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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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van de Wijdeven RM, Duvekot MHC, van der Geest PJ, Moudrous W, Dorresteijn KRIS, Wijnhoud AD, Mulder LJMM, Alblas KCL, Asahaad N, Kerkhoff H, Dippel DWJ, Roozenbeek B. Determinants of door-in-door-out time in patients with ischaemic stroke transferred for endovascular thrombectomy. Eur Stroke J 2023; 8:667-674. [PMID: 37248995 PMCID: PMC10472962 DOI: 10.1177/23969873231177768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Long door-in-door-out (DIDO) times are an important cause of treatment delay in patients transferred for endovascular thrombectomy (EVT) from primary stroke centres (PSC) to an intervention centre. Insight in causes of prolonged DIDO times may facilitate process improvement interventions. We aimed to quantify different components of DIDO time and to identify determinants of DIDO time. METHODS We performed a retrospective cohort study in a Dutch ambulance region consisting of six PSCs and one intervention centre. We included consecutive adult patients with anterior circulation large vessel occlusion, transferred from a PSC for EVT between October 1, 2019 and November 31, 2020. We subdivided DIDO into several time components and quantified contribution of these components to DIDO time. We used univariable and multivariable linear regression models to explore associations between potential determinants and DIDO time. RESULTS We included 133 patients. Median (IQR) DIDO time was 66 (52-83) min. The longest component was CTA-to-ambulance notification time with a median (IQR) of 24 (16-37) min. DIDO time increased with age (6 min per 10 years, 95% CI: 2-9), onset-to-door time outside 6 h (20 min, 95% CI: 5-35), M2-segment occlusion (15 min, 95% CI: 4-26) and right-sided ischaemia (12 min, 95% CI: 2-21). CONCLUSIONS The CTA-to-ambulance notification time is the largest contributor to DIDO time. Higher age, onset-to-door time longer than 6 h, M2-segment occlusion and right-sided occlusions are independently associated with a longer DIDO time. Future interventions that aim to decrease DIDO time should take these findings into account.
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Affiliation(s)
| | - Martijne HC Duvekot
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Annemarie D Wijnhoud
- Department of Neurology, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Laus JMM Mulder
- Department of Neurology, Ikazia Hospital, Rotterdam, the Netherlands
| | - Kees CL Alblas
- Department of Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Nabil Asahaad
- Department of Neurology, Van Weel-Bethesda Hospital, Dirksland, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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3
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Bösel J, Hubert GJ, Jesser J, Möhlenbruch MA, Ringleb PA. Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion. Neurol Res Pract 2023; 5:19. [PMID: 37198694 DOI: 10.1186/s42466-023-00245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for. AIM This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO. METHOD The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels. RESULTS This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care. CONCLUSIONS The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Gordian J Hubert
- TEMPiS Telestroke Center, Department of Neurology, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Munich, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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4
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Behrndtz A, Beare R, Iievlieva S, Andersen G, Mainz J, Gude M, Ma H, Srikanth V, Simonsen CZ, Phan T. Can Helicopters Solve the Transport Dilemma for Patients With Symptoms of Large-Vessel Occlusion Stroke in Intermediate Density Areas? A Simulation Model Based on Real Life Data. Front Neurol 2022; 13:861259. [PMID: 35547365 PMCID: PMC9082641 DOI: 10.3389/fneur.2022.861259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background This modeling study aimed to determine if helicopters may optimize the transportation of patients with symptoms of large vessel stroke in “intermediate density” areas, such as Denmark, by bringing them directly to the comprehensive stroke center. Methods We estimated the time for the treatment of patients requiring endovascular therapy or intravenous thrombolysis under four configurations: “drip and ship” with and without helicopter and “bypass” with and without helicopter. Time delays, stroke numbers per municipality, and helicopter dispatches for four helicopter bases from 2019 were obtained from the Danish Stroke and Helicopter Registries. Discrete event simulation (DES) was used to estimate the capacity of the helicopter fleet to meet patient transport requests, given the number of stroke codes per municipality. Results The median onset-to-needle time at the comprehensive stroke center (CSC) for the bypass model with the helicopter was 115 min [interquartile range (IQR): 108, 124]; the median onset-to-groin time was 157 min (IQR: 150, 166). The median onset-to-needle time at the primary stroke center (PSC) by ground transport was 112 min (IQR: 101, 125) and the median onset-to-groin time when primary transport to the PSC was prioritized was 234 min (IQR: 209, 261). A linear correlation between travel time by ground and the number of patients transported by helicopter (rho = 0.69, p < 0.001) indicated that helicopters are being used to transport more remote patients. DES demonstrated that an increase in helicopter capture zone by 20 min increased the number of rejected patients by only 5%. Conclusions Our model calculations suggest that using helicopters to transport patients with stroke directly to the CSC in intermediate density areas markedly reduce onset-to-groin time without affecting time to thrombolysis. In this setting, helicopter capacity is not challenged by increasing the capture zone.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Beare
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Svitlana Iievlieva
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Mainz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Gude
- Department of Clinical Medicine, Prehospital Department, Aarhus, Denmark
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Than Phan
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
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Yang Y, Chang Q, Chen J, Zou X, Xue Q, Song A. Application of Integrated Emergency Care Model Based on Failure Modes and Effects Analysis in Patients With Ischemic Stroke. Front Surg 2022; 9:874577. [PMID: 35449548 PMCID: PMC9018110 DOI: 10.3389/fsurg.2022.874577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To explore the application value of an integrated emergency care model based on failure modes and effects analysis (FMEA) in patients with acute ischemic stroke (AIS). Methods According to the convenience sampling method, 100 patients with AIS who visited the emergency department in our hospital from October 2018 to March 2019 were randomly selected as the control group and received routine emergency care mode intervention. Another 100 AIS patients who visited the emergency department from April to October 2019 were selected as the intervention group and received the integrated emergency care model based on FMEA. The total time spent from admission to completion of each emergency procedure [total time spent from admission to emergency physician reception (T0−1), total time spent from admission to stroke team reception (T0−2), total time spent from admission to imaging report out (T0−3), total time spent from admission to laboratory report out (T0−4), and total time spent from admission to intravenous thrombolysis (T0−5)] was recorded for both groups. The clinical outcome indicators (vascular recanalization rate, symptomatic intracerebral hemorrhage incidence, mortality rate) were observed for both groups. The National Institutes of Health Stroke Scale (NIHSS) score and Barthel score were evaluated for both groups after the intervention. The treatment satisfaction rate of the patients was investigated for both groups. Results The total time of T0−1, T0−2, T0−3, T0−4, T0−5 in the intervention group (0.55 ± 0.15, 1.23 ± 0.30, 21.24 ± 3.01, 33.30 ± 5.28, 44.19 ± 7.02) min was shorter than that of the control group (1.22 ± 0.28, 4.01 ± 1.06, 34.12 ± 4.44, 72.48 ± 8.27, 80.31 ± 9.22) min (P < 0.05). The vascular recanalization rate in the intervention group (23.00%) was higher than that in the control group (12.00%) (P < 0.05). There was no statistical significance in the symptomatic intracerebral hemorrhage incidence and mortality rate in the two groups (P > 0.05). After intervention, the NIHSS score of the intervention group (2.95 ± 0.91) was lower than that of the control group (6.10 ± 2.02), and the Barthel score (77.58 ± 7.33) was higher than that of the control group (53.34 ± 5.12) (P < 0.05). The treatment satisfaction rate in the intervention group (95.00%) was higher than that of the control group (86.00%) (P < 0.05). Conclusion Through FMEA, the failure mode that affects the emergency time of AIS patients is effectively analyzed and the targeted optimization process is proposed, which are important to enhance the efficiency and success rate of resuscitation of medical and nursing staff and improve the prognosis and life ability of patients.
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Affiliation(s)
- Yuying Yang
- Stroke Center Office, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Qing Chang
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Jing Chen
- Imaging Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Xiangkun Zou
- Information Section, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Qian Xue
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Aixia Song
- Department of Neurology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
- *Correspondence: Aixia Song
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6
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Dippel D, Roozenbeek B. Late thrombectomy for ischaemic stroke. Lancet 2022; 399:213-215. [PMID: 34774195 DOI: 10.1016/s0140-6736(21)02097-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Diederik Dippel
- Stroke Center, Department of Neurology, Erasmus MC, University Medical Center, PO BOX 2040, 3000 CA Rotterdam, Netherlands.
| | - Bob Roozenbeek
- Stroke Center, Department of Neurology, Erasmus MC, University Medical Center, PO BOX 2040, 3000 CA Rotterdam, Netherlands
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7
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Wheaton A, Fok PT, Holodinsky JK, Vanberkel P, Volders D, Kamal N. Optimal Transport Scenario With Rotary Air Transport for Access to Endovascular Therapy Considering Patient Outcomes and Cost: A Modeling Study. Front Neurol 2021; 12:768381. [PMID: 34975727 PMCID: PMC8718632 DOI: 10.3389/fneur.2021.768381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: For an ischemic stroke patient whose onset occurs outside of the catchment area of a hospital that is capable of Endovascular Treatment (EVT) and whose stroke is suspected to be caused by a large vessel occlusion (LVO), a transportation dilemma exists. Bypassing the nearest stroke hospital will delay Alteplase but expedite EVT. Not bypassing allows for confirmation of an LVO diagnosis before transfer to an EVT-enabled facility, but ultimately delays EVT. Air transport can reduce a patient's overall time to treatment however, it is costly. We expanded on an existing model to predict where Drip-and-Ship vs. Mothership provides better outcomes by including rotary air transport, and we also included prediction of where either the transport method was most cost effective. Methods: An existing model predicts the outcome of patients who screen positive for an LVO in the field based on how they were transported, Drip-and-Ship (alteplase-only facility first, then EVT-enabled facility) or Mothership (direct to EVT-enabled facility). In our model, the addition of rotary wing transportation was conditionally applied to inter-facility transfer scenarios where it provided a time advantage. Both patient outcome and transport cost functions were developed for Mothership and Drip-and-Ship strategies including transfers via either ground or air depending on the conditional probabilities. Experiments to model real world scenarios are presented by varying the driving time between the alteplase-only and EVT-enabled facility, time to treatment efficiencies at the alteplase-only facility, and EVT eligibility for LVO patients. Patient outcome and transport costs were evaluated for Mothership and Drip-and-Ship strategies. Results: The results are presented in temporospatial diagrams that are color coded to indicate which strategy optimizes the objectives. In most regions, there was overall agreement between the optimal solution when considering patient outcomes or transport costs. Small regions exist where outcome and cost are divergent; however, the difference between the divergence in Mothership and Drip-and-Ship in these regions is marginal. Conclusions: The optimal transport method can be optimized for both patient outcomes and transport costs.
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Affiliation(s)
- Ashlee Wheaton
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Patrick T. Fok
- Division of Emergency Medical Services (EMS), Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Jessalyn K. Holodinsky
- Department of Clinical Neurosciences, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter Vanberkel
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Department of Diagnostic Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
- Department of Clinical Neurosciences, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
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8
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Shlobin NA, Baig AA, Waqas M, Patel TR, Dossani RH, Wilson No Degree M, Cappuzzo JM, Siddiqui AH, Tutino VM, Levy EI. Artificial Intelligence for Large Vessel Occlusion Stroke: A Systematic Review. World Neurosurg 2021; 159:207-220.e1. [PMID: 34896351 DOI: 10.1016/j.wneu.2021.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Tatsat R Patel
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo NY USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | | | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo NY USA; Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo NY USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
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Goyal M, Ospel JM, Kim BJ, Kashani N, Duvekot MHC, Roozenbeek B, Ganesh A. A Bayesian Framework to Optimize Performance of Pre-Hospital Stroke Triage Scales. J Stroke 2021; 23:443-448. [PMID: 34649389 PMCID: PMC8521246 DOI: 10.5853/jos.2021.01312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mayank Goyal
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.,Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Johanna M Ospel
- Department.of.Neuroradiology, University.Hospital.Basel,.Basel,.Switzerland…
| | - Beom Joon Kim
- Cerebrovascular Center and Department of Neurology, Seoul National University Bundang Hospital, Seoul, Korea
| | - Nima Kashani
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Martijne H C Duvekot
- Departments of Neurology, Radiology, and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Bob Roozenbeek
- Departments of Neurology, Radiology, and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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10
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Paydarfar DA, Paydarfar D, Mucha PJ, Chang J. Optimizing Emergency Stroke Transport Strategies Using Physiological Models. Stroke 2021; 52:4010-4020. [PMID: 34407639 PMCID: PMC8607917 DOI: 10.1161/strokeaha.120.031633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. The criteria for choosing between drip and ship and mothership transport strategies in emergency stroke care is widely debated. Although existing data-driven probability models can inform transport decision-making at an epidemiological level, we propose a novel mathematical, physiologically derived framework that provides insight into how patient characteristics underlying infarct core growth influence these decisions.
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Affiliation(s)
- Daniel A Paydarfar
- Carolina Center for Interdisciplinary Applied Mathematics, Department of Mathematics (D.A.P., P.J.M.), University of North Carolina, Chapel Hill
| | - David Paydarfar
- Departments of Neurology (D.P., J.C.), Dell Medical School, Mulva Clinic for the Neurosciences and Oden Institute for Computational Engineering and Sciences, The University of Texas at Austin
| | - Peter J Mucha
- Carolina Center for Interdisciplinary Applied Mathematics, Department of Mathematics (D.A.P., P.J.M.), University of North Carolina, Chapel Hill
| | - Joshua Chang
- Departments of Neurology (D.P., J.C.), Dell Medical School, Mulva Clinic for the Neurosciences and Oden Institute for Computational Engineering and Sciences, The University of Texas at Austin.,Population Health (J.C.), Dell Medical School, Mulva Clinic for the Neurosciences and Oden Institute for Computational Engineering and Sciences, The University of Texas at Austin
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11
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Wang CH, Liu TY, Chiang WC, Tang SC, Tsai LK, Lee CW, Lin YH, Jeng JS, Ma MHM, Hsieh MJ, Lee YC. Expanding resources of endovascular thrombectomy: An optimization model. J Formos Med Assoc 2021; 121:978-985. [PMID: 34353719 DOI: 10.1016/j.jfma.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/03/2021] [Accepted: 07/15/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND/PURPOSE Recently optimized models for selecting the locations of hospitals capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the prehospital stroke scale assessment and possibility of secondary transport. Our study aimed to propose a new model for selecting existing hospitals with intravenous thrombolysis capability to become EVT-capable hospitals. METHODS A sequential order was provided to upgrade hospitals providing intravenous thrombolysis, using a mixed integer programming model based on current medical resource allocation. In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermining locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with suspected stroke, the model was implemented to determine the hospital that maximizes the number of patients receiving EVT treatment within call-to-definitive-treatment time. RESULTS All suspected stroke patients were sent to EVT-capable hospitals directly under the current medical resource allocation model. After upgrading one additional hospital to become an EVT-capable hospital, the percentage of patients receiving definitive treatment within the standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model, assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide treatment. CONCLUSION All patients eligible for acute stroke treatment are sent to EVT-capable hospitals in the simulation under the current medical resource allocation model. This model can be utilized to provide insights for capacity redistribution in other regions.
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Affiliation(s)
- Chun-Han Wang
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Ting-Yu Liu
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan.
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12
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Duvekot MHC, Venema E, Kerkhoff H, Dippel DWJ, Roozenbeek B. Prehospital scales in acute ischaemic stroke management - Authors' reply. Lancet Neurol 2021; 20:504-505. [PMID: 34146501 DOI: 10.1016/s1474-4422(21)00169-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Martijne H C Duvekot
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands.
| | - Esmee Venema
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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13
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Klingman JG, Alexander JG, Vinson DR, Klingman LE, Nguyen‐Huynh MN. Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy. J Am Coll Emerg Physicians Open 2021; 2:e12441. [PMID: 33969354 PMCID: PMC8087906 DOI: 10.1002/emp2.12441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of potential EST candidates in a hypothetical best-of-all-worlds situation. METHODS In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility. RESULTS Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral. CONCLUSIONS Even if field-based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST-capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door-to-needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST-capable centers.
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Affiliation(s)
- Jeffrey G. Klingman
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
| | - Janet G. Alexander
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
| | - David R. Vinson
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
- Department of Emergency MedicineKaiser Permanente, Northern CaliforniaRosevilleCaliforniaUSA
| | | | - Mai N. Nguyen‐Huynh
- Department of NeurologyKaiser Permanente, Northern CaliforniaWalnut CreekCaliforniaUSA
- Division of ResearchKaiser Permanente, Northern CaliforniaOaklandCaliforniaUSA
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14
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Wu X, Wira CR, Matouk CC, Forman HP, Gandhi D, Sanelli P, Schindler J, Malhotra A. Drip-and-ship versus mothership for endovascular treatment of acute stroke: A comparative effectiveness analysis. Int J Stroke 2021; 17:315-322. [PMID: 33759645 DOI: 10.1177/17474930211008701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Triage for suspected acute stroke has two main options: (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients. METHODS A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population was adult patient with sudden onset of acute stroke within 8 h of onset over a one-year horizon. The primary outcome was quantified in terms of quality-adjusted-life-years (QALYs). RESULTS The base case scenario show that the drip-and-ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the mothership strategy when the time to PSC is 30 min and to CSC is 65 min, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 h away), drip-and-ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-ship is favored by the reverse. CONCLUSION Drip-and-ship has a slightly higher utility than mothership. This study assesses the complex issue of prehospital triage of acute stroke patients and can provide a framework for real-world data input.
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Affiliation(s)
- Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Charles R Wira
- Department of Emergency Medicine, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Dheeraj Gandhi
- Radiology, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pina Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Joseph Schindler
- Department of Neurology, 12228Yale School of Medicine, New Haven, CT, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
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15
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Venema E, Lingsma HF. Optimizing Prehospital Organization of Stroke Care: A Methodological Challenge. Circ Cardiovasc Qual Outcomes 2021; 14:e007846. [PMID: 33813857 DOI: 10.1161/circoutcomes.121.007846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Esmee Venema
- Departments of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Neurology (E.V.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Departments of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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16
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Duvekot MHC, Venema E, Rozeman AD, Moudrous W, Vermeij FH, Biekart M, Lingsma HF, Maasland L, Wijnhoud AD, Mulder LJMM, Alblas KCL, van Eijkelenburg RPJ, Buijck BI, Bakker J, Plaisier AS, Hensen JH, Lycklama à Nijeholt GJ, van Doormaal PJ, van Es ACGM, van der Lugt A, Kerkhoff H, Dippel DWJ, Roozenbeek B, Dippel DW, Roozenbeek B, Kerkhoff H, Lingsma HF, van der Lugt A, van Es AC, Rozeman AD, Moudrous W, Vermeij FH, Venema E, Duvekot MH, Alblas KC, Mulder LJ, Wijnhoud AD, Maasland L, van Eijkelenburg RP, Biekart M, Willeboer ML, Buijck B, van Doormaal PJ, Bakker J, Hensen JH, Plaisier A, Lycklama à Nijeholt G, Hoek A, Oskam E, van der Zon MM, Zwets ED, Kuiper JW, van Moll BJ, Woudenberg M, de Leeuw AM, Noordam-Reijm A, Bevelander T, Chalos V, Wiegers EJ, Wolff L, van Kalkeren DC, van den Biggelaar J. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20:213-221. [DOI: 10.1016/s1474-4422(20)30439-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022]
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17
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Goyal M, Ospel JM. Adapting pre-hospital stroke triage systems to expanding thrombectomy indications. Neuroradiology 2021; 63:161-166. [PMID: 33439296 DOI: 10.1007/s00234-021-02638-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada. .,Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.
| | - Johanna M Ospel
- , Calgary, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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18
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Dippel DWJ. Improving the Delivery of High-Quality Reperfusion Therapy in the United States. Stroke 2020; 51:3492-3494. [PMID: 33161847 DOI: 10.1161/strokeaha.120.032405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Stroke Center, Rotterdam, the Netherlands
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19
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Venema E, Burke JF, Roozenbeek B, Nelson J, Lingsma HF, Dippel DWJ, Kent DM. Prehospital Triage Strategies for the Transportation of Suspected Stroke Patients in the United States. Stroke 2020; 51:3310-3319. [PMID: 33023425 PMCID: PMC7587242 DOI: 10.1161/strokeaha.120.031144] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose: Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States. Methods: We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies: (1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Rankin Scale score of >2). Results: Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 [65%]), followed by the algorithm with <60 minutes delay (n=10 [20%]). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31). Conclusions: Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.
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Affiliation(s)
- Esmee Venema
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, MI (J.F.B.)
| | - Bob Roozenbeek
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (B.R.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
| | - Hester F Lingsma
- Department of Public Health (E.V., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (E.V., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA (J.N., D.M.K.)
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20
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Tarkanyi G, Csecsei P, Szegedi I, Feher E, Annus A, Molnar T, Szapary L. Detailed severity assessment of Cincinnati Prehospital Stroke Scale to detect large vessel occlusion in acute ischemic stroke. BMC Emerg Med 2020; 20:64. [PMID: 32831019 PMCID: PMC7446055 DOI: 10.1186/s12873-020-00360-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background Selecting stroke patients with large vessel occlusion (LVO) based on prehospital stroke scales could provide a faster triage and transportation to a comprehensive stroke centre resulting a favourable outcome. We aimed here to explore the detailed severity assessment of Cincinnati Prehospital Stroke Scale (CPSS) to improve its ability to detect LVO in acute ischemic stroke (AIS) patients. Methods A cross-sectional analysis was performed in a prospectively collected registry of consecutive patients with first ever AIS admitted within 6 h after symptom onset. On admission stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) and the presence of LVO was confirmed by computed tomography angiography (CTA) as an endpoint. A detailed version of CPSS (d-CPSS) was designed based on the severity assessment of CPSS items derived from NIHSS. The ability of this scale to confirm an LVO was compared to CPSS and NIHSS respectively. Results Using a ROC analysis, the AUC value of d-CPSS was significantly higher compared to the AUC value of CPSS itself (0.788 vs. 0.633, p < 0.001) and very similar to the AUC of NIHSS (0.795, p = 0.510). An optimal cut-off score was found as d-CPSS≥5 to discriminate the presence of LVO (sensitivity: 69.9%, specificity: 75.2%). Conclusion A detailed severity assessment of CPSS items (upper extremity weakness, facial palsy and speech disturbance) could significantly increase the ability of CPSS to discriminate the presence of LVO in AIS patients.
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Affiliation(s)
- Gabor Tarkanyi
- Department of Neurology, University of Pecs, 13 Ifjusag utja, Pecs, 7624, Hungary
| | - Peter Csecsei
- Department of Neurology, University of Pecs, 13 Ifjusag utja, Pecs, 7624, Hungary
| | - Istvan Szegedi
- Department of Neurology, University of Debrecen, Debrecen, Hungary
| | - Evelin Feher
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Adam Annus
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Tihamer Molnar
- Department of Anaesthesiology and Intensive Therapy, University of Pecs, Pecs, Hungary
| | - Laszlo Szapary
- Department of Neurology, University of Pecs, 13 Ifjusag utja, Pecs, 7624, Hungary.
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21
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McTaggart RA, Holodinsky JK, Ospel JM, Cheung AK, Manning NW, Wenderoth JD, Phan TG, Beare R, Lane K, Haas RA, Kamal N, Goyal M, Jayaraman MV. Leaving No Large Vessel Occlusion Stroke Behind: Reorganizing Stroke Systems of Care to Improve Timely Access to Endovascular Therapy. Stroke 2020; 51:1951-1960. [PMID: 32568640 DOI: 10.1161/strokeaha.119.026735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan A McTaggart
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Jessalyn K Holodinsky
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K.H.)
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Andrew K Cheung
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.)
| | - Nathan W Manning
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Jason D Wenderoth
- Department of Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Department of Neurointervention, Liverpool Hospital, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Ingham Institute for Applied Medical Research, Sydney, Australia (A.K.C., N.W.M., J.D.W.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (N.W.M., J.D.W.)
| | - Thanh G Phan
- Department of Neurology, Monash Health and School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P.)
| | - Richard Beare
- Department of Medicine, Peninsula Health and Central Clinical School, Monash University and Murdoch Children's Research Institute Melbourne Australia (R.B.)
| | - Kendall Lane
- Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Richard A Haas
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada (J.M.O., M.G.).,Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
| | - Mahesh V Jayaraman
- Department of Diagnostic Imaging (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurology (R.A.M., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,Department of Neurosurgery (R.A.M., K.L., R.A.H., M.V.J.), Warren Alpert School of Medicine at Brown University, Providence, RI.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (R.A.M., R.A.H., M.V.J.)
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22
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Schlemm L, Endres M, Nolte CH. Bypassing the Closest Stroke Center for Thrombectomy Candidates. Stroke 2020; 51:867-875. [DOI: 10.1161/strokeaha.119.027512] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
Patients with acute ischemic stroke who have large vessel occlusion benefit from direct transport to a comprehensive stroke center (CSC) capable of endovascular therapy. To avoid harm for patients without large vessel occlusion from delayed access to intravenous thrombolysis (IVT), it has been suggested to only redirect patients with high likelihood of large vessel occlusion for whom the additional delay to intravenous thrombolysis (IVT) caused by transport to the CSC is below a certain threshold. However, which threshold achieves the greatest clinical benefit is unknown.
Methods—
We used mathematical modeling to calculate additional-delay-to-IVT thresholds associated with the greatest reduction in disability-adjusted life years in abstracted 2-stroke center and multiple-stroke center scenarios. Model parameters were extracted from recent meta-analyses or large prospective cohort studies. Uncertainty was quantified in probabilistic and 2-way univariate sensitivity analyses.
Results—
Assuming ideal treatment time performance metrics, transport to the nearest CSC was the preferred strategy irrespective of additional delay-to-IVT when the transfer time between primary stroke center and CSC was <40 minutes (95% credible interval: 25–66 minutes); otherwise, the optimal additional delay-to-IVT-threshold ranged from 28 to 139 minutes. In multiple-stroke center scenarios, optimal additional-delay-to-IVT thresholds were 30 to 54 minutes in urban and 49 to 141 minutes in rural settings; use of optimal thresholds as compared with a 15 minute-threshold saved 0 to 0.11 and 0 to 0.37 disability-adjusted life years per triage case, respectively. Assuming slower treatment times at primary stroke centers and CSCs yielded longer permissible additional delays.
Conclusions—
Our results suggest that patients with acute ischemic stroke with suspected large vessel occlusion should be redirected to a CSC if the additional delay to IVT is <30 minutes in urban and 50 minutes in rural settings.
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Affiliation(s)
- Ludwig Schlemm
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
| | - Matthias Endres
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Christian H. Nolte
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
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23
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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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24
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Venema E, Groot AE, Coutinho JM. Response by Venema et al to Letter Regarding Article, "Effect of Interhospital Transfer on Endovascular Treatment for Acute Ischemic Stroke". Stroke 2019; 50:e260. [PMID: 31272317 DOI: 10.1161/strokeaha.119.026210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Esmee Venema
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam
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