scholarly journals Impact of mobile stroke units

2021 ◽  
pp. jnnp-2020-324005
Author(s):  
Klaus Fassbender ◽  
Fatma Merzou ◽  
Martin Lesmeister ◽  
Silke Walter ◽  
Iris Quasar Grunwald ◽  
...  
Keyword(s):  
Cost Efficiency ◽  
Current Knowledge ◽  
Vascular Imaging ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Stroke Research ◽  
Mobile Stroke Unit ◽  
Novel Strategy

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

scholarly journals EXPRESS: COVID-19 AND STROKE – UNDERSTANDING THE RELATIONSHIP AND ADAPTING SERVICES. A GLOBAL WORLD STROKE ORGANISATION PERSPECTIVE

2021 ◽  
pp. 174749302110064
Author(s):  
Hugh S Markus ◽  
Sheila Cristina Ouriques Martins
Keyword(s):  
Large Scale ◽  
Stroke Care ◽  
Long Term Effects ◽  
Vessel Occlusion ◽  
Stroke Incidence ◽  
Stroke Research ◽  
Incidence And Mortality ◽  
Research Initiatives ◽  
Global World

A year ago the World Stroke Organisation (WSO) highlighted the enormous global impact of the COVID-19 pandemic on stroke care. In this review we consider a year later where we are now, what the future holds, and what the long term effects of the pandemic will be on stroke. Stroke occurs in about 1.4% of patients hospitalised with COVID-19 infection, who show an excess of large vessel occlusion and increased mortality. Despite this association, stroke presentations fell dramatically during the pandemic, although emerging data suggests that total stroke mortality may have risen with increased stroke deaths at home and in care homes. Strategies and guidelines have been developed to adapt stroke services worldwide, and protect healthcare workers. Adaptations include increasing use of telemedicine for all aspects of stroke care. The pandemic is exacerbating already marked global inequalities in stroke incidence and mortality. Lastly the pandemic has had a major impact on stroke research and funding, although it has also emphasised the importnace of large scale collaborative research initiatives.

Abstract P287: Delays in the Identification and Assessment of In-Hospital Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Stephanie Cummings ◽  
Andrew Olsen ◽  
Steven Messe
Keyword(s):  
Acute Stroke ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Vascular Imaging ◽  
Care Hospital ◽  
Univariable Analysis ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Stroke Team ◽  
Get With The Guidelines

Introduction: In-hospital stroke is associated with worse outcomes and fewer stroke interventions compared to patients with community-acquired stroke. We assessed factors associated with delays in symptom identification and stroke team alerting, and use of acute interventions for in-hospital strokes. Methods: The local Get With The Guidelines-Stroke and an in-hospital quality improvement database at our tertiary care hospital were screened over a 26-month period ending 10/2019, yielding 98 in-hospital strokes. Results: Strokes were more common on surgery services (70%), were predominantly ischemic (83%), and were moderate-to-severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from the time of last known normal (LKN) until stroke symptom identification (SxID) (median 5.1 hours, IQR 1.0-19.7 hours) and from SxID to stroke alert (median 2.1 hours, IQR 0.5-9.9 hours). In univariable analysis, being in an ICU, being intubated, being on a surgical service, having no lateralized weakness or neglect, and higher NIHSS were associated with delays; in multivariable analysis only intubation was associated with being above median from LKN to SxID (OR 4.3, 95% CI 1.2-16.2, p=0.03) and above median for SxID to stroke alert (OR 8.5, 95% CI 2.0-36.4). Acute stroke interventions were given to 15 patients (15%), including 3 (3%) who received IV tPA and 12 (12%) who underwent IA thrombectomy. Patients who received stroke interventions had shorter times from last normal to SxID (median 0.7 vs 8.2 hours, p=0.002) and times from SxID to stroke alert (median 0.2 vs 3.4 hours, p=0.006). Urgent vascular imaging occurred in 68/98 (69%) of patients and 23/68 (34%) had a large vessel occlusion (LVO). Of those patients with an LVO, 78% had lateralizing arm weakness or neglect on exam. Conclusions: There are long delays from LKN to SxID and from SxID to stroke alert in hospitalized patients leading to low rates of acute stroke treatment. Intubation was a robust risk factor for delays and protocols should be established to monitor these patients more carefully. Despite these delays, 1/3 of patients who had vascular imaging had an LVO identified that might have been eligible for intervention.

scholarly journals Improving Outcomes After Stroke: From Stroke Units to Mobile Stroke Units

Stroke ◽  
2021 ◽  
Author(s):  
Andrei V. Alexandrov ◽  
Yongchai Nilanont
Keyword(s):  
Stroke Care ◽  
Absolute Difference ◽  
Clinical Approach ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Golden Hour ◽  
Systemic Thrombolysis ◽  
Improved Outcomes ◽  
Mobile Stroke Unit ◽  
The Impact

A proactive clinical approach to stroke care improved functional outcomes with implementation of specialized in-hospital stroke units, urgently delivered systemic thrombolysis, mechanical thrombectomy and most recently with mobile stroke units deployed in the field. An 18% absolute difference in outcomes as a shift across all modified Rankin Scale strata at 3 months in the recent Berlin study may not be explained by just 8.8% more patients treated within the golden hour for thrombolytic treatment from symptom onset. These findings parallel the findings in the largest controlled multi-center BEST-MSU trial (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit) to date. A shortcoming in blinding of the investigators to the mode of transportation is similar to blinding to the endovascular treatment in PROBE (Prospective Randomized Open, Blinded End-Point) design used in thrombectomy trials. A faster access to stroke experts and brain imaging in the field for all patients suspect of stroke regardless symptom nature, severity, duration or resolution delivered by mobile stroke units is likely the reason for improved outcomes akin the impact observed in the initial multidisciplinary approach to in-hospital stroke units and reperfusion therapies delivery.

Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions

2017 ◽  
Vol 12 (6) ◽  
pp. 606-614 ◽  
Author(s):  
Simon F De Meyer ◽  
Tommy Andersson ◽  
Blaise Baxter ◽  
Martin Bendszus ◽  
Patrick Brouwer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Consensus Statement ◽  
Current Knowledge ◽  
Imaging Techniques ◽  
Cerebral Arteries ◽  
Clinical Engineering ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Interdisciplinary Approaches

Limited data exist on clot composition and detailed characteristics of arterial thrombi associated with large vessel occlusion in acute ischemic stroke. Advances in endovascular thrombectomy and related imaging modalities have created a unique opportunity to analyze thrombi removed from cerebral arteries. Insights into thrombus composition, etiology, physical properties and neurovascular interactions may lead to future advancements in acute ischemic stroke treatment and improved clinical outcomes. Advances in imaging techniques may enhance clot characterization and inform therapeutic decision-making prior to treatment and reveal stroke etiology to guide secondary prevention. Current imaging techniques can provide some information about thrombi, but there remains much to evaluate about relationships that may exist among thrombus composition, occlusion characteristics and treatment outcomes. Improved pathophysiological characterization of clot types, their properties and how these properties change over time, together with clinical correlates from ongoing studies, may facilitate revascularization with thrombolysis and thrombectomy. Interdisciplinary approaches covering clinical, engineering and scientific aspects of thrombus research will be key to advancing the understanding of thrombi and improving acute ischemic stroke therapy. This consensus statement integrates recent research on clots and thrombi retrieved from cerebral arteries and provides a rationale for further analyses, including current opportunities and limitations.

scholarly journals First Automated Stroke Imaging Evaluation via Electronic Alberta Stroke Program Early CT Score in a Mobile Stroke Unit

2016 ◽  
Vol 42 (5-6) ◽  
pp. 332-338 ◽  
Author(s):  
Iris Quasar Grunwald ◽  
Andreas Ragoschke-Schumm ◽  
Michael Kettner ◽  
Lenka Schwindling ◽  
Safwan Roumia ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Stroke Management ◽  
Imaging Evaluation ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Stroke Imaging ◽  
Mobile Stroke Unit ◽  
Potential Benefits ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Recently, a mobile stroke unit (MSU) was shown to facilitate acute stroke treatment directly at the emergency site. The neuroradiological expertise of the MSU is improved by its ability to detect early ischemic damage via automatic electronic (e) evaluation of CT scans using a novel software program that calculates the electronic Alberta Stroke Program Early CT Score (e-ASPECTS). Methods: The feasibility of integrating e-ASPECTS into an ambulance was examined, and the clinical integration and utility of the software in 15 consecutive cases evaluated. Results: Implementation of e-ASPECTS onto the MSU and into the prehospital stroke management was feasible. The values of e-ASPECTS matched with the results of conventional neuroradiologic analysis by the MSU team. The potential benefits of e-ASPECTS were illustrated by three cases. In case 1, excluding early infarct signs supported the decision to directly perform prehospital thrombolysis. In case 2, in which stroke was caused by large-vessel occlusion, the high e-ASPECTS value supported the decision to initiate intra-arterial treatment and triage the patient to a comprehensive stroke center. In case 3, the e-ASPECTS value was 10, indicating the absence of early infarct signs despite pre-existing cerebral microangiopathy and macroangiopathy, a finding indicating the program's robustness against artefacts. Conclusions: This study on the integration of e-ASPECTS into the prehospital stroke management via a MSU showed for the first time that such integration is feasible, and aids both decision regarding the treatment option and the triage regarding the most appropriate target hospital.

Abstract 1122‐000126: Mobile Stroke Unit Process Metrics in Large Vessel Occlusion Stroke Patients: BEST‐MSU Substudy

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Alexandra L Czap ◽  
Anne W Alexandrov ◽  
May Nour ◽  
Noopur Singh ◽  
Mengxi Wang ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Large Vessel ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Mobile Stroke Unit ◽  
Process Metrics

Introduction : Mobile Stroke Units (MSUs) speed thrombolytic treatment for acute ischemic stroke and improve clinical outcomes compared to standard management by Emergency Medical Services (EMS). However, MSU process metrics in the subset of patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) have yet to be optimized. Methods : A pre‐specified Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU) substudy of tPA‐eligible stroke patients with imaging evident LVOs was conducted. The primary outcome was process metrics related to treatment times from stroke onset and first medical alert. Safety outcomes included rates of symptomatic intracerebral hemorrhage and procedural complications. Groups were compared using Chi‐square or Fisher’s exact tests for categorical variables, and Wilcoxon rank‐sum tests for continuous variables. Results : A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU mean 19.0 [IQR 13.0,23.0] vs EMS 16.0 [11.0, 20.0], p = 0.003). 92% of MSU and 87% of EMS LVO patients received tPA, and 78% and 85% went on to have EVT. Process metrics are detailed in Table 1. MSU LVO patients had faster tPA bolus from 911‐alert (MSU 45.0 minutes [40.0, 53.5] vs EMS 76.0 [64.0, 87.8], p<0.001), however the two groups had similar alert to groin puncture (MSU 142.5 [116.8, 171.0] versus EMS 131.5 [114.0, 159.8], p = 0.15). MSU patients spent more time on‐scene, (EMS arrival to ED arrival, 53.0 [45.0, 62.0] vs 27.0 [22.0, 33.0], p<0.001) however less time prior to EVT (door to groin puncture, 76.5 [54.8, 108.5] vs 94.0 [72.0, 123.0], p<0.001) with variable use of field CTAs and direct cath lab admission with ED bypass, yielding a net neutral result. The variability among site protocols is reflected in the range of median alert to groin puncture times (minimum 107.0 minutes, maximum 152.0). In the 222 patients undergoing EVT, median alert to recanalization time was 181.5 minutes [146.8, 225.5] in the MSU group and 190.5 [157.5, 227.5] in the EMS group (p = 0.47). Recanalization (Thrombolysis In Cerebral Infarction [TICI] 2b/3) was achieved in 76% of MSU and 70% of EMS (p = 0.32) with comparable rates of EVT complications (including hemorrhage, perforation, dissection, hematoma). 54% MSU and 44% of EMS LVO patients achieved good functional outcome (modified Rankin Scale [mRS] ≤ 2) at 90 days (p = 0.11). Conclusions : In tPA‐eligible LVO stroke patients, MSU management did not increase or expedite EVT treatment times as compared to standard EMS management. Future MSU processes should include field CTA with direct admission to cath labs to maximize the early treatment advantage this technology provides.

Abstract WP76: Artificial Intelligence CTA Vessel Density Mapping to Enhance Identification of Large Vessel Occlusions in Mobile Stroke Unit

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kevin Brown ◽  
Bryan Villareal ◽  
Kenneth Harrell ◽  
Mersedeh Bahr Hosseini ◽  
Lucas Restrepo-Jimenez ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Clinical Decision Making ◽  
Vessel Density ◽  
Large Vessel ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Density Mapping ◽  
Mobile Stroke Unit

Background: Equipped with CT scanners capable of imaging the brain parenchyma and vasculature, Mobile Stroke Units (MSU) have the ability to image, diagnose and treat stroke patients in the prehospital setting. Automated CTA vessel density mapping could enhance frontline neurologist scan review in identifying large vessel occlusion (LVO), ensuring appropriate patient diagnosis and routing. Methods: We analyzed consecutive acute ischemic stroke patients undergoing CTA imaging in a regional Mobile Stroke Unit. Automated CTA vessel density mapping was performed in the field immediately after scan completion. CTA source images were wirelessly transferred to an off-site processing server (RAPID.Ai, IschemiaView) for artery reconstruction and color-coded density mapping, with blue, green, yellow, and red color shading indicating vessel density decreases of 70%-85%, 60%-75%, 45%-60%, and <45%. Results: Among all 16 patients, median processing time was 186 secs, and all images were available in time to aid clinical decision-making. Overall, automated processing yielded evaluable images in 94% (suboptimal contrast opacification precluded analysis of 1). Of the 15 diagnostically adequate exams, 100% (15/15) showed concordance for identification of anterior circulation occluded/abnormal vessel territories between automated CTA vessel density mapping and expert physician final CTA interpretation. Cases included true positives in 7, and true negatives in 8. Among true positives, CTA vessel density mapping identified the symptomatic occlusion in 6/6 and also correctly identified a severe cervical ICA stenosis unrelated to the clinical presentation in 1/1. Correctly detected intracranial occlusions included: ICA-17%. M1-17%, M1-M2 junction-17%, and M2-50%. Degree of vessel density diminution correlated with proximal-distal occlusion location. Conclusion: CTA vessel density mapping can feasibly and efficiently be conducted in Mobile Stroke Units and shows high accuracy in detection of large and medium intracranial vessel occlusions. Extension of mapping to the intracranial posterior circulation and algorithmic adjustment for proximal cervical stenoses/occlusions would further improve utility in aiding prehospital routing.

Abstract 21: Can Telemedicine Replace an On-board Vascular Neurologist in Deciding about Tissue Plasminogen Activator Treatment? A Pre-Specified Substudy of the BEST-MSU Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Tzu-Ching Wu ◽  
Stephanie A Parker ◽  
Amanda L Jagolino ◽  
Amy Yu ◽  
Jose-Miguel Yamal ◽  
...  
Keyword(s):  
Treatment Decision ◽  
Stroke Patients ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Standard Management ◽  
Mobile Stroke Unit ◽  
Tissue Plasminogen ◽  
Prehospital Triage ◽  
Remote Assessment ◽  
Technical Failures

Background: Faster treatment with tPA may be achieved by optimizing prehospital triage with mobile stroke units (MSUs). The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study is a prospective comparative effectiveness trial of outcomes in patients randomized to MSU or standard management (SM). Purpose: To evaluate the inter-rater agreement for tPA eligibility between a telemedicine vascular neurologist (TM-VN) and the onboard vascular neurologist (OB-VN) in acute stroke patients seen on the MSU. Methods: Cluster randomization of MSU and SM weeks started on August 18, 2014. On scene, both the TM-VN and OB-VN evaluated the patient and independently documented their tPA treatment decision, NIHSS and CT interpretation. Agreement was determined using Cohen’s kappa (K) statistic. TM related technical failures that impeded remote assessment were recorded. Results: The remote TM-VN evaluated 173 patients. In 4 (2%) cases the TM-VN was not able to make a decision about tPA because of technical difficulties ( 1 case due to TM camera failure and 3 cases due to poor connectivity). The TM-VN agreed with the OB-VN on 88% of evaluations, with a K of 0.73 representing substantial agreement. Baseline NIHSS correlation between the TM-VN and OB-VN was 0.88. Agreement about ICH on CTH was a near-perfect K of 0.97. Conclusions: We conclude from these results that remote VN assessment of stroke patients in the MSU via TM is clinically and technologically feasible, reliable and accurate. TM assessment of CTH and NIHSS was also comparable to the OB evaluation. These findings will allow either OB-VN or TM-VN assessment for the remainder of the study.

scholarly journals EXPRESS: COVID-19 AND STROKE – UNDERSTANDING THE RELATIONSHIP AND ADAPTING SERVICES. A GLOBAL WORLD STROKE ORGANISATION PERSPECTIVE

2021 ◽  
pp. 174749302110053
Author(s):  
Hugh S Markus ◽  
Sheila Martins
Keyword(s):  
Large Scale ◽  
Stroke Care ◽  
Long Term Effects ◽  
Vessel Occlusion ◽  
Stroke Incidence ◽  
Stroke Research ◽  
Incidence And Mortality ◽  
Research Initiatives ◽  
Global World

A year ago the World Stroke Organisation (WSO) highlighted the enormous global impact of the COVID-19 pandemic on stroke care. In this review we consider a year later where we are now, what the future holds, and what the long term effects of the pandemic will be on stroke. Stroke occurs in about 1.4% of patients hospitalised with COVID-19 infection, who show an excess of large vessel occlusion and increased mortality. Despite this association, stroke presentations fell dramatically during the pandemic, although emerging data suggests that total stroke mortality may have risen with increased stroke deaths at home and in care homes. Strategies and guidelines have been developed to adapt stroke services worldwide, and protect healthcare workers. Adaptations include increasing use of telemedicine for all aspects of stroke care. The pandemic is exacerbating already marked global inequalities in stroke incidence and mortality. Lastly the pandemic has had a major impact on stroke research and funding, although it has also emphasised the importnace of large scale collaborative research initiatives.

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