Imaging plus telestroke aids regional reperfusion decisions


10 Oct 2019

The use of multimodal CT imaging (mCT) in regional centres supported by telestroke can help identify patients most likely to benefit from thrombolysis, five‐year experience from a telestroke network in NSW shows. 

Writing in CNS Neuroscience Therapy, stroke neurologist Dr. Carlos Garcia‐Esperon, from the Department of Neurology, John Hunter Hospital, Newcastle and colleagues explained that in 2013 a telestroke network had been set up to provide acute stroke services to Hunter New England and Mid North Coast local health districts. In 2017 the service was extended to include the Mid North Coast local health district.

“Our principal hypothesis was that the use of mCT implemented in regional hospitals and supported by telestroke would deliver more refined patient selection for thrombolysis—specifically that it would allow selection of those most likely to benefit from therapies… and also of those unlikely to benefit, such as stroke mimics, large infarct cores, or small perfusion lesions where the natural history is excellent,” they wrote.

From April 2013 to June 2018, 240 of 334 consecutive patients assessed via telemedicine received mCT and 58 of these were thrombolysed (24.2%), making up 17.4% of all the calls received during the study period.

The decision to thrombolyse was made by the treating telestroke vascular neurologist in a “real world” clinical practice setting using the standard clinical/NCCT criteria.

The thrombolysed patients had moderate/severe strokes (median baseline NIHSS of 10), and 74% had a visible vessel occlusion on CTA, 1.7% had a symptomatic ICH and 3.5% a parenchymal hematoma.

Three months after their stroke, 55% of the patients were independent, a figure that the authors noted was similar to the SITS‐MOST registry and comparable to other studies.

This compared to 80% of the non-thrombolysed group,  a finding that the authors said was probably explained by a combination of very small or absent perfusion lesions, low percentage of large vessel occlusion and the presence of mimics. 

“These data suggest that mCT can identify patients traditionally eligible for thrombolysis, but who actually have an excellent natural history…. [the data] add to previous observations suggesting that patients with small perfusion deficits may do as well or even better without thrombolysis, calling into question strategies that reward high thrombolysis rates in a relatively undifferentiated population of patients presenting with acute focal neurologic deficit,” they wrote.

Over the study period the median onset to needle time was 172 minutes, the median door to needle time was 91 minutes and the median “call to stroke neurologist to needle time” was 65 minutes.

The authors acknowledged that their door to needle times “clearly show room for improvement”.

“As it has been the published experience internationally, it takes time to improve door to needle at sites new to thrombolysis. This is the subject of a current practice improvement project across our sites,” they wrote.

“Our results highlight the feasibility of using mCT in smaller centers lacking stroke neurologists, in particular its potential for reperfusion therapy decision‐making,” the study authors concluded.

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