Time to Treatment with Intravenous Tissue Plasminogen Activator and Outcome from Acute Ischemic Stroke

National Institute Of Neurological Disorders And Stroke

KEY POINTS
In patients with suspected acute stroke, immediate brain imaging, most frequently with computed tomography (CT), is essential to distinguish between an ischemic lesion and a hemorrhage.[1][1] In ischemic stroke, timely treatment with intravenous tissue plasminogen activator or

/pdf/the-mobile-stroke-unit-and-management-of-acute-stroke-in-49df0atndd.pdf

The mobile stroke unit and management of acute stroke in rural settings

Mimics account for almost half of hospital admissions for suspected stroke. Stroke mimics may present as a functional (conversion) disorder or may be part of the symptomatology of a neurological or...

Stroke mimics: incidence, aetiology, clinical features and treatment

Acute stroke is a treatable disease Nevertheless, only a minority of patients obtain guideline-adjusted therapy One major reason is the small time window in which therapies have to be administered in order to reverse or mitigate brain injury and prevent disability The Mobile Stroke Unit (MSU) concept, available for a decade now, is spreading worldwide, comprising ambulances, fully equipped with computed tomography, laboratory unit and telemedicine connection to the stroke centre and staffed with a specialised stroke team Besides its benefits, this concept adds a relevant amount of costs to health services The feasibility of the MSU and its impact on reducing treatment times have been proven by several research trials In addition, pre-hospital stroke diagnosis including computed tomographic angiography analysis facilitates correct triage of patients, needing mechanical recanalization, thereby reducing the number of secondary or inter-hospital transfers Even so, the concept is not yet fully implemented on a broad scale One reason is the still open question of cost-effectiveness There are assumptions based on the randomised trials of MSUs hinting towards an acceptable amount of money per quality-adjusted life years and overall cost-effectiveness Up to now, neither a prospective analysis nor a consideration of secondary transfer avoidance is available The MSU concept is an innovative and impactful strategy to improve stroke management, especially in times of constraints in healthcare economics and health care professionals Prospective information is needed to answer the cost-effectiveness question satisfactorily

Mobile Stroke Units - Cost-Effective or Just an Expensive Hype?

Background Evaluation of patients with a suspected stroke is one of the most common neurological emergencies requiring rapid, comprehensive assessment by the stroke service to determine patient eligibility for timely reperfusion therapies. Prehospital evaluation may help to improve patient selection and reduce avoidable admissions to overcapacity emergency departments. Methods and results We report on our early experience of prehospital triage of patients with a suspected stroke using a mobile stroke unit (MSU) equipped with CT scanner in rural Alberta. During the initial 4 months of operation, 28 patients were evaluated by the team in the MSU. Eight patients were within the time window of thrombolysis and were treated with intravenous tissue plasminogen activator in the MSU. No patients suffered haemorrhage or any other complications. Fourteen patients with multiple aetiologies (stroke mimics 6, transient ischaemic attacks 2, subacute stroke outside thrombolysis window 2, intracranial haemorrhage 3 and cerebral contusion 1) were assessed in the field and transferred to the tertiary hospital. Six patients after assessment and imaging were repatriated back to the local hospital as they were deemed stroke mimics or were outside of the reperfusion window. Conclusions The MSU offers a novel approach to performing timely evaluation and treatment of patients with a suspected stroke in rural settings and may help reduce admissions to overcapacity tertiary care facilities.

Mobile stroke unit triage of patients with a suspected stroke: a novel solution to reducing suspected stroke admissions in busy emergency departments

We present a conceptual approach to determine the optimal solution to delivering a health technology, consistent with the objective of maximizing patient outcomes subject to resources available to a publicly funded health system. The article addresses two key policy questions: 1) adding system values through appropriate planning of health services delivery and 2) considering the tradeoff between patient outcomes and costs to the health system through appropriate use of health technologies for conditions with time-dependent treatment outcomes. We develop a health technology optimization framework that considers geographical variation and searches for the best delivery method through a pairwise comparison of all possible strategies, factoring in controlled variables including disease epidemiology, time or distance to hospitals, available medical services, treatment eligibility, treatment efficacy, and costs. Taking variations of these factors into account would help support a more efficient allocation of health resources. Drawing identified strategies together then creates a map of optimal strategies. We apply the proposed method to a policy-relevant health technology assessment of endovascular therapy (EVT) for treating acute ischemic stroke. The best strategy for providing EVT relies on the geographical location of stroke onset and the decision maker's preference for either patient outcomes or economic efficiency. The proposed method produced an optimization map showing the optimal strategy for EVT delivery, which maximizes patient outcomes while minimizing health system costs. In the illustrative case study, there were no tradeoffs between health outcomes and costs, meaning that the delivery strategies that were clinically optimal for patients were also the most cost-effective. In conclusion, the health technology optimization approach is a useful tool for informing implementation decisions and coordinating the delivery of complex health services such as EVT.

https://journals.sagepub.com/doi/pdf/10.1177/2381468318774804

Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application.

Background: Telehealth videoconference technology shows promise in reducing rural-urban disparities in access to acute stroke care but more population-based studies are needed. The APSS has created a province-wide telehealth network (telestroke) centred around northern (University of Alberta Hospital) and southern (University of Calgary) tertiary care hub centres. In the northern half of the province we assessed the hypothesis that thrombolysis outcomes for stroke patients were similar in those treated using telestroke versus those treated without telestroke. Methods: The APSS created a prospective minimum dataset in June 2007 requiring submission of data for all ischemic stroke patients treated with tPA in the province. This dataset captures information on onset, arrival, and treatment times, whether telehealth was used, and occurrence of intracerebral hemorrhage associated with neurological worsening. From 2009 on we were able to differentiate post tPA petechial hemorrhage from intracerebral hematoma (ICH) in the database. Data were available for the northern half of the province. We examined door-to-treatment time using Wilcoxan rank - sum tests, and rate of neurological worsening associated with hemorrhage on brain CT using logistic regression. Results: In the northern half of the province, there were a total of 554 patients treated with tPA from 2007/08 until 2010/11. Telestroke was utilized in 119 of these (21%) from 9 rural Primary Stroke Centres. Of 435 patients who received tPA without telestroke, 318 (73%) were from one Comprehensive Stroke Centre and 117 (27%) were from three Primary Stroke Centres with neurologists or internists on-site. Telestroke patients had a mean age of 70y compared to 71y for non-telestroke patients. Median (Q1, Q3) door to needle time was 84 min (66, 105) in telestroke patients and 83 min (65, 107) in non-telestroke patients (p=0.337). Neurological worsening associated with either petechial hemorrhage or intracerebral hematoma by 36 hours occurred in 5.29% of non-telestroke patients and 8.4% of telestroke patients; this difference was not statistically significant (OR 0.608; p=0.207). The rate of neurological worsening associated with intracerebral hematoma was 3.0% to 7.9% for telestroke patients and 3.6% to 5.6% for non-telestroke patients when we examined 2009-10 and 2010-11 (OR 0.814; p= 0.732). Conclusion: With one hub centre it is feasible to create a telehealth network over a very large geographic area improving access to stroke care for remote rural communities. Door-to-treatment time and rate of hemorrhagic complications are comparable in telestroke-treated versus non telestroke-treated patients in real practice. Investment in telestroke is likely justified for health regions serving a large and scattered rural population.

Abstract 3107: Thrombolysis Using Telehealth Has Comparable Results To Non- Telehealth Thrombolysis Across Northern Alberta: The Alberta Provincial Stroke Strategy (APSS)

Shy Amlani

Papers

Mobile stroke unit triage of patients with a suspected stroke: a novel solution to reducing suspected stroke admissions in busy emergency departments

Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application.

Abstract 3107: Thrombolysis Using Telehealth Has Comparable Results To Non- Telehealth Thrombolysis Across Northern Alberta: The Alberta Provincial Stroke Strategy (APSS)