Emergency Medical Services Support for Acute Ischemic Stroke Patients Receiving Thrombolysis at a Primary Stroke Center

Background Emergency Medical Services (EMS) is a vital link in the overall chain of stroke survival. A Primary Stroke Center (PSC) relies heavily on the 9-1-1 response system along with the ability of EMS personnel to accurately diagnose acute stroke. Other critical elements include identifying time of symptom onset, providing pre-hospital care, selecting a destination PSC, and communicating estimated time of arrival (ETA). Purpose Our purpose was to evaluate the EMS component of thrombolysed acute ischemic stroke patient care at our PSC. Methods In a retrospective manner we retrieved electronic copies of the EMS incident reports for every thrombolysed ischemic stroke patient treated at our PSC from September 2001 to August 2005. The following data elements were extracted: location of victim, EMS agency, times of dispatch, scene, departure, emergency department (ED) arrival, recordings of time of stroke onset, blood pressure (BP), heart rate (HR), cardiac rhythm, blood glucose (BG), Glasgow Coma Scale (GCS), Cincinnati Stroke Scale (CSS) elements, emergency medical personnel field assessment, and transport decision making. Results Eighty acute ischemic stroke patients received thrombolysis during the study interval. Eighty-one percent arrived by EMS. Two EMS agencies transported to our PSC. Mean dispatch-to-scene time was 6 min, on-scene time was 16 min, transport time was 10 min. Stroke onset time was recorded in 68%, BP, HR, and cardiac rhythm each in 100%, BG in 81%, GCS in 100%, CSS in 100%, and acute stroke diagnosis was made in 88%. Various diagnostic terms were employed: cerebrovascular accident in 40%, unilateral weakness or numbness in 20%, loss of consciousness in 16%, stroke in 8%, other stroke terms in 4%. In 87% of incident reports there was documentation of decision-making to transport to the nearest PSC in conjunction with pre-notification. Conclusion The EMS component of thrombolysed acute ischemic stroke patients care at our PSC appeared to be very good overall. Diagnostic accuracy was excellent, field assessment, decision-making, and transport times were very good. There was still room for improvement in documentation of stroke onset and in employment of a common term for acute stroke.

Yi-Gan San Restores Behavioral Alterations and a Decrease of Brain Glutathione Level in a Mouse Model of Schizophrenia

The traditional Chinese herbal medicine yi-gan san has been used to cure neuropsychological disorders. Schizophrenia can be one of the target diseases of yi-gan san. We aimed at evaluating the possible use of yi-gan san in improving the schizophrenic symptoms of an animal model. Yi-gan san or distilled water was administered to mice born from pregnant mice injected with polyinosinic-polycytidilic acid or phosphate buffered saline. The former is a model of schizophrenia based on the epidemiological data that maternal infection leads to psychotic disorders including schizophrenia in the offspring. Prepulse inhibition and sensitivity to methamphetamine in open field tests were analyzed and the total glutathione content of whole brains was measured. Yi-gan san reversed the decrease in prepulse inhibition, hypersensitivity to methamphetamine and cognitive deficits found in the model mice to the level of control mice. Total glutathione content in whole brains was reduced in the model mice but was restored to normal levels by yi-gan san treatment. These results suggest that yi-gan san may have ameliorating effects on the pathological symptoms of schizophrenia.

Telemedicine and Alzheimer's Disease from Studio-Based Videoconferencing to Mobile Handheld Cell Phones

The use of Telemedicine in the assessment of cognitive impairment and Alzheimer's Disease is evolving with advances in Information and Communication Technology. This article outlines the course of evolution in Western Australia, a large state with a sparse population outside of the capital city. The starting point of the evolution, video-conferencing in Telehealth studios, is reviewed as well as the next stage, use of desktop technology, which enables the physician to consult from the office or clinic. A pilot study currently being undertaken to assess the validity of the latest stage in evolution of Telehealth—the use of handheld mobile cell phone video calling that allows the physician and patient to interact at locations convenient to both parties. The pitfalls and implications of the use of this stage, should it prove to be a valid approach, are discussed.

Views of Emergency Physicians on Thrombolysis for Acute Ischemic Stroke

Background The 3-hour window for treating stroke with intravenous tissue plasminogen activator (t-PA) requires well-organized, integrated efforts by emergency physicians and stroke neurologists. Objective To evaluate attitudes and knowledge of emergency physicians about intravenous t-PA for acute ischemic stroke, particularly in primary stroke centers (PSCs) with stroke neurology teams. Methods A 15-question pilot Internet survey administered by the Arizona College of Emergency Physicians. Results Between March and August 2005, 100 emergency physicians responded: 71 in Arizona and 29 in Missouri. Forty-eight percent practiced at PSCs; 48% thought t-PA was effective, 20% did not, and 32% were uncertain. PSC or non-PSC location of practice did not influence endorsement (odds ratio, 0.96; 95% confidence interval, 0.27–1.64). Of those opposing t-PA, 87% cited risk of hemorrhage. Conclusions Most emergency physicians did not endorse t-PA. Improved collaboration between emergency physicians and stroke neurologists is needed.

Teleradiology and Emergency Neurosurgery-Presence in a Small Asian City State and Need in a Large Canadian Province

Teleradiology involving the transfer of vital patient information such as scan images is an important technology to facilitate effective and efficient provision of neurosurgical care in the setting of scarce resources and geographic isolation. We review the implementation of teleradiology initiatives in the small city state of Singapore and its potential and need in the large province of Ontario and draw parallels in their strategic implementation. Although it may seem intuitive that teleradiology has greater applications in regions of vast geographical size, the technology has universal usefulness if applied appropriately in any neurosurgical or health care system.

Telesurgery of Microscopic Micromanipulator System “NeuRobot” in Neurosurgery: Interhospital Preliminary Study

Object Robotic surgery can be applied as a novel technology. Our master-slave microscopic-micromanipulator system (NeuRobot), which has a rigid endoscope and three robot-arms, has been developed to perform neurosurgical procedures, and employed successfully in some clinical cases. Although the master and slave parts of NeuRobot are directly connected by wire, it is possible to separate each part and to apply it to telesurgery with some modifications. To evaluate feasibility of NeuRobot in telesurgery, some basic experiments were performed. Methods The quality of telemedicine network system between Shinshu University and one of the affiliated hospitals, which was completely separated from other public network systems, was investigated. The communication delay was calculated from the transmitting and the receiving records in the computers set in each hospital. The relationship between the change in communication delay from the master part to the slave part of NeuRobot (0, 100, 300, 500 and 700 ms) respectively and feasibility of NeuRobot was investigated. The task performance time in each time changing group was compared. Feasibility of NeuRobot in telesurgical usage was evaluated. The master part and the slave part of NeuRobot placed in each hospital were connected through private network system. Interhospitally connected NeuRobot was compared with directly connected one in terms of task performance time. Results Less than 1 ms was required for corresponding the data in a steady transmitting state. Within 2 seconds after connection, relative time delay (maximum 40 ms) and packet loss were sometimes observed. The mean task performance time was significantly longer in over 500 ms delayed group compared with directly connected NeuRobot. There was no significant difference in the task performance time between directly connected NeuRobot and interhospitally connected NeuRobot. Conclusion Our results proved that telesurgical usage of NeuRobot was feasible. Telesurgical usage of telecontrolled manipulator system is recommended for application in a private network system in order to reduce technical and ethical problems. Some technical innovations will bring breakthrough to the telemedicine field.

Type D Syndrome of Inappropriate Antidiuretic Hormone Secretion in a Schizophrenia Patient with Polydipsia

A 55-year-old man with schizophrenia developed water intoxication due to primary polydipsia. His manner of antidiuretic hormone secretion was investigated by water loading and infusion of hypertonic saline to clarify the form of the syndrome of inappropriate antidiuretic hormone secretion. The plasma antidiuretic hormone level, which may be involved in the occurrence of water intoxication, was consistently low in this patient, and linked to type D syndrome of inappropriate antidiuretic hormone secretion, designated “hypovasopressinemic antidiuresis”. Although this type is not common, it should be considered as a pathophysiology for water intoxication in schizophrenia patients.

Identification of Stroke Mimics in the Emergency Department Setting

Background and Purpose Previous studies have shown a stroke mimic rate of 9%–31%. We aimed to establish the proportion of stroke mimics amongst suspected acute strokes, to clarify the aetiology of stroke mimic and to develop a prediction model to identify stroke mimics. Methods This was a retrospective cohort observational study. Consecutive “stroke alert” patients were identified over nine months in a primary stroke centre. 31 variables were collected. Final diagnosis was defined as “stroke” or “stroke mimic”. Multivariable regression analysis was used to define clinical predictors of stroke mimic. Results 206 patients were reviewed. 22% were classified as stroke mimics. Multivariable scoring did not help in identification of stroke mimics. 99.5% of patients had a neurological diagnosis at final diagnosis. Discussion 22% of patients with suspected acute stroke had a stroke mimic. The aetiology of stroke mimics was varied, with seizure, encephalopathy, syncope and migraine being commonest. Multivariable scoring for identification of stroke mimics is not feasible. 99.5% of patients had a neurological diagnosis. This strengthens the case for the involvement of stroke neurologists/stroke physicians in acute stroke care.