Ahmed Itrat

Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep

IMPORTANCE Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence. OBJECTIVE To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU. DESIGN, SETTING, AND PARTICIPANTS Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT). Data were entered into the medical record and a prospective registry. MAIN OUTCOMES AND MEASURES The study compared the evaluation and treatment of patients on the MSTU with a control group of patients brought to the emergency department via ambulance during the same year. Process times were measured from the time the patient entered the door of the MSTU or emergency department, and any problems encountered during his or her evaluation were recorded. RESULTS Ninety-nine of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes (interquartile range [IQR], 14-27 minutes). One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were 6 telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (13 minutes [IQR, 9-21 minutes]) and from the door to intravenous thrombolysis (32 minutes [IQR, 24-47 minutes]) were significantly shorter in the MSTU group compared with the control group (18 minutes [IQR, 12-26 minutes] and 58 minutes [IQR, 53-68 minutes], respectively). Times to CT interpretation did not differ significantly between the groups. CONCLUSIONS AND RELEVANCE An MSTU using telemedicine is feasible, with a low rate of technical failure, and may provide an avenue for reducing the high cost of such systems.

A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy.

Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on‐site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT.

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis

Objective: To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. Methods: We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014–November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. Results: Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. Conclusion: Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Pathological Evidence of Cardiac Papillary Fibroelastoma in a Retrieved Intracranial Embolus

Approximately one-quarter of all cardiac tumors present with systemic embolization. Cardiac papillary fibroelastomas (CPF) represent a potential embolic source, accounting for 8% of all primary cardiac tumors, second in frequency after cardiac myxomas. Most case reports describe papillary fibroelastoma as a potential source for stroke, but histopathological evidence of actual tumor fragment causing a stroke is lacking. We describe a case of histologically confirmed CPF mechanically retrieved from a cerebral artery during an emergent cerebral endovascular procedure with subsequent discovery of the CPF in the heart, providing in vivo demonstration of intracranial embolization of this cardiac tumor.

The role of very high high-sensitivity C-reactive protein levels on mortality after stroke

High-sensitivity C-reaction protein (hsCRP) levels are correlated with risk of vascular disease. The clinical implications of markedly elevated hsCRP levels in the setting of acute stroke are less understood. OBJECTIVE To determine the association of very high admission hsCRP levels (≥10mg/L) on all-cause mortality in patients with acute stroke. METHODS A retrospective cohort study of 1176 patients hospitalized with acute stroke between 2005 and 2012 who had a hsCRP assay drawn within seven days of admission. Mortality data was obtained using Ohio Death Index. Cox proportional analysis was used to determine hazard ratios of death among patients with hsCRP values >10mg/L after adjusting for age, sex, race and relevant co-morbid conditions. NIHSS was also adjusted in a subset of patients in whom it was available (n=378). RESULTS Patients with hsCRP >10mg/L had 2.65 (95% CI: 1.99, 3.53) increased hazard of all-cause mortality compared to stroke patients with hsCRP ≤10mg/L. Association of hsCRP with mortality was greater for patients with low NIHSS and declined in patients with increasing NIHSS scores. A higher proportion of patients with hsCRP >10 died from nonvascular causes than patients with hsCRP ≤10mg/L. CONCLUSION Very high levels of hsCRP may be a useful marker to identify stroke patients at increased risk for death, especially those with stroke of mild severity. More research is needed to determine how this information can be used to improve patient care, especially in patients with mild stroke.

Safe Readministration of Intravenous Thrombolysis in Recurrent Basilar Thrombosis

We report a patient who had recurrence of stroke in the basilar artery territory because of repeat thrombosis, and was administered intravenous recombinant tissue plasminogen activator (IV-rtPA) twice within a span of 3 weeks without any adverse events, with radiological evidence of successful thrombolysis. Because of minor and improving stroke symptoms with IV-rtPA, endovascular therapy was not performed and there was radiological evidence of recanalization with IV-rtPA alone. This report adds to the very limited literature on the topic demonstrating safe and successful use of repeat IV thrombolysis following a previous recent stroke.

Extensive stretching of intracranial aneurysm coil causing TIAs

A 58-year-old man with a history of ruptured posterior cerebral artery aneurysm, repaired with coil embolization 5 years previously, presented with right hemi-numbness lasting 30 minutes. Cerebral MRI did not reveal acute stroke. CT angiogram showed a stretched wire complex extending through the posterior communicating artery, down the carotid artery, and into the most inferior visualized portion of descending aorta, terminating in a loosely coiled wire (figure, A and B). A transesophageal echocardiogram showed evidence of a possible thrombus on the coil in the aortic arch (figure, C and D; video on the Neurology® Web site at Neurology.org). Coil stretching and migration is a rare complication of endovascular coil repair1,2 and can predispose to embolic events.