Outcomes of thrombolytic therapy in acute ischemic stroke: mothership, drip-and-ship, and ship-and-drip paradigms

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Abstract

Background

Chulalongkorn Stroke Center is a comprehensive stroke center (CSC) located in Bangkok, Thailand. Our stroke network consists of different levels of spoke hospitals, ranging from community hospitals where thrombolytic treatment is not available, to those capable of onsite thrombolytic therapy. This study aimed to assess the time to treatment and outcomes among acute ischemic stroke patients who received thrombolytic treatment in the Chulalongkorn Stroke Network by 1.) Direct arrival at the CSC (mothership) 2.) Telestroke-assisted thrombolytic treatment with secondary transfer to the CSC (drip-and-ship) 3.) Referral from community hospital to the CSC for thrombolytic treatment (ship-and-drip).

Methods

Acute ischemic stroke patients who received thrombolytic treatment during January 2016–December 2017 in the Chulalongkorn Stroke Network were studied. Time to treatment and clinical outcomes were compared among treatment groups.

Results

There were 273 patients in the study including 147, 87, and 39 patients in mothership, drip-and-ship, and ship-and-drip paradigms, respectively. The door-to-needle-time (DTN) and onset-to-needle-time (OTN) times were significantly longest in ship-and-drip group (146.5 ± 62/205.03 ± 44.88 mins) compared to mothership (38 ± 23/155.2 ± 60.54 mins) and drip-and-ship (63.0 ± 44/166.09 ± 87 mins), P < 0.05. There was no significant difference regarding functional independence defined by modified Rankin Scale (mRS) ≤ 2 at 3 months ( P = 0.12), in-hospital mortality ( P = 0.37), mortality at 3 months ( P = 0.73), and symptomatic intracerebral hemorrhage ( P = 0.24) among groups.

Conclusion

Thrombolytic treatment with drip and ship method under teleconsultation is feasible in Thailand. There was no difference of clinical outcome among the 3 treatment paradigms. However, DTN time and OTN time were longest in the ship-and-drip paradigm.

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Most cited references 25

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Stroke Epidemiology in Thailand

Nijasri Suwanwela (2014)

Stroke is a major health burden in Thailand. It is the leading cause of death and long term disability in both men and women. Despite the improvement of healthcare system, the mortality rate of stroke is still increasing during the past 5 years. The incidence of stroke in Thailand is now being studied in a large population based cohort. The prevalence of stroke is estimated to be 1.88% among adults 45 years and older. Stroke is more prevalent in men than in women and the mean age of stroke onset is 65 years. Hypertension, diabetes, dyslipidemia, metabolic syndrome, and atrial fibrillation are major risk factors of stroke in the Thai population. Evolution from predominantly rural to urbanized industrial communities result in the increasing prevalence of these risk factors. Similar to other parts of the world, ischemic stroke is the most common stroke type but the proportion of hemorrhagic stroke is higher when compared to Caucasian populations. Among patients with ischemic stroke, lacunar stroke is most common, accounting for almost half followed by atherosclerotic disease. Intracranial atherosclerosis is also prevalent in Thai population. For acute treatment, intravenous thrombolysis has been used in Thailand for over 20 years. Its cost is reimbursed by the national health care system but its use is still limited. With the introduction of the stroke fast track system, prompt stroke treatment across the country is warranted. Stroke unit is now the standard of care in large regional and provincial hospitals.

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“Telestroke”: The Application of Telemedicine for Stroke

Steven Levine, Mark Gorman (1999)

Background —Time is of the essence for effective intervention in acute ischemic stroke. Efforts including stroke teams that are “on call” around-the-clock are emerging to reduce the time from emergency room arrival to evaluation and treatment. Summary of Comment —Based on the results of the NINDS rt-PA Stroke Trial, which demonstrated both clinical effectiveness in reducing neurological deficits and disability and cost savings to health care systems, many community hospitals and managed-care organizations are exploring methods to enhance and expedite acute stroke care in their local communities. Only a small fraction of acute stroke victims is currently treated with thrombolytics (<1.5% nationally), and few benefit from the expertise and experience of the stroke teams. It is essential to develop new paradigms to improve acute stroke care in all settings, rural and urban. Rapid linkages to expert stroke care can help the underserved areas. Telemedicine for stroke, “Telestroke,” uses state-of-the-art video telecommunications that may be a potential solution and may maximize the number of patients given effective acute stroke treatment across the country and across the world. Telestroke could facilitate remote cerebrovascular specialty consults from virtually any location within minutes of attempted contact, adding greater expertise to the care of any individual patient. This model also has the potential to enhance patient entry into clinical trials. Telestroke would enhance stroke education through the use of Internet-based interactives for health-care professionals and patients. Education would be facilitated through the creation of telecommunication-linked classes providing interactive information on stroke care and prevention to places where they are otherwise not available. Health-care professionals will gain experience and expertise through the interaction with a remote expert—telementoring. Telestroke provides an excellent medium for data collection and an unprecedented opportunity for quality assurance. Monitoring of an entire tele-interaction can offer real-time assessments, which can then be analyzed in-depth at a later date for unique insights into health-care delivery. Prehospital use of telemedicine for stroke is already being piloted, linking patients in the ambulance to the emergency department. Legal and economic parameters must be established for telemedicine in the areas of reimbursement, liability, malpractice insurance, licensing, and credentialing. Issues of protection of privacy and confidentiality, informed consent, product liability, and industry standards must be addressed to facilitate the use of this new and potentially useful technology. Conclusions —Computer-based technology can now be used to integrate electronic medical information, clinical assessment tools, neuroradiology, laboratory data, and clinical pathways to bring state-of-the-art expert stroke care to underserved areas.

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Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy.

Peter U Heuschmann, Peter L Kolominsky-Rabas, Joachim Roether … (2004)

Data are limited regarding the risks and benefits of thrombolytic therapy for acute ischemic stroke outside of clinical trials. To investigate predictors of in-hospital mortality in patients with ischemic stroke treated with intravenous tissue plasminogen activator (tPA) within a pooled analysis of large German stroke registers. Prospective, observational cohort study conducted at 225 community and academic hospitals throughout Germany cooperating within the German Stroke Registers Study Group. A total of 1658 patients with acute ischemic stroke who were admitted to study hospitals between 2000 and 2002 and were treated with tPA. In-hospital mortality. One hundred sixty-six patients (10%) who received tPA died during hospitalization, with 67.5% of these deaths occurring within 7 days. Factors predicting in-hospital death after tPA use were older age (for each 10-year increment in age, adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.9) and altered level of consciousness (adjusted OR, 3.4; 95% CI, 2.4-4.7). The overall rate of symptomatic intracranial hemorrhage was 7.1% and increased with age. One or more serious complications was observed in 27.2% of all patients and in 83.9% of patients who died after tPA treatment. An inverse relation between the number of patients treated with tPA in the respective hospital and the risk of in-hospital death was observed (adjusted OR, 0.97; 95% CI, 0.96-0.99 for each additional patient treated with tPA per year). In patients with ischemic stroke who are treated with tPA, disturbances of consciousness and increasing age are associated with increased in-hospital mortality.

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Author and article information

Contributors

Naruchorn Kijpaisalratana:

ORCID: http://orcid.org/0000-0003-3260-491X

naruchorn.k@chula.ac.th

Journal

Journal ID (nlm-ta): BMC Neurol

Journal ID (iso-abbrev): BMC Neurol

Title: BMC Neurology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2377

Publication date (Electronic): 3 February 2020

Publication date PMC-release: 3 February 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 45

Affiliations

[1 ]GRID grid.7922.e, ISNI 0000 0001 0244 7875, Division of Neurology, Department of Medicine, Faculty of Medicine, , Chulalongkorn University, ; Rama IV Road, Bangkok, 10330 Thailand

[2 ]Chula Neuroscience Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Rama IV Road, Bangkok, 10330 Thailand

[3 ]GRID grid.7922.e, ISNI 0000 0001 0244 7875, Division of Academic Affairs, Faculty of Medicine, , Chulalongkorn University, ; Rama IV Road, Bangkok, 10330 Thailand

[4 ]GRID grid.411628.8, ISNI 0000 0000 9758 8584, Chulalongkorn Stroke Center, , King Chulalongkorn Memorial Hospital, ; Bangkok, Thailand

Author information

Naruchorn Kijpaisalratana http://orcid.org/0000-0003-3260-491X

Article

Publisher ID: 1631

DOI: 10.1186/s12883-020-1631-9

PMC ID: 6998331

PubMed ID: 32013906

SO-VID: bb991798-9c7b-42db-9bde-b205ac7f1fa4

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 9 September 2019

Date accepted : 29 January 2020

Custom metadata

ScienceOpen disciplines: Neurology

Keywords: acute ischemic stroke,thrombolytic,telestroke,mothership,drip-and-ship,ship-and-drip

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ScienceOpen disciplines: Neurology

Keywords: acute ischemic stroke, thrombolytic, telestroke, mothership, drip-and-ship, ship-and-drip

Outcomes of thrombolytic therapy in acute ischemic stroke: mothership, drip-and-ship, and ship-and-drip paradigms

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Stroke MRI

Most cited references 25

Stroke Epidemiology in Thailand

“Telestroke”: The Application of Telemedicine for Stroke

Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy.

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