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Stirparo G, Kacerik E, Ristagno G, Andreassi A, Coppo A, Migliari M, Albonico A, Sechi GM, Zoli A, Signorelli C. Management of possible stroke by laypeople in pre-hospital setting: who should we train? ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023203. [PMID: 37850778 PMCID: PMC10644920 DOI: 10.23750/abm.v94i5.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/20/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND AND AIM The pre-hospital management of a possible stroke is fundamental for the transport of patients to the correct HUB facility; thus, they must be transported to the Emergency Department (ED) by EMS vehicles. Our study aims to analyze the factors correlated with a higher probability of accessing the ED through the EMS in this event. METHODS This is a retrospective observational study. All accesses in the 120 EDs of the Lombardy region, with a diagnosis of discharge whose symptoms could resemble CPSS, were analyzed between 1 January 2019 and 31 December 2019. RESULTS We identified an increased probability of using the EMS vehicles of 0,05% (I.C. 95%: 0.04% - 0.06%; p<0.0001) for each additional year of age, considering patients aged 20 to 100 years and the percentage was significantly higher in the female population (58% vs 49%; p<0.001). Moreover, we calculated that the incidence of stroke was approximately 140 cases per 100,000 inhabitants. CONCLUSIONS Only half of the citizens in the Lombardy region use the EMS in case of suspicion of stroke; further information campaigns are essential to educate citizens. Information strategies should be directed especially at men between 30 and 59 years old.
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Affiliation(s)
- Giuseppe Stirparo
- Faculty of Medicine, School of Public Health - Università Vita-Salute San Raffaele, 20132 Milan, Italy.
| | - Erika Kacerik
- Faculty of Medicine, School of Public Health - Università Vita-Salute San Raffaele, 20132 Milan, Italy.
| | - Giuseppe Ristagno
- Department of Fisiopatologia Medico-Chirurgica e dei Trapianti - Università degli Studi di Milano, 20122 Milan.
| | - Aida Andreassi
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ).
| | - Anna Coppo
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ).
| | | | | | | | - Alberto Zoli
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ).
| | - Carlo Signorelli
- Faculty of Medicine, School of Public Health - Università Vita-Salute San Raffaele, 20132 Milan, Italy.
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2
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Nicholls JK, Ince J, Minhas JS, Chung EML. Emerging Detection Techniques for Large Vessel Occlusion Stroke: A Scoping Review. Front Neurol 2022; 12:780324. [PMID: 35095726 PMCID: PMC8796731 DOI: 10.3389/fneur.2021.780324] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Large vessel occlusion (LVO) is the obstruction of large, proximal cerebral arteries and can account for up to 46% of acute ischaemic stroke (AIS) when both the A2 and P2 segments are included (from the anterior and posterior cerebral arteries). It is of paramount importance that LVO is promptly recognised to provide timely and effective acute stroke management. This review aims to scope recent literature to identify new emerging detection techniques for LVO. As a good comparator throughout this review, the commonly used National Institutes of Health Stroke Scale (NIHSS), at a cut-off of ≥11, has been reported to have a sensitivity of 86% and a specificity of 60% for LVO. Methods: Four electronic databases (Medline via OVID, CINAHL, Scopus, and Web of Science), and grey literature using OpenGrey, were systematically searched for published literature investigating developments in detection methods for LVO, reported from 2015 to 2021. The protocol for the search was published with the Open Science Framework (10.17605/OSF.IO/A98KN). Two independent researchers screened the titles, abstracts, and full texts of the articles, assessing their eligibility for inclusion. Results: The search identified 5,082 articles, in which 2,265 articles were screened to assess their eligibility. Sixty-two studies remained following full-text screening. LVO detection techniques were categorised into 5 groups: stroke scales (n = 30), imaging and physiological methods (n = 15), algorithmic and machine learning approaches (n = 9), physical symptoms (n = 5), and biomarkers (n = 3). Conclusions: This scoping review has explored literature on novel and advancements in pre-existing detection methods for LVO. The results of this review highlight LVO detection techniques, such as stroke scales and biomarkers, with good sensitivity and specificity performance, whilst also showing advancements to support existing LVO confirmatory methods, such as neuroimaging.
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Affiliation(s)
- Jennifer K. Nicholls
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
| | - Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Emma M. L. Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Medical Physics, University Hospitals of Leicester, NHS Trust, Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
- School of Life Course Sciences, King's College London, London, United Kingdom
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3
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Schuler L, Bolognese M, Lakatos LB, Christ M. Strukturierte Erkennung von Patienten mit Schlaganfall in der Notfallsituation. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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4
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Nguyen TTM, van den Wijngaard IR, Bosch J, van Belle E, van Zwet EW, Dofferhoff-Vermeulen T, Duijndam D, Koster GT, de Schryver ELLM, Kloos LMH, de Laat KF, Aerden LAM, Zylicz SA, Wermer MJH, Kruyt ND. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78:157-164. [PMID: 33252631 DOI: 10.1001/jamaneurol.2020.4418] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. Objective To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. Design, Setting, and Participants This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Exposures Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Main Outcomes and Measures Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Results Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. Conclusions and Relevance This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.
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Affiliation(s)
- T Truc My Nguyen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
| | - Jan Bosch
- Emergency Medical Services Hollands-Midden, Leiden, the Netherlands
| | - Eduard van Belle
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Dion Duijndam
- Emergency Medical Services Haaglanden, The Hague, the Netherlands
| | - Gaia T Koster
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Loet M H Kloos
- Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands
| | | | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis Hospital, Delft, the Netherlands
| | - Stas A Zylicz
- Department of Neurology, Langeland Hospital, Zoetermeer, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,University Neurovascular Center Leiden-The Hague, the Netherlands
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5
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Leibinger F, Allou T, Van Damme L, Jebali C, Arquizan C, Farouil G, Laverdure A, Gaillard N, Ibanez M, Smadja P, Dutray A, Tardieu M, Nguyen Them L, Ousji A, Jurici S, Gascou G, Bensalah ZM, Olivier N, Damon F, Chaabane W, Fadat B, Lachcar M, Mas J, Mourand I, Ferraro A, Heve D, Dumitrana A, Blenet JC, Aptel S, Costalat V, Bonafe A, Ortega L, Sablot D. Usefulness of a single-parameter tool for the prediction of large vessel occlusion in acute stroke. J Neurol 2020; 268:1358-1365. [PMID: 33145651 DOI: 10.1007/s00415-020-10286-8] [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: 07/16/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In acute stroke, large vessel occlusion (LVO) should be promptly identified to guide patient's transportation directly to comprehensive stroke centers (CSC) for mechanical thrombectomy (MT). In many cases, prehospital multi-parameter scores are used by trained emergency teams to identify patients with high probability of LVO. However, in several countries, the first aid organization without intervention of skilled staff precludes the on-site use of such scores. Here, we assessed the accuracy of LVO prediction using a single parameter (i.e. complete hemiplegia) obtained by bystander's telephone-based witnessing. PATIENTS AND METHODS This observational, single-center study included consecutive patients who underwent intravenous thrombolysis at the primary stroke center and/or were directly transferred to a CSC for MT, from January 1, 2015 to March 1, 2020. We defined two groups: patients with initial hemiplegia (no movement in one arm and leg and facial palsy) and patients without initial hemiplegia, on the basis of a bystander's witnessing. RESULTS During the study time, 874 patients were included [mean age 73 years (SD 13.8), 56.7% men], 320 with initial hemiplegia and 554 without. The specificity of the hemiplegia criterion to predict LVO was 0.88, but its sensitivity was only 0.53. CONCLUSION Our results suggest that the presence of hemiplegia as witnessed by a bystander can predict LVO with high specificity. This single criterion could be used for decision-making about direct transfer to CSC for MT when the absence of emergency skilled staff precludes the patient's on-site assessment, especially in regions distant from a CSC.
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Affiliation(s)
- Franck Leibinger
- Intensive Care Unit, Centre Hospitalier de Perpignan, Perpignan, France
| | - Thibaut Allou
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Laurène Van Damme
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Chawki Jebali
- Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Caroline Arquizan
- Neurology Department, Montpellier University Hospital, Montpellier, France
| | - Geoffroy Farouil
- Radiology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | | | - Nicolas Gaillard
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France.,Neurology Department, Montpellier University Hospital, Montpellier, France
| | - Majo Ibanez
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Philippe Smadja
- Radiology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Anais Dutray
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Maxime Tardieu
- Radiology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Ludovic Nguyen Them
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Ali Ousji
- Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Snejana Jurici
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Gregory Gascou
- Neuroradiology Department, CHU Montpellier, Montpellier, France
| | | | - Nadège Olivier
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Frederique Damon
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France.,Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Wael Chaabane
- Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Bénédicte Fadat
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Marlène Lachcar
- Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Julie Mas
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Isabelle Mourand
- Neurology Department, Montpellier University Hospital, Montpellier, France
| | - Adelaïde Ferraro
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | - Didier Heve
- Regional Health Agency of Occitanie, Montpellier, France
| | - Adrian Dumitrana
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France
| | | | - Sabine Aptel
- Radiology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | | | - Alain Bonafe
- Radiology Department, Centre Hospitalier de Perpignan, Perpignan, France.,Neuroradiology Department, CHU Montpellier, Montpellier, France
| | - Laurent Ortega
- Emergency Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Denis Sablot
- Neurology Department, Centre Hospitalier de Perpignan, 20 avenue du Languedoc, BP 4052, 66046, Perpignan, France. .,Regional Health Agency of Occitanie, Montpellier, France.
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6
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Abstract
Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.
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Affiliation(s)
- Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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7
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Padgham M, Boeing G, Cooley D, Tierney N, Sumner M, Phan TG, Beare R. An Introduction to Software Tools, Data, and Services for Geospatial Analysis of Stroke Services. Front Neurol 2019; 10:743. [PMID: 31440197 PMCID: PMC6693386 DOI: 10.3389/fneur.2019.00743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/25/2019] [Indexed: 12/01/2022] Open
Abstract
Background: There is interest in the use geospatial data for development of acute stroke services given the importance of timely access to acute reperfusion therapy. This paper aims to introduce clinicians and citizen scientists to the possibilities offered by open source softwares (R and Python) for analyzing geospatial data. It is hoped that this introduction will stimulate interest in the field as well as generate ideas for improving stroke services. Method: Instructions on installation of libraries for R and Python, source codes and links to census data are provided in a notebook format to enhance experience with running the software. The code illustrates different aspects of using geospatial analysis: (1) creation of choropleth (thematic) map which depicts estimate of stroke cases per post codes; (2) use of map to help define service regions for rehabilitation after stroke. Results: Choropleth map showing estimate of stroke per post codes and service boundary map for rehabilitation after stroke. Conclusions The examples in this article illustrate the use of a range of components that underpin geospatial analysis. By providing an accessible introduction to these areas, clinicians and researchers can create code to answer clinically relevant questions on topics such as service delivery and service demand.
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Affiliation(s)
| | - Geoff Boeing
- School of Public Policy and Urban Affairs, Northeastern University, Boston, MA, United States
| | | | - Nicholas Tierney
- Department of Econometrics and Business Statistics, Monash University, Melbourne, VIC, Australia
| | - Michael Sumner
- Australian Antarctic Division, Department of the Environment and Energy, Kingston, TAS, Australia
| | - Thanh G Phan
- Clinical Trials Imaging and Informatics Division of Stroke and Aging Research Group, Monash University, Melbourne, VIC, Australia.,Stroke Unit, Monash Medical Centre, Melbourne, VIC, Australia
| | - Richard Beare
- Department of Medicine, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
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