Rapid Diagnosis Correct in Over 90% of Helsinki Stroke Cases

That's not good enough, what are you doing to get to 100%? You don't tell us the most important part. Is tPA delivery in 20 minutes fast enough to get full recovery? That is the goal, NOT rapid diagnosis. All these fucking useless words and never talks about recovery
Damn it all, does no one understand the ONLY goal in stroke; 100% recovery. To that end, EXACTLY how fast does tPA need to be delivered to get to 100%? From that you can solve the problem of getting there. Right now you are just shooting in the dark. A strategy and leadership would make solving stroke possible, instead of just flailing around.

Rapid Diagnosis Correct in Over 90% of Helsinki Stroke Cases

Finnish stroke service aces door-to-needle time of less than 20 minutes(NOT GOOD ENOUGH!)

• by Judy George, Contributing Writer, MedPage Today July 17, 2018

Action Points

• Note that this observational study in a single hospital found a nearly 15% rate of misdiagnosis among patients referred for acute recanalization therapy.
• Despite this, unnecessary treatment or failure to provide necessary treatment occurred in less than 5% of cases.

Ischemic stroke patients who were evaluated and treated in under 20 minutes at Helsinki University Hospital received an accurate diagnosis more than 90% of the time, an analysis of the hospital's stroke-code patients showed.

With door-to-thrombolysis times below 20 minutes, the neurologic emergency department (ED) correctly diagnosed 91% of acute cerebral ischemia cases, 99% of hemorrhagic strokes, and 62% of stroke mimics, reported Saana Pihlasviita, MD, of the University of Helsinki, and colleagues in Neurology.

"In 2011, we pushed the door-to-needle time [DTN] permanently below 20 minutes," co-author Perttu Lindsberg, MD, PhD, of Helsinki University Hospital, told MedPage Today. "What we had not been monitoring was how well we had maintained the accuracy of our ED diagnostic process regarding the wide variety of stroke code patients, which include a plethora of mimics."

"While EMS [emergency medical services] personnel in Helsinki are trained to suspect thrombolytic-eligible stroke patients and transport them quickly, diagnosis at admission is an independent clinical judgment," Lindsberg said. "The CT findings are largely non-diagnostic for acute changes, which led us to wonder whether the time-pressure and therapy-geared expectations might have blurred the diagnostic accuracy."

The analysis focused on acute stroke patients transported by EMS as candidates for acute recanalization therapy from May 2013 to November 2015, and assessed the accuracy of the initial evaluation only. Admission evaluations were performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily using CT imaging.

The investigators defined the initial diagnosis as the first working diagnosis the physician proposed after admission. The final diagnosis included all available patient records, including ancillary etiologic investigations after hospital discharge.

Among 1,015 stroke-code patients, the rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (517 ischemic stroke; 146 transient ischemic attack (TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics.

About 15% of patients (150/1,015) were misdiagnosed, of which 90% had no acute findings on initial imaging and 67.6% presented with a NIH Stroke Scale score of 0 to 2. Of the 150 misdiagnosed patients, the final diagnosis was acute cerebral ischemia in 59 cases, intracerebral hemorrhage in one case, and stroke mimics in 90 cases.

In 70 cases, misdiagnosis changed medical management. In 13 cases, tissue plasminogen activator (tPA) was given unnecessarily; in five cases, it was omitted. Misdiagnosis led to a delay in antiplatelet medication of about 1 day in 14 patients and unnecessary stroke unit stays for 10 patients. A detailed review identified eight cases (0.8%) in which misdiagnosis possibly or likely worsened outcomes, but no deaths occurred as a result.

"The overall rate of misdiagnosis in admission evaluation was 14.8% for all arriving stroke code patients when mainly CT-based imaging was used," Lindsberg said. "But it was rather surprising to find that for every 100 stroke-code patients, only two received unnecessary tPA, or was left without indicated tPA, due to inaccurate admission diagnosis."

The swift door-to-needle process at Helsinki has been developed and refined over several decades, Lindsberg noted.

"We realized that rapid neurological evaluation must build on as much information and preparation from the pre-hospital phase as possible," he said. "Pre-notification of essential clinical details enables us to activate the stroke team, review digital patient records for suitability and contraindications, review and pre-order necessary laboratory investigations, and ensure entry to an immediate CT to be interpreted by the treating neurologist." The patient is examined on arrival and tPA is administered on the CT table.

In the last decade, "strategies to streamline pre-hospital stroke management have arisen, e.g., use of mobile stroke units, allowing diagnostic workup, treatment, and correct triage decisions, starting at the emergency site with a view toward the targeted hospital," observed Klaus Fassbender, MD, of Saarland University Medical Center in Germany, and Kevin Sheth, MD, of Yale School of Medicine in New Haven, Connecticut, in an accompanying editorial.

In the U.S, for example, a modified Helsinki protocol using telestroke was associated with a median door-to-needle time of 34 minutes in northern California. And in Cleveland, stroke patients transported in a telemedicine-enabled mobile stroke unit were evaluated and treated in 31.5 minutes, nearly twice as fast as patients arriving by ambulance.

The Helsinki results show "that a protocol that sprints towards rapid treatment is feasible," Sheth told MedPage Today.

"Every hospital has to start cutting into the triage process with a multidisciplinary team that does a root-cause analysis and cuts out everything that is not essential for tPA administration," he said. "This is tough because people have a hard time changing protocols, but it can be done."

The Helsinki study's lack of a comparator -- either a parallel or historical control group -- was a limitation, Fassbender and Sheth noted. Future studies could include MRI or other imaging to ascertain the diagnosis and evaluate true positive and negative rates.

The study was funded by the Maire Taponen Foundation, Finnish Medical Foundation, Finnish Foundation for Cardiovascular Research, Helsinki University Hospital governmental research funds, Jane and Aatos Erkko Foundation, Signe and Ane Gyllenberg Foundation, and Sigrid Juse´lius Foundation.

Pihlasviita and Lindsberg disclosed no relevant relationships with industry. Co-authors disclosed relevant relationships with Boehringer Ingelheim, Pfizer, Bayer, Medfield Diagnostics, Lumosa Therapeutics, BrainsGate, Sanofi Aventis, PhotoThera, H.Lundbeck A/S, and Portola Pharmaceuticals.

Fassbender disclosed no relevant relationships with industry. Sheth disclosed holding a provisional patent for stroke detection technology and support from Remedy Pharmaceuticals, Bard, Stryker, and Novartis.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  Neurology

  Source Reference:
  Pihlasviita S, et al "Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes" Neurology 2018; DOI:10.1212/WNL.0000000000005954.

• Secondary Source

  Neurology

  Source Reference: Fassbender K, Sheth K "Hyperacute strok