Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

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Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke

JAMA Neurology ◽

10.1001/jamaneurol.2021.2485 ◽

2021 ◽

Author(s):

Tareq Kass-Hout ◽

Jungwha Lee ◽

Katie Tataris ◽

Christopher T. Richards ◽

Eddie Markul ◽

...

Keyword(s):

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center

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Personalized Prehospital Triage in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.118.022562 ◽

2019 ◽

Vol 50 (2) ◽

pp. 313-320 ◽

Cited By ~ 7

Author(s):

Esmee Venema ◽

Hester F. Lingsma ◽

Vicky Chalos ◽

Maxim J.H.L. Mulder ◽

Maarten M.H. Lahr ◽

...

Keyword(s):

Ischemic Stroke ◽

Large Vessel ◽

Base Case ◽

Large Vessel Occlusion ◽

Case Scenario ◽

Vessel Occlusion ◽

Base Case Scenario ◽

Primary Stroke Center ◽

Prehospital Triage ◽

Stroke Center

Background and Purpose— Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. Methods— We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). Results— Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. Conclusions— The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas.

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Abstract WMP66: Minnesota Prehospital Stroke Scale For Prediction of Emergent Large Vessel Occlusion

Stroke ◽

10.1161/str.47.suppl_1.wmp66 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Takamasa Higashimori ◽

David Anderson

Keyword(s):

Randomized Clinical Trials ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Patient Transport ◽

Primary Stroke Center ◽

Leg Weakness ◽

Stroke Center ◽

Endovascular Mechanical Thrombectomy

Intro: Recent randomized clinical trials have demonstrated the benefit of endovascular mechanical thrombectomy in acute ischemic stroke patients with Emergent Large Vessel Occlusion (ELVO). Cincinnati Prehospital Stroke Scale is widely used tool by EMS but not specifically designed to predict ELVO. Previously reported prehospital stroke scales for ELVO have been limited, and not widely used. It is imperative to establish a simple and accurate tool for EMS to predict ELVO facilitating rapid patient transport to hospitals capable of endovascular intervention. Hypothesis: Minnesota Prehospital Stroke Scale (MPSS) can predict the presence of ELVO with high accuracy comparable to NIHSS. Methods: The MPSS assesses five parameters: Facial weakness, Arm weakness, Leg weakness, Speech difficulty and Eye deviation, with total score ranging 0-10 (See Table). We set MPSS 6 or above and NIHSS 7 or above as a cutoff for ELVO. We retrospectively analyzed all the stroke code patients seen in ED between January 2015 and April 2015 at a primary stroke center (n=120). We selected patients arriving in less than 6 hours with prehospital stroke alert activated by EMS. Hemorrhagic stroke patients were excluded. The following data were collected: 1) Presence of ELVO, 2) Initial NIHSS in ED, and 3) MPSS abstracted from initial ER NIHSS, then assessed the results using 2x2 table for ELVO and MPSS vs. NIHSS. Results: Of 28 patients meeting criteria, 6 (21%) had ELVO (ICA, M1/M2): Mean MPSS was 7.5, whereas mean NIHSS was 15 for ELVO patients. Mean HPSS was 1.6, whereas mean NIHSS was 5.1 for non-ELVO patients. Sensitivity 83%, specificity 100%, PPV 100%, NPV 96%, and accuracy 96% for HPSS; sensitivity 83%, specificity 77%, PPV 50%, NPV 94% and accuracy 79% for NIHSS. Conclusion: MPSS may be a useful tool for predicting ELVO. Further studies are necessary to validate the efficacy of the scale.

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Pre- and Interhospital Workflow Times for Patients With Large Vessel Occlusion Stroke Transferred for Endovasvular Thrombectomy

Frontiers in Neurology ◽

10.3389/fneur.2021.730250 ◽

2021 ◽

Vol 12 ◽

Author(s):

Laura C. C. van Meenen ◽

Frank Riedijk ◽

Jeffrey Stolp ◽

Bas van der Veen ◽

Patricia H. A. Halkes ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Large Vessel ◽

Time Interval ◽

Large Vessel Occlusion ◽

Related Factors ◽

Vessel Occlusion ◽

Interhospital Transfer ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Patients with large vessel occlusion (LVO) stroke are often initially admitted to a primary stroke center (PSC) and subsequently transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). This interhospital transfer delays initiation of EVT. To identify potential workflow improvements, we analyzed pre- and interhospital time metrics for patients with LVO stroke who were transferred from a PSC for EVT.Methods: We used data from the regional emergency medical services and our EVT registry. We included patients with LVO stroke who were transferred from three nearby PSCs for EVT (2014–2021). The time interval between first alarm and arrival at the CSC (call-to-CSC time) and other time metrics were calculated. We analyzed associations between various clinical and workflow-related factors and call-to-CSC time, using multivariable linear regression.Results: We included 198 patients with LVO stroke. Mean age was 70 years (±14.9), median baseline NIHSS was 14 (IQR: 9–18), 136/198 (69%) were treated with intravenous thrombolysis, and 135/198 (68%) underwent EVT. Median call-to-CSC time was 162 min (IQR: 137–190). In 133/155 (86%) cases, the ambulance for transfer to the CSC was dispatched with the highest level of urgency. This was associated with shorter call-to-CSC time (adjusted β [95% CI]: −27.6 min [−51.2 to −3.9]). No clinical characteristics were associated with call-to-CSC time.Conclusion: In patients transferred from a PSC for EVT, median call-to-CSC time was over 2.5 h. The highest level of urgency for dispatch of ambulances for EVT transfers should be used, as this clearly decreases time to treatment.

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Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke

Stroke ◽

10.1161/strokeaha.120.030248 ◽

2020 ◽

Vol 51 (12) ◽

pp. 3495-3503 ◽

Cited By ~ 1

Author(s):

Jacob R. Morey ◽

Thomas J. Oxley ◽

Daniel Wei ◽

Christopher P. Kellner ◽

Neha S. Dangayach ◽

...

Keyword(s):

Clinical Outcomes ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Team ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Patient Presentation

Background and Purpose: Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models. Methods: This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months. Results: MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes ( P <0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively ( P =0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%; P <0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS ( P =0.10). Conclusions: MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03048292.

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Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017155 ◽

2021 ◽

pp. neurintsurg-2020-017155

Author(s):

Alexander M Kollikowski ◽

Franziska Cattus ◽

Julia Haag ◽

Jörn Feick ◽

Alexander G März ◽

...

Keyword(s):

Patient Characteristics ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Time Intervals ◽

Vessel Occlusion ◽

Before And After ◽

Transferred Patients ◽

Stroke Center

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

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Real-World Experience with Artificial Intelligence-Based Triage in Transferred Large Vessel Occlusion Stroke Patients

Cerebrovascular Diseases ◽

10.1159/000515320 ◽

2021 ◽

pp. 1-6

Author(s):

Jacob R. Morey ◽

Xiangnan Zhang ◽

Kurt A. Yaeger ◽

Emily Fiano ◽

Naoum Fares Marayati ◽

...

Keyword(s):

Artificial Intelligence ◽

Clinical Outcomes ◽

Warning System ◽

Large Vessel ◽

Time Interval ◽

Large Vessel Occlusion ◽

Time Intervals ◽

Vessel Occlusion ◽

Left Behind ◽

Stroke Center

Background and Purpose: Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) in clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A computer-aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, a communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment, leading to improved clinical outcomes. Methods: A retrospective analysis of a prospectively maintained database was assessed for patients who presented to a stroke center currently utilizing Viz LVO and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. Time intervals and clinical outcomes were compared for 55 patients divided into pre- and post-Viz cohorts. Results: The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 min [IQR = 12.0] vs. 40.0 min [IQR = 61.0]; p = 0.01) with less variation (p < 0.05) following Viz LVO implementation. The median initial door-to-skin puncture time interval was 25 min shorter in the post-Viz cohort, although this was not statistically significant (p = 0.15). Conclusions: Preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times. This application can serve as an early warning system and a failsafe to ensure that no LVO is left behind.

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