1.Organizing Healthcare for Optimal Acute Ischemic Stroke Treatment
Simone VIDALE ; Elio Clemente AGOSTONI
Journal of Clinical Neurology 2020;16(2):183-190
Stroke is a major health-care problem that represents a leading cause of death and also the top cause of disability in adulthood. In recent years there has been a significant paradigm shift in treatments for acute ischemic stroke to favor earlier reperfusion therapy, mainly using the systemic infusion of recombinant tissue plasminogen activator. Subsequent trials found that combining this treatment with endovascular therapy was effective in selected patients. The increased complexity of acute stroke treatments has resulted in a substantial reorganization of stroke care. This review reports on the evolution of acute ischemic stroke treatment and describes the main organizational models based on the hub-and-spoke system. The lack of evidence for comparisons of the effectiveness of different paradigms means that some decision-analysis models predicting the best organizational pathways are also reported, with a particular emphasis on the workflow timing in the prehospital and in-hospital settings. Major benchmarks and performance measures are also reported, focusing on the timing of interventions and rates of process indicators. Finally, future directions are illustrated, including using telemedicine for stroke, mobile stroke units, and artificial intelligence and automated machines to produce software for detecting large-vessel occlusion.
2.Mothership versus Drip-and-Ship Model for Mechanical Thrombectomy in Acute Stroke: A Systematic Review and Meta-Analysis for Clinical and Radiological Outcomes
Michele ROMOLI ; Maurizio PACIARONI ; Georgios TSIVGOULIS ; Elio Clemente AGOSTONI ; Simone VIDALE
Journal of Stroke 2020;22(3):317-323
Background:
and Purpose Substantial uncertainty exists on the benefit of organizational paradigms in stroke networks. Here we systematically reviewed and meta-analyzed data from studies comparing functional outcome between the mothership (MS) and the drip and ship (DS) models.
Methods:
The meta-analysis protocol was registered international prospective register of systematic reviews (PROSPERO) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Central databases were searched for randomized-controlled clinical trials (RCTs), retrospective and prospective studies comparing MS versus DS. Primary endpoints were functional independence at 90 days (modified Rankin Scale <3) and successful recanalization (Thrombolysis in Cerebral Infarction Scale [TICI] >2a); secondary endpoints were 3-month mortality and symptomatic intracranial haemorrhage (sICH). Odds ratios for endpoints were pooled using the random effects model and were compared between the two organizational models.
Results:
Overall, 18 studies (n=7,017) were included in quantitative synthesis. MS paradigm was superior to DS model for functional independence (odds ratio, 1.34; 95% confidence interval, 1.16 to 1.55; I2=30%). Meta-regression analysis revealed association between onset-to-needle time and good functional outcome, with longer onset-to-needle time being detrimental. Similar rates of recanalization, sICH and mortality at 90 days were documented between MS and DS.
Conclusions
Patients with acute ischemic stroke eligible for reperfusion strategies might benefit more from MS paradigm as compared to DS. RCTs are needed to further refine best management taking into account logistics, facilities and resources.
3.The Role of Atrial Cardiopathy as a Potential Cause of Embolic Stroke of Undetermined Source
Angelo Cascio RIZZO ; Ghil SCHWARZ ; Andrea BONELLI ; Andrea Di PIETRO ; Martina Di PIETRO ; Francesco ARUTA ; Cristina MOTTO ; Benedetta De CHIARA ; Antonella MOREO ; Elio Clemente AGOSTONI
Journal of Stroke 2024;26(2):330-334