Abstract 33: Diagnostic Accuracy, Reperfusion Delay and Triage Scale Comparison: Real-World Paramedic Validation Results From the ACT-FAST Triage Algorithm for Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Henry Zhao ◽  
Karen Smith ◽  
Stephen Bernard ◽  
Michael Stephenson ◽  
Christopher Bladin ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Real World ◽  
False Positive ◽  
Vessel Occlusion ◽  
Time Saving ◽  
Hospital Transfer ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Direct Bypass ◽  
Triage Algorithm

Background: Severity-based selection tools for large vessel occlusion (LVO) are limited by lack of validation in unselected prehospital stroke patients and concerns regarding delayed thrombolysis (tPA) and comprehensive stroke center (CSC) burdening. We examined these issues in a real-world validation of the two exam step (severe arm motor + speech or neglect) ACT-FAST LVO triage algorithm. Methods: The ACT-FAST statewide validation involved 15 metro and 17 rural hospitals in Victoria, Australia from Nov 2017-July 2019 with training of paramedics using an 8 min video. Prehospital paramedic assessments were correlated with hospital imaging to determine presence of LVO. Data were then examined for diagnostic accuracy, time saving for direct bypass to CSC using a validated Google maps model, rates and magnitude of delayed tPA in false-positive non-LVO infarcts, and extra CSC workload. Results: In 517 completed assessments, 58% involving non-EVT centers and including 114 (22%) LVO, ACT-FAST sensitivity was 81% (92/114) and specificity was 81% (325/403; 89% if ICH are not regarded as false-positive) for LVO. Figure compares to other LVO scales. Bypass to CSC was modelled to save median 71 min for analysis of 29 thrombectomy patients requiring inter-hospital transfer. Of 27 non-LVO infarcts with false positive ACT-FAST, only 4 (15%) received tPA at a non-CSC center, and bypass would have only added median 10 mins in these cases. The increase in CSC presentation using ACT-FAST triage was estimated to be 2-3.3 patients/week using estimated 7,200 suspected stroke cases/year across entire metro Victoria. Conclusion: In comprehensive real-world validation, the simple ACT-FAST algorithm detected LVO or ICH in almost 80% of positive assessments with highly favorable comparison to other scales. Prehospital bypass to CSC substantially reduces thrombectomy delay, and appears to strongly outweigh negatives of bypassing false positive cases on tPA delay and CSC overburdening.

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.

Abstract WMP89: Outcomes No Different in Real World Including Direct vs Drip-and-Ship Patients: Power of Reperfusion From Mechanical Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Darshan G Shah ◽  
Aravi Loganathan ◽  
Dan Truong ◽  
Fiona Chan ◽  
Bruce Campbell ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Real World ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Vessel Occlusion ◽  
Excellent Functional Outcome ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Mechanical thrombectomy (MT) became standard care in 2015 after positive trials in patients presenting with acute ischemic stroke and large vessel occlusion (LVO) 0-6h and in 2018 for selected patients up to 24h from symptom onset. Objective: To evaluate whether patients receiving MT at our center would have comparable outcomes in patients presenting to our comprehensive stroke center (direct) vs transfer patients (drip-and-ship) Methods: This is a retrospective observational study utilising prospectively collected stroke database for patients receiving MT for LVO in anterior and posterior circulation in South Brisbane network of 7 hospitals (6 drip-and-ship centers and 1 MT-capable center), Australia which serves 1.6 million. Day 90 modified Rankin scale (mRS) was used to assess functional outcomes via outpatient follow up at direct or referral center. The association of drip and ship versus mothership treatment with day 90 mRS was tested in ordinal logistic regression adjusted for age, baseline NIHSS and IV thrombolysis. Results: Of 191 patients who underwent Mechanical Thrombectomy from 2015 to June 2018 at our center, 22 patients were excluded from analysis as either their baseline mRS was >1 (13) or follow up data was missing (9). The mean age was 64.4 years. Median (inter-quartile range, IQR) NIHSS was 16 (9-21) on admission and 7 (2-18) on day 1. Thrombolysis in Cerebral Infarction (TICI) ≥2b was achieved in 88.9%. At 90 days, 50.9% achieved excellent functional outcome (mRS 0-1), 61.4% achieved good functional outcome (mRS 0-2) and 69% achieved favorable outcome (mRS 0-3). Median mRS was 1 (IQR 0-5) in 96 patients presenting directly to the endovascular center and 1 (IQR 1-4) in 73 drip-and-ship patients (common odds ratio 1.07 (95%CI 0.62-1.83), p=0.82) Conclusion: Our 7-center network experience confirms real world reproducibility of trial results, interestingly with no difference in functional outcomes for direct vs drip-and-ship patients.

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

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.

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 Coronavirus disease 2019 is threatening stroke care systems: a real-world study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jiawei Xin ◽  
Xuanyu Huang ◽  
Changyun Liu ◽  
Yun Huang
Keyword(s):  
Real World ◽  
Mainland China ◽  
Stroke Care ◽  
Hospital Length ◽  
Real World Data ◽  
Care Systems ◽  
Long Term Prognosis ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Medical Burden

Abstract Background Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the stroke care systems have been seriously affected because of social restrictions and other reasons. As the pandemic continues to spread globally, it is of great significance to understand how COVID-19 affects the stroke care systems in mainland China. Methods We retrospectively studied the real-world data of one comprehensive stroke center in mainland China from January to February 2020 and compared it with the data collected during the same period in 2019. We analyzed DTN time, onset-to-door time, severity, effects after treatment, the hospital length of stays, costs of hospitalization, etc., and the correlation between medical burden and prognosis of acute ischemic stroke (AIS) patients. Results The COVID-19 pandemic was most severe in mainland China in January and February 2020. During the pandemic, there were no differences in pre-hospital or in-hospital workflow metrics (all p>0.05), while the degree of neurological deficit on admission and at discharge, the effects after treatment, and the long-term prognosis were all worse (all p<0.05). The severity and prognosis of AIS patients were positively correlated with the hospital length of stays and total costs of hospitalization (all p<0.05). Conclusions COVID-19 pandemic is threatening the stroke care systems. Measures must be taken to minimize the collateral damage caused by COVID-19.

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

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.

Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke

2021 ◽  
Author(s):  
Tareq Kass-Hout ◽  
Jungwha Lee ◽  
Katie Tataris ◽  
Christopher T. Richards ◽  
Eddie Markul ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Center

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.

Developing a statewide protocol to ensure patients with suspected emergent large vessel occlusion are directly triaged in the field to a comprehensive stroke center: how we did it

2016 ◽  
Vol 9 (3) ◽  
pp. 330-332 ◽  
Author(s):  
Mahesh V Jayaraman ◽  
Arshad Iqbal ◽  
Brian Silver ◽  
Matthew S Siket ◽  
Caryn Amedee ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

We describe the process by which we developed a statewide field destination protocol to transport patients with suspected emergent large vessel occlusion to a comprehensive stroke center.

scholarly journals Impact of Viz LVO on Time-to-Treatment and Clinical Outcomes in Large Vessel Occlusion Stroke Patients Presenting to Primary Stroke Centers

2020 ◽  
Author(s):  
Jacob R. Morey ◽  
Emily Fiano ◽  
Kurt A. Yaeger ◽  
Xiangnan Zhang ◽  
Johanna T. Fifi
Keyword(s):  
New York ◽  
Clinical Outcomes ◽  
Large Vessel ◽  
Similar Proportion ◽  
Time Interval ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Time To Treatment ◽  
Comprehensive Stroke Center ◽  
Stroke Center

AbstractIntroductionRandomized controlled trials have demonstrated the importance of time-to-treatment on clinical outcomes in large vessel occlusion (LVO) stroke. Delays in interventional radiology (INR) consultation are associated with a significant delay in overall time to endovascular treatment (EVT). Delays in EVT are particularly prevalent in Primary Stroke Centers (PSC), hospitals without thrombectomy capability onsite, where the patient requires transfer to a Thrombectomy Capable or Comprehensive Stroke Center for EVT. A novel computer aided triage system, Viz LVO, assists in early notification of the PSC stroke team and affiliated INR team. This platform includes an image viewer, communication system, and an artificial intelligence algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts.HypothesisViz LVO will decrease time-to-treatment and improve clinical outcomes.MethodsA prospectively maintained database was assessed for all patients who presented to a PSC currently utilizing Viz LVO in the Mount Sinai Health System in New York and underwent EVT following transfer for LVO stroke between October 1, 2018 and March 15, 2020. There were 42 patients who fit the inclusion criteria and divided into pre- and post-Viz ContaCT implementation by comparing the periods of October 1, 2018, to March 15, 2019, “Pre-Viz”, and October 1, 2019, to March 15, 2020, “Post-Viz.” Time intervals and clinical outcomes were collected and compared.ResultsThe Pre- and Post-Viz cohorts were similar in terms of gender, age, proportion receiving IV-tPA, and proportion with revascularization of TICI > 2B. The presenting NIHSS and pre-stroke mRS scores were not statistically different.The median initial door-to-INR notification was significantly faster in the post-Viz cohort (21.5 minutes vs 36 minutes; p=0.02). The median initial door-to-puncture time interval was 20 minutes shorter in the Post-Viz cohort, but this was not statistically significant (p=0.20).The 5-day NIHSS and discharge mRS were both significantly lower in the Post-Viz cohort (p=0.02 and p=0.03, respectively). The median 90-day mRS scores were also significantly lower post-Viz implementation, although a similar proportion received a good outcome (mRS score ≤ 2) (p=0.02 and p=0.42, respectively).ConclusionsEVT is a time-sensitive intervention that is only available at select stroke centers. Significant delays in time-to-treatment are present when patients require transfer from PSCs to a EVT capable stroke center. In a large health care system, we have shown that Viz LVO implementation is associated with improved time to INR notification and clinical outcomes. Viz LVO has the potential for wide-spread improvement in clinical outcomes with implementation across large hub and stroke systems across the country.

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