Emergency Stroke Research Articles

Impact of the COVID-19 pandemic on emergency admission for patients with stroke: a time series study in Japan

BackgroundAppropriate treatment of stroke immediately after its onset contributes to the improved chances, while delay in hospitalisation affects stroke severity and fatality. This study aimed to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on emergency hospitalisation of patients with stroke in Japan.MethodsThis was an observational study that used nationwide administrative data of hospitalised patients diagnosed with stroke. We cross-sectionally observed patients’ background factors during April and May 2020, when the COVID-19 pandemic-related state of emergency was declared; we also observed these factors in the same period in 2019. We also modelled monthly trends in emergency stroke admissions, stroke admissions at each level of the Japan Coma Scale (JCS), fatalities within 24 h, stroke care unit use, intravenous thrombolysis administration, and mechanical thrombectomy implementation using interrupted time series (ITS) regression.ResultsThere was no difference in patients’ pre-hospital baseline characteristics between the pre-pandemic and pandemic periods. However, ITS regression revealed a significant change in the number of emergency stroke admissions after the beginning of the pandemic (slope: risk ratio [RR] = 0.97, 95% confidence interval [CI]: 0.95–0.99, P = 0.027). There was a significant difference in the JCS score for impaired consciousness in emergency stroke, which was more severe during the pandemic than the pre-pandemic (JCS3 in level: RR = 1.75, 95% CI: 1.29–2.33, P < 0.001). There was no change in the total number of fatalities with COVID-19, compared with those without COVID-19, but there were significantly more fatalities within 24 h of admission (fatalities within 24 h: RR = 1.75, 95% CI: 1.29–2.33, P < 0.001).ConclusionsThe infection prevalence of COVID-19 increased the number of fatalities within 24 h as well as the severity of illness in Japan. However, there was no difference in baseline characteristics, intravenous thrombolysis administration, and mechanical thrombectomy implementation during the COVID-19 pandemic. A decrease in the number of patients and fatalities was observed from the time the state of emergency was declared until August, the period of this study.

Helicopter emergency medical service for time critical interfacility transfers of patients with cardiovascular emergencies

BackgroundThe goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland.MethodsThis retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland’s largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated.FindingsA total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km.InterpretationCentralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain.Graphical

Building a Mobile Stroke Unit Based on 5G Technology - A Study Protocol.

Background: In-time treatment of acute stroke is critical to saving people’s lives and improving the quality of post-stroke life. A mobile stroke unit (MSU) with fifth-generation (5G) mobile networks strengthens the interaction of patient information and healthcare resources, thereby reducing response times and improving thrombolysis results. However, clinical evidence of better outcomes compared to regular care is still lacking.Method and Design: In this randomized controlled trial, 484 patients with acute stroke are allocated into the MSU and regular care groups. We establish medical records for each patient and conduct a follow-up of 90 days. The primary outcomes are functional results as defined by utility-weighted modified Rankin Scale (uw-mRS) 90 days after the incidence occurred, whereas secondary outcomes include the alarm to CT scan completed time, the alarm to treatment decision time, the alarm to thrombolytic time, quality of life, and symptomatic intracranial hemorrhage combined with NIHSS score as well as cost-effectiveness.Discussion: This study establishes an innovative MSU (based on 5G) to manage acute stroke, comparing its clinical and economic outcomes to regular care and informing decision-makers of the effectiveness of the stroke emergency system.Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx?proj=63874], identifier [ChiCTR2000039695].

Effect of pre-hospital notification on delays and neurological outcomes in acute ischemic stroke

BackgroundSince timely thrombolytic therapy is a crucial variable in acute ischemic stroke recovery, health care systems are trying to find new interventions to reduce treatment delay in order to improve neurological function. In Iran, SAMA code as a pre-hospital notification plan has been developed to help emergent stroke treatment. This study aimed to compare delay to thrombolysis therapy and neurological outcomes between SAMA-transported and self-transported patients in ischemic stroke. MethodsIn this retrospective cohort study, the data of 185 stroke patients treated with intravenous thrombolysis from Mar 2016 to May 2020 were collected. P-value < 0.05 was considered as significant. ResultsThe results showed that delays reduced in SAMA-transported patient compared to that in self-transported patients. There was a significant difference in Onset to Needle time, Door to Needle Time, and Door to CT Time but not Onset to Door time between SAMA-transported and self-transported patients (P values: 0.001, 0.000, 0.001, and 0.22 respectively). However, there was no significant difference between two groups in terms of neurologic deficit severity. ConclusionsAlthough pre-hospital notification could partially reduce treatment delays in stroke, that reduction was not enough to impact on neurologic deficit recovery. It seems more reduction in delay is needed to significantly improve neurological dysfunctions.

Abstract 13739: Emergency Medical Services Calls During COVID-19: Bottleneck Explained&amp;lt;A Narrative Review&amp;gt;

Background: During COVID-19 peak in 2020, EMS calls have surged unprecedently internationally, causing global disruption in EMS dispatch centers’ services and significant delays in emergency response worldwide. This negatively impacted the chain of survival for cardiac and stroke, and other emergencies. No studies yet have been done to examine this phenomenon globally. Objectives: This paper examines the interrelated effects of the unprecedented global increase of EMS calls, the effect of the COVID-19 crisis on responding to non-COVID-19 emergencies; mainly cardiac and stroke emergencies- among others, and the concurrent effects of having overwhelmed dispatch centers. We examined the bottleneck phenomenon that resulted in the disruption of EMS calls in different countries, and found three main factors: 1.EMS-related factors 2.Social-related factors 3.Patient-related factors. For better understanding, we also explained each factor based on the available literature. Eligibility Criteria : We examined the numbers of EMS calls internationally between March and June 2020, derived from published literature and news media. Only articles in English were selected, with certain keywords related to EMS calls, ambulance delay, stroke and cardiac arrest. Results: After applying the selection criteria, a total of 29 citations were chosen, and a pattern of knowledge resulted in the emergence of five themes: •EMS calls during COVID-19 •Reduced EMS operator response time •Ambulance response delays •Collateral mortality and morbidity among non-COVID-19 cases •Total ambulance call time Conclusion: Over the course of COVID-19 progress, there was a global phenomenon of exponential increases in EMS calls, which is expected to impose a great pressure on EMS dispatch centers. Several factors contributing to the bottleneck of EMS calls are identified and explained. By understanding these factors and their collateral impact on EMS calls, we can implement better crises and disaster response plans. This is an informative paper to EMS decision makers worldwide. Key words: EMS calls, COVID-19, Ambulance response time, Pandemic response, EMS access, Ambulance delay

Rete Middle Cerebral Artery Anomaly Presenting with a Large Intracerebral Hemorrhage: A Case Report

AbstractRete MCA anomaly is extremely rare and has been seldomly discussed in literature. Embryologically MCA develops by fusion of multiple twigs which form a single channel. If there is failure to fuse a plexiform network of vessels persists known as rete MCA. This web like network of vessels is at high risk of haemorrhagic stroke and therefore for patients presenting incidentally correct diagnosis is paramount. Here we report a case of rete MCA anomaly in a 35-year-old gentle man who presented with a large haemorrhagic stroke in emergency. DSA showed unilateral involvement of proximal MCA, and otherwise normal intra-cranial vasculature. With this report we aim to correctly diagnose this rare condition and avoid misdiagnosis leading to unnecessary treatments.

Practice of integrated treatment process for acute ischaemic stroke in hospital coordinated by emergency stroke nurses.

AimsTo explore the practice effect of establishing an integrated treatment process by stroke emergency nurses in general hospitals for acute ischaemic stroke (AIS).DesignCompared the time spent in each link before and after the establishment of AIS integrated treatment.MethodsSince March 2016, we set up a team of emergency stroke nurses (ESN), trained and assessed the knowledge of emergency stroke, and set up a post of ESN.ResultsThe median time of admission‐judgement, admission‐establishment of venous access, admission‐cranial CT examination and admission‐intravenous thrombolytic therapy was statistically significantly shortened after the implementation of the integrated treatment process of AIS coordinated by stroke emergency nurses (p < .01). The new treatment process of AIS further shortens the time of each treatment link and promotes the timeliness.

Indigenous Australians have a greater prevalence of heart, stroke, and vascular disease, are younger at death, with higher hospitalisation and more aeromedical retrievals from remote regions.

SummaryBackgroundWe aimed to determine whether heart, stroke, and vascular disease (HSVD) prevalence and emergency primary evacuation (EPE), hospitalisation, and mortality differ by patient characteristics.MethodsAn Australian-wide incidence population based study, with prospective data collected form the 1 July 2019 to the 30 October 2020.FindingsIndigenous Australians reported significantly higher prevalence of HSVD at 229.0 per-1000 as compared to 152.0 per-1000 non-Indigenous Australians: risk ratio 1.5 (95% CI 1.2-1.8). 583 remote patients received an EPE for HSVD, consisting of 388 (66.6%; 95% CI: 62.6-70.4) males and 195 (33.0%; 95% CI: 29.6-37.4) females. There were 289 (49.6%; 95% CI 45.4- 53.7) patients who identified as Indigenous, and 294 (50.4%; 95% CI 46.3- 54.6) as non-Indigenous. The mean Indigenous age during EPE was 48.0 (95% CI 45.9-50.1) years old, significantly lower than the non-Indigenous mean age of 55.6 (95% CI 53.8-57.4). Indigenous patients hospitalised for HSVD were younger, the majority younger than 65 years (n=21175; 73.7% 95% CI 73.2-74.2) as compared to non-Indigenous patients (n= 357654; 33.1% 95% CI 33.0-33.15). When adjusted for HSVD prevalence, remote Indigenous patients had a higher hospitalisation rate as compared to non-remote Indigenous patients (rate ratio: 1.6; 95% CI 1.3-2.0) and remote non-Indigenous patients (rate ratio: 1.2; 95% CI 1.0-1.5). More Indigenous patients died of HSVD before the age of 65 years (n=1875; 56.5% 95% CI 54.8-58.2) as compared to non-Indigenous patients (n= 16161; 10.6% 95% CI 10.45-10.8).InterpretationIndigenous Australians have a higher prevalence, and younger age during EPE, and hospitalisation for HSVD than non-Indigenous Australians.FundingThis is a self/internally-funded study, with the lead organisation being the Royal Flying Doctor Service (RFDS) of Australia. For the duration of the study period, the RFDS provided in-kind support including one full-time equivalent (FTE) and resources (office space, computer, research software, and office equipment). There was no external funding source that had a role in study design or data analysis or interpretation.

Estimating Intra-Urban Inequities in PM2.5-Attributable Health Impacts: A Case Study for Washington, DC.

Air pollution levels are uneven within cities, contributing to persistent health disparities between neighborhoods and population sub‐groups. Highly spatially resolved information on pollution levels and disease rates is necessary to characterize inequities in air pollution exposure and related health risks. We leverage recent advances in deriving surface pollution levels from satellite remote sensing and granular data in disease rates for one city, Washington, DC, to assess intra‐urban heterogeneity in fine particulate matter (PM2.5)‐ attributable mortality and morbidity. We estimate PM2.5‐attributable cases of all‐cause mortality, chronic obstructive pulmonary disease, ischemic heart disease, lung cancer, stroke, and asthma emergency department (ED) visits using epidemiologically derived health impact functions. Data inputs include satellite‐derived annual mean surface PM2.5 concentrations; age‐resolved population estimates; and statistical neighborhood‐, zip code‐ and ward‐scale disease counts. We find that PM2.5 concentrations and associated health burdens have decreased in DC between 2000 and 2018, from approximately 240 to 120 cause‐specific deaths and from 40 to 30 asthma ED visits per year (between 2014 and 2018). However, remaining PM2.5‐attributable health risks are unevenly and inequitably distributed across the District. Higher PM2.5‐attributable disease burdens were found in neighborhoods with larger proportions of people of color, lower household income, and lower educational attainment. Our study adds to the growing body of literature documenting the inequity in air pollution exposure levels and pollution health risks between population sub‐groups, and highlights the need for both high‐resolution disease rates and concentration estimates for understanding intra‐urban disparities in air pollution‐related health risks.

Acute spinal cord ischemic stroke; A rare but potentially devastating stroke emergency in young healthy adults

Introduction: Acute spinal cord infarction represents 1% of all strokes. The neurological presentation of spinal cord infarction is defined by vascular territory i.e. anterior or posterior spinal arteries. A broad spectrum of diseases can cause spinal cord infarction, most common cause is surgical repair or diseases of the thoracoabdominal aorta. MRI of the spine shows hyperintensities on T2WI, restricted diffusion on DWI and vertebral body infarction adjacent to a cord signal abnormality. Poor prognostic factors for recovery are severe impairment at presentation, female sex, advanced age, and lack of improvement in the first 24 hours. We describe clinical presentation, radiological findings and 3-month outcome of four patients who presented with ischemic spinal cord infarction. Methods: We retrospectively analysed our prospectively collected data and found four cases of spinal cord infarction for the period of May 2020 to April 2021. Total of 1,326 stroke patients (1125 i.e. 85% ischemic and 201 i.e. 15% haemorrhagic) were admitted in Hamad General Hospital. At our centre, spinal cord infarction accounts 0.30% of total stroke and 0.35% of ischemic strokes. We describe four young patients, presented with abrupt onset of focal neurologic deficit. Their MRI of the spine revealed hyperintensity signals in T2WI, restricted diffusion on DWI of spinal cord. Two patients had vertebral artery occlusion or dissection. One patient was discharged home and three patients underwent multidisciplinary rehabilitation program. Discussion: Spinal cord infarction may present with acute paraparesis or quadriparesis with devastating consequences. Blood flow to the spinal cord is influenced by perfusion pressure. The most common cause of spinal cord infarction in this case series was vertebral artery dissection or occlusion. Our case series suggests early recognition of spinal cord stroke, appropriate investigations and early treatment with further rehabilitation could improve patient outcome. Conclusion: Spinal cord infarction, a rare but devastating condition, represents 1% of all strokes but 0.3% of total strokes at our centre. Early recognition of spinal cord ischemia especially when presenting with abrupt onset focal neurological deficit, focus on underlying pathology with appropriate imaging and further investigations, secondary stroke prevention and rehabilitation are vital factors to improve neurological recovery. Future randomized trails are needed to establish the efficacy and safety of drug therapy including rt-PA in spinal cord infarction. Abbreviations: ASA: Anterior spinal artery; PSA: Posterior spinal artery; MRI: Magnetic resonance imaging; MRA: Magnetic resonance arteriogram; DWI: Diffusion weighted imaging; ICP: Intra-cranial pressure.

Emergency stroke management during COVID-19 pandemic: Experience from Triveneto area

COVID-19 pandemic is a major problem for global healthcare. There are many challenges for stroke emergency chain to maintain high medical care levels: many European Countries showed changes in neurological admissions and treatments. Our aim was to investigate the amount of admissions and treatment of stroke patients Friuli-Venezia-Giulia, Veneto and Trentino-Alto-Adige during the first wave of COVID-19.

Gender Disparities in Stroke Code Activation in Patients with Intracerebral Hemorrhage

ObjectivesRoutine implementation of protocol-driven stroke “codes” results in timelier and more effective acute stroke management. However, it is unclear if patient demographics contribute to disparities in stroke code activation. We aimed to explore these demographic factors in a retrospective cohort study of patients with intracerebral hemorrhage (ICH). Materials and MethodsWe identified consecutive patients with non-traumatic ICH who presented directly to our Comprehensive Stroke Center over 2 years and collected data on demographics, clinical features, and stroke code activation. We used multivariable logistic regression to examine differences in stroke code activation based on patient demographics while adjusting for initial clinical features (NIH Stroke Scale, FAST [facial drooping, arm weakness, speech difficulties] vs. non-FAST symptoms, time from last-known-well [LKW], and systolic blood pressure [SBP]). ResultsAmong 265 patients, 68% (n=179) had a stroke code activation. Stroke codes occurred less frequently in women (62%) than men (72%) and in non-white (57%) vs. white patients (70%). Non-stroke code patients were less likely to have FAST symptoms (37% vs. 87%) and had lower initial SBP (mean±SD 159.3±34.2 vs. 176.0±31.9 mmHg) than stroke code patients. In our primary multivariable models, neither age nor race were associated with stroke code activation. However, women were significantly less likely to have stroke codes than men (OR 0.49 [95% CI 0.24-0.98]), as were non-FAST symptoms (OR 0.11 [95% CI 0.05-0.22]). ConclusionsOur data suggest gender disparities in emergency stroke care that should prompt further investigations into potential systemic biases. Increased awareness of atypical stroke symptoms is also warranted.

Factors associated with delayed revascularization in patients with ischemic stroke: a prospective study in one French region.

Optimizing the care pathway of stroke is crucial for the revascularization of ischemic stroke. to identify factors associated with (1) a time interval over 4 h between the symptom onset and cerebral imaging in suspected stroke patients and (2) the absence of revascularization in patients with ischemic stroke. Patients over 18 years old with a suspected stroke admitted in 22 emergency rooms or stroke units in one French region between 1 March 2019 and 30 April 2019 were prospectively included by filling a dedicated form. Factors associated with the previously mentioned outcome measures were identified using logistic regression models. In total 991 patients were included; 537 patients (64% of 845 with available time intervals) were admitted more than 4 h after symptom onset. Three predictors were identified: not calling emergency medical services (EMS) [odds-ratio (OR) 5.2; 95% confidence interval (3.4-8.1)], a preexisting autonomy loss [2.0 (1.3-2.9)] and atypical clinical presentation [2.0 (1.3-3.1)]. A total of 385 patients had an ischemic stroke of whom 93 underwent a revascularization procedure (24%). The same three predictors were associated with the absence of revascularization procedure, added to an initial admission in a hospital without stroke unit [3.1 (1.1-8.6)]. This study shows that efforts to organize the care chain for stroke need to be intensified in the region to reduce treatment time intervals, which could include information campaigns focused on the impact of EMS call and the clinical presentation recognition.

Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes

Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97–5.69) compared to 3.06 (95%CI 2.95–3.12) (p < 0.001). A score of greater or equal to 4 yielded the highest combination of sensitivity (77.78%) and specificity (65.34%) with positive likelihood ratio 2.24 (95% CI 2.00–2.52) and negative likelihood ratio 0.34 (95% CI 0.25–0.46). Area under the ROC curve was 0.77 (95%CI 0.73, 0.81). A CPSS with all three items positive demonstrated a sensitivity of 73.20% and 69.57% specificity, with an ROC area of 0.73 (95% CI 0.70–0.77). When comparing a FAST-ED ≥4 to a CPSS of all positive items, there was no significant difference in sensitivity (p > 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p < 0.005). Conclusion: As stroke care advances, EMS agencies must consider their destination triage needs. This study suggests agencies must consider the use of single versus secondary scales, and to determine the ideal sensitivity and specificity for their system.

Frequency of stroke in the hospital emergency in the metropolitan region of Porto Alegre/RS

Frequency of stroke in the hospital emergency in the metropolitan region of Porto Alegre/RS

The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke.

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min.Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window.Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed.Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time.Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.

Optimizing Emergency Stroke Transport Strategies Using Physiological Models.

The criteria for choosing between drip and ship and mothership transport strategies in emergency stroke care is widely debated. Although existing data-driven probability models can inform transport decision-making at an epidemiological level, we propose a novel mathematical, physiologically derived framework that provides insight into how patient characteristics underlying infarct core growth influence these decisions. We represent the physiology of time-dependent infarct core growth within an ischemic penumbra as an exponential function with consideration to rate-determining collateral blood flow. Monte Carlo methods generate distributions of infarct core volumes, which are translated to distributions of 90-day modified Rankin Scale scores. We apply the model to a stroke network that serves rural Bastrop County and urban Travis County by simulating transport strategies from thousands of potential patient pickup locations. In every pickup location, the simulation yields a distribution of outcomes corresponding to each transport strategy. A 2-sample Kolmogorov-Smirnov test and Student t test determine which transport strategy provides a significantly better probability of a good outcome for a given pickup location in each respective county (P<0.01). In Travis County, drip and ship provides significantly better probabilities of a good outcome in 24.0% of the pickup locations, while 59.8% favor mothership. In Bastrop County, 11.3% of the pickup locations favor drip and ship, while only 7.1% favor mothership. The remaining pickup locations in each county are not statistically significant in either direction. We also reveal how differing rates of infarct core growth, the application of bypass policies, and the use of large vessel occlusion field tests impact these results. Modeling stroke physiology enables the use of clinically relevant metrics for determining comparative significance between drip and ship and mothership in a given geography. This formalism can help understand and inform emergency medical service transport decision-making, as well as regional bypass policies.

Assessing the impact of education in atrial fibrillation: A systematic review

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial Fibrillation (AF) is the most common heart rhythm disorder. Patient education is recommended as part of comprehensive AF management. Despite this the impact of education alone on outcomes in AF populations is unknown. Purpose The aim of this study was to describe the impact of education on clinically relevant outcomes in patient with AF including mortality, hospital admissions, emergency department presentations, stroke and quality of life. Methods The authors searched Pubmed, Embase, CINAHL, Cochrane database and Psycinfo from inception until September 2019. Studies were included if they were prospective and of randomized controlled or observational design with a minimum follow-up 3 months and published in English. Results A total of 1667 studies were screened with 37 undergoing full text review and 6 meeting eligibility criteria. There was a total of 588 participants with a mean age of 65.63 ± 11.05 and 60.71% were male. A meta-analysis was unable to be performed due to heterogeneity in reporting of outcomes. Two studies examined the impact of education on mortality with no impact evident from either intervention. The impact of education on hospitalisations (all cause – 3 studies, cardiovascular – 1 study and AF - 2 studies) was explored in five studies with no impact on this outcome from any intervention. Similarly, there was no impact of education on emergency department presentations, except for one study in which a video was used in addition to standardised education. There was no impact on stroke from two studies exploring this outcome. There was no evidence of impact of education on general or AF specific quality of life. Conclusions There is little evidence to suggest that educational interventions to date have significantly impacted on death, hospitalisations, emergency department presentations or quality of life in AF populations. There is an urgent need to identify optimal modes and components of educational interventions to improve patient outcomes and reduce health care burden in AF.

IV tPA given in the golden hour for emergent large vessel occlusion stroke improves recanalization rates and clinical outcomes

BackgroundEarly thrombolysis for acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) is associated with better clinical outcome. This is thought to be due to greater tissue salvage with earlier recanalization. We explored whether ultra-early administration of intravenous tissue plasminogen activator (IV tPA) within 60 min (Golden Hour) of symptom onset for AIS due to ELVO is associated with a higher rate of recanalization. MethodsWe performed a retrospective analysis of recanalization rates and clinical outcomes in patients with AIS due to ELVO treated with IV tPA, comparing patients who received IV tPA within 60 min of stroke symptom onset with those treated beyond 60 min. ResultsBetween January 2013 and December 2016, 158 patients with AIS due to ELVO were treated with IV tPA. Of these, 25 (15.8%) patients received IV tPA within 60 min of stroke symptom onset, while the remaining 133 (84.2%) patients received IV tPA beyond 60 min. The ultra-early treatment group was found to have a higher rate of complete recanalization (28.0% vs 6.8%, 95% CI 1.78–16.63), better chance of early neurological improvement (76.0% vs 50.4%, 95% CI 1.16–8.65), favorable clinical outcomes (mRS ≤ 2 or return to premorbid mRS) (65.0% vs 36.8%, 95% CI 1.42–9.34), and lower mortality (5% vs 31.1%, 95% CI 0.01–0.74) at 90-day follow-up compared to the later treatment group. ConclusionOur data suggest that ultra-early administration of IV tPA significantly improves recanalization rates and clinical outcomes in patients with AIS due to ELVO.

Prestroke Glucose Control and Functional Outcome in Patients With Acute Large Vessel Occlusive Stroke and Diabetes After Thrombectomy.

OBJECTIVETo evaluate whether prestroke glucose control is associated with functional outcomes in patients with acute large vessel occlusive stroke and diabetes who underwent intra-arterial thrombectomy (IAT).RESEARCH DESIGN AND METHODSFrom the Clinical Research Center for Stroke–Korea registry, we included patients with emergent large vessel occlusive stroke with diabetes who underwent IAT between January 2009 and March 2020. The association between the HbA1c level at admission and functional outcomes (modified Rankin Scale at 3 months after the index stroke) was assessed.RESULTSA total of 1,351 patients were analyzed. Early neurological deterioration was more common in patients with higher levels of HbA1c at admission (P = 0.02 according to HbA1c quintiles, P = 0.003 according to an HbA1c cutoff value of 7.0%) than in those with lower HbA1c levels. Higher HbA1c levels at admission were significantly associated with decreased odds of favorable functional outcomes at a threshold of 7.0–7.1%. The association was consistently observed in subgroups divided according to age, sex, stroke subtype, occlusion site, degree of recanalization, thrombolysis modalities, time from symptom onset to groin puncture, and treatment period.CONCLUSIONSPrestroke glucose control with a target HbA1c of ≤7.0% may be beneficial for neurological recovery in patients with diabetes undergoing IAT for large vessel occlusive stroke, regardless of stroke subtype, bridging intravenous thrombolysis, occlusion site, degree of recanalization, and treatment period.