Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy

BackgroundThe number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes.ObjectiveOur mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes.ResultsOver 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable.ConclusionsMobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.

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Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital

Frontiers in Neurology ◽

10.3389/fneur.2021.655434 ◽

2021 ◽

Vol 12 ◽

Author(s):

Piotr Sobolewski ◽

Wiktor Szczuchniak ◽

Danuta Grzesiak-Witek ◽

Jacek Wilczyński ◽

Karol Paciura ◽

...

Keyword(s):

Retrospective Study ◽

Stroke Unit ◽

Community Hospital ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Staff Members ◽

Second Wave

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area.Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 (“first wave”), and between September 15 and November 30, 2020 (“second wave”). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19.Results: During the “first wave,” 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the “second wave” were infected with SARS-CoV-2 (p < 0.001). During the “second wave,” more SU staff members were infected with COVID-19 than during the “first wave” (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60–47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04–34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed.Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the “second wave” of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

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Economic evaluation of the Melbourne Mobile Stroke Unit

International Journal of Stroke ◽

10.1177/1747493020929944 ◽

2020 ◽

pp. 174749302092994 ◽

Cited By ~ 1

Author(s):

Joosup Kim ◽

Damien Easton ◽

Henry Zhao ◽

Skye Coote ◽

Garveeta Sookram ◽

...

Keyword(s):

Stroke Unit ◽

Standard Care ◽

Stroke Care ◽

Reperfusion Therapy ◽

Sensitivity Analyses ◽

Local Data ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Mobile Stroke Unit ◽

Life Years

Background The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy. Aims To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care). Methods The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses. Results In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care. Conclusions There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.

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Diagnosis and management of acute ischaemic stroke

Practical Neurology ◽

10.1136/practneurol-2020-002557 ◽

2020 ◽

Vol 20 (4) ◽

pp. 304-316 ◽

Cited By ~ 1

Author(s):

Robert Hurford ◽

Alakendu Sekhar ◽

Tom A T Hughes ◽

Keith W Muir

Keyword(s):

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Neuronal Damage ◽

Early Recognition ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Close Monitoring ◽

Endovascular Thrombectomy ◽

Early Neurological Deterioration ◽

Ischaemic Penumbra

Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.

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Mobile Stroke Units: Current and Future Impact on Stroke Care

Seminars in Neurology ◽

10.1055/s-0040-1722724 ◽

2021 ◽

Vol 41 (01) ◽

pp. 009-015

Author(s):

Ritvij Bowry ◽

James C. Grotta

Keyword(s):

Ischemic Stroke ◽

Clinical Outcomes ◽

Stroke Care ◽

The United States ◽

Hospital Treatment ◽

Additional Time ◽

Stroke Units ◽

Require Time ◽

Intravenous Tissue Plasminogen Activator ◽

Telemedicine Technology

AbstractIschemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.

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Delayed Intravenous Thrombolysis in Patients with Minor Stroke

Cerebrovascular Diseases ◽

10.1159/000492123 ◽

2018 ◽

Vol 46 (1-2) ◽

pp. 52-58 ◽

Cited By ~ 4

Author(s):

Joonsang Yoo ◽

Sung-Il Sohn ◽

Jinkwon Kim ◽

Seong Hwan Ahn ◽

Kijeong Lee ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Stroke Care ◽

Minor Stroke ◽

Acute Stroke Care ◽

Nihss Score ◽

Delayed Treatment ◽

Intravenous Tissue Plasminogen Activator ◽

Stroke Group ◽

Suspected Stroke ◽

Iv Tpa

Background: The actions and responses of the hospital personnel during acute stroke care in the emergency department (ED) may differ according to the severity of a patient’s stroke symptoms. We investigated whether the time from arrival at ED to various care steps differed between patients with minor and non-minor stroke who were treated with intravenous tissue plasminogen activator (IV tPA). Methods: We included consecutive patients who received IV tPA during a 1.5 year-period in 5 hospitals. Minor stroke was defined as a National Institutes of Health Stroke Scale (NIHSS) score < 5. We compared various intervals from arrival at the ED to treatment between patients with minor stroke and those with non-minor stroke (NIHSS score ≥5). Delayed treatment was defined as a door-to-needle time > 40 min. Results: During the study period, 356 patients received IV tPA treatment. The median door-to-needle time was significantly longer in the minor stroke group than it was in the non-minor stroke group (43 min [interquartile range [IQR] 35.5–55.5] vs. 37 min [IQR 30–46], p < 0.001). The minor stroke group had a significantly longer door-to-notification time (7 min [IQR 4.5–12] vs. 5 min [IQR 3–8], p < 0.001) and door-to-imaging time (20 min [IQR 15–26.5] vs. 16 min [IQR 11–21], p < 0.001) than did the non-minor stroke group. However, the imaging-to-needle time was not different between the groups. Multivariable analyses revealed that minor stroke was associated with delayed treatment (OR 2.54 [95% CI 1.52–4.30], p = 0.001). Conclusions: Our findings show that the door-to-needle time was longer in patients with minor stroke than it was in those with non-minor stroke, mainly owing to delayed action in the initial steps of neurology notification and imaging. Our findings suggest that some quality improvement initiatives are necessary for patients with suspected stroke with minor symptoms.

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Low stroke incidence in the TEMPiS telestroke network during COVID-19 pandemic – effect of lockdown on thrombolysis and thrombectomy

Journal of Telemedicine and Telecare ◽

10.1177/1357633x20943327 ◽

2020 ◽

pp. 1357633X2094332 ◽

Cited By ~ 2

Author(s):

Felix Schlachetzki ◽

Carmen Theek ◽

Nikolai D Hubert ◽

Mustafa Kilic ◽

Roman L Haberl ◽

...

Keyword(s):

Rebound Effect ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Population Mobility ◽

Stroke Patients ◽

Stroke Incidence ◽

Endovascular Thrombectomy ◽

Exact Test ◽

Mobility Data ◽

Ap Value

Background During the COVID-19 pandemic emergency departments have noted a significant decrease in stroke patients. We performed a timely analysis of the Bavarian telestroke TEMPiS “working diagnosis” database. Methods Twelve hospitals from the TEMPiS network were selected. Data collected for January through April in years 2017 through 2020 were extracted and analyzed for presumed and definite ischemic stroke (IS), amongst other disorders. In addition, recommendations for intravenous thrombolysis (rtPA) and endovascular thrombectomy (EVT) were noted and mobility data of the region analyzed. If statistically valid, group-comparison was tested with Fisher’s exact test considering unpaired observations and ap-value < 0.05 was considered significant. Results Upon lockdown in mid-March 2020, we observed a significant reduction in recommendations for rtPA compared to the preceding three years (14.7% [2017–2019] vs. 9.2% [2020], p = 0.0232). Recommendations for EVT were significantly higher in January to mid-March 2020 compared to 2017–2019 (5.4% [2017–2019] vs. 9.3% [2020], p = 0.0013) reflecting its increasing importance. Following the COVID-19 lockdown mid-March 2020 the number of EVT decreased back to levels in 2017–2019 (7.4% [2017–2019] vs. 7.6% [2020], p = 0.1719). Absolute numbers of IS decreased in parallel to mobility data. Conclusions The reduced stroke incidence during the COVID-19 pandemic may in part be explained by patient avoidance to seek emergency stroke care and may have an association to population mobility. Increasing mobility may induce a rebound effect and may conflict with a potential second COVID-19 wave. Telemedical networks may be ideal databases to study such effects in near-real time.

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Bringing Emergency Neurology to Ambulances: Mobile Stroke Unit

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0037-1607994 ◽

2017 ◽

Vol 38 (06) ◽

pp. 713-717 ◽

Cited By ~ 5

Author(s):

Ritvij Bowry ◽

James Grotta

Keyword(s):

Clinical Outcomes ◽

Stroke Unit ◽

Mechanical Thrombectomy ◽

Cost Effective ◽

The United States ◽

Conclusive Evidence ◽

Golden Hour ◽

Intravenous Tissue Plasminogen Activator ◽

Mobile Stroke Unit ◽

Emergency Neurology

AbstractIschemic stroke results from blocked arteries in the brain, with earlier thrombolysis with intravenous tissue plasminogen activator (tPA) and/or mechanical thrombectomy resulting in improved clinical outcomes. Mobile Stroke Unit (MSU) can speed up the treatment with tPA and facilitate faster triage for patients to hospitals for mechanical thrombectomy. The first registry-based MSU study in Germany demonstrated faster treatment times with tPA using a MSU, a higher proportion of patients being treated within the first “golden hour,” and a suggestion of improved 3-month clinical outcomes. The first multicenter, prospective, randomized clinical trial comparing MSU versus standard care was started in 2014 after the launch of the MSU in Houston, TX, demonstrating the feasibility and safety of MSU operation in the United States, and reliability of telemedicine to evaluate stroke patients for tPA eligibility. Although conclusive evidence from clinical trials to support MSUs as being cost effective and improving clinical outcomes is still needed, there are a myriad of other clinical and research applications of MSUs that could have profound implications for managing patients with neurological emergencies.

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Estimation of Stroke Outcomes Based on Time to Thrombolysis and Thrombectomy

10.20944/preprints202007.0444.v1 ◽

2020 ◽

Author(s):

Michael Allen ◽

Kerry Pearn ◽

Ken Stein ◽

Martin James

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Outcomes ◽

Revascularization Therapy ◽

Method Model

Background & Motivation: Stroke outcomes following revascularization therapy (intravenous thrombolysis, IVT, and/or mechanical thrombectomy, MT) depend critically on time from stroke onset to treatment. Different service configurations may prioritise time to IVT or time to MT. In order to evaluate alternative acute stroke care configurations, it is necessary to estimate clinical outcomes given differing times to IVT and MT. Method: Model using an algorithm coded in Python. This is available at https://github.com/MichaelAllen1966/stroke_outcome_algorithm. Results: We demonstrate how the code may be used to estimate clinical outcomes given varying times to IVT and MT. Conclusion: Python code has been developed and shared to enable estimation of clinical outcome given times to IVT and MT. Here we share pseudocode and links to full Python code.

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Estimation of stroke outcomes based on time to thrombolysis and thrombectomy

10.1101/2020.07.18.20156653 ◽

2020 ◽

Author(s):

Michael Allen ◽

Kerry Pearn ◽

Ken Stein ◽

Martin James

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Outcomes ◽

Revascularization Therapy ◽

Method Model

Background & Motivation: Stroke outcomes following revascularization therapy (intravenous thrombolysis, IVT, and/or mechanical thrombectomy, MT) depend critically on time from stroke onset to treatment. Different service configurations may prioritise time to IVT or time to MT. In order to evaluate alternative acute stroke care configurations, it is necessary to estimate clinical outcomes given differing times to IVT and MT. Method: Model using an algorithm coded in Python. This is available at https://github.com/MichaelAllen1966/stroke_outcome_algorithm Results: We demonstrate how the code may be used to estimate clinical outcomes given varying times to IVT and MT. Conclusion: Python code has been developed and shared to enable estimation of clinical outcome given times to IVT and MT. Here we share pseudocode and links to full Python code.

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Pathway Design for Acute Stroke Care in the Era of Endovascular Thrombectomy

Stroke ◽

10.1161/strokeaha.120.030392 ◽

2020 ◽

Vol 51 (11) ◽

pp. 3452-3460 ◽

Cited By ~ 1

Author(s):

Willemijn J. Maas ◽

Maarten M.H. Lahr ◽

Erik Buskens ◽

Durk-Jouke van der Zee ◽

Maarten Uyttenboogaart ◽

...

Keyword(s):

Acute Stroke ◽

Intravenous Thrombolysis ◽

Patient Characteristics ◽

Stroke Care ◽

Organizational Models ◽

Acute Stroke Care ◽

Endovascular Thrombectomy ◽

Regular Treatment ◽

Model Based ◽

Comprehensive Stroke Center

The efficacy of intravenous thrombolysis and endovascular thrombectomy (EVT) for acute ischemic stroke is highly time dependent. Optimal organization of acute stroke care is therefore important to reduce treatment delays but has become more complex after the introduction of EVT as regular treatment for large vessel occlusions. There is no singular optimal organizational model that can be generalized to different geographic regions worldwide. Current dominant organizational models for EVT include the drip-and-ship- and mothership model. Guidelines recommend routing of suspected patients with stroke to the nearest intravenous thrombolysis capable facility; however, the choice of routing to a certain model should depend on regional stroke service organization and individual patient characteristics. In general, design approaches for organizing stroke care are required, in which 2 key strategies could be considered. The first entails the identification of interventions within existing organizational models for optimizing timely delivery of intravenous thrombolysis and/or EVT. This includes adaptive patient routing toward a comprehensive stroke center, which focuses particularly on prehospital triage tools; bringing intravenous thrombolysis or EVT to the location of the patient; and expediting services and processes along the stroke pathway. The second strategy is to develop analytical or simulation model-based approaches enabling the design and evaluation of organizational models before their implementation. Organizational models for acute stroke care need to take regional and patient characteristics into account and can most efficiently be assessed and optimized through the application of model-based approaches.

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