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Röhrs KJ, Audebert H. Pre-Hospital Stroke Care beyond the MSU. Curr Neurol Neurosci Rep 2024; 24:315-322. [PMID: 38907812 PMCID: PMC11258185 DOI: 10.1007/s11910-024-01351-0] [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] [Accepted: 06/11/2024] [Indexed: 06/24/2024]
Abstract
PURPOSE OF REVIEW Mobile stroke units (MSU) have established a new, evidence-based treatment in prehospital stroke care, endorsed by current international guidelines and can facilitate pre-hospital research efforts. In addition, other novel pre-hospital modalities beyond the MSU are emerging. In this review, we will summarize existing evidence and outline future trajectories of prehospital stroke care & research on and off MSUs. RECENT FINDINGS The proof of MSUs' positive effect on patient outcomes is leading to their increased adoption in emergency medical services of many countries. Nevertheless, prehospital stroke care worldwide largely consists of regular ambulances. Advancements in portable technology for detecting neurocardiovascular diseases, telemedicine, AI and large-scale ultra-early biobanking have the potential to transform prehospital stroke care also beyond the MSU concept. The increasing implementation of telemedicine in emergency medical services is demonstrating beneficial effects in the pre-hospital setting. In synergy with telemedicine the exponential growth of AI-technology is already changing and will likely further transform pre-hospital stroke care in the future. Other promising areas include the development and validation of miniaturized portable devices for the pre-hospital detection of acute stroke. MSUs are enabling large-scale screening for ultra-early blood-based biomarkers, facilitating the differentiation between ischemia, hemorrhage, and stroke mimics. The development of suitable point-of-care tests for such biomarkers holds the potential to advance pre-hospital stroke care outside the MSU-concept. A multimodal approach of AI-supported telemedicine, portable devices and blood-based biomarkers appears to be an increasingly realistic scenario for improving prehospital stroke care in regular ambulances in the future.
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Affiliation(s)
- Kian J Röhrs
- Department of Neurology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Heinrich Audebert
- Department of Neurology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Peycheva M, Seiler A, Wagner F, Li L, Heldner MR. Journal Club: Prehospital Detection of Large Vessel Occlusion Stroke With Electroencephalography: Results of the ELECTRA-STROKE Study. Neurology 2024; 103:e209587. [PMID: 38870459 DOI: 10.1212/wnl.0000000000209587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
The ELECTRA-STROKE study investigated the potential of EEG for prehospital triage of patients with ischemic stroke due to large vessel occlusion (LVO), in which fast triage to stroke centers for endovascular treatment is crucial. The study was conducted in 4 phases, and this Journal Club article focuses on the fourth phase in the prehospital setting with suspected stroke patients. An EEG cap with dry electrodes was used to measure brain activity. The main focus was on the diagnostic accuracy of the theta/alpha ratio, which yielded an area under the receiver operator characteristic curve (AUC) of 0.80. Secondary endpoints, particularly the Brain Symmetry Index (a quantified EEG interhemispheric cortical power asymmetry index) in the delta frequency band, showed an AUC of 0.91. Despite the convenient study design and user-friendly EEG device, limitations include a single-arm design, a relatively small sample size, and exclusions due to data quality issues. The usefulness of EEG in the detection of neuronal changes based on brain ischemia was highlighted, but uncertainties remain regarding its use in certain patient groups. The improvements in the Brain Symmetry Index from phase 3 to 4 of the study indicate the potential for further refinement and investigation of combined methods to improve diagnostic accuracy. The study provides insight into the role of EEG in prehospital stroke detection, recognizing both the strengths and limitations. Overall, the study contributes to understanding the promise of EEG in optimizing LVO stroke triage and urges further refinement and exploration of complementary diagnostic approaches.
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Affiliation(s)
- Marieta Peycheva
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Andrea Seiler
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Franca Wagner
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Linxin Li
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Mirjam R Heldner
- From the Department of Neurology (M.P.), Medical University of Plovdiv; Research Institute at Medical University of Plovdiv (M.P.), Bulgaria; Department of Neurology (A.S., M.R.H.), and Institute of Diagnostic and Interventional Neuroradiology (F.W.), Inselspital, University Hospital and University of Bern, Switzerland; and Wolfson Centre for the Prevention of Stroke and Dementia (L.L.), Nuffield Department of Clinical Neurosciences, Wolfson Building-John Radcliffe Hospital, University of Oxford, United Kingdom
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Krothapalli N, Hasan D, Lusk J, Poli S, Hussain S, de Havenon A, Grotta J, Grory BM. Mobile stroke units: Beyond thrombolysis. J Neurol Sci 2024; 463:123123. [PMID: 38981417 DOI: 10.1016/j.jns.2024.123123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
In the last decade, mobile stroke units (MSUs) have shown the potential to transform prehospital stroke care, marking a paradigm shift in delivering ultra-rapid thrombolysis and streamlining triage processes. These units bring acute stroke care directly to patients, significantly shortening treatment times. This review outlines the rationale for MSU care and discusses the potential applications beyond the original purpose of delivering thrombolysis, including large vessel occlusion detection, intracerebral hemorrhage management, and innovative forms of prehospital research.
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Affiliation(s)
- Neeharika Krothapalli
- Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - David Hasan
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA; Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Jay Lusk
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Shazam Hussain
- Department of Neurology, Cleveland Clinic Health Foundation, Cleveland, OH, USA
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT, USA
| | - James Grotta
- Department of Neurology, University of Texas Health Science Center, Houston, TX, USA
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
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Hagrass AI, Elsayed SM, Doheim MF, Mostafa MA, Elfil M, Al-Kafarna M, Almaghary BK, Fayoud AM, Hamdallah A, Hasan MT, Ragab KM, Nourelden AZ, Zaazouee MS, Medicherla C, Lerario M, Czap AL, Chong J, Nour M, Al-Mufti F. Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 "T Letter" Domains. Cardiol Rev 2024; 32:297-313. [PMID: 38602410 DOI: 10.1097/crd.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.
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Affiliation(s)
| | | | - Mohamed Fahmy Doheim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | | | | | | | | | | | - Mackenzie Lerario
- Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Alexandra L Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY
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Teede H, Cadilhac DA, Purvis T, Kilkenny MF, Campbell BCV, English C, Johnson A, Callander E, Grimley RS, Levi C, Middleton S, Hill K, Enticott J. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 2024; 22:198. [PMID: 38750449 PMCID: PMC11094907 DOI: 10.1186/s12916-024-03416-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 04/30/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit. MAIN TEXT Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement. CONCLUSIONS The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.
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Affiliation(s)
- Helena Teede
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia.
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia.
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia.
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia.
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Bruce C V Campbell
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Coralie English
- School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia
| | - Alison Johnson
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia
| | - Emily Callander
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia
| | - Rohan S Grimley
- School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia
- Clinical Excellence Division, Queensland Health, Brisbane, Australia
| | - Christopher Levi
- John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia
| | - Sandy Middleton
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
- Nursing Research Institute, St Vincent's Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia
| | - Kelvin Hill
- Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia
| | - Joanne Enticott
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia
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Lam TJR, Liu Z, Tan BYQ, Ng YY, Tan CK, Wong XY, Venketasubramanian N, Yeo LLL, Ho AFW, Ong MEH. Prehospital stroke care in Singapore. Singapore Med J 2024:00077293-990000000-00102. [PMID: 38449072 DOI: 10.4103/singaporemedj.smj-2023-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/03/2023] [Indexed: 03/08/2024]
Abstract
ABSTRACT Due to the narrow window of opportunity for stroke therapeutics to be employed, effectiveness of stroke care systems is predicated on the efficiency of prehospital stroke systems. A robust prehospital stroke system of care that provides a rapid and well-coordinated response maximises favourable poststroke outcomes, but achieving this presents a unique set of challenges dependent on demographic and geographical circumstances. Set in the context of a highly urbanised first-world nation with a rising burden of stroke, Singapore's prehospital stroke system has evolved to reflect the environment in which it operates. This review aims to characterise the current state of prehospital stroke care in Singapore, covering prehospital aspects of the stroke survival chain from symptom onset till arrival at the emergency department. We identify areas for improvement and innovation, as well as provide insights into the possible future of prehospital stroke care in Singapore.
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Affiliation(s)
| | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Yih Ying Ng
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore
- Ministry of Home Affairs, Singapore Civil Defence Force, Singapore
| | - Colin Kaihui Tan
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | - Xiang Yi Wong
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | | | | | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
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van Stigt MN, Groenendijk EA, van Meenen LCC, van de Munckhof AAGA, Theunissen M, Franschman G, Smeekes MD, van Grondelle JAF, Geuzebroek G, Siegers A, Visser MC, van Schaik SM, Halkes PHA, Majoie CBLM, Roos YBWEM, Koelman JHTM, Koopman MS, Marquering HA, Potters WV, Coutinho JM. Prehospital Detection of Large Vessel Occlusion Stroke With EEG. Neurology 2023; 101:e2522-e2532. [PMID: 37848336 PMCID: PMC10791060 DOI: 10.1212/wnl.0000000000207831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) is standard treatment for anterior large vessel occlusion stroke (LVO-a stroke). Prehospital diagnosis of LVO-a stroke would reduce time to EVT by allowing direct transportation to an EVT-capable hospital. We aim to evaluate the diagnostic accuracy of dry electrode EEG for the detection of LVO-a stroke in the prehospital setting. METHODS ELECTRA-STROKE was an investigator-initiated, prospective, multicenter, diagnostic study, performed in the prehospital setting. Adult patients were eligible if they had suspected stroke (as assessed by the attending ambulance nurse) and symptom onset <24 hours. A single dry electrode EEG recording (8 electrodes) was performed by ambulance personnel. Primary endpoint was the diagnostic accuracy of the theta/alpha frequency ratio for LVO-a stroke (intracranial ICA, A1, M1, or proximal M2 occlusion) detection among patients with EEG data of sufficient quality, expressed as the area under the receiver operating characteristic curve (AUC). Secondary endpoints were diagnostic accuracies of other EEG features quantifying frequency band power and the pairwise derived Brain Symmetry Index. Neuroimaging was assessed by a neuroradiologist blinded to EEG results. RESULTS Between August 2020 and September 2022, 311 patients were included. The median EEG duration time was 151 (interquartile range [IQR] 151-152) seconds. For 212/311 (68%) patients, EEG data were of sufficient quality for analysis. The median age was 74 (IQR 66-81) years, 90/212 (42%) were women, and the median baseline NIH Stroke Scale was 1 (IQR 0-4). Six (3%) patients had an LVO-a stroke, 109/212 (51%) had a non-LVO-a ischemic stroke, 32/212 (15%) had a transient ischemic attack, 8/212 (4%) had a hemorrhagic stroke, and 57/212 (27%) had a stroke mimic. AUC of the theta/alpha ratio was 0.80 (95% CI 0.58-1.00). Of the secondary endpoints, the pairwise derived Brain Symmetry Index in the delta frequency band had the highest diagnostic accuracy (AUC 0.91 [95% CI 0.73-1.00], sensitivity 80% [95% CI 38%-96%], specificity 93% [95% CI 88%-96%], positive likelihood ratio 11.0 [95% CI 5.5-21.7]). DISCUSSION The data from this study suggest that dry electrode EEG has the potential to detect LVO-a stroke among patients with suspected stroke in the prehospital setting. Toward future implementation of EEG in prehospital stroke care, EEG data quality needs to be improved. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov identifier: NCT03699397. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that prehospital dry electrode scalp EEG accurately detects LVO-a stroke among patients with suspected acute stroke.
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Affiliation(s)
- Maritta N van Stigt
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Eva A Groenendijk
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Laura C C van Meenen
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Anita A G A van de Munckhof
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Monique Theunissen
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Gaby Franschman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Martin D Smeekes
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Joffry A F van Grondelle
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Geertje Geuzebroek
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Arjen Siegers
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Marieke C Visser
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Sander M van Schaik
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Patricia H A Halkes
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Charles B L M Majoie
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Yvo B W E M Roos
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Johannes H T M Koelman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Miou S Koopman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Henk A Marquering
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Wouter V Potters
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Jonathan M Coutinho
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
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8
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Purvis T, Cadilhac DA, Hill K, Reyneke M, Olaiya MT, Dalli LL, Kim J, Murphy L, Campbell BC, Kilkenny MF. Twenty years of monitoring acute stroke care in Australia through the national stroke audit programme (1999-2019): A cross-sectional study. J Health Serv Res Policy 2023; 28:252-261. [PMID: 37212454 DOI: 10.1177/13558196231174732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND National organisational surveys and clinical audits to monitor and guide improvements to the delivery of evidence-based acute stroke care have been undertaken in Australia since 1999. This study aimed to determine the association between repeated national audit cycles on stroke service provision and care delivery from 1999 to 2019. METHODS Cross-sectional study using data from organisational surveys (1999, 2004, 2007-2019) and clinical data from the biennial National Stroke Acute Audit (2007-2019). Age-, sex-, and stroke severity-adjusted proportions were reported for adherence to guideline-recommended care processes. Multivariable, logistic regression models were performed to determine the association between repeated audit cycles and service provision (organisational) and care delivery (clinical). RESULTS Overall, 197 hospitals provided organisational survey data (1999-2019), with 24,996 clinical cases from 136 hospitals (around 40 cases per audit) (2007-2019). We found significant improvements in service organisation between 1999 and 2019 for access to stroke units (1999: 42%, 2019: 81%), thrombolysis services (1999: 6%, 2019: 85%), and rapid assessment/management for patients with transient ischaemic attack (1999: 11%, 2019: 61%). Analyses of patient-level audits for 2007 to 2019 found the odds of receiving care processes per audit cycle to have significantly increased for thrombolysis (2007: 3%, 2019: 11%; OR 1.15, 95% CI 1.13, 1.17), stroke unit access (2007: 52%, 2019: 69%; OR 1.15, 95% CI 1.14, 1.17), risk factor advice (2007: 40%, 2019: 63%; OR 1.10, 95% CI 1.09, 1.12), and carer training (2007: 24%, 2019: 51%; OR 1.12, 95% CI 1.10, 1.15). CONCLUSIONS Between 1999 and 2019, the quality of acute stroke care in Australia has improved in line with best practice evidence. Standardised monitoring of stroke care can inform targeted efforts to reduce identified gaps in best practice, and illustrate the evolution of the health system for stroke.
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Affiliation(s)
- Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Kelvin Hill
- Stroke Foundation, Melbourne, VIC, Australia
| | - Megan Reyneke
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Lisa Murphy
- Stroke Foundation, Melbourne, VIC, Australia
| | - Bruce Cv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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9
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Redfern J, Shang C, Hsu MP, Doyle K, Nutbeam D, Audehm R, Inglis SC, Hamilton-Craig C, Raffoul N, Shaw T, Figtree GA, Jennings G. Cardiovascular Disease Implementation and Policy Priorities for Australia: Recommendations From an Australian Stakeholder Roundtable. Heart Lung Circ 2023; 32:1141-1147. [PMID: 37758637 DOI: 10.1016/j.hlc.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/15/2023] [Indexed: 09/29/2023]
Abstract
The Australian Cardiovascular Alliance (ACvA), the Cardiac Society of Australia and New Zealand (CSANZ) and the National Heart Foundation of Australia (NHFA) recently joined forces to bring the cardiovascular and stroke community together to convene and document a national discussion and propose a national CVD Implementation and Policy agenda and action plan. This includes prevention and screening, acute care and secondary prevention.
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Affiliation(s)
- Julie Redfern
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, AUSTRALIA; Australian Cardiovascular Alliance, Australia.
| | | | | | - Kerry Doyle
- Australian Cardiovascular Alliance, Australia
| | - Don Nutbeam
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, AUSTRALIA; Sydney Health Partners, Charles Perkins Centre, Sydney, NSW, Australia
| | - Ralph Audehm
- National Heart Foundation of Australia, Australia; Department of General Practice and Primary Healthcare, University of Medicine, Melbourne, Vic, Australia
| | - Sally C Inglis
- Cardiac Society of Australia and New Zealand, Sydney, Australia; University of Technology Sydney, Sydney, NSW, Australia
| | - Christian Hamilton-Craig
- Cardiac Society of Australia and New Zealand, Sydney, Australia; Faculty of Medicine, University of Queensland and Centre for Advanced Imaging, Brisbane, Qld, Australia
| | | | - Timothy Shaw
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, AUSTRALIA
| | - Gemma A Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, AUSTRALIA; Australian Cardiovascular Alliance, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, Sydney, NSW, Australia; Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Garry Jennings
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, AUSTRALIA; Australian Cardiovascular Alliance, Australia; Sydney Health Partners, Charles Perkins Centre, Sydney, NSW, Australia; National Heart Foundation of Australia, Australia
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10
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [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: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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11
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Bagot KL, Purvis T, Hancock S, Zhao H, Coote S, Easton D, Campbell BCV, Davis SM, Donnan GA, Foster S, Langenberg F, Smith K, Stephenson M, Bernard S, McGowan S, Yan B, Mitchell P, Middleton S, Cadilhac DA. Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation. J Eval Clin Pract 2023; 29:495-512. [PMID: 36648226 DOI: 10.1111/jep.13803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. AIM To identify successes and challenges in the pre- and initial operations of the first Australian MSU service from an interdisciplinary perspective. METHODS Process evaluation of the Melbourne MSU with a mixed-methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June-September 2019) and semistructured interviews (October-November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. RESULTS Participants representing executive/program operations, MSU clinicians and hospital-based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. CONCLUSIONS Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.
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Affiliation(s)
- Kathleen L Bagot
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Shaun Hancock
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Skye Coote
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Damien Easton
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia.,Stroke Foundation, Melbourne, Victoria, Australia
| | - Steve M Davis
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff A Donnan
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Shane Foster
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Francesca Langenberg
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Michael Stephenson
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | | | - Bernard Yan
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Mitchell
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Sandy Middleton
- St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Nursing Research Institute, Australian Catholic University, Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia.,Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Gao L, Parsons M, Churilov L, Zhao H, Campbell BCV, Yan B, Mitchell P, Coote S, Langenberg F, Smith K, Anderson D, Stephenson M, Davis SM, Donnan G, Easton D, Bivard A. Cost-effectiveness of tenecteplase versus alteplase for stroke thrombolysis evaluation trial in the ambulance. Eur Stroke J 2023; 8:448-455. [DOI: 10.1177/23969873231165086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Background: Tenecteplase administered to patients with ischaemic stroke in a mobile stroke unit (MSU) has been shown to reduce the perfusion lesion volumes and result in ultra-early recovery. We now seek to assess the cost-effectiveness of tenecteplase in the MSU. Methods: A within-trial (TASTE-A) economic analysis and a model-based long-term cost-effectiveness analysis were performed. This post hoc within-trial economic analysis utilised the patient-level data (intention to treat, ITT) prospectively collected over the trial to calculate the difference in both healthcare costs and quality-adjusted life years (QALYs, estimated from modified Rankin scale score). A Markov microsimulation model was developed to simulate the long-term costs and benefits. Results: In total, there were 104 patients with ischaemic stroke randomised to tenecteplase ( n = 55) or alteplase ( n = 49) treatment groups, respectively in the TASTE-A trial. The ITT-based analysis showed that treatment with tenecteplase was associated with non-signficantly lower costs (A$28,903 vs A$40,150 ( p = 0.056)) and greater benefits (0.171 vs 0.158 ( p = 0.457)) than that for the alteplase group over the first 90 days post the index stroke. The long-term model showed that tenecteplase led to greater savings in costs (−A$18,610) and more health benefits (0.47 QALY or 0.31 LY gains). Tenecteplase-treated patients had reduced costs for rehospitalisation (−A$1464), nursing home care (−A$16,767) and nonmedical care (−A$620) per patient. Conclusions: Treatment of ischaemic stroke patients with tenecteplase appeared to be cost-effective and improve QALYs in the MSU setting based on Phase II data. The reduced total cost from tenecteplase was driven by savings from acute hospitalisation and reduce need for nursing home care.
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13
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Mackey J, Yamal JM, Parker SA, Silnes K, Rajan SS, Jacob AP, Wang M, Singh N, Jones WJ, Spokoyny I, Navi BB, Saver JL, Grotta JC. Golden Hour Treatment With tPA (Tissue-Type Plasminogen Activator) in the BEST-MSU Study. Stroke 2023; 54:415-425. [PMID: 36689579 DOI: 10.1161/strokeaha.122.039821] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/19/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Treatment of patients with acute ischemic stroke on mobile stroke units (MSUs) improves outcomes compared with management by standard emergency medical services ambulances and is associated with more patients treated with intravenous tPA (tissue-type plasminogen activator) in the first golden hour after last known normal. We explored the predictors and outcomes of first-hour treatment (FHT) compared with later treatment in an alternating-week cluster-controlled trial of MSUs. METHODS We analyzed all patients treated with intravenous tPA in the BEST-MSU Study (Benefits of Stroke Treatment Delivered by a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). After stratifying by treatment timeframe, we identified factors associated with FHT. We performed adjusted analyses of the association between FHT and clinical outcome and modeled the shape of the relationship between last known normal-to-treatment time and excellent outcome. RESULTS Among 941 tPA-treated patients, 206 (21.8%) had lytic started within 60 minutes. Treatment on the MSU, older age, male sex, alert by 911, faster arrival on-scene and imaging, more severe stroke, atrial fibrillation, and absence of heart failure and pretreatment antihypertensive treatment were associated with FHT. Compared with later treatment, FHT was associated with higher adjusted odds ratio for 90-day modified Rankin Scale score of 0 to 1 (odds ratio, 1.87 [95% CI, 1.25-2.84]; P=0.003). Among FHT patients, 68% achieved a 90-day modified Rankin Scale of 0 or 1 or returned to their baseline status. FHT was not associated with higher risk of hemorrhage and was associated with reduced risk of treating neurovascular mimics. CONCLUSIONS FHT almost doubles the odds of excellent clinical outcome without increased risk compared with later treatment, which supports the use of MSUs.
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Affiliation(s)
- Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M., K.S.)
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - Stephanie A Parker
- Department of Neurology, University of Texas McGovern Medical School, Houston (S.A.P., A.P.J.)
| | - Kelly Silnes
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M., K.S.)
- University of Buckingham Medical School, United Kingdom (K.S.)
| | - Suja S Rajan
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - Asha P Jacob
- Department of Neurology, University of Texas McGovern Medical School, Houston (S.A.P., A.P.J.)
| | - Mengxi Wang
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - Noopur Singh
- Department of Biostatistics and Data Science, University of Texas School of Public Health, Houston (J.-M.Y., S.S.R., M.W., N.S.)
| | - William J Jones
- Department of Neurology, University of Colorado, Aurora (W.J.J.)
| | - Ilana Spokoyny
- Department of Neurology, Mills Peninsula Medical Center, Burlingame, CA (I.S.)
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY (B.B.N.)
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center (J.L.S.)
| | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston (J.C.G.)
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14
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Tanaka K, Reeves MJ. Mobile Stroke Units and Pursuit of Intravenous Tissue-Type Plasminogen Activator Treatment in the Golden Hour. Stroke 2023; 54:426-429. [PMID: 36689589 DOI: 10.1161/strokeaha.122.041391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
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15
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Botelho A, Rios J, Fidalgo AP, Ferreira E, Nzwalo H. Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316357. [PMID: 36498429 PMCID: PMC9735885 DOI: 10.3390/ijerph192316357] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS. METHODOLOGY Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. RESULTS A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART. CONCLUSIONS Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.
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Affiliation(s)
- Ana Botelho
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Jonathan Rios
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Ana Paula Fidalgo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Eugénia Ferreira
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
| | - Hipólito Nzwalo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal
- Algarve Biomedical Research Institute, 8005-139 Faro, Portugal
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16
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Muacevic A, Adler JR, Alves M, Papoila AL, Nunes AP. Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region. Cureus 2022; 14:e32659. [PMID: 36660499 PMCID: PMC9844243 DOI: 10.7759/cureus.32659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Endovascular treatment (EVT) with mechanical thrombectomy and acute carotid stenting has become an integral part of the treatment of acute ischemic stroke with large vessel occlusion. Despite being included in the most recent stroke guidelines, only comprehensive centers can offer EVT and thus patients frequently need to be transferred from primary hospitals. We aimed to assess which pre-hospital model of care - direct admission to a comprehensive stroke center (mothership) or transfer to a comprehensive stroke center after the first admission to the nearest hospital (drip-and-ship) - had the most benefit in stroke patients in a Portuguese urban region. Methods We selected patients admitted to a comprehensive stroke center who underwent EVTs between January 2018 and December 2020, in Lisbon, Portugal. We used data from the Safe Implementation of Treatments in Stroke (SITS) International registry on stroke severity, previous modified Rankin Scale (mRS), time from symptom onset to the first admission, time from symptom onset to the procedure, and mRS three months post stroke. We defined an unfavorable outcome as having an mRS >2 at three months post stroke. For patients with previous mRS >2, an unfavorable outcome was defined as any increase in mRS at three months post stroke. Results We analyzed the data of 1154 patients, of which 407 were admitted through a mothership approach and 747 through a drip-and-ship approach. Both groups were similar regarding sociodemographic characteristics, stroke risk factors, previous disability, and stroke severity. Median onset-to-door time was higher (126 vs 110 minutes, p-value=0.002) but onset-to-procedure time was lower (199 vs 339 minutes, p-value<0.001) in the mothership group. The mothership group had a higher proportion of patients with mRS <3 at three months post stroke than the drip-and-ship group (41.3% vs 34.9%, p-value=0.035). Mortality was similar in both groups. A multivariate logistic regression model confirmed a lower probability of unfavorable outcomes with the mothership approach (OR = 0.677, 95% CI 0.514-0.892, p-value=0.006). Surprisingly, onset-to-procedure time did not have an impact on functional outcomes. Conclusion Our findings show that the mothership model results in better functional outcomes for patients with acute ischemic stroke with large vessel occlusion. Further studies are needed to better define patient selection for this strategy and the impact of a mothership model in comprehensive stroke centers.
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Al Saiegh F, Velagapudi L, Khanna O, Baldassari MP, Mouchtouris N, Hafazalla K, Roussis J, DePrince M, Tjoumakaris S, Gooch MR, Herial N, Rosenwasser RH, Jabbour P. Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via a Mobile Stroke Unit. World Neurosurg 2022; 166:e546-e550. [PMID: 35863651 DOI: 10.1016/j.wneu.2022.07.047] [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: 03/30/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally. METHODS A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means. RESULTS Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 minutes ±77.53 vs. 483.51 minutes ±322.66, P = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86 ± 1.35 vs. 3.57 ± 1.88, P = 0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed. CONCLUSIONS Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
| | - Lohit Velagapudi
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karim Hafazalla
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Roussis
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maureen DePrince
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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18
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Tan S, Stephens K, Gao L, Tan E, Frost T, Choi PMC. Practical utility of the ACT-FAST triage algorithm from a primary stroke centre perspective. BMJ Neurol Open 2022; 4:e000325. [PMID: 36110929 PMCID: PMC9462081 DOI: 10.1136/bmjno-2022-000325] [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: 05/25/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Rapid reperfusion in ischaemic stroke with emergent large vessel occlusion (ELVO) reduces morbidity and mortality. Limited distribution of endovascular clot retrieval (ECR) capable comprehensive stroke centres (CSCs) necessitates development of pre-hospital models of care to provide equitable and economical access to reperfusion therapy. We examine the time metrics of the traditional secondary transfer strategy in comparison to the direct bypass strategy and the potential utility of the ACT-FAST prehospital triage algorithm on a large volume Melbourne primary stroke centre (PSC). Method: Retrospective analysis of consecutive patients presenting to a PSC from 1 January 2020 to 31 December 2020. Clinical records were interrogated for ACT-FAST positive patients. Time metrics were established using Google Maps traffic modelling and local/published door-to-needle, door-in-door out and door-to-groin data. Results: 88 patients during the study period were ACT-FAST positive. Of these, 49/88 (56%) cases had ELVO ischaemic strokes, 24/88 (27%) cases had intracranial haemorrhages and the remaining 15/88 (17%) had non ELVO ischaemic strokes or mimics (seizure, complex migraine, etc). 28/88 (32%) cases met indication for and were subsequently transferred to a CSC for consideration of ECR. The modelled median scene to groin time for the direct bypass strategy is 94 min whereas the median scene to groin time for the secondary transfer strategy is 109 min, giving a difference of 15 min. Conclusion: Time savings to groin puncture for the direct bypass strategy is substantially less than previous estimates and suggests that the secondary transfer strategy continues to be a viable pathway for a high efficiency PSC.
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Affiliation(s)
- Shuangyue Tan
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Karen Stephens
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Lan Gao
- Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Elise Tan
- Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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19
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Yu AY, Bravata DM, Norrving B, Reeves MJ, Liu L, Kilkenny MF. Measuring Stroke Quality: Methodological Considerations in Selecting, Defining, and Analyzing Quality Measures. Stroke 2022; 53:3214-3221. [DOI: 10.1161/strokeaha.122.036485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Knowledge about stroke and its management is growing rapidly and stroke systems of care must adapt to deliver evidence-based care. Quality improvement initiatives are essential for translating knowledge from clinical trials and recommendations in guidelines into routine clinical practice. This review focuses on issues central to the measurement of the quality of stroke care, including selection and definition of quality measures, identification of the eligible patient cohorts, optimization of data quality, and considerations for data analysis and interpretation.
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Affiliation(s)
- Amy Y.X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (A.Y.X.Y.)
| | - Dawn M. Bravata
- VA HSR&D Center for Health Information and Communication (CHIC)‚ Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.)
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (D.M.B.)
- Regenstrief Institute, Indianapolis, IN (D.M.B.)
| | - Bo Norrving
- Department of Clinical Sciences (Neurology), Lund, Lund University, and Neurology, Skåne University Hospital Lund/Malmö, Sweden (B.N.)
| | - Mathew J. Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (L.L.)
| | - Monique F. Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (M.F.K.)
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (M.F.K.)
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20
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Bladin CF, Bagot KL, Vu M, Kim J, Bernard S, Smith K, Hocking G, Coupland T, Pearce D, Badcock D, Budge M, Nadurata V, Pearce W, Hall H, Kelly B, Spencer A, Chapman P, Oqueli E, Sahathevan R, Kraemer T, Hair C, Stub D, Cadilhac DA. Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care. BMJ Open 2022; 12:e052332. [PMID: 35851025 PMCID: PMC9297229 DOI: 10.1136/bmjopen-2021-052332] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine if a digital communication app improves care timelines for patients with suspected acute stroke/ST-elevation myocardial infarction (STEMI). DESIGN Real-world feasibility study, quasi-experimental design. SETTING Prehospital (25 Ambulance Victoria branches) and within-hospital (2 hospitals) in regional Victoria, Australia. PARTICIPANTS Paramedics or emergency department (ED) clinicians identified patients with suspected acute stroke (onset <4.5 hours; n=604) or STEMI (n=247). INTERVENTION The Pulsara communication app provides secure, two-way, real-time communication. Assessment and treatment times were recorded for 12 months (May 2017-April 2018), with timelines compared between 'Pulsara initiated' (Pulsara) and 'not initiated' (no Pulsara). PRIMARY OUTCOME MEASURE Door-to-treatment (needle for stroke, balloon for STEMI) Secondary outcome measures: ambulance and hospital processes. RESULTS Stroke (no Pulsara n=215, Pulsara n=389) and STEMI (no Pulsara n=76, Pulsara n=171) groups were of similar age and sex (stroke: 76 vs 75 years; both groups 50% male; STEMI: 66 vs 63 years; 68% and 72% male). When Pulsara was used, patients were off ambulance stretcher faster for stroke (11(7, 17) vs 19(11, 29); p=0.0001) and STEMI (14(7, 23) vs 19(10, 32); p=0.0014). ED door-to-first medical review was faster (6(2, 14) vs 23(8, 67); p=0.0001) for stroke but only by 1 min for STEMI (3 (0, 7) vs 4 (0, 14); p=0.25). Door-to-CT times were 44 min faster (27(18, 44) vs 71(43, 147); p=0.0001) for stroke, and percutaneous intervention door-to-balloon times improved by 17 min, but non-significant (56 (34, 88) vs 73 (49, 110); p=0.41) for STEMI. There were improvements in the proportions of patients treated within 60 min for stroke (12%-26%, p=0.15) and 90 min for STEMI (50%-78%, p=0.20). CONCLUSIONS In this Australian-first study, uptake of the digital communication app was strong, patient-centred care timelines improved, although door-to-treatment times remained similar.
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Affiliation(s)
- Chris F Bladin
- Ambulance Victoria, Doncaster, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Kathleen L Bagot
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Stroke and Ageing Research, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Michelle Vu
- Epworth Hospital, Richmond, Victoria, Australia
| | - Joosup Kim
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Stroke and Ageing Research, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | | | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | - Debra Pearce
- Ballarat Health Services, Ballarat, Victoria, Australia
| | | | - Marc Budge
- Bendigo Health, Bendigo, Victoria, Australia
| | | | - Wayne Pearce
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Howard Hall
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Ben Kelly
- Ballarat Health Services, Ballarat, Victoria, Australia
| | - Angie Spencer
- Ballarat Health Services, Ballarat, Victoria, Australia
| | | | - Ernesto Oqueli
- Ballarat Health Services, Ballarat, Victoria, Australia
- Department of Medicine, Deakin University, Burwood, Sydney, Australia
| | - Ramesh Sahathevan
- Ballarat Health Services, Ballarat, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Casey Hair
- Ballarat Health Services, Ballarat, Victoria, Australia
| | - Dion Stub
- Ambulance Victoria, Doncaster, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- Stroke and Ageing Research, Department of Medicine, Monash University, Clayton, Victoria, Australia
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21
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Lund UH, Stoinska-Schneider A, Larsen K, Bache KG, Robberstad B. Cost-Effectiveness of Mobile Stroke Unit Care in Norway. Stroke 2022; 53:3173-3181. [PMID: 35862205 PMCID: PMC9508956 DOI: 10.1161/strokeaha.121.037491] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project).
METHODS:
We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway.
RESULTS:
MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated.
CONCLUSIONS:
MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.
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Affiliation(s)
- Ulrikke Højslev Lund
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Anna Stoinska-Schneider
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
| | - Kristi G. Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
- Research and Dissemination, Østfold University College, Halden, Norway (K.G.B.)
| | - Bjarne Robberstad
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
- Department of Global Public Health and Primary Care, University of Bergen, Norway (B.R.)
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22
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Ellens NR, Schartz D, Rahmani R, Akkipeddi SMK, Kelly AG, Benesch CG, Parker SA, Burgett JL, Proper D, Pilcher WH, Mattingly TK, Grotta JC, Bhalla T, Bender MT. Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis. Front Neurol 2022; 13:868051. [PMID: 35614916 PMCID: PMC9124821 DOI: 10.3389/fneur.2022.868051] [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: 02/02/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance. Methods Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day. Results Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I2 = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I2 = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I2 = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I2 = 91%). Conclusions In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Sajal Medha K. Akkipeddi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Adam G. Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Curtis G. Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Stephanie A. Parker
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, United States
| | - Jason L. Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Webster H. Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital—Texas Medical Center, Houston, TX, United States
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
- *Correspondence: Matthew T. Bender
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23
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Bivard A, Zhao H, Churilov L, Campbell BCV, Coote S, Yassi N, Yan B, Valente M, Sharobeam A, Balabanski AH, Dos Santos A, Ng JL, Yogendrakumar V, Ng F, Langenberg F, Easton D, Warwick A, Mackey E, MacDonald A, Sharma G, Stephenson M, Smith K, Anderson D, Choi P, Thijs V, Ma H, Cloud GC, Wijeratne T, Olenko L, Italiano D, Davis SM, Donnan GA, Parsons MW. Comparison of tenecteplase with alteplase for the early treatment of ischaemic stroke in the Melbourne Mobile Stroke Unit (TASTE-A): a phase 2, randomised, open-label trial. Lancet Neurol 2022; 21:520-527. [DOI: 10.1016/s1474-4422(22)00171-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 12/19/2022]
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24
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Bivard A, Zhao H, Coote S, Campbell B, Churilov L, Yassi N, Yan B, Valente M, Sharobeam A, Balabanski A, Dos Santos A, Ng F, Langenberg F, Stephenson M, Smith K, Bernard S, Thijs V, Cloud G, Choi P, Ma H, Wijeratne T, Chen C, Olenko L, Davis SM, Donnan GA, Parsons M. Tenecteplase versus Alteplase for Stroke Thrombolysis Evaluation Trial in the Ambulance (Mobile Stroke Unit-TASTE-A): protocol for a prospective randomised, open-label, blinded endpoint, phase II superiority trial of tenecteplase versus alteplase for ischaemic stroke patients presenting within 4.5 hours of symptom onset to the mobile stroke unit. BMJ Open 2022; 12:e056573. [PMID: 35487712 PMCID: PMC9058803 DOI: 10.1136/bmjopen-2021-056573] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mobile stroke units (MSUs) equipped with a CT scanner are increasingly being used to assess and treat stroke patients' prehospital with thrombolysis and transfer them to the most appropriate hospital for ongoing stroke care and thrombectomy when indicated. The effect of MSUs in both reducing the time to reperfusion treatment and improving patient outcomes is now established. There is now an opportunity to improve the efficacy of treatment provided by the MSU. Tenecteplase is a potent plasminogen activator, which may have benefits over the standard of care stroke lytic alteplase. Specifically, in the MSU environment tenecteplase presents practical benefits since it is given as a single bolus and does not require an infusion over an hour like alteplase. OBJECTIVE In this trial, we seek to investigate if tenecteplase, given to patients with acute ischaemic stroke as diagnosed on the MSU, improves the rate of early reperfusion. METHODS AND ANALYSIS TASTE-A is a prospective, randomised, open-label, blinded endpoint (PROBE) phase II trial of patients who had an ischaemic stroke assessed in an MSU within 4.5 hours of symptom onset. The primary endpoint is early reperfusion measured by the post-lysis volume of the CT perfusion lesion performed immediately after hospital arrival. ETHICS AND DISSEMINATION The study was approved by the Royal Melbourne Hospital Human Ethics committee. The findings will be published in peer-reviewed journals, presented at academic conferences and disseminated among consumer and healthcare professional audiences. TRIAL REGISTRATION NUMBER NCT04071613.
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Affiliation(s)
- Andrew Bivard
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Skye Coote
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Valente
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Angelos Sharobeam
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Anna Balabanski
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Angela Dos Santos
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Felix Ng
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Francesca Langenberg
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | | | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Stroke Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neurology, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, Footscray, Victoria, Australia
| | - Chushuang Chen
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liudmyla Olenko
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark Parsons
- School of Medicine and Public Health, Department of Neurology Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
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25
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Sepponen R, Saviluoto A, Jäntti H, Harve-Rytsälä H, Lääperi M, Nurmi J. Validation of Score to Detect Intracranial Lesions in Unconscious Patients in Prehospital Setting. J Stroke Cerebrovasc Dis 2022; 31:106319. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/09/2022] [Indexed: 11/30/2022] Open
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26
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Coote S, Mackey E, Alexandrov AW, Cadilhac DA, Alexandrov AV, Easton D, Zhao H, Langenberg F, Bivard A, Stephenson M, Parsons MW, Campbell BCV, Donnan GA, Davis SM, Middleton S. The Mobile Stroke Unit Nurse: An International Exploration of Their Scope of Practice, Education, and Training. J Neurosci Nurs 2022; 54:61-67. [PMID: 35245919 DOI: 10.1097/jnn.0000000000000632] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Mobile stroke units (MSUs) are ambulance-based prehospital stroke care services. Through immediate roadside assessment and onboard brain imaging, MSUs provide faster stroke management with improved patient outcomes. Mobile stroke units have enabled the development of expanded scope of practice for stroke nurses; however, there is limited published evidence about these evolving prehospital acute nursing roles. AIMS: The aim of this study was to explore the expanded scope of practice of nurses working on MSUs by identifying MSUs with onboard nurses; describing the roles and responsibilities, training, and experience of MSU nurses, through a search of the literature; and describing 2 international MSU services incorporating nurses from Memphis, Tennessee, and Melbourne, Australia. METHODS: We searched PubMed, CINAHL, and the Joanna Briggs Institute Evidence-Based Practice database using the terms "mobile stroke unit" and "nurse." Existing MSUs were identified through the PRE-hospital Stroke Treatment Organization to determine models that involved nurses. We describe 2 MSUs involving nurses: one in Memphis and one in Melbourne, led by 2 of our authors. RESULTS: Ninety articles were found describing 15 MSUs; however, staffing details were lacking, and it is unknown how many employ nurses. Nine articles described the role of the nurse, but role specifics, training, and expertise were largely undocumented. The MSU in Memphis, the only unit to be staffed exclusively by onboard nurse practitioners, is supported by a neurologist who consults via telephone. The Melbourne MSU plans to trial a nurse-led telemedicine model in the near future. CONCLUSION: We lack information on how many MSUs employ nurses, and the nurses' scope of practice, training, and expertise. Expert stroke nurse practitioners can safely perform many of the tasks undertaken by the onboard neurologist, making a nurse-led telemedicine model an effective and potentially cost-effective model that should be considered for all MSUs.
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27
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Navi BB, Audebert HJ, Alexandrov AW, Cadilhac DA, Grotta JC. Mobile Stroke Units: Evidence, Gaps, and Next Steps. Stroke 2022; 53:2103-2113. [PMID: 35331008 DOI: 10.1161/strokeaha.121.037376] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mobile stroke units (MSUs) are specialized ambulances equipped with the personnel, equipment, and imaging capability to diagnose and treat acute stroke in the prehospital setting. Over the past decade, MSUs have proliferated throughout the world, particularly in European and US cities, culminating in the formation of an international consortium. Randomized trials have demonstrated that MSUs increase stroke thrombolysis rates and reduce onset-to-treatment times but until recently it was uncertain if these advantages would translate into better patient outcomes. In 2021, 2 pivotal, large, controlled clinical trials, B_PROUD and BEST-MSU, demonstrated that as compared with conventional emergency care, treatment aboard MSUs was safe and led to improved functional outcomes in patients with stroke. Further, the observed benefit of MSUs appeared to be primarily driven by the higher frequency of ultra-early thrombolysis within the golden hour. Nevertheless, questions remain regarding the cost-effectiveness of MSUs, their utility in nonurban settings, and optimal infrastructure. In addition, in much of the world, MSUs are currently not reimbursed by insurers nor accepted as standard care by regulatory bodies. As MSUs are now established as one of the few proven acute stroke interventions with an effect size that is comparable to that of intravenous thrombolysis and stroke units, stroke leaders and organizations should work with emergency medical services, governments, and community stakeholders to determine how MSUs might benefit individual communities, and their optimal organization and financing. Future research to explore the effect of MSUs on intracranial hemorrhage and thrombectomy outcomes, cost-effectiveness, and novel models including the use of rendezvous transports, helicopters, and advanced neuroimaging is ongoing. Recommended next steps for MSUs include reimbursement by insurers, integration with ambulance networks, recognition by program accreditors, and inclusion in registries that monitor care quality.
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Affiliation(s)
- Babak B Navi
- Department of Neurology and Brain and Mind Research Institute, Weill Cornell Medicine and NewYork-Presbyterian Hospital' New York (B.B.N.)
| | - Heinrich J Audebert
- Department of Neurology, Center for Stroke Research, Charite-Universitatsmedizin, Berlin, Germany (H.J.A.)
| | | | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia (D.A.C.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston
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28
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Wassélius J, Arnberg F, von Euler M, Wester P, Ullberg T. Endovascular thrombectomy for acute ischemic stroke. J Intern Med 2022; 291:303-316. [PMID: 35172028 DOI: 10.1111/joim.13425] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.
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Affiliation(s)
- Johan Wassélius
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Fabian Arnberg
- Department of Neuroradiology, Karolinska University Hospital, Solna, Sweden
| | - Mia von Euler
- School of Medicine, Örebro University, Örebro, SE-70182, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Teresa Ullberg
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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29
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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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30
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Turc G, Hadziahmetovic M, Walter S, Churilov L, Larsen K, Grotta JC, Yamal JM, Bowry R, Katsanos AH, Zhao H, Donnan G, Davis SM, Hussain MS, Uchino K, Helwig SA, Johns H, Weber JE, Nolte CH, Kunz A, Steiner T, Sacco S, Ebinger M, Tsivgoulis G, Faßbender K, Audebert HJ. Comparison of Mobile Stroke Unit With Usual Care for Acute Ischemic Stroke Management: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:281-290. [PMID: 35129584 PMCID: PMC8822443 DOI: 10.1001/jamaneurol.2021.5321] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE So far, uncertainty remains as to whether there is sufficient cumulative evidence that mobile stroke unit (MSU; specialized ambulance equipped with computed tomography scanner, point-of-care laboratory, and neurological expertise) use leads to better functional outcomes compared with usual care. OBJECTIVE To determine with a systematic review and meta-analysis of the literature whether MSU use is associated with better functional outcomes in patients with acute ischemic stroke (AIS). DATA SOURCES MEDLINE, Cochrane Library, and Embase from 1960 to 2021. STUDY SELECTION Studies comparing MSU deployment and usual care for patients with suspected stroke were eligible for analysis, excluding case series and case-control studies. DATA EXTRACTION AND SYNTHESIS Independent data extraction by 2 observers, following the PRISMA and MOOSE reporting guidelines. The risk of bias in each study was determined using the ROBINS-I and RoB2 tools. In the case of articles with partially overlapping study populations, unpublished disentangled results were obtained. Data were pooled in random-effects meta-analyses. MAIN OUTCOMES AND MEASURES The primary outcome was excellent outcome as measured with the modified Rankin Scale (mRS; score of 0 to 1 at 90 days). RESULTS Compared with usual care, MSU use was associated with excellent outcome (adjusted odds ratio [OR], 1.64; 95% CI, 1.27-2.13; P < .001; 5 studies; n = 3228), reduced disability over the full range of the mRS (adjusted common OR, 1.39; 95% CI, 1.14-1.70; P = .001; 3 studies; n = 1563), good outcome (mRS score of 0 to 2: crude OR, 1.25; 95% CI, 1.09-1.44; P = .001; 6 studies; n = 3266), shorter onset-to-intravenous thrombolysis (IVT) times (median reduction, 31 minutes [95% CI, 23-39]; P < .001; 13 studies; n = 3322), delivery of IVT (crude OR, 1.83; 95% CI, 1.58-2.12; P < .001; 7 studies; n = 4790), and IVT within 60 minutes of symptom onset (crude OR, 7.71; 95% CI, 4.17-14.25; P < .001; 8 studies; n = 3351). MSU use was not associated with an increased risk of all-cause mortality at 7 days or at 90 days or with higher proportions of symptomatic intracranial hemorrhage after IVT. CONCLUSIONS AND RELEVANCE Compared with usual care, MSU use was associated with an approximately 65% increase in the odds of excellent outcome and a 30-minute reduction in onset-to-IVT times, without safety concerns. These results should help guideline writing committees and policy makers.
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Affiliation(s)
- 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
| | | | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Leonid Churilov
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital–Texas Medical Center, Houston
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health, Houston
| | - Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Aristeidis H. Katsanos
- Division of Neurology, McMaster University Population Health Research Institute, Hamilton, Ontario, Canada,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Henry Zhao
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Geoffrey Donnan
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Stephen M. Davis
- Department of Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia,Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Muhammad S. Hussain
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, and Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Hannah Johns
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
| | - Alexander Kunz
- Klinik für Neurologie, Neurologische Intensivmedizin, Zentrum für Hirngefäßerkrankungen, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Martin Ebinger
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany,Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - 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
| | - Klaus Faßbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin, Berlin, Germany
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Hariharan P, Tariq MB, Grotta JC, Czap AL. Mobile Stroke Units: Current Evidence and Impact. Curr Neurol Neurosci Rep 2022; 22:71-81. [PMID: 35129761 DOI: 10.1007/s11910-022-01170-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Several approaches have been developed to optimize prehospital systems for acute stroke given poor access and significant delays to timely treatment. Specially equipped ambulances that directly initiate treatment, known as Mobile Stroke Units (MSUs), have rapidly proliferated across the world. This review provides a comprehensive summary on the efficacy of MSUs in acute stroke, its various applications beyond thrombolysis, as well as the establishment, optimal setting and cost-effectiveness of incorporating an MSU into healthcare systems. RECENT FINDINGS MSUs speed stroke treatment into the first "golden hour" when better outcomes from thrombolysis are achieved. While evidence for the positive impact of MSUs on outcomes was previously unavailable, two recent landmark controlled trials, B_PROUD and BEST-MSU, show that MSUs result in significantly lesser disability compared to conventional ambulance care. Emerging literature prove the significant impact of MSUs. Adaptability however remains limited by significant upfront financial investment, challenges with reimbursements and pending evidence on their cost-effectiveness.
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Affiliation(s)
- Praveen Hariharan
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - Muhammad Bilal Tariq
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA.
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Bringing CT Scanners to the Skies: Design of a CT Scanner for an Air Mobile Stroke Unit. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12031560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Stroke is the second most common cause of death and remains a persistent health challenge globally. Due to its highly time-sensitive nature, earlier stroke treatments should be enforced for improved patient outcome. The mobile stroke unit (MSU) was conceptualized and implemented to deliver the diagnosis and treatment to a stroke patient in the ultra-early time window (<1 h) in the pre-hospital setting and has shown to be clinically effective. However, due to geographical challenges, most rural communities are still unable to receive timely stroke intervention, as access to specialized stroke facilities for optimal stroke treatment poses a challenge. Therefore, the aircraft counterpart (Air-MSU) of the conventional road MSU offers a plausible solution to this shortcoming by expanding the catchment area for regional locations in Australia. The implementation of Air-MSU is currently hindered by several technical limitations, where current commercially available CT scanners are still oversized and too heavy to be integrated into a conventional helicopter emergency medical service (HEMS). In collaboration with the Australian Stroke Alliance and Melbourne Brain Centre, this article aims to explore the possibilities and methodologies in reducing the weight and, effectively, the size of an existing CT scanner, such that it can be retrofitted into the proposed search and rescue helicopter—Agusta Westland AW189. The result will be Australia’s first-ever customized CT scanner structure designed to fit in a search-and-rescue helicopter used for Air-MSU.
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34
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Werdiger F, Bivard A, Parsons M. Artificial Intelligence in Acute Ischemic Stroke. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bender MT, Mattingly TK, Rahmani R, Proper D, Burnett WA, Burgett JL, LEsperance J, Cushman JT, Pilcher WH, Benesch CG, Kelly AG, Bhalla T. Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy. Stroke Vasc Neurol 2021; 7:209-214. [PMID: 34952889 PMCID: PMC9240459 DOI: 10.1136/svn-2021-001119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes. OBJECTIVE Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes. RESULTS Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable. CONCLUSIONS Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Walter A Burnett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason L Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Joshua LEsperance
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Webster H Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Affiliation(s)
- Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, and the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.)
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston University School of Medicine, MA (T.N.N.)
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Czap AL, Bahr-Hosseini M, Singh N, Yamal JM, Nour M, Parker S, Kim Y, Restrepo L, Abdelkhaleq R, Salazar-Marioni S, Phan K, Bowry R, Rajan SS, Grotta JC, Saver JL, Giancardo L, Sheth SA. Machine Learning Automated Detection of Large Vessel Occlusion From Mobile Stroke Unit Computed Tomography Angiography. Stroke 2021; 53:1651-1656. [PMID: 34865511 PMCID: PMC9038611 DOI: 10.1161/strokeaha.121.036091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Prehospital automated large vessel occlusion (LVO) detection in Mobile Stroke Units (MSUs) could accelerate identification and treatment of patients with LVO acute ischemic stroke. Here, we evaluate the performance of a machine learning (ML) model on CT angiograms (CTAs) obtained from 2 MSUs to detect LVO. METHODS Patients evaluated on MSUs in Houston and Los Angeles with out-of-hospital CTAs were identified. Anterior circulation LVO was defined as an occlusion of the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or anterior cerebral artery vessels and determined by an expert human reader. A ML model to detect LVO was trained and tested on independent data sets consisting of in-hospital CTAs and then tested on MSU CTA images. Model performance was determined using area under the receiver-operator curve statistics. RESULTS Among 68 patients with out-of-hospital MSU CTAs, 40% had an LVO. The most common occlusion location was the middle cerebral artery M1 segment (59%), followed by the internal carotid artery (30%), and middle cerebral artery M2 (11%). Median time from last known well to CTA imaging was 88.0 (interquartile range, 59.5-196.0) minutes. After training on 870 in-hospital CTAs, the ML model performed well in identifying LVO in a separate in-hospital data set of 441 images with area under receiver-operator curve of 0.84 (95% CI, 0.80-0.87). ML algorithm analysis time was under 1 minute. The performance of the ML model on the MSU CTA images was comparable with area under receiver-operator curve 0.80 (95% CI, 0.71-0.89). There was no significant difference in performance between the Houston and Los Angeles MSU CTA cohorts. CONCLUSIONS In this study of patients evaluated on MSUs in 2 cities, a ML algorithm was able to accurately and rapidly detect LVO using prehospital CTA acquisitions.
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Affiliation(s)
- Alexandra L Czap
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Mersedeh Bahr-Hosseini
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, CA (M.B.-H., M.N., L.R., J.L.S.)
| | - Noopur Singh
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Sciences Center at Houston (N.S., J.-M.Y.)
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Sciences Center at Houston (N.S., J.-M.Y.)
| | - May Nour
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, CA (M.B.-H., M.N., L.R., J.L.S.)
| | - Stephanie Parker
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Youngran Kim
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Lucas Restrepo
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, CA (M.B.-H., M.N., L.R., J.L.S.)
| | - Rania Abdelkhaleq
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Sergio Salazar-Marioni
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Kenny Phan
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Ritvij Bowry
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
| | - Suja S Rajan
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Sciences Center at Houston (S.S.R.)
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospial Texas Medical Center, Houston (J.C.G.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, CA (M.B.-H., M.N., L.R., J.L.S.)
| | - Luca Giancardo
- Center for Precision Health, UTHealth School of Biomedical Informatics, UTHealth McGovern Medical School, Houston, TX (L.G.)
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston TX (A.L.C., S.P., Y.K., R.A., S.S.-M., K.P., R.B., S.A.S.)
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Yassi N, Zhao H, Churilov L, Campbell BCV, Wu T, Ma H, Cheung A, Kleinig T, Brown H, Choi P, Jeng JS, Ranta A, Wang HK, Cloud GC, Grimley R, Shah D, Spratt N, Cho DY, Mahawish K, Sanders L, Worthington J, Clissold B, Meretoja A, Yogendrakumar V, Ton MD, Dang DP, Phuong NTM, Nguyen HT, Hsu CY, Sharma G, Mitchell PJ, Yan B, Parsons MW, Levi C, Donnan GA, Davis SM. Tranexamic acid for intracerebral haemorrhage within 2 hours of onset: protocol of a phase II randomised placebo-controlled double-blind multicentre trial. Stroke Vasc Neurol 2021; 7:158-165. [PMID: 34848566 PMCID: PMC9067256 DOI: 10.1136/svn-2021-001070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Rationale Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth. Methods and design Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework. Hypothesis In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo. Sample size estimates A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients. Intervention Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo. Primary efficacy measure The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan. Discussion We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia .,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, Victoria, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Annemarei Ranta
- Department of Medicine, Dunedin School of Medicine, University of Otago, Wellington, New Zealand
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, Yanchao, Kaohsiung, Taiwan
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Clinical Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Nambour, Queensland, Australia
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Lauren Sanders
- Department of Neurology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - John Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Ben Clissold
- Department of Neurology, Geelong Hospital, Geelong, Victoria, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi, Viet Nam
| | - Duc Phuc Dang
- Stroke Department, 103 Military Hospital, Hanoi, Hanoi, Viet Nam
| | | | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Chung Y Hsu
- Department of Neurology, China Medical University, Taichung, Taiwan
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Sydney, New South Wales, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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Saini V, Guada L, Yavagal DR. Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions. Neurology 2021; 97:S6-S16. [PMID: 34785599 DOI: 10.1212/wnl.0000000000012781] [Citation(s) in RCA: 317] [Impact Index Per Article: 105.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/23/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW To provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide. RECENT FINDINGS Randomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients. SUMMARY Stroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%-20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.
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Affiliation(s)
- Vasu Saini
- From the Departments of Neurology (V.S., L.G., D.R.Y.) and Neurosurgery (V.S., D.R.Y.), Jackson Memorial Hospital and University of Miami Miller School of Medicine, FL
| | - Luis Guada
- From the Departments of Neurology (V.S., L.G., D.R.Y.) and Neurosurgery (V.S., D.R.Y.), Jackson Memorial Hospital and University of Miami Miller School of Medicine, FL
| | - Dileep R Yavagal
- From the Departments of Neurology (V.S., L.G., D.R.Y.) and Neurosurgery (V.S., D.R.Y.), Jackson Memorial Hospital and University of Miami Miller School of Medicine, FL.
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40
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Davis SM, Donnan GA. Ischemic Penumbra: A Personal View. Cerebrovasc Dis 2021; 50:656-665. [PMID: 34736251 DOI: 10.1159/000519730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
The concept of the ischemic penumbra was defined over 40 years ago by Lindsay Symon and his group and is now an established principle of all acute ischemic stroke therapies. These reperfusion treatments rescue threatened, critically hypoperfused brain tissue and have been proven to improve clinical outcomes. We have been fortunate to have observed and played a small part in the penumbral story from its beginnings in the 1970s to its pivotal position today. Over this period, we have witnessed penumbral imaging evolve from positron emission tomography through to magnetic resonance imaging and now predominantly computed tomography perfusion, with the advent of automated imaging facilitating case selection for reperfusion therapies. We and others have conducted clinical trials using penumbral imaging to extend the time window for intravenous thrombolysis and select patients for thrombectomy. Together with the concept of fast- and slow-growing ischemic infarct patterns, this embeds the penumbral principle in everyday clinical management. The opportunity now exists to make penumbral imaging even more portable, affordable, and more widely available using mobile platforms, novel imaging techniques, digital linkage, and artificial intelligence.
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Affiliation(s)
- Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Victoria, Victoria, Australia
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Victoria, Victoria, Australia
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41
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Vuorinen PET, Ollikainen JPJ, Ketola PA, Vuorinen RLK, Setälä PA, Hoppu SE. Emergency medical dispatchers' ability to identify large vessel occlusion stroke during emergency calls. Scand J Trauma Resusc Emerg Med 2021; 29:97. [PMID: 34281596 PMCID: PMC8287663 DOI: 10.1186/s13049-021-00914-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background In acute ischemic stroke, conjugated eye deviation (CED) is an evident sign of cortical ischemia and large vessel occlusion (LVO). We aimed to determine if an emergency dispatcher can recognise LVO stroke during an emergency call by asking the caller a binary question regarding whether the patient’s head or gaze is away from the side of the hemiparesis or not. Further, we investigated if the paramedics can confirm this sign at the scene. In the group of positive CED answers to the emergency dispatcher, we investigated what diagnoses these patients received at the emergency department (ED). Among all patients brought to ED and subsequently treated with mechanical thrombectomy (MT) we tracked the proportion of patients with a positive CED answer during the emergency call. Methods We collected data on all stroke dispatches in the city of Tampere, Finland, from 13 February 2019 to 31 October 2020. We then reviewed all patient records from cases where the dispatcher had marked ‘yes’ to the question regarding patient CED in the computer-aided emergency response system. We also viewed all emergency department admissions to see how many patients in total were treated with MT during the period studied. Results Out of 1913 dispatches, we found 81 cases (4%) in which the caller had verified CED during the emergency call. Twenty-four of these patients were diagnosed with acute ischemic stroke. Paramedics confirmed CED in only 9 (11%) of these 81 patients. Two patients with positive CED answers during the emergency call and 19 other patients brought to the emergency department were treated with MT. Conclusion A small minority of stroke dispatches include a positive answer to the CED question but paramedics rarely confirm the emergency medical dispatcher’s suspicion of CED as a sign of LVO. Few patients in need of MT can be found this way. Stroke dispatch protocol with a CED question needs intensive implementation.
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Affiliation(s)
- Pauli E T Vuorinen
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa Hospital District, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland.
| | - Jyrki P J Ollikainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Pasi A Ketola
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa Hospital District, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
| | | | - Piritta A Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa Hospital District, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
| | - Sanna E Hoppu
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa Hospital District, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
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Chowdhury SZ, Baskar PS, Bhaskar S. Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta-analysis. Acad Emerg Med 2021; 28:781-801. [PMID: 33387368 DOI: 10.1111/acem.14204] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. METHODS The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta-analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large-vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR] = 1.80, 95% confidence interval [CI] = 1.18 to 2.75); however, MSU did not (RR = 1.22, 95% CI = 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD] = -0.82, 95% CI = -1.32 to -0.32), LVO bypass (SMD = -0.80, 95% CI = -1.13 to -0.47), and MSU (SMD = -0.87, 95% CI = -1.57 to -0.17) were found to significantly reduce door-to-needle time for IVT. MSU was found to significantly reduce call-to-needle (SMD = -1.41, 95% CI = -1.94 to -0.88) and onset-to-needle (SMD = -1.15, 95% CI = -1.74 to -0.56) times for IVT. MSU additionally demonstrated significant reduction in door-to-perfusion (SMD = -0.72, 95% CI = -1.32 to -0.12) as well as call-to-perfusion (SMD = -0.73, 95% CI = -1.08 to -0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR = 1.04, 95% CI = 0.97 to 1.12) or mortality at 90 days (RR = 1.00, 95% CI = 0.76 to 1.31). CONCLUSIONS This systematic review and meta-analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often-neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis-à-vis PSWOs are warranted.
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Affiliation(s)
- Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Sonu Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical ResearchClinical Sciences Stream Sydney New South Wales Australia
- University of New South Wales (UNSWSouth Western Sydney Clinical SchoolUNSW Medicine Sydney New South Wales Australia
- Department of Neurology & Neurophysiology Liverpool Hospital & South West Sydney Local Health District (SWSLHD Sydney New South Wales Australia
- Stroke & Neurology Research Group Ingham Institute for Applied Medical Research Sydney New South Wales Australia
- NSW Brain Clot BankNSW Health Statewide Biobank and NSW Health Pathology Sydney New South Wales Australia
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43
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Cooley SR, Zhao H, Campbell BCV, Churilov L, Coote S, Easton D, Langenberg F, Stephenson M, Yan B, Desmond PM, Mitchell PJ, Parsons MW, Donnan GA, Davis SM, Yassi N. Mobile Stroke Units Facilitate Prehospital Management of Intracerebral Hemorrhage. Stroke 2021; 52:3163-3166. [PMID: 34187178 DOI: 10.1161/strokeaha.121.034592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Mobile stroke units (MSUs) improve reperfusion therapy times in acute ischemic stroke (AIS). However, prehospital management options for intracerebral hemorrhage (ICH) are less established. We describe the initial Melbourne MSU experience in ICH. METHODS Consecutive patients with ICH and AIS treated by the Melbourne MSU were included. We describe demographics, proportions of patients receiving specific therapies, and bypass to comprehensive/neurosurgical centers. We also compare operational time metrics between patients with MSU-ICH and MSU-AIS. RESULTS During a 2-year period, the Melbourne MSU managed 49 patients with ICH, mean (SD) age 74 (12) years, median (interquartile range) National Institutes of Health Stroke Scale 17 (12-20). Intravenous antihypertensives were the commonest treatment provided (46.9%). Bypass of a primary center to a comprehensive center with neurosurgical expertise occurred in 32.7% of patients with MSU-ICH compared with 20.5% of patients with MSU-AIS. Compared with patients with MSU-AIS, patients with MSU-ICH had faster onset-to-emergency-call, and onset-to-scene-arrival times at the median and 75th percentiles. CONCLUSIONS MSUs can facilitate ultra-early ICH diagnosis, management, and triage.
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Affiliation(s)
- S Regan Cooley
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Henry Zhao
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.).,Ambulance Victoria. Australia (H.Z., B.C.V.C., M.S.)
| | - Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.).,Ambulance Victoria. Australia (H.Z., B.C.V.C., M.S.)
| | - Leonid Churilov
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.).,Department of Medicine, Austin Health, Melbourne Medical School, University of Melbourne, Australia. (L.C.)
| | - Skye Coote
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Damien Easton
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Francesca Langenberg
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.).,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia. (F.L., P.M.D., P.J.M.)
| | | | - Bernard Yan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia. (F.L., P.M.D., P.J.M.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia. (F.L., P.M.D., P.J.M.)
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.)
| | - Nawaf Yassi
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Australia. (S.R.C., H.Z., B.C.V.C., L.C., S.C., D.E., F.L., B.Y., M.W.P., G.A.D., S.M.D., N.Y.).,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Australia (N.Y.)
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Larsen K, Jaeger HS, Tveit LH, Hov MR, Thorsen K, Røislien J, Solyga V, Lund CG, Bache KG. Ultraearly thrombolysis by an anesthesiologist in a mobile stroke unit: A prospective, controlled intervention study. Eur J Neurol 2021; 28:2488-2496. [PMID: 33890385 DOI: 10.1111/ene.14877] [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] [Received: 02/04/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute stroke treatment in mobile stroke units (MSU) is feasible and reduces time-to-treatment, but the optimal staffing model is unknown. We wanted to explore if integrating thrombolysis of acute ischemic stroke (AIS) in an anesthesiologist-based emergency medical services (EMS) reduces time-to-treatment and is safe. METHODS A nonrandomized, prospective, controlled intervention study. INCLUSION CRITERIA age ≥18 years, nonpregnant, stroke symptoms with onset ≤4 h. The MSU staffing is inspired by the Norwegian Helicopter Emergency Medical Services crew with an anesthesiologist, a paramedic-nurse and a paramedic. Controls were included by conventional ambulances in the same catchment area. Primary outcome was onset-to-treatment time. Secondary outcomes were alarm-to-treatment time, thrombolytic rate and functional outcome. Safety outcomes were symptomatic intracranial hemorrhage and mortality. RESULTS We included 440 patients. MSU median (IQR) onset-to-treatment time was 101 (71-155) minutes versus 118 (90-176) minutes in controls, p = 0.007. MSU median (IQR) alarm-to-treatment time was 53 (44-65) minutes versus 74 (63-95) minutes in controls, p < 0.001. Golden hour treatment was achieved in 15.2% of the MSU patients versus 3.7% in the controls, p = 0.005. The thrombolytic rate was higher in the MSU (81% vs 59%, p = 0.001). MSU patients were more often discharged home (adjusted OR [95% CI]: 2.36 [1.11-5.03]). There were no other significant differences in outcomes. CONCLUSIONS Integrating thrombolysis of AIS in the anesthesiologist-based EMS reduces time-to-treatment without negatively affecting outcomes. An MSU based on the EMS enables prehospital assessment of acute stroke in addition to other medical and traumatic emergencies and may facilitate future implementation.
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Affiliation(s)
- Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Henriette S Jaeger
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Lars H Tveit
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maren R Hov
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | - Jo Røislien
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Volker Solyga
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
| | | | - Kristi G Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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45
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van Meenen LCC, van Stigt MN, Siegers A, Smeekes MD, van Grondelle JAF, Geuzebroek G, Marquering HA, Majoie CBLM, Roos YBWEM, Koelman JHTM, Potters WV, Coutinho JM. Detection of Large Vessel Occlusion Stroke in the Prehospital Setting: Electroencephalography as a Potential Triage Instrument. Stroke 2021; 52:e347-e355. [PMID: 33940955 DOI: 10.1161/strokeaha.120.033053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.
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Affiliation(s)
- Laura C C van Meenen
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Maritta N van Stigt
- Department of Clinical Neurophysiology (M.N.v.S., J.H.T.M.K., W.V.P.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Arjen Siegers
- Ambulance Amsterdam, Amsterdam, the Netherlands (A.S., J.A.F.v.G., G.G.)
| | - Martin D Smeekes
- Emergency Medical Services North-Holland North, Alkmaar, the Netherlands (M.D.S.)
| | | | - Geertje Geuzebroek
- Ambulance Amsterdam, Amsterdam, the Netherlands (A.S., J.A.F.v.G., G.G.)
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (H.A.M., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (H.A.M., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Johannes H T M Koelman
- Department of Clinical Neurophysiology (M.N.v.S., J.H.T.M.K., W.V.P.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Wouter V Potters
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands.,Department of Clinical Neurophysiology (M.N.v.S., J.H.T.M.K., W.V.P.), Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology (L.C.C.v.M., Y.B.W.E.M.R., W.V.P., J.M.C.), Amsterdam UMC, University of Amsterdam, the Netherlands
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46
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Kate MP, Jeerakathil T, Buck BH, Khan K, Nomani AZ, Butt A, Thirunavukkarasu S, Nowacki T, Kalashyan H, Lloret-Villas MI, D'Souza A, Mishra S, McCombe J, Butcher K, Jickling G, Saqqur M, Shuaib A. Pre-hospital triage of suspected acute stroke patients in a mobile stroke unit in the rural Alberta. Sci Rep 2021; 11:4988. [PMID: 33654223 PMCID: PMC7925585 DOI: 10.1038/s41598-021-84441-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 02/08/2021] [Indexed: 11/09/2022] Open
Abstract
Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.
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Affiliation(s)
- Mahesh P Kate
- Clinical Neurosciences, Edmonton Zone, Alberta Health Services, Edmonton, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Khurshid Khan
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ali Zohair Nomani
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Asif Butt
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Tomasz Nowacki
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Hayrapet Kalashyan
- Clinical Neurosciences, Central Zone, Alberta Health Services, Red Deer, Canada
| | | | - Atlantic D'Souza
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sachin Mishra
- Clinical Neurosciences, Edmonton Zone, Alberta Health Services, Edmonton, Canada
| | - Jennifer McCombe
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Kenneth Butcher
- Department of Clinical Neurosciences, Prince of Wales Clinical School, Randwick, Australia
| | - Glen Jickling
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada.
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Ebinger M, Siegerink B, Kunz A, Wendt M, Weber JE, Schwabauer E, Geisler F, Freitag E, Lange J, Behrens J, Erdur H, Ganeshan R, Liman T, Scheitz JF, Schlemm L, Harmel P, Zieschang K, Lorenz-Meyer I, Napierkowski I, Waldschmidt C, Nolte CH, Grittner U, Wiener E, Bohner G, Nabavi DG, Schmehl I, Ekkernkamp A, Jungehulsing GJ, Mackert BM, Hartmann A, Rohmann JL, Endres M, Audebert HJ. Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin. JAMA 2021; 325:454-466. [PMID: 33528537 PMCID: PMC7856548 DOI: 10.1001/jama.2020.26345] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Effects of thrombolysis in acute ischemic stroke are time-dependent. Ambulances that can administer thrombolysis (mobile stroke units [MSUs]) before arriving at the hospital have been shown to reduce time to treatment. OBJECTIVE To determine whether dispatch of MSUs is associated with better clinical outcomes for patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This prospective, nonrandomized, controlled intervention study was conducted in Berlin, Germany, from February 1, 2017, to October 30, 2019. If an emergency call prompted suspicion of stroke, both a conventional ambulance and an MSU, when available, were dispatched. Functional outcomes of patients with final diagnosis of acute cerebral ischemia who were eligible for thrombolysis or thrombectomy were compared based on the initial dispatch (both MSU and conventional ambulance or conventional ambulance only). EXPOSURE Simultaneous dispatch of an MSU (computed tomographic scanning with or without angiography, point-of-care laboratory testing, and thrombolysis capabilities on board) and a conventional ambulance (n = 749) vs conventional ambulance alone (n = 794). MAIN OUTCOMES AND MEASURES The primary outcome was the distribution of modified Rankin Scale (mRS) scores (a disability score ranging from 0, no neurological deficits, to 6, death) at 3 months. The coprimary outcome was a 3-tier disability scale at 3 months (none to moderate disability; severe disability; death) with tier assignment based on mRS scores if available or place of residence if mRS scores were not available. Common odds ratios (ORs) were used to quantify the association between exposure and outcome; values less than 1.00 indicated a favorable shift in the mRS distribution and lower odds of higher levels of disability. RESULTS Of the 1543 patients (mean age, 74 years; 723 women [47%]) included in the adjusted primary analysis, 1337 (87%) had available mRS scores (primary outcome) and 1506 patients (98%) had available the 3-tier disability scale assessment (coprimary outcome). Patients with an MSU dispatched had lower median mRS scores at month 3 (1; interquartile range [IQR], 0-3) than did patients without an MSU dispatched (2; IQR, 0-3; common OR for worse mRS, 0.71; 95% CI, 0.58-0.86; P < .001). Similarly, patients with an MSU dispatched had lower 3-month coprimary disability scores: 586 patients (80.3%) had none to moderate disability; 92 (12.6%) had severe disability; and 52 (7.1%) had died vs patients without an MSU dispatched: 605 (78.0%) had none to moderate disability; 103 (13.3%) had severe disability; and 68 (8.8%) had died (common OR for worse functional outcome, 0.73, 95% CI, 0.54-0.99; P = .04). CONCLUSIONS AND RELEVANCE In this prospective, nonrandomized, controlled intervention study of patients with acute ischemic stroke in Berlin, Germany, the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly associated with lower global disability at 3 months. Clinical trials in other regions are warranted.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
| | - Alexander Kunz
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Wendt
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | - Joachim E. Weber
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Eugen Schwabauer
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Frederik Geisler
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Erik Freitag
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Julia Lange
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Janina Behrens
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Hebun Erdur
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Ramanan Ganeshan
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Thomas Liman
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Jan F. Scheitz
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Ludwig Schlemm
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Peter Harmel
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Katja Zieschang
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | - Irina Lorenz-Meyer
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Ira Napierkowski
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
| | - Carolin Waldschmidt
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- Klinik für Neurologie–Stroke Unit–Zentrum für Epilepsie; Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Christian H. Nolte
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health (BIH), Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
| | - Edzard Wiener
- Institut für Neuroradiologie, Charité–Universitätsmedizin Berlin, Germany
| | - Georg Bohner
- Institut für Neuroradiologie, Charité–Universitätsmedizin Berlin, Germany
| | - Darius G. Nabavi
- Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Ingo Schmehl
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | - Axel Ekkernkamp
- Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
| | | | - Bruno-Marcel Mackert
- Klinik für Neurologie mit Stroke Unit, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | | | - Jessica L. Rohmann
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Institute of Public Health, Charité–Universitätsmedizin Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
- NeuroCure Cluster of Excellence, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany
| | - Heinrich J. Audebert
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
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Artificial Intelligence in Acute Ischemic Stroke. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
BACKGROUND AND PURPOSE Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. METHODS Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. RESULTS Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0-61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. CONCLUSIONS The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.
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50
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Park A, Campbell B. The frontiers of acute stroke management. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2020. [DOI: 10.47795/upyu3565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The field of stroke has rapidly advanced in recent years with more effective reperfusion therapies (thrombolysis and endovascular thrombectomy) applied to a broader range of patients, including using imaging-based selection to treat beyond standard time windows. Recent trials have provided signals that neuroprotection and specific treatments for intracerebral haemorrhage may be achievable. The range of targeted secondary prevention strategies has also expanded, particularly with direct oral anticoagulants, more potent lipid lowering agents and patent foramen ovale closure.
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