Abstract P186: New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michal Bar ◽  
Martin Cabal ◽  
Ondrej Volny ◽  
Petr Jaššo ◽  
David Holeš ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT, and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes. Methods: In a prospective interventional multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion, and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database. Results: For EVT patients, the median OGT was 213 min in 2015, and 142 min in 2018; and median TT was 118 min in 2015, and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015, and 109 min in 2018; and median TT was 41 min in 2015, and 48 min in 2018. Clinical outcome did not significantly change. The median mRS at 3 months after stroke onset in both 2015 and 2018 was 2 among tPA patients, and 3 among EVT patients. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60% vs 59% in tPA patients, and 40% vs 44% in EVT patients. Conclusions: The new prehospital triage has yielded shorter onset-to-groin times for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

scholarly journals New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

2021 ◽  
Vol 12 ◽  
Author(s):  
Martin Cabal ◽  
Linda Machova ◽  
Daniel Vaclavik ◽  
Petr Jasso ◽  
David Holes ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Stroke Onset ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Mortality And Morbidity ◽  
Prehospital Triage ◽  
Favorable Clinical Outcome ◽  
Suspected Stroke

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here, we examined whether changing a triage model from “drip and ship” to “mothership” yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes.Methods: In a before/after multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian–Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database.Results: For EVT patients, the median OGT was 213 min in 2015 and 142 min in 2018, and the median TT was 142 min in 2015 and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015 and 109 min in 2018, and the median TT was 41 min in 2015 and 48 min in 2018. Clinical outcome did not significantly change. The percentages of patients with favorable clinical outcome (mRS 0–2) were comparable between 2015 and 2018: 60 vs. 59% in tPA patients and 40 vs. 44% in EVT patients.Conclusions: The new prehospital triage has yielded shorter OGTs for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

scholarly journals Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis

2021 ◽  
pp. 197140092110091
Author(s):  
Hanna Styczen ◽  
Matthias Gawlitza ◽  
Nuran Abdullayev ◽  
Alex Brehm ◽  
Carmen Serna-Candel ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Intracranial Haemorrhage ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion

Background Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience. Methods A retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010–September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded. Results In total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up. Conclusion Mechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.

Abstract W P211: Clinical Characteristics of Pseudo Negative Cases in Prehospital Triage for Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Shuichi Tonomura
Keyword(s):  
Acute Stroke ◽  
Clinical Characteristics ◽  
Stroke Onset ◽  
The Other ◽  
Small Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Subtypes ◽  
Prehospital Triage ◽  
Prehospital Diagnosis

Objective: The accuracy of prehospital diagnosis for stroke by emergency medical services (EMS) is improved using instruments for symptom recognition. On the other hand, prehospital misdiagnosis for stroke and subsequent delay in presentation to a hospital with stroke expertise play a critical role in the exclusion of potential therapeutic candidates. Our study aims to investigate the clinical characteristics of pseudo-negative cases in prehospital triage for stroke/TIA by EMS. Methods: From April 2013 to April 2014, consecutive 644 acute stroke patients were transferred by EMS to our hospital. We investigated prehospital diagnosis, Cincinnati prehospital stroke scale (CPSS) by EMS, neurological symptoms and complaints of patients themselves at stroke onset. We also examined activity of daily life (ADL) and cognitive impairments before stroke onset, and stroke subtypes in final diagnoses. Results: Among 644 acute stroke patients, 36 patients (22 men, mean 72.5±4.4 years old) were pseudo-negative cases in prehospital triage for stroke and had no abnormalities in CPSS by EMS. When EMS arrived at emergency site, 12 patients (33%) had loss of consciousness. Before stroke onset, 6 patients (17%) had impaired ADL (modified Rankin Scale >2), and 5 (14%) cognitive impairment. Among the stroke subtypes, the proportion of small vessel occlusion (22.4%, p=0.0025) and transient ischemic attack (TIA) (25%, p=0.0021) was significant higher in pseudo negative cases in prehospital triage; on the other hand, intracranial hemorrage (11%, p=0.0028) was lower. In complaint of patients themselves at stroke onset, weakness in one or two extremities was reported in 20 patients (56%), abnormal speech/language in 13 (36%), however all of them were not clarified by EMS. Conclusion: This study showed that small vessel occlusion and TIA tend to be misdiagnosed in a prehospital triage by EMS. The complaint of patients themselves at stroke onset is important to prehospital diagnoses by EMS.

Abstract WP148: Functional Independence Score of Acute Stroke Patients Can Predict Favorable Clinical Outcome at 3 Months After Stroke Onset

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Takashi Johno ◽  
Hiroyuki Kawano ◽  
Masataka Torii ◽  
Hiroshi Kamiyama ◽  
Tatsuo Amano ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Functional Independence ◽  
Stroke Onset ◽  
Stroke Patients ◽  
Favorable Clinical Outcome

scholarly journals The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Taylor Haight ◽  
Burton Tabaac ◽  
Kelly-Ann Patrice ◽  
Michael S. Phipps ◽  
Jaime Butler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Emergency Medical Services ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Emergency Medical ◽  
Suspected Stroke

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

Abstract WP282: Use of Emergent Ambulance Transport With Lights and Siren Leads to Significant Time Savings for Inter-Facility Transfers of Patients With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nathaniel R Hunt ◽  
Mollie McDermott ◽  
Scott F Dye ◽  
Cemal B Sozener
Keyword(s):  
Small Sample ◽  
Large Vessel ◽  
P Value ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Transport Time ◽  
Vessel Occlusion ◽  
Significant Time ◽  
The Mean ◽  
Time Savings

Introduction: When emergency medical services (EMS) responds to a field call for a patient experiencing stroke symptoms, the response is emergent, necessitating the use of lights and siren (L&S) to allow for expedited transport to a stroke-capable center. With the expanded use of endovascular therapy (EVT) for large-vessel occlusion (LVO), many stroke-capable centers are transferring larger numbers of LVO patients to EVT-capable centers for definitive care. Interestingly, many EMS systems do not respond to or transport inter-facility transfers emergently with L&S. This can potentially lead to delays in care and worse clinical outcomes. Given increased scrutiny surrounding the safety and utility of L&S transport among EMS providers, we investigated the difference between emergent and non-emergent transfer of confirmed LVO stroke patients from two institutions with varied distances and traffic patterns. Methods: A retrospective analysis was performed of 127 consecutive inter-facility transfers for LVO from two facilities, Hospital A (38.5 miles) and Hospital B (5.5 miles), to the University of Michigan Comprehensive Stroke Center over 3 years and 2 years respectively. Transfers by helicopter (17/127; 13.4%) and those without available EMS data (9/127; 7.1%) were excluded. Final review included 50 cases from Hospital A and 51 from Hospital B. Run times and use of L&S during transport were collected. A t-test was used to examine whether the observed differences in transport times were statistically significant. Results: Of the 50 transfers from Hospital A, 22 were transported without L&S use and 28 with L&S. The mean transport time was 44 minutes versus 35 minutes, respectively. From Hospital B, there were 14 transfers transported without L&S use and 37 with L&S. The mean transport time was 15 minutes versus 9 minutes, respectively. For both samples, p-value was <0.01. Conclusion: Despite a small sample size, this analysis demonstrates significant time savings using L&S during inter-facility transfer of stroke patients with confirmed LVO. While inherent risk is associated with the use of L&S during EMS transport, judicious use for confirmed time-sensitive indications seems warranted.

Abstract 3130: A 101 cm 3 Diffusion-Weighted Imaging (DWI) Cerebral Infarct Volume is the Maximum Volume Compatible with Good 30- Day Functional Outcome

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Esteban Cheng-Ching ◽  
Junya Aoki ◽  
Yohei Tateishi ◽  
Dolora Wisco ◽  
Gabor Toth ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Functional Outcome ◽  
Diffusion Weighted Imaging ◽  
Infarct Volume ◽  
Cerebral Infarct ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Treatment

Background: Several predictors of clinical outcome have been identified in acute ischemic stroke patients, including age, National Institutes of Health Stroke Scale scores (NIHSS), and large vessel occlusion. Predicted infarct volumes are thought to generally correlate with clinical outcome, however, to date, mostly small studies have failed to demonstrate a convincing relationship between Diffusion-weighted imaging (DWI) volumes and clinical outcome, and this correlation is controversial. Hypothesis: We hypothesized that final DWI infarction volumes would correlate with 30-day modified Rankin Score (mRS). We also sought to describe the maximum cerebral infarct volume compatible with a favorable 30 day (mRS of 0-2) outcome. Methods: We retrospectively reviewed a prospectively collected database of acute stroke patients with large vessel occlusion who were potential intra-arterial therapy candidate, which recently incorporated systematically collected imaging data at our large academic medical center. Additional inclusion criteria were MRI on admission as per our hyperacute stroke treatment protocol, and available 30-day mRS (n=91). Final DWI volume was obtained from the last MRI the patient had during their stroke treatment admission. Differences between final DWI volume and 30-day mRS were analyzed using the Kruskal-Wallis test. Results: See Table 1 for DWI volumes by individual mRS. There was a strong overall positive relationship between final DWI volume and 30-day mRS [Kruskall Wallis p= .0047]. No patient with an mRS of 0 had a DWI volume >12.1 cm 3 . No patients with an mRS of ≤1 had an DWI volume over 85 cm 3 , and no patient with a mRS of ≤2 had a DWI volume over 101 cm 3 . Conclusions: Cerebral infarct volumes strongly correlate with 30-day functional outcome, but there is great individual variability. The maximum infarct volume compatible with survival and mild or less disability at 30 days was 101 cm 3 . In this study, the maximum cerebral infarct volume compatible with zero clinical symptoms or disability at 30 days was 12.1 cm 3 .

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