Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

Taschner, Christian; Trinks, Alexandra; Bardutzky, Jürgen; Brich, Jochen; Hartmann, Ralph; Urbach, Horst; Niesen, Wolf‐Dirk

doi:10.3389/fneur.2021.743151

Cited by 11 publications

(10 citation statements)

References 23 publications

(27 reference statements)

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“…Data from nonrandomized studies suggest that this workflow can lead to shorter EVT treatment initiation times and better clinical outcomes for patients with an LVO-a stroke. 5,7,91011 By contrast, the RACECAT trial—performed in a nonurban area with relatively long initial transport times—did not find a difference in clinical outcome in suspected LVO stroke patients between a mothership and drip-and-ship model. 37 This discrepancy between studies may be attributed to geographic differences and emphasize the need for regional solutions to optimize stroke care.…”

Section: Discussionmentioning

confidence: 82%

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Prehospital Detection of Large Vessel Occlusion Stroke With EEG

van Stigt,

Groenendijk,

van Meenen

et al. 2023

Neurology

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Background and objectivesEndovascular thrombectomy (EVT) is standard treatment for anterior large vessel occlusion stroke (LVO-a stroke). Prehospital diagnosis of LVO-a stroke would reduce time-to-EVT by allowing direct transportation to an EVT-capable hospital. We aim to evaluate the diagnostic accuracy of dry electrode electroencephalography (EEG) for detection of LVO-a stroke in the prehospital setting.MethodsELECTRA-STROKE was an investigator-initiated, prospective, multi-center, diagnostic study, performed in the prehospital setting. Adult patients were eligible if they had suspected stroke (as assessed by the attending paramedic), and symptom onset <24 hours. A single dry electrode EEG recording (8 electrodes) was performed by the paramedic. Primary endpoint was the diagnostic accuracy of the theta/alpha frequency ratio for LVO-a stroke (intracranial ICA, A1, M1 or proximal M2 occlusion) among patients with EEG data of sufficient quality, expressed as the area under the receiver operating characteristic curve (AUC). Secondary endpoints were diagnostic accuracies of other EEG features quantifying frequency band power and the pairwise derived Brain Symmetry Index. Neuroimaging was assessed by a neuroradiologist blinded to EEG results.ResultsBetween August 2020 and September 2022, 311 patients were included. Median EEG duration time was 151 (IQR 151-152) seconds. For 212/311 (68%) patients, EEG data were of sufficient quality for analysis. Median age was 74 (IQR 66-81) years, 90/212 (42%) were women, and median baseline NIHSS was 1 (IQR 0-4). Six (3%) patients had an LVO-a stroke, 109/212 (51%) a non-LVO-a ischemic stroke, 32/212 (15%) a transient ischemic attack, 8/212 (4%) a hemorrhagic stroke, and 57/212 (27%) a stroke mimic. AUC for the theta/alpha ratio was 0.80 (95% CI 0.58-1.00). Of the secondary endpoints, the pairwise derived Brain Symmetry Index in the delta frequency band had highest diagnostic accuracy (AUC 0.91 [95% CI 0.73-1.00]; sensitivity 80% [95% CI 38%-96%]; specificity 93% [95% CI 88%-96%]; positive likelihood ratio 11.0 [95% CI 5.5-21.7]).DiscussionThe data from this study suggest that dry electrode EEG has potential to detect LVO-a stroke among patients with suspected stroke in the prehospital setting. Towards future implementation of EEG in prehospital stroke care, EEG data quality needs to be improved.Trial registrationClinicalTrials.gov identifier:NCT03699397.Classification of EvidenceThis study provides Class II evidence that prehospital dry electrode scalp EEG accurately detects LVO-a stroke among patients with suspected acute stroke.

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Section: Discussionmentioning

confidence: 82%

“…5-9 On average, this so-called drip-and-ship workflow delays the initiation of EVT by 39–114 minutes and is associated with a 7.8%–21.4% lower chance of functional independence at 90 days. 5,7,91011…”

Section: Introductionmentioning

confidence: 99%

Prehospital Detection of Large Vessel Occlusion Stroke With EEG

van Stigt,

Groenendijk,

van Meenen

et al. 2023

Neurology

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“…Because MTE is mostly available in larger hospitals due to the necessary infrastructure and skilled staff required for the performance of MTEs, disparities in access to MTEs remain a significant issue, even more than for IVT [ 1 ]. Particularly rural patients and patients living in underdeveloped regions have a lower MTE rate and worse outcomes after MTE in part because of longer transfer times [ 17 , 21 ]. However we were able to demonstrate a continuing trend towards a reduction in the number of regions with poor access to MTEs in Germany.…”

Section: Discussionmentioning

confidence: 99%

The evolution of acute stroke care in Germany from 2019 to 2021: analysis of nation-wide administrative datasets

Ungerer,

Bartig,

Richter

et al. 2024

Neurol. Res. Pract.

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Background The treatment of ischemic stroke (IS) has changed considerably in recent years. Particularly the advent of mechanical thrombectomy (MTE) has revolutionized the available treatment options. Most patients in developed countries have access to intravenous thrombolysis (IVT). However access to MTE remains restricted in some regions despite efforts to increase its availability. We performed an evaluation of national datasets to monitor improvements made in access to revascularization therapies for IS patients in Germany. Methods We analyzed national datasets on German Diagnosis-Related Groups and structured quality reports by extracting information of patients admitted with stroke with and without IVT and MTE for the period of 2019–2021. Data from 2016 and limited data for 2022 were also included for comparison. Results Admissions with ischemic stroke declined during the years of the COVID 19 pandemic by 4.5% from 227,258 in 2019 to 216,923 in 2021. IVT rates were stable with 16.3% being treated with IVT in 2019 and 2021. MTE rates continued to increase from 7.1 to 8.4% and the number of MTE centers increased by 14.8% in the same period. Over 87.3% of MTEs were performed in centers with a case volume exceeding 50 cases per year in 2021. The largest increase in the relative share of MTEs was seen in large MTE centers (n ≥ 200). Patient age for MTEs surpassed the age for IVTs in 2019 and the proportion of patients ≥ 80 years receiving MTE continued to increase. The proportion of regions in Germany with poor MTE rates (≤ 4.1%) decreased significantly from 2019 (12.3%) to 2021 (5.3%) (p < 0.001). Conclusions We found strong evidence that while IVT rates reached a temporary ceiling effect, both the absolute number of and access to MTEs continued to increase in Germany. Regional disparities have become less significant and the majority of MTEs are performed in centers with medium or high case volumes.

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“…The MS model may be preferred in urban areas where transport to the MT center is less than 30-45 min, while patients beyond this time limit may benefit more from DS [7]. Observational studies suggest that for suspected LVO stroke patients the MS model offers better functional outcomes [47][48][49][50][51][52][53]. The mothership model, compared with DS, offers shorter transfer times, 275 vs. 179.5 min, respectively [31].…”

Section: What Needs To Be Donementioning

confidence: 99%

Acute ischemic stroke treatment model for Poland in the mechanical thrombectomy era – which way to go?

Pawłowski¹,

Dziadkiewicz²,

Klaudel³

et al. 2022

pwki

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The interventional treatment of acute ischemic stroke with large vessel occlusion has revolutionized patient care in recent years. The Mechanical Thrombectomy Pilot Program in Poland is due to end soon. It seems the right time to summarize the achievements and name the problems of a centralized stroke care system and decide what future model of treatment and transportation to implement. In order to provide the best care for our patients, it is crucial to establish the actual needs in stroke and tailor the mechanical thrombectomy system structure accordingly. The analysis of data from well-organized health systems in the world suggests that to deliver adequate numbers of mechanical thrombectomy to stroke patients in Poland, we would need to at least double the number of procedures currently performed. To achieve this, an essential system reorganization and adjustments are required, with special emphasis on the number of mechanical thrombectomy centers and transportation models. The strengths and weaknesses of two dominant transportation models (mothership and drip-and-ship) are herein discussed, and a proposal on how to build an efficient and cost-effective mechanical thrombectomy stroke network in Poland is put forward. The article is an invitation to open an interdisciplinary discussion on the best treatment model of acute ischemic stroke patients requiring mechanical thrombectomy in Poland.

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Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

Cited by 11 publications

References 23 publications

Prehospital Detection of Large Vessel Occlusion Stroke With EEG

Prehospital Detection of Large Vessel Occlusion Stroke With EEG

The evolution of acute stroke care in Germany from 2019 to 2021: analysis of nation-wide administrative datasets

Acute ischemic stroke treatment model for Poland in the mechanical thrombectomy era – which way to go?

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