Pre-hospital triage of suspected acute stroke patients in a mobile stroke unit in the rural Alberta

AbstractMobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

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Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

Cerebrovascular Diseases ◽

10.1159/000508910 ◽

2020 ◽

Vol 49 (4) ◽

pp. 388-395

Author(s):

Iris Q. Grunwald ◽

Daniel J. Phillips ◽

David Sexby ◽

Viola Wagner ◽

Martin Lesmeister ◽

...

Keyword(s):

Hospital Admission ◽

Acute Stroke ◽

Stroke Unit ◽

Hospital Admissions ◽

Hospital Treatment ◽

Stroke Patients ◽

Transient Ischaemic Attacks ◽

Accident And Emergency ◽

Mobile Stroke Unit ◽

The Uk

Background: Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. Objective: The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. Methods: Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. Results: In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40–60). Conclusion: This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

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Air-Mobile Stroke Unit for access to stroke treatment in rural regions

International Journal of Stroke ◽

10.1177/1747493018784450 ◽

2018 ◽

Vol 13 (6) ◽

pp. 568-575 ◽

Cited By ~ 12

Author(s):

Silke Walter ◽

Henry Zhao ◽

Damien Easton ◽

Cees Bil ◽

Jonas Sauer ◽

...

Keyword(s):

Rural Areas ◽

Stroke Unit ◽

Systems Of Care ◽

Intravenous Thrombolysis ◽

Rural And Remote ◽

Stroke Patients ◽

Stroke Treatment ◽

Remote Areas ◽

Mobile Stroke Unit ◽

Rural And Remote Areas

Background In recent years, important progress has been made in effective stroke treatment, however, patients living in rural and remote areas have nil or very limited access to timely reperfusion therapies. Aims Novel systems of care to overcome the detrimental treatment gap for stroke patients living in rural and remote regions need to be developed. Summary of review A possible solution to the treatment disparity between stroke patients living in metropolitan and rural areas may involve the use of specially designed aircrafts equipped with the ability to diagnose and treat acute stroke at remote emergency sites. We describe technical solutions for an Air-Mobile Stroke Unit (Air-MSU) concept, where an aircraft is customized with the ability to perform multimodal computed tomography, in addition to onboard laboratory equipment and telemedicine connection. The Air-MSU is envisioned not only to allow intravenous thrombolysis in the field but also to allow prehospital triage to a comprehensive stroke center through use of contrast intracerebral vascular imaging. Several options for the Air-MSU approach are described, and issues regarding the potential medical benefit, optimal operating environment, technical realization, and integration in pre-existing solutions (e.g., flying doctor service) are addressed. Conclusion The Air-MSU may represent a novel tool to reduce treatment disparity for stroke patients in rural and remote areas. However, this approach requires further implementation research to determine the overall benefit to these communities.

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DOOR-TO-NEEDLE TIME AND THE FACTORS IMPEDING THROMBOLYSIS OF ACUTE STROKE PATIENTS AT A TERTIARY CARE CENTER IN INDIA

10.36106/ijar/7400431 ◽

2021 ◽

pp. 10-12

Author(s):

Darpan Sohni

Keyword(s):

Acute Stroke ◽

Care Center ◽

Tertiary Care ◽

Intravenous Thrombolysis ◽

Temporal Data ◽

Stroke Patients ◽

The Public ◽

Window Period ◽

The Mean ◽

Major Factors

Background: Intravenous thrombolysis for acute ischemic stroke is time-sensitive with a narrow window period for treatment initiation. The recommended Door-to-needle (DTN) time of <60 minutes is seldom achieved in Indian centers. In this study, we aimed to evaluate the DTN time at our hospital and identify the factors that limit thrombolysis of acute stroke patients. Materials and Methods: All patients that presented with signs of stroke from September to December 2019 were studied. Patient's demographics, details of symptoms, time of symptom onset, and contraindications to thrombolysis were recorded. The Symptom-to-Door, Doorto-Physician, Door-to-Imaging and Door-to-Needle times were calculated from key temporal data. The factors that inuenced the DTN time were also recorded. Results: Out of the 241 patients that presented with symptoms of stroke, 43 (17.8%) were within the window period. Nine patients were thrombolysed and among these, one (11.1%) was started on rt-PA within 1 hour of arrival. The mean DTN time was 112 minutes (median - 102 minutes). Conclusion: The DTN time in this study was much higher than what is recommended. The major factors that impede thrombolysis are: ignorance among the public, lack of a proper triage system at various levels, and lack of a dedicated stroke protocol/team.

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Determinants of aphasia recovery in first 3 months following first ever acute stroke: Experience from a tertiary care centre stroke unit in Kolkata, India

Frontiers in Human Neuroscience ◽

10.3389/conf.fnhum.2019.01.00037 ◽

2019 ◽

Vol 13 ◽

Author(s):

Durjoy Lahiri ◽

Souvik Dubey ◽

Alfredo Ardila ◽

Debasish Sanyal ◽

Gautam Das ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Unit ◽

Tertiary Care ◽

Care Centre ◽

Tertiary Care Centre ◽

Aphasia Recovery

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Application of Mobile Stroke Unit in Prehospital Thrombolysis of Acute Stroke: Experience from China

Cerebrovascular Diseases ◽

10.1159/000514370 ◽

2021 ◽

pp. 1-6

Author(s):

Tengfei Zhou ◽

Liangfu Zhu ◽

Meiyun Wang ◽

Tianxiao Li ◽

Yucheng Li ◽

...

Keyword(s):

Thrombolytic Therapy ◽

Acute Stroke ◽

Sample Size ◽

Stroke Unit ◽

Early Stage ◽

Intravenous Thrombolysis ◽

Small Sample ◽

Control Group ◽

Prehospital Thrombolysis ◽

Mobile Stroke Unit

Background and Purpose: Most patients cannot receive intravenous thrombolytic therapy in the early stage of stroke onset, and the application of mobile stroke unit (MSU) in prehospital intravenous thrombolytic therapy of acute stroke may change this situation. The first MSU in China was put into use in 2017. Herein, we aimed to explore the preliminary experience of MSU in prehospital thrombolysis of acute stroke. Methods: Patients who received prehospital intravenous thrombolytic therapy using MSU were classified to the MSU thrombolysis group, and the control group consisted of stroke patients admitted by regular ambulances, who were transferred to hospital for intravenous thrombolytic therapy. The feasibility, safety, and duration of procedures were compared. Results: There were 14 patients received prehospital intravenous thrombolysis on the MSU, and 24 patients underwent intravenous thrombolysis in the emergency center, who were transferred by the ordinary ambulance during the same period. The median call-to-needle time was 59.5 min in the MSU thrombolysis group, while it was 89 min in the control group; the difference between the 2 groups was statistically significant (p = 0.001). The median time from onset to thrombolysis was 70 and 102.5 min, respectively, in the 2 groups (p = 0.002). The percentages of good clinical outcome (modified Rankin Scale score ≤ 2) at 90-day follow-up were 79 and 67%, respectively (p = 0.488). The rate of symptomatic intracranial hemorrhage and mortality during the perioperative period did not differ significantly between 2 groups. Conclusion: Despite the small sample size, our preliminary experience of the application of MSU in the prehospital thrombosis therapy seems to indicate a significant reduction in time from call to needle, the efficacy of MSU in the treatment of acute stroke needs further experiment and larger sample size to confirm.

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Acute stroke treatment and outcome in the oldest old (90 years and older) at a tertiary care medical centre in Germany-a retrospective study showing safety and efficacy in this particular patient population

BMC Geriatrics ◽

10.1186/s12877-021-02566-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jil Kauffmann ◽

Daniel Grün ◽

Umut Yilmaz ◽

Gudrun Wagenpfeil ◽

Klaus Faßbender ◽

...

Keyword(s):

Retrospective Study ◽

Acute Stroke ◽

Functional Outcome ◽

Mechanical Thrombectomy ◽

Oldest Old ◽

Tertiary Care ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Stroke Treatment ◽

Acute Stroke Treatment

Abstract Background Stroke is among the most common causes of death and disability worldwide. Despite the relevance of stroke-related disease burden, which is constantly increasing due to the demographic change in industrialized countries with an ageing population and consecutively an increase in age-associated diseases, there is sparse evidence concerning acute stroke treatment and treatment-related outcome in the elderly patient group. This retrospective study aimed at analysing patient characteristics, therapy-related complications and functional outcome in stroke patients aged 90 years or older who underwent acute stroke treatment (i.e. intravenous thrombolysis, mechanical thrombectomy, or both). Methods We identified files of all inpatient stays at the Department of Neurology at Saarland University Medical Center (tertiary care level with a comprehensive stroke unit) between June 2011 and December 2018 and filtered for subjects aged 90 years or older at the time of admission. We reviewed patient files for demographic data, symptoms upon admission, (main) diagnoses, comorbidities, and administered therapies. For patients admitted due to acute stroke we reviewed files for therapy-related complications and functional outcome. We compared the modified Rankin scale (mRS) scores upon admission and at discharge for these patients. Results We identified 566 inpatient stays of subjects aged 90 years or older. Three hundred sixty-seven of the 566 patients (64.8%) were admitted and discharged due to symptoms indicative of stroke. Two hundred eleven patients received a diagnosis of ischaemic stroke. These 211 patients were analysed subsequently. Sixty-four patients qualified for acute stroke treatment (intravenous thrombolysis n = 22, mechanical thrombectomy n = 26, intravenous thrombolysis followed by mechanical thrombectomy n = 16) and showed a significant improvement in their functional status as measured by change in mRS score (admission vs. discharge, p 0.001) with 7 (10.9%) observed potentially therapy-related complications (relevant drop in haemoglobin n = 2, subarachnoidal haemorrhage n = 1, cerebral haemorrhage n = 3, extracranial bleeding n = 1). One intravenous thrombolysis was stopped because of an uncontrollable hypertensive crisis. Patients who did not qualify for these treatments (including those declining acute treatment) did not show a change of their functional status between admission and discharge (p 0.064). Conclusion Our data indicate that acute stroke treatment is effective and safe in the oldest old. Age alone is no criterion to withhold an acute intervention even in oldest old stroke patients.

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In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

CardioVascular and Interventional Radiology ◽

10.1007/s00270-020-02727-8 ◽

2020 ◽

Author(s):

Juha-Pekka Pienimäki ◽

Jyrki Ollikainen ◽

Niko Sillanpää ◽

Sara Protto

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis ◽

Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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Retrospective Review and Proof of Concept of Asia’s First Mobile Stroke Unit Experience in Kovai Medical Center and Hospital

Journal of Stroke Medicine ◽

10.1177/2516608520968418 ◽

2020 ◽

Vol 3 (2) ◽

pp. 116-123

Author(s):

Mathew Cherian ◽

Pankaj Mehta ◽

Shriram Varadharajan ◽

Santosh Poyyamozhi ◽

Elango Swamiappan ◽

...

Keyword(s):

Acute Stroke ◽

Retrospective Review ◽

Stroke Unit ◽

Care Pathway ◽

Clinical Care ◽

Stroke Care ◽

First Year ◽

Proof Of Concept ◽

Mobile Stroke Unit ◽

Clinical Care Pathway

Background: We review our initial experience of India’s and Asia’s first mobile stroke unit (MSU) following the completion of its first year of operation. We outline the clinical care pathway integrating the MSU services using a case example taking readers along our clinical care workflow while highlighting the challenges faced in organizing and optimizing such services in India. Methods: Retrospective review of data collected for all patients from March 2018 to February 2019 transported and treated within the MSU during the first year of its operation. Recent case example is reviewed highlighting complete comprehensive acute clinical care pathway from prehospital MSU services to advanced endovascular treatment with focus on challenges faced in developing nation for stroke care. Results: The MSU was dispatched and utilized for 14 patients with clinical symptoms of acute stroke. These patients were predominantly males (64%) with median age of 59 years. Ischemic stroke was seen in 7 patients, hemorrhagic in 6, and 1 patient was classified as stroke mimic. Intravenous tissue plasminogen activator was administered to 3 patients within MSU. Most of the patients’ treatment was initiated within 2 h of symptom onset and with the median time of patient contact (rendezvous) following stroke being 55 mins. Conclusion: Retrospective review of Asia’s first MSU reveals its proof of concept in India. Although the number of patients availing treatment in MSU is low as compared to elsewhere in the world, increased public awareness with active government support including subsidizing treatment costs could accelerate development of optimal prehospital acute stroke care policy in India.

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