Welcome to the ESOC 2021 Virtual Conference Calendar

Background And Aims

Stroke reperfusion therapy is time critical. Improving pre-hospital diagnostic accuracy can aid in making efficient and appropriate diversion decisions and has the potential to improve onset-to-treatment time. Our aim was to investigate whether pre-hospital telestroke improves diagnostic accuracy when compared with paramedic assessments, and determine the ease of integrating this service into patient care.

Methods

We conducted a pragmatic, community-based, cluster randomised controlled trial of routine ambulance screening (FAST and glucose, seizure, and posterior circulation screen) plus specialist telestroke assessments inside the ambulance compared with routine ambulance screening plus modified Los Angeles Motor Scale (PASTA score). Primary outcome was the accuracy of predicting reperfusion candidates; secondary outcomes were accuracy, sensitivity, specificity, positive, and negative predictive values to identify, actual stroke patient, thrombolysis and thrombectomy candidates.

Results

Of 76 patients (35 in the telestroke and 41 in the PASTA arms) recruited between August 2019 and September 2020, 38/76 (50%) had a final diagnosis of acute stroke and 12/76 (15.8%) received reperfusion therapy. Compared to neurologist assessment in the emergency department FAST+Telestroke was 100% (95% CI 90-100%) and FAST+PASTA 70.7% (54.5-83.9%) accurate in predicting ‘stroke for reperfusion’ (p=0.004). In predicting stroke for thrombolysis, telestroke was 97.1% (85.1-99.9%) and FAST+PASTA 61.0% (44.5-75.8%) accurate (p=0.002). In predicting eventual thrombectomy, telestroke was 88.6% (73.3-96.8%) and PASTA 56.1% (39.3-71.5%) accurate (p=0.004). Overall, the service model was acceptable to both neurologists and paramedics.

Conclusions

Pre-hospital telestroke assessment is feasible, highly accurate in diagnosing stroke for acute reperfusion therapies, and is superior to standard care plus the PASTA score.

Trial Registration Number

ACTRN12619001678189

Group Name

UCLH Telemedicine Research

Background And Aims

As a consequence of the COVID-19 pandemic prehospital video assessment (PHVA) of possible stroke was commenced by University College London Hospital and London Ambulance Service. We compared the accuracy of this assessment tool against conventional screening with FAST.

Methods

We examined the accuracy of PHVA from May 2020 to April 2021, together with final diagnoses, timings for treatment provided and ambulance crew primary assessment (FAST status) wherever this was recorded.

Results

Of 1300 patients triaged, 600 (46%) were sent to HASU, 570 (44%) were AE diverts and 65 (5%) were sent to their local TIA clinic. 40 patients (3%) were returned to their LAS pathway and missing data was noted for 25 patients (2%).

From 426 patients where FAST status was recorded, diagnosis of likely stroke/ TIA was correct in 89% (278) of PHVA versus 55% (173) of FAST assessed cases. Correct identification of non-stroke was correct in 84% (96) of PHVA versus 65% (75) of FAST assessed cases. A positive predictive value of 93% (PHVA) versus 59% (FAST) and negative predictive value 96% (PHVA) versus 84% (FAST) is noted.

46 thrombolysis and 12 thrombectomy cases with median treatment time before and during PHVA of 35 minutes (Interquartile range (IQR)- 26) vs 33 (IQR-15) and 136 (IQR- 87) vs 125 (IQR- 49) minutes respectively, were noted.

Conclusions

PHVA has been validated further, showing superior accuracy to the existing FAST assessment and may improve hyperacute treatment times and their variance.

Trial Registration Number

Not applicable

Background And Aims

The Stockholm Stroke Triage System (SSTS), implemented in 2017, identifies patients with high likelihood of large vessel occlusion (LVO) stroke. Using a 3-step algorithm including an ambulance-to-hospital teleconsultation, high likelihood patients bypass the primary stroke center. Previous reports have shown SSTS to notably reduce time to endovascular thrombectomy (EVT) and improve outcomes. As the indication for EVT now includes patients up to 24 hours, we aimed to assess SSTS triage accuracy for LVO stroke and EVT treatment for patients presenting late (within 6-24 hours or with an unknown onset), put in contrast to triage accuracy within 0-6 h.

Methods

Between October 2017 and October 2018, we included 2905 patients with suspected stroke, transported by priority 1 ground ambulance to a Stockholm Region hospital. Patients assessed 6-24 hours from last known well or with unknown onset were defined as late-presenting; those within 6 hours as early-presenting. Triage positivity was defined as transport to comprehensive stroke center due to suspected stroke, hemiparesis and high likelihood of EVT-eligible LVO per teleconsultation.

Results

Overall triage accuracy was high in late-presenting patients (90.9% for LVO,93.9% for EVT), with high specificity (95.7% for LVO, 94.5% for EVT), and low to moderate sensitivity (34.3% for LVO, 64.7% for EVT), with similar findings in the early-presenting group.

Conclusions

Our results support using the SSTS for primary stroke center bypass in patients assessed by ambulance up to 24 hours from time of last known well.

Trial Registration Number

Not applicable

Group Name

The BERLIN_PREHOSPITAL OR USUAL CARE DELIVERY IN ACUTE STROKE (B_PROUD) investigators

Background And Aims

In patients with spontaneous acute intracerebral haemorrhage (ICH), ESO guidelines suggest that blood pressure reduction with systolic blood pressure (sBP) target <140mmHg is safe and “should be started as soon and fast as possible”. Through prehospital imaging, Mobile Stroke Units (MSU) enable earlier ICH diagnosis and thereby earlier initiation of blood pressure lowering treatment.

Methods

ICH patients were included as a companion cohort in the prospective, controlled B_PROUD-study in Berlin, which primarily estimated effects for ischemic stroke patients. ICH patients within MSU catchment areas were included if onset-to-alarm time was ≤ 6h. MSU availability determined allocation (dispatch of MSU or conventional ambulance alone). We compared first sBP at ambulance arrival with first sBP measured in emergency departments as well as 7-day mortality and 3-month modified Rankin Scale (mRS) scores (range: 0, no neurological deficits, to 6, death; good outcome: 0-2).

Results

From February 1^st, 2017 to May 8^th, 2019, MSUs were dispatched to 113 ICH patients and conventional ambulances alone to 110 ICH patients (age: 72±13y vs. 71±12y, 48% vs. 42% female, median admission NIHSS: 12±7 vs. 12±8). First prehospital sBP was similar between MSU and conventional groups (176±34 vs. 172±36mmHg), but lower at emergency department arrival (163±34 vs. 179±38mmHg). 7-day mortality was 21% after MSU dispatch and 17% in conventional care (p=0.50). Odds ratio for good outcome at 3-months was 0.81 (95%-CI: 0.42-1.6; p=0.53) after MSU-dispatch.

Conclusions

Although MSU dispatch led to a significant prehospital blood pressure reduction, this did not translate into better outcomes for ICH patients.

Trial Registration Number

NCT02869386

Background And Aims

Results from the B_PROUD study have shown that the dispatch of mobile stroke units (MSUs), compared with conventional ambulances alone, was associated with lower global disability and higher quality of life at 3 months for patients with acute ischemic stroke in Berlin (Germany). However, the economic consequences of MSUs’ dispatch have not yet been analysed in B_PROUD. We aimed to assess the cost-utility, cost-effectiveness and cost-benefit of the deployment of MSUs in comparison with standard care.

Methods

We use data from B_PROUD, a prospective, non-randomized, controlled intervention study with group allocation based on availability of MSUs at time of dispatch. Outcomes considered for the cost-utility and cost-effectiveness analysis are quality-adjusted life years (QALYs) derived from the EQ-5D and the modified Rankin Scale (mRS) score. Costs prospectively collected during the study by the Berlin Fire Department and by the participating hospitals will be analysed from the societal perspective. An additional statutory-health insurance perspective will consider official reimbursement values for each service.

Results

Data from 1543 patients (MSU group = 749, standard care = 794) will be analysed. Results from this study will be presented at ESOC.

Conclusions

MSU dispatch was associated with better outcomes among acute stroke patients. This health economic evaluation analysing costs and effects of MSU dispatch will provide important information on cost-utility, cost-effectiveness and cost-benefit of MSUs when compared with standard care in the Berlin (Germany) setting.

Trial Registration Number

Clinical Trials ID: NCT03027453

Background And Aims

The Stockholm Stroke Triage System (SSTS), implemented 2017, combines teleconsultation with testing for moderate-to-severe unilateral hemiparesis. Sex differences in clinical characteristics among acute ischemic stroke (AIS) patients may affect triage accuracy, however this has not been evaluated in SSTS. We aimed to determine whether there are sex differences in triage accuracy of SSTS to predict large artery occlusion (LAO) stroke and endovascular thrombectomy (EVT), and whether characteristics differ between men and women undergoing “code stroke” ambulance transport.

Methods

This retrospective observational study analyzed data collected October 2017-October 2018. We included 2905 patients, transported by first-priority ground ambulance to a Stockholm Region hospital, with acute stroke suspected by an ambulance nurse. Exclusion criteria were private or helicopter transport, onset outside Stockholm, or in-hospital stroke. We compared sensitivity, specificity, positive and negative predictive values, and overall accuracy between sexes. Pearson’s Chi² and Mann-Whitney U were used for categorical and continuous variables.

Results

No significant sex differences in SSTS predictive performance for LAO or EVT were found, overall accuracy for LAO 87.3% in women versus 86.7% in men. Women were median 4 years older (P<.001) and more frequently had stroke mimics (46.2% vs 41.8%, P=.016). Women more commonly had decreased level of consciousness (14.0% vs 10.2%, P=.005) and severe motor symptoms (2.0-6.0 more %-points, P=.003-.044), and less commonly had limb ataxia (7.2% vs 9.7%, P=.037).

Conclusions

Despite sex differences in clinical characteristics among patients undergoing ambulance transport due to suspected stroke, SSTS had equally good predictive performance for LAO stroke and EVT among men and women.

Group Name

the MISSION Trial Investigators

Background And Aims

Rapid intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) is crucial for improving outcomes. However, randomized trials to reduce in-hospital delay are clearly limited in China. We aimed to evaluate the effect of a multi-component intervention on thrombolytic door-to needle time (DNT) of AIS patients via video teleconference based on the Behavior Change Wheel method.

Methods

This trial randomly allocated 22 hospitals equally to PEITEM (Persuasion Environment reconstruction Incentivisation Training Education Modeling) intervention or routine care plus stroke registry and subsequently enrolled 1634 AIS patients who receiving IVT within 4.5 hours upon stroke onset from participant hospitals. The PEITEM group received a one-year PEITEM intervention based on the behavioral theory monthly via video teleconference

Results

A total of 1,634 patients from the 22 hospitals were enrolled. The proportion of DNT ≤ 60 minutes was 82.0% in the PEITEM group and 73.7% in the control group (adjusted odds ratio, 1.85; 95% confidence interval [CI], 1.42 to 2.42, P < 0.001). The average DNT was 43 minutes in the PEITEM group and 50 minutes in the control group (β: -9.00; 95% CI, -11.37 to -6.63, P < 0.001). Favorable neurological outcomes were achieved in 55.6% patients in the PEITEM group and 50.4% patients in the control group (adjusted odds ratio, 1.34; 95% CI, 1.02 to 1.75; P = 0.04).

Conclusions

The teleconference-delivered PEITEM intervention resulted in a moderately but clinically relevant shorter DNT and better neurological outcomes in the AIS treated with the IVT. Video teleconference may be more appropriate and easier for quality improvement in the current global COVID-19 public health crisis disrupting healthcare services.

Trial Registration Number

NCT 03317639

Background And Aims

Due to its greater ease of administration, increasing trial evidence reporting safety, and recent Australian Guideline endorsement we switched to tenecteplase for stroke thrombolysis from alteplase. We describe our change process and real-world post-implementation outcomes.

Methods

We consulted early and widely, conducted pre- and post-implementation surveys, and assessed patient outcomes/treatment metrics pre- and post-implementation, adjusting regression analyses for age, sex, NIHSS, pre-morbid mRS, and thrombectomy.

Results

The Central New Zealand Hyper-Acute Stroke Network serves 1.17 million people. Pre-switch consultation involved stroke and emergency clinicians, pharmacists, national regulatory bodies, and hospital legal teams. All survey responders (90% response rate) supported the proposed change and remained satisfied 12 months post-implementation. Between January 2018 and February 2021, we treated 555 patients with alteplase pre- and 284 with tenecteplase post-switch, which occured on 2 March 2020. Population-based thrombolysis rates were unchanged (23.9 vs 24.3 per 100,000/year). Patients treated with tenecteplase had greater odds of a favourable mRS using both shift (aOR=1.67; 95%CI=1.19-2.33) and dichotomous analyses (mRS 0-2; aOR=1.95; 95%CI=1.17-3.25) and shorter median (IQR) door-to-needle time (median 53 (38-73.5) vs 61 minutes (45-85), p=0.0002). Symptomatic intracranial haemorrhage rates (tenecteplase 1.8% vs 3.4%, aOR 0.46; 95%CI=0.13-1.63), death by day seven (tenecteplase 7.5% vs 11.8%; aOR 0.54; 95%CI=0.27-1.10), and median (IQR) needle to groin time for the 42 transferred regional patients (tenecteplase 155 (113-248) vs 200 (158-266);p=0.27) did not significantly differ.

Conclusions

Following stakeholder consultation and endorsement, a region-wide switch from alteplase to tenecteplase was successfully implemented. Our real-world outcome data found evidence of benefit and no evidence of harm.