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Pre-hospital logistics can make or break opportunities for endovascular thrombectomy and thrombolytics in acute ischemic stroke, so regional networks need reworking to get the right patients to the right hospitals in the right time, , argues in this video.
"Improving the logistics of pre-hospital and acute hospital stroke care has greater potential to improve patient outcomes than any new clot retrieval technology or new medical reperfusion therapies," says Broderick, director of the University of Cincinnati Neuroscience Institute.
Here is a transcript of his comments:
A recent pooling of data from the first five endovascular stent-retriever trials for acute stroke re-emphasized the importance of time to reperfusion for endovascular therapy. Just as it is for medical reperfusion with tPA [tissue plasminogen activator], every minute counts.
If time to reperfusion is critical for both IV tPA and endovascular therapy, the next major challenge for acute stroke therapy is in the pre-hospital setting, where potential stroke patients are evaluated by pre-hospital personnel. The questions for the pre-hospital personnel are:
1) Does the patient likely have a stroke?
2) Does the patient have a severe stroke that is likely to require endovascular therapy, and
3) Most difficult of all, when should the ambulance transport the patient to the closest primary stroke center where tPA can be started quickly, versus when to transfer to the comprehensive stroke center where both IV tPA and endovascular therapy can be started ASAP?
The previously mentioned endovascular trials have demonstrated that those patients who are assessed first at a community or primary stroke hospital, and then transferred to a comprehensive center for endovascular therapy, have about a 2-hour delay in the start of endovascular therapy. Not surprisingly, these patients have less favorable outcomes than those patients taken directly to the comprehensive stroke centers.
Several pre-hospital assessment tools show good promise in identification of patients with more severe strokes and who are most likely to have occlusions of a major artery. These tools include the Cincinnati Stroke Triage Assessment Tool (CSTAT), the Los Angeles Motor Scale or LAMS, RAPID, three-item stroke scale, and the full NIHSS. Use of telemedicine by pre-hospital personnel to access vascular neurology expertise is another technology currently being tested. Finally, mobile stroke units with mobile imaging and neurologically-trained personnel are being used in a few cities to decrease the time to initiation of tPA therapy and can expedite transfer of patients with severe stroke to the comprehensive stroke center. These mobile units deliver the highest level of technology and expertise in the field, but are very expensive to build and maintain.
Currently, patients should be transported rapidly to the closest available certified primary stroke center or comprehensive stroke center, or, if no such centers exist, the most appropriate institution that can provide emergency stroke care. When a primary stroke center and a comprehensive stroke center are equally close, the patient should be taken to the comprehensive stroke center. When the comprehensive stroke center is further away than the primary stroke center, we currently don't know at what time point the ambulance should transport a stroke patient directly to the primary stroke center for IV tPA, or transport to the comprehensive center for potential endovascular therapy. In my opinion, when the stroke appears to be severe by one of these tested pre-hospital scales, or if a mobile stroke unit identifies a major arterial occlusion, the comprehensive stroke center should be the primary place of transport, even if there may be an additional 15 to 30 minutes of transport.
We need to redesign our pre-hospital and stroke hospital networks for each region. This will require pre-hospital, physician, and hospital leadership working together with state and regional health authorities. Improving the logistics of pre-hospital and acute hospital stroke care has greater potential to improve patient outcomes than any new clot retrieval technology or new medical reperfusion therapies.
From the American Heart Association: