Prehospital computed tomography in a rural district for rapid diagnosis and treatment of stroke.

BACKGROUND: Early diagnosis and triage of patients with ischemic stroke is essential for rapid reperfusion therapy. The prehospital delay may be substantial and patients from rural districts often arrive at their local hospital too late for disability-preventing thrombolytic therapy due to prolonged transport times. METHODS: Hallingdal District Medical Centre (HDMC) is located in a rural area of Norway and is equipped with a computed tomography (CT) scanner. We established emergency pathways of CT imaging and thrombolytic treatment of patients with acute ischemic stroke at HDMC. During office hours these pathways were managed by a radiographer and a general physician supported by videoconference from the Primary Stroke Centre. Outside office hours we remotely controlled the CT exam and supported telestroke guided paramedics handling and examining the patients. With a primary aim of demonstrating the feasibility of this de novo concept we enrolled patients in the period 2017-2021 into a comparative cohort observational study. We compared patients treated at HDMC (the Rural CT group) to patients from two other rural regions in Norway with similar distances to their local hospital but without access to a rural CT scanner (the Reference group). RESULTS: A total of 86 patients were included in the Rural CT group (mean age 74, 52% male, 43% stroke mimics), and 69 patients were included in the Reference group (mean age 70, 42% male, 28% stroke mimics). Median time from onset of symptoms to completed CT examination was 93 min in the Rural CT group as compared to 240 min in the Reference group (p < 0.05). In patients receiving intravenous thrombolysis time from onset of symptoms to treatment was median 124 min in the Rural CT group and 213 min in the Reference group, p < 0.05. The frequency of thrombolysis for ischemic stroke did not significantly differ between the two groups. CONCLUSION: Combining prehospital rural CT examination with telestroke guided diagnosis and thrombolytic treatment by paramedics may facilitate earlier initiation of thrombolysis for patients with ischemic stroke.

Exploring the Impact of Age and Pre-Stroke Modified Rankin Scale in Elderly Thrombectomy: A 15-Year Single-Center Experience.

INTRODUCTION: The selection of endovascular thrombectomy (EVT) for acute ischemic stroke in the elderly remains challenging due to the underrepresentation of these patients in landmark randomized trials. The aim of this study was to assess the association between age and the pre-stroke modified Rankin scale score with functional outcomes after EVT in elderly patients aged ≥80 years. METHODS: We prospectively collected data from consecutive elderly patients who underwent EVT of the anterior or posterior circulation at our institution between 2007 and 2022. Clinical and radiological parameters were analyzed using a fair outcome (mRS ≤3 or retained pre-stroke mRS score of 4) as the primary outcome. RESULTS: In total, 307 elderly patients were included in the analysis. Fair functional outcomes were achieved in 162 (53%) patients. Eighty-four (27.4%) patients were deceased at 3-month follow-up and the mortality rate increased to 37.1% (114 deceased) at 1-year follow-up. The likelihood of achieving a fair functional outcome decreased by 8% for every 1-year age increase (OR 0.81, 95% CI 0.73-0.90). Lower National Institutes of Health Stroke Scale (OR 0.89, 95% CI 0.85-0.93, p < 0.001) and pre-stroke mRS (OR 0.67, 95% CI 0.53-0.84, p < 0.001) were associated with fair outcomes. CONCLUSIONS: EVT in elderly patients with stroke is beneficial in selected cases. Increasing age was associated with an increased risk of an mRS change to 4 or worse and death within 1 year. The pre-stroke mRS may aid clinicians in the selection of elderly patients for EVT.

External validation of clinical risk prediction score for elderly treated with endovascular thrombectomy.

BACKGROUND AND AIM: The thrombectomy in the elderly prediction score (TERPS) for functional outcome after anterior circulation endovascular therapy (EVT) in patients ≥ 80 years was recently developed. The aim of this study was to assess predictors of functional outcome in the elderly and validate the prediction model. METHODS: Consecutive patients treated with EVT from the Oslo Acute Reperfusion Stroke Study were evaluated for inclusion. Clinical and radiological parameters were used to calculate the TERPS, and functional outcome were assessed at 3-month follow-up. RESULTS: Out of 1028 patients who underwent EVT for acute ischemic stroke from January 2017 to July 2022, 218 (21.2%) patients ≥ 80 years with anterior ischemic stroke were included. Fair outcome, defined as modified Rankin scale ≤ 3 (mRS), was achieved in 117 (53.7%). In bivariate analyses, male sex (p 0.035), age (p 0.025), baseline National Institute of Health Stroke Scale (NIHSS, p < 0.001), pre-stroke mRS (p 0.002) and Alberta Stroke Program Early Computed Tomography score (ASPECTS, p 0.001) were associated with fair outcome. Significant predictors for fair outcome in regression analyses were lower pre-stroke mRS, adjusted odd ratio, (aOR) 0.67 (95% CI 0.50-0.91, p 0.01), NIHSS, aOR 0.92 (95% CI 0.87-0.97, p 0.002), and higher ASPECTS, aOR 1.22 (95% CI 1.03-1.44, p 0.023). The area under the curve (AUC) using TERPS was 0.74 (95% CI 0.67-0.80). CONCLUSIONS: The risk prediction score TERPS showed moderate performance in this external validation. Other variables may still be included to improve the model and validation using other cohorts is recommended. TRIAL REGISTRATION: NCT06220981.

Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses.

BACKGROUND AND OBJECTIVES: Early access to hospital for diagnosis and treatment is strongly recommended for patients with acute stroke. Unfortunately, prehospital delay frequently occurs. The aim of the current study was to gain in-depth insight into patient experience and behavior in the prehospital phase of a stroke. METHODS: We conducted qualitative interviews with a purposive sample of 11 patients and six witnesses within four weeks post stroke. The interviews were audio recorded, transcribed, and analyzed utilizing Systematic Text Condensation. RESULTS: The material was classified according to two main categories each containing three subgroups. The first category contained the diversity of sudden changes that all participants noticed. The subgroups were confusing functional changes, distinct bodily changes and witnesses' observations of abnormal behavior or signs. The second category was delaying and facilitating factors. To trivialize or deny stroke symptoms, or having a high threshold for contacting emergency services, led to time delay. Factors facilitating early contact were severe stroke symptoms, awareness of the consequences of stroke or a witness standing by when the stroke occurred. CONCLUSIONS: Prehospital delays involved interrelated elements: (1) Difficulties in recognition of a stroke when symptoms were mild, odd and/or puzzling; (2) Recognition of a stroke or need for medical assistance were facilitated by interaction/communication; (3) High threshold for calling emergency medical services, except when symptoms were severe. The findings may be helpful in planning future public stroke campaigns and in education and training programs for health personnel.

Mechanical thrombectomy in acute ischaemic stroke. / Mekanisk trombektomi ved akutt hjerneinfarkt.

Mechanical thrombectomy is now the standard treatment for acute ischaemic stroke with occlusion of a carotid or intercranial artery. With occlusions of this type, thrombolytic treatment often has limited effect. The therapeutic outcome with the use of thrombectomy is time-dependent, and a personalised approach to indication is always necessary. To achieve the best possible results, the main prerequisites are good clinical procedures, an optimal patient pathway, high neuroradiological competence and coordinated, interdisciplinary teams.

Pre-hospital ct diagnosis of subarachnoid hemorrhage.

BACKGROUND: Subarachnoid hemorrhage (SAH) is associated with higher mortality in the acute phase than other stroke types. There is a particular risk of early and devastating re-bleeding. Patients therefore need urgent assessment in a neurosurgical department, and the shorter the time from symptom onset to diagnosis the better. CASE PRESENTATION: The Norwegian Acute Stroke Pre-hospital Project (NASPP) has developed a Mobile Stroke Unit (MSU) model, which is staffed with anesthesiologists also trained in pre-hospital clinical assessment of acute stroke patients and interpretation of computerized tomography (CT). The MSU was operated on-call from the local dispatch center in a rural area 45-160 km away from a neurosurgical department. Two patients presented with clinical symptoms and signs compatible with SAH. In both cases, the CT examination confirmed the diagnosis of SAH. Both were transported directly from patient location to the regional neurosurgical department, saving at least 2-2.5 h of pre-neurosurgical time. CONCLUSION: The Norwegian MSU model staffed with anesthesiologists can rapidly establish an exact diagnosis of SAH, which in a rural area significantly reduces time to neurosurgical care. TRIAL REGISTRATION: Study data are retrospectively registered in ClinicalTrail.gov. NCT03036020 Unique Protocol ID: NASPP-2 Brief Title: The Norwegian Acute Stroke Prehospital Project Overall Status: Completed Primary Completion Date: January 2016 [Actual] Verification Date: January 2017.