Stroke Network Research Articles

Transition from alteplase to tenecteplase for treatment of acute ischemic stroke in a rural stroke network of the Midwest: Planning, execution, safety, and outcomes

PurposeThis study aims to document the transition from alteplase to tenecteplase within a rural stroke network in the Midwest. It emphasizes the planning and execution of the transition, and evaluates safety and outcomes of tenecteplase compared to alteplase one year after the adoption of the new thrombolytic. MethodsThis is a retrospective observational study of patients who were treated with thrombolytic therapy for suspected acute ischemic stroke at Southern Illinois Healthcare rural stroke network between July 2017 and July 2024. For each patient, demographics, past medical history, clinical presentation, National Institutes of Health Stroke Scale (NIHSS), and laboratory values were reviewed. Type of thrombolytic was noted. Door-to-needle time (DTN) and complications of thrombolytic therapy including symptomatic ICH (sICH) were reviewed. The primary outcome was the rate of sICH after administration of thrombolytic therapy. Secondary outcomes included target DTN ≤ 60minutes and modified Rankin Scale (mRS) 0-2 at 30 days. ResultsOut of 279 patients treated with thrombolytics, 215 (77%) received alteplase, and 64 (23%) received tenecteplase. The two groups were severity matched, and did not differ in terms of demographics or baseline comorbidities. Median DTN (IQR) was comparable between alteplase and tenecteplase, in minutes ((50 (40-69) vs. 53 (37-65)). In three distinct regression models for each of the predetermined outcomes, accounting for markers of stroke severity, the type of thrombolytic was not associated with development of sICH (OR 1.59, SE 1.445, p=0.61), target DTN ≤60min (OR 0.996, SE 0.304, p=0.988), nor mRS 0-2 at 30 days (OR 1.086, SE 0.446, p=0.842). ConclusionsIn our population, safety and outcome of thrombolytic therapy for acute ischemic stroke did not differ based on the type of thrombolytic used. Our study highlights the planning and execution of the transition from alteplase to tenecteplase, with challenges faced and lessons learned, and supports the use of tenecteplase in real-world rural practice.

VISIT STROKE: non-inferiority of telemedicine-based neurological consultation for post-acute stroke patients – protocol of a prospective observational controlled multi-center study

BackgroundTelemedicine provides specialized medical expertise in underserved areas where neurological expertise is frequently not available on a daily basis for hospitalized stroke patients. While tele-consultations are well established in acute stroke assessment, the value of telemedicine-based ward-rounds in the subsequent in-patient stroke management is unknown.MethodsFour telemedicine stroke networks in Germany, implemented in eight out of 16 federal states, participate in this prospective observational multi-center study. We plan to enroll 523 patients hospitalized due to acute (suspected or confirmed) stroke or transient ischemic attack. Each recruited patient will receive both a tele-consultation and an on-site consultation at the same day within the first three days after hospital admission. We will test non-inferiority of telemedicine-based assessments in ward-rounds in terms of quality of medical assessment and recommendations for hospitalized stroke patients. The correctness of the medical assessment and recommendation is defined as positive evaluation (binary, correct vs. in-correct) of six out of six predefined quality indicators by at least two out of three blinded independent raters. The non-inferiority margin for the difference in proportions of correct assessments is set to 5%-points.DiscussionIf non-inferiority of telemedicine-based ward-rounds compared to on-site ward-rounds by a neurologist were demonstrated, telemedicine-based neurological consultation for post-acute stroke patients may contribute to deliver evidence-based high-quality stroke care more easily in underserved regions.Trial registrationDRKS - DRKS00028671 (https://drks.de/search/de/trial/DRKS00028671; registration date 09-27-2022).

Validation of Prognostic Scales for Functional Outcome in Ischemic Stroke Patients Treated with Intravenous Thrombolysis in a Rural Setting

Introduction: Early prediction of functional outcome after rtPA helps clinicians in prognostic conversations with stroke patients and their families. Three prognostic tools have been developed in this regard: DRAGON, MRI-DRAGON, and S-TPI scales. These tools, all performing with comparable accuracy, have been internally and externally validated in tertiary care centers. However, their performance in rural areas remains uncertain. This study addresses this gap in the literature by evaluating the effectiveness of those prognostic tools in stroke patients treated in a rural area of the Midwest. Methods: We conducted a retrospective study of stroke patients treated with thrombolytics at Southern Illinois Healthcare Stroke Network from July 2017 to June 2024. Data on demographics, clinical presentations, laboratory values, neuroimaging, and stroke metrics were collected. Modified Rankin Scale (mRS) at 1 month, classified into good (mRS ≤2) and poor (mRS ≥5) outcomes were noted. DRAGON and MRI-DRAGON scores were calculated. S-TPI model was built. Area under the receiver operating characteristic curve (AUC) with its 95% confidence interval was calculated for each prognostic model. Results: A total of 279 patients were included in this study. Of those, 43% (n = 119) were male. Median age (interquartile range [IQR]) was 69 (57–80) years. NIHSS at presentation (IQR) was 7 (4–13). 12% of the cohort (n = 34) had posterior circulation stroke. At 1 month, 66% of patients (n = 185) had mRS ≤2, whereas 14% of patients (n = 39) had mRS ≥5. MRI-DRAGON showed the highest accuracy in predicting both good (AUC = 0.86, 95% CI: 0.81–0.90) and poor outcomes (AUC = 0.84, 95% CI: 0.76–0.91). DRAGON also demonstrated high accuracy for good (AUC = 0.85, 95% CI: 0.80–0.89) and poor (AUC = 0.82, 95% CI: 0.75–0.90) outcomes. Conversely, in our population, the S-TPI model had the lowest accuracy for good (AUC = 0.56, 95% CI: 0.49–0.63) and poor (AUC = 0.68, 95% CI: 0.61–0.76) outcomes. Conclusion: Among the available grading scores, MRI-DRAGON score can be considered the more accurate short-term prognostic tool for stroke patients treated with rtPA in the rural setting.

The regional development and implementation of home-based stroke rehabilitation using participatory action research

Purpose This study aims to overcome the challenges experienced in the regional development and implementation of home-based stroke rehabilitation (HBSR) and to understand the change process needed. Materials and methods Using participatory action research (PAR), participants and researchers collaboratively produced knowledge and took action to improve the offered HBSR. Different methods for data generation and analysis were used, depending on the aim of the PAR phase and the participants’ stages of change. The Consolidated Framework for Implementation Research (CFIR) was used to select implementation strategies and to evaluate the implementation process. Results Developing and implementing HBSR resulted in multiple products that promoted the implementation of a regional stroke network and affiliated work arrangements. Work arrangements were embodied in a stroke care pathway, follow-up tool, and expertise requirements. Evaluating the PAR process identified participants being able to take the lead, being facilitated by others, and making progress visible, as implementation facilitators. Collaborating within a primary care project can be challenging but is considered essential and has a positive impact on multiple levels. Also, the implementation of HBSR calls for multiple implementation strategies reflecting multiple CFIR constructs. Conclusion This study highlights the complexity and achievements of developing and implementing HBSR using PAR.

Effect of stroke etiology on treatment-related outcomes in young adults with large vessel occlusion: Results from a retrospective cohort study

IntroductionLarge vessel occlusion-acute ischemic stroke (LVO-AIS) is infrequent in young adults and exhibits distinct stroke mechanisms compared to older adults. This study sought to evaluate the impact of varying stroke etiologies on treatment-related outcomes in young adults with LVO-AIS, an aspect that remains unclear. MethodsThis retrospective cohort study included patients aged 18-50 presenting with AIS from January 2017 to December 2021 within our multi-center stroke network. Patients with LVO on CTA/MRA at presentation were included. We assessed demographics, stroke etiology (TOAST classification), and treatment-related outcomes. Based on intervention received, patients were divided into 5 groups [IV-thrombolysis (IVT) only, Mechanical Thrombectomy (MT) only, IVT+MT, no treatment, unsuccessful MT]. ResultsAmong 1210 AIS patients, 220 with LVO were included. The median age was 42 (36, 46). 75 (34.1 %) patients underwent successful MT (46.7 % received IVT+MT). 26 (11.8 %) received IVT only, 110 (50 %) received neither intervention, and 9 (4.1 %) underwent unsuccessful MT. Per TOAST, 17.4 % had large artery atherosclerosis (LAA), 19.2 % cardio-embolism, 28.6 % stroke of other etiology, and 34.7 % had undetermined etiology. Favorable thrombectomy outcomes (TICI 2b/2c/3) were observed in 87.2 %. Discharge NIH Stroke Scale (NIHSS) scores improved for patients with IVT+MT in all TOAST categories except LAA. ConclusionsYoung adults with LVO-AIS had good outcomes irrespective of stroke etiology, except LAA, which was associated with a higher discharge NIHSS. Moreover, 50 % of young adults in our study received no intervention, a quarter of those owing to delayed presentation. Further studies are needed to identify barriers in seeking acute treatment in young adults with LVO-AIS.

Performance and clinical outcomes in telestroke remain robust during the COVID-pandemic: insight into the NEVAS network.

The COVID-19 pandemic had significant impact on global healthcare, including stroke management. Telemedical stroke networks have emerged with positive results for patient outcome in rural areas without stroke expertise. However, telestroke faced enormous on-site challenges during the pandemic. So far, data on performance and clinical outcomes in telestroke settings during the COVID-pandemic are scarce. We retrospectively analyzed data from stroke patients treated in four spoke hospitals of the Bavarian telestroke network NEVAS in 2020-2021 and 2019 as reference year and compared the 3years for various parameters. Primary outcome was functional outcome according to the modified Rankin scale (mRS). Secondary outcome parameters included time intervals, periprocedural intracranial hemorrhage rates, and mortality. In 2019-2021, 2820 patients were treated for acute ischemic stroke with an admission decrease of 10% during the pandemic. Of those, 241 received only IVT and 204 were transferred to our center for MT. Door-to-imaging, door-to-needle, and symptom-onset-to-groin times remained comparable in the 3years. Complication rates remained at a low level. Good clinical outcome rates (mRS 0-2) at discharge remained stable for all stroke patients (82-84%) and for those treated with IVT (64-77%). Good clinical outcome rates at 3month follow-up for MT patients declined in 2020 (23% vs. 35% in 2019) but recovered again in 2021 (42%). Mortality rates did not increase for all patient groups analyzed. Stroke care remained robust during the COVID-pandemic within our network, indicating that well-established telestroke networks can overcome unexpected critical challenges such as a pandemic, guaranteeing best practice stroke care in rural areas.

Comparison of Telemedicine-Administered Thrombolytic Therapy for Acute Ischemic Stroke by Neurology Subspecialty: A Cross-Sectional Study.

To determine if any difference exists in safety and outcomes of thrombolytic therapy for acute ischemic stroke administered via telemedicine, based on the subspeciality of the treating neurologist. We performed a retrospective cross-sectional study using data from our local stroke registry of thrombolytic therapy administered via telemedicine at our rural stroke network over 5 years. The cohort was divided in 2 groups based on the subspecialty of the treating neurologist: vascular neurology (VN) and neurocritical care (NCC). Demographics, clinical characteristics, stroke metrics, thrombolytic complications, and final diagnosis were reviewed. In-hospital mortality and mRS and 30 days were noted. Among 142 patients who received thrombolytic therapy via telemedicine, 44 (31%) were treated by VN specialists; 98 (69%) by NCC specialist. There was no difference in baseline characteristics and stroke metrics between the 2 groups. Compared to NCC, VN had a trend toward higher, but non-significant, sICH (6% vs 1%, P = 0.05). In a logistic regression analysis, correcting for NIHSS, SBP, door-to-needle time, and use of antiplatelet therapy, the type of neurology subspecialty was not independently associated with development of sICH (OR: 0.141, SE: 0.188, P = 0.141). The rate of in-hospital mortality was also similar between VN and NCC (7% vs 5%, P = 0.8). In a model that accounted for stroke severity, no association was established between the type of neurology subspecialty and mRS at 30 days (OR: 1.589, SE: 0.662, P = 0.266). Safety and outcome of thrombolytic therapy via telemedicine was not influenced by the subspecialty of treating neurologist. Our study supports the expansion of telemedicine for acute stroke patients in rural and underserved areas.

Early recanalization after tenecteplase versus alteplase: Experience in a large stroke network

IntroductionPreviously published data are conflicting regarding the ability of tenecteplase versus alteplase to produce early recanalization of an intracranial large vessel occlusion. We compared the performance of each thrombolytic in a stroke network. MethodsWe queried our prospectively collected code stroke registry for basilar, internal carotid, or proximal middle cerebral artery occlusion patients treated with intravenous thrombolysis from 11/17/2021-9/16/2023. The primary outcome was early recanalization, defined using angiographic or clinical criteria. Secondary and safety outcomes included 90-day functional independence and symptomatic intracranial hemorrhage. A multivariable regression analysis was performed to determine independent associations with the primary outcome. Results233 patients, with mean age 66.9 (16.6) years and median National Institutes of Health Stroke Scale score 15 (10-21), were included. One-hundred twenty-four of 233 (53.2 %) patients were treated with alteplase while 109/233 (46.8 %) were treated with tenecteplase. Endovascular thrombectomy was performed in 82 % of subjects. Early recanalization rates were similar between the groups (alteplase 22.6 %, tenecteplase 14.7 %; p = 0.14), as were rates of 90-day independent neurological function, symptomatic intracranial hemorrhage, and mortality. Patients with an internal carotid artery occlusion or with higher presenting stroke severity were less likely to achieve early recanalization. ConclusionsTenecteplase and alteplase have similar rates of early recanalization, 90-day functional independence, and safety outcomes in large vessel occlusion patients. Occlusion site and stroke severity predict response to thrombolysis. Future studies may investigate other factors associated with a positive response to thrombolytics as expanded treatment indications are explored.

“I didn’t even wonder why I was on the floor” – mixed methods exploration of stroke awareness and help-seeking behaviour at stroke symptom onset

IntroductionTo better target stroke awareness efforts (pre and post first stroke) and thereby decrease the time window for help-seeking, this study aims to assess quantitatively whether stroke awareness is associated with appropriate help-seeking at symptom onset, and to investigate qualitatively why this may (not) be the case.MethodsThis study conducted in a German regional stroke network comprises a convergent quantitative-dominant, hypothesis-driven mixed methods design including 462 quantitative patient questionnaires combined with qualitative interviews with 28 patients and seven relatives. Quantitative associations were identified using Pearson’s correlation analysis. Open coding was performed on interview transcripts before the quantitative results were used to further focus qualitative analysis. Joint display analysis was conducted to mix data strands. Cooperation with the Patient Council of the Department of Neurology ensured patient involvement in the study.ResultsOur hypothesis that stroke awareness would be associated with appropriate help-seeking behaviour at stroke symptom onset was partially supported by the quantitative data, i.e. showing associations between some dimensions of stroke awareness and appropriate help-seeking, but not others. For example, knowing stroke symptoms is correlated with recognising one’s own symptoms as stroke (r = 0.101; p = 0.030*; N = 459) but not with no hesitation before calling help (r = 0.003; p = 0.941; N = 457). A previous stroke also makes it more likely to recognise one’s own symptoms as stroke (r = 0.114; p = 0.015*; N = 459), but not to be transported by emergency ambulance (r = 0.08; p = 0.872; N = 462) or to arrive at the hospital on time (r = 0.02; p = 0.677; N = 459). Qualitative results showed concordance, discordance or provided potential explanations for quantitative findings. For example, qualitative data showed processes of denial on the part of patients and the important role of relatives in initiating appropriate help-seeking behaviour on patients’ behalf.ConclusionsOur study provides insights into the complexities of the decision-making process at stroke symptom onset. As our findings suggest processes of denial and inabilities to translate abstract disease knowledge into correct actions, we recommend to address relatives as potential saviours of loved ones, increased use of specific situational examples (e.g. lying on the bathroom floor) and the involvement of patient representatives in the preparation of informational resources and campaigns. Future research should include mixed methods research from one sample and more attention to potential reporting inconsistencies.

Impact of the Stroke Law in Neuquén. First Experience in Argentina

This study examines the impact of Neuque n's pioneering Stroke Law in Argentina, focusing on its enactment and implementation. Neuque n, facing a high stroke incidence, established the first Argentinean legislation for stroke management, including prevention, acute treatment, and rehabilitation. The law led to the creation of the Provincial Stroke Network and inclusion of alteplase in the Neuque n Therapeutic Formulary. Results demonstrate advancements in healthcare delivery, with significant implications for public health policy and stroke management in Argentina. The study highlights challenges, particularly during the COVID-19 pandemic, and suggests future directions for comprehensive stroke care.

Italy's Post-COVID-19 Stroke Network: Has It Returned to Pre-Pandemic Standards?

The COVID-19 pandemic strongly transformed the healthcare system in the Lombardy region (Italy), forcing a rapid reorganization of hospital structures. The emergency medical service (EMS) system and emergency departments (EDs) were among the most affected departments. Several studies have shown a change in the epidemiology of time-dependent pathologies, such as stroke, during the pandemic's peak. However, there is little scientific evidence regarding the interpandemic phase. The regional register for ED accesses (EUOL) was analyzed, taking into consideration all accesses for stroke and stroke-like syndromes during the years 2019, 2020, and 2021. The analysis shows a significant difference in the average number of diagnoses per month [2092 vs. 1815 vs. 2015, respectively (p < 0.05)] and an increase in the percentage of transports carried out by EMS vehicles to EDs [17% vs. 25% vs. 22%, respectively (p < 0.05)]. The length of stay (LOS) increased for both discharged patients (9.0 vs. 10.1 vs. 11.2 h, respectively; p < 0.005) and hospitalized patients (7.5 vs. 9.7 vs. 10.6 h, respectively; p < 0.005). During the COVID-19 pandemic, the overall number of stroke diagnoses decreased, while the percentage of patients transported to EDs by EMS vehicles increased. Furthermore, an increased processing time in EDs was highlighted.

Utility of A2L2 score in acute ischemic stroke patient triage: the "H.uni" experience.

Two or more National Institutes of Health Stroke Scale (NIHSS) points on each motor items (A2L2 score) have shown good accuracy in predicting large vessel occlusion (LVO) in the prehospital setting of acute ischemic stroke (AIS) care. We aimed to study this score for LVO prediction in our stroke network and predictors of poor outcome (PO) after mechanical thrombectomy (MT). From our Safe Implementation of Thrombolysis in Stroke (SITS) registry including patients receiving reperfusion therapy for AIS, we retrospectively computed the A2L2 score from the admission NIHSS to test the diagnostic accuracy for LVO prediction. Multivariable analysis for independent predictors of LVO on the entire cohort and PO from patients with LVO were performed. From the 853 patients with AIS (67% LVO), A2L2 was positive in 52%. A2L2 score (Odds ratio [OR] 4.6;95%CI 3.36-6.34), smoking (OR 2.1;95%CI 1.14-3.85), atrial fibrillation (OR 1.6;95%CI1.1-2.4) and younger age (OR 0.98;95%CI0.97-0.99) were independent predictors of LVO. A2L2 score showed 82%/49% positive/negative predictive values with 66% accuracy (64%/72% sensitivity/specificity) for LVO prediction. Age (OR 1.05;95%CI 1.03-1.07), atrial fibrillation (OR 4.85;95%CI 1.5-15.7), diabetes (OR 2.62;95% CI 1.14-6.05), dyslipidemia (OR 2;95% CI 1.04-3.87), A2L2 score (OR 2.68;95% CI 1.45-4.98), longer onset-to-groin time (OR 1.003;95% CI 1.001-1.01), MT procedure (OR 1.01;95%CI 1.003-1.02) general anaesthesia (OR 2.06;95% CI 1.1-3.83) and symptomatic intracranial hemorrhage (OR 12.10;95%CI 3.15-46.44) were independent predictors of PO. A2L2 score independently predicted LVO and PO after MT. Patient characteristics and procedural factors determined PO of LVO patients after MT.

Adapting the stroke therapy outcome measure for use by Multidisciplinary Teams: considering reliability

Purpose The Therapy Outcome Measure (TOM) comprises many profession and client group-specific adapted scales based on the International Classification of Functioning Model, used by different Health Care Professionals (HCPs). A new Multidisciplinary stroke TOM scale (MDT Stroke TOMs) was developed by amalgamating the relevant scales. This study aimed to develop a scale to describe patients’ abilities and improve communication and collaboration within the stroke Multidisciplinary Team (MDT). The present study investigated the inter-rater and intra-rater reliability of this adaptation. Materials and Methods The MDT Stroke TOM Scale was developed by combining and rewording four profession-specific adapted TOM scales following iterative trials and discussions leading to an agreed version. 150 stroke Allied Health Professional (AHPs) and nurses were trained virtually in TOM and the MDT Stroke TOM Scale. Ten AHP and nursing raters from five professions evaluated ten composite stroke case studies for inter-rater reliability. Six participated in the intra-rater reliability review of the same three case studies at different time points. Reliability was quantified using intraclass correlation coefficients and measurement error using the smallest detectable change. Results There was good to excellent concordance between the raters in terms of scoring. Raters’ scores were also consistent. The MDT Stroke TOMs is being used consistently across the South West London Stroke Network. Conclusion The Stroke MDT TOMs is psychometrically robust and should assist with improving team work in the rehabilitation of stroke patients and their carers. Future research may use MDT Stroke TOM to promote interprofessional team working and facilitate communication in Stroke Rehabilitation.

An Ischemic Stroke Complicating Acute Dehydration in an Infant: A Case Report

Stroke in children is an important public health problem because, even if it is 10 folds less frequent than in adults, it may have severe consequences. Therefore, it is important to know the initial clinical symptoms of stroke in children as well as the lack of aphasia opposed to the great frequency of epilepsy, and dystonia. The causes are different; genetic, cardiac or thrombophilic origin. Prognosis is more favourable compared to that of adults. The management of stroke in childhood must be included in the stroke network of adults, associating the paediatricians.

Development of a stroke network in Kinshasa (Democratic Republic of the Congo): a humanitarian project of the Italian Stroke Association—Associazione Italiana Ictus

In sub-Saharan Africa (SSA), stroke incidence is ~316 cases per 100,000 inhabitants and in 75% of SSA countries stroke is among the top three causes of death. This epidemiological evolution results from the exponential growth of the African population as well as the lack of policies for prevention and therapy. The Democratic Republic of Congo is one of the countries included as a “low-income country” in the 2023 Organization for Economic Co-operation and Development's Development Assistance Committee List; its capital, Kinshasa, is a megalopolis with more than 18 million inhabitants. According to our knowledge, no hospital in Kinshasa is currently capable of admitting and treating patients with stroke according to international guidelines. The Italian Stroke Association—Associazione Italiana Ictus (ISA-AII) is a multidisciplinary scientific society for the fight against cerebrovascular diseases. Some members of the ISA-AII joined to form a working group dedicated to the care of stroke in Africa. In this article, we explain the project designed by ISA Africa that, in collaboration with the referral hospital of a district of Kinshasa, has the aim of building a network for diagnosing and treating stroke, including ambulance services, a stroke team in the emergency room, a stroke unit, an outpatient clinic, and primary prevention activities among the population.

Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case–control study

Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50). There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Door to Puncture in Large Vessel Occlusions Pre‐ and Postimplementation of an Automated Image Interpretation and Communication Platform: A Single Center Study

Background Artificial intelligence platforms, like Viz.ai with large vessel occlusion detection, have been used for disease detection and interprovider communication. Whether this software expedites patient transfer and evaluation for treatment needs further exploration. Methods A single‐center retrospective registry was queried for patients with acute large vessel occlusion of the intracranial internal carotid, middle cerebral M1 or M2 segments, or basilar artery treated in a comprehensive stroke network (8 spokes, 1 hub) for 6 months pre‐ and post‐implementation of the Viz large vessel occlusion platform (excluding a 1‐month “washout” period). Robust regression was used to summarize time from initial hospital contact to arterial puncture (primary outcome) between periods, with prespecified subgroup analyses, which were assessed using interaction terms. Results Of the 132 patients (n = 58 preintervention), there were nonsignificantly fewer patients undergoing endovascular therapy in the postintervention period (86.2% preintervention versus 73.0% postintervention; P = 0.07). Among patients who underwent endovascular therapy (n = 50 preintervention, n = 54 postintervention), there was a nonsignificant reduction in time from first contact to arterial puncture (median 155 minute preintervention versus 116 minute postintervention; P = 0.10); however, this became significant in adjusted robust regression accounting for stroke severity, age, Alberta Stroke Program Early Computed Tomography Scale score, daytime versus nighttime and weekend versus weekday arrival, and use of perfusion imaging (β −20.9 [95% CI, −40.5 to −1.4)]. There was also a significant interaction observed for the association between spoke versus hub arrival and the Viz large vessel occlusion period, with shorter intervals observed for transferred patients (n = 32 preintervention with a median of 169 versus 142 minutes for n = 33 postintervention; P interaction &lt;0.01). Conclusion Implementation of the artificial intelligence platform was not associated with shorter intervals between initial hospital contact and neurointervention among all‐comers. A meaningful difference in time to treatment was observed among transferred patients. Larger data sets are needed to validate these observations.

Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network.

Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.

Pre-hospital telestroke and expanded hyper-acute telestroke network solutions to reduce geographic inequities: a brief review from the South Pacific

Hyper-acute stroke treatments are time sensitive, and decision-making is complex. Telemedicine has been highly effective in breaking down regional access barriers by providing front line rural hospital clinicians with remote telemedicine decision support by remote stroke experts. With the advent of mechanical thrombectomy, hyper-acute stroke care has grown even more complex from both a decision-making and logistical perspective. Mobile Stroke Units (MSU) have been deployed in a few urban settings globally but are unlikely to address all global access issues due to geographical and logistical factors. This paper reviews the feasibility and benefit of extending telestroke into the pre-hospital setting as an adjunct or alternative to MSUs. It will discuss how this service model can fit into existing stroke networks and potential deployment strategies. Finally, the paper also considers potential scalability of pre- and in-hospital telestroke support across regional and international boundaries to further reduce global hyper-acute access inequities.

Identification of Anterior Large Vessel Occlusion Stroke During the Emergency Call: Protocol for a Controlled, Nonrandomized Trial.

Endovascular thrombectomy (ET), combined with intravenous thrombolysis if possible, is an effective treatment option for patients with stroke who have confirmed anterior large vessel occlusion (aLVO). However, ET is mainly limited to comprehensive stroke centers (CSCs), resulting in a lack of ET capacity in remote, sparsely populated areas. Most stroke networks use the "Drip and Ship" or "Mothership" strategy, resulting in either delayed ET or intravenous thrombolysis, respectively. This study protocol introduces the Leitstellen-Basierte Erkennung von Schlaganfall-Patienten für eine Thrombektomie und daraufhin abgestimmte Optimierung der Rettungskette (LESTOR) strategy, developed to optimize the preclinical part of the stroke chain of survival to improve the clinical outcome of patients with suspected aLVO stroke. This involves refining the dispatch strategy for identifying patients with acute aLVO stroke using a phone-based aLVO query. This includes dispatching emergency physicians and emergency medical services (EMS) to urban emergency sites, as well as dispatching helicopter EMS to remote areas. If a highly suspected aLVO is identified after a standardized aLVO score evaluation during a structured examination at the emergency scene, prompt transport to a CSC should be prioritized. The LESTOR study is a controlled, nonrandomized study implementing the LESTOR strategy, with a stepped-wedge, cluster trial design in 6 districts in southwest Germany. In an interprofessional, iterative approach, an aLVO query or dispatch protocol intended for use by dispatchers, followed by a coordinated aLVO examination score for use by EMS, is being developed, evaluated, and pretested in a simulation study. After the training of all participating health care professionals with the corresponding final aLVO query, the LESTOR strategy is being implemented stepwise. Patients otherwise receive usual stroke care in both the control and intervention groups. The primary outcome is the modified Rankin Scale at 90 days in patients with stroke receiving endovascular treatment. We will use a generalized linear mixed model for data analysis. This study is accompanied by a cost-effectiveness analysis and a qualitative process evaluation. This paper describes and discusses the protocol for this controlled, nonrandomized LESTOR study. Enrollment was completed in June 2023. Data analysis is ongoing and the first results are expected to be submitted for publication in 2024. The project started in April 2020 and will end in February 2024. We expect that the intervention will improve the clinical outcome of patients with aLVO stroke, especially outside the catchment areas of CSCs. The results of the accompanying process evaluation and the cost-effectiveness analysis will provide further insights into the implementation process and allow for a better interpretation of the results. German Clinical Trials Register DRKS00022152; https://drks.de/search/de/trial/DRKS00022152. DERR1-10.2196/51683.