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In light of recently published clinical trials and their implication for clinical practice, does a large catchment area acute hospital require 24 hour CT neck and head angiography and/or neuro-interventional services in the setting of acute ischaemic stroke?

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Abstract

Background

Recently published clinical trials have resulted in a significant change in the guidelines used to manage patients suffering an acute ischaemic stroke. New neuro-interventional techniques have revolutionised stroke outcomes. Currently, such services are only available in two specialist centres.

Aims

We attempted to evaluate the need for the provision of routine computed tomography (CT) angiography and neuro-interventional services at a university teaching hospital in Limerick.

Methods

A retrospective study was performed based on data collated by the stroke service, University Hospital Limerick (UHL). All patients with a suspected acute ischaemic stroke of anterior circulation and known evolution were included. Baseline clinical and imaging characteristics, thrombolysis data, stroke unit admission rates and discharge destinations were recorded.

Results

All 141 patients were suitable for CT angiography and should be performed in accordance with guidelines. Additionally, 165 patients excluded from the study due to an unknown stroke evolution timeframe may have benefitted. Non-contrast CT scan confirmed just 12 anterior circulation strokes. The need for neuro-interventional services proved more difficult to assess, primarily due to the lack of provision of routine CT angiography, employed to confirm anterior circulation occlusion. Secondary results showed a thrombolysis rate of 10.8% and confirmed that time efficiencies result in higher thrombolysis eligibility rates. Stroke unit admissions and discharge destinations were also recorded.

Conclusion

UHL should provide routine CT angiography to all patients presenting with acute ischaemic stroke in line with current guidelines. The need for provision of neuro-interventional services on-site proved more difficult to assess and requires further analysis.

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Notes

  1. Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimising CT to recanalization times.

  2. Scores on National Institutes of Health Stroke Scale (NIHSS) range from 0 to 42, with higher scores indicating more severe neurological deficits. It is an important score. Thrombolysis is indicated in UHL if NIHSS score is in the range 4–24, above which the risk may outweigh any benefit. Additionally, thrombectomy may be indicated in scores of ≥ 5.

  3. Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) is an imaging measure of the extent of the ischaemic stroke. Score range from 0 to 10, with higher scores indicating a smaller infarct core.

  4. The modified Rankin scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It has become the most widely used clinical outcome measure for stroke clinical trials. The scale runs from 0 to 6, running from perfect health without symptoms to death.

    0—No symptoms.

    1—No significant disability. Able to carry out all usual activities, despite some symptoms.

    2—Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

    3—Moderate disability. Requires some help, but able to walk unassisted.

    4—Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

    5—Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

    6—Dead.

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Author information

Authors and Affiliations

  1. Department of Medicine, University Hospital Limerick (UHL), Limerick, Republic of Ireland

    J. Halpin

  2. Department of Elderly Medicine, UHL, Limerick, Republic of Ireland

    C. Peters

  3. Department of Radiology, UHL, Limerick, Republic of Ireland

    J. O’Brien, T. Scanlon & M. Shelly

  4. Department of Medicine, UHL, Limerick, Republic of Ireland

    N. Cunningham

  5. Graduate-Entry Medical School, University of Limerick, Limerick, Republic of Ireland

    L. Hickey

Authors
  1. J. Halpin
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  2. C. Peters
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  3. J. O’Brien
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  4. T. Scanlon
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  5. M. Shelly
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  6. N. Cunningham
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  7. L. Hickey
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Corresponding author

Correspondence to J. Halpin.

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There was no funding for this research.

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The authors declare that they have no conflict of interest.

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This article does not contain any studies with human participants performed by any of the authors.

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Halpin, J., Peters, C., O’Brien, J. et al. In light of recently published clinical trials and their implication for clinical practice, does a large catchment area acute hospital require 24 hour CT neck and head angiography and/or neuro-interventional services in the setting of acute ischaemic stroke?. Ir J Med Sci 187, 351–358 (2018). https://doi.org/10.1007/s11845-017-1674-0

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  • DOI: https://doi.org/10.1007/s11845-017-1674-0

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