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

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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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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Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽

10.1161/strokeaha.120.033053 ◽

2021 ◽

Author(s):

Laura C.C. van Meenen ◽

Maritta N. van Stigt ◽

Arjen Siegers ◽

Martin D. Smeekes ◽

Joffry A.F. van Grondelle ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Stroke Care ◽

Prehospital Setting ◽

Large Vessel ◽

Large Vessel Occlusion ◽

User Friendliness ◽

Vessel Occlusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

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Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke

Journal of the American Heart Association ◽

10.1161/jaha.119.012665 ◽

2019 ◽

Vol 8 (12) ◽

Cited By ~ 6

Author(s):

Ludwig Schlemm ◽

Matthias Endres ◽

Jan F. Scheitz ◽

Marielle Ernst ◽

Christian H. Nolte ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Disability Adjusted Life Years ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Disability Adjusted Life ◽

Life Years ◽

Comprehensive Stroke Center ◽

Stroke Center

Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.

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Developing a statewide protocol to ensure patients with suspected emergent large vessel occlusion are directly triaged in the field to a comprehensive stroke center: how we did it

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012275 ◽

2016 ◽

Vol 9 (3) ◽

pp. 330-332 ◽

Cited By ~ 21

Author(s):

Mahesh V Jayaraman ◽

Arshad Iqbal ◽

Brian Silver ◽

Matthew S Siket ◽

Caryn Amedee ◽

...

Keyword(s):

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Comprehensive Stroke Center ◽

Stroke Center

We describe the process by which we developed a statewide field destination protocol to transport patients with suspected emergent large vessel occlusion to a comprehensive stroke center.

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Impact of Viz LVO on Time-to-Treatment and Clinical Outcomes in Large Vessel Occlusion Stroke Patients Presenting to Primary Stroke Centers

10.1101/2020.07.02.20143834 ◽

2020 ◽

Author(s):

Jacob R. Morey ◽

Emily Fiano ◽

Kurt A. Yaeger ◽

Xiangnan Zhang ◽

Johanna T. Fifi

Keyword(s):

New York ◽

Clinical Outcomes ◽

Large Vessel ◽

Similar Proportion ◽

Time Interval ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Time To Treatment ◽

Comprehensive Stroke Center ◽

Stroke Center

AbstractIntroductionRandomized controlled trials have demonstrated the importance of time-to-treatment on clinical outcomes in large vessel occlusion (LVO) stroke. Delays in interventional radiology (INR) consultation are associated with a significant delay in overall time to endovascular treatment (EVT). Delays in EVT are particularly prevalent in Primary Stroke Centers (PSC), hospitals without thrombectomy capability onsite, where the patient requires transfer to a Thrombectomy Capable or Comprehensive Stroke Center for EVT. A novel computer aided triage system, Viz LVO, assists in early notification of the PSC stroke team and affiliated INR team. This platform includes an image viewer, communication system, and an artificial intelligence algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts.HypothesisViz LVO will decrease time-to-treatment and improve clinical outcomes.MethodsA prospectively maintained database was assessed for all patients who presented to a PSC currently utilizing Viz LVO in the Mount Sinai Health System in New York and underwent EVT following transfer for LVO stroke between October 1, 2018 and March 15, 2020. There were 42 patients who fit the inclusion criteria and divided into pre- and post-Viz ContaCT implementation by comparing the periods of October 1, 2018, to March 15, 2019, “Pre-Viz”, and October 1, 2019, to March 15, 2020, “Post-Viz.” Time intervals and clinical outcomes were collected and compared.ResultsThe Pre- and Post-Viz cohorts were similar in terms of gender, age, proportion receiving IV-tPA, and proportion with revascularization of TICI > 2B. The presenting NIHSS and pre-stroke mRS scores were not statistically different.The median initial door-to-INR notification was significantly faster in the post-Viz cohort (21.5 minutes vs 36 minutes; p=0.02). The median initial door-to-puncture time interval was 20 minutes shorter in the Post-Viz cohort, but this was not statistically significant (p=0.20).The 5-day NIHSS and discharge mRS were both significantly lower in the Post-Viz cohort (p=0.02 and p=0.03, respectively). The median 90-day mRS scores were also significantly lower post-Viz implementation, although a similar proportion received a good outcome (mRS score ≤ 2) (p=0.02 and p=0.42, respectively).ConclusionsEVT is a time-sensitive intervention that is only available at select stroke centers. Significant delays in time-to-treatment are present when patients require transfer from PSCs to a EVT capable stroke center. In a large health care system, we have shown that Viz LVO implementation is associated with improved time to INR notification and clinical outcomes. Viz LVO has the potential for wide-spread improvement in clinical outcomes with implementation across large hub and stroke systems across the country.

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Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Stroke ◽

10.1161/str.51.suppl_1.tp248 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Kavit Shah ◽

Shashvat Desai ◽

Benjamin Morrow ◽

Pratit Patel ◽

Habibullah Ziayee ◽

...

Keyword(s):

Internal Carotid ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

To Receive ◽

Rapid Transfer

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

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Thrombectomy 6-24 hours after stroke in trial ineligible patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013915 ◽

2018 ◽

Vol 10 (11) ◽

pp. 1033-1037 ◽

Cited By ~ 28

Author(s):

Shashvat M Desai ◽

Marcelo Rocha ◽

Bradley J Molyneaux ◽

Matthew Starr ◽

Cynthia L Kenmuir ◽

...

Keyword(s):

Time Window ◽

Functional Independence ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Off Label ◽

Symptomatic Intracranial Hemorrhage ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

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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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