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Checkouri T, Sablot D, Varnier Q, Fryder I, Collemiche FL, Azais B, Dargazanli C, Leibinger F, Cagnazzo F, Mahmoudi M, Lefevre PH, Van Damme L, Gascou G, Schmidt J, Arquizan C, Plantard C, Farouil G, Costalat V. Becoming a thrombectomy-capable stroke center: Clinical and medico-economical effectiveness at the hospital level. Eur Stroke J 2024:23969873241254239. [PMID: 38760934 DOI: 10.1177/23969873241254239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024] Open
Abstract
INTRODUCTION Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure. PATIENTS AND METHODS This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital. RESULTS The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825€ per patient for the hospital. DISCUSSION Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.
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Affiliation(s)
- Thomas Checkouri
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Denis Sablot
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Quentin Varnier
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Ivan Fryder
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | - Benoit Azais
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | | | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Mehdi Mahmoudi
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | | | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Julia Schmidt
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
| | - Carole Plantard
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024:S0140-6736(24)00642-1. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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Day J, Simmonds RL, Shaw L, Price CI, McClelland G, Ford GA, James M, White P, Stein K, Pope C. Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study. Emerg Med J 2024:emermed-2023-213350. [PMID: 38729751 DOI: 10.1136/emermed-2023-213350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 04/10/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.
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Affiliation(s)
- Jo Day
- NIHR Applied Research Collaboration South West Peninsula, Health and Community Sciences, University of Exeter, Exeter, Devon, UK
| | | | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graham McClelland
- North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, UK
- Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Martin James
- Royal Devon University Healthcare NHS Foundation Trust and University of Exeter, University of Exeter, Exeter, Devon, UK
| | - Phil White
- Stroke Research Group, Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ken Stein
- NIHR Applied Research Collaboration South West Peninsula, University of Exeter, Exeter, Devon, UK
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hou Z, Brenner JS. Developing targeted antioxidant nanomedicines for ischemic penumbra: Novel strategies in treating brain ischemia-reperfusion injury. Redox Biol 2024; 73:103185. [PMID: 38759419 PMCID: PMC11127604 DOI: 10.1016/j.redox.2024.103185] [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: 03/25/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
During cerebral ischemia-reperfusion conditions, the excessive reactive oxygen species in the ischemic penumbra region, resulting in neuronal oxidative stress, constitute the main pathological mechanism behind ischemia-reperfusion damage. Swiftly reinstating blood perfusion in the ischemic penumbra zone and suppressing neuronal oxidative injury are key to effective treatment. Presently, antioxidants in clinical use suffer from low bioavailability, a singular mechanism of action, and substantial side effects, severely restricting their therapeutic impact and widespread clinical usage. Recently, nanomedicines, owing to their controllable size and shape and surface modifiability, have demonstrated good application potential in biomedicine, potentially breaking through the bottleneck in developing neuroprotective drugs for ischemic strokes. This manuscript intends to clarify the mechanisms of cerebral ischemia-reperfusion injury and provides a comprehensive review of the design and synthesis of antioxidant nanomedicines, their action mechanisms and applications in reversing neuronal oxidative damage, thus presenting novel approaches for ischemic stroke prevention and treatment.
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Affiliation(s)
- Zhitao Hou
- College of Basic Medical and Sciences, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, 150040, China; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated with Beijing University of Chinese Medicine, Beijing, 100700, China; The First Hospital Affiliated with Heilongjiang University of Chinese Medicine, Harbin, 150010, Heilongjiang, China
| | - Jacob S Brenner
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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del Toro-Pérez C, Amaya-Pascasio L, Arjona-Padillo A, Martínez-Sánchez P. Impact of Direct Transport to Thrombectomy-Capable Center vs. Nearby/Distant Local Stroke Centers on Stroke Outcome in Patients Undergoing Thrombectomy: A Real-Life Study. J Pers Med 2024; 14:395. [PMID: 38673022 PMCID: PMC11050859 DOI: 10.3390/jpm14040395] [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: 03/13/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Our aim was to compare the stroke outcomes of a direct transfer (DT) to a thrombectomy-capable center vs. initial care at two local stroke centers: a nearby hospital (NH, 36 km) and a distant hospital (DH, 113 km). Patients who underwent a mechanical thrombectomy were analyzed (February 2017-October 2021), and the outcome was considered favorable if the modified Rankin scale (mRS) score was ≤ 2 at three months. A total of 300 patients were included, 55 of which were transferred from the NH and 58 from the DH. There was a difference in the median (IQR) transfer time of 39 min between the hospitals (149 min for the NH vs. 188 min for the DH, p = 0.003). After adjusting for confounding variables, a secondary transfer from the DH, compared to a DT, was associated with a lower functional independence: mRS score ≤ 2 (OR = 0.37, 95% CI = 0.14-0.97, p = 0.043), without significant differences in the mortality between the groups. These differences were not observed in patients from the NH. Conclusions: A secondary transfer from a distant hospital was associated with a poorer functional outcome at 3 months. This unfavorable outcome was not observed among patients transferred from a nearby hospital. These findings highlight the importance of categorizing the suitability of one transfer model over another based on the proximity of hospitals to the thrombectomy center, but also in accordance with organizational and geographic characteristics that vary within each health region.
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Affiliation(s)
- Cristina del Toro-Pérez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Laura Amaya-Pascasio
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Antonio Arjona-Padillo
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Patricia Martínez-Sánchez
- Stroke Centre, Department of Neurology, Torrecárdenas University Hospital, 04009 Almería, Spain
- Faculty of Health Sciences, CEINSA (Center of Health Research), University of Almería, 04120 Almería, Spain
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Masouris I, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Trumm C, Liebig T, Kellert L, Schöberl F. Basilar artery occlusion: drip-and-ship versus direct-to-center for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria (NEVAS). J Neurol 2024; 271:1885-1892. [PMID: 38095722 DOI: 10.1007/s00415-023-12126-x] [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: 09/20/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Recent clinical trials revealed a substantial clinical benefit for mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO). While urban areas are sufficiently covered with comprehensive stroke centers and MT expertise, rural areas lack such resources. Structured telemedical stroke networks offer rural hospitals instant consultation by stroke experts, enabling swift administration of intravenous thrombolysis (IVT) on-site and transportation for MT. For BAO patients, data on performance and clinical outcomes in telemedical stroke networks are lacking. METHODS We retrospectively analyzed data from patients with acute BAO eligible for MT: those treated directly in our comprehensive stroke center (direct-to-center/DC) and those treated in rural hospitals that were telemedically consulted by the Neurovascular Network of Southwest Bavaria (NEVAS) and transferred to our center for MT (drip-and-ship, DS). Key time intervals, stroke management performance and functional outcome after 90 days were compared. RESULTS Baseline characteristics, including premorbid status and stroke severity, were comparable. Time from symptom onset to IVT was identical in both groups (118 min). There was a delay of 180 min until recanalization in DS patients, mainly due to patient transport for MT. Procedural treatment time intervals, success of recanalization and complications were comparable. Clinical outcome at 3 months follow-up of DS patients was not inferior to DC patients. CONCLUSION We show for the first time that patients with BAO in rural areas benefit from a structured telemedicine network such as NEVAS, regarding both on-site processing and drip-and-ship for MT. Clinical outcomes are comparable among DS and DC patients.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | - J Wischmann
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Schniepp
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - L Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - G F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - C Trumm
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - T Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - L Kellert
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - F Schöberl
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
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Leto N, Bjørshol CA, Kurz M, Østerås Ø, Fromm A, Lindner TW. Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway. Emerg Med J 2024; 41:249-254. [PMID: 37968092 PMCID: PMC10982621 DOI: 10.1136/emermed-2023-213236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/30/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND In 2019, the emergency medical services (EMS) covering the western Norway Regional Health Authority area implemented its version of the prehospital clinical criteria G-FAST (Gaze deviation, Facial palsy, Arm weakness, Visual loss, Speech disturbance) to detect acute ischaemic stroke (AIS) with large vessel occlusion (LVO). For patients with gaze deviation and at least one other G-FAST symptom, a primary stroke centre (PSC) may be bypassed and the patient taken directly to a comprehensive stroke centre (CSC) for rapid endovascular treatment (EVT) evaluation. The study aim was to investigate the efficacy of the G-FAST criteria for LVO patient selection and direct transfer to a CSC. METHODS This retrospective study included patients with code-red emergency medical communication centre (EMCC) stroke suspicion ambulance dispatch between August to December 2020. Stroke suspicion was defined as having at least one G-FAST symptom at EMS arrival. We obtained patient data from dispatches from EMCCs, EMS records and local EVT registries. Clinical features, CT images, and reperfusion treatment were recorded. The test characteristics for gaze deviation plus one other G-FAST symptom in detecting LVO were determined. RESULTS Among 643 patients, 59 were diagnosed with LVO at hospital arrival. In this group, seven fulfilled the G-FAST criteria for direct transport to a CSC at EMS arrival on scene, resulting in a sensitivity of 12% (95% CI 5% to 23%). The specificity was 99.66% (95% CI 98.77% to 99.96%), the positive predictive value 78%, and the negative predictive value 92%. EVT was performed in 64% (38/59) of LVO cases. Median time from PSC arrival to start of EVT at a CSC was 163 min. CONCLUSION The use of local G-FAST prehospital criteria by EMS personnel to identify patients with AIS with LVO is not suitable for selection of patients with LVO for direct transfer to a CSC.
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Affiliation(s)
- Nedim Leto
- The Regional Centre for Emergency Medical Research Western Norway, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Conrad Arnfinn Bjørshol
- The Regional Centre for Emergency Medical Research Western Norway, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Martin Kurz
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Østerås
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Thomas Werner Lindner
- The Regional Centre for Emergency Medical Research Western Norway, Stavanger University Hospital, Stavanger, Norway
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Feldmeier M, Kim AS, Zachrison KS, Alberts MJ, Shen YC, Hsia RY. Heterogeneity of State Stroke Center Certification and Designation Processes. Stroke 2024; 55:1051-1058. [PMID: 38469729 DOI: 10.1161/strokeaha.123.045368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. METHODS In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. RESULTS Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). CONCLUSIONS Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.
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Affiliation(s)
- Madeline Feldmeier
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
| | - Anthony S Kim
- Department of Neurology, UCSF Weill Institute of Neurosciences, University of California, San Francisco. (A.S.K.)
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (K.S.Z.)
- Harvard Medical School, Boston, MA (K.S.Z.)
| | - Mark J Alberts
- Ayer Neuroscience Institute, Hartford HealthCare, CT (M.J.A.)
| | - Yu-Chu Shen
- Department of Defense Management, Naval Postgraduate School, Monterey, CA (Y.-C.S.)
- National Bureau of Economic Research, Cambridge, MA (Y.-C.S.)
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. (R.Y.H.)
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10
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Kaesmacher J, Cavalcante F, Kappelhof M, Treurniet KM, Rinkel L, Liu J, Yan B, Zi W, Kimura K, Eker OF, Zhang Y, Piechowiak EI, van Zwam W, Liu S, Strbian D, Uyttenboogaart M, Dobrocky T, Miao Z, Suzuki K, Zhang L, van Oostenbrugge R, Meinel TR, Guo C, Seiffge D, Yin C, Bütikofer L, Lingsma H, Nieboer D, Yang P, Mitchell P, Majoie C, Fischer U, Roos Y, Gralla J. Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA 2024; 331:764-777. [PMID: 38324409 PMCID: PMC10851137 DOI: 10.1001/jama.2024.0589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy. Objective To determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset. Design, Setting, and Participants Individual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313). Exposure Interval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone. Main Outcomes and Measures The primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT. Results In 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, -3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes. Conclusions and Relevance In patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Kilian M. Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Omer F. Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People’s Hospital of Nanjing Medical University, Nanjing, China
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Congguo Yin
- Department of Neurology, Hangzhou First People’s Hospital of Zhejiang University, Hangzhou, China
| | | | - Hester Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Sablot D, Touzé E, Ellie E, Alamowitch S, De Broucker T, Guillon B, Sellal F, Crozier S, Sibon I. Medical demography at stroke centers: Current situation in France. Rev Neurol (Paris) 2024; 180:171-176. [PMID: 37880036 DOI: 10.1016/j.neurol.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/20/2023] [Accepted: 08/23/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Following the 2010-2014 French national stroke action plan, the number of stroke center (SC) has gradually increased in France, allowing a homogeneous coverage and access to neurovascular care in organized and territorially defined structures. However, operational difficulties within SCs have been progressively reported over the last few years. The objective of this study was to identify the medical staff shortages in SC that may contribute to these difficulties. METHODS A survey on the medical staffing level as of January 1, 2021 was sent to all French SC managers. Specific questions related on vacancies, need of interim medical staff, and participation in out-of-hour healthcare services. RESULTS Among the 139 SC managers contacted, 122 (88%) filled in the questionnaire. Analysis of the data showed that over 879 physician positions opened, 163 (18.5%) remained vacant for a mean of two years, and that in 51 SCs (41.9%), more than two positions were unfilled. In 13 of these 51 SCs, the out-of-hour healthcare services relied on less than four practitioners, defining a critical situation, and three other SCs had to close temporarily (2) or permanently (1). Moreover, 39.2% of SCs with at least one vacancy used interim physicians, for a median period of 12.5 weeks/year (IQR 5-18). CONCLUSION This study highlights the significant medical staff shortage in French SCs. In the absence of urgent measures, more SCs will close, jeopardizing the regional network and access to care for stroke patients.
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Affiliation(s)
- D Sablot
- Service de neurologie, hôpital St-Jean, Perpignan, France.
| | - E Touzé
- Stroke Unit, CHU de Caen, université de Caen, Caen, France
| | - E Ellie
- Service de neurologie, hôpital de la côte basque, Bayonne, France
| | - S Alamowitch
- Département des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, Paris, France
| | - T De Broucker
- Service de neurologie, hôpital Delafontaine, St-Denis, France
| | - B Guillon
- Stroke unit, hôpital Hôtel-Dieu, CHU de Nantes, Nantes, France
| | - F Sellal
- Service de neurologie, hôpital Louis-Pasteur, Colmar, France
| | - S Crozier
- Département des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, Paris, France
| | - I Sibon
- Stroke unit, CHU de Bordeaux, université de Bordeaux, Bordeaux, France
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12
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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13
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Wang CM, Chang YM, Tzeng RC, Chen TS, Wu ST, Lin KH, Chang CC, Huang MH, Vong SC, Wu MH, Chen CH, Lin CW, Sung PS. A simple, organized web-based system improved the transfer efficiency and patient outcomes for endovascular thrombectomy in regional stroke network. J Formos Med Assoc 2024:S0929-6646(24)00089-5. [PMID: 38360489 DOI: 10.1016/j.jfma.2024.02.002] [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: 10/09/2023] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is a time-sensitive treatment for acute ischemic stroke with large vessel occlusion. To optimize transfer efficiency, a web-based platform was introduced in the Tainan Stroke Network (TSN). We assessed its application and effectiveness in regional stroke care. METHOD This new web-based platform containing a questionnaire-style interface was introduced on October 1, 2021. To assess the transfer efficiency and patient outcomes, acute stroke patients transferred from PSCs to CSC for EVT from April 01, 2020, to December 30, 2022, were enrolled. The patients were classified into the traditional transferal pathway (TTP) group and the new transferal pathway (NTP) group depending on mode of transfer. Patient characteristics, time segments after stroke onset and outcome were compared between groups. RESULT A total of 104 patients were enrolled, with 77 in the TTP group and 27 in the NTP group. Compared to the TTP group, the NTP group had a significantly shorter onset-to-CSC door time (TTP vs. NTP: 267 vs. 198 min; p = 0.041) and a higher EVT rate (TTP vs. NTP: 18.2% vs. 48.1%, p = 0.002). Among EVT patients, those in the NTP group had a significantly shorter CSC door-to-puncture time (TTP vs. NTP: 131.5 vs. 110 min; p = 0.029). The NTP group had a higher rate of good functional outcomes at 3 months (TTP vs. NTP: 21% vs. 61.5%; p = 0.034). CONCLUSION This new web-based EVT transfer system provides notable improvements in clinical outcomes, transfer efficiency, and EVT execution for potential EVT candidates without markedly changing the regional stroke care paradigm.
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Affiliation(s)
- Chun-Min Wang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ming Chang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ray-Chang Tzeng
- Department of Neurology, Tainan Municipal Hospital, Tainan, Taiwan
| | | | | | | | - Che-Chao Chang
- An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Meng-Hua Huang
- Kaohsiung Veterans General Hospital Tainan Branch, Tainan, Taiwan
| | | | - Mu-Han Wu
- Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Che-Wei Lin
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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14
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Wimmesberger N, Rau D, Schuchardt F, Meier S, Herrmann ML, Bergmann U, Farin-Glattacker E, Brich J. Identification of Anterior Large Vessel Occlusion Stroke During the Emergency Call: Protocol for a Controlled, Nonrandomized Trial. JMIR Res Protoc 2024; 13:e51683. [PMID: 38349728 PMCID: PMC10900077 DOI: 10.2196/51683] [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: 08/09/2023] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (ET), combined with intravenous thrombolysis if possible, is an effective treatment option for patients with stroke who have confirmed anterior large vessel occlusion (aLVO). However, ET is mainly limited to comprehensive stroke centers (CSCs), resulting in a lack of ET capacity in remote, sparsely populated areas. Most stroke networks use the "Drip and Ship" or "Mothership" strategy, resulting in either delayed ET or intravenous thrombolysis, respectively. OBJECTIVE This study protocol introduces the Leitstellen-Basierte Erkennung von Schlaganfall-Patienten für eine Thrombektomie und daraufhin abgestimmte Optimierung der Rettungskette (LESTOR) strategy, developed to optimize the preclinical part of the stroke chain of survival to improve the clinical outcome of patients with suspected aLVO stroke. This involves refining the dispatch strategy for identifying patients with acute aLVO stroke using a phone-based aLVO query. This includes dispatching emergency physicians and emergency medical services (EMS) to urban emergency sites, as well as dispatching helicopter EMS to remote areas. If a highly suspected aLVO is identified after a standardized aLVO score evaluation during a structured examination at the emergency scene, prompt transport to a CSC should be prioritized. METHODS The LESTOR study is a controlled, nonrandomized study implementing the LESTOR strategy, with a stepped-wedge, cluster trial design in 6 districts in southwest Germany. In an interprofessional, iterative approach, an aLVO query or dispatch protocol intended for use by dispatchers, followed by a coordinated aLVO examination score for use by EMS, is being developed, evaluated, and pretested in a simulation study. After the training of all participating health care professionals with the corresponding final aLVO query, the LESTOR strategy is being implemented stepwise. Patients otherwise receive usual stroke care in both the control and intervention groups. The primary outcome is the modified Rankin Scale at 90 days in patients with stroke receiving endovascular treatment. We will use a generalized linear mixed model for data analysis. This study is accompanied by a cost-effectiveness analysis and a qualitative process evaluation. RESULTS This paper describes and discusses the protocol for this controlled, nonrandomized LESTOR study. Enrollment was completed in June 2023. Data analysis is ongoing and the first results are expected to be submitted for publication in 2024. The project started in April 2020 and will end in February 2024. CONCLUSIONS We expect that the intervention will improve the clinical outcome of patients with aLVO stroke, especially outside the catchment areas of CSCs. The results of the accompanying process evaluation and the cost-effectiveness analysis will provide further insights into the implementation process and allow for a better interpretation of the results. TRIAL REGISTRATION German Clinical Trials Register DRKS00022152; https://drks.de/search/de/trial/DRKS00022152. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51683.
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Affiliation(s)
- Nicole Wimmesberger
- Section Health Care Research and Rehabilitation Research, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Diana Rau
- Section Health Care Research and Rehabilitation Research, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Florian Schuchardt
- Department of Neurology and Neurophysiology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simone Meier
- Department of Neurology and Neurophysiology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias L Herrmann
- Department of Neurology and Neurophysiology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrike Bergmann
- Department of Neurology and Neurophysiology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erik Farin-Glattacker
- Section Health Care Research and Rehabilitation Research, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jochen Brich
- Department of Neurology and Neurophysiology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Colasurdo M, Chen H, Schrier C, Khalid M, Khunte M, Miller TR, Cherian J, Malhotra A, Gandhi D. Predictors for large vessel recanalization before stroke thrombectomy: the HALT score. J Neurointerv Surg 2024; 16:237-242. [PMID: 37100595 DOI: 10.1136/jnis-2023-020220] [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: 02/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Large vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis. METHODS In this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed. RESULTS 640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0-2) HALT scores. CONCLUSIONS IVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.
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Affiliation(s)
- Marco Colasurdo
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Huanwen Chen
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Chad Schrier
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mihir Khunte
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jacob Cherian
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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16
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Vuorinen P, Setälä P, Ollikainen J, Hoppu S. A hybrid strategy using an ambulance and a helicopter to convey thrombectomy candidates to definite care: a prospective observational study. BMC Emerg Med 2024; 24:17. [PMID: 38273239 PMCID: PMC10809465 DOI: 10.1186/s12873-024-00931-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy is the treatment of choice for large vessel occlusion strokes done only in comprehensive stroke centres (CSC). We investigated whether the transportation time of thrombectomy candidates from another hospital district could be reduced by using an ambulance and a helicopter and how this affected their recovery. METHODS We prospectively gathered the time points of thrombectomy candidates referred to the Tampere University Hospital from the hospital district of Southern Ostrobothnia. Primary and secondary transports were included. In Hybrid transport, the helicopter emergency medical services (HEMS) unit flew from an airport near the CSC to meet the patient during transport and continued the transport to definitive care. Ground transport was chosen only when the weather prevented flying, or the HEMS crew was occupied in another emergency. We contacted the patients treated with mechanical thrombectomy 90 days after the intervention and rated their recovery with the modified Rankin Scale (mRS). Favourable recovery was considered mRS 0-2. RESULTS During the study, 72 patients were referred to the CSC, 71% of which were first diagnosed at the PSC. Hybrid transport (n = 34) decreased the median time from the start of transport from the PSC to the computed tomography (CT) at the CSC when compared to Ground (n = 17) transport (84 min, IQR 82-86 min vs. 109 min, IQR 104-116 min, p < 0.001). The transport times straight from the scene to CT at the CSC were equal: median 93 min (IQR 80-102 min) in the Hybrid group (n = 11) and 97 min (IQR 91-108 min) in the Ground group (n = 10, p = 0.28). The percentages of favourable recovery were 74% and 50% in the Hybrid and Ground transport groups (p = 0.38) from the PSC. Compared to Ground transportation from the scene, Hybrid transportation had less effect on the positive recovery percentages of 60% and 50% (p = 1.00), respectively. CONCLUSION Adding a HEMS unit to transporting a thrombectomy candidate from a PSC to CSC decreases the transport time compared to ambulance use only. This study showed minimal difference in the recovery after thrombectomy between Hybrid and Ground transports.
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Affiliation(s)
- Pauli Vuorinen
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland.
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.
- Emergency Medical Services, Tampere University Hospital, FI-33521, Tampere, PO Box 2000, Finland.
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland
| | - Jyrki Ollikainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland
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Sporns PB, Fischer U, Katan M, Ospel JM, Brehm A, Tsogkas I, Holodinsky JK, Kamal N, Fiehler J, Psychogios MN. Simulation of transportation of acute stroke patients in border regions. Sci Rep 2024; 14:1736. [PMID: 38242912 PMCID: PMC10798996 DOI: 10.1038/s41598-024-51959-y] [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: 05/22/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
Determining the optimal transportation for each stroke patient is critically important to achieve the best possible outcomes. In border regions the next comprehensive stroke center may be just across an international border, but bureaucratic and financial hurdles may prevent a simple transfer to the next stroke center. We hypothesized that in regions close to international borders, patients may benefit from an "open border, closed transfer scenario", meaning that patients in whom a large vessel occlusion (LVO) is detected in the primary stroke center will benefit from a transfer to the nearest stroke center offering endovascular thrombectomy-even if this may be across a national border. We used the Swiss-German-French trinational region as an example for a region with several international borders within close proximity to one another, and compared two feasible scenarios; (a) a "closed borders, open transfer" scenario, where the patient is transported to any center in the same country, (b) an "open border, closed transfer" scenario, where patients are always transported to the nearby primary stroke center first and then to the nearest comprehensive stroke center in either the same or a neighboring country and (c) and "open borders, open transfer" scenario. The outcome of interest was the predicted probability of acute ischemic stroke patients to achieve a good outcome using a conditional probability model which predicts the likelihood of excellent outcome (modified Rankin scale score of 0-1 at 90 days post-stroke) for patients with suspected LVO. Results were modeled in a virtual map from which the ideal transport concept emerged. For an exemplary LVO stroke patient in Germany, the probability of a good outcome was higher in an open border, closed transfer scenario than with closed borders, open transfer (33.1 vs. 30.1%). Moreover, time to EVT would decrease from 232 min in the first scenario to 169 min in an open border, closed transfer scenario. The catchment area of the University Hospital Basel was almost double the size in an open border, closed transfer scenario compared to closed borders (1674 km2 vs. 2897 km2) and would receive transfers from 3 primary stroke centers in other countries (2 in Germany and 1 in France). Stroke patients showed a higher likelihood of good outcome in the "open border" scenarios without transfer restrictions to a specific healthcare system. This probably has implications for stroke treatment in all border regions where EVT eligible stroke patients may benefit from transport to the closest EVT capable center whenever possible, regardless of whether this hospital is located in the same or a neighboring country/jurisdiction.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland.
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Urs Fischer
- Department of Neurology, University Hospital of Basel, 4031, Basel, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital of Basel, 4031, Basel, Switzerland
| | - Johanna M Ospel
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Ioannis Tsogkas
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Jessalyn K Holodinsky
- Department of Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
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Nagaratnam K, Neuhaus A, Briggs JH, Ford GA, Woodhead ZVJ, Maharjan D, Harston G. Artificial intelligence-based decision support software to improve the efficacy of acute stroke pathway in the NHS: an observational study. Front Neurol 2024; 14:1329643. [PMID: 38304325 PMCID: PMC10830745 DOI: 10.3389/fneur.2023.1329643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/28/2023] [Indexed: 02/03/2024] Open
Abstract
Introduction In a drip-and-ship model for endovascular thrombectomy (EVT), early identification of large vessel occlusion (LVO) and timely referral to a comprehensive center (CSC) are crucial when patients are admitted to an acute stroke center (ASC). Several artificial intelligence (AI) decision-aid tools are increasingly being used to facilitate the rapid identification of LVO. This retrospective cohort study aimed to evaluate the impact of deploying e-Stroke AI decision support software in the hyperacute stroke pathway on process metrics and patient outcomes at an ASC in the United Kingdom. Methods Except for the deployment of e-Stroke on 01 March 2020, there were no significant changes made to the stroke pathway at the ASC. The data were obtained from a prospective stroke registry between 01 January 2019 and 31 March 2021. The outcomes were compared between the 14 months before and 12 months after the deployment of AI (pre-e-Stroke cohort vs. post-e-Stroke cohort) on 01 March 2020. Time window analyses were performed using Welch's t-test. Cochran-Mantel-Haenszel test was used to compare changes in disability at 3 months assessed by modified Rankin Score (mRS) ordinal shift analysis, and Fisher's exact test was used for dichotomised mRS analysis. Results In the pre-e-Stroke cohort, 19 of 22 patients referred received EVT. In the post-e-Stroke cohort, 21 of the 25 patients referred were treated. The mean door-in-door-out (DIDO) and door-to-referral times in pre-e-Stroke vs. post-e-Stroke cohorts were 141 vs. 79 min (difference 62 min, 95% CI 96.9-26.8 min, p < 0.001) and 71 vs. 44 min (difference 27 min, 95% CI 47.4-5.4 min, p = 0.01), respectively. The adjusted odds ratio (age and NIHSS) for mRS ordinal shift analysis at 3 months was 3.14 (95% CI 0.99-10.51, p = 0.06) and the dichotomized mRS 0-2 at 3 months was 16% vs. 48% (p = 0.04) in the pre- vs. post-e-Stroke cohorts, respectively. Conclusion In this single-center study in the United Kingdom, the DIDO time significantly decreased since the introduction of e-Stroke decision support software into an ASC hyperacute stroke pathway. The reduction in door-in to referral time indicates faster image interpretation and referral for EVT. There was an indication of an increased proportion of patients regaining independent function after EVT. However, this should be interpreted with caution given the small sample size. Larger, prospective studies and further systematic real-world evaluation are needed to demonstrate the widespread generalisability of these findings.
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Affiliation(s)
- Kiruba Nagaratnam
- Stroke Medicine, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - Ain Neuhaus
- Stroke Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - James H. Briggs
- Stroke Medicine, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
- Brainomix Limited, Oxford, United Kingdom
| | - Gary A. Ford
- Stroke Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Dibyaa Maharjan
- Stroke Medicine, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - George Harston
- Stroke Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- Brainomix Limited, Oxford, United Kingdom
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19
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Flores A, Garcia-Tornel A, Seró L, Ustrell X, Requena M, Pellisé A, Rodriguez P, Monterde A, Lara L, Gonzalez-de-Echavarri JM, Molina CA, Doncel-Moriano A, Dorado L, Cardona P, Cánovas D, Krupinski J, Más N, Purroy F, Zaragoza-Brunet J, Palomeras E, Cocho D, Garcia J, Colom C, Silva Y, Gomez-Cocho M, Jiménez X, Ros-Roig J, Abilleira S, Pérez de la Ossa N, Ribo M. Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis. J Neurointerv Surg 2024; 16:143-150. [PMID: 37068936 DOI: 10.1136/jnis-2023-020125] [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: 01/25/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND The influence of vascular imaging acquisition on workflows at local stroke centers (LSCs) not capable of performing thrombectomy in patients with a suspected large vessel occlusion (LVO) stroke remains uncertain. We analyzed the impact of performing vascular imaging (VI+) or not (VI- at LSC arrival on variables related to workflows using data from the RACECAT Trial. OBJECTIVE To compare workflows at the LSC among patients enrolled in the RACECAT Trial with or without VI acquisition. METHODS We included patients with a diagnosis of ischemic stroke who were enrolled in the RACECAT Trial, a cluster-randomized trial that compared drip-n-ship versus mothership triage paradigms in patients with suspected acute LVO stroke allocated at the LSC. Outcome measures included time metrics related to workflows and the rate of interhospital transfers and thrombectomy among transferred patients. RESULTS Among 467 patients allocated to a LSC, vascular imaging was acquired in 277 patients (59%), of whom 198 (71%) had a LVO. As compared with patients without vascular imaging, patients in the VI+ group were transferred less frequently as thrombectomy candidates to a thrombectomy-capable center (58% vs 74%, P=0.004), without significant differences in door-indoor-out time at the LSC (median minutes, VI+ 78 (IQR 69-96) vs VI- 76 (IQR 59-98), P=0.6). Among transferred patients, the VI+ group had higher rate of thrombectomy (69% vs 55%, P=0.016) and shorter door to puncture time (median minutes, VI+ 41 (IQR 26-53) vs VI- 54 (IQR 40-70), P<0.001). CONCLUSION Among patients with a suspected LVO stroke initially evaluated at a LSC, vascular imaging acquisition might improve workflow times at thrombectomy-capable centers and reduce the rate of futile interhospital transfers. These results deserve further evaluation and should be replicated in other settings and geographies.
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Affiliation(s)
- Alan Flores
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | | | - Laia Seró
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Xavier Ustrell
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Anna Pellisé
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Paula Rodriguez
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Angela Monterde
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Lidia Lara
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Jose María Gonzalez-de-Echavarri
- Stroke Unit, Neurology Department, Hospital Universitari de Tarragona Joan XXIII. Institut d'Investigació Sanitaria Pere Virgili, Tarragona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Antonio Doncel-Moriano
- Stroke Unit, Department of Neurology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Laura Dorado
- Stroke Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Catalunya, Spain
| | - Pedro Cardona
- Bellvitge University Hospital, L'Hospitalet de Llobregat, Catalunya, Spain
| | - David Cánovas
- Department of Neurology, Consorci Sanitari Parc Taulí, Barcelona, Spain
| | | | - Natalia Más
- Department of Neurology, Hospital Althaia, Manresa, Manresa, Catalunya, Spain
| | | | - Jose Zaragoza-Brunet
- Stroke Unit, Department of Neurology, Hospital Verge de la Cinta, Tortosa, Catalunya, Spain
| | - Ernesto Palomeras
- Department of Neurology, Hospital de Mataró, Mataro, Catalunya, Spain
| | - Dolores Cocho
- Department of Neurology, Hospital General de Granollers, Granollers, Catalunya, Spain
| | - Jessica Garcia
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedes, Catalunya, Spain
| | - Carla Colom
- Department of Neurology, Hospital Universitario de Igualada, Igualada, Catalunya, Spain
| | - Yolanda Silva
- Neurology Department, Stroke Unit, Doctor Josep Trueta University Hospital of Girona, Girona, Catalunya, Spain
| | - Manuel Gomez-Cocho
- Department of Neurology, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
| | - Xavier Jiménez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Josep Ros-Roig
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sonia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain
- Catalan Stroke Program, Barcelona, Spain
| | - Marc Ribo
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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20
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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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21
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Charbonnier G, Consoli A, Bonnet L, Biondi A, Vuillier F, Rabenorosoa K, Mendes Pereira V, Moulin T. Telestroke network to robotic telestroke network: How to upgrade regional stroke care to include remote robotics? Digit Health 2024; 10:20552076241254986. [PMID: 38766366 PMCID: PMC11100382 DOI: 10.1177/20552076241254986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/23/2024] [Indexed: 05/22/2024] Open
Abstract
Objective Selected patients with large vessel occlusion (LVO) strokes can benefit from endovascular therapy (EVT). However, the effectiveness of EVT is largely dependent on how quickly the patient receives treatment. Recent technological developments have led to the first neurointerventional treatments using robotic assistance, opening up the possibility of performing remote stroke interventions. Existing telestroke networks provide acute stroke care, including remote administration of intravenous thrombolysis (IVT). Therefore, the introduction of remote EVT in distant stroke centers requires an adaptation of the existing telestroke networks. The aim of this work was to propose a framework for centers that are potential candidates for telerobotics according to the resources currently available in these centers. Methods In this paper, we highlight the future challenges for including remote robotics in telestroke networks. A literature review provides potential solutions. Results Existing telestroke networks need to determine which centers to prioritize for remote robotic technologies based on objective criteria and cost-effectiveness analysis. Organizational challenges include regional coordination and specific protocols. Technological challenges mainly concern telecommunication networks. Conclusions Specific adaptations will be necessary if regional telestroke networks are to include remote robotics. Some of these can already be put in place, which could greatly help the future implementation of the technology.
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Affiliation(s)
- Guillaume Charbonnier
- CHU Besançon, Interventional Neuroradiology Department, Besançon, France
- CHU Besançon, Neurology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
| | - Arturo Consoli
- Interventional Neuroradiology Department, Hôpital Foch, Paris, France
| | - Louise Bonnet
- CHU Besançon, Neurology Department, Besançon, France
| | - Alessandra Biondi
- CHU Besançon, Interventional Neuroradiology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
| | - Fabrice Vuillier
- CHU Besançon, Neurology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
| | | | - Vitor Mendes Pereira
- St. Michael's Hospital Li Ka Shing Knowledge Institute, RADIS Lab, Toronto, ON, Canada
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Thierry Moulin
- CHU Besançon, Neurology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
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22
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Pardo K, Naftali J, Barnea R, Findler M, Perlow A, Brauner R, Auriel E, Raphaeli G. Effect of time delay in inter-hospital transfer on outcomes of endovascular treatment of acute ischemic stroke. Front Neurol 2023; 14:1303061. [PMID: 38187154 PMCID: PMC10766796 DOI: 10.3389/fneur.2023.1303061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
Background Endovascular treatment (EVT) with mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke (AIS). The most common approach today is to perform EVT in a comprehensive stroke center (CSC) and transfer relevant patients for EVT from a primary stroke center (PSC). Rapid and efficient treatment of LVO is a key factor in achieving a good clinical outcome. Methods We present our retrospective cohort of patients who underwent EVT between 2018 and 2021, including direct admissions and patients transferred from PSC. Primary endpoints were time intervals (door-to-puncture, onset-to-puncture, door-to-door) and favorable outcome (mRS ≤ 2) at 90 days. Secondary outcomes were successful recanalization, mortality rate, and symptomatic intracranial hemorrhage (sICH). Additional analysis was performed for transferred patients not treated with EVT; endpoints were time intervals, favorable outcomes, and reason for exclusion of EVT. Results Among a total of 405 patients, 272 were admitted directly to our EVT center and 133 were transferred; there was no significant difference between groups in the occluded vascular territory, baseline NIHSS, wake-up strokes, or thrombolysis rate. Directly admitted patients had a shorter door-to-puncture time than transferred patients (190 min vs. 293 min, p < 0.001). The median door-to-door shift time was 204 min. We found no significant difference in functional independence, successful recanalization rates, or sICH rates. The most common reason to exclude transferred patients from EVT was clinical or angiographic improvement (55.6% of patients). Conclusion Our results show that transferring patients to the EVT center does not affect clinical outcomes, despite the expected delay in EVT. Reassessment of patients upon arrival at the CSC is crucial, and patient selection should be done based on both time and tissue window.
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Affiliation(s)
- Keshet Pardo
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Michael Findler
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Alain Perlow
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
| | - Ran Brauner
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center – Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
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23
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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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24
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van Stigt MN, Groenendijk EA, van Meenen LCC, van de Munckhof AAGA, Theunissen M, Franschman G, Smeekes MD, van Grondelle JAF, Geuzebroek G, Siegers A, Visser MC, van Schaik SM, Halkes PHA, Majoie CBLM, Roos YBWEM, Koelman JHTM, Koopman MS, Marquering HA, Potters WV, Coutinho JM. Prehospital Detection of Large Vessel Occlusion Stroke With EEG. Neurology 2023; 101:e2522-e2532. [PMID: 37848336 PMCID: PMC10791060 DOI: 10.1212/wnl.0000000000207831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) is standard treatment for anterior large vessel occlusion stroke (LVO-a stroke). Prehospital diagnosis of LVO-a stroke would reduce time to EVT by allowing direct transportation to an EVT-capable hospital. We aim to evaluate the diagnostic accuracy of dry electrode EEG for the detection of LVO-a stroke in the prehospital setting. METHODS ELECTRA-STROKE was an investigator-initiated, prospective, multicenter, diagnostic study, performed in the prehospital setting. Adult patients were eligible if they had suspected stroke (as assessed by the attending ambulance nurse) and symptom onset <24 hours. A single dry electrode EEG recording (8 electrodes) was performed by ambulance personnel. Primary endpoint was the diagnostic accuracy of the theta/alpha frequency ratio for LVO-a stroke (intracranial ICA, A1, M1, or proximal M2 occlusion) detection among patients with EEG data of sufficient quality, expressed as the area under the receiver operating characteristic curve (AUC). Secondary endpoints were diagnostic accuracies of other EEG features quantifying frequency band power and the pairwise derived Brain Symmetry Index. Neuroimaging was assessed by a neuroradiologist blinded to EEG results. RESULTS Between August 2020 and September 2022, 311 patients were included. The median EEG duration time was 151 (interquartile range [IQR] 151-152) seconds. For 212/311 (68%) patients, EEG data were of sufficient quality for analysis. The median age was 74 (IQR 66-81) years, 90/212 (42%) were women, and the median baseline NIH Stroke Scale was 1 (IQR 0-4). Six (3%) patients had an LVO-a stroke, 109/212 (51%) had a non-LVO-a ischemic stroke, 32/212 (15%) had a transient ischemic attack, 8/212 (4%) had a hemorrhagic stroke, and 57/212 (27%) had a stroke mimic. AUC of the theta/alpha ratio was 0.80 (95% CI 0.58-1.00). Of the secondary endpoints, the pairwise derived Brain Symmetry Index in the delta frequency band had the highest diagnostic accuracy (AUC 0.91 [95% CI 0.73-1.00], sensitivity 80% [95% CI 38%-96%], specificity 93% [95% CI 88%-96%], positive likelihood ratio 11.0 [95% CI 5.5-21.7]). DISCUSSION The data from this study suggest that dry electrode EEG has the potential to detect LVO-a stroke among patients with suspected stroke in the prehospital setting. Toward future implementation of EEG in prehospital stroke care, EEG data quality needs to be improved. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov identifier: NCT03699397. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that prehospital dry electrode scalp EEG accurately detects LVO-a stroke among patients with suspected acute stroke.
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Affiliation(s)
- Maritta N van Stigt
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Eva A Groenendijk
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Laura C C van Meenen
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Anita A G A van de Munckhof
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Monique Theunissen
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Gaby Franschman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Martin D Smeekes
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Joffry A F van Grondelle
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Geertje Geuzebroek
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Arjen Siegers
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Marieke C Visser
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Sander M van Schaik
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Patricia H A Halkes
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Charles B L M Majoie
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Yvo B W E M Roos
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Johannes H T M Koelman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Miou S Koopman
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Henk A Marquering
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Wouter V Potters
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
| | - Jonathan M Coutinho
- From the Departments of Clinical Neurophysiology (M.N.v.S., E.A.G., J.H.T.M.K.), Neurology (M.N.v.S., E.A.G., L.C.C.v.M., A.A.G.A.v.d.M., M.C.V., Y.B.W.E.M.R., J.M.C.), Radiology and Nuclear Medicine (C.B.L.M.M., M.S.K., H.A.M.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC location University of Amsterdam; Witte Kruis Ambulancezorg (M.T., G.F.), Alkmaar; Ambulancezorg Nederland (M.D.S.), Zwolle; Ambulance Amsterdam (J.A.F.v.G., G.G., A.S.); Department of Neurology (S.M.v.S.), OLVG Hospital location West, Amsterdam; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep location Alkmaar; TrianecT (W.V.P.), Utrecht, the Netherlands
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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Abou Loukoul W, Richard S, Mione G, Finitsis S, Derelle AL, Zhu F, Liao L, Anxionnat R, Douarinou M, Humbertjean L, Gory B. Outcome of stroke patients eligible to mechanical thrombectomy managed by spoke center, primary stroke center or comprehensive stroke center in the East of France. Rev Neurol (Paris) 2023:S0035-3787(23)01113-X. [PMID: 38036405 DOI: 10.1016/j.neurol.2023.08.020] [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: 03/31/2023] [Revised: 07/20/2023] [Accepted: 08/25/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND AND PURPOSE Patients with suspected stroke are referred to the nearest hospital and are managed either in a spoke center (SC), a primary stroke center (PSC), or a comprehensive stroke center (CSC) in order to benefit from early intravenous thrombolysis (IVT). In case of large vessel occlusion (LVO), mechanical thrombectomy (MT) is only performed in the CSC, whereas the effectiveness of MT is highly time-dependent. There is a debate about the best management model of patients with suspected LVO. Therefore, we aimed to compare functional and safety outcomes of LVO patients eligible for MT managed through our regional telestroke system. METHOD We performed a retrospective analysis of our observational prospective clinical registry in all consecutive subjects with LVO within six hours of onset who were admitted to the SC, PSC, or CSC in the east of France between October 2017 and November 2022. The primary endpoint was the functional independence defined as modified Rankin scale (mRS) score 0 to 2 at 90 days. Secondary endpoints were functional outcome, early neurological improvement, symptomatic intracranial hemorrhage and 90-day mortality. RESULTS Among the 794 included patients with LVO who underwent MT, 122 (15.4%) were managed by a SC, 403 (50.8%) were first admitted to a PSC, and 269 (33.9%) were first admitted to the CSC. The overall median NIHSS and ASPECTS score were 16 and 8, respectively. Multivariate analysis did not find any significant difference for the primary endpoint between patients managed by PSC versus CSC (OR 1.06 [95% CI 0.64;1.76], P=0.82) and between patient managed by SC versus CSC (OR 0.69 [0.34;1.40], P=0.30). No difference between the three groups was found except for the parenchymal hematoma rate between PSC and CSC (15.7 versus 7.4%, OR 2.25 [1.07;4.74], P=0.032). CONCLUSIONS Compared with a first admission to a CSC, the clinical outcomes of stroke patients with LVO eligible for MT first admitted to a SC or a PSC are similar.
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Affiliation(s)
- W Abou Loukoul
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - S Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France; Université de Lorraine, Inserm U1116, Nancy, France
| | - G Mione
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France
| | - S Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - A-L Derelle
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - F Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France; Université de Lorraine, Inserm U1254, Nancy, France
| | - L Liao
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - R Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France; Université de Lorraine, Inserm U1254, Nancy, France
| | - M Douarinou
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France
| | - L Humbertjean
- Department of Neurology, Stroke Unit, CHRU-Nancy, Nancy, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Central, CHRU-Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France; Université de Lorraine, Inserm U1254, Nancy, France.
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Behrndtz A, Blauenfeldt RA, Johnsen SP, Valentin JB, Gude MF, Al-Jazi MA, von Weitzel-Mudersbach P, Modrau B, Damgaard D, Hougaard KD, Hjort N, Diedrichsen T, Poulsen M, Schmitz ML, Fisher M, Andersen G, Simonsen CZ. Transport Strategy in Patients With Suspected Acute Large Vessel Occlusion Stroke: TRIAGE-STROKE, a Randomized Clinical Trial. Stroke 2023; 54:2714-2723. [PMID: 37800374 PMCID: PMC10589426 DOI: 10.1161/strokeaha.123.043875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND When patients with acute ischemic stroke present with suspected large vessel occlusion in the catchment area of a primary stroke center (PSC), the benefit of direct transport to a comprehensive stroke center (CSC) has been suggested. Equipoise remains between transport strategies and the best transport strategy is not well established. METHODS We conducted a national investigator-driven, multicenter, randomized, assessor-blinded clinical trial. Patients eligible for intravenous thrombolysis (IVT) who were suspected for large vessel occlusion were randomized 1:1 to admission to the nearest PSC (prioritizing IVT) or direct CSC admission (prioritizing endovascular therapy). The primary outcome was functional improvement at day 90 for all patients with acute ischemic stroke, measured as shift towards a lower score on the modified Rankin Scale score. RESULTS From September 2018 to May 2022, we enrolled 171 patients of whom 104 had acute ischemic stroke. The trial was halted before full recruitment. Baseline characteristics were well balanced. Primary analysis of shift in modified Rankin Scale (ordinal logistic regression) revealed an odds ratio for functional improvement at day 90 of 1.42 (95% CI, 0.72-2.82, P=0.31). Onset to groin time for patients with large vessel occlusion was 35 minutes (P=0.007) shorter when patients were transported to a CSC first, whereas onset to needle (IVT) was 30 minutes (P=0.012) shorter when patients were transported to PSC first. IVT was administered in 67% of patients in the PSC group versus 78% in the CSC group and EVT was performed in 53% versus 63% of the patients, respectively. CONCLUSIONS This trial investigated the benefit of bypassing PSC. We included only IVT-eligible patients presenting <4 hours from onset and with suspected large vessel occlusion. Lack of power prevented the results from showing effect on functional outcome for patients going directly to CSC. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03542188.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark (A.B., R.A.B., C.Z.S.)
| | - Rolf A. Blauenfeldt
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Neurology (B.M.), Aarhus University Hospital, Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (S.P.J., J.B.V.)
| | - Jan B. Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (S.P.J., J.B.V.)
| | - Martin F. Gude
- Prehospital Emergency Medical Services, Central Denmark Region (M.F.G.), Goedstrup Hospital
| | | | | | - Boris Modrau
- Department of Neurology (B.M.), Aarhus University Hospital, Denmark
| | - Dorte Damgaard
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Kristina Dupont Hougaard
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Niels Hjort
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Tove Diedrichsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marika Poulsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marie Louise Schmitz
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston (M.F.)
| | - Grethe Andersen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Claus Z. Simonsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark (A.B., R.A.B., C.Z.S.)
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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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29
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Royan R, Meurer WJ. Going for Distance or Speed? Determining the Optimal Hospital Destination for Patients With Acute Stroke in the Prehospital Setting. J Am Heart Assoc 2023; 12:e032263. [PMID: 37830339 PMCID: PMC10757537 DOI: 10.1161/jaha.123.032263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Affiliation(s)
- Regina Royan
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - William J. Meurer
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Department of NeurologyUniversity of MichiganAnn ArborMIUSA
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30
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Wechsler PM, Navi BB. Bypassing Closest Stroke Center for Intracerebral Hemorrhage-Not So Fast! JAMA Neurol 2023; 80:1022-1025. [PMID: 37603365 DOI: 10.1001/jamaneurol.2023.2753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Affiliation(s)
- Paul M Wechsler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
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31
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Ramos-Pachón A, Rodríguez-Luna D, Martí-Fàbregas J, Millán M, Bustamante A, Martínez-Sánchez M, Serena J, Terceño M, Vera-Cáceres C, Camps-Renom P, Prats-Sánchez L, Rodríguez-Villatoro N, Cardona-Portela P, Urra X, Solà S, del Mar Escudero M, Salvat-Plana M, Ribó M, Abilleira S, Pérez de la Ossa N, Silva Y. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol 2023; 80:1028-1036. [PMID: 37603325 PMCID: PMC10442788 DOI: 10.1001/jamaneurol.2023.2754] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/05/2023] [Indexed: 08/22/2023]
Abstract
Importance Prehospital transfer protocols are based on rapid access to reperfusion therapies for patients with ischemic stroke. The effect of different protocols among patients receiving a final diagnosis of intracerebral hemorrhage (ICH) is unknown. Objective To determine the effect of direct transport to an endovascular treatment (EVT)-capable stroke center vs transport to the nearest local stroke center. Design, Setting, and Participants This was a prespecified secondary analysis of RACECAT, a multicenter, population-based, cluster-randomized clinical trial conducted from March 2017 to June 2020 in Catalonia, Spain. Patients were evaluated by a blinded end point assessment. All consecutive patients suspected of experiencing a large vessel occlusion stroke (Rapid Arterial Occlusion Evaluation Scale [RACE] score in the field >4 on a scale of 0 to 9, with lower to higher stroke severity) with final diagnosis of ICH were included. A total of 1401 patients were enrolled in RACECAT with suspicion of large vessel occlusion stroke. The current analysis was conducted in October 2022. Intervention Direct transport to an EVT-capable stroke center (n = 137) or to the closest local stroke center (n = 165). Main Outcomes and Measures The primary outcome was tested using cumulative ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI of the shift analysis of disability at 90 days as assessed by the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) in the intention-to-treat population. Secondary outcomes, included 90-day mortality, death or severe functional dependency, early neurological deterioration, early mortality, ICH volume and enlargement, rate of neurosurgical treatment, rate of clinical complications during initial transport, and rate of adverse events until day 5. Results Of 1401 patients enrolled, 1099 were excluded from this analysis (32 rejected informed consent, 920 had ischemic stroke, 29 had transient ischemic attack, 12 had subarachnoid hemorrhage, and 106 had stroke mimic). Thus, 302 patients were included (204 [67.5%] men; mean [SD] age 71.7 [12.8] years; and median [IQR] RACE score, 7 [6-8]). For the primary outcome, direct transfer to an EVT-capable stroke center (mean [SD] mRS score, 4.93 [1.38]) resulted in worse functional outcome at 90 days compared with transfer to the nearest local stroke center (mean [SD] mRS score, 4.66 [1.39]; adjusted common OR, 0.63; 95% CI, 0.41-0.96). Direct transfer to an EVT-capable stroke center also suggested potentially higher 90-day mortality compared with transfer to the nearest local stroke center (67 of 137 [48.9%] vs 62 of 165 [37.6%]; adjusted hazard ratio, 1.40; 95% CI, 0.99-1.99). The rates of medical complications during the initial transfer (30 of 137 [22.6%] vs 9 of 165 patients [5.6%]; adjusted OR, 5.29; 95% CI, 2.38-11.73) and in-hospital pneumonia (49 of 137 patients [35.8%] vs 29 of 165 patients [17.6%]; OR, 2.61; 95% CI, 1.53-4.44) were higher in the EVT-capable stroke center group. Conclusions and Relevance In this secondary analysis of the RACECAT randomized clinical trial, bypassing the closest stroke center resulted in reduced chances of functional independence at 90 days for patients who received a final diagnosis of ICH. Trial Registration ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Anna Ramos-Pachón
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Mònica Millán
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Marina Martínez-Sánchez
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
| | | | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Luis Prats-Sánchez
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | | | - Pere Cardona-Portela
- Stroke Unit, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain
| | - Xabier Urra
- Stroke Unit, Hospital Clínic, and August Pi i Sunyer Biomedical Research Institute Barcelona, Barcelona, Spain
| | - Silvia Solà
- Sistema d’Emergències Mèdiques, Barcelona, Spain
| | | | - Mercè Salvat-Plana
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sònia Abilleira
- Catalan Stroke Program, Agency for Health Quality and Assessment of Catalonia, and CIBER Epidemiology and Public Health, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurosciences, Hospital Germans Trias i Pujol, and Germans Trias i Pujol Research Institute (IGTP), Badalona, Barcelona, Spain
| | - Yolanda Silva
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain
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Schlemm E, Piepke M, Kessner SS, Meyer L, Cheng B, Gerloff C, Thomalla G. Clinical Judgment vs Triage Scales for Detecting Large Vessel Occlusions in Suspected Acute Stroke. JAMA Netw Open 2023; 6:e2332894. [PMID: 37698866 PMCID: PMC10498329 DOI: 10.1001/jamanetworkopen.2023.32894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/25/2023] [Indexed: 09/13/2023] Open
Abstract
This cohort study examines clinical judgment of large vessel occlusions compared with triage scales in a sample of patients admitted to the emergency department with suspicion of acute stroke.
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Affiliation(s)
- Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius Piepke
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon S. Kessner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Psychosomatic Medicine und Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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33
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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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34
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Guterud M, Fagerheim Bugge H, Røislien J, Kramer-Johansen J, Toft M, Ihle-Hansen H, Bache KG, Larsen K, Braarud AC, Sandset EC, Ranhoff Hov M. Prehospital screening of acute stroke with the National Institutes of Health Stroke Scale (ParaNASPP): a stepped-wedge, cluster-randomised controlled trial. Lancet Neurol 2023; 22:800-811. [PMID: 37596006 DOI: 10.1016/s1474-4422(23)00237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Timely treatment of acute stroke depends on early identification and triage. Improved methods for recognition of stroke in the prehospital setting are needed. We aimed to assess whether use of the National Institutes of Health Stroke Scale (NIHSS) by paramedics in the ambulance could improve communication with the hospital, augment triage, and enhance diagnostic accuracy of acute stroke. METHODS The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge, single-blind, cluster-randomised controlled trial. Patients with suspected acute stroke, who were evaluated by paramedics from five ambulance stations in Oslo, Norway, were eligible for inclusion. The five ambulance stations (defined as clusters) all initially managed patients according to a standard stroke protocol (control group), with randomised sequential crossover of each station to the intervention group. The intervention consisted of supervised training on NIHSS scoring, a mobile application to aid scoring, and standardised communication with stroke physicians. Random allocation was done via a simple lottery draw by administrators at Oslo University Hospital, who were independent of the research team. Allocation concealment was not possible due to the nature of the intervention. The primary outcome was the positive predictive value (PPV) for prehospital identification of patients with a final discharge diagnosis of acute stroke, analysed by intention to treat. Prespecified secondary safety outcomes were median prehospital on-scene time and median door-to-needle time. This trial is registered with ClinicalTrials.gov, NCT04137874, and is completed. FINDINGS Between June 3, 2019, and July 1, 2021, 935 patients were evaluated by paramedics for suspected acute stroke. 134 patients met exclusion criteria or did not consent to participate. The primary analysis included 447 patients in the intervention group and 354 in the control group. There was no difference in PPV for prehospital identification of patients with a final discharge diagnosis of acute stroke between the intervention group (48·1%, 95% CI 43·4-52·8) and control group (45·8%, 40·5-51·1), with an estimated percentage points difference between groups of 2·3 (95% CI -4·6 to 9·3; p=0·51). Median prehospital on-scene time increased by 5 min in the intervention group (29 min [IQR 23-36] vs 24 min [19-31]; p<0·0001), whereas median door-to-needle time was similar between groups (26 min [21-36] vs 27 min [20-36]; p=0·90). No prehospital deaths were reported in either group. INTERPRETATION The intervention did not improve diagnostic accuracy in patients with suspected stroke. A general increase in prehospital time during the pandemic and the identification of smaller strokes that require more deliberation are possible explanations for the increased on-scene time. The ParaNASPP model is to be implemented in Norway from 2023, and will provide real-life data for further research. FUNDING Norwegian Air Ambulance Foundation and Oslo University Hospital.
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Affiliation(s)
- Mona Guterud
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Helge Fagerheim Bugge
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jo Røislien
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jo Kramer-Johansen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mathias Toft
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Kristi G Bache
- Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Research and Dissemination, Østfold University College, Halden, Norway
| | - Karianne Larsen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | | | - Else Charlotte Sandset
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maren Ranhoff Hov
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway; Department of Health Science, Oslo Metropolitan University, Oslo, Norway.
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Habib P, Dimitrov I, Pinho J, Schürmann K, Bach JP, Wiesmann M, Schulz JB, Reich A, Nikoubashman O. Point-of-Care Ultrasound to Detect Acute Large Vessel Occlusions in Stroke Patients: A Proof-of-Concept Study. Can J Neurol Sci 2023; 50:656-661. [PMID: 35872570 DOI: 10.1017/cjn.2022.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A primary admission of patients with suspected acute ischemic stroke and large vessel occlusion (LVO) to centers capable of providing endovascular stroke therapy (EVT) may induce shorter time to treatment and better functional outcomes. One of the limitations in this strategy is the need for accurately identifying LVO patients in the prehospital setting. We aimed to study the feasibility and diagnostic performance of point-of-care ultrasound (POCUS) for the detection of LVO in patients with acute stroke. METHODS We conducted a proof-of-concept study and selected 15 acute ischemic stroke patients with angiographically confirmed LVO and 15 patients without LVO. Duplex ultrasonography (DUS) of the common carotid arteries was performed, and flow profiles compatible with LVO were scored independently by one experienced and one junior neurologist. RESULTS Among the 15 patients with LVO, 6 patients presented with an occlusion of the carotid-T and 9 patients presented with an M1 occlusion. Interobserver agreement between the junior and the experienced neurologist was excellent (kappa = 0.813, p < 0.001). Flow profiles of the CAA allowed the detection of LVO with a sensitivity of 73%, a positive predictive value of 92 and 100%, and a c-statistics of 0.83 (95%CI = 0.65-0.94) and 0.87 (95%CI = 0.69-0.94) (experienced neurologist and junior neurologist, respectively). In comparison with clinical stroke scales, DUS was associated with better trade-off between sensitivity and specificity. CONCLUSION POCUS in acute stroke setting is feasible, it may serve as a complementary tool for the detection of LVO and is potentially applicable in the prehospital phase.
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Affiliation(s)
- Pardes Habib
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Ivaylo Dimitrov
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Kolja Schürmann
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Jan Philipp Bach
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
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Brauer L, Geraedts M. Exploring regional healthcare utilisation and quality of care for endometriosis in rural areas in Hesse, Germany: a mixed methods study protocol. BMJ Open 2023; 13:e074259. [PMID: 37620261 PMCID: PMC10450047 DOI: 10.1136/bmjopen-2023-074259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION The need of a regional healthcare monitoring in order to evaluate quality and utilisation of health services in smaller scale is internationally and in Germany well established. Little is known about variation in healthcare in rural German areas, especially for women's health. In particular, endometriosis is highly prevalent and known to be unsatisfactorily treated. Thus, this study aims to investigate utilisation and quality of care, the influence of structural determinants on quality and the patient's experiences on endometriosis healthcare in rural Hesse. METHODS AND ANALYSIS We will use a mixed methods approach to ensure reliable mapping of the care situation for endometriosis patients in seven counties in Central and Eastern Hesse. First, retrospective secondary utilisation data and quality indicators will be used to describe possible regional variation in the treatment of endometriosis in the outpatient and inpatient sector. Second, we compare structural determinants of regions with quality of care. Third, we conduct qualitative, semistructured interviews with endometriosis patients on their perspective and experiences in those chosen rural regions. Data will then be analysed using descriptive statistics, small area variation analyses and multifactorial analyses of variance (ANOVAs). The interview will be interpreted using the experience-focused phenomenological approach. ETHICS AND DISSEMINATION The study has been approved by the ethics committee of Philipps-University Marburg. Utilisation data and structural determinants are anonymised and partly aggregated. The interview will use tokens for pseudonymisation to prevent the collected data from being assigned to an individual person. Also, informed consent will be obtained from patients.The results of this study will be reported to the scientific community in peer-reviewed journals and at conferences. A summary of the key findings will be provided to the interviewed patients and the Endometriosis Association Germany.
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Affiliation(s)
- Lara Brauer
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Marburg, Hessen, Germany
| | - Max Geraedts
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Marburg, Hessen, Germany
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Raha O, Hall C, Malik A, D'Anna L, Lobotesis K, Kwan J, Banerjee S. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ MEDICINE 2023; 2:e000407. [PMID: 37577026 PMCID: PMC10414072 DOI: 10.1136/bmjmed-2022-000407] [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: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/15/2023]
Abstract
Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.
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Affiliation(s)
- Oishik Raha
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Hall
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Abid Malik
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Lucio D'Anna
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Joseph Kwan
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Soma Banerjee
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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Wischmann J, Pradhan C, Zimmermann H, Keidel L, Tiedt S, Dimitriadis K, Liebig T, Höglinger G, Kellert L. Impact of ongoing intravenous thrombolysis until completion of endovascular treatment in large vessel occlusion stroke patients. Front Neurol 2023; 14:1231530. [PMID: 37602252 PMCID: PMC10437055 DOI: 10.3389/fneur.2023.1231530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background Recent studies have implied that ongoing intravenous thrombolysis (IVT) during endovascular treatment (ET) improves functional outcomes in patients who have undergone stroke caused by a large vessel occlusion (LVO). In this study, we investigated the effect of ongoing IVT until completion of ET on procedure duration, first-pass thrombectomy rate, and periprocedural complications. Methods We analyzed patients from the German Stroke Registry-Endovascular Treatment dataset, collected between June 2015 and December 2021. Primary outcomes were modified Rankin Scale (mRS) score after 3 months and achievement of a Thrombolysis In Cerebral Infarction (TICI) score of 2b-3. Secondary parameters included ET duration, first-pass thrombectomy, and periprocedural complications. Results Of the 13,082 patients in the dataset, 1,639 met the study inclusion criteria. A total of n = 317 patients (19.3%) underwent ongoing IVT until completion of ET, while IVT was completed prior to ET in 1,322 patients (80.7%). Ongoing IVT was associated with higher rates of achievement of an mRS score of 0-2 (or a back-to-baseline) after 3 months [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.08-2.17]. Furthermore, ongoing IVT was predictive of achievement of a TICI score of 2b-3 (OR 1.37; 95% CI 1.03-1.83) and of first-pass thrombectomy (OR 2.07; 95% CI 1.51-2.84), while reducing the rate of peri-interventional complications (OR 0.64; 95% CI 0.44-0.94) and reducing ET duration by 24 min [β = -24.35; 95% CI -32.92-(-15.79)]. Conclusion Our findings suggest that ongoing IVT until ET completion has a favorable impact on both clinical and angiographic outcomes, as well as on periprocedural conditions, regardless of the overall time intervals involved. Therefore, rapid ET after IVT should be sought in order to take advantage of the additive effect of ongoing IVT during ET. Future studies should consider IVT timing in the context of ET as a potential confounder and treatment target.
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Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
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Abstract
This JAMA Guide to Statistics and Methods discusses the early stopping of clinical trials for futility due to lack of evidence supporting the desired benefit, evidence of harm, or practical issues that make successful completion unlikely.
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Affiliation(s)
| | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Statistical Editor, JAMA
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Tariq MB, Ali I, Salazar-Marioni S, Iyyangar AS, Azeem HM, Khose S, Lopez V, Abdelkhaleq R, McCullough LD, Sheth SA, Kim Y. Women With Large Vessel Occlusion Acute Ischemic Stroke Are Less Likely to Be Routed to Comprehensive Stroke Centers. J Am Heart Assoc 2023; 12:e029830. [PMID: 37462071 PMCID: PMC10382091 DOI: 10.1161/jaha.123.029830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/15/2023] [Indexed: 07/20/2023]
Abstract
Background Prehospital routing of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) to centers capable of performing endovascular therapy may improve clinical outcomes. Here, we explore whether distance to comprehensive stroke centers (CSCs), stroke severity, and sex are associated with direct-to-CSC prehospital routing in patients with LVO AIS. Methods and Results In this cross-sectional study, we identified consecutive patients with LVO AIS from a prospectively collected multihospital registry throughout the greater Houston area from January 2019 to June 2020. Primary outcome was prehospital routing to CSC and was compared between men and women using modified Poisson regression including age, sex, race or ethnicity, first in-hospital National Institutes of Health Stroke Scale score, travel time, and distances to the closest primary stroke center and CSC. Among 503 patients with LVO AIS, 413 (82%) were routed to CSCs, and women comprised 46% of the study participants. Women with LVO AIS compared with men were older (73 versus 65, P<0.01) and presented with greater National Institutes of Health Stroke Scale score (14 versus 12, P=0.01). In modified Poisson regression, women were 9% less likely to be routed to CSCs compared with men (adjusted relative risk [aRR], 0.91 [0.84-0.99], P=0.024) and distance to nearest CSC ≤10 miles was associated with 38% increased chance of routing to CSC (aRR, 1.38 [1.26-1.52], P<0.001). Conclusions Despite presenting with more significant stroke syndromes and living within comparable distance to CSCs, women with LVO AIS were less likely to be routed to CSCs compared with men. Further study of the mechanisms behind this disparity is needed.
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Affiliation(s)
- Muhammad Bilal Tariq
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Iman Ali
- Department of Neurology UTHealth McGovern Medical School Houston TX
| | | | | | - Hussain M Azeem
- Department of Neurology UTHealth McGovern Medical School Houston TX
| | - Swapnil Khose
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Victor Lopez
- Department of Neurosurgery Boston Medical Center Boston MA
| | | | - Louise D McCullough
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Sunil A Sheth
- Department of Neurology UTHealth McGovern Medical School Houston TX
- Memorial Hermann Hospital-Texas Medical Center Houston TX
| | - Youngran Kim
- Department of Management, Policy and Community Health UTHealth School of Public Health Houston TX
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Bathla G, Ajmera P, Mehta PM, Benson JC, Derdeyn CP, Lanzino G, Agarwal A, Brinjikji W. Advances in Acute Ischemic Stroke Treatment: Current Status and Future Directions. AJNR Am J Neuroradiol 2023:ajnr.A7872. [PMID: 37202115 PMCID: PMC10337623 DOI: 10.3174/ajnr.a7872] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 04/03/2023] [Indexed: 05/20/2023]
Abstract
The management of acute ischemic stroke has undergone a paradigm shift in the past decade. This has been spearheaded by the emergence of endovascular thrombectomy, along with advances in medical therapy, imaging, and other facets of stroke care. Herein, we present an updated review of the various stroke trials that have impacted and continue to transform stroke management. It is critical for the radiologist to stay abreast of the ongoing developments to provide meaningful input and remain a useful part of the stroke team.
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Affiliation(s)
- G Bathla
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - P Ajmera
- Department of Radiology (P.A.), University College of Medical Sciences, Delhi, India
| | - P M Mehta
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - G Lanzino
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - A Agarwal
- Department of Radiology (A.A.), Mayo Clinic, Jacksonville, Florida
| | - W Brinjikji
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
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Bösel J, Hubert GJ, Jesser J, Möhlenbruch MA, Ringleb PA. Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion. Neurol Res Pract 2023; 5:19. [PMID: 37198694 DOI: 10.1186/s42466-023-00245-9] [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: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for. AIM This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO. METHOD The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels. RESULTS This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care. CONCLUSIONS The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Gordian J Hubert
- TEMPiS Telestroke Center, Department of Neurology, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Munich, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Huebinger R, Bobrow BJ. Smarter Prehospital Clinical Trials Through a Smartphone App. Resuscitation 2023; 187:109813. [PMID: 37121461 DOI: 10.1016/j.resuscitation.2023.109813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/22/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Ryan Huebinger
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth); Texas Emergency Medicine Research Center.
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth); Texas Emergency Medicine Research Center
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Selman CJ, Lee KJ, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: protocol for a scoping review. Trials 2023; 24:286. [PMID: 37085929 PMCID: PMC10119829 DOI: 10.1186/s13063-023-07262-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/18/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) aim to assess the effect of one (or more) unproven health interventions relative to other reference interventions. RCTs sometimes use an ordinal outcome, which is an endpoint that comprises of multiple, monotonically ordered categories that are not necessarily separated by a quantifiable distance. Ordinal outcomes are appealing in clinical settings as specific disease states can represent meaningful categories that may be of clinical importance to researchers. Ordinal outcomes can also retain information and increase statistical power compared to dichotomised outcomes and can allow multiple clinical outcomes to be comprised in a single endpoint. Target parameters for ordinal outcomes in RCTs may vary depending on the nature of the research question, the modelling assumptions and the expertise of the data analyst. The aim of this scoping review is to systematically describe the use of ordinal outcomes in contemporary RCTs. Specifically, we aim to: [Formula: see text] Identify which target parameters are of interest in trials that use an ordinal outcome, and whether these parameters are explicitly defined. [Formula: see text] Describe how ordinal outcomes are analysed in RCTs to estimate a treatment effect. [Formula: see text] Describe whether RCTs that use an ordinal outcome adequately report key methodological aspects specific to the analysis of the ordinal outcome. Results from this review will outline the current state of practice of the use of ordinal outcomes in RCTs. Ways to improve the analysis and reporting of ordinal outcomes in RCTs will be discussed. METHODS AND ANALYSIS We will review RCTs that are published in the top four medical journals (British Medical Journal, New England Journal of Medicine, The Lancet and the Journal of the American Medical Association) between 1 January 2012 and 31 July 2022 that use an ordinal outcome as either a primary or a secondary outcome. The review will identify articles through a PubMed-specific search strategy. Our review will adhere to guidelines for scoping reviews as described in the PRISMA-ScR checklist. The study characteristics and details of the study design and analysis, including the target parameter(s) and statistical methods used to analyse the ordinal outcome, will be extracted from eligible studies. The screening, review and data extraction will be conducted using Covidence, a web-based tool for managing systematic reviews. The data will be summarised using descriptive statistics.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Pajor MJ, Adeoye OM. Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era. Neurotherapeutics 2023; 20:655-663. [PMID: 36977818 PMCID: PMC10047478 DOI: 10.1007/s13311-023-01371-7] [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] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Thrombectomy became the gold-standard treatment of acute ischemic stroke caused by large-vessel occlusions (LVO) in 2015 after five clinical trials published that year demonstrated significantly improved patient outcomes. In subsequent years, advances in stroke systems of care have centered around improving access to and expanding patient eligibility for thrombectomy. The prehospital and acute stroke treatment settings have had the greatest emphasis. Numerous prehospital stroke scales now provide emergency medical services with focused physical exams to identify LVOs, and many devices to non-invasively detect LVO are undergoing clinical testing. Mobile stroke units deployed throughout Western Europe and the USA also show promising results by bringing elements of acute stroke care directly to the patient. Numerous clinical trials since 2015 have aimed to increase candidates for thrombectomy by expanding indications and the eligibility time window. Further optimizations of thrombectomy treatment have focused on the role of thrombolytics and other adjunctive therapies that may promote neuroprotection and neurorecovery. While many of these approaches require further clinical investigation, the next decade shows significant potential for further advances in stroke care.
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Affiliation(s)
- Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
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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: 0] [Impact Index Per Article: 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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Fassbender K, Lesmeister M, Merzou F. Prehospital stroke management and mobile stroke units. Curr Opin Neurol 2023; 36:140-146. [PMID: 36794965 PMCID: PMC9994848 DOI: 10.1097/wco.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Delayed presentation at the hospital contributes to poorer patient outcomes and undertreatment of acute stroke patients. This review will discuss recent developments in prehospital stroke management and mobile stroke units aimed to improve timely access to treatment within the past 2 years and will point towards future directions. RECENT FINDINGS Recent progress in research into prehospital stroke management and mobile stroke units ranges from interventions aimed at improving patients' help-seeking behaviour, to the education of emergency medical services team members, to the use of innovative referral methods, such as diagnostic scales, and finally to evidence of improved outcomes by the use of mobile stroke units. SUMMARY Understanding is increasing about the need for optimizing stroke management over the entire stroke rescue chain with the goal of improving access to highly effective time-sensitive treatment. In the future, we can expect that novel digital technologies and artificial intelligence will become relevant in effective interaction between prehospital and in-hospital stroke-treating teams, with beneficial effects on patients' outcomes.
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Affiliation(s)
- Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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Sheth SA. Mechanical Thrombectomy for Acute Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:443-461. [PMID: 37039404 DOI: 10.1212/con.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Endovascular stroke therapy has greatly improved the ability to treat the deadliest and most disabling form of acute ischemic stroke. This article summarizes some of the recent innovations in this field and discusses likely future developments. LATEST DEVELOPMENTS At present, there is robust activity to improve all facets of care for patients with large vessel occlusion stroke, including better prehospital routing, more efficient in-hospital screening, expanding indications for thrombectomy eligibility, innovating novel thrombectomy devices, and improving the effects of recanalization on clinical outcomes. In addition, the integration of endovascular stroke therapy (EVT)-an emergent and frequently off-hours procedure that requires a specialized team of nurses, technologists, and physicians-into acute stroke care has transformed referral patterns, hospital accreditation pathways, and physician practices. The eligibility for the procedure will potentially continue to grow to include patients screened without advanced imaging, larger core infarcts, and more distal occlusions. ESSENTIAL POINTS In this review, we discuss the current state of EVT and its implications for practice, and present three cases that highlight some of the directions in which the field is moving.
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Worthmann H, Winzer S, Schuppner R, Gumbinger C, Barlinn J. Telestroke networks for area-wide access to endovascular stroke treatment. Neurol Res Pract 2023; 5:9. [PMID: 36864498 PMCID: PMC9983226 DOI: 10.1186/s42466-023-00237-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. MAIN BODY Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. CONCLUSION The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.
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Affiliation(s)
- Hans Worthmann
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany.
| | - S. Winzer
- grid.412282.f0000 0001 1091 2917Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
| | - R. Schuppner
- grid.10423.340000 0000 9529 9877Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623 Hannover, Germany
| | - C. Gumbinger
- grid.5253.10000 0001 0328 4908Klinik Für Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - J. Barlinn
- grid.412282.f0000 0001 1091 2917Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
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