Three mechanisms to speed up the screening, admission, and management of patients will be key to improving the current landscape of stroke care, a review article suggested.
Rapid screening tests by paramedics — such as the Los Angeles Motor Scale, the Cincinnati Prehospital Stroke Severity Scale, and the Rapid Arterial Occlusion Evaluation — are crucial in deciding whether the patient needs to go to a specialized endovascular center, L. Nelson Hopkins, MD, of University at Buffalo, State University of New York, and colleagues noted in the June 7 issue of the Journal of the American College of Cardiology.
“Such quick examinations are not designed to serve as a substitute for imaging tests to confirm or exclude large vessel occlusion but rather as screening tools to help determine the appropriate level of care (e.g., community hospital, primary stroke center, comprehensive stroke center) appropriate for an individual patient,” they wrote.
Mobile Stroke Units
Even when it remains unclear where to send a patient, Hopkins and colleagues noted, “mobile stroke units have emerged as an elegant solution for patients who require both IV recombinant tissue plasminogen activator (rtPA) and endovascular therapy … their use led to a decrease in time to IV rtPA treatment, with no increase in adverse events.”
With equipment such as a noncontrast CT scanner and point-of-care laboratory on these specialized ambulances to differentiate between ischemic stroke or intracranial hemorrhage and offer pre-hospital administration of thrombolytics, “those patients who are also candidates for thrombectomy (on the basis of pre-hospital neurological assessment scales) can safely bypass the nearest primary stroke center and instead be transported directly to a hospital capable of offering endovascular therapy.”
An early U.S. MSU experience in Houston showed that equipment cost $600,000 during the first year for the treatment of two patients per week.
But the costs do not have to be so high, suggested the review, noting that they can be “offset by direct transport of thrombectomy-eligible patients to comprehensive stroke centers, thus eliminating the costs (and not just the time saved) of unnecessary patient transfer to the nearest primary stroke center, and by a reduction in costs of long-term stroke care as a result of improved outcomes from faster rtPA administration.”
Just having more comprehensive stroke centers won’t do, the reviewers added. “In addition to concerns for cost-effectiveness, growth in the number of comprehensive stroke centers, if not matched by a steady increase in the number of thrombectomy-eligible stroke patients, will lead to widespread establishment of centers that perform only few stroke interventions per year.”
Instead, focus should shift to “improving communication and networking between currently existing comprehensive stroke centers and other health care facilities that participate in early management of acute stroke patients,” Hopkins and colleagues suggested.
The group recommended more randomized studies to evaluate pre-hospital triage, transfer protocols, imaging modalities, and new technologies for the early management of acute stroke patients.
Hopkins reported receiving research support from Toshiba; consulting for Abbott, Boston Scientific, Cordis, Covidien, and Medtronic; having financial interests in Apama, Augmenix, Axtria, Boston Scientific, Claret Medical, Ellipse, Endomation, Medina Medical, NextPlain, Ostial Corporation, Photolitec, Silk Road, StimSox, ValenTx, and Valor Medical; serving in a board/trustee/officer position for Claret Medical; and receiving honoraria from Complete Conference Management, Covidien, and Memorial Healthcare System.
Journal of the American College of Cardiology
Mokin M, et al “Recent endovascular stroke trials and their impact on stroke systems of care” J Am Coll Cardiol 2016; DOI: 10.1016/j.jacc.2015.12.077.