Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting

Lahr, Maarten; Luijckx, Gert-Jan; Vroomen, Patrick; Zee, Durk-Jouke van der; Buskens, Erik

doi:10.1161/strokeaha.111.641795

Cited by 80 publications

(81 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Many patients received IV-rtPA in our study. Although the proportion of patients who arrive in hospitals within 4.5 h that receive IV-rtPA has increased up to 50% in The Netherlands in recent years [60] , this proportion is even higher in our study, which could indicate selection bias. In addition, ASPECTS was used for the assessment of ischemia in the anterior circulation and pcASPECTS for the posterior circulation.…”

Section: Discussioncontrasting

confidence: 62%

The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke

Seeters¹,

Biessels

Kappelle

et al. 2015

Cerebrovasc Dis

View full text Add to dashboard Cite

Background: CT angiography (CTA) and CT perfusion (CTP) are important diagnostic tools in acute ischemic stroke. We investigated the prognostic value of CTA and CTP for clinical outcome and determined whether they have additional prognostic value over patient characteristics and non-contrast CT (NCCT). Methods: We included 1,374 patients with suspected acute ischemic stroke in the prospective multicenter Dutch acute stroke study. Sixty percent of the cohort was used for deriving the predictors and the remaining 40% for validating them. We calculated the predictive values of CTA and CTP predictors for poor clinical outcome (modified Rankin Scale score 3-6). Associations between CTA and CTP predictors and poor clinical outcome were assessed with odds ratios (OR). Multivariable logistic regression models were developed based on patient characteristics and NCCT predictors, and subsequently CTA and CTP predictors were added. The increase in area under the curve (AUC) value was determined to assess the additional prognostic value of CTA and CTP. Model validation was performed by assessing discrimination and calibration. Results: Poor outcome occurred in 501 patients (36.5%). Each of the evaluated CTA measures strongly predicted outcome in univariable analyses: the positive predictive value (PPV) was 59% for Alberta Stroke Program Early CT Score (ASPECTS) ≤7 on CTA source images (OR 3.3; 95% CI 2.3-4.8), 63% for presence of a proximal intracranial occlusion (OR 5.1; 95% CI 3.7-7.1), 66% for poor leptomeningeal collaterals (OR 4.3; 95% CI 2.8-6.6), and 58% for a >70% carotid or vertebrobasilar stenosis/occlusion (OR 3.2; 95% CI 2.2-4.6). The same applied to the CTP measures, as the PPVs were 65% for ASPECTS ≤7 on cerebral blood volume maps (OR 5.1; 95% CI 3.7-7.2) and 53% for ASPECTS ≤7 on mean transit time maps (OR 3.9; 95% CI 2.9-5.3). The prognostic model based on patient characteristics and NCCT measures was highly predictive for poor clinical outcome (AUC 0.84; 95% CI 0.81-0.86). Adding CTA and CTP predictors to this model did not improve the predictive value (AUC 0.85; 95% CI 0.83-0.88). In the validation cohort, the AUC values were 0.78 (95% CI 0.73-0.82) and 0.79 (95% CI 0.75-0.83), respectively. Calibration of the models was satisfactory. Conclusions: In patients with suspected acute ischemic stroke, admission CTA and CTP parameters are strong predictors of poor outcome and can be used to predict long-term clinical outcome. In multivariable prediction models, however, their additional prognostic value over patient characteristics and NCCT is limited in an unselected stroke population.

show abstract

Section: Discussioncontrasting

confidence: 62%

The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke

Seeters¹,

Biessels

Kappelle

et al. 2015

Cerebrovasc Dis

View full text Add to dashboard Cite

show abstract

“…12 The approach of areabased tPA rate provides better comparability as hospital-based tPA rates are often severely biased by prehospital selection, especially in centralized systems of care.…”

Section: Discussionmentioning

confidence: 99%

“…Also, the lower number of tPA administrations per hospital is probably associated with less routine and less optimized procedures. 12,13,20 tPA administrations in each TEMPiS hospital ranged between 15 and 91 per year. In Helsinki, stroke neurologist is contacted before patient arrival in hospital, which further reduces in-hospital delay, a measure that is also intended in TEMPiS, but because of large number of emergency medical services teams and hospitals, does not seem to be achieved as well.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network)

Hubert

Meretoja

Audebert

et al. 2016

Stroke

View full text Add to dashboard Cite

Although the shortest overall delays can be achieved with a computed tomography (CT)-equipped ambulance, 4 the fastest hospital-based delays have been reported from the Helsinki University Central Hospital (HUCH), which covers the city of Helsinki and the surrounding province of Uusimaa in Finland. 5 In rural, sparsely inhabited regions, the coverage of tPA service is difficult and achievement of short time delays is more challenging, mainly because of long prehospital distances and reduced experience in tPA delivery in local hospitals compared with stroke centers. The Telemedical Project for Integrative Stroke Care (TEMPiS) attempted to address this challenge by setting up a decentralized system of telemedicine-linked stroke facilities (TeleStroke Units) in rural SouthEast Bavaria, Germany. 10,11 In such decentralized systems, the specialized stroke care facility will be closer to patients' home, thus reducing prehospital delays, but the volume of Background and Purpose-Intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke is more effective when delivered early. Timely delivery is challenging particularly in rural areas with long distances. We compared delays and treatment rates of a large, decentralized telemedicine-based system and a well-organized, large, centralized single-hospital system. Methods-We analyzed the centralized system of the Helsinki University Central Hospital (Helsinki 45).Conclusions-A decentralized telestroke thrombolysis service can achieve similar treatment rates and time delays for a rural population as a centralized system can achieve for an urban population.

show abstract

“…Some European stroke centers have also reported higher overall IV tPA rates than that reported in the present study of PSCs in the United States. 15 This may reflect differences in systems of care and geographic differences that contributes to variances in transportation times and percentages of patients arriving within IV tPA eligible time window.…”

Section: February 2017mentioning

confidence: 99%

Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization

Man

Cox

Patel

et al. 2017

Stroke

View full text Add to dashboard Cite

show abstract

Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting

Cited by 80 publications

References 29 publications

The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke

The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke

Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network)

Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization

Contact Info

Product

Resources

About