Abstracts From the 2010 International Stroke Conference: Oral Presentations

2010 Stroke  
As stroke is a time-urgent neuroemergency, start of treatment by paramedics in the field as soon as possible after symptom onset offers the greatest prospect of success for neuroprotective therapeutic agents. However, stroke patients represent only 2-3% of all field transports, and among patients with neurologic complaints encountered by paramedics, nonstroke causes are 10 times more common than stroke. To avoid exposing an untoward proportion of nonstroke patients to active agents, field
more » ... ent clinical trials and eventual clinical practice require a high rate of diagnostic accuracy. We evaluated the success of the stroke screening prehospital stroke identification procedures in the NIH Field Administration of Stroke Therapy -Magnesium (FAST-MAG) phase 3 trial, and the etiologies and clinical features of stroke mimics (SM). Methods: FAST-MAG is a randomized, double-blind, placebo-controlled trial of Magnesium Sulfate administered by paramedics to individuals with suspected stroke within 2 hours after symptom onset. We use a 2 step patient identification procedure: 1) Los Angeles Prehospital Stroke Screen (LAPSS) used by paramedics to identify potential patients, 2) Paramedics then call the central study neurologist from the scene by cellphone to give a brief report. The neurologist speaks to the patient or family member and performs a brief (15-90 second) stroke-focused history. The neurologist then renders a diagnosis of likely stroke. Prelaunch study sample size assumptions projected a 5% rate of SM patient entry into the trial. Results: This analysis was performed on the first 567 enrolled patients. Average time from last known well to start of study drug was 35ϩ/Ϫ52 minutes. Final diagnosis 3 months after the event was acute ischemic stroke (AIS) in 411 (72.5%), intracranial hemorrhage (ICH) in 136 (24%), and SM in 20 (3.5%). Final diagnoses of SM were seizures (6 patients, 30%), intracranial neoplasms (6 patients, including 1 with seizures), anxiety (2 patients, 10%), migraine (2 patients), metabolic abnormalities (1 patient with hypoglycemia, another with hyponatremia), urosepsis (1 case), and 3 had other conditions. The hyponatremia patient had a seizure. On average, compared to patients with final diagnosis of AIS or ICH, SM patients were younger (64Ϯ13 versus 70Ϯ13 years, pϭ0.06), had lower systolic blood pressure (SBP 141 versus 159 mm Hg, pϭ0.012) and milder neurological deficits on presentation (NIHSS 5.6 versus 9.3, pϭ0.009). Frequency of cardiovascular risk factors was similar between stroke and SM, except for diabetes (17.2 versus 35%, respectively, pϭ0.041). Conclusions: Combined LAPSS and neurologist phone screening enables patient enrollment hyperacutely in prehospital neuroprotective acute stroke trials with low, acceptable rates of SM entry. SM should be considered when patients are young, have normal SBP and have mild neurological deficits. Background: Dizziness and vertigo are common reasons for Emergency Department (ED) visits, but uncertainty about the underlying etiology is common at discharge. Given the potential that serious cerebrovascular and cardiovascular etiologies could be missed, we studied the frequency and timing of subsequent adverse vascular outcomes for ED patients who are discharged home with a primary diagnosis of dizziness or vertigo. Methods: We identified a cohort of all patients with an ED discharge diagnosis of dizziness or vertigo between January 1, 2005 and June 30, 2005 using encounter data from the California Office of Statewide Health Planning and Development. Inclusion criteria were in-state residence, age Ͼϭ 18, valid social security number and demographic information, disposition to home, and absence of primary outcomes at presentation. Using probabilistic record linkage and validated methods for determining outcomes, we identified the first hospitalization or death for cerebrovascular events (acute ischemic stroke and intracerebral hemorrhage), cardiovascular events (acute myocardial infarction, unstable angina and ventricular arrhythmia), and major vascular events combined (cerebrovascular and cardiovascular events) for 6 months after ED discharge. Data were analyzed using survival analysis. Results: Among 31,096 patients discharged with dizziness or vertigo diagnoses, mean age was 56.3 years and 63.1% were women. During 15,193 person-years of follow-up, there were 276 adverse vascular events, representing a 6-month cumulative risk of 0.89% (95% CI 0.79-1.00%). There were 188 strokes and 95 major cardiovascular events representing cumulative risks of 0.61% (0.53-0.70%) and 0.31% (0.25-0.37%) respectively (see Figure) . Although the rate of cardiovascular events was similar throughout the study period, the monthly stroke risk was higher in the first month compared to subsequent months (0.29% vs. 0.06%). Conclusions: ED patients who are discharged home with a primary diagnosis of dizziness or vertigo have a low rate of subsequent hospitalization and death from major vascular events overall, with a stroke attributable to the event occurring in only about 1 in 500 patients in the following month. Reassurance and more cost-effective evaluation may be indicated for the majority of these patients. Background: The development of comprehensive stroke centers within hub and spoke stroke networks offers the opportunity to increase the proportion of acute ischemic stroke (AIS) patients treated within intra-arterial (IA) therapies. A critical factor will be the facilitation of rapid hospital-to-hospital patient transfers. We evaluated whether transfer delay was a determinant of IA therapy in eligible patients. Methods: We collected data on consecutive patients with AIS between October 2006 and July 2009 who were transferred to our institution for possible endovascular treatment. We defined transfer time as time from initial transfer call from a referring hospital emergency room to time of arrival at our hospital and assessed whether transfer time was a predictor of IA treatment using logistic regression. A P-value Ͻ 0.05 was considered significant. Results: Among the 94 transferred patients, 36 (38.3%) were excluded from IA therapy on the basis of clinical factors (11 delayed initial presentation Ͼ 8 hours; 11 lacunar syndromes; 14 rapid improvement to NIHSS score Ͻ 4 on arrival). The remaining patients (nϭ58, 61.2%) were candidates for IA treatment (median age 60 years, median NIHSS score 18, 48.3% male). The median hospital-hospital distance was 12.7 (range 1.9-85.0) miles. The median time from symptom onset to initial call was 179 (range 67-574) minutes. The median transfer time was 106 (range 46-342) minutes. Forty-one of 58 (71%) patients underwent IA therapy. Transfer time was 30.9% lower among those who underwent IA therapy (98.5 vs. 142.5 minutes, P ϭ 0.003). Adjusting for age, NIHSS score on arrival, and distance between hospitals, transfer time remained an independent predictor of IA therapy (OR 0.98, 95% CI 0.97-0.99, P ϭ 0.011). The predicted probability of IA therapy was 90% at transfer time of 46 minutes and decreased by 2% per minute thereafter (Figure) . Conclusion: Delay in hospital-tohospital transfer is a principle reason AIS patients are excluded from interventional therapy. The likelihood of receiving acute endovascular revascularization therapy decreased by 2% per minute of delay in transfer time beyond 46 minutes. Specific goals for transfer time should be considered in future quality standards for hub-spoke organized stroke networks. Abstracts and presentations are embargoed for release at date and time of presentation or time of AHA/ASA news event. Information may not be released before then. Failure to honor embargo policies will result in the abstract being withdrawn and barred from presentation.
doi:10.1161/01.str.0000366114.11305.66 fatcat:2hsmmr7gcvg6xl543mxbyswqee