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Behrndtz A, Blauenfeldt RA, Johnsen SP, Valentin JB, Gude MF, Al-Jazi MA, von Weitzel-Mudersbach P, Modrau B, Damgaard D, Hougaard KD, Hjort N, Diedrichsen T, Poulsen M, Schmitz ML, Fisher M, Andersen G, Simonsen CZ. Transport Strategy in Patients With Suspected Acute Large Vessel Occlusion Stroke: TRIAGE-STROKE, a Randomized Clinical Trial. Stroke 2023; 54:2714-2723. [PMID: 37800374 PMCID: PMC10589426 DOI: 10.1161/strokeaha.123.043875] [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: 05/15/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND When patients with acute ischemic stroke present with suspected large vessel occlusion in the catchment area of a primary stroke center (PSC), the benefit of direct transport to a comprehensive stroke center (CSC) has been suggested. Equipoise remains between transport strategies and the best transport strategy is not well established. METHODS We conducted a national investigator-driven, multicenter, randomized, assessor-blinded clinical trial. Patients eligible for intravenous thrombolysis (IVT) who were suspected for large vessel occlusion were randomized 1:1 to admission to the nearest PSC (prioritizing IVT) or direct CSC admission (prioritizing endovascular therapy). The primary outcome was functional improvement at day 90 for all patients with acute ischemic stroke, measured as shift towards a lower score on the modified Rankin Scale score. RESULTS From September 2018 to May 2022, we enrolled 171 patients of whom 104 had acute ischemic stroke. The trial was halted before full recruitment. Baseline characteristics were well balanced. Primary analysis of shift in modified Rankin Scale (ordinal logistic regression) revealed an odds ratio for functional improvement at day 90 of 1.42 (95% CI, 0.72-2.82, P=0.31). Onset to groin time for patients with large vessel occlusion was 35 minutes (P=0.007) shorter when patients were transported to a CSC first, whereas onset to needle (IVT) was 30 minutes (P=0.012) shorter when patients were transported to PSC first. IVT was administered in 67% of patients in the PSC group versus 78% in the CSC group and EVT was performed in 53% versus 63% of the patients, respectively. CONCLUSIONS This trial investigated the benefit of bypassing PSC. We included only IVT-eligible patients presenting <4 hours from onset and with suspected large vessel occlusion. Lack of power prevented the results from showing effect on functional outcome for patients going directly to CSC. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03542188.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark (A.B., R.A.B., C.Z.S.)
| | - Rolf A. Blauenfeldt
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Neurology (B.M.), Aarhus University Hospital, Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (S.P.J., J.B.V.)
| | - Jan B. Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (S.P.J., J.B.V.)
| | - Martin F. Gude
- Prehospital Emergency Medical Services, Central Denmark Region (M.F.G.), Goedstrup Hospital
| | | | | | - Boris Modrau
- Department of Neurology (B.M.), Aarhus University Hospital, Denmark
| | - Dorte Damgaard
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Kristina Dupont Hougaard
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Niels Hjort
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Tove Diedrichsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marika Poulsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marie Louise Schmitz
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston (M.F.)
| | - Grethe Andersen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Claus Z. Simonsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark (A.B., R.A.B., C.Z.S.)
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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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Worthmann H, Winzer S, Schuppner R, Gumbinger C, Barlinn J. Telestroke networks for area-wide access to endovascular stroke treatment. Neurol Res Pract 2023; 5:9. [PMID: 36864498 PMCID: PMC9983226 DOI: 10.1186/s42466-023-00237-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. MAIN BODY Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. CONCLUSION The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.
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Affiliation(s)
- Hans Worthmann
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany.
| | - S Winzer
- Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
| | - R Schuppner
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany
| | - C Gumbinger
- Klinik Für Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - J Barlinn
- Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
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Jæger HS, Tranberg D, Larsen K, Valentin JB, Blauenfeldt RA, Luger S, Bache KG, Gude MF. Diagnostic performance of Glial Fibrillary Acidic Protein and Prehospital Stroke Scale for identification of stroke and stroke subtypes in an unselected patient cohort with symptom onset < 4.5 h. Scand J Trauma Resusc Emerg Med 2023; 31:1. [PMID: 36604741 PMCID: PMC9814331 DOI: 10.1186/s13049-022-01065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Rapid identification and treatment of stroke is crucial for the outcome of the patient. We aimed to determine the performance of glial fibrillary acidic protein (GFAP) independently and in combination with the Prehospital Stroke Score (PreSS) for identification and differentiation of acute stroke within 4.5 h after symptom onset. PATIENTS AND METHODS Clinical data and serum samples were collected from the Treat-Norwegian Acute Stroke Prehospital Project (Treat-NASPP). Patients with suspected stroke and symptoms lasting ≤ 4.5 h had blood samples collected and were evaluated with the National Institutes of Health Stroke Scale prospectively. In this sub study, NIHSS was retrospectively translated into PreSS and GFAP was measured using the sensitive single molecule array (SIMOA). RESULTS A total of 299 patients with suspected stroke were recruited from Treat-NASPP and included in this study (44% acute ischemic stroke (AIS), 10% intracranial hemorrhage (ICrH), 7% transient ischemic attack (TIA), and 38% stroke mimics). ICrH was identified with a cross-fold validated area under the receiver-operating characteristic curve (AUC) of 0.73 (95% CI 0.62-0.84). A decision tree with PreSS and GFAP combined, first identified patients with a low probability of stroke. Subsequently, GFAP detected patients with ICrH with a 25.0% sensitivity (95% CI 11.5-43.4) and 100.0% specificity (95% CI 98.6-100.0). Lastly, patients with large-vessel occlusion (LVO) were detected with a 55.6% sensitivity (95% CI 35.3-74.5) and 82.4% specificity (95% CI 77.3-86.7). CONCLUSION In unselected patients with suspected stroke, GFAP alone identified ICrH. Combined in a decision tree, GFAP and PreSS identified subgroups with high proportions of stroke mimics, ICrH, LVO, and AIS (non-LVO strokes).
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Affiliation(s)
- Henriette S. Jæger
- grid.420120.50000 0004 0481 3017The Norwegian Air Ambulance Foundation, Research and Development, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ditte Tranberg
- grid.425869.40000 0004 0626 6125Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Olof Palmes Allé 34, 2., 8200 Aarhus N, Denmark
| | - Karianne Larsen
- grid.420120.50000 0004 0481 3017The Norwegian Air Ambulance Foundation, Research and Development, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Jan B. Valentin
- grid.5117.20000 0001 0742 471XDanish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Rolf A. Blauenfeldt
- grid.154185.c0000 0004 0512 597XDepartment of Neurology and Danish Stroke Center, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Sebastian Luger
- grid.411088.40000 0004 0578 8220Department of Neurology, University Hospital Frankfurt/Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kristi G. Bache
- grid.5510.10000 0004 1936 8921Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway ,grid.446040.20000 0001 1940 9648Research and Dissemination, Østfold University College, Halden, Norway
| | - Martin F. Gude
- grid.425869.40000 0004 0626 6125Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Olof Palmes Allé 34, 2., 8200 Aarhus N, Denmark
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Mohamed GA, Marmarchi F, Fonkeu Y, Alshaer Q, Rangaraju S, Carr M, Jones A, Peczka M, Contreras I, Bahdsalvi L, Brasher C, Nahab F. Cincinnati Prehospital Stroke Scale Implementation of an Urban County Severity-Based Stroke Triage Protocol: Impact and Outcomes on a Comprehensive Stroke Center. J Stroke Cerebrovasc Dis 2022; 31:106575. [PMID: 35661542 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Screening scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers. Cincinnati prehospital stroke scale (CPSS) is a commonly used prehospital stroke screening tool and has been validated to identify large vessel occlusion (LVO). This study addresses the impact of county-based CPSS implementation to triage suspected LVO patients to a comprehensive stroke center (CSC). MATERIALS AND METHODS Dekalb County in Atlanta, Georgia, implemented CPSS-based protocol with score of 3 and last seen normal time < 24 h mandating transfer to the nearest CSC if the added bypass time was <15 min. Frequency of stroke codes, LVO, IV-tPA use, and thrombectomy treatment were compared six months before and after protocol change (November 1, 2020). RESULTS During the study period, 907 stroke patients presented to the CSC by EMS, including 289 (32%) with CPSS score 3. There was an increase in monthly ischemic stroke volume (pre-16 ± 2 vs.19 ± 3 p = 0.03), LVO (pre-4.3 ± 1.7 vs. post-7.0 ± 2.4; p = 0.03), EVT (pre-15% vs. post-30%; p = 0.001), without significant increase in stroke mimic volume or delay in mean time from last seen normal to IV-tPA (pre-165 ± 66, post-158 ± 49 min; p = 0.35). CPSS score 3 was associated with increased likelihood of LVO diagnosis (OR 8.5, 95% CI 5.0-14.4; p = 0.001) and decreased the likelihood of stroke mimics (OR 0.66, 95% CI 0.50-0.88; p = 0.004). CONCLUSION CPSS is a quick, easy to implement, and reliable prehospital severity scale for EMS to triage LVO to CSC without delaying IV-tPA treatment or significantly increasing stroke mimics.
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Affiliation(s)
- Ghada A Mohamed
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | - Fahad Marmarchi
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | - Yombe Fonkeu
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | - Qasem Alshaer
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | | | - Michael Carr
- Department of Emergency Medicine, Emory School of Medicine, American Medical Response (AMR) DeKalb County, Atlanta, GA, USA
| | - Andrew Jones
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA, USA
| | | | | | - Lori Bahdsalvi
- Department of Neurology, Emory University School of Medicine, USA
| | - Cynthia Brasher
- Department of Neurology, Emory University School of Medicine, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, USA.
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Behrndtz A, Beare R, Iievlieva S, Andersen G, Mainz J, Gude M, Ma H, Srikanth V, Simonsen CZ, Phan T. Can Helicopters Solve the Transport Dilemma for Patients With Symptoms of Large-Vessel Occlusion Stroke in Intermediate Density Areas? A Simulation Model Based on Real Life Data. Front Neurol 2022; 13:861259. [PMID: 35547365 PMCID: PMC9082641 DOI: 10.3389/fneur.2022.861259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background This modeling study aimed to determine if helicopters may optimize the transportation of patients with symptoms of large vessel stroke in “intermediate density” areas, such as Denmark, by bringing them directly to the comprehensive stroke center. Methods We estimated the time for the treatment of patients requiring endovascular therapy or intravenous thrombolysis under four configurations: “drip and ship” with and without helicopter and “bypass” with and without helicopter. Time delays, stroke numbers per municipality, and helicopter dispatches for four helicopter bases from 2019 were obtained from the Danish Stroke and Helicopter Registries. Discrete event simulation (DES) was used to estimate the capacity of the helicopter fleet to meet patient transport requests, given the number of stroke codes per municipality. Results The median onset-to-needle time at the comprehensive stroke center (CSC) for the bypass model with the helicopter was 115 min [interquartile range (IQR): 108, 124]; the median onset-to-groin time was 157 min (IQR: 150, 166). The median onset-to-needle time at the primary stroke center (PSC) by ground transport was 112 min (IQR: 101, 125) and the median onset-to-groin time when primary transport to the PSC was prioritized was 234 min (IQR: 209, 261). A linear correlation between travel time by ground and the number of patients transported by helicopter (rho = 0.69, p < 0.001) indicated that helicopters are being used to transport more remote patients. DES demonstrated that an increase in helicopter capture zone by 20 min increased the number of rejected patients by only 5%. Conclusions Our model calculations suggest that using helicopters to transport patients with stroke directly to the CSC in intermediate density areas markedly reduce onset-to-groin time without affecting time to thrombolysis. In this setting, helicopter capacity is not challenged by increasing the capture zone.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Beare
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Svitlana Iievlieva
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Mainz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Gude
- Department of Clinical Medicine, Prehospital Department, Aarhus, Denmark
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Than Phan
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
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Gude MF, Blauenfeldt RA, Behrndtz AB, Nielsen CN, Speiser L, Simonsen CZ, Johnsen SP, Kirkegaard H, Andersen G. The Prehospital Stroke Score and telephone conference: A prospective validation. Acta Neurol Scand 2022; 145:541-550. [PMID: 35023151 DOI: 10.1111/ane.13580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 12/08/2021] [Accepted: 12/26/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The main aim of the study is to investigate the performance of a two-part stroke scale for screening and subsequent severity assessment combined with a telephone conference (teleconference). MATERIALS AND METHODS During a 6-month period, we prospectively tested the Prehospital Stroke Score (PreSS). PreSS part 1 is designed to identify stroke or TIA in a prehospital setting. PreSS part 2 is a stroke severity scale designed to identify large-vessel occlusion (LVO). PreSS was performed by emergency medical service (EMS) providers prior to a teleconference with a stroke neurologist. RESULTS Combined teleconference and PreSS part 1 were performed on 79.3% of all patients diagnosed with stroke/TIA, and 99.1% of the patients with positive scores were subsequently PreSS part 2 scored. PreSS part 1 and teleconference had a sensitivity to identify stroke/TIA of 89.3% (95% CI 85.7-92.2), specificity of 64.5% (95% CI 59.3-69.5), and an area under the curve (AUC) of 0.80 (95% CI 0.77-0.83). Regarding LVO, PreSS part 1 with teleconference recognized 96.7% (95% CI 88.7-99.6) of all cases as stroke. PreSS part 2 had a sensitivity of 55.7% (95% CI 42.4-68.5), specificity of 91.5% (95% CI 89.0-93.6), and AUC of 0.86 (95% CI 0.82-0.90) for identification of LVO. CONCLUSIONS PreSS was feasible and the sensitivity for stroke/TIA and LVO was high to moderate providing an overall high precision. Almost all LVO cases were ensured acute stroke admission. The high specificity for LVO could be useful for determining transfers strategies. CLASSIFICATION OF EVIDENCE This study provides Class I evidence when evaluating PreSS combined with teleconference.
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Affiliation(s)
- Martin F. Gude
- Department of Research and Development Prehospital Emergency Medical Services Central Denmark Region and Aarhus University Aarhus Denmark
| | - Rolf A. Blauenfeldt
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
| | - Anne B. Behrndtz
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
| | - Casper N. Nielsen
- Department of Research and Development Prehospital Emergency Medical Services Central Denmark Region and Aarhus University Aarhus Denmark
| | - Lasse Speiser
- Department of Radiology Aarhus University Hospital Aarhus Denmark
| | - Claus Z. Simonsen
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Services Research Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Hans Kirkegaard
- Department of Research and Development Prehospital Emergency Medical Services Central Denmark Region and Aarhus University Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Grethe Andersen
- Danish Stroke Center Department of Neurology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
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Ramos A, Guerrero WR, Pérez de la Ossa N. Prehospital Stroke Triage. Neurology 2021; 97:S25-S33. [PMID: 34785601 DOI: 10.1212/wnl.0000000000012792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center ("drip and ship"), direct transfer of the patient to an endovascular center ("mothership"), transfer of the neurointerventional team to a local primary center ("drip and drive"), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed. RECENT FINDINGS Local observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol. SUMMARY Prehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.
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Affiliation(s)
- Anna Ramos
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa
| | - Waldo R Guerrero
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa
| | - Natalia Pérez de la Ossa
- From the Stroke Unit, Department of Neuroscience (A.R., N.P.O.), University Hospital Germans Trias I Pujol, Badalona, Spain; and Department of Neurosurgery (W.R.G.), University of South Florida Morsani College of Medicine, Tampa.
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9
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Boss EG, Bohmann FO, Misselwitz B, Kaps M, Neumann-Haefelin T, Pfeilschifter W, Kurka N. Quality assurance data for regional drip-and-ship strategies- gearing up the transfer process. Neurol Res Pract 2021; 3:38. [PMID: 34334134 PMCID: PMC8327429 DOI: 10.1186/s42466-021-00136-x] [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: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke patients with large vessel occlusion (LVO) require endovascular therapy (EVT) provided by comprehensive stroke centers (CSC). One strategy to achieve fast stroke symptom 'onset to treatment' times (OTT) is the preclinical selection of patients with severe stroke for direct transport to CSC. Another is the optimization of interhospital transfer workflow. Our aim was to investigate the dynamics of the OTT of 'drip-and-ship' patients as well as the current 'door-in-door-out' time (DIDO) and its determinants at representative regional German stroke units. METHODS We determined the numbers of all EVT treatments, 'drip-and-ship' and 'direct-to-center' patients and their median OTT from the mandatory quality assurance registry of the federal state of Hesse, Germany (2012-2019). Additionally, we captured process time stamps from primary stroke centers (PSC) in a consecutive registry of patients referred for EVT in our regional stroke network over a 3 months period. RESULTS Along with an increase of the EVT rate, the proportion of drip-and-ship patients grew steadily from 19.4% in 2012 to 31.3% in 2019. The time discrepancy for the median OTT between 'drip-and-ship' and 'direct-to-center' patients continuously declined from 173 to 74 min. The largest share of the DIDO (median 92, IQR 69-110) is spent with the organization of EVT and consecutive patient transfer. CONCLUSIONS 'Drip-and-ship' patients are an important and growing proportion of stroke patients undergoing EVT. The discrepancy in OTT for EVT between 'drip-and-ship' and 'direct-to-center' patients has been reduced considerably. Further optimization of the DIDO primarily aiming at the processes after the detection of LVO is urgently needed to improve stroke patient care.
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Affiliation(s)
- Erendira G Boss
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.
| | | | | | - Manfred Kaps
- Department of Neurology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | | | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
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10
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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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11
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Yu AT, Regenhardt RW, Whitney C, Schwamm LH, Patel AB, Stapleton CJ, Viswanathan A, Hirsch JA, Lev M, Leslie-Mazwi TM. CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals. AJNR Am J Neuroradiol 2021; 42:435-440. [PMID: 33541900 DOI: 10.3174/ajnr.a6950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/03/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns. MATERIALS AND METHODS A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy. RESULTS There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011). CONCLUSIONS Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.
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Affiliation(s)
- A T Yu
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - R W Regenhardt
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - C Whitney
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - L H Schwamm
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - A B Patel
- Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
| | | | - A Viswanathan
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - J A Hirsch
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - M Lev
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - T M Leslie-Mazwi
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.).,Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
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12
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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13
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Maas WJ, Lahr MMH, Buskens E, van der Zee DJ, Uyttenboogaart M. Pathway Design for Acute Stroke Care in the Era of Endovascular Thrombectomy: A Critical Overview of Optimization Efforts. Stroke 2020; 51:3452-3460. [PMID: 33070713 DOI: 10.1161/strokeaha.120.030392] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The efficacy of intravenous thrombolysis and endovascular thrombectomy (EVT) for acute ischemic stroke is highly time dependent. Optimal organization of acute stroke care is therefore important to reduce treatment delays but has become more complex after the introduction of EVT as regular treatment for large vessel occlusions. There is no singular optimal organizational model that can be generalized to different geographic regions worldwide. Current dominant organizational models for EVT include the drip-and-ship- and mothership model. Guidelines recommend routing of suspected patients with stroke to the nearest intravenous thrombolysis capable facility; however, the choice of routing to a certain model should depend on regional stroke service organization and individual patient characteristics. In general, design approaches for organizing stroke care are required, in which 2 key strategies could be considered. The first entails the identification of interventions within existing organizational models for optimizing timely delivery of intravenous thrombolysis and/or EVT. This includes adaptive patient routing toward a comprehensive stroke center, which focuses particularly on prehospital triage tools; bringing intravenous thrombolysis or EVT to the location of the patient; and expediting services and processes along the stroke pathway. The second strategy is to develop analytical or simulation model-based approaches enabling the design and evaluation of organizational models before their implementation. Organizational models for acute stroke care need to take regional and patient characteristics into account and can most efficiently be assessed and optimized through the application of model-based approaches.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Maarten Uyttenboogaart
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands
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Abstract
Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.
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Affiliation(s)
- Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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