Endovascular Thrombectomy in Young Patients With Stroke: A MR CLEAN Registry Study.
Brouwer Josje,Smaal Johanna A,Emmer Bart J,de Ridder Inger R,van den Wijngaard Ido R,de Leeuw Frank-Erik,Hofmeijer Jeannette,van Zwam Wim H,Martens Jasper M,Roos Yvo B W E M,Majoie Charles B,van Oostenbrugge Robert J,Coutinho Jonathan M,
BACKGROUND AND PURPOSE:Acute ischemic stroke due to large vessel occlusion is uncommon in young adults. We assessed stroke cause in young patients and compared their outcomes after endovascular thrombectomy with older patients. METHODS:We used data (March 2014 until November 2017) of patients with an anterior circulation large vessel occlusion stroke from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a nationwide, prospective study on endovascular thrombectomy in the Netherlands. We compared young patients (18-49 years) with older patients (≥50 years). Outcomes included modified Rankin Scale score after 90 days (both shift and dichotomized analyses), expanded Thrombolysis in Cerebral Infarction score, and symptomatic intracranial hemorrhage. Analyses were adjusted for confounding. RESULTS:We included 3256 patients, 310 (10%) were 18 to 49 years old. Young patients had lower median National Institutes of Health Stroke Scale scores (14 versus 16, <0.001) and less cardiovascular comorbidities than older patients. Stroke etiologies in young patients included carotid dissection (16%), cardio-embolism (15%), large artery atherosclerosis (10%), and embolic stroke of undetermined source (31%). Clinical outcome was better in young than older patients (acOR for modified Rankin Scale shift: 1.8 [95% CI, 1.5-2.2]; functional independence [modified Rankin Scale score 0-2] 61 versus 39% [adjusted odds ratio, 2.1 [95% CI, 1.6-2.8]); mortality 7% versus 32%, adjusted odds ratio, 0.2 [95% CI, 0.1-0.3]). Symptomatic intracranial hemorrhage occurred less frequently in young patients (3% versus 6%, adjusted odds ratio, 0.5 [95% CI, 0.2-1.00]). Successful reperfusion (expanded Thrombolysis in Cerebral Infarction Score 2b-3) did not differ between groups. Onset to reperfusion time was shorter in young patients (253 versus 255 minutes, adjusted B in minutes 12.4 [95% CI, 2.4-22.5]). CONCLUSIONS:Ten percent of patients with acute ischemic stroke undergoing endovascular thrombectomy were younger than 50. Cardioembolism and carotid dissection were common underlying causes in young patients. In one-third of cases, no cause was identified, indicating the need for more research on stroke cause in young patients. Young patients had better prognosis and lower risk of symptomatic intracranial hemorrhage than older patients.
Bias in Stroke Evaluation: Rethinking the Cookie Theft Picture.
Despite a current emphasis on equity in stroke care, one of the most common stroke assessment tools that is used both nationally and internationally, includes an anachronistic image that projects cultural, linguistic, and socioeconomic bias. This image, titled The Cookie Theft picture, is included in the National Institutes of Health Stroke Scale and was originally developed in 1972. Now, 50 years later, it does not reflect our current diverse, linguistically rich, and multicultural patient population.
Reliability of Field Assessment Stroke Triage for Emergency Destination Scale Use by Paramedics: Mobile Stroke Unit First-Year Experience.
Bhatt Nirav R,Frankel Michael R,Nogueira Raul G,Fleming Carol,Bianchi Nicolas A,Morgan Olivia,Chester Katleen,English Stephen W,Janocko Nicholas,Navalkele Digvijaya,Haussen Diogo C
Background and Purpose:Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale is a helpful tool to triage patients with stroke in the field. However, data on its reliability in the prehospital setting are lacking. We aim to test the reliability of FAST-ED scale when used by paramedics in a mobile stroke unit covering a metropolitan area. Methods:As part of standard operating mobile stroke unit procedures, paramedics initially evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic upon patient contact (in-person) and then independently by a vascular neurologist (VN) immediately after paramedic evaluation (remotely/telemedicine). This allowed testing of the interrater agreement of the FAST-ED scoring performance between on-site prehospital providers and remotely located VN. Results:Of a total of 238 patients transported in the first 15 months of the mobile stroke unit’s activity, 173 were included in this study. Median age was 63 (interquartile range, 55.5–75) years and 52.6% were females. A final diagnosis of ischemic stroke was made in 71 (41%), transient ischemic attack in 26 (15%), intracranial hemorrhage in 15 (9%), whereas 61 (35%) patients were stroke mimics. The FAST-ED scores matched perfectly among paramedics and VN in 97 (56%) instances, while there was 0 to 1-point difference in 158 (91.3%), 0 to 2-point difference in 171 (98.8%), and 3 or more point difference in 2 (1.1%) patients. The intraclass correlation between VN and paramedic FAST-ED scores showed excellent reliability, intraclass correlation coefficient 0.94 (95% CI, 0.92–0.96; P<0.001). When VN recorded FAST-ED score ≥3, paramedics also scored FAST-ED≥3 in majority of instances (63/71 patients; 87.5%). A large vessel occlusion was identified in 16 (9.2%) patients; 13 occlusions were identified with a FAST-ED≥3 while 3 were missed. All of the latter patients had National Institutes of Health Stroke Scale score ≤5. Conclusions:We demonstrate excellent reliability of FAST-ED scale performed by paramedics when compared with VN, indicating that it can be accurately performed by paramedics in the prehospital setting.
Emergency Medical Service Time Intervals for Patients With Suspected Stroke in the United States.
Cash Rebecca E,Boggs Krislyn M,Richards Christopher T,Camargo Carlos A,Zachrison Kori S
BACKGROUND:Optimal care for patients with stroke relies on timely recognition and rapid transport to appropriate treatment, often by emergency medical services (EMS). Our primary objective was to describe EMS time intervals for patients with suspected stroke in the United States. We also sought to quantify the variation in EMS time intervals by geographic location and urbanicity. METHODS:We conducted a cross-sectional evaluation of EMS 9-1-1 activations (ie, calls for service) included in the 2018 and 2019 National EMS Information System datasets. We included ground or air EMS activations for a 9-1-1 scene response where a patient aged ≥18 years with suspected stroke was treated and transported by EMS. Time intervals for dispatch, response, scene, transport, and total prehospital time (ie, from dispatch to hospital arrival) were calculated, stratified by ground and air transport type. RESULTS:A total of 410 187 activations for suspected stroke were included, of which 98% were a ground transport. The median total prehospital time for ground transports was 35 minutes (interquartile range, 27-45, 90th percentile 58). Median total prehospital time for air transports was substantially longer at 56 minutes (interquartile range, 43-70, 90th percentile 86). Times varied by Census division and urbanicity with the shortest ground total prehospital times in the East North Central division and urban areas and longest times in the East South Central and rural and frontier areas. CONCLUSIONS:Timely EMS response and transport is critical for optimizing care of patients with suspected stroke. Using a large, national dataset of EMS activations, we found variations by geographic location and urbanicity in total prehospital time for ground and air EMS activations for patients with stroke.