But if you don't know how fast thrombectomy has to occur to get 100% recovery this really doesn't help. My definition of success is 100% recovery, NOTHING LESS! Wrong measurement.
Telemedicine-Based Prehospital Stroke Triage Speeds Thrombectomy
— Stockholm sees success??? with teleconsultation
Under this system, patients were transported directly to a comprehensive stroke center (CSC) with EVT capabilities under two conditions: if they displayed moderate-to-severe hemiparesis on the A2L2 test and were accepted following teleconsultation with the CSC. Thus, select patients could bypass primary stroke centers (PSCs) that did not offer thrombectomy.
Predictive performance of this triage system was good the first year it was implemented, Michael Mazya, MD, PhD, of Karolinska University Hospital-Solna, Stockholm, and colleagues reported in a paper published online in JAMA Neurology.
Accuracy was 87% for the identification of large artery occlusion stroke and 91% for predicting EVT initiation. Positive predictive values were 41% and 26%, respectively, while negative predictive values were 93% and 99%.
Moreover, the 323 triage-positive stroke patients in the study received timely treatment when compared to historical controls from the previous year, when people were still being sent to the nearest stroke center:
- Median onset-to-puncture time was 137 minutes vs 206 minutes (P<0.001)
- Median onset-to-needle time was unchanged at 115 minutes
- Median CSC IV thrombolysis door-to-needle time was 13 minutes vs 31 minutes (P<0.001)
This new patient selection strategy thus represents a new way to answer the question of where to send a potential candidate for stroke thrombectomy. Other options include mobile stroke units, scale-based triage, "drip-and-ship," and CSC mothership, according to Anne Alexandrov, PhD, RN, of the University of Tennessee Health Science Center in Memphis, and Klaus Fassbender, MD, of Saarland University Medical Center in Homburg, Germany.
"It remains to be determined which patient selection strategy ... will be most effective. This question may be answered differently in various regions and various health care environments," they wrote in an accompanying editorial.
The new triage system, implemented in routine practice in October 2017, covered the Stockholm region, an urban area with 2.3 million inhabitants. The region was served by one CSC and six PSCs, study authors noted.
Their population-based prospective cohort study was conducted across Sweden from October 2017 to October 2018.
Of the 2,905 patients transported by priority "code-stroke" ambulance to a hospital for suspected acute stroke during this period, 11% were triage-positive for direct transport to CSCs under the new system (median age 73 years, 48% women).
Triage-positive patients were slightly younger, presented with higher stroke severity, and had lower onset-to-first-hospital-door times compared with triage-negative individuals.
EVT was performed in 26% with triage-positive results and 1.4% with triage-negative results.
The study's findings may not be generalizable to locations outside Stockholm, cautioned Mazya and colleagues.
This was illustrated by the fact that due to local practices, PSCs considered 46.6% of patients with acute ischemic stroke to be large-vessel occlusion (LVO)-negative without confirmation by vascular imaging, according to Alexandrov and Fassbender.
"We recommend validation of our system's predictive accuracy for large-artery occlusion and EVT also in settings with other criteria for routine vessel imaging and EVT treatment," Mazya's group urged.
Another limitation of the study was its before-after design, Alexandrov and Fassbender said. "Time-related factors, such as better awareness about stroke or improved performance of EMS and hospital teams over the study period, could be confounding factors that may have affected the study's results," they suggested.
Disclosures
Mazya, Alexandrov, and Fassbender disclosed no conflicts.
Primary Source
JAMA Neurology
Secondary Source
JAMA Neurology
Source Reference: Alexandrov AW, Fassbender K "Triage based on preclinical scores -- low-c
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