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Endovascular therapy performed in six primary stroke centers and six comprehensive stroke centers in Kawasaki City, Japan, by Maria Prehospital Stroke Scale (MPSS) score.
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Aim
To establish prehospital triage in accordance with the new guidelines for endovascular therapy, we retrospectively analyzed the monitoring data of the city‐wide transportation system using the Maria Prehospital Stroke Scale (MPSS), a novel prehospital stroke scale for emergency medical technicians (EMTs) to predict the likelihood of thrombolyti...
Context in source publication
Context 1
... patients with an MPSS score ranging from 2 to 5, endovascular therapy was also carried out in the PSCs, but patients with delayed admission (onset-to-door time >120 min) did not receive endovascular therapy in the PSCs. The performance rate of endovascular therapy according to MPSS score and type of hospital in patients with ischemic stroke and admission within 6 h (onset-to-door time <360 min) are shown in Fig- ure 2. The performance rate increased along with the MPSS score in CSCs from 4.6% for patients with MPSS score 1, to 33.3% in patients with MPSS score 5. ...
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Citations
... However, the scores should be re-evaluated in the local setting in order to be able to improve the concept in a targeted manner e.g. change of the score used or the cut-off used (example of a study in a local setting [38]). A clear recommendation for a single score (one fits all) is currently not made [8]. ...
Background
Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured.
Main body
Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the “flying/driving interentionalists” are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety.
Conclusion
The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.
... 71) The observation, care, and prehospital triage of patients are standardized to ensure that ambulance staff appropriately transport patients with a possible stroke to specialized facilities, 72) hospitals where acute reperfusion therapy, including IV thrombolysis and mechanical thrombectomy, should be clarified to optimize the means for transporting patients according to the local medical resources. Ambulance staff make a triage of patients with a possible stroke and hospital selection using the prehospital stroke scale [73][74][75][76][77][78] defined in a community where severity and specificity have been verified, and they inform the emergency hospital of the transportation of patients with the potential to perform reperfusion therapy as soon as possible to reduce the time to initiate treatment after the patient's arrival at the hospital. 79,80) ...
... In recent years the literature has focussed on tools that have a higher specificity for acute strokes with LVO. The Rapid Arterial Occlusion Evaluation (RACE), Los Angeles Motor Score (LAMS), Cincinnati Pre-hospital Stroke Severity Score (CPSSS), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), National Institute of Stroke Scale 8 (NIHSS-8) and a host of other scores have been investigated (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). Typically, scales are derived from retrospective data sets with very few undergoing prospective field validation. ...
p style="margin: 0cm 0cm 0pt; line-height: 200%;"> Background
Occlusions of large cerebral vessels, including the internal carotid artery and middle cerebral artery, result in significant burden of morbidity. Treatment was previously limited to intravenous thrombolysis, however multiple studies have shown significant improvements when patients undergo endovascular clot retrieval. Early identification and triage to centres capable of delivering this is likely to contribute to improved outcomes. This systematic review aims to compare clinical assessment tools and their performance ‘in-field’ to identify usability and reliability to assist pre-hospital providers with identification of this sub-group of stroke patients.
Methods
Several databases were reviewed to identify studies that have validated large vessel occlusion clinical assessment tools within the pre-hospital environment. Sensitivity, specificity and predictive value were compared along with any biases. Six studies met the study criteria and were included. A total of 1384 patients were involved in the studies with sensitivities ranging from 51.9% to 100% and specificities ranging from 68% to 90%.
Conclusion
There is significant variation among studies and the emergency medical systems they have been performed within. It is likely that no single tool will suit every system and further research is required to determine the best tool for the Australian pre-hospital environment. </p
... However, the "typical" occupational class gradient in CVD that we have come to expect in contemporary Western settings has not been universally observed across time and space. 15 For example, in Japan, while high-quality medical care has been achieved irrespective of socioeconomic status through universal health coverage, annual health check-ups, and community-based comprehensive emergency medical service networks, [16][17][18][19][20] the socioeconomic distribution of major risk behaviors differs markedly from Western countries. Specifically, we have observed that higher-occupational class individuals tend to smoke and drink as much (or sometimes even more) compared with their lower-occupational class counterparts. ...
Background: In contemporary Western settings, higher occupational class is associated with lower risk for cardiovascular disease
(CVD) incidence, including coronary heart disease (CHD) and stroke. However, in non-Western settings (including Japan), the
occupational class gradient for cardiovascular disease risk has not been characterized.
Methods and Results: Using a nationwide, multicenter hospital inpatient data set (1984–2016) in Japan, we conducted a
matched hospital case-control study with ~1.1 million study subjects. Based on a standard national classification, we coded
patients according to their longest-held occupational class (blue-collar, service, professional, manager) within each industrial
sector (blue-collar, service, white-collar). Using blue-collar workers in blue-collar industries as the referent group, odds
ratios and 95% CIs were estimated by conditional logistic regression with multiple imputation, matched for sex, age, admission
date, and admitting hospital. Smoking and drinking were additionally controlled. Higher occupational class (professionals and
managers) was associated with excess risk for CHD. Even after controlling for smoking and drinking, the excess odds
across all industries remained significantly associated with CHD, being most pronounced among managers employed in
service industries (odds ratio, 1.19; 95% CI, 1.08–1.31). On the other hand, the excess CHD risk in higher occupational
class was offset by their lower risk for stroke (eg, odds ratio for professionals in blue-collar industries, 0.77; 95% CI, 0.70–
0.85).
Conclusions: The occupational “gradient” in cardiovascular disease (with lower risk observed in higher status occupations) may
not be a universal phenomenon. In contemporary Japanese society, managers and professionals may experience higher risk for
CHD.
Background:
Previous studies have demonstrated the efficacy of the "drip-and-ship" model in acute ischemic stroke (AIS) patients treated with intravenous (IV) thrombolysis. We investigated and report the outcomes of the safety and efficacy of the "drip-and-ship" model in AIS patients with acute large-vessel occlusion (LVO) in the anterior circulation who underwent endovascular treatment.
Methods:
A total of 92 AIS patients with LVO who underwent endovascular treatment enrolled from April 2017 to July 2018 at a single academic comprehensive stroke center (CSC) were included. Patients were divided into 2 groups: a front-door group (directly admitted to the CSC) and a drip-and-ship group (transferred to the CSC from other hospital). Logistic regression model was used to evaluate the functional outcome, mortality, and symptomatic intracranial hemorrhage (sICH) at 90 days.
Results:
After adjusting for age, gender, occlusion site, National Institutes of Health Stroke Scale (NIHSS) score, and other potential covariates, we did not see difference in modified Rankin Scale (mRS) score between the 2 groups at 90 days. The rate of excellent functional outcome (defined as mRS 0-1) in the drip-and-ship group is lower than the front-door group (p = 0.017); however, functional outcomes (defined as mRS 0-2) have no difference (p = 0.117). There was no significant difference in sICH (p = 0.909) and mortality (p = 0.319) between the 2 groups.
Conclusions:
The "drip-and-ship" model has the potential to be a feasible model for patients with LVO in the anterior circulation to undergo endovascular treatment. Further large-scale prospective studies are warranted to confirm these findings.
Background and purpose: The purpose of this study was to determine the factors for delayed diagnosis and treatment of in-hospital stroke. Methods: We retrospectively analyzed the data of consecutive patients with in-hospital stroke. We divided the patients into the early group (within 3 hours) and the delayed group (more than 3 hours) based on the time from the onset to the treatment by a stroke specialist, and analyzed the factors related to the delayed group by multivariate analysis. Results: There were 89 in-hospital stroke patients (mean age 73.6±9.0 years) registered from January 2012 to December 2014. In the early group of 37 patients, 62.2% of them had contraindications to iv-tPA. Compared to the delayed group, the early group included more patients with atrial fibrillation (17 cases, 45.9%) and more nurses as first callers (78.4%). Notably, it took 53.6±31.2 minutes for taking images even in the early group. Multivariate logistic analysis revealed that the “first caller was a doctor” was a significant factor for delay (OR=8.572, 95% CI 2.186–33.617, p=0.002), and the presence of atrial fibrillation was a significant avoidance factor for delay (OR=0.140, 95% CI 0.024–0.801, p=0.027). Conclusions: Three factors were considered to be important factors for delay (the location of discover, job type of the first discoverer, and the response of the primary doctor), suggesting the importance to build an in-hospital triage system and to educate medical staff.
Objective:
Current prehospital scales used to detect large vessel occlusion reveal very low endovascular thrombectomy (EVT) rates among selected patients. We developed a novel prehospital scale, the Madrid-Direct Referral to Endovascular Center (M-DIRECT), to identify EVT candidates for direct transfer to EVT-capable centers (EVT-Cs). The scale evaluated clinical examination, systolic blood pressure, and age. Since March 2017, patients closer to a stroke unit without EVT capabilities and an M-DIRECT positive score have been transferred to the nearest EVT-C. To test the performance of the scale-based routing protocol, we compared its outcomes with those of a simultaneous cohort of patients directly transferred to an EVT-C.
Methods:
In this prospective observational study of consecutive patients with stroke code seen by emergency medical services, we compared diagnoses, treatments, and outcomes of patients who were closer to an EVT-C (mothership cohort) with those transferred according to the M-DIRECT score (M-DIRECT cohort).
Results:
The M-DIRECT cohort included 327 patients and the mothership cohort 214 patients. In the M-DIRECT cohort, 227 patients were negative and 100 were positive. Twenty-four (10.6%) patients required secondary transfer, leaving 124 (38%) patients from the M-DIRECT cohort admitted to an EVT-C. EVT rates were similar for patients with ischemic stroke in both cohorts (30.9% vs 31.5%). The M-DIRECT scale had 79% sensitivity, 82% specificity, and 53% positive predictive value for EVT. Recanalization and independence rates at 3 months did not differ between the cohorts.
Conclusions:
The M-DIRECT scale was highly accurate for EVT, with treatment rates and outcomes similar to those of a mothership paradigm, thereby avoiding EVT-C overload with a low rate of secondary transfers.
The Kawasaki City Emergency Team used the Maria Prehospital Stroke Scale (MPSS) developed in our hospital to perform prehospital triage on stroke patients and undertake bypass transportation with the intent of administering intravenous tissue plasminogen activator (tPA) therapy. This study aimed to compare treatment results for citywide MPSS transportation cases with the results of intravenous tPA therapy in our hospital Stroke Care Unit (SCU) and to clarify future issues. Subjects comprised 1545 cerebral infarction patients admitted to our hospital during the 6 years from 2010 through 2015, and 89 patients who underwent intravenous tPA therapy. We also analyzed and compared treatment results for 4429 cases of Kawasaki citywide MPSS transportation. Intravenous tPA therapy was performed in 5.8% of all patients with cerebral infarction admitted to our hospital and in 23.1% of patients with cerebral infarction undergoing MPSS transportation. National Institutes of Health Stroke Scale (NIHSS) score was significantly improved at around 24 h after tPA administration, and a modified Rankin Scale (mRS) score of 0-1 was achieved at discharge in 31.4% of patients at 13 Kawasaki Stroke Network facilities and in 36.4% of patients at our SCU. Comparison of patients who underwent intravenous tPA therapy between the MPSS transportation group (n = 55) and the other group (n = 34) found a shorter time from onset to intravenous tPA injection and a higher frequency of achieving a mRS score of 0-1 at discharge in the MPSS transportation group. To improve the performance of comprehensive stroke centers, continued post-verification study is needed of in-hospital multidisciplinary collaboration and emergency services involved in MPSS transportation. Further training of personnel involved in stroke treatment will also be important.
Background and purpose:
It is increasingly recognized that time is one of the key determinants in acute stroke outcome when interventional stroke therapy is applied. With increasing device efficacy and understanding of imaging triage options, reducing pre-treatment time loss may be a critical component of improving interventional stroke outcomes for the population at large. Time sensitive procedures such as organ harvest have transported physicians to the patient site to improve time to procedure. Applying this same principle to interventional stroke management may be a valid paradigm.
Methods:
Previous logistical deliberation with hospital and Medevac companies was carried out to provide the rationale and funding for helicopter transfer of a neurointerventionalist to an in-network hospital with an on-site angiographic suite. An appropriate patient with large vessel occlusion and an NIH Stroke Scale score >8 was identified. MRI was performed, then the Medevac transport system was activated and the intervention was carried out. Times were collected during the case and assessed for time efficiency.
Results:
The proof of concept case was identified and Medevac was consulted at 12:13 after verifying that no in-house emergencies would prevent physician departure. Weather clearance was obtained and stroke intervention confirmed as a go at 12:24. Groin puncture occurred at 13:07 and the intervention was completed at 13:41. The total time from decision-to-treat to groin puncture was 43 min and groin closure was completed at 77 min from decision-to-treat.
Conclusions:
This proof of concept case is presented for logistical, financial and use-case analysis. As it is a first case, times can likely be improved. We assert that this model may be another option in the spoke-and-hub design of stroke systems of care.
