Medical complications during interhospital transfer for thrombectomy in patients with acute ischemic stroke.

INTRODUCTION: Patients with acute ischemic stroke (AIS) and large-vessel occlusion are frequently transferred by emergency physicians (EPs) from primary to comprehensive stroke centers (CSC) for thrombectomy, particular when thrombolysed. Data on complications during such transfers are highly limited. PATIENTS AND METHODS: Consecutive AIS patients transferred between 01/2015 and 10/2021 to our CSC were included. Associations of major (MACO) and minor (MICO) complications with clinical and imaging data were assessed. RESULTS: In total, 985 patients were included in the analysis (58.5% thrombolysed). MACO developed in 1.6%, MICO in 14.6%. Compared to patients without complications (NOCO), patients with MACO did not differ in terms of demographics, cerebrovascular risk factors, or site of vessel occlusion. They had more severe strokes (p = 0.026), neurological worsening was more severe (p = 0.008), and transport duration was longer (p = 0.050) but geographical distances did not differ. Thrombolysed patients had any complication more often than patients without thrombolysis (20.3% vs 10.5%; p < 0.001); however, this finding was driven by patients with MICO (p < 0.001) only (MACO: p = 0.804). No associations were observed between stroke severity and complications in either thrombolysed or nonthrombolysed patients. Neurological deterioration during transfer was observed in 21.2%, but multivariate analysis revealed no association with thrombolysis (OR 0.962; 95%CI 0.670-1.380, p = 0.832). Asymptomatic intracerebral hemorrhage was present in 1.1%, symptomatic in 0.1%. DISCUSSION AND CONCLUSION: In this large cohort, no patient-specific factor increasing the risk of complications during interhospital transfer was identified. Specifically, our results do not indicate that thrombolysis increases MACO. Hence, interhospital transfer without EPs appears reasonable in most patients.

Regional variation in access to and quality of acute stroke care: results of Germany's Health System Performance Assessment pilot, 2014-2020.

BACKGROUND: Health System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA's conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance. METHODS: We use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany's 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities. RESULTS: About 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74-98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0-9.7%, one outlier of 13.3%). CONCLUSIONS: The results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.

Management of patients with diffusion-weighted imaging-negative acute ischemic stroke: Retrospective analysis of 47 consecutive patients.

BACKGROUND: Few studies with a limited number of patients focused on the outcomes of patients with diffusion-weighted imaging (DWI)-negative acute ischemic stroke (AIS) after intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). METHODS: This retrospective observational, single-center study included all consecutive patients admitted for AIS involving the anterior circulation and treated with IVT and/or EVT between January 1, 2015 and December 31, 2023. The collected data were used to identify the characteristics of patients with negative DWI and to compare outcomes in patients with negative and positive DWI. RESULTS: Among the 1210 patients included, 47 (3.9 %) had negative (DWI-negative group) and 1163 had increased DWI signal (DWI-positive group). In the DWI-negative group, the mean age was 69 years (SD=19.4), 55.3 % were men, and 27 (57.4 %) had a large vessel occlusion. Thirty eight (80.9 %) were treated with IVT alone, 7 (14.9 %) with EVT alone, and 2 (4.3 %) with both. Fluid attenuated inversion recovery (FLAIR) sequences were the most sensitive to detect predictive factors of cerebral ischemia, such as vessel thrombosis and the spaghetti sign that were found in 68.1 % and 83 %, of patients, respectively. Oxyhemoglobin-sensitive (T2*) and susceptibility-weighted angiography (SWAN) sequences were less sensitive: vessel thrombosis and the brush sign were detected in 55.3 % and 19.1 % of patients, respectively. Comparison of the two DWI groups showed that M2 occlusion was more frequent (31.9 % vs 13 %, p<0.001) and M1 occlusion rarer (19.1 % vs 36 %, p<0.02) in the DWI-negative than DWI-positive group. At admission, the median National Institutes of Health Stroke Scale score was lower in the DWI-negative than DWI-positive group (2 vs 6, p=0.0001), but the median symptom onset-to-MRI time was similar in both groups (108 vs 111 min, p=0.88). CONCLUSIONS: In patients with DWI-negative AIS, symptoms are less severe. Large vessel occlusions, notably in the M2 segment, are more distal at the expense of the M1 segment of MCA. The spaghetti sign remains the most predictive feature of AIS that should be specifically searched in the absence of DWI lesions.

The Burden of Stroke Mimics Among Hyperacute Stroke Unit Attendees with Special Emphasis on Migraine: A 10-Year Evaluation.

BACKGROUND AND OBJECTIVES: Stroke and migraine are common neurological illnesses that cause tremendous suffering for patients. Certain diseases can mimic the clinical manifestations of an actual stroke. Migraine is one of the most commonly reported stroke mimics. The main goals of this study are to look at the prevalence of stroke mimics on the stroke pathway of Sheffield Teaching Hospitals and how many of them are migraines. MATERIALS AND METHODS: A retrospective service evaluation was conducted at the hyperacute stroke unit (HASU) of the Royal Hallamshire Hospital (RHH) in the United Kingdom. The total admissions from 2013 to 2022 were collected from the Sentinel Stroke National Audit Programme database, and the number of stroke mimics was evaluated each year. The burden of migraine stroke mimics was also evaluated. Then, a one-year sample of stroke mimics was extracted to look for the types of each mimic. RESULTS: From 2013 to 2022, 45.75% (n = 12156) of the stroke pathway patients (n = 26573) were stroke mimics, with an increment of up to 55% in the years 2021 and 2022. During these 10 years, migraine stroke mimics accounted for 10.21% of admissions (n = 1240). The three most common mimics in a one-year sample of stroke pathway patients were migraine (14.70%) (n = 373), functional neurological disorders (FNDs) (7.17%) (n = 182), and Guillain-Barré syndrome (6.66%) (n = 169). Seizures, syncope, and metabolic derangements were reported as mimics in 4.17% (n = 106), 3.14% (n = 80), and 1.77% (n = 45), respectively. CONCLUSIONS: About half of the HASU attendees were stroke mimics rather than actual strokes, and the most common mimics were migraines.

Pre-Hospital Stroke Care beyond the MSU.

PURPOSE OF REVIEW: Mobile stroke units (MSU) have established a new, evidence-based treatment in prehospital stroke care, endorsed by current international guidelines and can facilitate pre-hospital research efforts. In addition, other novel pre-hospital modalities beyond the MSU are emerging. In this review, we will summarize existing evidence and outline future trajectories of prehospital stroke care & research on and off MSUs. RECENT FINDINGS: The proof of MSUs' positive effect on patient outcomes is leading to their increased adoption in emergency medical services of many countries. Nevertheless, prehospital stroke care worldwide largely consists of regular ambulances. Advancements in portable technology for detecting neurocardiovascular diseases, telemedicine, AI and large-scale ultra-early biobanking have the potential to transform prehospital stroke care also beyond the MSU concept. The increasing implementation of telemedicine in emergency medical services is demonstrating beneficial effects in the pre-hospital setting. In synergy with telemedicine the exponential growth of AI-technology is already changing and will likely further transform pre-hospital stroke care in the future. Other promising areas include the development and validation of miniaturized portable devices for the pre-hospital detection of acute stroke. MSUs are enabling large-scale screening for ultra-early blood-based biomarkers, facilitating the differentiation between ischemia, hemorrhage, and stroke mimics. The development of suitable point-of-care tests for such biomarkers holds the potential to advance pre-hospital stroke care outside the MSU-concept. A multimodal approach of AI-supported telemedicine, portable devices and blood-based biomarkers appears to be an increasingly realistic scenario for improving prehospital stroke care in regular ambulances in the future.

Artificial intelligence to enhance prehospital stroke diagnosis and triage: a perspective.

As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.

COVID-19 Pandemic and Stroke Care in Patients with Dementia Compared to Other Stroke Patients.

OBJECTIVES: The primary objective of this study was to examine the impact of the COVID-19 pandemic on the quality of stroke care for patients with preexisting dementia, compared with patients who had only stroke. The secondary aim was to investigate how the quality of stroke care changed during the pandemic and post-pandemic periods compared with the pre-pandemic period in patients with preexisting dementia. DESIGN: A registry-based, nationwide cohort study in Sweden. SETTING AND PARTICIPANTS: We included patients with a first stroke between 2019 and 2022, both with and without dementia. The study periods were defined as follows: pre-pandemic (January 1, 2019, to February 29, 2020), COVID-19 pandemic (March 1, 2020, to February 24, 2022), and post-COVID-19 pandemic period (February 25, 2022, to September 19, 2022). The outcomes examined were the following quality indicators of stroke care, suggested by the national guideline of stroke care in Sweden: stroke admission site, performance of swallowing assessment, reperfusion treatment, assessment for rehabilitation, and early supported discharge. METHODS: The associations were studied through group comparisons and binary logistic regressions. RESULTS: Of the 21,795 patients with strokes, 1357 had documented preexisting dementia, and 20,438 had stroke without a dementia diagnosis. Throughout all study periods, a significantly lower proportion of patients with stroke with preexisting dementia, compared with stroke-only patients, received reperfusion treatment, assessments for rehabilitation, and early supported discharge from stroke units. In the subgroup of stroke patients with preexisting dementia, no significant associations were found regarding the quality indicators of stroke care before, during, and after the pandemic. CONCLUSIONS AND IMPLICATIONS: Disparities in quality of stroke care were observed between stroke patients with preexisting dementia and those with only stroke during the COVID-19 pandemic. However, there were no statistically significant differences in stroke care for patients with dementia across the pandemic.

Length of Hospitalization and Mortality among Stroke Patients before and after the Implementation of a Specialized Unit: A Retrospective Cohort Study Using Real-World Data from One Reference Hospital in Southern Brazil.

Stroke constitutes a significant global cause of mortality and disability. The implementation of stroke units influences hospital quality indicators, guiding care management. We aimed to compare hospital length of stay (LOS), in-hospital mortality, and post-discharge mortality between stroke patients admitted in the pre- and post-implementation periods of a stroke unit in a public hospital in southern Brazil. This retrospective cohort study used real-world data from one reference hospital, focusing on the intervention (stroke unit) and comparing it to the general ward (control). We analyzed the electronic medical records of 674 patients admitted from 2009 to 2012 in the general ward and 766 patients from 2013 to 2018 in the stroke unit. Admission to the stroke unit was associated with a 43% reduction in the likelihood of prolonged hospitalization. However, there was no significant difference in the risk of in-hospital mortality between the groups (Hazard ratio = 0.90; Interquartile range = 0.58 to 1.39). The incidence of death at three, six and twelve months post-discharge did not differ between the groups. Our study results indicate significant improvements in care processes for SU patients, including shorter LOS and better adherence to treatment protocols. However, our observations revealed no significant difference in mortality rates, either during hospitalization or after discharge, between the SU and GW groups. While SU implementation enhances efficiency in stroke care, further research is needed to explore long-term outcomes and optimize management strategies.

Potential effects of a mobile stroke unit on time to treatment and outcome in patients treated with thrombectomy or thrombolysis: A Danish-German cross-border analysis.

BACKGROUND AND PURPOSE: A mobile stroke unit (MSU) reduces delays in stroke treatment by allowing thrombolysis on board and avoiding secondary transports. Due to the beneficial effect in comparison to conventional emergency medical services, current guidelines recommend regional evaluation of MSU implementation. METHODS: In a descriptive study, current pathways of patients requiring a secondary transport for mechanical thrombectomy were reconstructed from individual patient records within a Danish (n = 122) and an adjacent German region (n = 80). Relevant timestamps included arrival times (on site, primary hospital, thrombectomy centre) as well as the initiation of acute therapy. An optimal MSU location for each region was determined. The resulting time saving was translated into averted disability-adjusted life years (DALYs). RESULTS: For each region, the optimal MSU location required a median driving time of 35 min to a stroke patient. Time savings in the German region (median [Q1; Q3]) were 7 min (-15; 31) for thrombolysis and 35 min (15; 61) for thrombectomy. In the Danish region, the corresponding time savings were 20 min (8; 30) and 43 min (25; 66). Assuming 28 thrombectomy cases and 52 thrombolysis cases this would translate to 9.4 averted DALYs per year justifying an annual net MSU budget of $0.8M purchasing power parity dollars (PPP-$) in the German region. In the Danish region, the MSU would avert 17.7 DALYs, justifying an annual net budget of PPP-$1.7M. CONCLUSION: The effects of an MSU can be calculated from individual patient pathways and reflect differences in the hospital infrastructure between Denmark and Germany.

Enriched Environments in Stroke Units: Defining Characteristics and Limitations.

BACKGROUND: Individuals with stroke rehabilitated in an enriched environment (EE) compared to a non-EE are more likely to participate in cognitive and social activities, promoting their rehabilitation and well-being. There is a need for a more comprehensive understanding of methods to implement EEs within complex health systems, particularly in stroke units. OBJECTIVE: The aim of this systematic review was to compile the concept of an EE in stroke units. METHODS: The literature was sourced from CINAHL, Embase, and Medline databases. A detailed screening and sifting process was used to identify relevant literature. Multiple reviewers independently appraised the identified literature using a Mixed-methods Appraisal Tool. After screening 336 studies, 11 were included. RESULTS: This review reveals an EE is challenging to define and almost exclusively about activities based on access to individual and communal equipment. Generally, there are no common descriptions or conceptual agreements. CONCLUSIONS: To the best of our knowledge, this is the first study to systematically review the concept of an EE in stroke units and shows that more studies on EEs are needed. The weak definitions and unclear theoretical backgrounds of an EE in the included studies could challenge operationalization. Future research should be based on more precise definitions of an EE and broader interventions that include changes to built and natural environments.

Spontaneous Simultaneous Bilateral Basal Ganglia, Thalamic, and Central Pontine Haemorrhage: A Case Report.

The basal ganglia, a complex of subcortical nuclei, form an important functional component of the brain. Spontaneous simultaneous bilateral basal ganglia haemorrhage (SSBBGH) is exceedingly uncommon and often associated with hypertension as a primary predisposing factor. We report a case of a 72-year-old female who presented to a local hospital following a dizzy spell and subsequent fall. Non-contrast CT brain revealed bilateral basal ganglia haemorrhage alongside central pontine haemorrhage. Subsequently, she was transferred to our tertiary-care specialist stroke unit where conservative management was pursued. She was discharged after brain imaging, multidisciplinary team (MDT) consultations, and follow-up plans. The MDT comprised stroke physicians, radiologists, physiotherapists, occupational therapists, and speech and language therapists. Given the limited number of documented cases of this rare occurrence (approximately 60 in the literature), we believe this report will contribute to the existing body of knowledge.

Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management.

OBJECTIVES: A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke. DESIGN: A cohort observational study over a 4-year period. SETTING: Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France). PARTICIPANTS: We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017. INTERVENTION: Patients transferred in the PSGU were compared to those admitted in other rehabilitation units. MEASUREMENTS: The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score). RESULTS: Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88). CONCLUSION: The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

Challenges in adapting a stroke unit in a middle-income country: warning about costs and underfunding to achieve the Brazilian Ministry of Health's benchmark.

Background: Since the implementation of the stroke care line in Brazil, the relationship (adequacy) of costs spent during hospitalization with the Brazilian Ministry of Health indicators for a stroke unit have not yet been analyzed. Aims: This study aimed to assess the adequacy of a comprehensive stroke center for key performance indicators and analyze the costs involved in hospitalization. We verified the association between stroke severity at admission and care costs during hospitalization. Methods: A retrospective medical chart review of 451 patients was performed using semiautomatic electronic data from a single comprehensive stroke center in Brazil between July 2018 and January 2020. Clinical and resource utilization data were collected, and the mean acute treatment cost per person was calculated. The Kruskal-Wallis test with Dunn's post-test was used to compare the total costs between stroke types and reperfusion therapies. A robust linear regression test was used to verify the association between stroke severity at hospital admission and the total hospitalization costs. Good adequacy rates were observed for several indicators. Results: Data from 451 patients were analyzed. The stroke unit had good adaptation to key performance indicators, but some critical points needed revision and improvement to adapt to the requirements of the Ministry of Health. The average total cost of the patient's stay was the USD 2,637.3, with the daily hospitalization, procedure, operating room, and materials/medication costs equating to USD 2,011.1, USD 220.7, USD 234.1, and USD 98.8, respectively. There was a positive association between the total cost and length of hospital stay (p < 0.001). Conclusion: The stroke unit complied with most of the main performance indicators proposed by the Brazilian Ministry of Health. Underfunding of the costs involved in the hospitalization of patients was verified, and high costs were associated with the length of stay, stroke severity, and mechanical thrombectomy.

Stroke Unit as an alternative to Intensive Care Unit for initial hospital admission of low-grade non-aneurysmal subarachnoid haemorrhage: A safety and cost-minimisation analysis.

INTRODUCTION: Stroke Units (SU) have been suggested as an alternative to Intensive Care units (ICU) for initial admission of low-grade non-aneurysmal spontaneous subarachnoid haemorrhage (naSAH). We hypothesised that the incidence of in-hospital complications and long-term clinical outcomes in low-grade naSAH patients would be comparable in both settings, and that a cost-minimisation analysis would favour the use of SU. PATIENTS AND METHODS: Retrospective, single-centre study at a third-level stroke-referral hospital, including low-grade spontaneous naSAH patients with WFNS 1-2. Primary outcomes were death and functional status at 3 months. Secondary outcomes were incidence of in-hospital major neurological and systemic complications. Additionally, a cost-minimisation analysis was conducted to estimate the average cost savings that could be achieved with the most efficient approach. RESULTS: Out of 96 naSAH patients, 30 (31%) were initially admitted to ICU and 66 (69%) to SU. Both groups had similar demographic and radiological features except for a higher proportion of WFNS 2 in ICU subgroup. There were no statistically significant differences between ICU and SU-managed subgroups in death rate (2 (7%) and 1 (2%), respectively), functional outcome at 90 days (28 (93%) and 61 (92%) modified Rankin Scale 0-2) or neurological and systemic in-hospital complications. Cost-minimisation analysis demonstrated significant monetary savings favouring the SU strategy. DISCUSSION AND CONCLUSION: Initial admission to the SU appears to be a safe and cost-effective alternative to the ICU for low-grade naSAH patients, with comparable clinical outcomes and a reduction of hospitalisation-related costs. Prospective multicenter randomised studies are encouraged to further evaluate this approach.

Global stroke statistics 2023: Availability of reperfusion services around the world.

BACKGROUND: Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed. AIMS: To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services. METHODS: We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary. RESULTS: Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world. CONCLUSION: Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.

Medical demography at stroke centers: Current situation in France.

INTRODUCTION: Following the 2010-2014 French national stroke action plan, the number of stroke center (SC) has gradually increased in France, allowing a homogeneous coverage and access to neurovascular care in organized and territorially defined structures. However, operational difficulties within SCs have been progressively reported over the last few years. The objective of this study was to identify the medical staff shortages in SC that may contribute to these difficulties. METHODS: A survey on the medical staffing level as of January 1, 2021 was sent to all French SC managers. Specific questions related on vacancies, need of interim medical staff, and participation in out-of-hour healthcare services. RESULTS: Among the 139 SC managers contacted, 122 (88%) filled in the questionnaire. Analysis of the data showed that over 879 physician positions opened, 163 (18.5%) remained vacant for a mean of two years, and that in 51 SCs (41.9%), more than two positions were unfilled. In 13 of these 51 SCs, the out-of-hour healthcare services relied on less than four practitioners, defining a critical situation, and three other SCs had to close temporarily (2) or permanently (1). Moreover, 39.2% of SCs with at least one vacancy used interim physicians, for a median period of 12.5 weeks/year (IQR 5-18). CONCLUSION: This study highlights the significant medical staff shortage in French SCs. In the absence of urgent measures, more SCs will close, jeopardizing the regional network and access to care for stroke patients.

[Delirium in stroke: systematic review and meta-analysis]. / Delir bei Schlaganfall: systematisches Review und Metaanalyse.

BACKGROUND: Due to the complexity of the symptoms, delirium detection poses a challenge in stroke patients. A large body of literature has established that neurospecific challenges can have a considerable impact on diagnosis and are underrepresented in screening. OBJECTIVES: An analysis of current scientific literature on delirium screening tests and their applicability in stroke patients, acknowledging neurospecific challenges and evaluating diagnostic test accuracy. METHODS: A systematic literature search was conducted in PubMed, CINAHL, and Cochrane Library databases. Studies published between 2018 and 2021 were evaluated and the study quality was assessed according to the Institute for Clinical Systems Improvement. Furthermore, the specificity and sensitivity of delirium screening tests were pooled RESULTS: The systematic literature review found a total of 2636 articles, following a review of the inclusion and exclusion criteria. Thus, 18 moderate-quality studies with a total of 3320 patients and 9 distinct delirium screenings were identified. Within those 18 studies, the prevalence of delirium was 34.2%. However, the delirium prevalence was significantly lower in 6 studies that included patients with neurologic impairments (26.5 vs. 32.1%, p = 0.0004). Pooled sensitivity and specificity for the 4AT (Rapid assessment test for delirium ) were 82 and 77%, while these values were 72 and 93% for the CAM-ICU (Confusion Assessment Method for Intensive Care Units) and 79 and 72% for the ICDSC (Intensive Care Delirium Screening Checklist). CONCLUSIONS: Neurological impairments may influence the test quality of delirium screening in stroke patients. The CAM-ICU can be recommended for nonaphasic patients. The ICDSC can be used in all stroke patients on stoke units with an adjusted cut-off value of > 5 points.

Direct to Angiosuite in Acute Stroke with Mobile Stroke Unit.

BACKGROUND: Early reperfusion has the best likelihood for a favorable outcome in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Our experience with mobile stroke unit (MSU) for direct to angiosuite (DTAS) transfer in AIS patients with suspected LVO is presented. METHODS: Retrospective review of prospectively collected data from November 2019 to August 2022, of patients evaluated and transferred by the University of Alberta Hospital MSU and moved to angiosuite for endovascular thrombectomy (EVT). RESULT: A total of 41 cases were included. Nine were chosen for DTAS and 32 were shifted to angiosuite after stopping for computed tomography (CT) angiography of the head and neck (no-DTAS). Stroke severity measured by NIHSS (median with interquartile range (IQR)) was higher in patients of DTAS, 22 (14-24) vs 14.5 (5-25) in no-DTAS (p = 0.001). The non-contrast CT head in MSU showed hyperdense vessels in 8 (88.88%) DTAS vs 11 (34.35%) no-DTAS patients (p = 0.003). The EVT timelines (median with IQR, 90th percentile) including "door to artery puncture time" were 31 (23-50, 49.2) vs 79 (39-264, 112.8) minutes, and "door to recanalization time" was 69 (49-110, 93.2) vs 105.5 (52-178, 159.5) minutes in DTAS vs no-DTAS group, respectively. The workflow times were significantly shorter in the DTAS group (p < 0.001). Eight (88.88%) out of 9 DTAS patients had LVO and underwent thrombectomy. CONCLUSIONS: MSU for DTAS in patients with high NIHSS scores, cortical signs, and CT showing hyperdense vessel is an effective strategy to reduce the EVT workflow time.

Effects of Mobile Stroke Unit dispatch on blood pressure management and outcomes in patients with intracerebral haematoma: Results from the Berlin_Prehospital Or Usual Care Delivery in acute Stroke (B_PROUD) controlled intervention study.

INTRODUCTION: In patients with acute intracerebral haemorrhage (ICH) and elevated systolic blood pressure (BP), guidelines suggest that systolic BP reduction to <140 mmHg should be rapidly initiated. Compared with conventional care, Mobile Stroke Units (MSUs) allow for earlier ICH diagnosis through prehospital imaging and earlier BP lowering. PATIENTS AND METHODS: ICH patients were prospectively evaluated as a cohort of the controlled B_PROUD-study in which MSU availability alone determined MSU dispatch in addition to conventional ambulance. We used inverse probability of treatment weighting to adjust for confounding to estimate the effect of additional MSU dispatch in ICH patients. Outcomes of interest were 7-day mortality (primary), systolic BP (sBP) at hospital arrival, dispatch-to-imaging time, largest haematoma volume, anticoagulation reversal, length of in-hospital stay, 3-month functional outcome. RESULTS: Between February 2017 and May 2019, MSUs were dispatched to 95 (mean age: 72 ± 13 years, 45% female) and only conventional ambulances to 78 ICH patients (mean age: 71 ± 12 years, 44% female). After adjusting for confounding, we found shorter dispatch-to-imaging time (mean difference: -17.75 min, 95% CI: -27.16 to -8.21 min) and lower sBP at hospital arrival (mean difference = -16.31 mmHg, 95% CI: -30.64 to -6.19 mmHg) in the MSU group. We found no statistically significant difference for the other outcomes, including 7-day mortality (adjusted odds ratio: 1.43, 95% CI: 0.68 to 3.31) or favourable outcome (adjusted odds ratio = 0.67, 95% CI: 0.27 to 1.67). CONCLUSIONS: Although MSU dispatch led to sBP reduction and lower dispatch-to-imaging time compared to conventional ambulance care, we found no evidence of better outcomes in the MSU dispatch group.

[What is confirmed in the treatment of ischemic stroke]. / Was ist gesichert in der Therapie des ischämischen Schlaganfalls?

Ischemic stroke is one of the leading causes of death worldwide and the most frequent cause of permanent disability in adulthood. The acute treatment of stroke is time-critical and, according to the time is brain principle, it is important to determine as soon as possible whether recanalization treatment that can save the penumbra is possible. Intravenous thrombolysis (IVT) and, if a large vessel occlusion is identified, endovascular treatment (EVT) possibly in combination with IVT, are recommended. Further treatment in a stroke unit is another important component of acute stroke treatment. The best secondary preventive treatment must already be initiated in the acute phase. The cause of stroke guides making decisions on the ideal secondary preventive strategy. The most important etiologies of stroke are cardiac embolism, atherosclerotic macroangiopathy and cerebral microangiopathy (small vessel disease). Less frequent causes are dissections of arteries supplying the brain or vasculitis. In up to 20-30% of all cases, however, no clear etiology can be determined despite intensive investigation of the cause. This means corresponding uncertainty in the optimal secondary prevention that consists in particular of an anticoagulant medication adapted to the etiology, treatment of cardiovascular risk factors and if necessary surgical or interventional desobliterative procedures. This article describes the diagnostic procedure and the evidence-based treatment of ischemic stroke.