Stroke Network Research Articles

Adequate access to mechanical thrombectomy during COVID-19 pandemic in lesser Poland Voivodeship in Poland

Many studies have shown that COVID-19 pandemic decreased the access to mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients. We studied, if the pandemic affected the access to MT in Lesser Poland Voivodeship (LPV) located in southeastern Poland (3.36 million of inhabitants). In LPV patients with AIS are admitted to the nearest stroke unit in the region (15-unit Stroke Network), where intravenous thrombolysis is performed. Those fulfilling the criteria for MT are admitted to the Comprehensive Stroke Unit at the University Hospital in Krakow. We compared the number of MT performed within 12 months before pandemic outburst, from March 2019 to February 2020 with the number of MT performed during pandemic, from March 2020 to February 2021. We also compared the time from stroke onset (SO) to groin puncture (GP) during the two studied periods. 146 had MTs performed during pre-pandemic period and 182 during the pandemic period. The number of MTs in the consecutive months of both periods was similar up to Novembers. The number of MT doubled from December 2020 to January 2021 as compared to the same period of time a year earlier. The mean SO-GP times were similar in both analyzed periods.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In LPV the number of MTs during COVID-19 pandemic was similar or even higher as compared to the corresponding pre-pandemic period. The time of the access to MT was not affected by the COVID-19 pandemic. Our results reflect the efficiency of the local medical system for stroke care, irrespectively of the COVID-19 challenges.

The benefit of a short-stay neurological observation unit in the COVID-19 era

Acute neurological symptoms are responsible for 5–15% of referral to the Emergency Department (ED). Since the COVID-19 outbreak, our stroke network shifted toward a mothership model with direct transport of stroke patients to the Comprehensive Stroke Center (“M. Bufalini” hospital, Cesena, Italy). To handle the increase in referrals due to mothership and guarantee a neurological fast-track in the ED, the Neurology service opened a four-bed Short-Stay Neurological Observation Unit (SSNO or “OBI Neuro”).

Maintaining acute stroke care during the covid-19 pandemic: The Tuscany stroke network performance in 2020

The COVID 19 pandemic is impacting on acute ischemic stroke (AIS) care: fewer patients reach the hospital within the therapeutic time-window. We aim at describing and quantifying this impact in terms of number of stroke hospital admissions and treatments across the Tuscany Stroke Network (TSN) in 2020.

GIS Mapping Evaluation of Stroke Service Areas in Bangkok Using Emergency Medical Services

Stroke is a major cause of death in Thailand. It requires a specific time period of 4.5 h from onset to treatment to increase recovery rates, and therefore, it can be categorized as a time-sensitive disease. The objective of this research is to identify whether the service areas of the main existing Emergency Medical Services (EMS) prehospital stroke practices cover all areas in Bangkok. This is determined by using GIS mapping. After verifying the current EMS delivery models, comparisons are drawn to find the travelling time of each model. The conditioning factors for GIS mapping were collected and verified, including the traffic speed and duration spent in each mode of the prehospital stroke process. After inputting all of the data into GIS, the service areas were visualized to show the area serviced in each delivery model. The results also show the different hospital groups, including the service areas for (1) non-network hospitals and (2) hospitals with stroke networks. Suggestions for re-networking and adding more hospitals to the existing networks were also identified using GIS. Regularly updating the service area with up-to-date data in GIS is key to improving stroke service areas.

Fewer COVID-19-associated strokes and reduced severity during the second COVID-19 wave: The Madrid Stroke Network.

Background and purposeThe experience gained during the first COVID‐19 wave could have mitigated the negative impact on stroke care in the following waves. Our aims were to analyze the characteristics and outcomes of patients with stroke admitted during the second COVID‐19 wave and to evaluate the differences in the stroke care provision compared with the first wave.MethodsThis retrospective multicenter cohort study included consecutive stroke patients admitted to any of the seven hospitals with stroke units (SUs) and endovascular treatment facilities in the Madrid Health Region. The characteristics of the stroke patients with or without a COVID‐19 diagnosis were compared and the organizational changes in stroke care between the first wave (25 February to 25 April 2020) and second wave (21 July to 21 November 2020) were analyzed.ResultsA total of 550 and 1191 stroke patients were admitted during the first and second COVID‐19 waves, respectively, with an average daily admission rate of nine patients in both waves. During the second wave, there was a decrease in stroke severity (median National Institutes of Health Stroke Scale 5 vs. 6; p = 0.000), in‐hospital strokes (3% vs. 8.1%) and in‐hospital mortality (9.9% vs. 15.9%). Furthermore, fewer patients experienced concurrent COVID‐19 (6.8% vs. 19.1%), and they presented milder COVID‐19 and less severe strokes. Fewer hospitals reported a reduction in the number of SU beds or deployment of SU personnel to COVID‐19 dedicated wards during the second wave.ConclusionsDuring the second COVID‐19 wave, fewer stroke patients were diagnosed with COVID‐19, and they had less stroke severity and milder COVID‐19.

Stroke care networks and the impact on quality of care

Lack of rapidly available neurological expertise, especially in rural areas, is one of the key obstacles in stroke care. Stroke care networks attempt to address this challenge by connecting hospitals with specialized stroke centers, stroke units, and hospitals of lower levels of care. While the benefits of stroke care networks are well-documented, travel distances are likely to increase when patients are transferred almost exclusively between members of the same network. This is particularly important for patients who require mechanical thrombectomy, an increasingly employed treatment method that requires equipment and expertise available in specialized stroke centers. This study aims to analyze the performance of the current design of stroke care networks in Bavaria, Germany, and to evaluate the improvement potential when the networks are redesigned to minimize travel distances. To this end, we define three fundamental criteria for assessing network design performance: 1) average travel distances, 2) the populace in the catchment area relative to the number of stroke units, and 3) the ratio of stroke units to lower-care hospitals. We generate several alternative stroke network designs using an analytical approach based on mathematical programming and clustering. Finally, we evaluate the performance of the existing networks in Bavaria via simulation. The results show that the current network design could be significantly improved concerning the average travel distances. Moreover, the existing networks are unnecessarily imbalanced when it comes to their number of stroke units per capita and the ratio of stroke units to lower-care hospitals.

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019.

Background:To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019.Methods:Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis.Results:The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in ‘size’: the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: ‘Transparent entrepreneurship’ (MD = 18.0% F(1) = 10.693, p = 0.001), ‘Roles and tasks’ (MD = 14.0% F(1) = 9.255, p = 0.003), ‘Patient-centeredness’ (MD = 12.9% F(1) = 9.255, p = 0.003), and ‘Commitment’ (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for ‘Transparent entrepreneurship’, ‘Result-focused learning’ and ‘Quality of care’. Conversely, there are small but negative associations between the volume of patients and implementation rates for ‘Interprofessional teamwork’ and ‘Patient-centredness’.Conclusion:This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Stroke network performance during the first COVID-19 pandemic stage: A meta-analysis based on stroke network models.

BackgroundThe effect of the COVID pandemic on stroke network performance is unclear, particularly with consideration of drip&ship vs. mothership models.AimsWe systematically reviewed and meta-analyzed variations in stroke admissions, rate and timing of reperfusion treatments during the first wave COVID pandemic vs. the pre-pandemic timeframe depending on stroke network model adopted.Summary of findingsThe systematic review followed registered protocol (PROSPERO-CRD42020211535), PRISMA and MOOSE guidelines. We searched MEDLINE, EMBASE, and CENTRAL until 9 October 2020 for studies reporting variations in ischemic stroke admissions, treatment rates, and timing in COVID (first wave) vs. control-period. Primary outcome was the weekly admission incidence rate ratio (IRR = admissions during COVID-period/admissions during control-period). Secondary outcomes were (i) changes in rate of reperfusion treatments and (ii) time metrics for pre- and in-hospital phase. Data were pooled using random-effects models, comparing mothership vs. drip&ship model. Overall, 29 studies were included in quantitative synthesis (n = 212,960). COVID-period was associated with a significant reduction in stroke admission rates (IRR = 0.69, 95%CI = 0.61–0.79), with higher relative presentation of large vessel occlusion (risk ratio (RR) = 1.62, 95% confidence interval (CI) = 1.24–2.12). Proportions of patients treated with endovascular treatment increased (RR = 1.14, 95%CI = 1.02–1.28). Intravenous thrombolysis decreased overall (IRR = 0.72, 95%CI = 0.54–0.96) but not in the mothership model (IRR = 0.81, 95%CI = 0.43–1.52). Onset-to-door time was longer for the drip&ship in COVID-period compared to the control-period (+32 min, 95%CI = 0–64). Door-to-scan was longer in COVID-period (+5 min, 95%CI = 2–7). Door-to-needle and door-to-groin were similar in COVID-period and control-period.ConclusionsDespite a 35% drop in stroke admissions during the first pandemic wave, proportions of patients receiving reperfusion and time-metrics were not inferior to control-period. Mothership preserved the weekly rate of intravenous thrombolysis and the onset-to-door timing to pre-pandemic standards.

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.

Quality assurance data for regional drip-and-ship strategies- gearing up the transfer process

BackgroundStroke patients with large vessel occlusion (LVO) require endovascular therapy (EVT) provided by comprehensive stroke centers (CSC). One strategy to achieve fast stroke symptom ‘onset to treatment’ times (OTT) is the preclinical selection of patients with severe stroke for direct transport to CSC. Another is the optimization of interhospital transfer workflow. Our aim was to investigate the dynamics of the OTT of ‘drip-and-ship’ patients as well as the current ‘door-in-door-out’ time (DIDO) and its determinants at representative regional German stroke units.MethodsWe determined the numbers of all EVT treatments, ‘drip-and-ship’ and ‘direct-to-center’ patients and their median OTT from the mandatory quality assurance registry of the federal state of Hesse, Germany (2012–2019). Additionally, we captured process time stamps from primary stroke centers (PSC) in a consecutive registry of patients referred for EVT in our regional stroke network over a 3 months period.ResultsAlong with an increase of the EVT rate, the proportion of drip-and-ship patients grew steadily from 19.4% in 2012 to 31.3% in 2019. The time discrepancy for the median OTT between ‘drip-and-ship’ and ‘direct-to-center’ patients continuously declined from 173 to 74 min. The largest share of the DIDO (median 92, IQR 69–110) is spent with the organization of EVT and consecutive patient transfer.Conclusions‘Drip-and-ship’ patients are an important and growing proportion of stroke patients undergoing EVT. The discrepancy in OTT for EVT between ‘drip-and-ship’ and ‘direct-to-center’ patients has been reduced considerably. Further optimization of the DIDO primarily aiming at the processes after the detection of LVO is urgently needed to improve stroke patient care.

Interdisciplinary networking for optimal treatment decision-making : Fast decision-making in acute ischemic stroke management

Every year, about 270,000 strokes occur in Germany. In the entire DACH region (Germany, Austria, Switzerland), more than 310,000cases are reported each year. Two thirds of the surviving patients are dependent on external assistance after the stroke. Increasingly, imaging data are becoming the focus of treatment decisions. These data provide critical information about the location and extent of vessel occlusion, infarct size, volume of salvageable brain tissue, and degree of collateralization. Certified stroke units and stroke networks already specialize in state-of-the-art therapeutic options, but they need additional information technology tools to deliver the right therapy to the right patient population as quickly as possible. For multidisciplinary, seamless support in stroke care, both prehospital and in-hospital processes need to be optimized. This article presents aconcept for supraregional stroke care by means of networking all involved actors in the prehospital as well as in the in-hospital area. Further needs analyses should ensure the implementation as well as the generalizability to different regions.

INSTRuCT: Protocol, Infrastructure, and Governance.

Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.

Central Triage of Acute Stroke Patients Across a Distributive Stroke Network Is Safe and Reduces Transfer Denials.

Mechanical thrombectomy has dramatically increased patient volumes transferred to comprehensive stroke centers (CSCs), resulting in transfer denials for patients who need higher level of care only available at a CSC. We hypothesized that a distributive stroke network (DSN), triaging low severity acute stroke patients to a primary stroke center (PSC) upon initial telestroke consultation, would safely reduce transfer denials, thereby providing additional volume to treat severe strokes at a CSC. In 2017, a DSN was implemented, in which mild stroke patients were centrally triaged, via telestroke consultation, to a PSC based upon a simple clinical severity algorithm, while higher acuity/severity strokes were triaged to the CSC. In an observational cohort study, data on acute ischemic stroke patients presenting to regional community hospitals were collected pre- versus post-DSN implementation. Safety outcomes and rate of CSC transfer denials were compared pre-DSN versus post-DSN. The pre-DSN cohort (n=150), triaged to the CSC, had a similar rate of symptomatic intracerebral hemorrhage and discharge location compared with the post-DSN cohort (n=150), triaged to the PSC. Time to stroke unit admission was faster post-DSN (2 hours 40 minutes) versus pre-DSN (3 hours 29 minutes; P<0.001). Transfer denials were reduced post-DSN (3.8%) versus pre-DSN (1.8%; P=0.02), despite an increase in telestroke consultation volume over the same period (median, 3 calls per day pre-DSN versus 5 calls per day post-DSN; P=0.001). No patients who were triaged to the PSC required subsequent transfer to the CSC. A DSN, triaging mild ischemic stroke patients from community hospitals to a PSC, safely reduced transfer denials to the CSC, allowing greater capacity at the CSC to treat higher acuity stroke patients.

Telemedicine in stroke-pertinent to stroke care in Germany

Hintergrund und ZielTelemedizinische Schlaganfall-Netzwerke tragen dazu bei, die Schlaganfallversorgung und insbesondere den Zugang zu zeitkritischen Schlaganfalltherapien in vorrangig strukturschwachen, ländlichen Regionen zu gewährleisten. Ziel ist eine Darstellung der Nutzungsfrequenz und regionalen Verteilung dieser Versorgungsstruktur.MethodenDie Kommission „Telemedizinische Schlaganfallversorgung“ der Deutschen Schlaganfall-Gesellschaft führte eine Umfragestudie in allen Schlaganfall-Netzwerken durch.ErgebnisseIn Deutschland sind 22 telemedizinische Schlaganfall-Netzwerke aktiv, welche insgesamt 43 Zentren (pro Netzwerk: Median 1,5, Interquartilsabstand [IQA] 1–3) sowie 225 Kooperationskliniken (pro Netzwerk: Median 9, IQA 4–17) umfassen und an einem unmittelbaren Zugang zur Schlaganfallversorgung für 48 Mio. Menschen teilhaben. Im Jahr 2018 wurden 38.211 Telekonsile (pro Netzwerk: Median 1340, IQA 319–2758) durchgeführt. Die Thrombolyserate betrug 14,1 % (95 %-Konfidenzintervall 13,6–14,7 %), eine Verlegung zur Thrombektomie wurde bei 7,9 % (95 %-Konfidenzintervall 7,5–8,4 %) der ischämischen Schlaganfallpatienten initiiert. Das Finanzierungssystem ist uneinheitlich mit einem Vergütungssystem für die Zentrumsleistungen in nur drei Bundesländern.DiskussionEtwa jeder 10. Schlaganfallpatient wird telemedizinisch behandelt. Die telemedizinischen Schlaganfall-Netzwerke erreichen vergleichbar hohe Lyseraten und Verlegungen zur Thrombektomie wie neurologische Stroke-Units und tragen zur Sicherstellung einer flächendeckenden Schlaganfallversorgung bei. Eine netzwerkübergreifende Sicherstellung der Finanzierung und einheitliche Erhebung von Qualitätssicherungsdaten haben das Potenzial diese Versorgungsstruktur zukünftig weiter zu stärken.Zusatzmaterial onlineDie Onlineversion dieses Beitrags (10.1007/s00115-021-01137-6) enthält weiteres Zusatzmaterial (Fragebogen). Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Cerebral Microbleeds and White Matter Hyperintensities are Associated with Cognitive Decline in an Asian Memory Clinic Study.

Cerebral Small Vessel Disease (SVD); lacunes, Cerebral Microbleeds (CMBs), and White Matter Hyperintensities (WMH) have a vital role in cognitive impairment and dementia. SVD in lobar location is related to cerebral amyloid angiopathy, whereas SVD in a deep location with hypertensive arteriopathy. It remains unclear how different locations of SVD affect long-term cognitive decline. The present study aimed to analyse the association between different locations and severity of SVD with global and domain-specific cognitive decline over the follow-up interval of 3 years. We studied 428 participants who had performed MRI scans at baseline and at least 3 neuropsychological assessments. Locations of lacunes and CMBs were categorized into strictly lobar, strictly deep and mixed-location, WMH volume into anterior and posterior. The National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Harmonization Neuropsychological Battery was used to assess cognitive function. To analyse the association between baseline location and severity of SVD with cognitive decline, linear regression models with generalized estimated equations were constructed to calculate the mean difference, 95% confidence interval and two-way interaction factor between time and SVD. Increased numbers of baseline CMBs were associated with a decline in global cognition as well as a decline in executive function and memory domains. Location-specific analysis showed similar results with strictly lobar CMBs. There was no association with strictly deep and mixed-location CMBs with cognitive decline. Baseline WMH volume was associated with a decline in global cognition, executive function and memory. Similar results were obtained with anterior and posterior WMH volumes. Lacunes and their locations were not associated with cognitive decline. Strictly lobar CMBs, as well as WMH volume in anterior and posterior regions, were associated with cognitive decline. Future research focuses are warranted to evaluate interventions that may prevent cognitive decline related to SVD.

Teleradiology-based stroke network in Western and Southern Transdanubia in Hungary

The possibilities of cerebral stroke management have changed substantially during the last few years. Following a few multicentric studies, mechanical thrombectomy became an established method besides thrombolysis. In addition, the therapeutic window for both methods is much wider now than before. These changes described above demanded more information of CT morphological changes due to ischemia, but the condition and functionality of the arterial and collateral system, and occasionally tissue perfusion performance should also be characterized. Recently, evaluation of different computer tomographic (CT) measurements can be done using artificial intelligence based methods, which perform data analysis in a few minutes. To establish a dedicated stroke teleradiology network with artificial intelligence based image analysis in Western and Southern Transdanubia in Hungary that involves six partner institutes. Integration of automated image analysis with teleradiology software was established, and the technical parameters of examination protocols were unified. Results of stroke CT image analysis became accessible through the teleradiology network. The daily use of integrated central image analysis and image communication had a positive impact on referrals and therapeutic evaluation of stroke cases. The number of image processing and mechanical thrombectomy increased during the last year. With the help of the dedicated teleradiology stroke network, we want to optimize the stroke care in the region: on the one hand, patients who are likely to benefit from thrombectomy should not be left unattended, on the other, the health care system should not be burdened with cases, when intervention is not recommended having the complete clinical data accessed. Orv Hetil. 2021; 162(17): 668-675.

Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta-analysis.

The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta-analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large-vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR]=1.80, 95% confidence interval [CI]= 1.18 to 2.75); however, MSU did not (RR=1.22, 95% CI= 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD]=-0.82, 95% CI= -1.32 to -0.32), LVO bypass (SMD=-0.80, 95% CI= -1.13 to -0.47), and MSU (SMD=-0.87, 95% CI= -1.57 to -0.17) were found to significantly reduce door-to-needle time for IVT. MSU was found to significantly reduce call-to-needle (SMD=-1.41, 95% CI= -1.94 to -0.88) and onset-to-needle (SMD=-1.15, 95% CI= -1.74 to -0.56) times for IVT. MSU additionally demonstrated significant reduction in door-to-perfusion (SMD=-0.72, 95% CI= -1.32 to -0.12) as well as call-to-perfusion (SMD=-0.73, 95% CI= -1.08 to -0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR=1.04, 95% CI= 0.97 to 1.12) or mortality at 90days (RR=1.00, 95% CI= 0.76 to 1.31). This systematic review and meta-analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often-neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis-à-vis PSWOs are warranted.

Concurrent validity of the short version of Montreal Cognitive Assessment (MoCA) for patients with stroke

The aim of the present study was to examine the concurrent validity of 2 Chinese versions of the short version of the Montreal Cognitive Assessment (MoCA) in patients with stroke, i.e., MoCA 5-minute protocol and National Institute for Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) 5-minute Protocol. A total of 54 patients and 27 healthy controls were enrolled in this study. In this study, the Neurobehavioural Cognitive Status Examination (NCSE) was used as an external criterion of cognitive impairment. We found that the 5-min protocol did not differ from the MoCA in differentiating patients with cognitive impairments from those without (area under the receiver operating characteristic curve, AUC, of 0.948 for the MoCA 5-min protocol v.s. 0.984 for MoCA, P = 0.097). These three assessments demonstrated equal performance in differentiating patients with stroke from controls. The Chinese version of the MoCA 5-min protocol can be used as a valid screening for patients with stroke.

Stroke management during the coronavirus disease 2019 (COVID-19) pandemic: experience from three regions of the north east of Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige)

BackgroundEfficiency of care chain response and hospital reactivity were and are challenged for stroke acute care management during the pandemic period of coronavirus disease 2019 (COVID-19) in North-Eastern Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige), counting 7,193,880 inhabitants (ISTAT), with consequences in acute treatment for patients with ischemic stroke.MethodsWe conducted a retrospective data collection of patients admitted to stroke units eventually treated with thrombolysis and thrombectomy, ranging from January to May 2020 from the beginning to the end of the main first pandemic period of COVID-19 in Italy. The primary endpoint was the number of patients arriving to these stroke units, and secondary endpoints were the number of thrombolysis and/or thrombectomy. Chi-square analysis was used on all patients; furthermore, patients were divided into two cohorts (pre-lockdown and lockdown periods) and the Kruskal-Wallis test was used to test differences on admission and reperfusive therapies.ResultsIn total, 2536 patients were included in 22 centers. There was a significant decrease of admissions in April compared to January. Furthermore, we observed a significant decrease of thrombectomy during the lockdown period, while thrombolysis rate was unaffected in the same interval across all centers.ConclusionsOur study confirmed a decrease in admission rate of stroke patients in a large area of northern Italy during the lockdown period, especially during the first dramatic phase. Overall, there was no decrease in thrombolysis rate, confirming an effect of emergency care system for stroke patients. Instead, the significant decrease in thrombectomy rate during lockdown addresses some considerations of local and regional stroke networks during COVID-19 pandemic evolution.

Abstract P286: The Effects of COVID-19 on the Reasons for Not Calling 911 for Acute Stroke

Objective: Our Stroke Program regularly provides community outreach and stroke education. The stroke team educates on signs and symptoms of stroke, risks factors, and 911 activation. Within a few days of discharge, Neuroscience nurses call stroke patients to ensure patients have obtained their prescription medications, have follow-up appointments, inquire about their satisfaction with our services, and reinforce stroke education. As part of these calls, our team asked why patients/families did not call 911. The purpose of this study was to determine if the COVID-19 crisis influenced the reasons why 911 was not called for possible stroke to better plan for targeted stroke education. Method: Discharge phone survey data from our stroke network was collected from Feb-Jul 2019 and compared to Feb-Jul 2020. Our stroke network includes 1 comprehensive stroke center and 2 primary stroke centers. Emergency Department (ED) stroke activation data was gathered for the same time periods. Discharge phone calls data was based on discharge date, whereas ED stroke alert data was based on admission date. Results: There was a notable decline in stroke volume between 2019 to 2020 with the largest decline occurring during the first peak (Apr 2020) in COVID-19 cases within our state. This decline was driven by a 16% decline in walk-in ED stroke arrivals as compared to a 1% decline in EMS stroke arrivals. Of those who did not call 911 in 2020, there was a 7% increase in failing to recognize stroke symptoms as an emergency, a 6% increase in concern about EMS cost, and 6% decrease in hospital preference. Conclusion: The COVID-19 crisis negatively influenced stroke volumes within our system stroke program. Reductions in stroke walk-ins accounted for this decline. COVID-19 affected the reasons why 911 was not called. The largest increase was in not recognizing stroke symptoms as an emergency and increased concern about EMS associated costs. Surprisingly, COVID-19 was not listed as a reasons for avoiding 911. Targeted community educational efforts on these concerns may lead to improved 911 usage for suspected stroke during the COVID-19 pandemic. Limitations: Further research is needed to investigate why those with a stroke who would have been walk-ins decided not to seek urgent medical attention.