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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. [PMID: 39371560 PMCID: PMC11362888 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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Stuby L, Suppan M, Desmettre T, Carrera E, Genoud M, Suppan L. A Two-Step Approach Using the National Health Institutes of Health Stroke Scale Assessed by Paramedics to Enhance Prehospital Stroke Detection: A Case Report and Concept Proposal. J Clin Med 2024; 13:5233. [PMID: 39274445 PMCID: PMC11396032 DOI: 10.3390/jcm13175233] [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: 07/10/2024] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Prehospital detection and triage of stroke patients mostly rely on the use of large vessel occlusion prediction scales to decrease onsite time. These quick but simplified scores, though useful, prevent prehospital providers from detecting posterior strokes and isolated symptoms such as limb ataxia or hemianopia. Case report: In the present case, an ambulance was dispatched to a 46-year-old man known for ophthalmic migraines and high blood pressure, who presented isolated visual symptoms different from those associated with his usual migraine attacks. Although the assessment advocated by the prehospital guideline was negative for stroke, the paramedic who assessed the patient was one of the few trained in the National Institutes of Health Stroke Scale assessment. Based on this assessment, the paramedic activated the fast-track stroke alarm and an ischemic stroke in the right temporal lobe was finally confirmed by magnetic resonance imaging. Discussion and conclusions: Current prehospital practice enables paramedics to detect anterior strokes but often limits the detection of posterior events or more subtle symptoms. Failure to identify such strokes delay or even forestall the initiation of thrombolytic therapy, thereby worsening patient outcomes. We therefore advocate a two-step prehospital approach: first, to avoid unnecessary delays, the prehospital stroke assessment should be carried out using a fast large vessel occlusion prediction scale; then, if this assessment is negative but potential stroke symptoms are present, a full National Institutes of Health Stroke Scale assessment could be performed to detect neurological deficits overlooked by the fast stroke scale.
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Affiliation(s)
- Loric Stuby
- Genève TEAM Ambulances, Emergency Medical Services, 1201 Geneva, Switzerland
| | - Mélanie Suppan
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
| | - Thibaut Desmettre
- Division of Emergency Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
| | - Emmanuel Carrera
- Stroke Center, Department of Neurology, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
| | - Matthieu Genoud
- Division of Emergency Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
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del Toro-Pérez C, Amaya-Pascasio L, Arjona-Padillo A, Martínez-Sánchez P. Impact of Direct Transport to Thrombectomy-Capable Center vs. Nearby/Distant Local Stroke Centers on Stroke Outcome in Patients Undergoing Thrombectomy: A Real-Life Study. J Pers Med 2024; 14:395. [PMID: 38673022 PMCID: PMC11050859 DOI: 10.3390/jpm14040395] [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: 03/13/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Our aim was to compare the stroke outcomes of a direct transfer (DT) to a thrombectomy-capable center vs. initial care at two local stroke centers: a nearby hospital (NH, 36 km) and a distant hospital (DH, 113 km). Patients who underwent a mechanical thrombectomy were analyzed (February 2017-October 2021), and the outcome was considered favorable if the modified Rankin scale (mRS) score was ≤ 2 at three months. A total of 300 patients were included, 55 of which were transferred from the NH and 58 from the DH. There was a difference in the median (IQR) transfer time of 39 min between the hospitals (149 min for the NH vs. 188 min for the DH, p = 0.003). After adjusting for confounding variables, a secondary transfer from the DH, compared to a DT, was associated with a lower functional independence: mRS score ≤ 2 (OR = 0.37, 95% CI = 0.14-0.97, p = 0.043), without significant differences in the mortality between the groups. These differences were not observed in patients from the NH. Conclusions: A secondary transfer from a distant hospital was associated with a poorer functional outcome at 3 months. This unfavorable outcome was not observed among patients transferred from a nearby hospital. These findings highlight the importance of categorizing the suitability of one transfer model over another based on the proximity of hospitals to the thrombectomy center, but also in accordance with organizational and geographic characteristics that vary within each health region.
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Affiliation(s)
- Cristina del Toro-Pérez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Laura Amaya-Pascasio
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Antonio Arjona-Padillo
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Patricia Martínez-Sánchez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
- Faculty of Health Sciences, CEINSA (Center of Health Research), University of Almería, 04120 Almería, Spain
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Colasurdo M, Chen H, Schrier C, Khalid M, Khunte M, Miller TR, Cherian J, Malhotra A, Gandhi D. Predictors for large vessel recanalization before stroke thrombectomy: the HALT score. J Neurointerv Surg 2024; 16:237-242. [PMID: 37100595 DOI: 10.1136/jnis-2023-020220] [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: 02/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Large vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis. METHODS In this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed. RESULTS 640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0-2) HALT scores. CONCLUSIONS IVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.
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Affiliation(s)
- Marco Colasurdo
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Huanwen Chen
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Chad Schrier
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mihir Khunte
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jacob Cherian
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Sanossian N, Fink E. What Will the Mobile Stroke Unit of the Future Look Like, and Will EEG Have a Role? Neurology 2023; 101:1085-1086. [PMID: 37848337 DOI: 10.1212/wnl.0000000000208047] [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: 08/01/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023] Open
Abstract
There have been major advances in prehospital evaluation and care of stroke patients in the past 2 decades. Because about half of patients experiencing stroke arrive to the emergency department (ED) by ambulance, emergency medical service providers are in a unique position to positively affect stroke outcomes. One development of great interest is the implementation of mobile stroke units (MSUs), large ambulances outfitted with mobile CT scanners, point-of-care laboratories, and access to clinical stroke expertise (either in-person or remotely).1.
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Affiliation(s)
- Nerses Sanossian
- From the Department of Neurology (N.S.), University of Southern California, Los Angeles; and Department of Neurology (E.F.), Houston Methodist Hospital, Baylor College of Medicine, TX
| | - Ezekiel Fink
- From the Department of Neurology (N.S.), University of Southern California, Los Angeles; and Department of Neurology (E.F.), Houston Methodist Hospital, Baylor College of Medicine, TX
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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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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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8
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Sveikata L, Melaika K, Wiśniewski A, Vilionskis A, Petrikonis K, Stankevičius E, Jurjans K, Ekkert A, Jatužis D, Masiliūnas R. Interactive Training of the Emergency Medical Services Improved Prehospital Stroke Recognition and Transport Time. Front Neurol 2022; 13:765165. [PMID: 35463146 PMCID: PMC9021450 DOI: 10.3389/fneur.2022.765165] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/24/2022] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Acute stroke treatment outcomes are predicated on reperfusion timeliness which can be improved by better prehospital stroke identification. We aimed to assess the effect of interactive emergency medical services (EMS) training on stroke recognition and prehospital care performance in a very high-risk cardiovascular risk population in Lithuania. Methods We conducted a single-center interrupted time-series study between March 1, 2019 and March 15, 2020. Two-hour small-group interactive stroke training sessions were organized for 166 paramedics serving our stroke network. We evaluated positive predictive value (PPV) and sensitivity for stroke including transient ischemic attack identification, onset-to-door time, and hospital-based outcomes during 6-months prior and 3.5 months after the training. The study outcomes were compared between EMS providers in urban and suburban areas. Results In total, 677 suspected stroke cases and 239 stroke chameleons (median age 75 years, 54.8% women) were transported by EMS. After the training, we observed improved PPV for stroke recognition (79.8% vs. 71.8%, p = 0.017) and a trend of decreased in-hospital mortality (7.8% vs. 12.3, p = 0.070). Multivariable logistic regression models adjusted for age, gender, EMS location, and stroke subtype showed an association between EMS stroke training and improved odds of stroke identification (adjusted odds ratio [aOR] 1.6 [1.1-2.3]) and onset-to-door ≤ 90 min (aOR 1.6 [1.1-2.5]). The improvement of PPV was observed in urban EMS (84.9% vs. 71.2%, p = 0.003), but not in the suburban group (75.0% vs. 72.6%, p = 0.621). Conclusions The interactive EMS training was associated with a robust improvement of stroke recognition, onset to hospital transport time, and a trend of decreased in-hospital mortality. Adapted training strategies may be needed for EMS providers in suburban areas. Future studies should evaluate the long-term effects of the EMS training and identify optimal retraining intervals.
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Affiliation(s)
- Lukas Sveikata
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Aleksandras Vilionskis
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
- Stroke Center, Republican Vilnius University Hospital, Vilnius, Lithuania
| | - Kȩstutis Petrikonis
- Department of Neurology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Edgaras Stankevičius
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kristaps Jurjans
- Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
- Department of Neurology, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Dalius Jatužis
- Center of Neurology, Vilnius University, Vilnius, Lithuania
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9
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Assessment of Neurological Status in Patients with Cerebrovascular Diseases through the Nursing Outcome Classification: A Methodological Study. NURSING REPORTS 2022; 12:152-163. [PMID: 35324562 PMCID: PMC8948868 DOI: 10.3390/nursrep12010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/09/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Nurses play an important role in healthcare, and the Nursing Outcomes Classification is a key tool for the standardization of care. This study aims to validate the nursing outcome “Neurological Status” for patients with cerebrovascular diseases. A methodological study was performed in four phases. In Phase 1, the relevance of the indicators was evaluated by seven specialists and the modified kappa coefficient and content validity index were calculated. In Phase 2, conceptual and operational definitions were formulated. In addition, their content was validated with a focus group in Phase 3. In Phase 4, the results were applied in clinical practice and convergence with the National Institute of Health Stroke Scale was verified. The reliability was measured by Cronbach’s alpha. Of the 22 initial indicators, 6 were excluded. The focus group suggested changes in the definitions and the exclusion of two indicators. In Phase 4, only 13 indicators were validated due to the impossibility of measuring intracranial pressure. A strong correlation between the two scales and agreement among all the indicators were observed. Following the specialists’ review, the nursing outcome was reliable and clinically validated with 13 indicators: consciousness, orientation, language, central motor control, cranial sensory and motor function, spinal sensory and motor function, body temperature, blood pressure, heart rate, eye movement pattern, pupil size, pupil reactivity, and breathing pattern.
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10
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Haight T, Tabaac B, Patrice KA, Phipps MS, Butler J, Johnson B, Aycock A, Toral L, Yarbrough KL, Schrier C, Lawrence E, Goldszmidt A, Marsh EB, Urrutia VC. The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke. Front Neurol 2021; 12:663472. [PMID: 34539541 PMCID: PMC8445030 DOI: 10.3389/fneur.2021.663472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min. Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window. Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed. Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time. Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.
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Affiliation(s)
- Taylor Haight
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Burton Tabaac
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kelly-Ann Patrice
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jaime Butler
- The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Anna Aycock
- Maryland Institute for Emergency Medical Services System (MIEMSS), Baltimore, MD, United States
| | - Linda Toral
- Sinai Hospital, Baltimore, MD, United States
| | | | - Chad Schrier
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Erin Lawrence
- Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | | | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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11
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Alijanpour S, Mostafazdeh-Bora M, Ahmadi Ahangar A. Different Stroke Scales; Which Scale or Scales Should Be Used? CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:1-21. [PMID: 33680393 PMCID: PMC7919174 DOI: 10.22088/cjim.12.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 02/01/2020] [Accepted: 02/12/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There has been a considerable development in the clinometric of stroke. But researchers are concerned that some scales are too generic, inherently and the insight may not be provided. The current study was conducted to determine which scale or scales should be used in stroke survivors. METHODS We selected 67 studies which were published between January 2010 and December 2018 from Up to date, CINAHL, ProQuest, Scopus, PubMed, Embase, Medline, Elsevier and Web of Science with MeSH terms. Inclusion criteria were: clinical trials, prospective studies, retrospective cohort studies, or cross-sectional studies; original research in adult human stroke survivors. We excluded the following articles: non-adult population; highly selected studies or treatment studies without incidence data; commentaries, single case reports, review article, editorials and non-English articles or articles without full text available. RESULTS Face Arm Speech Test and Cincinnati Pre-Hospital Stroke Scale scales because it was easy to learn and rapidly administer the recommended dose to use in pre-hospital, but there are not gold standard in stroke diagnosis in Pre-Hospital. National Institutes of Health Stroke Scale valuable in the acute stage for middle cerebral artery, not chronic or long term post stroke outcome. The Barthel Index scores for approximately three weeks could predict activities of daily living disabilities in 6 months. CONCLUSION Every scale has an advantage and a disadvantage and we were not able to introduce the gold standard for each item, but some special scales were used more in the studies, preferred for comparing with other studies to match the research results.
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Affiliation(s)
- Shayan Alijanpour
- Education, Research and Planning Unit, Pre-Hospital Emergency Organization and Emergency Medical Service Center, Babol University of Medical Sciences, Babol, Iran
- Student Research Committee, Faculty of Nursing and Midwifery, Isfahan University of Medical Science, Isfahan, Iran
| | | | - Alijan Ahmadi Ahangar
- Mobility Impairment Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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12
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Birnbaum L, Wampler D, Shadman A, de Leonni Stanonik M, Patterson M, Kidd E, Tovar J, Garza A, Blanchard B, Slesnick L, Blanchette A, Miramontes D. Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke. J Neurointerv Surg 2020; 13:505-508. [PMID: 32611621 DOI: 10.1136/neurintsurg-2020-016054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Numerous stroke severity scales have been published, but few have been studied with emergency medical services (EMS) in the prehospital setting. We studied the Vision, Aphasia, Neglect (VAN) stroke assessment scale in the prehospital setting for its simplicity to both teach and perform. This prospective prehospital cohort study was designed to validate the use and efficacy of VAN within our stroke systems of care, which includes multiple comprehensive stroke centers (CSCs) and EMS agencies. METHODS The performances of VAN and the National Institutes of Health Stroke Scale (NIHSS) ≥6 for the presence of both emergent large vessel occlusion (ELVO) alone and ELVO or any intracranial hemorrhage (ICH) combined were reported with positive predictive value, sensitivity, negative predictive value, specificity, and overall accuracy. For subjects with intraparenchymal hemorrhage, volume was calculated based on the ABC/2 formula and the presence of intraventricular hemorrhage was recorded. RESULTS Both VAN and NIHSS ≥6 were significantly associated with ELVO alone and with ELVO or any ICH combined using χ2 analysis. Overall, hospital NIHSS ≥6 performed better than prehospital VAN based on statistical measures. Of the 34 cases of intraparenchymal hemorrhage, mean±SD hemorrhage volumes were 2.5±4.0 mL for the five VAN-negative cases and 17.5±14.2 mL for the 29 VAN-positive cases. CONCLUSIONS Our VAN study adds to the published evidence that prehospital EMS scales can be effectively taught and implemented in stroke systems with multiple EMS agencies and CSCs. In addition to ELVO, prehospital scales such as VAN may also serve as an effective ICH bypass tool.
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Affiliation(s)
- Lee Birnbaum
- Neurosurgery, UTHSC at San Antonio, San Antonio, Texas, USA
| | - David Wampler
- Emergency Health Sciences, UTHSC at San Antonio, San Antonio, Texas, USA
| | - Arash Shadman
- Neurology, UTHSC at San Antonio, San Antonio, Texas, USA
| | | | - Michele Patterson
- Clinical Services, Saint Luke's Baptist Hospital, San Antonio, Texas, USA
| | - Emily Kidd
- Acadian Ambulance Service, San Antonio, Texas, USA
| | - Jeanette Tovar
- Neurosciences, University Hospital, San Antonio, Texas, USA
| | - Ashley Garza
- Neurosciences, University Hospital, San Antonio, Texas, USA
| | - Bonnie Blanchard
- Methodist Healthcare System of San Antonio Ltd, San Antonio, Texas, USA
| | - Lara Slesnick
- School of Medicine, UTHSC at San Antonio, San Antonio, Texas, USA
| | - Adam Blanchette
- Methodist Healthcare System of San Antonio Ltd, San Antonio, Texas, USA
| | - David Miramontes
- Emergency Health Sciences, UTHSC at San Antonio, San Antonio, Texas, USA
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13
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Comparison between stroke triage scale and emergency severity Index to triage patients with neurological Complaints: A randomized clinical trial. Int Emerg Nurs 2020; 53:100871. [PMID: 32312685 DOI: 10.1016/j.ienj.2020.100871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/17/2020] [Accepted: 03/30/2020] [Indexed: 11/24/2022]
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14
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Abstract
Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.
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Affiliation(s)
- Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3436] [Impact Index Per Article: 687.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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16
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Lawner BJ, Szabo K, Daly J, Foster K, McCoy P, Poliner D, Poremba M, Nawrocki PS, Rahangdale R. Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score. West J Emerg Med 2019; 21:441-448. [PMID: 32191202 PMCID: PMC7081843 DOI: 10.5811/westjem.2019.9.43127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol. Methods We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of “stroke/TIA,” “CVA,” or “neurological problem” were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score’s metrics were evaluated as a surrogate marker for a successful EMS triage protocol. Results We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%. Conclusion In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.
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Affiliation(s)
- Benjamin J Lawner
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania.,Temple University School of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Kelly Szabo
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Jonathan Daly
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Krista Foster
- University of Pittsburgh, Joseph M Katz Graduate School of Business, Pittsburgh, Pennsylvania
| | - Philip McCoy
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - David Poliner
- Penn Medicine, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Philadelphia, Pennsylvania
| | - Matthew Poremba
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania.,Temple University School of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Philip S Nawrocki
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Rahul Rahangdale
- University of Minnesota School of Medicine, Department of Neurology, Minneapolis, Minnesota
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17
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Tajaddini A, Phan TG, Beare R, Ma H, Srikanth V, Currie G, Vu HL. Application of Strategic Transport Model and Google Maps to Develop Better Clot Retrieval Stroke Service. Front Neurol 2019; 10:692. [PMID: 31316457 PMCID: PMC6611389 DOI: 10.3389/fneur.2019.00692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background and purpose: Two hubs are designated to provide endovascular clot retrieval (ECR) for the State of Victoria, Australia. In an earlier study, Google Maps application programming interface (API) was used to perform modeling on the combination of hospitals optimizing for catchment in terms of current traveling time and road conditions. It is not known if these findings would remain the same if the modeling was performed with a large-scale transport demand model such as Victorian Integrated Transport Model (VITM). This model is developed by the Victorian State Government Transport has the capability to forecast travel demand into the future including future road conditions which is not possible with a Google Maps based applications. The aim of this study is to compare the travel time to potential ECR hubs using both VITM and the Google Maps API and model stability in the next 5 and 10 years. Methods: The VITM was used to generate travel time from randomly generated addresses to four existing ECR capable hubs in Melbourne city, Australia (i.e., Royal Melbourne Hospital/RMH, Monash Medical Center/MMC, Alfred Hospital/ALF, and Austin Hospital/AUS) and the optimal service boundaries given a delivering time threshold are then determined. Results: The strategic transport model and Google map methods were similar with the R2 of 0.86 (peak and off peak) and the Nash-Sutcliffe model of efficiency being 0.83 (peak) and 0.76 (off-peak travel). Futures modeling using VITM found that this proportion decreases to 82% after 5 years and 80% after 10 years. The combination of RMH and ALF provides coverage for 74% of cases, 68% by 5 years, and 66% by 10 years. The combination of RMH and AUS provides coverage for 70% of cases in the base case, 65% at 5 years, and 63% by 10 years. Discussion: The results from strategic transport model are similar to those from Google Maps. In this paper we illustrate how this method can be applied in designing and forecast stroke service model in different cities in Australia and around the world.
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Affiliation(s)
- Atousa Tajaddini
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| | - Thanh G Phan
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Henry Ma
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Graham Currie
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| | - Hai L Vu
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
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18
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Venema E, Duvekot MHC, Lingsma HF, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, van der Lugt A, Kerkhoff H, Dippel DWJ, Roozenbeek B. Prehospital triage of patients with suspected stroke symptoms (PRESTO): protocol of a prospective observational study. BMJ Open 2019; 9:e028810. [PMID: 31289083 PMCID: PMC6615792 DOI: 10.1136/bmjopen-2018-028810] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting. METHODS AND ANALYSIS Prehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve. ETHICS AND DISSEMINATION The Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients. TRIAL REGISTRATION NUMBER NTR7595.
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Affiliation(s)
- Esmee Venema
- Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Martijne H C Duvekot
- Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Hester F Lingsma
- Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Anouk D Rozeman
- Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Walid Moudrous
- Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Marileen Biekart
- Ambulance Service Rotterdam-Rijnmond, Barendrecht, The Netherlands
| | - Aad van der Lugt
- Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Henk Kerkhoff
- Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Bob Roozenbeek
- Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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19
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Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, Khalessi AA, Bushnell C, Barsan WG, Panagos P, Alberts MJ, Tiner AC, Schwamm LH, Jauch EC. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. Stroke 2019; 50:e187-e210. [PMID: 31104615 DOI: 10.1161/str.0000000000000173] [Citation(s) in RCA: 225] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.
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20
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Nalleballe K, Sharma R, Kovvuru S, Brown A, Sheng S, Gundapaneni S, Ranabothu S, Veerapaneni P, Joiner R, Kapoor N, Culp W, Onteddu S. Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network? J Telemed Telecare 2019; 26:317-321. [PMID: 30741084 DOI: 10.1177/1357633x18824518] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to determine reasons for not giving intravenous tissue plasminogen activator to eligible patients with acute ischemic stroke in a telestroke network. METHODS We performed a retrospective analysis of prospectively collected data of patients who were seen as a telestroke consultation during 2015 and 2016 with the Arkansas Stroke Assistance through Virtual Emergency Support programme for possible acute ischemic stroke. RESULTS Total consultations seen were 809 in 2015 and 744 in 2016, out of which 238 patients in 2015 and 247 patients in 2016 received intravenous tissue plasminogen activator. In 2015 and 2016, out of the remaining 571 and 497 patients, 294 and 200 patients respectively were thought to be cases of acute stroke based on clinical evaluation. The most common reasons for not being treated in 2015 and 2016, respectively, were; (a) minimal deficits in 42.17% and 49.5% cases, (b) falling out of the 4.5-hour time window in 22.44% and 22% cases, (c) patient/next of kin refusal in 18.02% and 16.5% cases. Less common reasons included limited functional status, abnormal labs (thrombocytopenia, elevated international normalised ratio (INR)/prothrombin time (PT)/partial thromboplastin time (PTT), hypo or hyperglycemia etc), recent surgery and symptoms being too severe etc. CONCLUSION 'Minimal deficits' and 'out of time window' continue to be the major causes for not receiving thrombolysis during acute ischemic stroke in both traditional and telestroke systems. Patient/next of kin refusal was high in our telestroke system when compared to traditional practices. Considering the increasing utility of telestroke this needs to be further looked into, along with the ways to address it.
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Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Sukanthi Kovvuru
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, USA.,Department of Radiology, University of Arkansas for Medical Sciences, USA
| | - Sen Sheng
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | | | - Saritha Ranabothu
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | | | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, USA
| | - William Culp
- Department of Radiology, University of Arkansas for Medical Sciences, USA
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, USA
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21
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DiBiasio EL, Jayaraman MV, Oliver L, Paolucci G, Clark M, Watkins C, DeLisi K, Wilks A, Yaghi S, Hemendinger M, Baird GL, Oostema JA, McTaggart RA. Emergency medical systems education may improve knowledge of pre-hospital stroke triage protocols. J Neurointerv Surg 2018; 12:370-373. [DOI: 10.1136/neurintsurg-2018-014108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/10/2018] [Accepted: 07/18/2018] [Indexed: 11/04/2022]
Abstract
BackgroundFollowing the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs.PurposeWe developed a single-session training curriculum for EMS personnel focused on the Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate in the field, and our state-wide EMS stroke protocol. We assessed the effect of our training on EMS knowledge.MethodsWe assembled a focus group to develop a training curriculum and assessment questions that would mimic real-life conditions under which EMS personnel operate. Ten questions were formulated to assess content knowledge before and after training, and scores were compared using generalized mixed models.ResultsTraining was provided for 179 EMS providers throughout the state.Average pre-test score was 52.4% (95% CI 49% to 56%). Average post-test score was 85.6% (83%–88%, P<0.0001). Each of the 10 questions was individually assessed and all showed significant gains in EMS knowledge after training (P<0.0001).ConclusionsA brief educational intervention results in substantial improvements in EMS knowledge of prehospital stroke severity scales and severity-based field triage protocols. Further study is needed to establish whether these gains in knowledge result in improved real-world performance.
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22
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Nalleballe K, Sharma R, Brown A, Joiner R, Kapoor N, Morgan T, Benton T, Williamson C, Culp W, Lowery C, Onteddu S. Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt. J Telemed Telecare 2018; 26:174-179. [PMID: 30352525 DOI: 10.1177/1357633x18805661] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time. Methods We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN). Results The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients. Conclusions Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.
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Affiliation(s)
- Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Rohan Sharma
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA.,Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Renee Joiner
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tiffany Morgan
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tina Benton
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Conelia Williamson
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - William Culp
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA.,Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Curtis Lowery
- Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Sanjeeva Onteddu
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, USA
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23
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Beume LA, Hieber M, Kaller CP, Nitschke K, Bardutzky J, Urbach H, Weiller C, Rijntjes M. Large Vessel Occlusion in Acute Stroke. Stroke 2018; 49:2323-2329. [DOI: 10.1161/strokeaha.118.022253] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
To date, no clinical score has become widely accepted as an eligible prehospital marker for large vessel occlusion (LVO) and the need of mechanical thrombectomy (MT) in ischemic stroke. On the basis of pathophysiological considerations, we propose that cortical symptoms such as aphasia and neglect are more sensitive indicators for LVO and MT than motor deficits.
Methods—
We, thus, retrospectively evaluated a consecutive cohort of 543 acute stroke patients including patients with ischemia in the posterior circulation, hemorrhagic stroke, transient ischemic attack, and stroke mimics to best represent the prehospital setting.
Results—
Cortical symptoms alone showed to be a reliable indicator for LVO (sensitivity: 0.91; specificity: 0.70) and MT (sensitivity: 0.90; specificity: 0.60) in acute stroke patients, whereas motor deficits showed a sensitivity of 0.85 for LVO (specificity: 0.53) and 0.87 for MT (specificity: 0.48).
Conclusions—
We propose that in the prehospital setting, the presence of cortical symptoms is a reliable indicator for LVO and its presence justifies transportation to an MT-capable center.
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Affiliation(s)
- Lena-Alexandra Beume
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
- Freiburg Brain Imaging Center (L.-A.B., M.H., C.P.K., K.N., C.W., M.R.), Medical Center, University of Freiburg, Germany
- BrainLinks-BrainTools Cluster of Excellence (L.-A.B., M.H., C.P.K., K.N., C.W.), Medical Center, University of Freiburg, Germany
| | - Maren Hieber
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
- Freiburg Brain Imaging Center (L.-A.B., M.H., C.P.K., K.N., C.W., M.R.), Medical Center, University of Freiburg, Germany
- BrainLinks-BrainTools Cluster of Excellence (L.-A.B., M.H., C.P.K., K.N., C.W.), Medical Center, University of Freiburg, Germany
| | - Christoph P. Kaller
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
- Freiburg Brain Imaging Center (L.-A.B., M.H., C.P.K., K.N., C.W., M.R.), Medical Center, University of Freiburg, Germany
- BrainLinks-BrainTools Cluster of Excellence (L.-A.B., M.H., C.P.K., K.N., C.W.), Medical Center, University of Freiburg, Germany
| | - Kai Nitschke
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
- Freiburg Brain Imaging Center (L.-A.B., M.H., C.P.K., K.N., C.W., M.R.), Medical Center, University of Freiburg, Germany
- BrainLinks-BrainTools Cluster of Excellence (L.-A.B., M.H., C.P.K., K.N., C.W.), Medical Center, University of Freiburg, Germany
| | - Juergen Bardutzky
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology (H.U.), Medical Center, University of Freiburg, Germany
| | - Cornelius Weiller
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
- Freiburg Brain Imaging Center (L.-A.B., M.H., C.P.K., K.N., C.W., M.R.), Medical Center, University of Freiburg, Germany
- BrainLinks-BrainTools Cluster of Excellence (L.-A.B., M.H., C.P.K., K.N., C.W.), Medical Center, University of Freiburg, Germany
| | - Michel Rijntjes
- From the Department of Neurology and Neuroscience (L.-A.B., M.H., C.P.K., K.N., J.B., C.W., M.R.), Medical Center, University of Freiburg, Germany
- Freiburg Brain Imaging Center (L.-A.B., M.H., C.P.K., K.N., C.W., M.R.), Medical Center, University of Freiburg, Germany
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24
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Prehospital Prediction of Large Vessel Occlusion in Suspected Stroke Patients. Curr Atheroscler Rep 2018; 20:34. [DOI: 10.1007/s11883-018-0734-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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25
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Richards CT, Huebinger R, Tataris KL, Weber JM, Eggers L, Markul E, Stein-Spencer L, Pearlman KS, Holl JL, Prabhakaran S. Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke. PREHOSP EMERG CARE 2018; 22:312-318. [PMID: 29297717 PMCID: PMC6133654 DOI: 10.1080/10903127.2017.1387629] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. METHODS Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. RESULTS Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58-81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6-10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3-14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). CONCLUSIONS A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Chicago EMS/Region XI EMS System, Chicago, Illinois
| | - Ryan Huebinger
- Department of Emergency Medicine, University of Alabama-Birmingham, Birmingham, Alabama, Chicago, Illinois
| | - Katie L. Tataris
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joseph M. Weber
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Department of Emergency Medicine, John H. Stroger, Jr., Hospital of Cook County, Chicago, Illinois
| | - Laura Eggers
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Eddie Markul
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Department of Emergency Medicine, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Leslee Stein-Spencer
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Chicago Fire Department, City of Chicago, Chicago, Illinois
| | - Kenneth S. Pearlman
- Department of Emergency Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Chicago EMS/Region XI EMS System, Chicago, Illinois
| | - Jane L. Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Shyam Prabhakaran
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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Noorian AR, Sanossian N, Shkirkova K, Liebeskind DS, Eckstein M, Stratton SJ, Pratt FD, Conwit R, Chatfield F, Sharma LK, Restrepo L, Valdes-Sueiras M, Kim-Tenser M, Starkman S, Saver JL. Los Angeles Motor Scale to Identify Large Vessel Occlusion: Prehospital Validation and Comparison With Other Screens. Stroke 2018; 49:565-572. [PMID: 29459391 DOI: 10.1161/strokeaha.117.019228] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/14/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Prehospital scales have been developed to identify patients with acute cerebral ischemia (ACI) because of large vessel occlusion (LVO) for direct routing to Comprehensive Stroke Centers (CSCs), but few have been validated in the prehospital setting, and their impact on routing of patients with intracranial hemorrhage has not been delineated. The purpose of this study was to validate the Los Angeles Motor Scale (LAMS) for LVO and CSC-appropriate (LVO ACI and intracranial hemorrhage patients) recognition and compare the LAMS to other scales. METHODS The performance of the LAMS, administered prehospital by paramedics to consecutive ambulance trial patients, was assessed in identifying (1) LVOs among all patients with ACI and (2) CSC-appropriate patients among all suspected strokes. Additionally, the LAMS administered postarrival was compared concurrently with 6 other scales proposed for paramedic use and the full National Institutes of Health Stroke Scale. RESULTS Among 94 patients, age was 70 (±13) and 49% female. Final diagnoses were ACI in 76% (because of LVO in 48% and non-LVO in 28%), intracranial hemorrhage in 19%, and neurovascular mimic in 5%. The LAMS administered by paramedics in the field performed moderately well in identifying LVO among patients with ACI (C statistic, 0.79; accuracy, 0.72) and CSC-appropriate among all suspected stroke transports (C statistic, 0.80; accuracy, 0.72). When concurrently performed in the emergency department postarrival, the LAMS showed comparable or better accuracy versus the 7 comparator scales, for LVO among ACI (accuracies LAMS, 0.70; other scales, 0.62-0.68) and CSC-appropriate (accuracies LAMS, 0.73; other scales, 0.56-0.73). CONCLUSIONS The LAMS performed in the field by paramedics identifies LVO and CSC-appropriate patients with good accuracy. The LAMS performs comparably or better than more extended prehospital scales and the full National Institutes of Health Stroke Scale.
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Affiliation(s)
- Ali Reza Noorian
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.).
| | - Nerses Sanossian
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Kristina Shkirkova
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - David S Liebeskind
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Marc Eckstein
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Samuel J Stratton
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Franklin D Pratt
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Robin Conwit
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Fiona Chatfield
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Latisha K Sharma
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Lucas Restrepo
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Miguel Valdes-Sueiras
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - May Kim-Tenser
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Sidney Starkman
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
| | - Jeffrey L Saver
- From the Department of Neurology, Kaiser Permanente Orange County, Anaheim, CA (A.R.N.); Department of Neurology, University of Southern California, Los Angeles (N.S., M.K.-T.); Department of Emergency Medicine and Neurology (S.J.S., S.S.), Department of Emergency (F.D.P.), Department of Neurology (A.R.N., K.S., D.S.L., L.K.S., L.R., M.V.-S., J.L.S.), and Department of Biomathematics (J.G.), University of California, Los Angeles; Los Angeles EMS Agency, Orange County EMS Agency, Santa Ana, CA (S.J.S.); Department of Emergency Medicine, Keck School of Medicine of the University of Southern California and Los Angeles Fire Department (M.E.); Los Angeles County Department of Public Health, CA (F.D.P.); National Institutes of Health, National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); and Stanford University, CA (S.H.)
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e46-e110. [PMID: 29367334 DOI: 10.1161/str.0000000000000158] [Citation(s) in RCA: 3525] [Impact Index Per Article: 587.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates. METHODS Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format. RESULTS These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. CONCLUSIONS These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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28
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Chartrain AG, Kellner CP, Mocco J. Pre-hospital detection of acute ischemic stroke secondary to emergent large vessel occlusion: lessons learned from electrocardiogram and acute myocardial infarction. J Neurointerv Surg 2018; 10:549-553. [PMID: 29298860 DOI: 10.1136/neurintsurg-2017-013428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 11/03/2022]
Abstract
Currently, there is no device capable of detecting acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO) in the pre-hospital setting. The inability to reliably identify patients that would benefit from primary treatment with endovascular thrombectomy remains an important limitation to optimizing emergency medical services (EMS) triage models and time-to-treatment. Several clinical grading scales that rely solely on clinical examination have been proposed and have demonstrated only moderate predictive ability for ELVO. Consequently, a technology capable of detecting ELVO in the pre-hospital setting would be of great benefit. An analogous scenario existed decades ago, in which pre-hospital detection of acute myocardial infarction (AMI) was unreliable until the emergence of the 12-lead ECG and its adoption by EMS providers. This review details the implementation of pre-hospital ECG (PHECG) for the detection of AMI and explores how early experience with PHECG may be applied to ELVO detection devices, once they become available.
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Affiliation(s)
| | | | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
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29
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Richards CT, Wang B, Markul E, Albarran F, Rottman D, Aggarwal NT, Lindeman P, Stein-Spencer L, Weber JM, Pearlman KS, Tataris KL, Holl JL, Klabjan D, Prabhakaran S. Identifying Key Words in 9-1-1 Calls for Stroke: A Mixed Methods Approach. PREHOSP EMERG CARE 2017; 21:761-766. [PMID: 28661784 DOI: 10.1080/10903127.2017.1332124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Identifying stroke during a 9-1-1 call is critical to timely prehospital care. However, emergency medical dispatchers (EMDs) recognize stroke in less than half of 9-1-1 calls, potentially due to the words used by callers to communicate stroke signs and symptoms. We hypothesized that callers do not typically use words and phrases considered to be classical descriptors of stroke, such as focal neurologic deficits, but that a mixed-methods approach can identify words and phrases commonly used by 9-1-1 callers to describe acute stroke victims. METHODS We performed a mixed-method, retrospective study of 9-1-1 call audio recordings for adult patients with confirmed stroke who were transported by ambulance in a large urban city. Content analysis, a qualitative methodology, and computational linguistics, a quantitative methodology, were used to identify key words and phrases used by 9-1-1 callers to describe acute stroke victims. Because a caller's level of emotional distress contributes to the communication during a 9-1-1 call, the Emotional Content and Cooperation Score was scored by a multidisciplinary team. RESULTS A total of 110 9-1-1 calls, received between June and September 2013, were analyzed. EMDs recognized stroke in 48% of calls, and the emotional state of most callers (95%) was calm. In 77% of calls in which EMDs recognized stroke, callers specifically used the word "stroke"; however, the word "stroke" was used in only 38% of calls. Vague, non-specific words and phrases were used to describe stroke victims' symptoms in 55% of calls, and 45% of callers used distractor words and phrases suggestive of non-stroke emergencies. Focal neurologic symptoms were described in 39% of calls. Computational linguistics identified 9 key words that were more commonly used in calls where the EMD identified stroke. These words were concordant with terms identified through qualitative content analysis. CONCLUSIONS Most 9-1-1 callers used vague, non-specific, or distractor words and phrases and infrequently provide classic stroke descriptions during 9-1-1 calls for stroke. Both qualitative and quantitative methodologies identified similar key words and phrases associated with accurate EMD stroke recognition. This study suggests that tools incorporating commonly used words and phrases could potentially improve EMD stroke recognition.
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