000000201656] [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: 01/27/2022] [Accepted: 10/20/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Investigations of rapid neurologic improvement (RNI) in patients with acute cerebral ischemia (ACI) have focused on RNI occurring after hospital arrival. However, with stroke routing decisions and interventions increasingly migrating to the prehospital setting, there is a need to delineate the frequency, magnitude, predictors, and clinical outcomes of patients with ACI with ultra-early RNI (U-RNI) in the prehospital and early postarrival period. METHODS We analyzed prospectively collected data of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized clinical trial. Any U-RNI was defined as improvement by 2 or more points on the Los Angeles Motor Scale (LAMS) score between the prehospital and early post-emergency department (ED) arrival examinations and classified as moderate (2-3 point) or dramatic (4-5 point) improvement. Outcome measures included excellent recovery (modified Rankin Scale [mRS] score 0-1) and death by 90 days. RESULTS Among the 1,245 patients with ACI, the mean age was 70.9 years (SD 13.2); 45% were women; the median prehospital LAMS was 4 (interquartile range [IQR] 3-5); the median last known well to ED-LAMS time was 59 minutes (IQR 46-80 minutes), and the median prehospital LAMS to ED-LAMS time was 33 minutes (IQR 28-39 minutes). Overall, any U-RNI occurred in 31%, moderate U-RNI in 23%, and dramatic U-RNI in 8%. Any U-RNI was associated with improved outcomes, including excellent recovery (mRS score 0-1) at 90 days 65.1% (246/378) vs 35.4% (302/852), p < 0.0001; decreased mortality by 90 days 3.7% (14/378) vs 16.4% (140/852), p < 0.0001; decreased symptomatic intracranial hemorrhage 1.6% (6/384) vs 4.6% (40/861), p = 0.0112; and increased likelihood of being discharged home 56.8% (218/384) vs 30.2% (260/861), p < 0.0001. DISCUSSION U-RNI occurs in nearly 1 in 3 ambulance-transported patients with ACI and is associated with excellent recovery and decreased mortality at 90 days. Accounting for U-RNI may be useful for routing decisions and future prehospital interventions. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov. Unique identifier: NCT00059332.
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Affiliation(s)
- Clotilde Balucani
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD.
| | - Steven R Levine
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Nerses Sanossian
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Sidney Starkman
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - David Liebeskind
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Jeffrey A Gornbein
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Kristina Shkirkova
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Samuel Stratton
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Marc Eckstein
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Scott Hamilton
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Robin Conwit
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Latisha K Sharma
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
| | - Jeffrey L Saver
- From the Department of Neurology (C.B.), Neurocritical Care Division, NYU Langone Medical Center, Bellevue Hospital, New York, NY; Department of Neurology (S.R.L.), The State University of New York Downstate Medical Center, Brooklyn, NY & the Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY; Department of Neurology and Emergency Medicine (S.R.L.), Kings County Hospital Center, Brooklyn, NY; Department of Neurology (N.S.), University of Southern California, Los Angeles, CA; Department of Emergency Medicine (Sidney Starkman), University of California, Los Angeles, CA; Stroke Center (Sidney Starkman, D.L., K.S., L.K.S., J.L.S.), Department of Neurology, University of California, Los Angeles, CA; Department of Biomathematics (J.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine (Samuel Stratton), Harbor-University of California, Los Angeles Medical Center, LA; Los Angeles EMS Agency (Samuel Stratton), Los Angeles, CA; Orange County EMS Agency (Samuel Stratton), Orange County, CA; Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles, CA; Los Angeles Fire Department (M.E.), Los Angeles, CA; Department of Neurology (S.H.), Stanford University, Stanford, CA; and National Institute of Neurological Disorders and Stroke (R.C.), National Institutes of Health, Bethesda, MD
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Gordon Perue G, Then R, Gayle F, Galav S, Thotamalla Y, Hepburn M, Rowe D, Suazo L, Villamán C, Manosalva H, Ortega-Gutierrez S, Yavagal D, Inoa V. Mission thrombectomy 2020 (MT2020+) surveys of Caribbean stroke services: A call for action in our region. J Neurol Sci 2023; 449:120640. [PMID: 37060622 DOI: 10.1016/j.jns.2023.120640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
Stroke is the leading cause of death and adult-onset disability in the Caribbean region. Despite the tremendous advances in acute stroke care in the past 25 years, treatment in the Caribbean lags stroke standards of care. Mission Thrombectomy 2020+ (MT2020+) is a metrics based global campaign focused on increasing access to organized stroke care and mechanical thrombectomy. We conducted two consecutive online surveys across the MT2020+ Caribbean Region assessing access to thrombolytics, mechanical thrombectomy and stroke centers. The first survey - Mechanical Thrombectomy Access-Caribbean sub-study, allowed a comparison between global services and those in the MT2020+ Caribbean region. This survey provided a snapshot of the current state of stroke centers worldwide and confirmed lower available stroke resources in the MT2020+ Caribbean Region which has one certified stroke center, and 9 mechanical thrombectomy capable centers. The second survey - MT2020+ Caribbean Region infrastructure survey - was designed to determine the availability of stroke resources that are key components of stroke care in participating hospitals. Key infrastructural components such as 24/7 computerized tomographic scanners, access to thrombolytic therapy and access to mechanical thrombectomy capable centers were scarce. There were low volumes of mechanical thrombectomy performed in the Caribbean compared to other countries around the world. Limited resources and inadequate stroke infrastructure remains a major challenge in the Caribbean. We advocate for governmental support and investment, public and private partnerships and legislation to increase access and availability to acute stroke treatments to allow for equal access to care for all Caribbean citizens.
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Affiliation(s)
- Gillian Gordon Perue
- Department of Neurology, University of Miami, Miami, FL, United States of America.
| | - Ryna Then
- Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | | | | | | | - Madihah Hepburn
- Summa Health Neurosciences & Stroke Center, Akron, OH, United States of America
| | | | - Luis Suazo
- Centro de Medicina Avanzada y Telemedicina, Dominican Republic
| | - Cosme Villamán
- Dept. Neurointervención Clínica Corominas y Corazones del Cibao, Dominican Republic
| | | | | | - Dileep Yavagal
- Department of Neurology and Neurosurgery, University of Miami, United States of America
| | - Violiza Inoa
- Semmes-Murphey Clinic, Memphis, Tennessee, University of Tennessee Health Science Center, Memphis, TN, United States of America
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Yuksen C, Tienpratarn W, Treerasoradaj T, Jenpanitpong C, Termkijwanich P. The Clinical Predictive Score for Prehospital Large Vessel Occlusion Stroke: A Retrospective Cohort Study in the Asian Country. Open Access Emerg Med 2023; 15:53-60. [PMID: 36798910 PMCID: PMC9925388 DOI: 10.2147/oaem.s398061] [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: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Background Large vessel occlusive (LVO) stroke causes severe disabilities and occurs in more than 37% of strokes. Reperfusion therapy is the gold standard of treatment. Studies proved that endovascular thrombectomy (EVT) is more beneficial and decreases mortality. This study aimed to evaluate the factor associated with LVO stroke in an Asian population and to develop the scores to predict LVO in a prehospital setting. The score will hugely contribute to the future of stroke care in prehospital settings in the aspect of transferal suspected LVO stroke patients to appropriate EVT-capable stroke centers. Methods This study was a retrospective cohort study using an exploratory model at the emergency department of Ramathibodi Hospital, Bangkok, Thailand, between January 2018 and December 2020. We included the stroke patients aged >18 who visit ED and an available radiologic report representing LVO. Those whose stroke onset was >24 hours and no radiologic report were excluded. Multivariable logistic regression analysis developed the prediction model and score for LVO stroke. Results A total of 252 patients met the inclusion criteria; 61 cases (24%) had LVO stroke. Six independent factors were significantly predictive: comorbidity with atrial fibrillation, clinical hemineglect, gaze deviation, facial palsy, aphasia, and cerebellar sign abnormality. The predicted score had an accuracy of 92.5%. The LVO risk score was categorized into three groups: low risk (LVO score <3), moderate risk (LVO score 3-6), and high risk (LVO score >6). The positive likelihood ratio to predicting LVO stroke were 0.12 (95% CI 0.06-0.26), 2.33 (95% CI 1.53-3.53) and 45.40 (95% CI 11.16-184.78), respectively. Conclusion The Large Vessel Occlusion (LVO) Risk Score provides a screening tool for predicting LVO stroke. A clinical predictive score of ≥3 appears to be associated with LVO stroke.
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Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Welawat Tienpratarn
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,Correspondence: Welawat Tienpratarn, Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand, Email
| | - Thitibud Treerasoradaj
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Phatcha Termkijwanich
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Lu Z, Xiong Y, Yang K, Gu H, Duan C, Zhao X, Meng X, Wang Y. What predicts large vessel occlusion in mild stroke patients? BMC Neurol 2023; 23:29. [PMID: 36658535 PMCID: PMC9850683 DOI: 10.1186/s12883-022-03020-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/09/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND PURPOSE Mild acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) may benefit from thrombolysis or thrombectomy therapy. However, the predictors for LVO in mild AIS patients have not been extensively explored. We aimed to investigate the predictors for LVO in mild AIS patients. METHODS We collected the data of consecutive AIS patients with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 from The Third China National Stroke Registry - a prospective nationwide registry of AIS or transient ischemic attack (TIA) patients in China from August 2015 to March 2018. Patients were divided into LVO and non-LVO group based on the vascular imaging during the hospitalization. Multivariable regression analyses involving clinical characteristics and NIHSS subitems was performed to detect the predictors for LVO. RESULT A total of 7653 mild AIS patients from The Third China National Stroke Registry were included in this study. Among them, 620 patients (8.1%) had LVO. The level of consciousness (adjusted odds ratio, 1.87; 95% confidence interval, 1.08 to 3.23), visual field (adjusted odds ratio, 2.10; 95% confidence interval, 1.43 to 3.06) and sensory (adjusted odds ratio, 0.75; 95% confidence interval, 0.60 to 0.94) were predictors for mild AIS patients with LVO. CONCLUSIONS Impaired LOC, visual field and sensory were independently predictors for LVO in mild stroke patients. Further studies are warranted to test these predictors in prehospital setting and in other population.
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Affiliation(s)
- Zhengzhao Lu
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunyun Xiong
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.510934.a0000 0005 0398 4153Chinese Institute for Brain Research, Beijing, China
| | - Kaixuan Yang
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Chunmiao Duan
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.24696.3f0000 0004 0369 153XDepartment of Neurology, Beijing Daxing District People’s Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.510934.a0000 0005 0398 4153Chinese Institute for Brain Research, Beijing, China ,grid.506261.60000 0001 0706 7839Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, 2019RU018, Beijing, China
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The PRESTO study: awareness of stroke symptoms and time from onset to intervention. Neurol Sci 2023; 44:229-236. [PMID: 36190685 DOI: 10.1007/s10072-022-06399-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/11/2022] [Indexed: 11/05/2022]
Abstract
Timely access to medical assistance is the first crucial step to improving clinical outcomes of stroke patients. Many educational campaigns have been organized with the purpose of making people aware of what a stroke is and what is necessary to do after its clinical onset. The PRESTO campaign was organized in Genoa (Italy) to spread easy messages regarding the management of the acute phase of stroke. Educational material was disseminated to educate people to call the emergency medical services as soon as symptoms appear. Data collected were analyzed in three different phases of the campaign: before the beginning, during, and after the end. We enrolled 1,132 patients with ischemic stroke admitted to hospital within 24 hours of symptoms onset. Our data showed a mild reduction in onset-to-door time (24 minutes) during the months following the end of the campaign and a slight increase in number of patients who arrived at hospitals, in particular with milder symptoms and transient ischemic attack, as opposed to the same period before the campaign. Interestingly, in the months after the end of the campaign, we observed a slight reduction of the percentage of patients who accessed hospitals after 4.5 hours from symptoms onset. In conclusion, our results may suggest that an informative campaign can be successful in making people rapidly aware of stroke onset, with the consequent rapid access to hospitals. Considering the changing of way of access to information, we think that an extensive multimedia campaign should be evaluated in the next future.
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Carbonera LA, Souza ACD, Rodrigues MDS, Mottin MD, Nogueira RG, Martins SCO. FAST-ED scale for prehospital triage of large vessel occlusion: results in the field. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:885-892. [PMID: 36261126 PMCID: PMC9770065 DOI: 10.1055/s-0042-1755536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is an extremely time-sensitive condition. The field triage of stroke patients should consider a careful balance between the best destination for the timely delivery of intravenous and/or endovascular reperfusion therapies. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale has been shown to have an accuracy comparable to that of the National Institutes of Health Stroke Scale (NIHSS). However, it has not been tested in the field. OBJECTIVE To evaluate the accuracy of the FAST-ED scale in the detection of AIS due to large vessel occlusion (LVO) in the prehospital setting. METHODS A cross-sectional study of consecutive prospective data collected from February 2017 to May 2019 in the city of Porto Alegre, state of Rio Grande do Sul, Southern Brazil, correlating the prehospital FAST-ED scale scores with the hospital diagnosis of LVO. Area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS In total, 74 patients were included in the analysis. As compared with the diagnosis of LVO upon hospital discharge, the prehospital FAST-ED scale applied by paramedics had a sensitivity of 80%, a specificity of 47.7%, a PPV of 51.1%, an NPV of 77.8%, and an AUC of 0.68 (95% confidence interval [95%CI]: 0.55-0.80). Among the patients with a final diagnosis of AIS, the accuracy was higher, with an AUC of 0.75 (95%CI: 0.60-0.89), a sensitivity of 80%, a specificity of 60%, a PPV of 80%, and an NPV of 60%. CONCLUSIONS In the present study, the FAST-ED scale, which was applied by paramedics in the field, demonstrated moderate accuracy but high sensitivity and NPV, which are essential attributes for a triage scale. While larger studies are still needed, these findings further support the use of the FAST-ED in stroke triage.
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Affiliation(s)
- Leonardo Augusto Carbonera
- Hospital de Clínicas de Porto Alegre, Grupo de Pesquisa em Neurologia Vascular, Departamento de Neurologia, Porto Alegre RS, Brazil.,Hospital Moinhos de Vento, Departamento de Neurologia e Neurocirurgia, Porto Alegre RS, Brazil.,Address for correspondence Leonardo Augusto Carbonera
| | - Ana Claudia de Souza
- Hospital de Clínicas de Porto Alegre, Grupo de Pesquisa em Neurologia Vascular, Departamento de Neurologia, Porto Alegre RS, Brazil.,Hospital Moinhos de Vento, Departamento de Neurologia e Neurocirurgia, Porto Alegre RS, Brazil.
| | | | | | - Raul Gomes Nogueira
- Emory University School of Medicine, Neurology Department, Atlanta, United States.
| | - Sheila Cristina Ouriques Martins
- Hospital de Clínicas de Porto Alegre, Grupo de Pesquisa em Neurologia Vascular, Departamento de Neurologia, Porto Alegre RS, Brazil.,Hospital Moinhos de Vento, Departamento de Neurologia e Neurocirurgia, Porto Alegre RS, Brazil.,Universidade Federal do Rio Grande do Sul, Departamento de Medicina Interna, Porto Alegre RS, Brazil.
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