Nobl Barazangi

Generalized Safety and Efficacy of Simplified Intravenous Thrombolysis Treatment (SMART) Criteria in Acute Ischemic Stroke: The MULTI SMART Study

BACKGROUND Common intravenous recombinant tissue plasminogen activator (IV rt-PA) exclusion criteria may substantially limit the use of thrombolysis. Preliminary data have shown that the SMART (Simplified Management of Acute stroke using Revised Treatment) criteria greatly expand patient eligibility by reducing thrombolysis exclusions, but they have not been assessed on a large scale. We evaluated the safety and efficacy of general adoption of SMART thrombolysis criteria to a large regional stroke network. METHODS Retrospective analysis of consecutive patients who received IV thrombolysis within a regional stroke network was performed. Patients were divided into those receiving thrombolysis locally versus at an outside hospital. The primary outcome was modified Rankin Scale score (≤1) at discharge and the main safety outcome was symptomatic intracranial hemorrhage (sICH) rate. RESULTS There were 539 consecutive patients, and 50.5% received thrombolysis at an outside facility. Ninety percent of the patients possessed common conventional IV rt-PA contraindications. There were no significant differences between local and network treated patients in favorable outcome (45.4% versus 37.4%; odds ratio [OR], .72; P > .09), mortality (9% versus 14%; OR, 1.6; P > .07), or sICH rate (2.6% versus 5.1%; OR, 2.0; P = .13). Multivariate analysis showed no association between receiving IV rt-PA at an outlying spoke hospital and higher rate of sICH or worse outcome at discharge. CONCLUSIONS Generalized application of SMART criteria is safe and effective. Widespread application of these criteria could substantially increase the proportion of patients who might qualify for treatment.

Teleneurology and Neurointerventional Therapy for Acute Stroke

Teleneurology has expanded the availability of acute stroke treatment, particularly thrombolysis, as well as increased the availability of neurointerventional therapies to patients beyond large medical centers (El Khoury, Neurology 79(13 Suppl 1):S26–34, 2012). By promoting the appropriate triage of acute stroke patients, teleneurology helps facilitate the appropriate transfer of patients to appropriate centers to receive intra-arterial therapy for a variety of disorders, including acute ischemic stroke and subarachnoid hemorrhage. The objective of this chapter is to outline the workings of one large telestroke network, illustrating how teleneurology helps triage patients requiring neurointerventional therapy and facilitates the transfer of such patients for definitive treatment. The role of teleneurology in research and development of neurointerventional therapy is also discussed.