Direct admission to stroke centers reduces treatment delay and improves clinical outcome after intravenous thrombolysis

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Impact of Stroke Severity on the Smoking Paradox in Patients Treated with Intravenous Thrombolysis

OBJECTIVE

To our knowledge, no previous studies have investigated the impact of stroke severity on the smoking paradox after intravenous thrombolysis (IVT). We aimed to explore the contribution of stroke severity to the association between smoking and stroke prognosis after IVT.

METHODS

We enrolled consecutive patients who received IVT within 4.5 hours from stroke onset. A logistic regression model was used to estimate the unadjusted and adjusted odds ratios (ORs) with their 95% confidence intervals (CIs) for poor functional outcome and mortality at 3 months.

RESULTS

Among patients with moderate stroke, smokers experienced a lower risk of 3-month poor outcomes than non-smokers (33.0% vs. 44.4%, unadjusted OR: 0.616; 95% CI: 0.402-0.945). However, among those with severe stroke, smokers had a higher risk of 3-month poor outcomes than non-smokers (81.6% vs. 55.9%, unadjusted OR: 3.496; 95% CI: 1.207-10.127). After adjustment, the negative correlation between smoking and 3-month poor outcome following IVT lost statistical significance in patients with moderate stroke (OR: 0.677 [95% CI: 0.418-1.097]). However, smoking remained a risk factor for 3-month poor outcomes in patients with severe stroke (OR: 4.216 [95% CI: 1.236-14.385]). We also observed a significant interaction between smoking and stroke severity with regard to the risk of poor functional outcomes (p=0.023). However, no such interaction influenced mortality (p=0.901).

CONCLUSION

Stroke severity affects the association between smoking and 3-month clinical functional outcomes following IVT.

Comparison of mothership versus drip-and-ship models in treating patients with acute ischemic stroke: A systematic review and meta-analysis

INTRODUCTION

There is controversy if direct to comprehensive center "mothership" or stopping at primary center for thrombolysis before transfer to comprehensive center "drip-and-ship" are best models of treatment of acute stroke. In this study, we compare mothership and drip-and-ship models to evaluate the best option of functional outcome.

METHODS

Studies between 1990 and 2020 were extracted from online electronic databases. Clinical outcomes, critical time measurements, functional independence, and mortality were then compared.

RESULTS

A total of 7824 patients' data were retrieved from 13 publications (3 randomized control trials and 10 retrospective ones). In addition, 4639 (59.3%) patients were treated under mothership model, and 3185 (40.7%) followed the drip-and-ship model with mean age of 70.01 ± 3.58 versus 69.03 ± 3.36; p < 0.001, respectively. The National Institute Health Stroke Scale was 15.57 ± 3.83 for the mothership and 15.72 ± 2.99 for the drip-and-ship model (p ≤ 0.001). The mean symptoms onset-to-puncture time was significantly shorter in the mothership group compared to the drip-and-ship (159.69 min vs. 223.89 min; p ≤ 0.001, respectively). Moreover, the collected data indicated no significant difference between symptom's onset to intravenous thrombolysis time and stroke onset-to-successful recanalization time (p = 0.205 and p ≤ 0.001, respectively). Patients had significantly worse functional outcome (modified Rankin score) (3-6) at 90 days in the drip-and-ship model (odds ratio (OR): 1.47, 95% confidence interval (CI): 1.13-1.92, p < 0.004) and 1.49-folds higher likelihood of symptomatic intracerebral hemorrhage (OR: 1.49, 95% CI: 1.22-1.81, p < 0.0001) compared to mothership. However, there were no statistically significant difference in terms of mortality (OR: 1.16, 95% CI: 0.87-1.55, p = 0.32) and successful recanalization (OR: 1.12, 95% CI: 0.76-1.65, p = 0.56) between the two models of care.

CONCLUSION

Patients in the mothership model have significantly improved functional independence and recovery. Further studies are needed as the data from prospectively randomized studies are not of sufficient quality to make definite recommendations.

Mothership versus Drip-and-Ship Model for Mechanical Thrombectomy in Acute Stroke: A Systematic Review and Meta-Analysis for Clinical and Radiological Outcomes

Background and Purpose

Substantial uncertainty exists on the benefit of organizational paradigms in stroke networks. Here we systematically reviewed and meta-analyzed data from studies comparing functional outcome between the mothership (MS) and the drip and ship (DS) models.

Methods

The meta-analysis protocol was registered international prospective register of systematic reviews (PROSPERO) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Central databases were searched for randomized-controlled clinical trials (RCTs), retrospective and prospective studies comparing MS versus DS. Primary endpoints were functional independence at 90 days (modified Rankin Scale <3) and successful recanalization (Thrombolysis in Cerebral Infarction Scale [TICI] >2a); secondary endpoints were 3-month mortality and symptomatic intracranial haemorrhage (sICH). Odds ratios for endpoints were pooled using the random effects model and were compared between the two organizational models.

Results

Overall, 18 studies (n=7,017) were included in quantitative synthesis. MS paradigm was superior to DS model for functional independence (odds ratio, 1.34; 95% confidence interval, 1.16 to 1.55; I²=30%). Meta-regression analysis revealed association between onset-to-needle time and good functional outcome, with longer onset-to-needle time being detrimental. Similar rates of recanalization, sICH and mortality at 90 days were documented between MS and DS.

Conclusions

Patients with acute ischemic stroke eligible for reperfusion strategies might benefit more from MS paradigm as compared to DS. RCTs are needed to further refine best management taking into account logistics, facilities and resources.

Emerging Technologies in Optimizing Pre-Intervention Workflow for Acute Stroke

Over the last several years, thrombectomy for large vessel occlusions (LVOs) has emerged as a standard of care for acute stroke patients. Furthermore, the time to reperfusion has been identified as a predictor of overall patient outcomes, and much effort has been made to identify potential areas to target in enhancing preintervention workflow. As medical technology and stroke devices improve, nearly all time points can be affected, from field stroke triage to automated imaging interpretation to mass mobile stroke code communications. In this article, we review the preintervention stroke workflow with specific regard to emerging technologies in improving time to reperfusion and overall patient outcomes.

Cost-Consequence Analysis of Mobile Stroke Units vs. Standard Prehospital Care and Transport

Background: Mobile stroke units (MSUs) are the latest approach to improving time-sensitive stroke care delivery. Currently, there are no published studies looking at the expanded value of the MSU to diagnose and transport patients to the closest most appropriate facility. The purpose of this paper is to perform a cost consequence analysis of standard transport (ST) vs. MSU.

Methods and Results: A cost consequence analysis was undertaken within a decision framework to compare the incremental cost of care for patients with confirmed stroke that were served by the MSU vs. their simulated care had they been served by standard emergency medical services between July 2014 and October 2015. At baseline values, the incremental cost between MSU and ST was $70,613 ($856,482 vs. $785,869) for 355 patient transports. The MSU avoided 76 secondary interhospital transfers and 76 emergency department (ED) encounters. Sensitivity analysis identified six variables that had measurable impact on the model's variability and a threshold value at which MSU becomes the optimal strategy: number of stroke patients (>391), probability of requiring transfer to a comprehensive stroke center (CSC, >0.52), annual cost of MSU operations (<$696,053), cost of air transfer (>$8,841), probability initial receiving hospital is a CSC (<0.32), and probability of ischemic stroke with ST (<0.76).

Conclusions: MSUs can avert significant costs in the administration of stroke care once optimal thresholds are achieved. A comprehensive cost-effectiveness analysis is required to determine not just the operational value of an MSU but also its clinical value to patients and the society.

Contribution of Onset-to-Alarm Time to Prehospital Delay in Patients with Ischemic Stroke

BACKGROUND

Stroke is a leading cause of death and disability. Tissue plasminogen activator (tPA) improves the clinical outcome when administered properly; however, the most important factor to receive tPA is time. The main reason for late hospital arrival is a considerable delay in onset-to-alarm time (OAT), comprising more than 50% of the onset-to-door time.

AIMS

To identify the factors associated with a delay in OAT and evaluate its contribution to onset-to-door time in ischemic stroke patients.

METHODS

Prospective cohort of stroke patients admitted to the UANL University Hospital. OAT was defined as the time from identification of stroke symptoms to the decision to seek medical attention.

RESULTS

A total of 189 patients were included. Mean age was 61 ± 13 years, 62% were men. One-hundred and one patients had a short OAT, but only 20.9% arrived during the first 3 hours after stroke onset. Being employed (P = 0032; odds ratio [OR] 2.784, 95% confidence interval [CI] 1.091-7.104), attributing symptoms to stroke (P = 0016; OR 3.348, 95% CI 1.254-8.936), and perceiving stroke symptoms as severe (P = 0031;OR 2.428, 95% CI 1.083-5.445) were associated with a shorter OAT.

CONCLUSIONS

OAT consumes a considerable amount of the onset-to-door time. It is necessary to increase stroke knowledge and emphasize the severity of stroke, regardless of the severity of its clinical manifestations to reduce the prehospital delay, especially in countries with limited access to treatment with an extended time frame.

Factors affecting in-hospital delay of intravenous thrombolysis for acute ischemic stroke: A retrospective cohort study

This study was designed to investigate the factors affecting the in-hospital delay of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS).Two hundred and forty-eight consecutive AIS patients treated with intravenous administration of alteplase in Gansu Provincial Hospital from December 2014 to August 2018 were enrolled retrospectively in this study. According to door-to-needle (DTN) time, the patients were divided into either a delay group (DTN time > 60 minutes; n = 184) or a non-delay group (DTN time ≤60 minutes; n = 64). The baseline data, laboratory tests, onset-to-door (OTD) time, door-to-accepting time (DTA), door-to-imaging time (DTI), and decision-making time in both groups were recorded. Multivariate logistic analysis was performed to analyze the data.There were significant differences in previous history of cerebral ischemic attack, emergency system admission, education degree of decision makers, annual income, admission National Institutes of Health Stroke Scale (NIHSS), OTD time, DTA time, decision-making time between the 2 groups (all P < .05). Other baseline data and clinical features showed no significant difference between 2 groups (P > .05). Multivariate logistic regression analysis revealed that the risk of in-hospital delay was lower for the higher NIHSS score (OR = 0.775, 95% CI: 0.644-0.933, P = .007), the longer OTD time (OR = 0.963, 95% CI: 0.937-0.991, P = .010), the shorter decision-making time (OR = 1.224, 95% CI: 1.004-1.492, P = .045).This study suggested that NIHSS score, OTD time and decision-making time are the independent factors affecting the in-hospital delay of IVT for AIS.

Predictors of thrombolysis in the telestroke and non telestroke settings for hypertensive acute ischemic stroke patients

BACKGROUND

In acute ischemic stroke patients, telestroke technology provides sustainable approaches to improve the use of thrombolysis therapy. How this is achieved as it relates to inclusion or exclusion of clinical risk factors for thrombolysis is not fully understood. We investigated this in a population of hypertensive stroke patients.

METHODS

Structured data from a regional stroke registry that contained telestroke and non telestroke patients with a primary diagnosis of acute ischemic stroke with history of hypertension were collected between January 2014 and June 2016. Clinical risk factors associated with inclusion or exclusion for recombinant tissue plasminogen activator (rtPA) in the telestroke and non telestroke were identified using multiple regression analysis. Associations between variables and rtPA in the regression models were determined using variance inflation factors while the fitness of each model was determined using the ROC curve to predict the power of each logistic regression model.

RESULTS

The non telestroke admitted more patients (62% vs 38%), when compared with the telestroke. Although the telestroke admitted fewer patients, it excluded 11% and administered thrombolysis therapy to 89% of stroke patients with hypertension. In the non telestroke group, adjusted odd ratios showed significant associations of NIH stroke scale score (OR = 1.059, 95% CI, 1.025-1.093, P < 0.001) and coronary artery disease (OR = 2.003, 95% CI, 1.16-3.457, P = 0.013) with inclusion, while increasing age (OR = 0.979, 95% CI, 0.961-0.996, P = 0.017), higher INR (OR = 0.146, 95% CI, 0.032-0.665, P = 0.013), history of previous stroke (OR = 0.39, 95% CI, 0.223-0.68, P = 0.001), and renal insufficiency (OR = 0.153, 95% CI, 0.046-0.508, P = 0.002) were associated with rtPA exclusion. In the telestroke, only direct admission to the telestroke was associated with rtPA administration, (OR = 4.083, 95% CI, 1.322-12.611, P = 0.014).

CONCLUSION

The direct admission of hypertensive stroke patients to the telestroke network was the only factor associated with inclusion for thrombolysis therapy even after adjustment for baseline variables. The telestroke technology provides less restrictive criteria for clinical risk factors associated with the inclusion of hypertensive stroke patients for thrombolysis.

Fast-track versus long-term hospitalizations for patients with non-disabling acute ischaemic stroke

BACKGROUND AND PURPOSE

The aim was to assess the feasibility and safety of fast-track hospitalizations in a selected cohort of patients with stroke.

METHODS

Patients hospitalized at the Stroke Center of the University Hospital Basel, Switzerland, with an acute ischaemic stroke confirmed on magnetic resonance diffusion-weighted imaging were included. Neurological deficits of the included patients were non-disabling, i.e. not interfering with activities of daily living and compatible with a direct discharge home. Patients with premorbid disability were excluded. All patients were admitted to the Stroke Center for ≥24 h. Two study groups were compared - fast-track hospitalizations (≤72 h) and long-term hospitalizations (>72 h). The primary end-point was a composite of any unplanned rehospitalization for any reason within 3 months since hospital discharge and a modified Rankin Scale 3-6 at 3 months. Adjustment for confounders was done using the inverse probability of treatment weights (IPTW).

RESULTS

Amongst the 521 patients who met the inclusion criteria, fast-track hospitalizations were performed in 79 patients (15%). In the fast-track group, seven patients (8.9%) met the primary end-point, compared to 37 (8.4%) in the long-term group [odds ratio (OR) 1.06, 95% confidence interval (CI) 0.42-2.34, P = 0.88]. After weighting for IPTW, the odds of the primary end-point remained similar between the two arms (OR_IPTW 1.27, 95% CI 0.51-3.16, P = 0.61). The costs of fast-track hospitalizations were lower, on average, by $4994.

CONCLUSIONS

Fast-track hospitalizations including a full workup proved to be feasible, showed no increased risk and were less expensive than long-term hospitalizations.