Inter-Rater Agreement on Cincinnati Prehospital Stroke Scale (CPSS) and Prehospital Acute Stroke Severity Scale (PASS) Between EMS Providers, Neurology Residents and Neurology Consultants.

Objective: To examine the agreement between emergency medical service (EMS) providers, neurology residents and neurology consultants, using the Cincinnati Prehospital Stroke Scale (CPSS) and the Prehospital Acute Stroke Severity Scale (PASS). Methods: Patients with stroke, transient ischemic attack (TIA) and stroke mimic were included upon primary stroke admission or during rehabilitation. Patients were included from June 2018 to September 2019. Video recordings were made of patients being assessed with CPSS and PASS. The recordings were later presented to the healthcare professionals. To determine relative and absolute interrater reliability in terms of inter-rater agreement (IRA), we used generalisability theory. Group-level agreement was determined against a gold standard and presented as an area under the curve (AUC). The gold standard was a consensus agreement between two neurology consultants. Results: A total of 120 patient recordings were assessed by 30 EMS providers, two neurology residents and two neurology consultants. Using the CPSS and the PASS, a total of 1,800 assessments were completed by EMS providers, 240 by neurology residents and 240 by neurology consultants. The overall relative and absolute IRA for all items combined from the CPSS and PASS score was 0.84 (95% CI 0.80; 0.87) and 0.81 (95% CI 0.77; 0.85), respectively. Using the CPSS, the agreement on a group-level resulted in AUCs of 0.83 (95% CI 0.78; 0.88) for the EMS providers and 0.86 (95% CI 0.82; 0.90) for the neurology residents when compared with the gold standard. Using the PASS, the AUC was 0.82 (95% CI 0.77; 0.87) for the EMS providers and 0.88 (95% CI 0.84; 0.93) for the neurology residents. Conclusion: The high relative and absolute inter-rater agreement underpins a high robustness/generalisability of the two scales. A high agreement exists across individual raters and different groups of healthcare professionals supporting widespread applicability of the stroke scales.

Treatment Delays and Chance of Reperfusion Therapy in Patients with Acute Stroke: A Danish Nationwide Study.

INTRODUCTION: We aimed to determine the treatment delay for ischemic stroke patients in Denmark. METHODS: A nationwide register-based study on acute ischemic stroke patients admitted through emergency medical services. Treatment delay comprised patient, prehospital, and in-hospital delay. Analyses were stratified according to length of prehospital delay (<3 vs. ≥3 h). RESULTS: A total of 5,356 ischemic stroke episodes were included. The median onset-to-door time was 187 min, and 2,405 (43%) arrived at the stroke unit within 3 h. Overall, the median patient delay was 115 min. For early arrival (n = 2,280), patient delay was 27 min compared to 437 min for late arrivals (n = 2,448). Median prehospital delay varied by 9 min between early- and late-arriving patients. Approximately 48% of the early-arriving patients compared to 9% of the late-arriving patients received i.v. thrombolysis. For thrombectomy, the numbers were 10% and 3%, respectively. This corresponded to an unadjusted relative risk (RR) of 0.18 (95% CI: 0.16-0.21) and adjusted (age, sex, cohabitation status, and stroke severity) RR of 0.20 (95% CI: 0.18-0.23) for i.v. thrombolysis when comparing patients arriving later than 3 h with patients arriving earlier. For thrombectomy, the unadjusted and adjusted RRs were 0.30 (95% CI: 0.23-0.39) and 0.40 (95% CI: 0.31-0.52), respectively. CONCLUSIONS: Patient delay remains the most important barrier for use of reperfusion therapy among acute ischemic stroke patients calling 1-1-2, whereas system delay seems independent of patient delay.

Can Helicopters Solve the Transport Dilemma for Patients With Symptoms of Large-Vessel Occlusion Stroke in Intermediate Density Areas? A Simulation Model Based on Real Life Data.

Background: This modeling study aimed to determine if helicopters may optimize the transportation of patients with symptoms of large vessel stroke in "intermediate density" areas, such as Denmark, by bringing them directly to the comprehensive stroke center. Methods: We estimated the time for the treatment of patients requiring endovascular therapy or intravenous thrombolysis under four configurations: "drip and ship" with and without helicopter and "bypass" with and without helicopter. Time delays, stroke numbers per municipality, and helicopter dispatches for four helicopter bases from 2019 were obtained from the Danish Stroke and Helicopter Registries. Discrete event simulation (DES) was used to estimate the capacity of the helicopter fleet to meet patient transport requests, given the number of stroke codes per municipality. Results: The median onset-to-needle time at the comprehensive stroke center (CSC) for the bypass model with the helicopter was 115 min [interquartile range (IQR): 108, 124]; the median onset-to-groin time was 157 min (IQR: 150, 166). The median onset-to-needle time at the primary stroke center (PSC) by ground transport was 112 min (IQR: 101, 125) and the median onset-to-groin time when primary transport to the PSC was prioritized was 234 min (IQR: 209, 261).A linear correlation between travel time by ground and the number of patients transported by helicopter (rho = 0.69, p < 0.001) indicated that helicopters are being used to transport more remote patients. DES demonstrated that an increase in helicopter capture zone by 20 min increased the number of rejected patients by only 5%. Conclusions: Our model calculations suggest that using helicopters to transport patients with stroke directly to the CSC in intermediate density areas markedly reduce onset-to-groin time without affecting time to thrombolysis. In this setting, helicopter capacity is not challenged by increasing the capture zone.

Disentangling Sex Differences in Use of Reperfusion Therapy in Patients With Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Previous studies from local settings have reported that women with acute ischemic stroke have a lower chance of receiving reperfusion therapy treatment, including intravenous thrombolysis and thrombectomy, than men, but the underlying mechanisms of this disparity have not been identified. We aimed to examine sex differences in the utilization of reperfusion therapy focusing on all the phases of pre- and in-hospital time delay in a nationwide population-based cohort. METHODS: This study was based on data from nationwide public registries. The study population included patients aged at least 18 years admitted with acute ischemic stroke using emergency medical services in Denmark dispatched after an emergency call in the period 2016 to 2017. Study outcomes included time delays from symptom onset to start of reperfusion therapy and use of reperfusion therapy. Data were analyzed using multivariable quantile regression and logistic regression. RESULTS: A total of 5356 stroke events fulfilled the inclusion criteria. Women (26.6%) were less likely to receive intravenous thrombolysis than men (30.2 %), corresponding to an unadjusted odds ratio of 0.84 (95% CI, 0.74-0.95). In addition, women experienced a 20 minutes longer median time delay from stroke symptom onset to stroke unit arrival than men. Adjusting for onset-to-door time only appeared to have a limited effect on the sex differences in use of intravenous thrombolysis, whereas the odds ratio was 1.06 (95% CI, 0.93-1.21) when adjusting for age at stroke, stroke severity, and cohabitation status. No sex difference was observed for the use of thrombectomy. CONCLUSIONS: Women received less reperfusion therapy than men and had a longer time delay from symptom onset to stroke unit arrival, primarily due to a longer delay from symptom onset to emergency medical services call. These differences appeared to be due to the higher age and the higher proportion of women living alone at the time of the stroke.