scholarly journals Utility of Severity-Based Prehospital Triage for Endovascular Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 70-79
Author(s):  
Henry Zhao ◽  
Karen Smith ◽  
Stephen Bernard ◽  
Michael Stephenson ◽  
Henry Ma ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Fast Algorithm ◽  
False Negative ◽  
Assessment Tools ◽  
Metropolitan Region ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Tumor Patient ◽  
Interhospital Transfer ◽  
Prehospital Triage

Background and Purpose: Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. Methods: Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. Results: Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0–61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. Conclusions: The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.

Abstract TMP64: In-Field Paramedic Validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) Algorithm for Endovascular Thrombectomy

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Henry Zhao ◽  
Karen Smith ◽  
Stephen Bernard ◽  
Michael Stephenson ◽  
Mark Parsons ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Fast Algorithm ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Acute Stroke Treatment

009 The ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithmic pre-hospital triage tool for endovascular thrombectomy: ongoing paramedic validation

2018 ◽  
Vol 89 (6) ◽  
pp. A5.1-A5
Author(s):  
Henry Zhao ◽  
Lauren Pesavento ◽  
Edrich Rodrigues ◽  
Patrick Salvaris ◽  
Karen Smith ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Validation Study ◽  
Fast Algorithm ◽  
Predictive Value ◽  
Vessel Occlusion ◽  
Royal Melbourne Hospital ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Class 1 ◽  
Acute Stroke Treatment

IntroductionThe ambulance clinical triage-for acute stroke treatment (ACT-FAST) algorithm is a severity based 3-step paramedic triage tool for pre-hospital recognition of large vessel occlusion (LVO), designed to improve specificity and paramedic assessment reliability compared to existing triage scales. ACT-FAST sequentially assesses 1. Unilateral arm fall to stretcher <10 s; 2a. Severe language disturbance (right arm weak), or 2b. Severe gaze deviation/hemi-neglect assessed by shoulder tap (left arm weak); 3. Clinical eligibility questions. We present the results of the ongoing Ambulance Victoria paramedic validation study.MethodsAmbulance Victoria paramedics assessed ACT-FAST in all suspected stroke patients pre-hospital in metropolitan Melbourne, Australia, and in the Royal Melbourne Hospital Emergency Department since July 2017. Algorithm results were validated against a comparator of ICA/M1 occlusion on CT-angiography with NIHSS ≥6 (Class 1 indications for endovascular thrombectomy).ResultsData were available from n=119 assessments (ED n=68, pre-hospital n=51). Patient diagnoses were LVO n=20 (15.6%), non-LVO infarcts n=45 (38.5%), ICH n=10 (8.3%) and no stroke on imaging n=44 (37.6%). ACT-FAST showed 85% sensitivity, 88.9% specificity, 60.7% (72% excluding ICH) positive predictive value and 96.7% negative predictive value for LVO. Of 10 false-positives, 4 received thrombectomy for non-Class 1 indications (basilar/M2 occlusions/cervical dissection), 3 were ICH, and 1 was tumour. Three false-negatives were LVO with milder syndromes.DiscussionThe ongoing ACT-FAST algorithm validation study shows high accuracy for clinical recognition of LVO. The streamlined algorithmic approach with just two examination items provides a more practical option for implementation in large emergency service networks. Accurate pre-hospital recognition of LVO will allow bypass to endovascular centres and early activation of neuro-intervention services to expedite endovascular thrombectomy.

scholarly journals A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage

2019 ◽  
Vol 28 (6) ◽  
pp. 1759-1766
Author(s):  
Emily B. Finn ◽  
Meredith J. Campbell Britton ◽  
Alana P. Rosenberg ◽  
John E. Sather ◽  
Evie G. Marcolini ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Intracranial Hemorrhage ◽  
Interhospital Transfer

Interhospital Transfer Delays Anticoagulation Reversal in Warfarin-Associated Intracranial Hemorrhage

2018 ◽  
Vol 27 (11) ◽  
pp. 3345-3349
Author(s):  
Anne Zepeski ◽  
Stacey Rewitzer ◽  
Enrique C Leira ◽  
Karisa Harland ◽  
Brett A. Faine
Keyword(s):  
Intracranial Hemorrhage ◽  
Anticoagulation Reversal ◽  
Interhospital Transfer

Abstract P355: Real-Word Performance of Two Automated Software Platforms for Identification of Salvageable Tissue in Stroke Patients: A Single Center Experience

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Angelos Katramados ◽  
Horia Marin ◽  
Maximilian Kole ◽  
Owais Alsrouji ◽  
Pala Varun ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Significant Discrepancy ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Software Platforms ◽  
Automated Software ◽  
Selection Of Patients ◽  
Selection Of

Background and purpose: Modern stroke treatment has been revolutionized by image-guided selection of patients for endovascular thrombectomy. Current automated platforms allow for real-time identification of large vessel occlusion and salvageable brain tissue. We sought to evaluate the performance of these platforms with regard to identification of infarcted and salvageable tissue. Methods: We studied all patients that presented to Henry Ford Health System hospitals over a period of 6 weeks, received CT perfusion imaging of the brain upon initial presentation. The images were processed with two automated software platforms. We prospectively measured volumes of tissue with cerebral blood flow (CBF) < 30% of contralateral hemisphere, Tmax >6 secs, and hypoperfusion indices (defined as the ratio of volumes Tmax>10 secs and Tmax>6 secs). We compared the outputs of the two platforms and analyzed the performance of each platform. Results: 66 scans were included in our study. Both platforms were able to image all stroke patients within their FDA-approved indications. With regard to all scans, both platforms were noted to demonstrate comparable CBF<30% volumes (6.32 ml. vs 4.97 ml, p=0.276), and hypoperfusion indices (0.278 vs 0.338, p=0.344). However, there was statistically significant discrepancy in the volumes of tissue with Tmax>6 secs (23.96 vs 14.18 ml, p=0.023). Analysis of a subset of 12 scans, with evidence of LVO or severe symptomatic stenosis on corresponding CTA, showed again comparable CBF<30% volumes (12.84 ml vs 13.67 ml, p=0.725), and hypoperfusion indices (0.344 vs 0.314, p=0.699). However, the Tmax>6 secs volume discrepancy was greater and still statistically significant (75.54 ml vs 39.58 ml, p=0.048) Conclusions: Automated software platforms are an invaluable aid in the identification of salvageable tissue, and selection of patients for endovascular thrombectomy in the 6-24 hour window. However, the substantial difference in the identified volumes of hypoperfused tissue-at-risk may result in largely different clinical decisions and patient outcomes. Further validation efforts (and harmonization of algorithms) are required. Stroke teams should be aware of the limitations of automated analysis and need for expert review.

Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000013049
Author(s):  
Aristeidis H Katsanos ◽  
Konark Malhotra ◽  
Niaz Ahmed ◽  
Georgios Seitidis ◽  
Eva A. Mistry ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Individual Patient Data ◽  
Patient Data ◽  
Neurological Deterioration ◽  
Endovascular Thrombectomy ◽  
Early Neurological Deterioration ◽  
Symptomatic Intracranial Hemorrhage

Objective:To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).Methods:A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.Results:A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.Conclusion:Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.

Abstract TP272: Air versus Ground Transport for Interhospital Transfer Prior to Endovascular Stroke Treatment

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Michael T Froehler ◽  
Matthew R Fusco ◽  
Rohan Chitale ◽  
David S Liebeskind ◽  
Osama O Zaidat ◽  
...  
Keyword(s):  
Stroke Treatment ◽  
Interhospital Transfer

scholarly journals Lessons from Recent Advances in Ischemic Stroke Management and Targeting Kv2.1 for Neuroprotection

2020 ◽  
Vol 21 (17) ◽  
pp. 6107 ◽  
Author(s):  
Chung-Yang Yeh ◽  
Anthony J. Schulien ◽  
Bradley J. Molyneaux ◽  
Elias Aizenman
Keyword(s):  
Ischemic Stroke ◽  
Time Window ◽  
Stroke Therapy ◽  
Stroke Management ◽  
Preclinical Research ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Cell Death Pathway ◽  
To Receive ◽  
Neuroprotective Therapies

Achieving neuroprotection in ischemic stroke patients has been a multidecade medical challenge. Numerous clinical trials were discontinued in futility and many were terminated in response to deleterious treatment effects. Recently, however, several positive reports have generated the much-needed excitement surrounding stroke therapy. In this review, we describe the clinical studies that significantly expanded the time window of eligibility for patients to receive mechanical endovascular thrombectomy. We further summarize the results available thus far for nerinetide, a promising neuroprotective agent for stroke treatment. Lastly, we reflect upon aspects of these impactful trials in our own studies targeting the Kv2.1-mediated cell death pathway in neurons for neuroprotection. We argue that recent changes in the clinical landscape should be adapted by preclinical research in order to continue progressing toward the development of efficacious neuroprotective therapies for ischemic stroke.

scholarly journals Sensitivity and specificity of indirect ELISA for the detection of antibody titers against BVDV from beef cattle raised in Pará State

2017 ◽  
Vol 38 (5) ◽  
pp. 3049
Author(s):  
Rinaldo Batista Viana ◽  
Aline do Socorro Lima Kzam ◽  
Bruno Moura Monteiro ◽  
Cláudio Cabral Campello ◽  
Eliomar De Moura Sousa ◽  
...  
Keyword(s):  
Beef Cattle ◽  
Predictive Value ◽  
False Negative ◽  
Foot And Mouth Disease ◽  
Metropolitan Region ◽  
Enzyme Linked Immunosorbent Assay ◽  
Significance Level ◽  
Bovine Kidney ◽  
Diarrhea Virus ◽  
Positive Diagnosis

The aims of this study were to establish the prevalence of anti-bovine viral diarrhea virus (BVDV) antibodies (Ab) in beef cattle raised in Pará state, to compare the prevalence of seropositive animals to BVDV using a commercial indirect enzyme-linked immunosorbent assay kit (iELISA) and the virus neutralization (VN) test, and finally, to determine the sensitivity (Se) and specificity (Sp) of the iELISA for the detection of anti-BVDV Ab using VN as a gold standard. A total of 400 serum blood samples from Nelore cows aged at least 24 months from five farms in the Pará state from two mesoregions (Metropolitan Region of Belem and Northeast of Pará) were analyzed. All animals were vaccinated against brucellosis and foot-and-mouth disease. The examination of anti-BVDV Ab with VN was performed in the Laboratory of Bovine Viruses of the Biological Institute of Sao Paulo as described in the Manual of Diagnostic Tests and Vaccines for Terrestrial Animals. For VN, bovine kidney epithelial cells from the Madin Darby Bovine Kidney (MDBK) strain were used. The determinations of anti-BVDV Ab were performed with the iELISA test at the Laboratory of Immunology and Microbiology of the Federal Rural University of Amazonia according to the manufacturer's recommendations. The results were classified as follows: (a) correct positive diagnosis, (b) incorrect positive diagnosis, (c) correct negative diagnosis, and (d) incorrect negative diagnosis, according to the results obtained from VN. From the values obtained from VN and iELISA, Se [(a ÷ a + d) × 100], Sp [(c ÷ c + b) × 100], positive predictive value [(a ÷ a + B) × 100], and negative predictive value [(c ÷ c + d) × 100] were calculated for iELISA. The frequencies (%) of seropositive animals were determined and compared both between the different tests (iELISA and VN) and between the different farms (1, 2, 3, 4, and 5). The statistical analysis was performed with a significance level of 5%. The prevalence of seropositive animals was found to be different (P < 0.0001) using VN (39.25% [157/400]) and iELISA (54.50% [218/400]). It was observed that the Se and Sp of the iELISA assay were 98.72% and 74.07%, respectively. Of the total, 25.93% (63/243) of the samples were considered false-positive and 1.27% false-negative (2/157). It was concluded that the BVDV infection is present in beef cattle herds of the state of Para. Based on the speed of execution, ease of handling, and high Se of the iELISA, it is suggested that this assay can be used as a screening test for the detection of anti-BVDV Ab with the aim of eliminating infected animals from large herds of beef cattle.

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