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Checkouri T, Sablot D, Varnier Q, Fryder I, Collemiche FL, Azais B, Dargazanli C, Leibinger F, Cagnazzo F, Mahmoudi M, Lefevre PH, Van Damme L, Gascou G, Schmidt J, Arquizan C, Plantard C, Farouil G, Costalat V. Becoming a thrombectomy-capable stroke center: Clinical and medico-economical effectiveness at the hospital level. Eur Stroke J 2024:23969873241254239. [PMID: 38760934 DOI: 10.1177/23969873241254239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024] Open
Abstract
INTRODUCTION Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure. PATIENTS AND METHODS This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital. RESULTS The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825€ per patient for the hospital. DISCUSSION Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.
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Affiliation(s)
- Thomas Checkouri
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Denis Sablot
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Quentin Varnier
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Ivan Fryder
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | - Benoit Azais
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | | | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Mehdi Mahmoudi
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | | | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Julia Schmidt
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
| | - Carole Plantard
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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Maas WJ, van der Zee DJ, Lahr MMH, Bouma M, Buskens E, Uyttenboogaart M. 'Drive the doctor' for endovascular thrombectomy in a rural area: a simulation study. BMC Health Serv Res 2023; 23:778. [PMID: 37475023 PMCID: PMC10360278 DOI: 10.1186/s12913-023-09672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 06/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Patients who present in a primary stroke center (PSC) with ischemic stroke are usually transferred to a comprehensive stroke center (CSC) in case of a large vessel occlusion (LVO) for endovascular thrombectomy (EVT) treatment, the so-called 'drip-and-ship' (DS) model. The 'drive-the-doctor' (DD) model modifies the DS model by allowing mobile interventionalists (MIs) to transfer to an upgraded PSC acting as a thrombectomy capable stroke center (TSC), instead of transferring patients to a CSC. Using simulation we estimated time savings and impact on clinical outcome of DD in a rural region. METHODS Data from EVT patients in northern Netherlands was prospectively collected in the MR CLEAN Registry between July 2014 - November 2017. A Monte Carlo simulation model of DS patients served as baseline model. Scenarios included regional spread of TSCs, pre-hospital patient routing to 'the nearest PSC' or 'nearest TSC', MI's notification after LVO confirmation or earlier prehospital, and MI's transport modalities. Primary outcomes are onset to groin puncture (OTG) and predicted probability of favorable outcome (PPFO) (mRS 0-2). RESULTS Combining all scenarios OTG would be reduced by 28-58 min and PPFO would be increased by 3.4-7.1%. Best performing and acceptable scenario was a combination of 3 TSCs, prehospital patient routing based on the RACE scale, MI notification after LVO confirmation and MI's transfer by ambulance. OTG would reduce by 48 min and PPFO would increase by 5.9%. CONCLUSIONS A DD model is a feasible scenario to optimize acute stroke services for EVT eligible patients in rural regions. Key design decisions in implementing the DD model for a specific region are regional spread of TSCs, patient routing strategy, and MI's notification moment and transport modality.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands.
| | - Maarten M H Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc Bouma
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Urbanek C, Jung J, Güney R, Potreck A, Nagel S, Grau AJ, Boujan T, Luckscheiter A, Bendszus M, Möhlenbruch MA, Seker F. Clinical outcome, recanalization success, and time metrics in drip-and-ship vs. drive-the-doctor: A retrospective analysis of the HEI-LU-Stroke registry. Front Neurol 2023; 14:1142983. [PMID: 36970521 PMCID: PMC10035332 DOI: 10.3389/fneur.2023.1142983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
PurposeThis study aimed at comparing clinical outcome, recanalization success and time metrics in the “drip and ship” (DS) vs. “drive the doctor” (DD) concept in a comparable setting.MethodsThis is a retrospective analysis of thrombectomy registries of a comprehensive stroke center (CSC) and a thrombectomy-capable stroke center (TSC). Patients, who were transferred from the TSC to the CSC, were classified as DS. Patients treated at the TSC by an interventionalist transferred from the CSC were classified as DD. Good outcome was defined as mRS 0–2 or equivalent to premorbid mRS at discharge. Recanalization (TICI 2b-3 or equivalent) and time metrics were compared in both groups.ResultsIn total, 295 patients were included, of which 116 (39.3%) were treated in the DS concept and 179 (60.7%) in the DD concept. Good clinical outcome was similarly achieved in DS and DD (DS 25.0% vs. DD 31.3%, P = 0.293). mRS on discharge (DS median 4, DD median 4, P = 0.686), NIHSS improvement (DS median 4, DD median 5, P = 0.582) and NIHSS on discharge (DS median 9, DD median 7, P = 0.231) were similar in both groups. Successful reperfusion was achieved similarly in DS (75.9%) and DD as well (81.0%, P = 0.375). Time from onset to reperfusion (median DS 379 vs. DD 286 min, P = 0.076) and time from initial imaging to reperfusion were longer in DS compared to DD (median DS 246 vs. DD 162 min, P < 0.001).ConclusionThe DD concept is time saving while achieving similar clinical outcome and recanalization results.
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Affiliation(s)
- Christian Urbanek
- Department of Neurology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Jasmin Jung
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Resul Güney
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Armin J. Grau
- Department of Neurology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Timan Boujan
- Department of Radiology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Andre Luckscheiter
- Department of Anaesthesiology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
- *Correspondence: Fatih Seker
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Worthmann H, Winzer S, Schuppner R, Gumbinger C, Barlinn J. Telestroke networks for area-wide access to endovascular stroke treatment. Neurol Res Pract 2023; 5:9. [PMID: 36864498 PMCID: PMC9983226 DOI: 10.1186/s42466-023-00237-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. MAIN BODY Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. CONCLUSION The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.
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Affiliation(s)
- Hans Worthmann
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany.
| | - S Winzer
- Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
| | - R Schuppner
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany
| | - C Gumbinger
- Klinik Für Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - J Barlinn
- Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
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Bénard A, Gallard R, Lesaine E, Domecq S, Maugeais M, Gilbert F, Marnat G, Rouanet F. Factors associated with the time from the first call to emergency medical services to puncture for mechanical thrombectomy for ischaemic stroke patients in Gironde, France, in 2017 and 2018. Rev Epidemiol Sante Publique 2023; 71:101414. [PMID: 36563615 DOI: 10.1016/j.respe.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND PURPOSE When an ischaemic stroke due to a large vessel occlusion occurs, the sooner Mechanical Thrombectomy (MT) is performed, the better the functional prognosis. However, the organisation of care does not systematically allow rapid access to MT. The aim of our study was to determine the clinical and organisational factors associated with the time to access to MT. METHODS We conducted a cohort study in Gironde County, France. Patients admitted for MT and regulated by the Gironde Emergency Medical Services (EMS) between 01/01/2017 and 31/12/2018 were included. The time to access to MT was the difference between the first call to EMS and groin puncture for MT. The main explanatory variables were: type of pathway (mothership (MS), drip and ship (DS) with cerebral imaging performed in the local hospital centre (LHC), and DS without imaging in the LHC); NIHSS score; driving distance to MT; time of stroke onset (weekend or holiday, school holidays, other); age and sex. Linear regression models were used to explain time to access to MT. Missing data were handled using a multiple imputation procedure (Full conditional specification, Mice R-Package) carried out in our multivariable linear regression model. A quantitative bias analysis was performed by weighing the imputed time to access to MT and identifying the weight changing the conclusions of our analysis. RESULTS Among the 314 included patients, 152 were women (48.4%), and the mean NIHSS score was 16.4. Two hundred and two (64.3%) patients were managed through the MS pathway. The average time from onset to femoral puncture was 251 minutes. In the multivariate analysis, the time to MT was longer when patients were managed DS with imaging in the LHC pathway (+106 min, p = 0.03), and even longer in the DS without imaging in the LHC pathway (+197 min, p = 0.002), compared with MS. Time from onset to MT decreased with increasing NIHSS score (-6 min per NIHSS point, p <.0001). In our quantitative bias analysis, we multiplied the imputed time in access to MT in the DS pathways only (with or without imaging in the LHC) by weights varying from 0.9 to 0.2 (imputed delays reduced from 10% to 80%). With reduction of 40% or more, there was no longer any difference in time to access to MT between the three studied pathways. CONCLUSIONS The DS pathway can be shortened by generalizing access to cerebral imaging in LHCs. Optimizing pre-admission orientation toward MT is a major issue in LVOS management.
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Affiliation(s)
- Antoine Bénard
- CHU de Bordeaux, pôle de santé publique, USMR & CIC-EC 14-01, F-33000 Bordeaux, France; Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, Team EMOS, UMR 1219, F-33000 Bordeaux, France.
| | - Romain Gallard
- CHU de Bordeaux, pôle de santé publique, USMR & CIC-EC 14-01, F-33000 Bordeaux, France; Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, Team EMOS, UMR 1219, F-33000 Bordeaux, France
| | - Emilie Lesaine
- CHU Bordeaux, INSERM, Bordeaux Population Health Research Center, CIC-EC 14-01, F-33000 Bordeaux, France
| | - Sandrine Domecq
- CHU Bordeaux, INSERM, Bordeaux Population Health Research Center, CIC-EC 14-01, F-33000 Bordeaux, France
| | - Mélanie Maugeais
- CHU Bordeaux, INSERM, Bordeaux Population Health Research Center, CIC-EC 14-01, F-33000 Bordeaux, France
| | - Florian Gilbert
- CHU Bordeaux, INSERM, Bordeaux Population Health Research Center, CIC-EC 14-01, F-33000 Bordeaux, France
| | - Gaultier Marnat
- CHU Bordeaux, Pôle Imagerie Médicale, unité neuro-radiologie diagnostique et interventionnelle, F-33000 Bordeaux, France
| | - François Rouanet
- CHU de Bordeaux, Pôle Neurosciences, Unité Neuro-vasculaire, F-33000 Bordeaux, France
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Coors M, Flemming R, Schüttig W, Hubert GJ, Hubert ND, Sundmacher L. Health economic evaluation of the 'Flying Intervention Team' as a novel stroke care concept for rural areas: study protocol of the TEMPiS-GÖA study. BMJ Open 2022; 12:e060533. [PMID: 36127094 PMCID: PMC9490577 DOI: 10.1136/bmjopen-2021-060533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Providing comprehensive stroke care poses major organisational and financial challenges to the German healthcare system. The quasi-randomised TEMPiS-Flying Intervention Team (TEMPiS-FIT) study aims to close the gap in the treatment of patients who had ischaemic stroke in rural areas of Southeast Bavaria by flying a team of interventionalists via helicopter directly to patients in the regional TEMPiS hospitals instead of transporting the patients to the next comprehensive stroke centre. The objective of the present paper is to describe the methods for the economic evaluation (TEMPiS-Gesundheitsökonomische Analyse (TEMPiS-GÖA)) alongside the TEMPiS-FIT study to determine whether the new form of care is cost-effective compared with standard care. METHODS AND ANALYSIS The within-trial cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) will be performed from a statutory health insurance perspective as well as from a societal perspective over the time horizon of 12 months after the patients' hospital discharge. Direct costs from outpatient and inpatient care are collected from routine data of the participating health insurance funds, while medical and non-medical costs from a patient's perspective are retrieved from primary data collected during the TEMPiS-FIT study and follow-up questionnaires. Results will be presented as incremental cost-effectiveness ratio and incremental cost-utility ratio quantifying the incremental costs and health benefits compared with standard care practice. The outcome of the CEA will be measured in costs per minute reduction in mean process time to thrombectomy. The outcome of the CUA will be presented as costs per quality-adjusted life year gained. ETHICS AND DISSEMINATION Ethical approval for the TEMPiS-FIT study was granted by the Bavarian State Medical Association Ethics Committee (# 17056). Results will be disseminated via reports, presentations of the results in publications and at conferences and on the TEMPiS website. TRIAL REGISTRATION NUMBER German Clinical Trials Register DRKS00023885. Registered on 2 July 2021 - retrospectively registered.
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Affiliation(s)
- Marie Coors
- Department of Health Economics, Technical University of Munich, Munich, Germany
| | - Ronja Flemming
- Department of Health Economics, Technical University of Munich, Munich, Germany
| | - Wiebke Schüttig
- Department of Health Economics, Technical University of Munich, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Centre, München Klinik Harlaching, Munich, Germany
| | - Nikolai Dominik Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Centre, München Klinik Harlaching, Munich, Germany
| | - Leonie Sundmacher
- Department of Health Economics, Technical University of Munich, Munich, Germany
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Ennab Vogel N, Tatlisumak T, Wester P, Lyth J, Levin LÅ. Prediction modelling the impact of onset to treatment time on the modified Rankin Scale score at 90 days for patients with acute ischaemic stroke. BMJ Neurol Open 2022; 4:e000312. [PMID: 36072349 PMCID: PMC9386213 DOI: 10.1136/bmjno-2022-000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/20/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Shortening the time from stroke onset to treatment increases the effectiveness of endovascular stroke therapies. Aim This study aimed to predict the modified Rankin Scale score at 90 days post-stroke (mRS-90d score) in patients with acute ischaemic stroke (AIS) with respect to four types of treatment: conservative therapy (CVT), intravenous thrombolysis only (IVT), mechanical thrombectomy only (MT) and pretreatment with IVT before MT (IVT+MT). Patients and methods This nationwide observational study included 124 484 confirmed cases of acute stroke in Sweden over 6 years (2012–2017). The associations between onset-to-treatment time (OTT), patient age and hospital admission National Institutes of Health Stroke Scale (NIHSS) score with the five-levelled mRS-90d score were retrospectively studied. A generalised linear model (GLM) was fitted to predict the mRS-90d scores for each patient group. Results The fitted GLM for CVT patients is a function of age and NIHSS score. For IVT, MT and IVT+MT patients, GLMs additionally employed OTT variables. By reducing the mean OTTs by 15 min, the number needed-to-treat (NNT) for one patient to make a favourable one-step shift in the mRS was 30 for IVT, 48 for MT and 21 for IVT+MT. Discussion and conclusion This study demonstrates linear associations of mRS-90d score with OTT for IVT, MT and IVT+MT, and shows in absolute effects measures that OTT reductions for IVT and/or MT produces substantial health gains for patients with AIS. Even moderate OTT reductions led to sharp drops in the NNT.
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Affiliation(s)
- Nicklas Ennab Vogel
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Turgut Tatlisumak
- Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden
- Department of Clinical Science, Karolinska Institute Danderyds Hospital, Stockholm, Sweden
| | - Johan Lyth
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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Hou J, Guo ZL, Huang ZC, Wang HS, You SJ, Xiao GD. Influences of different referral modes on clinical outcomes after endovascular therapy for acute ischemic stroke. BMC Neurol 2022; 22:228. [PMID: 35729557 PMCID: PMC9210676 DOI: 10.1186/s12883-022-02751-w] [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: 02/04/2022] [Accepted: 06/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background and purpose As endovascular thrombectomy (EVT) is time-dependent, it is crucial to refer patients promptly. Current referral modes include Mothership (MS), Drip and Ship (DS) and Drive the Doctor (DD). The purpose of this study was to investigate the influences of different referral modes on the clinical outcomes of patients with acute ischemic stroke after EVT. Methods A total of 349 patients from 15 hospitals between April 2017 and March 2020 were enrolled. The primary outcomes include poor outcome (modified Rankin Scale score of 3 to 6), symptomatic intracranial hemorrhage transformation (sICH), mortality and cost. Regression analysis was used to assess the association of referral modes with poor outcome, sICH, mortality and cost in acute ischemic stroke patients. Results Among the 349 patients, 83 were in DD group (23.78%), 85 in MS group (24.36%) and 181 in DS group (51.86%). There were statistically significant differences in intravenous thrombolysis, onset-to-door time, onset-to-puncture time, puncture-to-recanalization time, door-to-puncture time, door-to-recanalization time, and cost among the DD, MS, and DS groups (59.04% vs 35.29% vs 33.15%, P<0.001; 90 vs 166 vs 170 minutes, P<0.001; 230 vs 270 vs 270 minutes, P<0.001; 82 vs 54 vs 51 minutes, P<0.001; 110 vs 85 vs 96 minutes, P=0.004; 210 vs 146 vs 150 minutes, P<0.001; 64258 vs 80041 vs 70750 Chinese Yuan, P=0.018). In terms of sICH, mortality and poor outcome, there was no significant difference among the DD, MS, and DS groups (22.89% vs 18.82% vs 19.34%, P=0.758; 24.10% vs 24.71% vs 29.83%, P=0.521; 64.47% vs 64.71% vs 68.51%, P=0.827). The results of multiple regression analysis indicated that there was no independent correlation between different referral modes regarding sICH (ORMS: 0.50, 95%CI: 0.18, 1.38, P=0.1830; ORDS: 0.47, 95%CI: 0.19, 1.16, P=0.1000), mortality (ORMS: 0.56, 95%CI: 0.19, 1.67, P=0.2993; ORDS: 0.65, 95%CI: 0.25, 1.69, P=0.3744) and poor outcome (ORMS: 0.61, 95%CI: 0.25, 1.47, P=0.2705; ORDS: 0.53, 95%CI: 0.24, 1.18, P=0.1223). However, there was a correlation between MS group and cost (β=30449.73, 95%CI: 11022.18, 49877.29; P=0.0023). The multiple regression analysis on patients finally admitted in comprehensive stroke center (MS+DS) versus patients finally admitted in primary stroke center (DD) showed that DD mode was independently associated with lower costs (β=-19438.86, 95%CI: -35977.79, -2899.94; P=0.0219). Conclusion There was no independent correlation between three referral modes and sICH, mortality, poor outcome correspondingly. Different referral modes can be implemented in clinical practice according to the situations encountered. Compared to MS and DS modes, DD mode is more economical. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02751-w.
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Affiliation(s)
- Jie Hou
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Zhi-Liang Guo
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Zhi-Chao Huang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Huai-Shun Wang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Shou-Jiang You
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Guo-Dong Xiao
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China.
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Times to endovascular treatment following two triage models. Neurol Sci 2022; 43:3967-3971. [DOI: 10.1007/s10072-022-05995-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
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Hubert GJ, Hubert ND, Maegerlein C, Kraus F, Wiestler H, Müller-Barna P, Gerdsmeier-Petz W, Degenhart C, Hohenbichler K, Dietrich D, Witton-Davies T, Regler A, Paternoster L, Leitner M, Zeman F, Koller M, Linker RA, Bath PM, Audebert HJ, Haberl RL. Association Between Use of a Flying Intervention Team vs Patient Interhospital Transfer and Time to Endovascular Thrombectomy Among Patients With Acute Ischemic Stroke in Nonurban Germany. JAMA 2022; 327:1795-1805. [PMID: 35510389 PMCID: PMC9092197 DOI: 10.1001/jama.2022.5948] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke is highly time-dependent, and it is challenging to expedite treatment for patients in remote areas. OBJECTIVE To determine whether deployment of a flying intervention team, compared with patient interhospital transfer, is associated with a shorter time to endovascular thrombectomy and improved clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This was a nonrandomized controlled intervention study comparing 2 systems of care in alternating weeks. The study was conducted in a nonurban region in Germany including 13 primary telemedicine-assisted stroke centers within a telestroke network. A total of 157 patients with acute ischemic stroke for whom decision to pursue thrombectomy had been made and deployment of flying intervention team or patient interhospital transfer was initiated were enrolled between February 1, 2018, and October 24, 2019. The date of final follow-up was January 31, 2020. EXPOSURES Deployment of a flying intervention team for EVT in a primary stroke center vs patient interhospital transfer for EVT to a referral center. MAIN OUTCOMES AND MEASURES The primary outcome was time delay from decision to pursue thrombectomy to start of the procedure in minutes. Secondary outcomes included functional outcome after 3 months, determined by the distribution of the modified Rankin Scale score (a disability score ranging from 0 [no deficit] to 6 [death]). RESULTS Among the 157 patients included (median [IQR] age, 75 [66-80] y; 80 [51%] women), 72 received flying team care and 85 were transferred. EVT was performed in 60 patients (83%) in the flying team group vs 57 (67%) in the transfer group. Median (IQR) time from decision to pursue EVT to start of the procedure was 58 (51-71) minutes in the flying team group and 148 (124-177) minutes in the transfer group (difference, 90 minutes [95% CI, 75-103]; P < .001). There was no significant difference in modified Rankin Scale score after 3 months between patients in the flying team (n = 59) and transfer (n = 57) groups who received EVT (median [IQR] score, 3 [2-6] vs 3 [2-5]; adjusted common odds ratio for less disability, 1.91 [95% CI, 0.96-3.88]; P = .07). CONCLUSIONS AND RELEVANCE In a nonurban stroke network in Germany, deployment of a flying intervention team to local stroke centers, compared with patient interhospital transfer to referral centers, was significantly associated with shorter time to EVT for patients with acute ischemic stroke. The findings may support consideration of a flying intervention team for some stroke systems of care, although further research is needed to confirm long-term clinical outcomes and to understand applicability to other geographic settings.
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Affiliation(s)
- Gordian J. Hubert
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nikolai D. Hubert
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Frank Kraus
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Hanni Wiestler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Peter Müller-Barna
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | | | - Christoph Degenhart
- Department of Diagnostic and Interventional Radiology, München Klinik, Munich, Germany
| | - Katharina Hohenbichler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Dennis Dietrich
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Witton-Davies
- Department of Diagnostic and Interventional Radiology, München Klinik, Munich, Germany
| | - Angelika Regler
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Laura Paternoster
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Miriam Leitner
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Ralf A. Linker
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - Philip M. Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Heinrich J. Audebert
- Department of Neurology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Roman L. Haberl
- TEMPiS telestroke center, Department of Neurology, München Klinik, Academic Teaching hospital of the Ludwig-Maximilians-University, Munich, Germany
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11
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Seker F, Fifi JT, Morey JR, Osanai T, Oki S, Brekenfeld C, Fiehler J, Bendszus M, Möhlenbruch MA. Transferring neurointerventionalists saves time compared with interhospital transfer of stroke patients for endovascular thrombectomy: a collaborative pooled analysis of 1001 patients (EVEREST). J Neurointerv Surg 2022; 15:517-520. [PMID: 35501118 DOI: 10.1136/neurintsurg-2021-018049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 04/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Interhospital transfer of stroke patients (drip and ship concept) is associated with longer treatment times compared with primary admission to a comprehensive stroke center (mothership concept). In recent years, studies on a novel concept of performing endovascular thrombectomy (EVT) at external hospitals (EXT) by transferring neurointerventionalists, instead of patients, have been published. This collaborative study aimed at answering the question of whether EXT saves time in the workflow of acute stroke treatment across various geographical regions. METHODS This was a patient level pooled analysis of one prospective observational study and four retrospective cohort studies, the EVEREST collaboration (EndoVascular thrombEctomy at Referring and External STroke centers). Time from initial stroke imaging to EVT (vascular puncture) was compared in mothership, drip and ship, and EXT concepts. RESULTS In total, 1001 stroke patients from various geographical regions who underwent EVT due to large vessel occlusion were included. These were divided into mothership (n=162, 16.2%), drip and ship (n=458, 45.8%), and EXT (n=381, 38.1%) cohorts. The median time periods from onset to EVT (195 min vs 320 min, p<0.001) and from imaging to EVT (97 min vs 184 min, p<0.001) in EXT were significantly shorter than for drip and ship thrombectomy concept. CONCLUSIONS This pooled analysis of the EVEREST collaboration adds evidence that performing EVT at external hospitals can save time compared with drip and ship across various geographical regions. We encourage conducting randomized controlled trials comparing both triage concepts.
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Affiliation(s)
- Fatih Seker
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Jacob R Morey
- Neurosurgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Toshiya Osanai
- Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sogo Oki
- Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Caspar Brekenfeld
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Bendszus
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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12
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Hang Y, Jia ZY, Zhao LB, Cao YZ, Huang H, Shi HB, Liu S. Effect of "drip-and-ship" and "drip-and-drive" on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study. Acta Radiol 2022; 63:658-663. [PMID: 33827276 DOI: 10.1177/02841851211006897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). PURPOSE To compare the efficacy and prognosis of the two strategies. MATERIAL AND METHODS From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. RESULTS Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group (P = 1.000). Favorable functional outcomes (mRS 0-2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days (P = 0.089). CONCLUSION Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.
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Affiliation(s)
- Yu Hang
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Zhen Yu Jia
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Lin Bo Zhao
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Yue Zhou Cao
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Huang Huang
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Hai-Bin Shi
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Sheng Liu
- Department of Interventional Radiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
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13
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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14
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Kurogi A, Onozuka D, Hagihara A, Nishimura K, Kada A, Hasegawa M, Higashi T, Kitazono T, Ohta T, Sakai N, Arai H, Miyamoto S, Sakamoto T, Iihara K. Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016. Sci Rep 2022; 12:3252. [PMID: 35228551 PMCID: PMC8885934 DOI: 10.1038/s41598-022-06074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013–2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013–2014, 1461 patients) and II (2015–2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915–0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001–1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.
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Affiliation(s)
- Ai Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Onozuka
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Hagihara
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Kada
- Department of Clinical Research Planning and Management, Clinical Research Center, National Hospital Organization Nagoya Medical Centre, Nagoya, Japan
| | - Manabu Hasegawa
- Immunization Office, Health Service Division, Health Service Bureau, Ministry of Health, Labor and Welfare, Tokyo, Japan
| | - Takahiro Higashi
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Centre General Hospital, Kobe, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Neurosurgery, Director General of the Hospital, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmmachi, Suita, Osaka, 564-8565, Japan.
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15
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Nielsen M, Waldmann M, Frölich AM, Flottmann F, Hristova E, Bendszus M, Seker F, Fiehler J, Sentker T, Werner R. Deep Learning-Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study. Stroke 2021; 52:3497-3504. [PMID: 34496622 DOI: 10.1161/strokeaha.120.033807] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose Mechanical thrombectomy is an established procedure for treatment of acute ischemic stroke. Mechanical thrombectomy success is commonly assessed by the Thrombolysis in Cerebral Infarction (TICI) score, assigned by visual inspection of X-ray digital subtraction angiography data. However, expert-based TICI scoring is highly observer-dependent. This represents a major obstacle for mechanical thrombectomy outcome comparison in, for instance, multicentric clinical studies. Focusing on occlusions of the M1 segment of the middle cerebral artery, the present study aimed to develop a deep learning (DL) solution to automated and, therefore, objective TICI scoring, to evaluate the agreement of DL- and expert-based scoring, and to compare corresponding numbers to published scoring variability of clinical experts. Methods The study comprises 2 independent datasets. For DL system training and initial evaluation, an in-house dataset of 491 digital subtraction angiography series and modified TICI scores of 236 patients with M1 occlusions was collected. To test the model generalization capability, an independent external dataset with 95 digital subtraction angiography series was analyzed. Characteristics of the DL system were modeling TICI scoring as ordinal regression, explicit consideration of the temporal image information, integration of physiological knowledge, and modeling of inherent TICI scoring uncertainties. Results For the in-house dataset, the DL system yields Cohen’s kappa, overall accuracy, and specific agreement values of 0.61, 71%, and 63% to 84%, respectively, compared with the gold standard: the expert rating. Values slightly drop to 0.52/64%/43% to 87% when the model is, without changes, applied to the external dataset. After model updating, they increase to 0.65/74%/60% to 90%. Literature Cohen’s kappa values for expert-based TICI scoring agreement are in the order of 0.6. Conclusions The agreement of DL- and expert-based modified TICI scores in the range of published interobserver variability of clinical experts highlights the potential of the proposed DL solution to automated TICI scoring.
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Affiliation(s)
- Maximilian Nielsen
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Moritz Waldmann
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Andreas M Frölich
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.)
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Thilo Sentker
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Rene Werner
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
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16
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MacKenzie IER, Arusoo T, Sigounas D. Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e387-e397. [PMID: 34087463 DOI: 10.1016/j.wneu.2021.05.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. METHODS A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0-2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. RESULTS Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0-2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (P < 0.001). CONCLUSIONS This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.
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Affiliation(s)
- Isobel E R MacKenzie
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Toomas Arusoo
- Department of Radiology, George Washington University, Washington, DC, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, George Washington University, Washington, DC, USA.
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17
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Nardai S, Lanzer P, Abelson M, Baumbach A, Doehner W, Hopkins LN, Kovac J, Meuwissen M, Roffi M, Sievert H, Skrypnik D, Sulzenko J, van Zwam W, Gruber A, Ribo M, Cognard C, Szikora I, Flodmark O, Widimsky P. Interdisciplinary management of acute ischaemic stroke: Current evidence training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention. Eur Heart J 2021; 42:298-307. [PMID: 33521827 DOI: 10.1093/eurheartj/ehaa833] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/07/2020] [Accepted: 09/23/2020] [Indexed: 11/15/2022] Open
Abstract
This ESC Council on Stroke/EAPCI/EBNI position paper summarizes recommendations for training of cardiologists in endovascular treatment of acute ischaemic stroke. Interventional cardiologists adequately trained to perform endovascular stroke interventions could complement stroke teams to provide the 24/7 on call duty and thus to increase timely access of stroke patients to endovascular treatment. The training requirements for interventional cardiologists to perform endovascular therapy are described in details and should be based on two main principles: (i) patient safety cannot be compromised, (ii) proper training of interventional cardiologists should be under supervision of and guaranteed by a qualified neurointerventionist and within the setting of a stroke team. Interdisciplinary cooperation based on common standards and professional consensus is the key to the quality improvement in stroke treatment.
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Affiliation(s)
- Sandor Nardai
- Department Section of Neurointervention, National Institute of Clinical Neurosciences, Semmelweis University Heart and Vascular Center and Semmelweis University, Budapest, Hungary
| | - Peter Lanzer
- Mitteldeutsches Herzzentrum, Standort Bitterfeld-Wolfen, Germany
| | - Mark Abelson
- Vergelegen MediClinic, Somerset West, University of Cape Town, South Africa
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), and Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany
| | - L Nelson Hopkins
- Gates Vascular Institute and Jacobs Institute, Neurosurgery and Radiology, University at Buffalo, USA
| | - Jan Kovac
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Marco Roffi
- Division of cardiology, University Hospitals, Geneva, Switzerland
| | - Horst Sievert
- CardioVascular Center Frankfurt, Germany and Anglia Ruskin University, Chelmsford, UK
| | - Dmitry Skrypnik
- Department of Interventional Cardiology, Moscow Hospital I. Davydovsky and Moscow State University of Medicine and Dentistry, Russian Federation
| | - Jakub Sulzenko
- Cardiocenter, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicin, Academic Hospital of Maastricht, Maastricht, The Netherlands
| | - Andreas Gruber
- Universitätsklinik für Neurochirurgie, Kepler Universitäts Klinikum, Linz, Austria
| | - Marc Ribo
- Department of Neurology, Hospital Wall d'Hebron, Barcelona, Spain
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology Hôpital Purpan, Toulouse, France
| | - Istvan Szikora
- Department Section of Neurointervention, National Institute of Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Olof Flodmark
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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18
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Seker F, Fiehler J, Möhlenbruch MA, Herweh C, Flottmann F, Ringleb PA, Thomalla G, Steiner T, Kraemer C, Brekenfeld C, Bendszus M. Clinical Outcome After Endovascular Thrombectomy in 3 Triage Concepts: A Prospective, Observational Study (NEUROSQUAD). Stroke 2021; 52:e213-e216. [PMID: 33910365 DOI: 10.1161/strokeaha.120.030520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE NEUROSQUAD (Stroke Treatment: Quality and Efficacy in Different Referral Systems) is a prospective, observational, bicenter study comparing 3 triage pathways in endovascular stroke treatment: mothership, drip and ship (DS), and transferring a neurointerventionalist to a remote hospital for thrombectomy (drive the doctor [DD]). METHODS Patients with anterior circulation stroke and premorbid modified Rankin Scale (mRS) score 0-3 who underwent thrombectomy within 24 hours after stroke onset were included. Primary outcome measure was good clinical outcome defined as 90-day mRS score 0-2 or clinical recovery to the status before stroke onset (ie, equal premorbid mRS and 90-day mRS). Secondary outcome measures were successful reperfusion, National Institutes of Health Stroke Scale at discharge, and mRS shift. RESULTS In total, 360 patients were included in this study, of whom 111 patients (30.8%) were in the mothership group, 204 patients (56.7%) were in the DS group, and 45 patients (12.5%) were in the DD group. Good clinical outcome was achieved similarly in all three groups (mothership, 45.9%; DS, 43.1%; DD, 40.0%; P=0.778). Likewise, frequency of successful reperfusion was similar in all three groups (mothership, 86.5%; DS, 85.3%; DD, 82.2%; P=0.714). There was no significant difference among the groups regarding the National Institutes of Health Stroke Scale at discharge (P=0.115) and mRS shift (P=0.342). In the multivariate analysis, triage concept was not an independent predictor of good outcome (unadjusted odds ratio, 0.89 [CI, 0.64-1.23]; P=0.479). CONCLUSIONS Our data suggest that clinical outcome after thrombectomy is similar in mothership, DS, and DD. Hence, DD can be a valuable triage option in acute stroke treatment.
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Affiliation(s)
- Fatih Seker
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
| | - Jens Fiehler
- Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Markus A Möhlenbruch
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
| | - Christian Herweh
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
| | - Fabian Flottmann
- Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Peter A Ringleb
- Neurology (P.A.R., T.S.), Heidelberg University Hospital, Germany
| | - Götz Thomalla
- Neurology (G.T.), University Hospital Hamburg-Eppendorf, Germany
| | - Thorsten Steiner
- Neurology (P.A.R., T.S.), Heidelberg University Hospital, Germany.,Neurology, Klinikum Frankfurt Höchst, Germany (T.S.)
| | | | - Caspar Brekenfeld
- Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Martin Bendszus
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
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19
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Danziger R, Tan C, Churilov L, Mitchell P, Dowling R, Bush S, Yan B. Intrinsic hospital factors: overlooked cause for variations in delay to transfer for endovascular thrombectomy. J Neurointerv Surg 2021; 13:968-973. [PMID: 33593802 DOI: 10.1136/neurintsurg-2020-016836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intrinsic hospital factors leading to time delay to inter-hospital transfer for endovascular thrombectomy (EVT) have not been adequately investigated, leading to uncertainty in generalizability of hub and spoke EVT services. We investigated the contribution of intrinsic hospital factors to variations in time delay in a multicenter, retrospective study. METHODS The setting was a hub and spoke EVT state-wide system for a population of 6.3 million and 34 spoke hospitals. We collected data on acute large vessel occlusion strokes transferred from spoke to hub for consideration of EVT between January 2016 and December 2018. The primary endpoint was the proportion of variability in delay-time in transfer cases contributed to by intrinsic hospital factors estimated through variance component analysis implemented as a mixed-effect linear regression model with hospitals as random effects. RESULTS We included 434 patients. The median age was 72 years (IQR 62-79), 44% were female, and the median baseline National Institutes of Health Stroke Scale (NIHSS) was 16 (IQR 11-20). The median onset to CT time was 100 mins (IQR 69-157) at the spoke hospitals and CT acquisition at the spoke hospital to time of transfer was 93 min (IQR 70-132). 53% of the observed variability in time from CT acquisition at the spoke hospital to transfer to the EVT center was explained by intrinsic hospital factors, as opposed to patient-related factors. CONCLUSIONS Intrinsic hospital factors explained more than half of the observed variability in time from CT acquisition at the spoke hospital to departure for transfer. We recommend that the design of hub and spoke EVT services should account for intrinsic hospital factors to minimize hospital transfer delay.
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Affiliation(s)
- Ron Danziger
- Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Christina Tan
- Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Peter Mitchell
- Radiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Richard Dowling
- Radiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Steven Bush
- Radiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Bernard Yan
- Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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20
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Bechstein M, Goebell E, Fiehler J. [Remote proctoring in neuroradiological interventions]. DER NERVENARZT 2021; 92:107-114. [PMID: 33481058 PMCID: PMC7820829 DOI: 10.1007/s00115-020-01057-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 11/24/2022]
Abstract
Hintergrund Endovaskuläre Verfahren haben einen festen Platz bei der Behandlung von Hirngefäßerkrankungen, z. B. die Thrombektomie beim Schlaganfall. Die ständige Weiterentwicklung der hierbei verwendeten Materialien (z. B. Katheter und Stents) fordert von den behandelnden Ärzten ein permanentes Lernen. Fragestellung Technische Hilfsmöglichkeiten zur Unterstützung bei neuen neuroendovaskulären Verfahren. Material und Methode Integration von Streamingtechnologien in das Ausbildungskonzept von Neuroradiologen. Ergebnisse Die Übertragung angiographischer Aufnahmen auf einen entfernten Computerarbeitsplatz in Echtzeit ist mittels spezifischer Streamingtechnologie ortsunabhängig möglich. Hierdurch kann ein neuroendovaskulärer Spezialist geographisch entfernte Interventionalisten bei der Durchführung eines Kathetereingriffes am Gehirn beraten, die Handhabung der verwendeten Materialien überblicken und bei Bedarf anleiten (Remote-Proctoring). Schlussfolgerungen Insbesondere bei Notfalleingriffen und während Reisebeschränkungen kann durch Zuschaltung eines weiteren neuroendovaskulären Spezialisten per Livestreaming die Patientensicherheit erhöht werden.
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Affiliation(s)
- M Bechstein
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinik Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - E Goebell
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinik Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - J Fiehler
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinik Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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21
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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22
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Morey JR, Oxley TJ, Wei D, Kellner CP, Dangayach NS, Stein L, Hom D, Wheelwright D, Rubenstein L, Skliut M, Shoirah H, De Leacy RA, Singh IP, Zhang X, Persaud S, Tuhrim S, Dhamoon M, Bederson J, Mocco J, Fifi JT, Boniece IR, Brockington CD, Fara M, Hao Q, Horowitz DR, Lay C, Liang J, Nasrallah EJ, Roche T, Sheinart KF, Paul Singh I, Tegtmeyer C, Weinberger J. Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke. Stroke 2020; 51:3495-3503. [DOI: 10.1161/strokeaha.120.030248] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose:
Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models.
Methods:
This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months.
Results:
MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes (
P
<0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively (
P
=0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%;
P
<0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS (
P
=0.10).
Conclusions:
MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03048292.
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Affiliation(s)
- Jacob R. Morey
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Thomas J. Oxley
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Daniel Wei
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Christopher P. Kellner
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Neha S. Dangayach
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Laura Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Danny Hom
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Danielle Wheelwright
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Liorah Rubenstein
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Maryna Skliut
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Hazem Shoirah
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Reade A. De Leacy
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - I. Paul Singh
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Xiangnan Zhang
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Steven Persaud
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
| | - Joshua Bederson
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - J Mocco
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
| | - Johanna T. Fifi
- Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.)
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (N.S.D., L.S., D.W., M.S., H.S., I.P.S., S.T., M.D., J.T.F.)
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23
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Berge J, Marnat G, Hubrecht R, Veunac L, Rouanet F. Setting up mechanical thrombectomy centres to improve access for acute stroke patients. J Neuroradiol 2020; 47:331-333. [PMID: 32603769 DOI: 10.1016/j.neurad.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Jérôme Berge
- Neuroradiology department, University Hospital, Bordeaux, France.
| | - Gaultier Marnat
- Neuroradiology department, University Hospital, Bordeaux, France.
| | | | - Louis Veunac
- Radiology department, Bayonne Hospital, Aquitaine, France.
| | - François Rouanet
- Neuroradiology department, University Hospital, Bordeaux, France.
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24
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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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25
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Bechstein M, Buhk JH, Frölich AM, Broocks G, Hanning U, Erler M, Anđelković M, Debeljak D, Fiehler J, Goebell E. Training and Supervision of Thrombectomy by Remote Live Streaming Support (RESS) : Randomized Comparison Using Simulated Stroke Interventions. Clin Neuroradiol 2019; 31:181-187. [PMID: 31863121 DOI: 10.1007/s00062-019-00870-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/07/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Stroke patients are excluded from expeditious thrombectomy in regions lacking neurointerventional specialists. An audiovisual online streaming system was tested, allowing a neurointerventional specialist located at a neurovascular center to supervise and instruct a thrombectomy performed at a distant hospital without being physically present (remote streaming support [RESS]). METHODS In total, 36 thrombectomy procedures were performed on a Mentice endovascular simulator by six radiologists not specialized in neurointerventions. Each radiologist was challenged with six different endovascular simulation scenarios under alternating conventional local support (specialist inside the room [LOS]) and RESS, which was performed using an advanced live streaming platform. RESULTS Both support modes led to a median of 2 attempts (interquartile range [IQR] 2.0-2.0 each) until successful recanalization. There was no statistically significant difference in time from first catheter insertion to recanalization between LOS (median 24.9 min, IQR 21.0-31.5 min) and RESS (23.9 min, IQR 21.7-28.7 min, p = 0.89). The percentage of thrombi covered by the stent-retriever and average speed when retrieving the stent-retriever (3.7 mm/s, IQR 3.25-5.35 mm/s vs. 3.6 mm/sec, IQR 2.5-4.7) were similar in both groups. Fluoroscopy time did not differ (19.0 min, IQR 16.9-23.5 min vs. 19.9 min, IQR 15.9-23.5 min) with a trend towards increased median amounts of contrast medium used under RESS (62.9 ml vs. 43.1 ml; p = 0.055). CONCLUSION This study confirmed the feasibility of RESS for thrombectomy procedures in a simulated environment. This serves as basis for future studies planned to analyze the effectiveness of RESS in a real-world environment and to test if it improves the learning curve of interventionalists with limited thrombectomy experience in remote areas.
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Affiliation(s)
- Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Andreas Maximilian Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Martin Erler
- TEGUS Medical GmbH, Stresemannstraße 375, Unit 11, 22761, Hamburg, Germany
| | - Milan Anđelković
- TEGUS Medical GmbH, Stresemannstraße 375, Unit 11, 22761, Hamburg, Germany
| | - Dragan Debeljak
- TEGUS Medical GmbH, Stresemannstraße 375, Unit 11, 22761, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Einar Goebell
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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