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Zarei H, Ebrahimzade M, Hajiqasemi M, Janmohamadi M, Adel Ramawad H, Haji Aghajani M, Yousefifard M. Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis. Am J Emerg Med 2024; 83:114-125. [PMID: 39003928 DOI: 10.1016/j.ajem.2024.07.004] [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: 05/01/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS. METHODS A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated. RESULTS Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity. CONCLUSION 3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.
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Affiliation(s)
- Hamed Zarei
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Mandana Ebrahimzade
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Hajiqasemi
- Department of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahrokh Janmohamadi
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamzah Adel Ramawad
- Department of Emergency Medicine, NYC Health & Hospitals Coney Island, New York, NY, USA
| | - Mohammad Haji Aghajani
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Kang J, Song H, Kim SE, Kim JY, Park HK, Cho YJ, Lee KB, Lee J, Lee JS, Choi AR, Kang MY, Gorelick PB, Bae HJ. Network analysis of stroke systems of care in Korea. BMJ Neurol Open 2024; 6:e000578. [PMID: 38618152 PMCID: PMC11015290 DOI: 10.1136/bmjno-2023-000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/03/2024] [Indexed: 04/16/2024] Open
Abstract
Background The landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes. Methods We extracted patient-level data on acute stroke care and hospital connectivity by integrating national stroke audit data with reimbursement claims data. We then used this information to transform interhospital transfers into a network framework, where hospitals were designated as nodes and transfers as edges. Using the Louvain algorithm, we grouped densely connected hospitals into distinct stroke care communities. The quality and characteristics in given stroke communities were analysed, and their distinct types were derived using network parameters. The clinical implications of this network model were also explored. Results Over 6 months, 19 113 patients with acute ischaemic stroke initially presented to 1009 hospitals, with 3114 (16.3%) transferred to 246 stroke care hospitals. These connected hospitals formed 93 communities, with a median of 9 hospitals treating a median of 201 patients. Derived communities demonstrated a modularity of 0.904 , indicating a strong community structure, highly centralised around one or two hubs. Three distinct types of structures were identified: single-hub (n=60), double-hub (n=22) and hubless systems (n=11). The endovascular treatment rate was highest in double-hub systems, followed by single-hub systems, and was almost zero in hubless systems. The hubless communities were characterised by lower patient volumes, fewer hospitals, no hub hospital and no stroke unit. Conclusions This network analysis could quantify the national stroke care system and point out areas where the organisation and functionality of acute stroke care could be improved.
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Affiliation(s)
- Jihoon Kang
- Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Hyunjoo Song
- School of Computer Science and Engineering, Soongsil University, Seoul, Korea (the Republic of)
| | - Seong Eun Kim
- Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Jun Yup Kim
- Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea (the Republic of)
| | - Hong-Kyun Park
- Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (the Republic of), Korea (the Republic of)
| | - Yong-Jin Cho
- Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (the Republic of)
| | - Kyung Bok Lee
- Neurology, Soonchunhyang University Hospital, Yongsan-gu, Seoul, Korea (the Republic of)
| | - Juneyoung Lee
- Biostatistics, Korea University School of Medicine, Seoul, Korea (the Republic of)
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea (the Republic of)
| | - Ah Rum Choi
- Health Insurance Review & Assessment Service, Wonju, Korea (the Republic of)
| | - Mi Yeon Kang
- Health Insurance Review & Assessment Service, Wonju, Korea (the Republic of)
| | - Philip B Gorelick
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hee-Joon Bae
- Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea (the Republic of)
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Baser Y, Zarei H, Gharin P, Baradaran HR, Sarveazad A, Roshdi Dizaji S, Yousefifard M. Cincinnati Prehospital Stroke Scale (CPSS) as a Screening Tool for Early Identification of Cerebral Large Vessel Occlusions; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2024; 12:e38. [PMID: 38737135 PMCID: PMC11088790 DOI: 10.22037/aaem.v12i1.2242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Introduction Large vessel occlusion (LVO) strokes are associated with worse functional outcomes and higher mortality rates. In the present systematic review and meta-analysis, we evaluated the diagnostic yield of the Cincinnati Prehospital Stroke Scale (CPSS) in detecting LVO. Methods We performed an extensive systematic search among online databases including Medline, Embase, Web of Science, and Scopus, until July 31st, 2023. We also conducted a manual search on Google and Google scholar, along with citation tracking to supplement the systematic search in retrieving all studies that evaluated the diagnostic accuracy of the CPSS in detecting LVO among patients suspected to stroke. Results Fourteen studies were included in the present meta-analysis. CPSS showed the sensitivity of 97% (95% CI: 87%-99%) and the specificity of 17% (95% CI: 4%-54%) at the cut-off point of ≥1. The optimal threshold was determined to be ≥2, with a sensitivity of 82% (95% CI: 74%-88%) and specificity of 62% (95% CI: 48%-74%) in detecting LVO. At the highest cut-off point of ≥3, the CPSS had the lowest sensitivity of 60% (95% CI: 51%-69%) and the highest specificity of 81% (95% CI: 71%-88%). Sensitivity analyses showed the robustness of the results regardless of study population, inclusion of hemorrhagic stroke patients, pre-hospital or in-hospital settings, and the definition of LVO. Conclusion A very low level of evidence demonstrated that CPSS, with a threshold set at ≥2, is a useful tool for identifying LVO stroke and directing patients to CSCs, both in prehospital and in-hospital settings.
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Affiliation(s)
- Yazdan Baser
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
- Both authors contributed equally to this work
| | - Hamed Zarei
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
- Both authors contributed equally to this work
| | - Pantea Gharin
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Baradaran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shayan Roshdi Dizaji
- Men’s Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
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Fiorella D, Jovin TG, Arthur AS, Nogueira R, Siddiqui AH, Hirsch JA, Albuquerque FC. Triage of Emergent Large Vessel Occlusion (ELVO) patients directly to Comprehensive Stroke Centers (CSCs) is good practice and benefits patients in Urban and Suburban population Centers - New insights from the TRIAGE-STROKE and RACECAT studies. J Neurointerv Surg 2023; 16:1-3. [PMID: 38114326 DOI: 10.1136/jnis-2023-021341] [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] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- SUNY SB, Stony Brook, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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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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Gude MF, Valentin JB, Christensen HC, Mikkelsen S, Søvsø MB, Andersen G, Kirkegaard H, Johnsen SP. Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. Intern Emerg Med 2023; 18:2355-2365. [PMID: 37369888 PMCID: PMC10635938 DOI: 10.1007/s11739-023-03349-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
To investigate the association between the Emergency Medical Service dispatcher's initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017-2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1-76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was - 33.2 min (95% CI - 44.4; - 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI - 18.9; - 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.
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Affiliation(s)
- Martin F Gude
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark.
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Central Denmark Region, Aarhus, Denmark.
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helle C Christensen
- Copenhagen Emergency Medical Services, Capital Region of Denmark, Copenhagen, Denmark
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Morten B Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, 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
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Jayaraman MV, Baird G, Oueidat K, Paolucci G, Haas RA, Torabi R, Moldovan K, Rhodes J, Potvin J, Alexander-Scott N, Yaghi S, Madsen T, Furie K, McTaggart RA. Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion. J Neurointerv Surg 2023; 15:e86-e92. [PMID: 35896319 DOI: 10.1136/jnis-2022-019250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between two adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC). METHODS During the study period, one of the two states implemented severity-based triage for suspected emergent large vessel occlusion, while in the other state, patients were transported to the closest hospital regardless of severity. We compared times to treatment and clinical outcomes between these two states. We also performed a matched pairs analysis, matching on date treated and distance from field to CSC. RESULTS 639 patients met the inclusion criteria, 407 in State 1 (with field triage) and 232 in State 2 (without field triage). In State 1, scene to EVT decreased 6% (or 8.13 min, p=0.0004) every year but no decrease was observed for State 2 (<1%, p=0.94). Cumulatively over 5.5 years, there was a reduction of 43 min in time to EVT in State 1, but no change in State 2. Lower rates of disability were seen in State 1, both for the entire cohort (all OR 1.22, 95% CI 1.07 to 1.40, p=0.0032) and for those independent at baseline (1.36, 95% CI 1.15 to 1.59, p=0.0003). CONCLUSIONS Comparing adjacent states over time, the implementation of severity-based field triage significantly reduced time to EVT.
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Affiliation(s)
- Mahesh V Jayaraman
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Grayson Baird
- Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Karim Oueidat
- Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Gino Paolucci
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Richard A Haas
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Radmehr Torabi
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurosurgery and Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Krisztina Moldovan
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurosurgery, Brown University, Providence, Rhode Island, USA
| | - Jason Rhodes
- Department of Health, State of Rhode Island, Providence, Rhode Island, USA
| | - John Potvin
- Division of Emergency Medical Services, City of East Providence, East Providence, Rhode Island, USA
| | | | - Shadi Yaghi
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurology, Brown University, Providence, Rhode Island, USA
| | - Tracy Madsen
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Emergency Medicine, Brown University, Providence, Rhode Island, USA
| | - Karen Furie
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
- Neurology, Brown University, Providence, Rhode Island, USA
| | - Ryan A McTaggart
- Diagnostic Imaging, Neurology and Neurosurgery, Brown University, Providence, Rhode Island, USA
- Neurovascular Center, Rhode Island Hospital, Providence, Rhode Island, USA
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8
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Maas WJ, van der Zee DJ, Buskens E, Uyttenboogaart M, Lahr MM. Simulation modelling to study the impact of adding comprehensive stroke centres. Can we deliver endovascular thrombectomy sooner? BMJ Open 2023; 13:e068749. [PMID: 37487678 PMCID: PMC10373665 DOI: 10.1136/bmjopen-2022-068749] [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] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES Regional accessibility and distribution of endovascular thrombectomy (EVT) capable facilities, that is, comprehensive stroke centres (CSCs), may significantly influence time to treatment. We analysed the impact of adding CSCs in the north of the Netherlands, a region with roughly 1.7 million inhabitants currently served by one CSC and eight primary stroke centres (PSCs). DESIGN Monte Carlo simulation modelling was used to establish new CSCs in our region by hypothetically upgrading existing PSCs to CSCs and ensuing adjustments in health services set-up. SETTING One CSC and eight PSCs in the north of the Netherlands. PARTICIPANTS 165 patients with acute stroke treated with EVT and underwent interhospital transfer between PSC and CSC (drip and ship patients). PRIMARY AND SECONDARY OUTCOMES Time from onset to groin (OTG) puncture and predicted probability of favourable outcome (modified Rankin Scale 0-2) after 90 days. Sensitivity analyses were performed to assess uncertainty in workflow efficiency of CSCs. RESULTS Adding one or two CSCs would reduce the OTG time up to approximately 17 min and increases the predicted probability of favourable outcome by approximately 2%. Sensitivity analyses revealed that 'slow-acting' CSCs may reduce OTG by 3-5 min compared with 24-32 min for 'fast-acting' CSCs. CONCLUSIONS This study suggests that adding one or two CSCs in the north of the Netherlands would have modest impact. Improving workflow efficiencies seems to be more potent when aiming to improve existing acute stroke care systems.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten Mh Lahr
- Health Technology Assessment, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
- Aletta Jacobs School of Public Health, University of Groningen, Groningen, The Netherlands
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9
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Arthur KC, Huang S, Gudenkauf JC, Mohseni A, Wang R, Aslan A, Nabi M, Hoseinyazdi M, Johnson B, Patel N, Urrutia VC, Yedavalli V. Assessing the Relationship between LAMS and CT Perfusion Parameters in Acute Ischemic Stroke Secondary to Large Vessel Occlusion. J Clin Med 2023; 12:jcm12103374. [PMID: 37240480 DOI: 10.3390/jcm12103374] [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: 03/14/2023] [Revised: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity which has also been shown to accurately predict large vessel occlusions (LVOs). However, to date there is no study exploring whether LAMS correlates with the computed tomography perfusion (CTP) parameters in LVOs. METHODS Patients with LVO between September 2019 and October 2021 were retrospectively reviewed and included if the CTP data and admission neurologic exams were available. The LAMS was documented based on emergency personnel exams or scored retrospectively using an admission neurologic exam. The CTP data was processed by RAPID (IschemaView, Menlo Park, CA, USA) with an ischemic core volume (relative cerebral blood flow [rCBF] < 30%), time-to-maximum (Tmax) volume (Tmax > 6 s delay), hypoperfusion index (HI), and cerebral blood volume (CBV) index. Spearman's correlations were performed between the LAMS and CTP parameters. RESULTS A total of 85 patients were included, of which there were 9 intracranial internal carotid artery (ICA), 53 proximal M1 branch middle cerebral artery M1, and 23 proximal M2 branch occlusions. Overall, 26 patients had LAMS 0-3, and 59 had LAMS 4-5. In total, LAMS positively correlated with CBF < 30% (Correlation Coefficient (CC): 0.32, p < 0.01), Tmax > 6 s (CC:0.23, p < 0.04), HI (CC:0.27, p < 0.01), and negatively correlated with the CBV index (CC:-0.24, p < 0.05). The relationships between LAMS and CBF were < 30% and the HI was more pronounced in M1 occlusions (CC:0.42, p < 0.01; 0.34, p < 0.01 respectively) and proximal M2 occlusions (CC:0.53, p < 0.01; 0.48, p < 0.03 respectively). The LAMS also correlated with a Tmax > 6 s in M1 occlusions (CC:0.42, p < 0.01), and negatively correlated with the CBV index in M2 occlusions (CC:-0.69, p < 0.01). There were no significant correlations between the LAMS and intracranial ICA occlusions. CONCLUSIONS The results of our preliminary study indicate that the LAMS is positively correlated with the estimated ischemic core, perfusion deficit, and HI, and negatively correlated with the CBV index in patients with anterior circulation LVO, with stronger relationships in the M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with the collateral status and estimated ischemic core in patients with LVO.
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Affiliation(s)
- Karissa C Arthur
- Department of Neurology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Shenwen Huang
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Julie C Gudenkauf
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Alireza Mohseni
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Alperen Aslan
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Mehreen Nabi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Navangi Patel
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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10
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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11
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Saban M, Moskovitz A, Ohanyan S, Reznik A, Ribo M, Sivan-Hoffmann R. Validation of a cloud-based tele-stroke system reliability in determining national institutes of health stroke scale scores for acute ischemic stroke screening in the emergency department. Front Neurol 2022; 13:973165. [PMID: 36203984 PMCID: PMC9531031 DOI: 10.3389/fneur.2022.973165] [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: 06/19/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background and purpose The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for objectively quantifying the impairment caused by a suspected stroke. Nevertheless, it is mainly used by trained neurologists in the emergency department (ED). To bring forward the NIHSS to the pre-hospital setting, a smartphone-based Telestroke system was developed. It captures the full NIHSS by video, transmits it off-line, and enables assessment by a distant stroke physician. We aimed to compare the reliability of an NIHSS score determined by a neurologist from afar, using the platform with a standard NIHSS assessment performed in the emergency departments. Methods A multi-center prospective study was conducted in two centers (Vall d'Hebron, Barcelona, and Rambam, Israel). Patients admitted to the ED with suspected stroke had a neurological exam based on the NIHSS, while being recorded by the system. A skilled neurologist rated the NIHSS according to the videos offline. The results were compared with the NIHSS score given by a neurologist at the bedside. Results A total of 95 patients with suspected stroke were included. The overall intraclass correlation coefficient was 0.936 (0.99 in VdH and 0.84 in Rambam), indicating excellent and good reliability, respectively. Conclusion Remote stroke assessment based on the NIHSS, using videos segments collected by a dedicated platform, installed on a standard smartphone, is a reliable measurement as compared with the bedside evaluation.
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Affiliation(s)
- Mor Saban
- The Gertner Institute for Health Policy and Epidemiology, Ramat-Gan, Israel
- *Correspondence: Mor Saban ;
| | - Anner Moskovitz
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Sona Ohanyan
- Department of Neurology, Rambam Healthcare Campus, Haifa, Israel
| | - Anna Reznik
- Department of Neurology, Rambam Healthcare Campus, Haifa, Israel
| | - Marc Ribo
- Department of Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Rotem Sivan-Hoffmann
- Department of Interventional Neuroradiology, Rambam Healthcare Campus, Haifa, Israel
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12
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McClelland G, Hepburn S, Finch T, Price CI. How do interventions to improve the efficiency of acute stroke care affect prehospital times? A systematic review and narrative synthesis. BMC Emerg Med 2022; 22:153. [PMID: 36057767 PMCID: PMC9440533 DOI: 10.1186/s12873-022-00713-6] [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: 08/31/2021] [Accepted: 08/26/2022] [Indexed: 12/05/2022] Open
Abstract
Background Emergency medical services (EMS) are the first point of contact for most acute stroke patients. EMS call to hospital times have increased in recent years for stroke patients in the UK which is undesirable due to the relationship between time and effectiveness of reperfusion treatment. This review aimed to identify and describe interventions devised to improve the efficiency of acute stroke care which reported an impact on ground-based EMS call to hospital times. Methods A systematic review of published literature identified from five databases (Medline, EMBASE, CINAHL, the Cochrane library and the Database of Research in Stroke (DORIS)) from January 2000 to December 2020 with narrative synthesis was conducted. Inclusion criteria were primary studies of ground-based EMS, focused on stroke and aiming to improve EMS times. Papers published before 2000, focussing on mobile stroke units or in languages other than English were excluded. Two reviewers independently screened prospective titles. Cochrane ROB2 and ROBINS-I tools were used to assess for risk of bias. This review was funded by a Stroke Association fellowship. Results From 3767 initial records, 11 studies were included in the review. Included studies were categorised into three groups: studies targeting EMS dispatch and EMS clinicians (n = 4); studies targeting EMS clinicians only (n = 4); and studies targeting whole system change (n = 3). Suspected stroke patients were the primary population studied and most (n = 10) interventions involved clinician education. Only one study (9%) reported a significant decrease in call to hospital time in one subgroup whereas two studies (18%) reported a significant increase in call to hospital time and all other studies (73%) reported no significant change. Conclusions Based on the included studies, interventions intended to improve the efficiency of the acute stroke pathway rarely improved EMS call to hospital times. Included studies were heterogenous and rarely focussed on the review topic which limits the usability of the findings. Further research is needed to explore the trade-off between changes to EMS stroke care and call to hospital times and subsequent impacts on in-hospital care and patient outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00713-6.
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Affiliation(s)
- Graham McClelland
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, England. .,North East Ambulance Service NHS Foundation Trust, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne, NE15 8NY, England.
| | - Sarah Hepburn
- North East Ambulance Service NHS Foundation Trust, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne, NE15 8NY, England
| | - Tracy Finch
- Department of Nursing, Midwifery & Health, Northumbria University, Room B126 Coach Lane Campus West, Newcastle upon Tyne, NE7 7XA, England
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, England
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13
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Keselman B, Berglund A, Ahmed N, Grannas D, von Euler M, Holmin S, Laska AC, Mathé JM, Sjöstrand C, Eriksson EE, Mazya MV. Analysis and modelling of mistriage in the Stockholm stroke triage system. Eur Stroke J 2022; 7:126-133. [PMID: 35647317 PMCID: PMC9134772 DOI: 10.1177/23969873221077845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION The Stockholm Stroke Triage System (SSTS) is a prehospital triage system for detection of patients eligible for endovascular thrombectomy (EVT). Assessment of hemiparesis combined with ambulance-hospital teleconsultation is used to route patients directly to the thrombectomy centre. Some patients are not identified and require secondary transport for EVT (undertriage) while others taken to the thrombectomy centre do not undergo EVT (overtriage). The aims of this study were to characterize mistriaged patients, model for and evaluate alternative triage algorithms. PATIENTS AND METHODS Patients with suspected stroke transported by priority 1 ground ambulance between October 2017 and October 2018 (n = 2905) were included. Three triage algorithms were modelled using prehospital data. Decision curve analysis was performed to calculate net benefit (correctly routing patients for EVT without increasing mistriage) of alternative models vs SSTS. RESULTS Undertriage for EVT occurred in n = 35/2582 (1.4%) and overtriage in n = 239/323 (74.0%). Compared to correct thrombectomy triages, undertriaged patients were younger and had lower median NIHSS (10 vs 18), despite 62.9% with an M1 occlusion. In overtriaged patients, 77.0% had a stroke diagnosis (29.7% haemorrhagic). Hemiparesis and FAST items face and speech were included in all models. Decision curve analysis showed highest net benefit for SSTS for EVT, but lower for large artery occlusion (LAO) stroke. DISCUSSION Undertriaged patients had lower NIHSS, likely due to better compensated proximal occlusions. SSTS was superior to other models for identifying EVT candidates, but lacked information allowing comparison to other prehospital scales. CONCLUSION Using prehospital data, alternative models did not outperform the SSTS in finding EVT candidates.
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Affiliation(s)
- Boris Keselman
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Berglund
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Grannas
- Unit of Biostatistics, IMM, Karolinska
Institutet, Stockholm, Sweden
| | - Mia von Euler
- Department of Clinical Science and Education, Karolinska Institutet Stroke Research
Network at Södersjukhuset, Stockholm, Sweden
- School of Medicine, Örebro University, Örebro, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University
Hospital, Stockholm, Sweden
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital Karolinska
Institutet, Stockholm, Sweden
| | - Jan M. Mathé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Capio St Göran’s
Hospital, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Einar E. Eriksson
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Michael V. Mazya
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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14
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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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15
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Puolakka T, Virtanen P, Kuisma M, Strbian D. Comparison of large vessel occlusion scales using prehospital patient reports. Acta Neurol Scand 2022; 145:265-272. [PMID: 34882786 DOI: 10.1111/ane.13565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/20/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prehospital identification of large vessel occlusion (LVO) holds significant potential to decrease the onset-to-treatment time. Several prehospital scales have been developed to identify LVO but data on their comparison has been limited. The aim of this study was to review the currently available prehospital LVO scales and compare their performance using prehospital data. METHODS All patients transported by ambulance using stroke code on a six-month period were enrolled into the study. The prehospital patient reports were retrospectively evaluated by two investigators using sixteen LVO scales identified by literature search and expert opinion. After the evaluation, the computed tomography angiography results were reviewed by a neuroradiologist to confirm or exclude LVO. RESULTS Sixteen different LVO scales met the predetermined study criteria and were selected for further comparison. Using them, a total of 610 evaluations were registered. The sensitivity of the scales varied between 8%-73%, specificity between 71%-97% and overall accuracy between 71%-87%. The areas under curve (AUC) varied between 0.61-0.80 for the whole scale range and 0.53%-0.74 for the scales' binary cut-offs. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was the only scale with AUC > 0.8. Regarding scales' binary cut-offs, The FAST-ED (0.70), Gaze - Face Arm Speech Time (G-FAST) (0.74) and Emergency Medical Stroke Assessment (EMSA) (0.72) were the only scales with AUC > 0.7. CONCLUSIONS In a comparison of 16 different LVO scales, the FAST-ED, G-FAST and EMSA achieved the highest overall performance.
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Affiliation(s)
- Tuukka Puolakka
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
- Department of Anaesthesiology & Intensive Care Medicine Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Pekka Virtanen
- Department of Radiology Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Markku Kuisma
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Daniel Strbian
- Department of Neurology Helsinki University Hospital and University of Helsinki Helsinki Finland
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16
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Ter Schiphorst A, Duflos C, Mourand I, Gaillard N, Dargazanli C, Corti L, Prin P, Lippi A, Ayrignac X, Charif M, Wacongne A, Bouly S, Lalu T, Sablot D, Blanchet-Fourcade G, Landragin N, Jacob F, Sayad C, Derraz I, Cagnazzo F, Lefevre PH, Gascou G, Beaufils O, Costalat V, Arquizan C. A regional strategy to decrease the time to thrombectomy in patients with low probability of treatment by thrombolysis. Rev Neurol (Paris) 2021; 178:558-568. [PMID: 34903351 DOI: 10.1016/j.neurol.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE The best transportation strategy for patients with suspected large vessel occlusion (LVO) is unknown. Here, we evaluated a new regional strategy of direct transportation to a Comprehensive Stroke Center (CSC) for patients with suspected LVO and low probability of receiving intravenous thrombolysis (IVT) at the nearest Primary Stroke Center (PSC). METHODS Patients could be directly transported to the CSC (bypass group) if they met our pre-hospital bypass criteria: high LVO probability (i.e., severe hemiplegia) with low IVT probability (contraindications) and/or travel time difference between CSC and PSC<15 minutes. The other patients were transported to the PSC according to a "drip-and-ship" strategy. Treatment time metrics were compared in patients with pre-hospital bypass criteria and confirmed LVO in the bypass and drip-and-ship groups. RESULTS In the bypass group (n=79), 54/79 (68.3%) patients met the bypass criteria and 29 (36.7%) had confirmed LVO. The positive predictive value of the hemiplegia criterion for LVO detection was 0.49. In the drip-and-ship group (n=457), 92/457 (20.1%) patients with confirmed LVO met our bypass criteria. Among the 121 patients with bypass criteria and confirmed LVO, direct routing decreased the time between symptom discovery and groin puncture by 55 minutes compared with the drip-and-ship strategy (325 vs. 229 minutes, P<0.001), without significantly increasing the time to IVT (P=0.19). CONCLUSIONS Our regional strategy led to the correct identification of LVO and a significant decrease of the time to mechanical thrombectomy, without increasing the time to IVT, and could be easily implemented in other territories.
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Affiliation(s)
- A Ter Schiphorst
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - C Duflos
- Clinical Research and Epidemiology Unit, CHU Montpellier, University Montpellier, Montpellier, France
| | - I Mourand
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - N Gaillard
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - C Dargazanli
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - L Corti
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - P Prin
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - A Lippi
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - X Ayrignac
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - M Charif
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France
| | - A Wacongne
- Department of Neurology, CHRU Carémeau, Nîmes, France
| | - S Bouly
- Department of Neurology, CHRU Carémeau, Nîmes, France
| | - T Lalu
- Department of Neurology, CH de Béziers, Béziers, France
| | - D Sablot
- Department of Neurology, CH de Perpignan, Perpignan, France
| | | | - N Landragin
- Department of Neurology, Clinique du Millénaire, Montpellier, France
| | - F Jacob
- Emergency Department, CH de Millau, Millau, France
| | - C Sayad
- Emergency Department, CH de Mende, Mende, France
| | - I Derraz
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - F Cagnazzo
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - P-H Lefevre
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - G Gascou
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - O Beaufils
- Emergency Department, CHRU Gui de Chauliac, Montpellier, France
| | - V Costalat
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - C Arquizan
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France.
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17
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Sangari A, Akhoundzadeh K, Vahedian M, Sharifipour E. Effect of pre-hospital notification on delays and neurological outcomes in acute ischemic stroke. Australas Emerg Care 2021; 25:172-175. [PMID: 34810150 DOI: 10.1016/j.auec.2021.11.005] [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: 06/15/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since timely thrombolytic therapy is a crucial variable in acute ischemic stroke recovery, health care systems are trying to find new interventions to reduce treatment delay in order to improve neurological function. In Iran, SAMA code as a pre-hospital notification plan has been developed to help emergent stroke treatment. This study aimed to compare delay to thrombolysis therapy and neurological outcomes between SAMA-transported and self-transported patients in ischemic stroke. METHODS In this retrospective cohort study, the data of 185 stroke patients treated with intravenous thrombolysis from Mar 2016 to May 2020 were collected. P-value < 0.05 was considered as significant. RESULTS The results showed that delays reduced in SAMA-transported patient compared to that in self-transported patients. There was a significant difference in Onset to Needle time, Door to Needle Time, and Door to CT Time but not Onset to Door time between SAMA-transported and self-transported patients (P values: 0.001, 0.000, 0.001, and 0.22 respectively). However, there was no significant difference between two groups in terms of neurologic deficit severity. CONCLUSIONS Although pre-hospital notification could partially reduce treatment delays in stroke, that reduction was not enough to impact on neurologic deficit recovery. It seems more reduction in delay is needed to significantly improve neurological dysfunctions.
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Affiliation(s)
| | - Kobra Akhoundzadeh
- Faculty of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran.
| | - Mostafa Vahedian
- Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran.
| | - Ehsan Sharifipour
- Neuroscience Research Center, Qom University of Medical Sciences, Qom, Iran.
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18
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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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19
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Puolakka T, Virtanen P, Kinnunen J, Kuisma M, Strbian D. Prehospital identification of large vessel occlusion using the FAST-ED score. Acta Neurol Scand 2021; 144:400-407. [PMID: 34028825 DOI: 10.1111/ane.13474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The prehospital identification of stroke patients with large vessel occlusion (LVO) enables appropriate hospital selection and reduces the onset-to-treatment time. The aim of this study was to investigate whether the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale could be reconstructed from existing prehospital patient reports and to compare its performance with neurologist's clinical judgement using the same prehospital data. MATERIALS & METHODS All patients transported by ambulance using stroke code on a six-month period were registered for the study. The prehospital patient reports were retrospectively evaluated using the FAST-ED scale by two investigators. The performance of FAST-ED score (≥4 points) in LVO identification was compared to neurologist's clinical judgement ('LVO or not'). The presence of LVO was verified using computed tomography angiography imaging. RESULTS A total of 610 FAST-ED scores were obtained. The FAST-ED had a sensitivity of 57.8%, specificity of 87.2%, positive predictive value (PPV) of 37.3%, negative predictive value (NPV) of 93.4% and area under curve (AUC) of 0.724. Interclass correlation coefficient for both raters over the entire range of FAST-ED was 0.92 (0.88-0.94). The neurologist's clinical judgement raised sensitivity to 79.4%, NPV to 97.1% and PPV to 45.0% with an AUC of 0.837 (p < .05). CONCLUSIONS The existing patient report data could be feasibly used to reconstruct FAST-ED scores to identify LVO. The binary FAST-ED score had a moderate sensitivity and good specificity for prehospital LVO identification. However, the FAST-ED was surpassed by neurologist's clinical judgement which further increased the sensitivity of identification.
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Affiliation(s)
- Tuukka Puolakka
- Department of Emergency Medicine and Services Helsinki University Hospital and University of Helsinki Helsinki Finland
- Department of Anesthesiology and Intensive Care Medicine Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Pekka Virtanen
- Department of Radiology Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Janne Kinnunen
- Department of Neurology Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Markku Kuisma
- Department of Emergency Medicine and Services Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Daniel Strbian
- Department of Neurology Helsinki University Hospital and University of Helsinki Helsinki Finland
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20
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Keselman B, Berglund A, Ahmed N, Bottai M, von Euler M, Holmin S, Laska AC, Mathé JM, Sjöstrand C, Eriksson EE, Mazya MV. The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation. Stroke 2021; 53:473-481. [PMID: 34583527 DOI: 10.1161/strokeaha.121.034195] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The Stockholm Stroke Triage System (SSTS) is a prehospital algorithm for detection of endovascular thrombectomy (EVT)-eligible patients, combining symptom severity assessment and ambulance-to-hospital teleconsultation, leading to a decision on primary stroke center bypass. In the Stockholm Region (6 primary stroke centers, 1 EVT center), SSTS implementation in October 2017 reduced onset-to-EVT time by 69 minutes. We compared clinical outcomes before and after implementation of SSTS in an observational study. METHODS We prospectively recruited patients transported by Code Stroke ambulance within the Stockholm region under the SSTS, treated with EVT during October 2017 to October 2019, and compared to EVT patients from 2 previous years. OUTCOMES shift in modified Rankin Scale (mRS) scores, mRS score 0 to 1, mRS score 0 to 2, and death (all 3 months), National Institutes of Health Stroke Scale (NIHSS) score change 24-hour post-EVT, recanalization (Thrombolysis in Cerebral Infarction 2b-3), and symptomatic intracranial hemorrhage. mRS outcomes were adjusted for age and baseline NIHSS. RESULTS Patients with EVT in the SSTS group (n=244) were older and had higher baseline NIHSS versus historical controls (n=187): median age 74 (interquartile range, 63-81) versus 71 (61-78); NIHSS score 17 (11.5-21) versus 15 (10-20). During SSTS, median onset-to-puncture time was 136 versus 205 minutes (P<0.001). Adjusted common odds ratio for lower mRS in SSTS patients was 1.7 (95% CI, 1.2-2.3) versus controls. During SSTS, 83/240 (34.6%) versus 44/186 (23.7%) reached 3-month mRS score 0 to 1 (P=0.014), adjusted common odds ratio 2.3 (95% CI, 1.4-3.6). Median NIHSS change 24-hour post-EVT was 6 versus 4 (P=0.005). Differences in Thrombolysis in Cerebral Infarction, symptomatic intracranial hemorrhage, and death were nonsignificant. CONCLUSIONS With an onset to arterial puncture time reduction by 69 minutes, outcomes in thrombectomy-treated patients improved significantly after region-wide large artery occlusion triage system implementation. These results warrant replication studies in other geographic and organizational circumstances.
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Affiliation(s)
- Boris Keselman
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
| | - Annika Berglund
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
| | - Matteo Bottai
- Unit of Biostatistics, Karolinska Institutet, Stockholm, Sweden. IMM (M.B.)
| | - Mia von Euler
- Department of Clinical Science and Education, Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden (M.v.E.).,School of Medicine, Örebro University, Sweden (M.v.E.)
| | - Staffan Holmin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden. (S.H.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. (A.-C.L.)
| | - Jan M Mathé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.).,Department of Neurology, Capio St Göran's Hospital, Stockholm, Sweden (J.M.M.)
| | - Christina Sjöstrand
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
| | - Einar E Eriksson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
| | - Michael V Mazya
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden. (B.K., A.B., N.A., C.S., E.E.E., M.V.M.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. (B.K., A.B., N.A., S.H., J.M.M., C.S., E.E.E., M.V.M.)
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21
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Alexandrov AW, Arthur AS, Bryndziar T, Swatzell VM, Dusenbury W, Hardage K, McCormick S, Rhudy JP, Maleki AHZ, Singh S, Krishnaiah B, Nearing K, Rubin MN, Malkoff MD, McKendry C, Metter EJ, Alexandrov AV. High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit. J Neurointerv Surg 2021; 14:623-627. [PMID: 34433646 DOI: 10.1136/neurintsurg-2021-017697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported. METHODS We performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified. RESULTS 1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5-4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1-3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90-139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required. CONCLUSIONS MSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.
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Affiliation(s)
| | - Adam S Arthur
- Neurosurgery, UTHSC COM, Memphis, Tennessee, USA.,Vascular Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
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22
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Daly M, Cummings C, Kittell M, Dubuque A, Plante L, Linares G, Wolfson D. Validation of field assessment stroke triage for emergency destination for prehospital use in a rural EMS system. Am J Emerg Med 2021; 50:178-182. [PMID: 34371326 DOI: 10.1016/j.ajem.2021.07.035] [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: 04/05/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Field Assessment Stroke Triage for Emergency Destination (FAST-ED) is a simple and accurate prehospital stroke severity scale that has been shown to have comparable accuracy to the gold standard National Institutes of Health Stroke Scale (NIHSS) but requires further field validation for use by emergency medical services (EMS), particularly in rural systems. FAST-ED scores ≥4 are considered high probability for large vessel occlusion (LVO) strokes, while scores <4 are low to moderate probability for LVO. The objective of this study was to assess inter-rater reliability of the EMS FAST-ED (EMS) score to the emergency department FAST-ED (ED-MD) scores. METHODS EMS calculated FAST-ED scores prior to transport to the emergency department (ED) on patients with a positive prehospital stroke screen. EDMD calculated FAST-ED scores for the same patients upon arrival to the ED. Interrater reliability and test characteristics were calculated. RESULTS A total of 95 patients were included in this study and 14 were subsequently diagnosed with an LVO. EMS assigned 34 patients (35.8%) a FAST-ED score of ≥4. EDMD assigned 25 patients (26.3%) a FAST-ED score of ≥4. Using the clinical cut-points of FAST-ED scores <4 and ≥ 4, a linearly weighted Cohen's kappa coefficient showed moderate interrater reliability when comparing EMS and EDMD scores (kw 0.44, 95% CI 0.25-0.63). At ≥4, EMS FAST-ED scores had a sensitivity 0.48, specificity 0.75, PPV 0.62, NPV 0.62 for predicting an LVO, while EDMD FAST-ED scores had a sensitivity 0.36, specificity 0.82, PPV 0.64, NPV 0.60. Comparable receiver operator curve area under the curve values were obtained. CONCLUSIONS EMS and EDMD FAST-ED scores were moderately comparable in a rural EMS system. Similar NPVs compared to EDMD suggest the use of FAST-ED as an appropriate screening tool for EMS to predict the probability of LVO in the prehospital setting and make destination determinations regarding primary transport to a thrombectomy-capable stroke center.
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Affiliation(s)
- Madison Daly
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America.
| | - Cori Cummings
- Medical University of South Carolina, Department of Neurology, Charleston, SC, United States of America
| | - Miles Kittell
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Amy Dubuque
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Laurel Plante
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
| | - Guillermo Linares
- Saint Louis University School of Medicine, Department of Neurology, Saint Louis, MO, United States of America
| | - Daniel Wolfson
- University of Vermont Larner College of Medicine, Division of Emergency Medicine, Burlington, VT, United States of America
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23
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Ospel JM, McDonough R, Kunz WG, Goyal M. Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1? J Neurointerv Surg 2021; 14:568-572. [PMID: 34187871 DOI: 10.1136/neurintsurg-2021-017817] [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: 05/22/2021] [Accepted: 06/08/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase. METHODS We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost. RESULTS When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis. CONCLUSION EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.
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Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Rosalie McDonough
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Diagnostic and Interventional Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Mayank Goyal
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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24
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Kägi G, Schurter D, Niederhäuser J, De Marchis GM, Engelter S, Arni P, Nyenhuis O, Imboden P, Bonvin C, Luft A, Renaud S, Nedeltchev K, Carrera E, Cereda C, Fischer U, Arnold M, Michel P. Swiss guidelines for the prehospital phase in suspected acute stroke. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x21999230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.
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Affiliation(s)
- Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - David Schurter
- Protection & Rescue Zurich, Ambulance, Zurich, Switzerland
| | | | - Gian Marco De Marchis
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
- Neurorehabilitation Felix Platter, University of Basel, Basel, Switzerland
| | - Patrick Arni
- Protection and Rescue Bern, Medical Police, Bern, Switzerland
| | | | - Paul Imboden
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Kantonsspital St. Gallen, Switzerland
| | - Christophe Bonvin
- Division of Neurology and Stroke Unit, Hôpital du Valais, Sion, Switzerland
| | - Andreas Luft
- Department of Neurology, University Hospital Zurich and Cereneo, Vitznau, Switzerland
| | - Susanne Renaud
- Division of Neurology, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, University Hospitals of Geneva, Geneva, Switzerland
| | - Carlo Cereda
- Department of Neurology, Neurocentro della Svizzera Italiana, Lugano Civic Hospital, Lugano, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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25
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Nehme A, Rivet S, Choisi TJ, Dallaire M, de Montigny L, Deschaintre Y, Daneault N, Jacquin G, Legault C, Levy JP, Neves Briard J, Odier C, Poppe AY, Segal E, Stapf C, Gioia LC. Prospective Evaluation of a Two-Scale Protocol for Prehospital Large Vessel Occlusion Detection. PREHOSP EMERG CARE 2021; 26:348-354. [PMID: 33689555 DOI: 10.1080/10903127.2021.1901164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background and purposes: Stroke severity scales may expedite prehospital large vessel occlusion (LVO) stroke detection, but few are validated for paramedic use. We evaluated the feasibility of introducing the Cincinnati Stroke Triage Assessment Tool (C-STAT) in the field and its capacity to detect LVO stroke.Methods: We performed a prospective paramedic-based study assessing C-STAT in the field on patients currently redirected to two comprehensive stroke centers (CSC), based on a Cincinnati Prehospital Stroke Scale (CPSS) score of 3/3. C-STAT was administered by on-site paramedics with telephone guidance from trained centralized clinical support paramedics.Results: Between October 2018 and November 2019, C-STAT scores were obtained in 188/218 (86.2%) patients, among which 118/188 (62.8%) were positive. Paramedics reported performing the C-STAT in less than 5 minutes on 170/188 (90.4%) patients and noted no difficulties administering the scale in 151/188 (80.3%). A positive C-STAT identified 51/68 (75%) LVO strokes in the cohort, demonstrating a 43% (95% CI: 38%-48%) positive and 76% (95% CI: 66%-83%) negative predictive value for LVO stroke diagnosis. In a cohort of 100 patients with CPSS 3/3, requiring a positive C-STAT for redirection would decrease CSC patient volume by 37 but miss 9 of 36 LVO strokes.Conclusion: Prehospital administration of the C-STAT was feasible, using a model of minimal paramedic training and real-time telephone guidance. A protocol based on both a CPSS 3/3 and a positive C-STAT would decrease CSC redirected patient volume by one-third but would miss one-quarter of LVO strokes when compared to a CPSS-based protocol.
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26
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Almqvist T, Berglund A, Sjöstrand C, Eriksson E, Mazya MV. Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset. Stroke 2021; 52:1441-1445. [PMID: 33641383 DOI: 10.1161/strokeaha.120.033676] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE The Stockholm Stroke Triage System, implemented in 2017, identifies patients with high likelihood of large vessel occlusion (LVO) stroke. A previous report has shown Stockholm Stroke Triage System notably reduced time to endovascular thrombectomy (EVT). As the indication for EVT now includes patients up to 24 hours, we aimed to assess Stockholm Stroke Triage System triage accuracy for LVO stroke and EVT treatment for patients presenting late (within 6-24 hours or with an unknown onset), put in contrast to triage accuracy within 0 to 6 hours. METHODS Between October 2017 and October 2018, we included 2905 patients with suspected stroke, transported by priority 1 ground ambulance to a Stockholm Region hospital. Patients assessed 6 to 24 hours from last known well or with unknown onset were defined as late-presenting; those within <6 hours as early-presenting. Triage positivity was defined as transport to comprehensive stroke center because of suspected stroke, hemiparesis and high likelihood of EVT-eligible LVO per teleconsultation. RESULTS Overall triage accuracy was high in late-presenting patients (90.9% for LVO, 93.9% for EVT), with high specificity (95.7% for LVO, 94.5% for EVT), and low to moderate sensitivity (34.3% for LVO, 64.7% for EVT), with similar findings in the early-presenting group. CONCLUSIONS Our results may support using the Stockholm Stroke Triage System for primary stroke center bypass in patients assessed by ambulance up to 24 hours from time of last known well.
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Affiliation(s)
- Tove Almqvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
| | - Annika Berglund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.)
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
| | - Einar Eriksson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
| | - Michael V Mazya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A., A.B., C.S., E.E., M.V.M.).,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (A.B., C.S., E.E., M.V.M.)
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Santana Baskar P, Cordato D, Wardman D, Bhaskar S. In-hospital acute stroke workflow in acute stroke - Systems-based approaches. Acta Neurol Scand 2021; 143:111-120. [PMID: 32882056 DOI: 10.1111/ane.13343] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/20/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022]
Abstract
Clinical outcomes of acute ischaemic stroke patients have significantly improved with the advent of reperfusion therapy. However, time continues to be a critical factor. Reducing treatment delays by improving workflows can improve the efficacy of acute reperfusion therapy. Systems-based approaches have improved in-hospital temporal parameters, maximizing the utility of reperfusion therapies and improving clinical benefit to patients. However, studies aimed at optimizing and hence reducing treatment delays in emergency department (ED) settings are limited. The aim of this article is to discuss existing systems-based approaches to optimize ED acute stroke workflows and its value in reducing treatment delays and identify gaps in existing workflows that need optimization. Identifying gaps in acute stroke workflow, variations in processes and challenges in implementation, in the in-hospital settings, is essential for systems-based interventions to be effective in delivering improved outcomes for patients with acute ischaemic stroke.
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Affiliation(s)
- Prithvi Santana Baskar
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research, Clinical Sciences Stream Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
| | - Dennis Cordato
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South West Sydney Local Health District (SWSLHD) Sydney NSW Australia
- Stroke and Neurology Research Group Ingham Institute for Applied Medical Research Sydney NSW Australia
| | - Daniel Wardman
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South West Sydney Local Health District (SWSLHD) Sydney NSW Australia
- Stroke and Neurology Research Group Ingham Institute for Applied Medical Research Sydney NSW Australia
| | - Sonu Bhaskar
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research, Clinical Sciences Stream Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South West Sydney Local Health District (SWSLHD) Sydney NSW Australia
- Stroke and Neurology Research Group Ingham Institute for Applied Medical Research Sydney NSW Australia
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Boltyenkov AT, Wang JJ, Malhotra A, Katz JM, Martinez G, Sanelli PC. Early Thrombectomy Outcomes in Transfer Patients. Air Med J 2021; 40:102-107. [PMID: 33637271 DOI: 10.1016/j.amj.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/15/2020] [Accepted: 12/30/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The optimal patient transportation destination of acute ischemic stroke (AIS) patients remains uncertain. The purpose of this study was to evaluate the predictive variables that determine stroke outcomes depending on the patient transportation destination. METHODS We performed a retrospective study using an AIS database consisting of patients who underwent thrombectomy admitted to our institution from November 1, 2011, through October 1, 2018. RESULTS A total of 171 patients were included in the statistical analysis; 42.1% (72/171) of patients were in the mothership group (directly admitted) and 57.9% (99/171) in the drip-and-ship group (transferred). Multivariable logistic regression revealed the predictive factors for favorable outcomes were driving distance (expressed in miles) between the patient's home and a comprehensive stroke center (CSC) (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.90-0.99; P = .035), absence of diabetes mellitus (OR = 3.60; 95% CI, 1.20-10.82; P = .022), lower National Institutes of Health Stroke Scale score at admission (OR = 0.91; 95% CI, 0.85-0.97; P = .003), and shorter symptom onset to CSC arrival time (expressed in hours) (OR = 0.84; 95% CI, 0.72-0.99; P = .038). CONCLUSIONS Our study revealed that a shorter driving distance between the patient's home and CSC, absence of diabetes, lower National Institutes of Health Stroke Scale score, and shorter onset to hospital arrival time positively impacted the outcomes of endovascularly treated AIS patients.
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Affiliation(s)
- Artem T Boltyenkov
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Siemens Medical Solutions USA Inc., Malvern, PA.
| | - Jason J Wang
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Siemens Medical Solutions USA Inc., Malvern, PA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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29
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Pre-hospital Diagnosis of Large Vessel Occlusion in Patients Being Transported by Helicopter. J Stroke Cerebrovasc Dis 2021; 30:105416. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022] Open
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30
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Gaze Deviation and Paresis Score (GPS) Sufficiently Predicts Emergent Large Vessel Occluding Strokes. J Stroke Cerebrovasc Dis 2020; 30:105518. [PMID: 33388631 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105518] [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: 10/08/2020] [Revised: 11/15/2020] [Accepted: 11/26/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The prognosis of patients with acute ischemic stroke (AIS) essentially depends on both prompt diagnosis and appropriate treatment. Endovascular stroke therapy (EST) proved to be highly efficient in the treatment of emergent large vessel occluding (ELVO) strokes in the anterior circulation. To achieve a timely diagnosis, a robust combination of few and simple signs to identify ELVOs in AIS patients applicable by paramedics in the prehospital triage is worthwhile. MATERIALS AND METHODS This retrospective single-center study included 904 AIS patients (324 ELVO, 580 non-ELVO) admitted between 2010 and 2015 in a tertiary stroke center. We re-evaluated two symptoms based on NIHSS items, gaze deviation and hemiparesis of the limbs ("Gaze deviation and Paresis Score, GPS") for the pre-hospital prediction of ELVO. RESULTS A positive GPS AIS in patients predicted ELVO with a sensitivity of 0.89, specificity = 0.97, positive predictive value (PPV) = 0.95, negative predictive value (NPV) = 0.94 and diagnostic odds ratio (DOR) = 34.25 (CI: 20.75-56.53). The positive Likelihood-ratio (LR+) was 29.67, the negative Likelihood ratio (LR-) 0.11. NIHSS of patients with positive GPS (gaze palsy NIHSS ≥ 0, Motor arm NIHSS ≥2 and Motor leg NIHSS ≥2) was markedly higher compared to negative GPS patients (p < 0.001). CONCLUSIONS The GPS proved to be similarly accurate in detecting ELVO in the anterior circulation of AIS patients and even more specific than other published clinical scores. Its simplicity and clarity might enable non-neurological medical staff to identify ELVO AIS patients with high certainty in a preclinical setting.
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Kang J, Kim SE, Park HK, Cho YJ, Kim JY, Lee KJ, Park JM, Park KY, Lee KB, Lee SJ, Lee JS, Lee J, Yang KH, Choi AR, Kang MY, Choi NC, Gorelick PB, Bae HJ. Routing to Endovascular Treatment of Ischemic Stroke in Korea: Recognition of Need for Process Improvement. J Korean Med Sci 2020; 35:e347. [PMID: 33107228 PMCID: PMC7590651 DOI: 10.3346/jkms.2020.35.e347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/19/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To track triage, routing, and treatment status regarding access to endovascular treatment (EVT) after acute ischemic stroke (AIS) at a national level. METHODS From national stroke audit data, potential candidates for EVT arriving within 6 hours with National Institute of Health Stroke Scale score of ≥ 7 were identified. Acute care hospitals were classified as thrombectomy-capable hospitals (TCHs, ≥ 15 EVT cases/year) or primary stroke hospital (PSH, < 15 cases/year), and patients' initial routes and subsequent inter-hospital transfer were described. Impact of initial routing to TCHs vs. PSHs on EVT and clinical outcomes were analyzed using multilevel generalized mixed effect models. RESULTS Out of 14,902 AIS patients, 2,180 (14.6%) were EVT candidates. Eighty-one percent of EVT candidates were transported by ambulance, but only one-third were taken initially to TCHs. Initial routing to TCHs was associated with greater chances of receiving EVT compared to initial routing to PSHs (33.3% vs 12.1%, P < 0.001; adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.59-2.92) and favorable outcome (38.5% vs. 28.2%, P < 0.001; aOR, 1.52; 95% CI, 1.16-2.00). Inter-hospital transfers to TCHs occurred in 17.4% of those initially routed to a PSH and was associated with the greater chance of EVT compared to remaining at PSHs (34.8% vs. 7.5%, P < 0.001), but not with better outcomes. CONCLUSION Two-thirds of EVT candidates were initially routed to PSHs despite greater chance of receiving EVT and having favorable outcomes if routed to a TCH in Korea. Process improvement is needed to direct appropriate patients to TCHs.
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Affiliation(s)
- Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Seong Eun Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hong Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Yong Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Jun Yup Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Keon Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kwang Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ah Rum Choi
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Mi Yeon Kang
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Nack Cheon Choi
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea.
| | - Philip B Gorelick
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hee Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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Siegler JE, Jovin TG. Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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33
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Saviluoto A, Björkman J, Olkinuora A, Virkkunen I, Kirves H, Setälä P, Pulkkinen I, Laukkanen-Nevala P, Raatiniemi L, Jäntti H, Iirola T, Nurmi J. The first seven years of nationally organized helicopter emergency medical services in Finland - the data from quality registry. Scand J Trauma Resusc Emerg Med 2020; 28:46. [PMID: 32471467 PMCID: PMC7260827 DOI: 10.1186/s13049-020-00739-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022] Open
Abstract
Background Helicopter Emergency Medical Services (HEMS) play an important role in prehospital care of the critically ill. Differences in funding, crew composition, dispatch criteria and mission profile make comparison between systems challenging. Several systems incorporate databases for quality control, performance evaluation and scientific purposes. FinnHEMS database was incorporated for such purposes following the national organization of HEMS in Finland 2012. The aims of this study are to describe information recorded in the database, data collection, and operational characteristics of Finnish HEMS during 2012–2018. Methods All dispatches of the six Finnish HEMS units recorded in the national database from 2012 to 2018 were included in this observational registry study. Five of the units are physician staffed, and all are on call 24/7. The database follows a template for uniform reporting in physician staffed pre-hospital services, exceeding the recommended variables of relevant guidelines. Results The study included 100,482 dispatches, resulting in 33,844 (34%) patient contacts. Variables were recorded with little or no missing data. A total of 16,045 patients (16%) were escorted by HEMS to hospital, of which 2239 (2%) by helicopter. Of encountered patients 4195 (4%) were declared deceased on scene. The number of denied or cancelled dispatches was 66,638 (66%). The majority of patients were male (21,185, 63%), and the median age was 57.7 years. The median American Society of Anesthesiologists Physical Scale classification was 2 and Eastern Cooperative Oncology Group performance class 0. The most common reason for response was trauma representing 26% (8897) of the patients, followed by out-of-hospital cardiac arrest 20% (6900), acute neurological reason excluding stroke 13% (4366) and intoxication and related psychiatric conditions 10% (3318). Blunt trauma (86%, 7653) predominated in the trauma classification. Conclusions Gathering detailed and comprehensive data nationally on all HEMS missions is feasible. A national database provides valuable insights into where the operation of HEMS could be improved. We observed a high number of cancelled or denied missions and a low percentage of patients transported by helicopter. The medical problem of encountered patients also differs from comparable systems.
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Affiliation(s)
- Anssi Saviluoto
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland. .,University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.
| | - Johannes Björkman
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland.,University of Helsinki, PO Box 4, FI-00014, Helsinki, Finland
| | - Anna Olkinuora
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Ilkka Virkkunen
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Hetti Kirves
- Prehospital Emergency Care, Hyvinkää hospital area, Hospital District of Helsinki and Uusimaa, PO Box 585, FI-05850, Hyvinkää, Finland
| | - Piritta Setälä
- Emergency Medical Services, Tampere University Hospital, PO Box 2000, FI-33521, Tampere, Finland
| | - Ilkka Pulkkinen
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Päivi Laukkanen-Nevala
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Lasse Raatiniemi
- Centre for Prehospital Emergency Care, Oulu University Hospital, PO Box 50, FI-90029, Oulu, Finland
| | - Helena Jäntti
- University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.,Center for Prehospital Emergency Care, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Timo Iirola
- Emergency Medical Services, Turku University Hospital and University of Turku, PO Box 52, FI-20521, Turku, Finland
| | - Jouni Nurmi
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland.,Emergency Medicine and Services, Helsinki University Hospital and Emergency Medicine, University of Helsinki, PO Box 100, FI-00029, Helsinki, Finland
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Ospel JM, Holodinsky JK, Goyal M. Management of Acute Ischemic Stroke Due to Large-Vessel Occlusion. J Am Coll Cardiol 2020; 75:1832-1843. [DOI: 10.1016/j.jacc.2019.10.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/20/2019] [Accepted: 10/23/2019] [Indexed: 02/04/2023]
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Ospel JM, Mayank A, Yoshimura S, Goyal M. Optimizing Stroke Care for Patients with Large Vessel Occlusions: Current State of the Art and Future Directions. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:203-214. [PMID: 37501700 PMCID: PMC10370651 DOI: 10.5797/jnet.ra.2020-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/04/2020] [Indexed: 07/29/2023]
Abstract
Acute ischemic stroke (AIS) is a severely disabling disease. Endovascular therapy is a powerful and highly effective treatment option for these patients and has recently become standard of care. The benefits of endovascular treatment (EVT) are tremendous both from a patient and from an economic perspective, since it dramatically improves individual patient outcomes while reducing long-term healthcare costs at the same time. The effect of EVT is highly time-dependent. Thus, the overarching goal in AIS is to quickly transport and diagnose the patient to minimize treatment delays. In this review, we provide an overview about the current state of stroke care, propose a fast and simplified imaging protocol and management approach for AIS patients. We also highlight the challenges we are currently facing in endovascular stroke treatment and suggest possible solutions to overcome these.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnuv Mayank
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Shinichi Yoshimura
- Department of Neurosurgery Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, Canada
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Schlemm L, Endres M, Nolte CH. Bypassing the Closest Stroke Center for Thrombectomy Candidates. Stroke 2020; 51:867-875. [DOI: 10.1161/strokeaha.119.027512] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
Patients with acute ischemic stroke who have large vessel occlusion benefit from direct transport to a comprehensive stroke center (CSC) capable of endovascular therapy. To avoid harm for patients without large vessel occlusion from delayed access to intravenous thrombolysis (IVT), it has been suggested to only redirect patients with high likelihood of large vessel occlusion for whom the additional delay to intravenous thrombolysis (IVT) caused by transport to the CSC is below a certain threshold. However, which threshold achieves the greatest clinical benefit is unknown.
Methods—
We used mathematical modeling to calculate additional-delay-to-IVT thresholds associated with the greatest reduction in disability-adjusted life years in abstracted 2-stroke center and multiple-stroke center scenarios. Model parameters were extracted from recent meta-analyses or large prospective cohort studies. Uncertainty was quantified in probabilistic and 2-way univariate sensitivity analyses.
Results—
Assuming ideal treatment time performance metrics, transport to the nearest CSC was the preferred strategy irrespective of additional delay-to-IVT when the transfer time between primary stroke center and CSC was <40 minutes (95% credible interval: 25–66 minutes); otherwise, the optimal additional delay-to-IVT-threshold ranged from 28 to 139 minutes. In multiple-stroke center scenarios, optimal additional-delay-to-IVT thresholds were 30 to 54 minutes in urban and 49 to 141 minutes in rural settings; use of optimal thresholds as compared with a 15 minute-threshold saved 0 to 0.11 and 0 to 0.37 disability-adjusted life years per triage case, respectively. Assuming slower treatment times at primary stroke centers and CSCs yielded longer permissible additional delays.
Conclusions—
Our results suggest that patients with acute ischemic stroke with suspected large vessel occlusion should be redirected to a CSC if the additional delay to IVT is <30 minutes in urban and 50 minutes in rural settings.
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Affiliation(s)
- Ludwig Schlemm
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
| | - Matthias Endres
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Christian H. Nolte
- From the Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Germany (L.S., M.E., C.H.N.)
- Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany (M.E., C.H.N.)
- DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Germany (M.E., C.H.N.)
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Panesar SS, Volpi JJ, Lumsden A, Desai V, Kleiman NS, Sample TL, Elkins E, Britz GW. Telerobotic stroke intervention: a novel solution to the care dissemination dilemma. J Neurosurg 2020; 132:971-978. [PMID: 31783366 DOI: 10.3171/2019.8.jns191739] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sandip S Panesar
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| | - John J Volpi
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| | - Alan Lumsden
- 2Department of Cardiovascular Surgery, Texas Medical Center
| | - Virendra Desai
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
| | - Neal S Kleiman
- 3Department of Interventional Cardiology, Houston Methodist Hospital
| | | | - Eric Elkins
- 5Cardiac Catheterization Laboratory, Houston Methodist Hospital, Houston, Texas
| | - Gavin W Britz
- 1Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital
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Price CI, Shaw L, Dixit A, Graziadio S, Lendrem C, Mitra D, Rodgers H, Sutcliffe L, White P. Asymmetrical Bioimpedance in the Anterior Circulation for Urgent Stratification of suspected Stroke (ABACUS Stroke): study protocol for a diagnostic accuracy study. Diagn Progn Res 2020; 4:2. [PMID: 32110739 PMCID: PMC7033905 DOI: 10.1186/s41512-019-0068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/28/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Early identification and treatment of stroke improve outcome. Ischaemic stroke due to large vessel occlusion (LVO) benefits from time-critical thrombectomy but this is only available in highly specialised healthcare services. Cerebral Bioimpedance Asymmetry (CBA) measurement obtained with the portable and rapid Cerebrotech Visor™ System device may be able to identify certain types of stroke including LVO. This test could be deployed pre-hospital and used to immediately direct patients to the most appropriate healthcare service for treatment. This study is evaluating the diagnostic accuracy of CBA measurements obtained from a real-world population of suspected stroke. METHODS Study design: Prospective observational cohort study.Setting: A hyperacute stroke unit and neuroscience centre in North East England.Participants: Adults with a paramedic assigned diagnosis of suspected stroke arriving at hospital within 6 hours of symptom onset.Index Test: Cerebral Bioimpedance Asymmetry measurement performed using the Cerebrotech Visor™ System. Measurement values produce continuous data (range 0 -100); pre-defined threshold for positive state ≥ 10.Reference Standard Tests: Standard CT brain +/- CT/MR angiography, and expert clinician opinion will establish the following clinical outcomes which constitute the suspected stroke population: ischaemic stroke +/- large vessel occlusion; symptomatic severe anterior vessel stenosis; large (≥60ml) and small (<60mls) vessel intracerebral haemorrhage; transient ischaemic attack; stroke mimic conditions; prior territorial stroke.Analyses: Sensitivity, specificity, negative and positive predictive values, area under the Receiver Operating Characteristic curve for identification of i) "complex stroke" (ischaemic stroke with large vessel occlusion or symptomatic severe anterior vessel stenosis or intracerebral haemorrhage ≥60ml or prior territorial stroke) and ii) ischaemic stroke with large vessel occlusion in isolation.Sample size: 124 participants. DISCUSSION The results from this study will determine how accurately CBA measurement using the Cerebrotech Visor™ System can identify key stroke types within the suspected stroke population. Acceptable diagnostic performance would be an important step forwards for access to time-critical treatments. TRIAL REGISTRATION Registered with ISRCTN (identifier: ISRCTN79169844) on 06/08/2018.
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Affiliation(s)
- Christopher I. Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Anand Dixit
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.061, William Leech Building, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.061, William Leech Building, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Dipayan Mitra
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Lou Sutcliffe
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
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Ospel JM, Kashani N, Fischer U, Menon BK, Almekhlafi M, Wilson AT, Foss MM, Saposnik G, Goyal M, Hill MD. How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT. AJNR Am J Neuroradiol 2020; 41:262-267. [PMID: 31974081 DOI: 10.3174/ajnr.a6396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE With increasing use of endovascular therapy, physicians' attitudes toward intravenous alteplase in endovascular therapy-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians in endovascular therapy- and alteplase-eligible patients with acute stroke using prespecified case scenarios and compared how their current local treatment practices differ compared with an assumed ideal environment. MATERIALS AND METHODS In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case scenarios, among them 14 with guideline-based alteplase recommendations (9 with level 1A and 5 with level 2B recommendation) and were asked how they would treat the patient: A) under their current local resources, and B) under assumed ideal conditions. Answer options were the following: 1) anticoagulation/antiplatelet therapy, 2) endovascular therapy, 3) endovascular therapy plus intravenous alteplase, and 4) intravenous alteplase. Decision rates were calculated, and multivariable regression analysis was performed to determine variables associated with the decision to abandon intravenous alteplase. RESULTS In cases with guideline recommendations for alteplase, physicians favored alteplase in 82.0% under current local resources and in 79.3% under assumed ideal conditions (P < .001). Under assumed ideal conditions, interventional neuroradiologists would refrain from intravenous alteplase most often (6.28%, OR = 2.40; 95% CI, 1.01-5.71). When physicians' current and ideal decisions differed, most would like to add endovascular therapy to intravenous alteplase in an ideal setting (196/3861 responses, 5.1%). CONCLUSIONS In patients eligible for endovascular therapy and intravenous alteplase, we observed a slightly lower decision rate in favor of intravenous alteplase under assumed ideal conditions compared with the decision rate under current local resources.
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Affiliation(s)
- J M Ospel
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - N Kashani
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - U Fischer
- University Hospital Bern (U.F.), Inselspital, University of Bern, Bern, Switzerland
| | - B K Menon
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - A T Wilson
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - M M Foss
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - G Saposnik
- Division of Neurology (G.S.), Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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Behrndtz A, Johnsen SP, Valentin JB, Gude MF, Blauenfeldt RA, Andersen G, Majoie CB, Fisher M, Simonsen CZ. TRIAGE-STROKE: Treatment strategy In Acute larGE vessel occlusion: Prioritize IV or endovascular treatment-A randomized trial. Int J Stroke 2020; 15:103-108. [PMID: 31446847 DOI: 10.1177/1747493019869830] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
RATIONALE For patients with acute ischemic stroke and large vessel occlusions, intravenous thrombolysis and endovascular therapy are standard of care, but the effect of endovascular therapy is superior to intravenous thrombolysis. If a severe stroke with symptoms indicating large vessel occlusions occurs in the catchment area of a primary stroke center, there is equipoise regarding optimal transport strategy. AIM For patients presenting with suspected large vessel occlusions (PASS ≥ 2) and a final diagnosis of acute ischemic stroke, we hypothesize that bypassing the primary stroke center will result in an improved 90-day functional outcome. SAMPLE SIZE We aim to randomize 600 patients, 1:1. DESIGN A national investigator-driven, multi-center, randomized assessor-blinded clinical trial. The Prehospital Acute Stroke Severity Scale has been developed. It identifies most patients with large vessel occlusions in the pre-hospital setting. Patients without a contraindication for intravenous thrombolysis are randomized to either transport directly to a comprehensive stroke centers for intravenous thrombolysis and of endovascular therapy or to a primary stroke center for intravenous thrombolysis and subsequent transport to a comprehensive stroke centers for of endovascular therapy, if needed. OUTCOMES The primary outcome will be the 90-day modified Rankin Scale score (mRS) for all patients with acute ischemic stroke. Secondary outcomes include 90-day mRS for all randomized patients, all patients with ischemic stroke but without large vessel occlusions, and patients with hemorrhagic stroke. The safety outcomes include severe dependency or death and time to intravenous thrombolysis for ischemic stroke patients. DISCUSSION Study results will influence decision making regarding transport strategy for patients with suspected large vessel occlusions.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aarhus, Denmark
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aarhus, Denmark
| | - Martin F Gude
- Pre-hospital Emergency Medical Services, Central Denmark Region, Department of Clinical medicine, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, The Netherlands
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Holodinsky JK, Williamson TS, Demchuk AM, Zhao H, Zhu L, Francis MJ, Goyal M, Hill MD, Kamal N. Modeling Stroke Patient Transport for All Patients With Suspected Large-Vessel Occlusion. JAMA Neurol 2019; 75:1477-1486. [PMID: 30193366 DOI: 10.1001/jamaneurol.2018.2424] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Ischemic stroke with large-vessel occlusion can be treated with alteplase and/or endovascular therapy; however, the administration of each treatment is time sensitive. Objective To identify the optimal triage and transport strategy: direct to the endovascular center (mothership) or immediate alteplase treatment followed by transfer to the endovascular center (drip and ship), for all patients with suspected large-vessel occlusion stroke. Design Setting, and Participants This was a theoretical, conditional probability modeling study. Existing data from clinical trials of stroke treatment were used for model generation. The study was conducted from February 1, 2017, to March 1, 2018. Main Outcomes and Measures The time-dependent efficacy of alteplase and endovascular therapy and the accuracy of large-vessel occlusion screening tools were modeled to estimate the probability of positive outcome (modified Rankin Scale score, 0-1 at 90 days) for both the drip-and-ship and mothership transport strategies. Based from onset to treatment, the strategy that estimates the greatest probability of excellent outcome is determined in several different scenarios. Results The patient's travel time from both thrombolysis and endovascular therapy centers, speed of treatment, and positive predictive value of the screening tool affect whether the drip-and-ship or mothership strategy estimates best outcomes. With optimal treatment times (door-to-needle time: 30 minutes; door-in-door-out time: 50 minutes; door-to-groin-puncture time: 60 minutes [mothership], 30 minutes [drip and ship]), both options estimate similar outcomes when the centers are 60 minutes or less apart. However, with increasing travel time between the 2 centers (90 or 120 minutes), drip and ship is favored if the patient would have to travel past the thrombolysis center to reach the endovascular therapy center or if the patient would arrive outside the alteplase treatment time window in the mothership scenario. Holding other variables constant, if treatment times are slow at the thrombolysis center (door-to-needle time: 60 minutes; door-in-door-out time: 120 minutes), the area where mothership estimates the best outcomes expands, especially when the 2 centers are close together (60 minutes apart or less). The area where mothership estimates the best outcome also expands as the positive predictive value of the screening tool increases. Conclusions and Relevance This study suggests that decision making for prehospital transport can be modeled using existing clinical trial data and that these models can be dynamically adapted to changing realities. Based on current median treatment times to realize the full benefit of endovascular therapy on a population level, the study findings suggest that delivery of the treatment should be regionally centralized. The study modeling suggests that transport decision making is context specific and the radius of superiority of the transport strategy changes based on treatment times at both centers, transport times, and the triaging tool used.
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Affiliation(s)
- Jessalyn K Holodinsky
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyler S Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry Zhao
- Department of Medicine and Neurology, Royal Melbourne Hospital, Parkville, Australia
| | - Luke Zhu
- Student, Department of Chemical and Petroleum Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Francis
- Student, Department of Mechanical and Manufacturing Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Electrical and Computer Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada.,Department of Mechanical and Manufacturing Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
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Jayaraman MV, Hemendinger ML, Baird GL, Yaghi S, Cutting S, Saad A, Siket M, Madsen TE, Williams K, Rhodes J, Haas RA, Furie KL, McTaggart RA. Field triage for endovascular stroke therapy: a population-based comparison. J Neurointerv Surg 2019; 12:233-239. [DOI: 10.1136/neurintsurg-2019-015033] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 11/04/2022]
Abstract
BackgroundEndovascular therapy (EVT) for stroke improves outcomes but is time sensitive.ObjectiveTo compare times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC).MethodsDuring the study, a portion of our region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. We compared times to treatment and clinical outcomes between those two groups. Additionally, we performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC.ResultsOver 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC; 144 were taken to the closest PSC and 88 to the more distant CSC. The median additional transport time to the CSC was 7 min. Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; p<0.001 for both). Among patients who were independent before the stroke, the OR for less disability in the direct group was 1.47 (95% CI 1.13 to 1.93, p=0.003), and 2.06 (95% CI 1.10 to 3.89, p=0.01) for the matched pairs.ConclusionsIn a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.
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Cincinnati Prehospital Stroke Scale for EMS Redirection of Large Vessel Occlusion Stroke. Can J Neurol Sci 2019; 46:684-690. [DOI: 10.1017/cjn.2019.242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT:Introduction:Prehospital identification of large vessel occlusion (LVO) stroke may expedite treatment by direct transport to comprehensive stroke centers (CSCs) with endovascular capabilities. The Cincinnati Prehospital Stroke Scale (CPSS) is commonly used for prehospital stroke detection. We aimed to assess whether (1) a high CPSS score can identify LVO and (2) an Emergency Medical Service (EMS) redirection protocol based on high CPSS accelerated endovascular treatment (EVT).Methods:A retrospective comparison of patients transported by EMSs for suspected stroke to a high-volume CSC over a 16-month period, before and after implementation of an EMS redirection protocol based on high CPSS score (3/3). Charts were reviewed to determine the presence of LVO. Time to EVT and 3-month outcomes were compared before and after implementation.Results:A prehospital CPSS 3/3 score was found in 223 (59%) patients, demonstrating positive and negative predictive values for LVO of 29% and 94%, respectively. CPSS-based EMS redirection increased the proportion of EVT performed after direct transport to CSC [before: 21 (36%), after: 45 (63%), p < 0.01] and decreased median first door-to-groin puncture time by 28 minutes [109 (interquartile range (IQR) 64–116) versus 81 (IQR 56–130), p = 0.03]. At 3 months, the proportion of patients achieving functional independence (modified Rankin score 0–2) went from 20/57 (35%) to 29/68 (43%) (p = 0.39) following implementation.Conclusions:CPSS-based EMS redirection accelerated identification of LVO strokes in the out-of-hospital setting and decreased time to EVT. Nevertheless, this protocol was also associated with high rates of non-LVO stroke. Impact on clinical outcomes should be evaluated in a larger cohort.
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Saber H, Navi BB, Grotta JC, Kamel H, Bambhroliya A, Vahidy FS, Chen PR, Blackburn S, Savitz SI, McCullough L, Sheth SA. Real-World Treatment Trends in Endovascular Stroke Therapy. Stroke 2019; 50:683-689. [PMID: 30726185 PMCID: PMC6407696 DOI: 10.1161/strokeaha.118.023967] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
Abstract
Background and Purpose- Recent landmark trials provided overwhelming evidence for effectiveness of endovascular stroke therapy (EST). Yet, the impact of these trials on clinical practice and effectiveness of EST among lower volume centers remains poorly characterized. Here, we determine population-level patterns in EST performance in US hospitals and compare EST outcomes from higher versus lower volume centers. Methods- Using validated diagnosis codes from data on all discharges from hospitals and Emergency Rooms in Florida (2006-2016) and the National Inpatient Sample (2012-2016) we identified patients with acute ischemic stroke treated with EST. The primary end point was good discharge outcome defined as discharge to home or acute rehabilitation facility. Multivariate regressions adjusted for medical comorbidities, intravenous tPA (tissue-type plasminogen activator) usage and annual hospital stroke volume were used to evaluate the likelihood of good outcome over time and by annual hospital EST volume. Results- A total of 3890 patients (median age, 73 [61-82] years, 51% female) with EST were identified in the Florida cohort and 42 505 (median age, 69 [58-79], 50% female) in the National Inpatient Sample. In both Florida and the National Inpatient Sample, the number of hospitals performing EST increased continuously. Increasing numbers of EST procedures were performed at lower annual EST volume hospitals over the studied time period. In adjusted multivariate regression, there was a continuous increase in the likelihood of good outcomes among patients treated in hospitals with increasing annual EST procedures per year (odds ratio, 1.1; 95% CI, 1.1-1.2 in Florida and odds ratio, 1.3; 95% CI, 1.2-1.4 in National Inpatient Sample). Conclusions- Analysis of population-level datasets of patients treated with EST from 2006 to 2016 demonstrated an increase in the number of centers performing EST, resulting in a greater number of procedures performed at lower volume centers. There was a positive association between EST volume and favorable discharge outcomes in EST-performing hospitals.
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Affiliation(s)
- Hamidreza Saber
- From the Department of Neurology, Wayne State University School of Medicine, Detroit, MI (H.S.)
| | - Babak B Navi
- Department of Neurology (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
- Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.G.)
| | - Hooman Kamel
- Department of Neurology (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
- Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
| | - Arvind Bambhroliya
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Farhaan S Vahidy
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Peng Roc Chen
- Department of Neurosurgery (P.R.C., S.B.), UT Health McGovern School of Medicine, Houston, TX
| | - Spiros Blackburn
- Department of Neurosurgery (P.R.C., S.B.), UT Health McGovern School of Medicine, Houston, TX
| | - Sean I Savitz
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Louise McCullough
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Sunil A Sheth
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
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Holodinsky JK, Almekhlafi MA, Goyal M, Kamal N. Mathematical Modeling for Decision-Making in the Field for Acute Stroke Patients With Suspected Large Vessel Occlusion. Stroke 2019; 50:212-217. [PMID: 30580736 DOI: 10.1161/strokeaha.118.021381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jessalyn K Holodinsky
- From the Department of Community Health Sciences, Cumming School of Medicine (J.K.H., M.A.A.), University of Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine (J.K.H., M.A.A., M.G.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- From the Department of Community Health Sciences, Cumming School of Medicine (J.K.H., M.A.A.), University of Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine (J.K.H., M.A.A., M.G.), University of Calgary, Canada
- Department of Radiology, Cumming School of Medicine (M.A.A., M.G.), University of Calgary, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine (M.A.A., M.G., N.K.), University of Calgary, Canada
| | - Mayank Goyal
- Hotchkiss Brain Institute, Cumming School of Medicine (J.K.H., M.A.A., M.G.), University of Calgary, Canada
- Department of Radiology, Cumming School of Medicine (M.A.A., M.G.), University of Calgary, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine (M.A.A., M.G., N.K.), University of Calgary, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, Cumming School of Medicine (M.A.A., M.G., N.K.), University of Calgary, Canada
- Department of Electrical and Computer Engineering, Schulich School of Engineering (N.K.), University of Calgary, Canada
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Détraz L, Ernst M, Bourcier R. Stroke Transfer and its Organizational Paradigm. Clin Neuroradiol 2018; 28:473-480. [DOI: 10.1007/s00062-018-0715-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
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47
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Chartrain AG, Shoirah H, Jauch EC, Mocco J. A review of acute ischemic stroke triage protocol evidence: a context for discussion. J Neurointerv Surg 2018; 10:1047-1052. [PMID: 30002087 DOI: 10.1136/neurintsurg-2018-013951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 11/03/2022]
Abstract
Endovascular thrombectomy (EVT) is now the standard of care for eligible patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO). However, there remains uncertainty in how hospital systems can most efficiently route patients with suspected ELVO for EVT treatment. Given the relative geographic distribution of centers with and without endovascular capabilities, the value of prehospital triage directly to centers with the ability to provide EVT remains debated. While there are no randomized trial data available to date, there is substantial evidence in the literature that may offer guidance on the subject. In this review we examine the available data in the context of improving the existing AIS triage systems and discuss how prehospital triage directly to endovascular-capable centers may confer clinical benefits for patients with suspected ELVO.
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Affiliation(s)
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Edward C Jauch
- Departments of Emergency Medicine and Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
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48
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Holodinsky JK, Patel AB, Thornton J, Kamal N, Jewett LR, Kelly PJ, Murphy S, Collins R, Walsh T, Cronin S, Power S, Brennan P, O’hare A, McCabe DJH, Moynihan B, Looby S, Wyse G, McCormack J, Marsden P, Harbison J, Hill MD, Williams D. Drip and ship versus direct to endovascular thrombectomy: The impact of treatment times on transport decision-making. Eur Stroke J 2018; 3:126-135. [PMID: 31008345 PMCID: PMC6460407 DOI: 10.1177/2396987318759362] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 01/23/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In ischaemic stroke care, fast reperfusion is essential for disability free survival. It is unknown if bypassing thrombolysis centres in favour of endovascular thrombectomy (mothership) outweighs transport to the nearest thrombolysis centre for alteplase and then transfer for endovascular thrombectomy (drip-and-ship). We use conditional probability modelling to determine the impact of treatment times on transport decision-making for acute ischaemic stroke. MATERIALS AND METHODS Probability of good outcome was modelled using a previously published framework, data from the Irish National Stroke Register, and an endovascular thrombectomy registry at a tertiary referral centre in Ireland. Ireland was divided into 139 regions, transport times between each region and hospital were estimated using Google's Distance Matrix Application Program Interface. Results were mapped using ArcGIS 10.3. RESULTS Using current treatment times, drip-and-ship rarely predicts best outcomes. However, if door to needle times are reduced to 30 min, drip-and-ship becomes more favourable; even more so if turnaround time (time from thrombolysis to departure for the endovascular thrombectomy centre) is also reduced. Reducing door to groin puncture times predicts better outcomes with the mothership model. DISCUSSION This is the first case study modelling pre-hospital transport for ischaemic stroke utilising real treatment times in a defined geographic area. A moderate improvement in treatment times results in significant predicted changes to the optimisation of a national acute stroke patient transport strategy. CONCLUSIONS Modelling patient transport for system-level planning is sensitive to treatment times at both thrombolysis and thrombectomy centres and has important implications for the future planning of thrombectomy services.
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Affiliation(s)
- Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary,
Alberta, Canada
| | - Alka B Patel
- Department of Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary,
Calgary, Alberta, Canada
| | - John Thornton
- Department of Neuroradiology, Royal College of Surgeons in
Ireland, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Noreen Kamal
- Department of Clinical Neurosciences, University of Calgary,
Calgary, Alberta, Canada
| | - Lauren R Jewett
- Department of Geography, University of Calgary, Calgary,
Alberta, Canada
| | - Peter J Kelly
- Neurovascular Unit for Translational and Therapeutics Research,
Mater Misericordiae University Hospital/University College Dublin, Dublin,
Ireland
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, Royal College of
Surgeons in Ireland, Dublin, Ireland
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ronan Collins
- Department of Geriatric and Stroke Medicine, Tallaght Hospital,
Dublin, Ireland
| | - Thomas Walsh
- Department of Stroke and Geriatric Medicine, Galway University
Hospital, Galway, Ireland
| | - Simon Cronin
- Cork NeuroScience Centre, University College Cork, Cork,
Ireland
- Department of Neurology, Cork University Hospital, Cork,
Ireland
| | - Sarah Power
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Paul Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O’hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Dominick JH McCabe
- Department of Neurology, Stroke Service, and Vascular Neurology
Research Foundation, The Adelaide and Meath
Hospital (incorporating the National Children’s Hospital), Dublin,
Ireland
- Department of Clinical Neurosciences, UCL Institute of
Neurology, London, UK
- Academic Unit of Neurology, School of Medicine, Trinity College
Dublin, Dublin, Ireland
| | - Barry Moynihan
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Gerald Wyse
- Department of Neuroradiology, Cork University Hospital, Cork,
Ireland
| | - Joan McCormack
- Faculty of Science and Health, Dublin City University, Dublin,
Ireland
| | - Paul Marsden
- Department of Public Health, Health Services Executive,
Tulamore, Ireland
| | - Joseph Harbison
- Department of Medical Gerontology, Trinity College Dublin,
Dublin, Ireland
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary,
Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary,
Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary,
Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary,
Alberta, Canada
- Department of Medicine, University of Calgary, Calgary,
Alberta, Canada
- Calgary Stroke Program, University of Calgary, Calgary,
Alberta, Canada
| | - David Williams
- Beaumont Hospital, Dublin, Ireland
- Department of Geriatric and Stroke Medicine, Royal College of
Surgeons in Ireland, Dublin, Ireland
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49
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Richards CT, Huebinger R, Tataris KL, Weber JM, Eggers L, Markul E, Stein-Spencer L, Pearlman KS, Holl JL, Prabhakaran S. Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke. PREHOSP EMERG CARE 2018; 22:312-318. [PMID: 29297717 PMCID: PMC6133654 DOI: 10.1080/10903127.2017.1387629] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. METHODS Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. RESULTS Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58-81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6-10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3-14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). CONCLUSIONS A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Chicago EMS/Region XI EMS System, Chicago, Illinois
| | - Ryan Huebinger
- Department of Emergency Medicine, University of Alabama-Birmingham, Birmingham, Alabama, Chicago, Illinois
| | - Katie L. Tataris
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joseph M. Weber
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Department of Emergency Medicine, John H. Stroger, Jr., Hospital of Cook County, Chicago, Illinois
| | - Laura Eggers
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Eddie Markul
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Department of Emergency Medicine, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Leslee Stein-Spencer
- Chicago EMS/Region XI EMS System, Chicago, Illinois
- Chicago Fire Department, City of Chicago, Chicago, Illinois
| | - Kenneth S. Pearlman
- Department of Emergency Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Chicago EMS/Region XI EMS System, Chicago, Illinois
| | - Jane L. Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Shyam Prabhakaran
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
- Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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50
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Zhao H, Pesavento L, Coote S, Rodrigues E, Salvaris P, Smith K, Bernard S, Stephenson M, Churilov L, Yassi N, Davis SM, Campbell BC. Ambulance Clinical Triage for Acute Stroke Treatment. Stroke 2018. [DOI: 10.1161/strokeaha.117.019307] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Henry Zhao
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Lauren Pesavento
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Skye Coote
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Edrich Rodrigues
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Patrick Salvaris
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Karen Smith
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Stephen Bernard
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Michael Stephenson
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Leonid Churilov
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Nawaf Yassi
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Stephen M. Davis
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
| | - Bruce C.V. Campbell
- From the Melbourne Brain Centre and Department of Neurology, Royal Melbourne Hospital, Australia (H.Z., L.P., S.C., E.R., P.S., N.Y., S.M.D., B.C.V.C.); Ambulance Victoria, Melbourne, Australia (K.S., S.B., M.S.); The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (L.C., N.Y.); Department of Epidemiology and Preventive Medicine, and Department of Community Emergency Health and Paramedic Practice, Monash University, Australia (K.S., M.S.); and Discipline of
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