Morgan, Olivia

Background and Purpose: Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale is a helpful tool to triage patients with stroke in the field. However, data on its reliability in the prehospital setting are lacking. We aim to test the reliability of FAST-ED scale when used by paramedics in a mobile stroke unit covering a metropolitan area. Methods: As part of standard operating mobile stroke unit procedures, paramedics initially evaluated patients. If the event characterized a stroke alert, the FAST-ED score was determined by the paramedic upon patient contact (in-person) and then independently by a vascular neurologist (VN) immediately after paramedic evaluation (remotely/telemedicine). This allowed testing of the interrater agreement of the FAST-ED scoring performance between on-site prehospital providers and remotely located VN. Results: Of a total of 238 patients transported in the first 15 months of the mobile stroke unit’s activity, 173 were included in this study. Median age was 63 (interquartile range, 55.5–75) years and 52.6% were females. A final diagnosis of ischemic stroke was made in 71 (41%), transient ischemic attack in 26 (15%), intracranial hemorrhage in 15 (9%), whereas 61 (35%) patients were stroke mimics. The FAST-ED scores matched perfectly among paramedics and VN in 97 (56%) instances, while there was 0 to 1-point difference in 158 (91.3%), 0 to 2-point difference in 171 (98.8%), and 3 or more point difference in 2 (1.1%) patients. The intraclass correlation between VN and paramedic FAST-ED scores showed excellent reliability, intraclass correlation coefficient 0.94 (95% CI, 0.92–0.96; P <0.001). When VN recorded FAST-ED score ≥3, paramedics also scored FAST-ED≥3 in majority of instances (63/71 patients; 87.5%). A large vessel occlusion was identified in 16 (9.2%) patients; 13 occlusions were identified with a FAST-ED≥3 while 3 were missed. All of the latter patients had National Institutes of Health Stroke Scale score ≤5. Conclusions: We demonstrate excellent reliability of FAST-ED scale performed by paramedics when compared with VN, indicating that it can be accurately performed by paramedics in the prehospital setting.

Introduction: Evidence regarding the optimal acute antiplatelet strategies in emergent endovascular therapies is scarce, and practices varies institutionally. Ticagrelor, a P2Y3B inhibitor with a lower incidence of resistance, may be effective in achieving rapid platelet inhibition. We explore the safety and efficacy of emergent Ticagrelor use in patient undergoing neurointerventions. Methods: We reviewed our database for all consecutive patients from 2016 to 2019 who received emergent administration of Ticagrelor (within 30 minutes before or after) for neuro-interventional procedures. The primary outcome measure was the incidence of major systemic hemorrhages including symptomatic intracranial hemorrhage as well as intraprocedural and post-procedural thrombotic events. Results: 81 patients were analyzed (Mean age 62±11, 70% male, 73 undergoing interventions for ischemic strokes, 8 aneurysm patients undergoing embolization). Twenty (24.7%) patients received Ticagrelor pre-puncture, 28 (35%) during and 33 (41%) after closure. Median PRU achieved in 43 patients after excluding for concomitant use of GPIIbIIIa use was 54 [36-111]. Major bleeding occurred in 7/81 patients (9.2%) - 4 gastrointestinal bleeding and 3 symptomatic ICH. Eleven (14%) patients experienced intraprocedural occlusions. Five (6.2%) cases were complicated by post-procedural occlusions while on Ticagrelor, two of which were asymptomatic. Pre-procedural Ticagrelor was associated with less frequent administration of subsequent GPIIbIIIa (OR = 0.15, 95% CI (0.03-0.64), p=0.01), as well as shorter procedure duration (Spearman’s rho 0.409, p =0.001). The use of GPIIbIIIa plus Ticagrelor was associated with increased bleeding complications (0% vs. 14%; p =0.04) than in patients receiving Ticagrelor only. Bleeding was an independently predictive risk factor for death by 3 months (OR 7.18, 95% CI (1.33-38.8, p=0.02 or 43% vs. 9.5%; p=0.04) Conclusion: Early and emergent use of Ticagrelor, prior to endovascular procedure as early as within 30 minutes, may obviate the need for administration of GPIIbIIIa. Combined use of GPIIbIIa antithrombotics with Ticagrelor was associated with hemorrhagic complications, which could contribute to increased mortality.