scholarly journals Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke

2019 ◽  
Vol 8 (12) ◽  
Author(s):  
Ludwig Schlemm ◽  
Matthias Endres ◽  
Jan F. Scheitz ◽  
Marielle Ernst ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Disability Adjusted Life Years ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.

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

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.

scholarly journals Bypassing the Closest Stroke Center for Thrombectomy Candidates

Stroke ◽  
2020 ◽  
Vol 51 (3) ◽  
pp. 867-875 ◽  
Author(s):  
Ludwig Schlemm ◽  
Matthias Endres ◽  
Christian H. Nolte
Keyword(s):  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Disability Adjusted Life Years ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Rural Settings ◽  
Multiple Stroke ◽  
Stroke Center

Background and Purpose— Patients with acute ischemic stroke who have large vessel occlusion benefit from direct transport to a comprehensive stroke center (CSC) capable of endovascular therapy. To avoid harm for patients without large vessel occlusion from delayed access to intravenous thrombolysis (IVT), it has been suggested to only redirect patients with high likelihood of large vessel occlusion for whom the additional delay to intravenous thrombolysis (IVT) caused by transport to the CSC is below a certain threshold. However, which threshold achieves the greatest clinical benefit is unknown. Methods— We used mathematical modeling to calculate additional-delay-to-IVT thresholds associated with the greatest reduction in disability-adjusted life years in abstracted 2-stroke center and multiple-stroke center scenarios. Model parameters were extracted from recent meta-analyses or large prospective cohort studies. Uncertainty was quantified in probabilistic and 2-way univariate sensitivity analyses. Results— Assuming ideal treatment time performance metrics, transport to the nearest CSC was the preferred strategy irrespective of additional delay-to-IVT when the transfer time between primary stroke center and CSC was <40 minutes (95% credible interval: 25–66 minutes); otherwise, the optimal additional delay-to-IVT-threshold ranged from 28 to 139 minutes. In multiple-stroke center scenarios, optimal additional-delay-to-IVT thresholds were 30 to 54 minutes in urban and 49 to 141 minutes in rural settings; use of optimal thresholds as compared with a 15 minute-threshold saved 0 to 0.11 and 0 to 0.37 disability-adjusted life years per triage case, respectively. Assuming slower treatment times at primary stroke centers and CSCs yielded longer permissible additional delays. Conclusions— Our results suggest that patients with acute ischemic stroke with suspected large vessel occlusion should be redirected to a CSC if the additional delay to IVT is <30 minutes in urban and 50 minutes in rural settings.

Abstract 32: Intravenous Tpa Delays Door-to-puncture Time in Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Shashvat Desai ◽  
Jay Dolia ◽  
Kavit Shah ◽  
Merritt Brown ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Empirical Studies ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Negative Effect ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Background: The current 2018 AHA/ASA Guidelines for early stroke management recommend use of IV tPA in all eligible acute ischemic stroke patients within 4.5 hours of onset while being considered for mechanical thrombectomy (MT). Whether or not tPA administration is beneficial prior to thrombectomy is still an ongoing debate. Potential delay of MT initiation due to tPA start is a major concern but has not been well-delineated in empirical studies. Methods: In a prospective large volume comprehensive stroke center registry, we analyzed all patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with thrombectomy between 2012-2017, who arrived directly from field to ED within 4.5h of last known well. Patients without contraindication to IV-tPA are given bolus dose in the scanner suite and the remainder of the 1h infusion en route to and in the angio-suite to prevent delay. Results: Among 777 thrombectomy patients identified in the database, 237 arrived directly within 4.5 hours from onset, including 65.8% (156) not treated with IV-tPA and 34.2% (81) receiving IV-tPA, both well-matched in age and NIHSS. Overall, the door-to-needle (DTN) time was 40m (IQR31-56), surpassing the Target Stroke national targets (60m and 45m) active during the study period. However, median door-to-puncture (DTP) time was 22m longer in the IV-tPA group, 74 vs 52m (p<0.001). IV-tPA was not independently associated with better recanalization rate (TICI 2B-3 95.9% vs 92.9%) or functional independent outcome (modified Rankin score 0-2) at 90 days, 37.3% vs 39.4%. Conclusion: IV-tPA administration in AIS-LVO was associated with delayed door-to-puncture times in a comprehensive stroke center with efficient DTN times surpassing advanced national targets, without change in recanalization rate or outcomes. Randomized trials are needed to determine the net positive, neutral, or negative effect of IV-tPA in this population.

Abstract P483: Immediate Feedback to Emergency Medical Services Reduce Door to Angiogram and Transfer Time for Endovascular Treatment of Large Vessel Occlusion Ischemic Strokes

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kimberley Stephania Yescas Garibay ◽  
Nguyen Vo ◽  
Syung Jung ◽  
Sun Lee
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Transfer Time ◽  
Large Vessel Occlusion ◽  
Immediate Feedback ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The morbidity of acute ischemic Stroke (AIS) caused by a large vessel occlusion (LVO) can be significantly reduced with endovascular intervention. However, delay in diagnosis can exclude a patient from therapy.Rapid Arterial Occlusion evaluation (RACE) score of five or more have an 85% chance of being LVO acute ischemic stroke. Pre-arrival notification of potential LVO cases by EMS (Emergency Medical Service) is an important factor to reduce door-to-transfer time from a Primary Stroke Center (PSC) to a Comprehensive Stroke center (CSC). We hypothesize that immediate feedback to EMS teams on their pre-hospital RACE score reporting will improve prehospital recognition of LVO strokes. Therefore, reducing the Door to Needle CTA (CT Angiogram) and/or Door to Transfer Time for endovascular treatment. Methods: Our inclusion criteria included patients with a diagnosis of AIS brought in by EMS with a RACE score of five or more, was given IV thrombolytics, or transferred to a comprehensive stroke center for endovascular treatment. A 5-item feedback form was developed for each case and was reviewed biweekly with our EMS liaison. Feedback included compliance with RACE score reporting, presence of IV access, CTA time, and TPA/Transfer time. Direct feedback was verbally given to the EMS transport team. Results: Comparison of data from a twelve-month preintervention period (n=29) to a four-month postintervention period (n=12) was conducted through direct comparison. This showed a decrease in mean Door-to-CTA time from 212.14 (CI ±83.3) to 97.08 (CI ±54.92) minutes with a p-value of 0.0126 in a one-tailed t-Test, a 54% reduction and a reduction in door to transfer time (305 minutes to 132 minutes, a 56.7 % reduction ). Conclusion: A pilot project focused on providing immediate feedback to EMS regarding accurate prehospital notification of RACE score showed a statistically significant improvement in door to CTA time and door to transfer time. Extension of the post study period is needed to confirm the significance of transfer time. This study demonstrates the importance of collaboration between a PSC and EMS to ensure prompt diagnosis and transfer for endovascular treatment of AIS caused by LVO.

scholarly journals Mean Platelet Volume as a Potential Marker of Large Vessel Occlusion and Predictor of Outcome in Acute Ischemic Stroke Patients Treated with Reperfusion Therapy

Life ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. 469
Author(s):  
Aleksander Dębiec ◽  
Aleksandra Pogoda-Wesołowska ◽  
Piotr Piasecki ◽  
Adam Stępień ◽  
Jacek Staszewski
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Surrogate Marker ◽  
Reperfusion Therapy ◽  
Large Vessel ◽  
Stroke Outcome ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Potential Marker ◽  
Stroke Center

(1) Background: An early diagnosis of a large vessel occlusion (LVO) is crucial in the management of the acute ischemic stroke (AIS). The laboratory predictors of LVO and a stroke outcome remain unknown. We have hypothesized that high MPV—a surrogate marker of the activated platelet—may be associated with LVO, and it may predict a worse AIS outcome. (2) Methods: This was a retrospective study of 361 patients with AIS who were treated with thrombolysis (tPA, 65.7%) and/or mechanical thrombectomy (MT, 34.3%) in a tertiary Stroke Center between 2011 and 2019. (3) Results: The mean MPV in the cohort was 9.86 ± 1.5 fL (1st–4th quartiles: <8.8, >10.80 fL). Patients in the 4th quartile compared to the 1st had a significantly (p < 0.01) more often incidence of an LVO related stroke (75% vs. 39%) and a severe stroke manifestation with a higher RACE score (5.2 ± 2.8 vs. 3.3 ± 2.4), NIHSS at baseline (mean ± SD, 14 ± 6.5 vs. 10.9 ± 5.2), and NIHSS at discharge (6.9 ± 7 vs. 3.9 ± 3.6). A multivariate analysis revealed that quartiles of MPV (OR 1.4; 95%CI 1.2–1.8) significantly predicted an LVO stroke, also after the adjustment for RACE < 5 (OR 1.4; 95%CI 1.08–1.89), but MPV quartiles did not predict a favorable stroke outcome (mRS ≤ 2) (OR 0.89; 95%CI 0.7–1.13). (4) Conclusion: Our data suggest that MPV is an independent predictor of LVO in patients with an acute ischemic stroke.

scholarly journals Emergency medical dispatchers’ ability to identify large vessel occlusion stroke during emergency calls

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Pauli E. T. Vuorinen ◽  
Jyrki P. J. Ollikainen ◽  
Pasi A. Ketola ◽  
Riikka-Liisa K. Vuorinen ◽  
Piritta A. Setälä ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Emergency Call ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Emergency Response System ◽  
Emergency Medical ◽  
Cortical Ischemia

Abstract Background In acute ischemic stroke, conjugated eye deviation (CED) is an evident sign of cortical ischemia and large vessel occlusion (LVO). We aimed to determine if an emergency dispatcher can recognise LVO stroke during an emergency call by asking the caller a binary question regarding whether the patient’s head or gaze is away from the side of the hemiparesis or not. Further, we investigated if the paramedics can confirm this sign at the scene. In the group of positive CED answers to the emergency dispatcher, we investigated what diagnoses these patients received at the emergency department (ED). Among all patients brought to ED and subsequently treated with mechanical thrombectomy (MT) we tracked the proportion of patients with a positive CED answer during the emergency call. Methods We collected data on all stroke dispatches in the city of Tampere, Finland, from 13 February 2019 to 31 October 2020. We then reviewed all patient records from cases where the dispatcher had marked ‘yes’ to the question regarding patient CED in the computer-aided emergency response system. We also viewed all emergency department admissions to see how many patients in total were treated with MT during the period studied. Results Out of 1913 dispatches, we found 81 cases (4%) in which the caller had verified CED during the emergency call. Twenty-four of these patients were diagnosed with acute ischemic stroke. Paramedics confirmed CED in only 9 (11%) of these 81 patients. Two patients with positive CED answers during the emergency call and 19 other patients brought to the emergency department were treated with MT. Conclusion A small minority of stroke dispatches include a positive answer to the CED question but paramedics rarely confirm the emergency medical dispatcher’s suspicion of CED as a sign of LVO. Few patients in need of MT can be found this way. Stroke dispatch protocol with a CED question needs intensive implementation.

Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2

2021 ◽  
Vol 50 (4) ◽  
pp. 397-404
Author(s):  
Kotaro Tatebayashi ◽  
Kazutaka Uchida ◽  
Hiroto Kageyama ◽  
Hirotoshi Imamura ◽  
Nobuyuki Ohara ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Tandem Occlusion ◽  
The Mean ◽  
Patient Prognosis

<b><i>Introduction:</i></b> The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). <b><i>Methods:</i></b> The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. <b><i>Results:</i></b> Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, <i>p</i> = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, <i>p</i> = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, <i>p</i> &#x3c; 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, <i>p</i> = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, <i>p</i> = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1–5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30–0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, <i>p</i> = 0.42). <b><i>Discussion/Conclusion:</i></b> The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

Abstract TP1: The Promising System to Support Rural Area Where No Intervenitionists to Perform Embolectomy for Acute Ischemic Stroke "Drive and Retrieve Method"

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Toshiya Osanai
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Rural Area ◽  
Median Time ◽  
Prospective Trial ◽  
Large Vessel ◽  
Full Time ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Introduction: In Japan, endovascular treatment for acute ischemic stroke from large vessel occlusion should be performed by neurointerventionists. However, most hospitals in rural area , that offer treatment for cerebral vascular disease do not have access to a neurointerventionist; the rural areas are especially affected. Thus, Our University has offered support to institutions without a neurointerventionist, to perform endovascular treatment. The neurointerventionists stationed in other hospitals drive to retrieve the resultant clot since the acute ischemic stroke from large vessel occlusion. We called this the “drive and retrieve system” method, and launched the prospective trial to evaluate the validity and efficacy of this method. Herein, we report the initial results of this trial. Methods: Nine institutes across our affiliated hospitals within a one-hour drive from Sapporo City took part in this trial. Three of these 9 institutes that have a full-time neurointerventionist were registered as the source. When an episode of acute ischemic stroke requiring intervention occurred in the other 6 hospitals, the available neurointerventionist provided treatment based on the drive and retrieve method. The neurointerventionists’ schedules was updated and distributed to all participating units twice a week, so that the supported hospitals could immediately make contact when required. We analysis the data of 44 cases in this trial from July 2015 to April 2016. Results: For 41 out of 44 cases (93%), Neurointerventionaists were able to respond immediately. The median time from door-to-puncture was 90 min (interquartile range [IQR]: 72-125). The median time from puncture to recanalization was also 76 min (IQR: 57.5-99.5). The recanalization rate (TICI 2b/3) was 77 %. mRS 0-2 was 39%. Conclusion: The drive and retrieve system has the potential to support rural medical institutes that do not have access to a full-time neurointerventionist.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
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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