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

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.

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

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000126 ◽

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.

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Review of the Mobile Stroke Unit Experience Worldwide

Interventional Neurology ◽

10.1159/000487334 ◽

2018 ◽

Vol 7 (6) ◽

pp. 347-358 ◽

Cited By ~ 23

Author(s):

Victoria J. Calderon ◽

Brittany M. Kasturiarachi ◽

Eugene Lin ◽

Vibhav Bansal ◽

Osama O. Zaidat

Keyword(s):

Stroke Unit ◽

Time Window ◽

Economic Cost ◽

Current Status ◽

Utilization Rate ◽

Stroke Management ◽

Treatment Benefit ◽

Stroke Treatment ◽

Neurological Emergencies ◽

Mobile Stroke Unit

Background: The treatment of stroke is dependent on a narrow therapeutic time window that requires interventions to be emergently pursued. Despite recent “FAST” initiatives that have underscored “time is brain,” many patients still fail to present within the narrow time window to receive maximum treatment benefit from advanced stroke therapies, including recombinant tissue plasminogen activator (tPA) and mechanical thrombectomy. The convergence of emergency medical services, telemedicine, and mobile technology, including transportable computed tomography scanners, has presented a unique opportunity to advance patient stroke care in the prehospital field by shortening time to hyperacute stroke treatment with a mobile stroke unit (MSU). Summary: In this review, we provide a look at the evolution of the MSU into its current status as well as future directions. Our summary statement includes historical and implementation information, economic cost, and published clinical outcome and time metrics, including the utilization rate of thrombolysis. Key Messages: Initially hypothesized in 2003, the first MSUs were launched in Germany and adopted worldwide in acute, prehospital stroke management. These specialized ambulances have made the diagnosis and treatment of many neurological emergencies, in addition to ischemic and hemorrhagic stroke, possible at the emergency site. Providing treatment as early as possible, including within the prehospital phase of stroke management, improves patient outcomes. As MSUs continue to collect data and improve their methods, shortened time metrics are expected, resulting in more patients who will benefit from faster treatment of their acute neurological emergencies in the prehospital field.

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Impact of mobile stroke units

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2020-324005 ◽

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.

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Value of repeated imaging in patients with a stroke who are transferred for endovascular treatment

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017050 ◽

2021 ◽

pp. neurintsurg-2020-017050

Author(s):

Laura C C van Meenen ◽

Nerea Arrarte Terreros ◽

Adrien E Groot ◽

Manon Kappelhof ◽

Ludo F M Beenen ◽

...

Keyword(s):

Endovascular Treatment ◽

Clinical Improvement ◽

Treatment Delay ◽

Clinical Deterioration ◽

Large Vessel Occlusion ◽

Intracranial Hemorrhages ◽

Vessel Occlusion ◽

Quality Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

BackgroundPatients with a stroke who are transferred to a comprehensive stroke center for endovascular treatment (EVT) often undergo repeated neuroimaging prior to EVT.ObjectiveTo evaluate the yield of repeating imaging and its effect on treatment times.MethodsWe included adult patients with a large vessel occlusion (LVO) stroke who were referred to our hospital for EVT by primary stroke centers (2016–2019). We excluded patients who underwent repeated imaging because primary imaging was unavailable, incomplete, or of insufficient quality. Outcomes included treatment times and repeated imaging findings.ResultsOf 677 transferred LVO stroke, 551 were included. Imaging was repeated in 165/551 patients (30%), mostly because of clinical improvement (86/165 (52%)) or deterioration (40/165 (24%)). Patients who underwent repeated imaging had higher door-to-groin-times than patients without repeated imaging (median 43 vs 27 min, adjusted time difference: 20 min, 95% CI 15 to 25). Among patients who underwent repeated imaging because of clinical improvement, the LVO had resolved in 50/86 (58%). In patients with clinical deterioration, repeated imaging led to refrainment from EVT in 3/40 (8%). No symptomatic intracranial hemorrhages (sICH) were identified. Ultimately, 75/165 (45%) of patients with repeated imaging underwent EVT compared with 326/386 (84%) of patients without repeated imaging (p<0.01).ConclusionsNeuroimaging was repeated in 30% of patients with an LVO stroke and resulted in a median treatment delay of 20 minutes. In patients with clinical deterioration, no sICH were detected and repeated imaging rarely changed the indication for EVT. However, in more than half of patients with clinical improvement, the LVO had resolved, resulting in refrainment from EVT.

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Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

Acta Radiologica ◽

10.1177/02841851211006897 ◽

2021 ◽

pp. 028418512110068

Author(s):

Yu Hang ◽

Zhen Yu Jia ◽

Lin Bo Zhao ◽

Yue Zhou Cao ◽

Huang Huang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Secondary Endpoints ◽

Comprehensive Stroke Center ◽

Stroke Center

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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Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017365 ◽

2021 ◽

pp. neurintsurg-2021-017365

Author(s):

Mais Al-Kawaz ◽

Christopher Primiani ◽

Victor Urrutia ◽

Ferdinand Hui

Keyword(s):

Mobile Application ◽

Secondary Analysis ◽

Multiple Linear Regression Model ◽

Stroke Care ◽

Mobile App ◽

Large Vessel ◽

Vessel Occlusion ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

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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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Abstract P833: Standardized Protocols Reduce Response Times for LVO Strokes

Stroke ◽

10.1161/str.52.suppl_1.p833 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Vanesa K Vanderhye ◽

Lynda Christel ◽

Ali Turkmani ◽

Kara A Sands

Keyword(s):

Response Times ◽

Vessel Occlusion ◽

Early Reperfusion ◽

Notification System ◽

Stroke Treatment ◽

Phone Calls ◽

Data Points ◽

Stroke Center ◽

High Level ◽

Cerebral Reperfusion

Introduction: Acute ischemic stroke treatment is time sensitive especially for large vessel occlusion (LVO) strokes with the goal to achieve early cerebral reperfusion. Research suggests standardized protocols incorporate early notification to reduce time from arrival to mechanical thrombectomy (MT). The MT workflow at a certified stroke center required multiple phone calls to mobilize staff and resources resulting in treatment delays. The average time from neurosurgery notification (NN) to case start (CST) was 60.4 minutes (min) resulting in average door-to-puncture (DTP) time of 124.8 min further delaying early reperfusion. Purpose: Standardize MT workflows and incorporate a 1-step notification system to reduce average NN to CST by 20% to 45 min to achieve 90 min average DTP time by 90 days post implementation. Methods: Baseline data for MT cases admitted 1/1/18 - 9/2/19 arriving in the emergency room (ER) and occurring inpatient were abstracted from stroke alert logs and the electronic health record. MT transfers were excluded. A multidisciplinary group of key stakeholders completed both high level process and workflow analysis maps and mock simulations to identify gaps. Both an analysis of variance and Tukey-Kramer’s T Test were performed revealing NN to CST was most statistically significant (p<.0001) and largest root cause for overall increased DTP times. New service-specific workflows were developed including 1-step notification activated via an existing group paging system used for other purposes. Activation notified on call staff of the MT case and patient location. Data points collected were NN to CST (ED and inpatient) and DTP (ED only). Results: Average NN to CST time was 26.7 min (33.3 min decrease or 55.1%; p<.0001, n=12) resulting in DTP average of 83.4 min (41.4 min decrease or 35.3%, n=10) 90 days post-implementation. The paging system was cost-neutral due to existing licensing agreements. Conclusion: In conclusion, streamlined workflows incorporating 1-step notification reduced time from notification to staff response so MT procedures could start sooner. A multidisciplinary approach along with key stakeholder buy-in was instrumental in successful project implementation.

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Abstract WP339: Validation of the Fast-ed Scale Use by Paramedics in a Mobile Stroke Unit

Stroke ◽

10.1161/str.51.suppl_1.wp339 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Diogo C Haussen ◽

Raul G Nogueira ◽

Nirav Bhatt ◽

Carol Flemming ◽

Nicolas Bianchi ◽

...

Keyword(s):

Stroke Unit ◽

Hospital Setting ◽

Final Diagnosis ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Hospital Arrival ◽

Mobile Stroke Unit ◽

Standard Operating ◽

Intravenous Alteplase ◽

Cerebrovascular Imaging

Introduction: FAST-ED scale is a helpful tool to triage stroke patients in the field. However, data on the accuracy of the scale in the pre-hospital setting is lacking. We aim to validate the use of FAST-ED by paramedics in a mobile stroke unit (MSU) covering a metropolis. Methods: As part of standard operating MSU procedures, paramedics clinically evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic (in-person) upon patient contact, and independently by a vascular neurologist (telemedicine) immediately after the paramedic evaluation. An MSU nurse determined the NIHSS. This will allow testing of the inter-rater agreement of the FAST-ED scoring performance between on-site pre-hospital providers and remotely located vascular neurologists. Results: In the first 13 months of the MSU’s activity 193 stroke-alert patients were evaluated. 103 (53%) patients had a final diagnosis of stroke/TIA (75/28, respectively), 21 (11%) intracranial hemorrhage, and 69 (36%) were considered stroke mimics. 28 (14%) patients received intravenous alteplase. In the first 48 patients, FAST-ED was only scored by the paramedic and in 145 patients by both the physician and paramedic. FAST-ED scores matched perfectly amongst paramedics and physicians in 77 (53%) instances, while there was only 1-point difference in 51 (35%), 2-point difference in 10 (6%) and 3-point difference in two. Correlation between physician and paramedic FAST-ED scores was highly positive (rho 0.898; 2-sided p<0.001), as well as the correlation between physicians FAST-ED score and NIHSS (rho 0.853; 2-sided p<0.001). When the physician recorded FAST-ED score≥3 (n=62), the paramedics also scored FAST-ED≥3 in the vast majority of instances (n=55; 89%). After hospital arrival, cerebrovascular imaging was deemed necessary and performed in 144 patients within 24 hours of arrival. A visible large vessel occlusion was identified in 30 patients; 18 occlusions were identified with a FAST-ED≥3 while 12 were missed (10/12 had NIHSS≤5). Conclusion: The correlation of the FAST-ED scoring between vascular neurologists and paramedics was highly positive, indicating that FAST-ED is accurately and reliably utilized by paramedics in the pre-hospital setting.

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