Welcome to the WSC 2022 Interactive Program

Background and Aims

Mechanical thrombectomy can only be performed in comprehensive stroke centres (CSC) which provide on-site interventional radiology and neurosurgical services. The benefits of direct admission to a CSC versus secondary transfer following initial admission to a stroke unit without MT service are heavily contested.

Nottingham University Hospitals provides the East Midlands’ Mechanical Thrombectomy (MT) service in the United Kingdom. With an aim to reduce the number of transfers for patients eligible for MT within the region, we relocated our stroke services from Nottingham City Hospital (NCH) to Queens’ Medical Centre (QMC), a major trauma centre with on-site interventional services in July 2020.

Methods

We compared timings of stroke assessment and outcomes for consecutive patients transferred from NCH to those who were directly admitted to QMC after the change in our service model.

Results

101 patients admitted from Nottingham underwent MT between January 2019 and January 2022. For patients transferred (n=48) and patients directly admitted (n=53) respectively: average time from CT scan to groin puncture were 163 and 151 minutes; reperfusion rates (TICI>2a) were 100% and 96%. The median modified Rankin Score on discharge were 3.5 and 3.6 respectively.

Conclusions

Although shorter imaging-to-groin puncture time was demonstrated post-relocation, comparable functional outcomes were seen between patients transferred and directly admitted to our CSC. This could be attributed to an increased time window of MT eligibility from 6 to 24 hours post symptom onset after our relocation. Further studies are required to establish its effects and explore the impacts of the COVID-19 pandemic on our stroke service.

Background and Aims

The Face-Arm-Speech-Time (FAST) score to recognize stroke patients primarily detects clinical symptoms of anterior circulation strokes and is less effective in posterior circulation strokes.^1,2 The purpose of the presented study was to investigate if stroke detection in the emergency setting might be improved by extending the established FAST score by 4 additional items („Dizziness“, „Diplopic images“, „Deficit in field of view“, „Dysmetria“) to a new FAST4D score.

Methods

This prospective observational analysis was performed in a district of Hessen, Germany. Paramedics were instructed to use FAST4D instead of FAST by extending the standard operating procedure of stroke treatment. We included all patients who were admitted to the emergency department with suspected stroke and all patients with the diagnosis of stroke when being discharged from hospital. Differences between the sensitivity and specificity of FAST and FAST4D were calculated.

Results

Between 05/2019 and 06/2021 a total of 2,436 patients were screened and 1,876 were included. FAST4D detected 190 (15%) patients more with stroke then did the FAST score. This observation showed a sensitivity for FAST4D of 91% in contrast to FAST with a sensitivity of 71%. Specificity decreased from 56% using FAST to 8% with FAST4D.

Conclusions

The extension of FAST with the 4 additional items to FAST4D increased the stroke detection rate about 15% and potentially improves the time-critical primary care by correct allocation of these patients. The lower specificity should be accepted in light of the necessity to treat stroke patients immediately.

¹Jones EmergMed, 2021; ²Hoyer. FrontNeurol, 2021

Background and Aims

There is potential risk of temporal confounding when assessing Tenecteplase (TNK) real world data using the typical before and after design. After our change to TNK in 2020 we were forced to change back in 2021 due to a sudden cessation of drug supply providing a unique opportunity to control for temporal trends.

Methods

In New Zealand all thrombolysed patients are entered prospectively into a central database for safety monitoring. We assessed patient outcomes and treatment metrics over three time periods: before switch (January 2018- January 2020); during TNK use (February 2020-February 2021) and after reverting to Alteplase (February 2021 to February 2022) adjusting regression analyses for age, sex, NIHSS, pre-morbid mRS and thrombectomy.

Results

The Central Hyper-Acute Stroke Network serves 1.17 million people. Between January 2018 and February 2022, we treated 773 patients with alteplase and 284 with TNK. Overall, patients treated with TNK had greater odds of mRS of 0-2 (aOR=1.81; 95%CI=1.13-2.89); shorter median (IQR) door-to-needle (DTN) time (52 (38-73) vs 60 (45-84) minutes, p=0.0001) and needle to groin (NTG) times (118 (74.5-218.5) versus 159 (104-244); p=0.11). Symptomatic ICH rate was lower in TNK group but did not quite reach statistical significance (p=0.071). DTN and NTG times were shorter with TNK ((52 (38-73) and 118 (74.5-218.5)) compared with alteplase pre-TNK (61 (45-85) and 157.5 (92-219)) and Alteplase post-TNK (60 (45-82) and 163 (116-265)).

Conclusions

A forced reversion from Tenecteplase to Alteplase demonstrates that previously reported benefits from TNK in a real-world setting were not simply attributable to a concurrent temporal trend.

Background and Aims

Patients presenting with stroke-like symptoms (stroke mimics) comprise over half the case load seen by stroke teams in the UK. There are limited data to date that investigate factors associated with thrombolysis intervention for this subset of patients.

Methods

Sentinel Stroke National Audit Programme, a national quality improvement registry, collected data on mimics admitted during September 2021. Gender, ethnicity, and diagnoses were compared between those who did and did not receive thrombolysis using Chi² tests. Age was compared using Mann-Whitney U test. Univariate unadjusted logistic regression was used to determine the likelihood of thrombolysis treatment.

Results

6,295 mimics admitted to 107 hospitals were included in this study; of these, 45 were thrombolysed (0.7%). Median age of thrombolysed mimics was 12 years younger (58 vs 70, p < 0.001) and there was a 2.3% decrease in the odds of receiving thrombolysis each additional year increase in age (OR: 0.977; 95% CI, [0.962 – 0.992]) . No differences were observed between the gender and ethnic make-up of each group. Migraine was the most frequent diagnosis to receive thrombolysis (26.7% of all thrombolysed mimics), followed by unclassified diagnoses (15.6%), functional neurological disorders (FND - 13.3%) and seizure (11.1%). Migraines and FND were significantly more prevalent in the group that received thrombolysis (migraine 26.7% vs 9.5%, p<0.001; FND 13.3% vs 1.2%, p<0.001).

Conclusions

A small but clinically significant proportion of stroke mimics are thrombolysed. They tend to be younger than other mimics, and more likely to have migraine or FND as the final diagnosis.