Personalized Prehospital Triage in Acute Ischemic Stroke

Background and Purpose— Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. Methods— We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). Results— Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. Conclusions— The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas.

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

JAMA Neurology ◽

10.1001/jamaneurol.2021.2485 ◽

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

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

Journal of the American Heart Association ◽

10.1161/jaha.119.012665 ◽

2019 ◽

Vol 8 (12) ◽

Cited By ~ 6

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.

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Abstract WMP66: Minnesota Prehospital Stroke Scale For Prediction of Emergent Large Vessel Occlusion

Stroke ◽

10.1161/str.47.suppl_1.wmp66 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Takamasa Higashimori ◽

David Anderson

Keyword(s):

Randomized Clinical Trials ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Patient Transport ◽

Primary Stroke Center ◽

Leg Weakness ◽

Stroke Center ◽

Endovascular Mechanical Thrombectomy

Intro: Recent randomized clinical trials have demonstrated the benefit of endovascular mechanical thrombectomy in acute ischemic stroke patients with Emergent Large Vessel Occlusion (ELVO). Cincinnati Prehospital Stroke Scale is widely used tool by EMS but not specifically designed to predict ELVO. Previously reported prehospital stroke scales for ELVO have been limited, and not widely used. It is imperative to establish a simple and accurate tool for EMS to predict ELVO facilitating rapid patient transport to hospitals capable of endovascular intervention. Hypothesis: Minnesota Prehospital Stroke Scale (MPSS) can predict the presence of ELVO with high accuracy comparable to NIHSS. Methods: The MPSS assesses five parameters: Facial weakness, Arm weakness, Leg weakness, Speech difficulty and Eye deviation, with total score ranging 0-10 (See Table). We set MPSS 6 or above and NIHSS 7 or above as a cutoff for ELVO. We retrospectively analyzed all the stroke code patients seen in ED between January 2015 and April 2015 at a primary stroke center (n=120). We selected patients arriving in less than 6 hours with prehospital stroke alert activated by EMS. Hemorrhagic stroke patients were excluded. The following data were collected: 1) Presence of ELVO, 2) Initial NIHSS in ED, and 3) MPSS abstracted from initial ER NIHSS, then assessed the results using 2x2 table for ELVO and MPSS vs. NIHSS. Results: Of 28 patients meeting criteria, 6 (21%) had ELVO (ICA, M1/M2): Mean MPSS was 7.5, whereas mean NIHSS was 15 for ELVO patients. Mean HPSS was 1.6, whereas mean NIHSS was 5.1 for non-ELVO patients. Sensitivity 83%, specificity 100%, PPV 100%, NPV 96%, and accuracy 96% for HPSS; sensitivity 83%, specificity 77%, PPV 50%, NPV 94% and accuracy 79% for NIHSS. Conclusion: MPSS may be a useful tool for predicting ELVO. Further studies are necessary to validate the efficacy of the scale.

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

Stroke ◽

10.1161/str.51.suppl_1.32 ◽

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.

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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 ◽

10.3390/life11060469 ◽

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.

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Pre- and Interhospital Workflow Times for Patients With Large Vessel Occlusion Stroke Transferred for Endovasvular Thrombectomy

Frontiers in Neurology ◽

10.3389/fneur.2021.730250 ◽

2021 ◽

Vol 12 ◽

Author(s):

Laura C. C. van Meenen ◽

Frank Riedijk ◽

Jeffrey Stolp ◽

Bas van der Veen ◽

Patricia H. A. Halkes ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Large Vessel ◽

Time Interval ◽

Large Vessel Occlusion ◽

Related Factors ◽

Vessel Occlusion ◽

Interhospital Transfer ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Patients with large vessel occlusion (LVO) stroke are often initially admitted to a primary stroke center (PSC) and subsequently transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). This interhospital transfer delays initiation of EVT. To identify potential workflow improvements, we analyzed pre- and interhospital time metrics for patients with LVO stroke who were transferred from a PSC for EVT.Methods: We used data from the regional emergency medical services and our EVT registry. We included patients with LVO stroke who were transferred from three nearby PSCs for EVT (2014–2021). The time interval between first alarm and arrival at the CSC (call-to-CSC time) and other time metrics were calculated. We analyzed associations between various clinical and workflow-related factors and call-to-CSC time, using multivariable linear regression.Results: We included 198 patients with LVO stroke. Mean age was 70 years (±14.9), median baseline NIHSS was 14 (IQR: 9–18), 136/198 (69%) were treated with intravenous thrombolysis, and 135/198 (68%) underwent EVT. Median call-to-CSC time was 162 min (IQR: 137–190). In 133/155 (86%) cases, the ambulance for transfer to the CSC was dispatched with the highest level of urgency. This was associated with shorter call-to-CSC time (adjusted β [95% CI]: −27.6 min [−51.2 to −3.9]). No clinical characteristics were associated with call-to-CSC time.Conclusion: In patients transferred from a PSC for EVT, median call-to-CSC time was over 2.5 h. The highest level of urgency for dispatch of ambulances for EVT transfers should be used, as this clearly decreases time to treatment.

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Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke

Stroke ◽

10.1161/strokeaha.120.030248 ◽

2020 ◽

Vol 51 (12) ◽

pp. 3495-3503 ◽

Cited By ~ 1

Author(s):

Jacob R. Morey ◽

Thomas J. Oxley ◽

Daniel Wei ◽

Christopher P. Kellner ◽

Neha S. Dangayach ◽

...

Keyword(s):

Clinical Outcomes ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Team ◽

Primary Stroke Center ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Patient Presentation

Background and Purpose: Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models. Methods: This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months. Results: MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes ( P <0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively ( P =0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%; P <0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS ( P =0.10). Conclusions: MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03048292.

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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 ◽

10.1161/str.52.suppl_1.p483 ◽

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.

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