Prehospital Computed Tomography Angiography in Acute Stroke Management

2017 ◽  
Vol 44 (5-6) ◽  
pp. 338-343 ◽  
Author(s):  
Michael Kettner ◽  
Stefan Alexander Helwig ◽  
Andreas Ragoschke-Schumm ◽  
Lenka Schwindling ◽  
Safwan Roumia ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Point Of Care ◽  
Vascular Pathology ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Spot Sign ◽  
Specialized Treatment ◽  
Mobile Stroke Unit ◽  
Prehospital Management

Background: An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. Methods: Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. Results: Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. Conclusion: Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.

scholarly journals Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1613-1615 ◽  
Author(s):  
Alexandra L. Czap ◽  
Noopur Singh ◽  
Ritvij Bowry ◽  
Amanda Jagolino-Cole ◽  
Stephanie A. Parker ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computed Tomography Angiography ◽  
Stroke Unit ◽  
Interquartile Range ◽  
National Institutes Of Health ◽  
Unique Identifier ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Unit Management ◽  
Mobile Stroke Unit

Background and Purpose— Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods— We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results— Median DTPT was 53.5 (95% CI, 35–67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0–63.5) versus 94.5 minutes (interquartile range, 69.8–117.3; P <0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8–35.5) versus 27.0 minutes (interquartile range, 23.0–31.0) ( P <0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=−0.2, P =0.07). Conclusions— Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration— URL: https://clinicaltrials.gov ; Unique identifier: NCT02190500.

scholarly journals Prehospital Stroke Triage

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S25-S33
Author(s):  
Anna Ramos ◽  
Waldo R. Guerrero ◽  
Natalia Pérez de la Ossa
Keyword(s):  
Acute Stroke ◽  
Randomized Clinical Trials ◽  
Vessel Occlusion ◽  
Novel Technologies ◽  
Maximum Benefit ◽  
Prehospital Management ◽  
Prehospital Triage ◽  
Clinical Tools ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit

2018 ◽  
Vol 14 (3) ◽  
pp. 265-269 ◽  
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Lauren Pesavento ◽  
Brett Jones ◽  
Edrich Rodrigues ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Intravenous Thrombolysis ◽  
Inpatient Rehabilitation ◽  
Reperfusion Therapy ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Prehospital Treatment ◽  
Mobile Stroke Unit ◽  
Stroke Team

Background Administration of intravenous idarucizumab to reverse dabigatran anticoagulation prior to thrombolysis for patients with acute ischemic stroke has been previously described, but not in the prehospital setting. The speed and predictability of idarucizumab reversal is well suited to prehospital treatment in a mobile stroke unit and allows patients with recent dabigatran intake to access reperfusion therapy. Aims To describe feasibility of prehospital idarucizumab administration prior to thrombolysis on the Melbourne mobile stroke unit. Methods The Melbourne mobile stroke unit is a specialized stroke ambulance servicing central metropolitan Melbourne, Australia and provides prehospital assessment, scanning and treatment with an integrated CT scanner and multidisciplinary stroke team. All cases were identified through the mobile stroke unit treatment registry since launch in November 2017. Results Of a total of n = 20 thrombolysis cases in the first 4 months of operation, three patients (15%) received intravenous idarucizumab 5 g for dabigatran reversal prior to thrombolysis. Mean time between idarucizumab administration and thrombolysis was approximately 10 minutes. Two of the three patients were shown to have large vessel occlusion on CTA in the mobile stroke unit and proceeded to endovascular thrombectomy. At 24 hours, only one patient had a small amount of asymptomatic petechial hemorrhage on follow-up imaging. All patients demonstrated substantial neurological recovery and were discharged to inpatient rehabilitation. Conclusions Rapid treatment with prehospital administration of idarucizumab prior to thrombolysis using a mobile stroke unit is feasible and facilitates hyperacute treatment.

scholarly journals Direct Transfer to Angio-Suite Versus Computed Tomography–Transit in Patients Receiving Mechanical Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (9) ◽  
pp. 2630-2638 ◽  
Author(s):  
Johannes A.R. Pfaff ◽  
Silvia Schönenberger ◽  
Christian Herweh ◽  
Christian Ulfert ◽  
Simon Nagel ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Hospital Admission ◽  
Mechanical Thrombectomy ◽  
Controlled Trial ◽  
Direct Transfer ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Time Saving ◽  
End Point ◽  
Stroke Imaging

Background and Purpose: To quantify workflow metrics in patients receiving stroke imaging (noncontrast-enhanced computed tomography [CT] and CT-angiography) in either a computed-tomography scanner suite (CT-Transit [CTT]) or an angio-suite (direct transfer to angio-suite—[DTAS]—using flat-panel CT) before undergoing mechanical thrombectomy. Methods: Prospective, single-center investigator initiated randomized controlled trial in a comprehensive stroke center focusing on time from imaging to groin puncture (primary end point) and time from hospital admission to final angiographic result (secondary end point) in patients receiving mechanical thrombectomy for anterior circulation large vessel occlusion after randomization to the CTT or DTAS pathway. Results: The trial was stopped early after the enrollment of n=60 patients (CTT: n=34/60 [56.7 %]; DTAS: n=26/60 [43.3%]) of n=110 planned patients because of a preplanned interim analysis. Time from imaging to groin puncture was shorter in DTAS-patients (in minutes, median [interquartile range]: CTT: 26 [23–32]; DTAS: 19 [15–23]; P value: 0.001). Time from hospital admission to stroke imaging was longer in patients randomized to DTAS (in minutes, mean [SD]: CTT: 12 [13]; DTAS: 21 [14], P value: 0.007). Time from hospital admission to final angiographic reperfusion was comparable between patient groups (CTT: 78 [58–92], DTAS: 80 [66–118]; P value: 0.067). Conclusions: This trial showed a reduction in time from imaging to groin-puncture when patients are transferred directly to the angiosuite for advanced stroke-imaging compared with imaging in a CT scanner suite. This time saving was outweighed by a longer admission to imaging time and could not translate into a shorter time to final angiographic reperfusion in this trial.

scholarly journals Risk Assessment of the Door‐In‐Door‐Out Process at Primary Stroke Centers for Patients With Acute Stroke Requiring Transfer to Comprehensive Stroke Centers

2021 ◽  
Vol 10 (18) ◽  
Author(s):  
Jane L. Holl ◽  
Rebeca Khorzad ◽  
Rebecca Zobel ◽  
Amy Barnard ◽  
Maureen Hillman ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Risk Assessment ◽  
Acute Stroke ◽  
Failure Modes ◽  
Learning Collaborative ◽  
Vessel Occlusion ◽  
Solution Design ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Criticality Analysis

Background Patients with acute stroke at non‐ or primary stroke centers (PSCs) are transferred to comprehensive stroke centers for advanced treatments that reduce disability but experience significant delays in treatment and increased adjusted mortality. This study reports the results of a proactive, systematic, risk assessment of the door‐in‐door‐out process and its application to solution design. Methods and Results A learning collaborative (clinicians, patients, and caregivers) at 2 PSCs and 3 comprehensive stroke centers in Chicago, Illinois participated in a failure modes, effects, and criticality analysis to identify steps in the process; failures of each step, underlying causes; and to characterize each failure’s frequency, impact, and safeguards using standardized scores to calculate risk priority and criticality numbers for ranking. Targets for solution design were selected among the highest‐ranked failures. The failure modes, effects, and criticality analysis process map and risk table were completed during in‐person and virtual sessions. Failure to detect severe stroke/large‐vessel occlusion on arrival at the PSC is the highest‐ranked failure and can lead to a 45‐minute door‐in‐door‐out delay caused by failure to obtain a head computed tomography and computed tomography angiogram together. Lower risk failures include communication problems and delays within the PSC team and across the PSC comprehensive stroke center and paramedic teams. Seven solution prototypes were iteratively designed and address 4 of the 10 highest‐ranked failures. Conclusions The failure modes, effects, and criticality analysis identified and characterized previously unrecognized failures of the door‐in‐door‐out process. Use of a risk‐informed approach for solution design is novel for stroke and should mitigate or eliminate the failures.

Abstract WMP62: Achieving Ultra-Fast Door-to-Needle Times With a “Treat-in-CT” Acute Stroke Protocol

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Andria L Ford ◽  
Jennifer A Williams ◽  
Brian Hoff ◽  
David Curfman ◽  
Rebecca Wiesehan ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Lean Manufacturing ◽  
Treatment Time ◽  
Point Of Care ◽  
Patient Flow ◽  
Vital Signs ◽  
Ct Scanner ◽  
Rapid Improvement ◽  
Ct Protocol ◽  
Before And After

Background: Ultra-early thrombolysis [onset-to-treatment time (OTT) < 90 min], leads to better clinical outcomes. We utilized lean manufacturing principles to re-choreograph patient flow such that tPA was delivered in the CT scanner rather than moving the patient to a separate treatment room. We tested the efficiency and safety of a “Treat-in-CT” protocol comparing metrics and outcomes before and after implementation. Methods: In July 2014, a LEAN rapid improvement event was conducted to design a “Treat-in-CT” stroke protocol. Several changes included: (1) Vital signs monitors and point of care glucose and INR were placed near the scanner. (2) Computer monitors were placed in the scanner to allow for rapid charting and order entry. (3) Local EMS crews, physicians, nursing staff, and CT technicians were trained on parallel work-flow in the scanner. The “Treat-in-CT” protocol went live 10/1/2014. We directly compared the “Pre” and “Post” Treat-in-CT epochs (1/2013-9/2014 and 10/2014-8/2015, respectively) with regard to baseline variables, metrics, and outcomes. Non-parametric statistics were used with p<0.05 required for significance. Results: In the Pre- and Post-Treat-in-CT epochs, 139 and 74 patients were treated with IV tPA, respectively. Baseline variables were similar between the two epochs. Median door-to-needle time was lower in the Post-Treat-in-CT epoch: 38 min pre vs. 29 min post (p=0.002) with a trend towards lower OTT: 131 min pre vs. 100 min post (p=0.07). To ensure that efficiency did not impact safety, favorable discharge location (87% pre vs. 81% post, p=0.3), symptomatic hemorrhage rate (2.9% pre vs. 1.5% post, p=1.0), stroke mimic rate, and 90 day mRS were compared and did not differ. Conclusions: The AHA Target: Stroke-Phase II guidelines recommend administration of tPA bolus while in the CT scanner. A “Treat-in-CT” acute stroke protocol using efficient choreography and parallel processing expedited tPA delivery without compromising safety.

scholarly journals Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography

Stroke ◽  
2020 ◽  
Vol 51 (10) ◽  
pp. 3133-3137
Author(s):  
Marta Olive-Gadea ◽  
Carlos Crespo ◽  
Cristina Granes ◽  
Maria Hernandez-Perez ◽  
Natalia Pérez de la Ossa ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Deep Learning ◽  
Positive Predictive Value ◽  
Acute Stroke ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Learning Algorithm ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Noncontrast Computed Tomography

Background and Purpose: Reliable recognition of large vessel occlusion (LVO) on noncontrast computed tomography (NCCT) may accelerate identification of endovascular treatment candidates. We aim to validate a machine learning algorithm (MethinksLVO) to identify LVO on NCCT. Methods: Patients with suspected acute stroke who underwent NCCT and computed tomography angiography (CTA) were included. Software detection of LVO (MethinksLVO) on NCCT was tested against the CTA readings of 2 experienced radiologists (NR-CTA). We used a deep learning algorithm to identify clot signs on NCCT. The software image output trained a binary classifier to determine LVO on NCCT. We studied software accuracy when adding National Institutes of Health Stroke Scale and time from onset to the model (MethinksLVO+). Results: From 1453 patients, 823 (57%) had LVO by NR-CTA. The area under the curve for the identification of LVO with MethinksLVO was 0.87 (sensitivity: 83%, specificity: 71%, positive predictive value: 79%, negative predictive value: 76%) and improved to 0.91 with MethinksLVO+ (sensitivity: 83%, specificity: 85%, positive predictive value: 88%, negative predictive value: 79%). Conclusions: In patients with suspected acute stroke, MethinksLVO software can rapidly and reliably predict LVO. MethinksLVO could reduce the need to perform CTA, generate alarms, and increase the efficiency of patient transfers in stroke networks.

scholarly journals Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke

2021 ◽  
pp. neurintsurg-2021-017863
Author(s):  
Hayato Araki ◽  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Kaoru Kurisu ◽  
Nobuaki Shime ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Success Rate ◽  
Preparation Time ◽  
Transport Time ◽  
Multicenter Cohort Study ◽  
Vessel Occlusion ◽  
Multicenter Cohort ◽  
Prehospital Management ◽  
Suspected Stroke ◽  
Time Of Intervention

BackgroundPrehospital stroke triage scales help with the decision to transport patients with suspected stroke to suitable hospitals.ObjectiveTo explore the effect of the region-wide use of the Japan Urgent Stroke Triage (JUST) score, which can predict several types of stroke: large vessel occlusion (LVO), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral infarction other than LVO (CI).MethodsWe implemented the JUST score and conducted a retrospective and prospective multicenter cohort study at 13 centers in Hiroshima from April 1, 2018, to March 31, 2020. We investigated the success rate of the first request to the hospital, on-scene time, and transport time to hospital. We evaluated the door-to-puncture time, puncture-to-reperfusion time, and 90-day outcome among patients with final diagnoses of LVO.ResultsThe cohort included 5141 patients (2735 before and 2406 after JUST score implementation). Before JUST score implementation, 1269 strokes (46.4%) occurred, including 140 LVO (5.1%), 394 ICH (14.4%), 120 SAH (4.4%), and 615 CI (22.5%). The JUST score was used in 1484 (61.7%) of the 2406 patients after implementation, which included 1267 (52.7%) cases of stroke (186 LVO (7.7%), 405 ICH (16.8%), 109 SAH (4.5%), and 567 CI (23.6%)). Success rate of the first request to the hospital significantly increased after JUST score implementation (76.3% vs 79.7%, p=0.004). JUST score implementation significantly shortened the door-to-puncture time (84 vs 73 min, p=0.03), but the prognosis remained unaltered among patients with acute LVO.ConclusionsUse of prehospital stroke triage scales improved prehospital management and preparation time of intervention among patients with acute stroke.

scholarly journals Effects of a Feedback-Demanding Stroke Clock on Acute Stroke Management

Stroke ◽  
2020 ◽  
Vol 51 (10) ◽  
pp. 2895-2900
Author(s):  
Mathias Fousse ◽  
Daniel Grün ◽  
Stefan A. Helwig ◽  
Silke Walter ◽  
Adam Bekhit ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Neurological Examination ◽  
Point Of Care ◽  
Intravenous Thrombolysis ◽  
Stroke Management ◽  
Active Feedback ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up

Background and Purpose: This randomized study aimed to evaluate whether the use of a stroke clock demanding active feedback from the stroke physician accelerates acute stroke management. Methods: For this randomized controlled study, a large-display alarm clock was installed in the computed tomography room, where admission, diagnostic work-up, and intravenous thrombolysis occurred. Alarms were set at the following target times after admission: (1) 15 minutes (neurological examination completed); (2) 25 minutes (computed tomography scanning and international normalized ratio determination by point-of-care laboratory completed); and (3) 30 minutes (intravenous thrombolysis started). The responsible stroke physician had to actively provide feedback by pressing a buzzer button. The alarm could be avoided by pressing the button before time out. Times to therapy decision (primary end point, defined as the end of all diagnostic work-up required for decision for or against recanalizing treatment), neurological examination, imaging, point-of-care laboratory, needle, and groin puncture were assessed by a neutral observer. Functional outcome (modified Rankin Scale) was assessed at day 90. Results: Of 107 participants, 51 stroke clock patients exhibited better stroke-management metrics than 56 control patients. Times from door to (1) end of all indicated diagnostic work-up (treatment decision time; 16.73 versus 26.00 minutes, P <0.001), (2) end of neurological examination (7.28 versus 10.00 minutes, P <0.001), (3) end of computed tomography (11.17 versus 14.00 minutes, P =0.002), (4) end of computed tomography angiography (14.00 versus 17.17 minutes, P =0.001), (5) end of point-of-care laboratory testing (12.14 versus 20.00 minutes, P <0.001), and (6) needle times (18.83 versus 47.00 minutes, P =0.016) were improved. In contrast, door-to-groin puncture times and functional outcomes at day 90 were not significantly different. Conclusions: This study showed that the use of a stroke clock demanding active feedback significantly improves acute stroke-management metrics and, thus, represents a potential low-cost strategy for streamlining time-sensitive stroke treatment.

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