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BackgroundTelestroke networks aim to address variability in both quality and access to stroke care in rural areas, by providing remote access to expert stroke neurologists. Implementation of telestroke requires adaptation of workflow processes and education. We previously developed virtual reality (VR) workflow training and documented acceptability, utility and feasibility. The effects on acute stroke treatment metrics have not been previously described.AimsThe overall aim was to improve hyperacute stroke metrics and shorten the time-to-reperfusion therapy administration in rural settings.MethodsThis study applies a natural experiment approach, collecting stroke metric data during transition from a pre-existing pilot to a statewide telestroke service at five rural hospitals. Pre- and post-intervention data included baseline patient demographics and assessment, diagnosis, and treatment delivery metrics. The primary study outcome was door-to-decision time (thrombolysis and endovascular thrombectomy). Secondary outcomes included door-to-computerized tomography time, door-to-thrombolysis time and proportion of patients receiving thrombolysis or thrombectomy treatment. Usage data relating to the VR stroke workflow training of interprofessional healthcare professionals was automatically captured via Wi-Fi. Statistical comparisons of clinical metrics between the pre- and post-intervention time periods, defined as the timeframes before and after VR deployment, were performed.ResultsA total of 2,683 patients were included (April 2013–December 2022); 1910 pre- and 773 post-intervention. All acute stroke time metrics significantly improved post-intervention. The primary outcome, door-to-decision time, decreased from 80 min [56–118] to 54 min [40–76; P < 0.001]. Secondary outcomes also improved, including door-to-thrombolysis time (90 min [68–114] vs. 68.5 min [54–90]; P < 0.001) and proportion of patients thrombolysed (11 vs. 16%; P < 0.001). The proportion of patients transferred for thrombectomy was unchanged (6 vs. 7%; P = 0.69). Seventy VR sessions totaling 15 h 39 min of training time were logged. VR training usage varied across sites (3–31 sessions per site).ConclusionsDelivery of a multi-factorial intervention including infrastructure, funding, education and training (with VR workflow training) as part of a state-wide telestroke rollout was associated with improved acute stroke treatment metrics. Additional work is required to identify the contribution of each intervention component on clinical outcomes and to increase training uptake and sustainment.

BackgroundAt least 20% of strokes involve the posterior circulation (PC). Compared to the anterior circulation, posterior circulation infarction (POCI) are frequently misdiagnosed. CT perfusion (CTP) has advanced stroke care by improving diagnostic accuracy and expanding eligibility for acute therapies. Clinical decisions are predicated upon precise estimates of the ischaemic penumbra and infarct core. Current thresholds for defining core and penumbra are based upon studies of anterior circulation stroke. We aimed to define the optimal CTP thresholds for core and penumbra in POCI.MethodsData were analyzed from 331-patients diagnosed with acute POCI enrolled in the International-stroke-perfusion-registry (INSPIRE). Thirty-nine patients with baseline multimodal-CT with occlusion of a large PC-artery and follow up diffusion weighted MRI at 24–48 h were included. Patients were divided into two-groups based on artery-recanalization on follow-up imaging. Patients with no or complete recanalisation were used for penumbral and infarct-core analysis, respectively. A Receiver operating curve (ROC) analysis was used for voxel-based analysis. Optimality was defined as the CTP parameter and threshold which maximized the area-under-the-curve. Linear regression was used for volume based analysis determining the CTP threshold which resulted in the smallest mean volume difference between the acute perfusion lesion and follow up MRI. Subanalysis of PC-regions was performed.ResultsMean transit time (MTT) and delay time (DT) were the best CTP parameters to characterize ischaemic penumbra (AUC = 0.73). Optimal thresholds for penumbra were a DT >1 s and MTT>145%. Delay time (DT) best estimated the infarct core (AUC = 0.74). The optimal core threshold was a DT >1.5 s. The voxel-based analyses indicated CTP was most accurate in the calcarine (Penumbra-AUC = 0.75, Core-AUC = 0.79) and cerebellar regions (Penumbra-AUC = 0.65, Core-AUC = 0.79). For the volume-based analyses, MTT >160% demonstrated best correlation and smallest mean-volume difference between the penumbral estimate and follow-up MRI (R2 = 0.71). MTT >170% resulted in the smallest mean-volume difference between the core estimate and follow-up MRI, but with poor correlation (R2 = 0.11).ConclusionCTP has promising diagnostic utility in POCI. Accuracy of CTP varies by brain region. Optimal thresholds to define penumbra were DT >1 s and MTT >145%. The optimal threshold for core was a DT >1.5 s. However, CTP core volume estimates should be interpreted with caution.

Background and Purpose: CT perfusion (CTP) has been implemented widely in regional areas of Australia for telestroke assessment. The aim of this study was to determine if, as part of telestroke assessment, CTP provided added benefit to clinical features in distinguishing between strokes and mimic and between transient ischaemic attack (TIA) and mimic.Methods: We retrospectively analysed 1,513 consecutively recruited patients referred to the Northern New South Wales Telestroke service, where CTP is performed as a part of telestroke assessment. Patients were classified based on the final diagnosis of stroke, TIA, or mimic. Multivariate regression models were used to determine factors that could be used to differentiate between stroke and mimic and between TIA and mimic.Results: There were 693 strokes, 97 TIA, and 259 mimics included in the multivariate regression models. For the stroke vs. mimic model using symptoms only, the area under the curve (AUC) on the receiver operator curve (ROC) was 0.71 (95% CI 0.67–0.75). For the stroke vs. mimic model using the absence of ischaemic lesion on CTP in addition to clinical features, the AUC was 0.90 (95% CI 0.88–0.92). The multivariate regression model for predicting mimic from TIA using symptoms produced an AUC of 0.71 (95% CI 0.65–0.76). The addition of absence of an ischaemic lesion on CTP to clinical features for the TIA vs. mimic model had an AUC of 0.78 (95% CI 0.73–0.83)Conclusions: In the telehealth setting, the absence of an ischaemic lesion on CTP adds to the diagnostic accuracy in distinguishing mimic from stroke, above that from clinical features.

Background: One-year risk of stroke in transient ischemic attack and minor stroke (TIAMS) managed in secondary care settings has been reported as 5–8%. However, evidence for the outcomes of TIAMS in community care settings is limited.Methods: The INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study was a prospective inception cohort community-based study of patients of 16 general practices in the Hunter–Manning region (New South Wales, Australia). Possible-TIAMS patients were recruited from 2012 to 2016 and followed-up for 12 months post-index event. Adjudication as TIAMS or TIAMS-mimics was by an expert panel. We established 7-days, 90-days, and 1-year risk of stroke, TIA, myocardial infarction (MI), coronary or carotid revascularization procedure and death; and medications use at 24 h post-index event.Results: Of 613 participants (mean age; 70 ± 12 years), 298 (49%) were adjudicated as TIAMS. TIAMS-group participants had ischemic strokes at 7-days, 90-days, and 1-year, at Kaplan-Meier (KM) rates of 1% (95% confidence interval; 0.3, 3.1), 2.1% (0.9, 4.6), and 3.2% (1.7, 6.1), respectively, compared to 0.3, 0.3, and 0.6% of TIAMS-mimic-group participants. At one year, TIAMS-group-participants had twenty-five TIA events (KM rate: 8.8%), two MI events (0.6%), four coronary revascularizations (1.5%), eleven carotid revascularizations (3.9%), and three deaths (1.1%), compared to 1.6, 0.6, 1.0, 0.3, and 0.6% of TIAMS-mimic-group participants. Of 167 TIAMS-group participants who commenced or received enhanced therapies, 95 (57%) were treated within 24 h post-index event. For TIAMS-group participants who commenced or received enhanced therapies, time from symptom onset to treatment was median 9.5 h [IQR 1.8–89.9].Conclusion: One-year risk of stroke in TIAMS participants was lower than reported in previous studies. Early implementation of antiplatelet/anticoagulant therapies may have contributed to the low stroke recurrence.

Delays in acute stroke treatment contribute to severe and negative impacts for patients and significant healthcare costs. Variability in clinical care is a contributor to delayed treatment, particularly in rural, regional and remote (RRR) areas. Targeted approaches to improve stroke workflow processes improve outcomes, but numerous challenges exist particularly in RRR settings. Virtual reality (VR) applications can provide immersive and engaging training and overcome some existing training barriers. We recently initiated the TACTICS trial, which is assessing a “package intervention” to support advanced CT imaging and streamlined stroke workflow training. As part of the educational component of the intervention we developed TACTICS VR, a novel VR-based training application to upskill healthcare professionals in optimal stroke workflow processes. In the current manuscript, we describe development of the TACTICS VR platform which includes the VR-based training application, a user-facing website and an automated back-end data analytics portal. TACTICS VR was developed via an extensive and structured scoping and consultation process, to ensure content was evidence-based, represented best-practice and is tailored for the target audience. Further, we report on pilot implementation in 7 Australian hospitals to assess the feasibility of workplace-based VR training. A total of 104 healthcare professionals completed TACTICS VR training. Users indicated a high level of usability, acceptability and utility of TACTICS VR, including aspects of hardware, software design, educational content, training feedback and implementation strategy. Further, users self-reported increased confidence in their ability to make improvements in stroke management after TACTICS VR training (post-training mean ± SD = 4.1 ± 0.6; pre-training = 3.6 ± 0.9; 1 = strongly disagree, 5 = strongly agree). Very few technical issues were identified, supporting the feasibility of this training approach. Thus, we propose that TACTICS VR is a fit-for-purpose, evidence-based training application for stroke workflow optimisation that can be readily deployed on-site in a clinical setting.

Introduction: A telestroke network in Northern New South Wales, Australia has been developed since 2017. We theorized that the telestroke network development would drive a progressive improvement in stroke care metrics over time.Aim: This study aimed to describe changes in acute stroke workflow metrics over time to determine whether they improved with network experience.Methods: We prospectively collected data of patients assessed by telestroke who received multimodal computed tomography (mCT) and were diagnosed with ischemic stroke or transient ischemic attack from January 2017 to July 2019. The period was divided into two phases (phase 1: January 2017 – October 2018 and phase 2: November 2018 – July 2019). We compared median door-to-call, door-to-image, and door-to-decision time between the two phases.Results: We included 433 patients (243 in phase 1 and 190 in phase 2). Each spoke site treated 1.5–5.2 patients per month. There were Door-to-call time (median 39 in phase 1, 35 min in phase 2, p = 0.18), and door-to-decision time (median 81.5 vs. 83 min, p = 0.31) were not improved significantly. Similarly, in the reperfusion therapy subgroup, door-to-call time (median 29 vs. 24.5 min, p = 0.12) and door-to-decision time (median 70.5 vs. 67.5 min, p = 0.75) remained substantially unchanged. Regression analysis showed no association between time in the network and door-to-decision time (coefficient 1.5, p = 0.32).Conclusion: In our telestroke network, acute stroke timing metrics did not improve over time. There is the need for targeted education and training focusing on both stroke reperfusion competencies and the technical aspects of telestroke in areas with limited workforce and high turnover.

Aims: Multimodal computed tomography (mCT) (non-contrast CT, CT angiography, and CT perfusion) is not routinely used to assess posterior fossa strokes. We described the area under the curve (AUC) of brain NCCT, WB-CTP automated core-penumbra maps and comprehensive CTP analysis (automated core-penumbra maps and all perfusion maps) for posterior fossa strokes.Methods: We included consecutive patients with signs and symptoms of posterior fossa stroke who underwent acute mCT and follow up magnetic resonance diffusion weighted imaging (DWI). Multimodal CT images were reviewed blindly and independently by two stroke neurologists and area under the receiver operating characteristic curve (AUC) was used to compare imaging modalities.Results: From January 2014 to December 2019, 83 patients presented with symptoms suggestive of posterior fossa strokes and had complete imaging suitable for inclusion (49 posterior fossa strokes and 34 DWI negative patients). For posterior fossa strokes, comprehensive CTP analysis had an AUC of 0.68 vs. 0.62 for automated core-penumbra maps and 0.55 for NCCT. For cerebellar lesions >5 mL, the AUC was 0.87, 0.81, and 0.66, respectively.Conclusion: Comprehensive CTP analysis increases the detection of posterior fossa lesions compared to NCCT and should be implemented as part of the routine imaging assessment in posterior fossa strokes.

Rationale: More than half of patients who receive thrombolysis for acute ischaemic stroke fail to recanalize. Elucidating biological factors which predict recanalization could identify therapeutic targets for increasing thrombolysis success.Hypothesis: We hypothesize that individual patient plasmin potential, as measured by in vitro response to recombinant tissue-type plasminogen activator (rt-PA), is a biomarker of rt-PA response, and that patients with greater plasmin response are more likely to recanalize early.Methods: This study will use historical samples from the Barcelona Stroke Thrombolysis Biobank, comprised of 350 pre-thrombolysis plasma samples from ischaemic stroke patients who received serial transcranial-Doppler (TCD) measurements before and after thrombolysis. The plasmin potential of each patient will be measured using the level of plasmin-antiplasmin complex (PAP) generated after in-vitro addition of rt-PA. Levels of antiplasmin, plasminogen, t-PA activity, and PAI-1 activity will also be determined. Association between plasmin potential variables and time to recanalization [assessed on serial TCD using the thrombolysis in brain ischemia (TIBI) score] will be assessed using Cox proportional hazards models, adjusted for potential confounders.Outcomes: The primary outcome will be time to recanalization detected by TCD (defined as TIBI ≥4). Secondary outcomes will be recanalization within 6-h and recanalization and/or haemorrhagic transformation at 24-h. This analysis will utilize an expanded cohort including ~120 patients from the Targeting Optimal Thrombolysis Outcomes (TOTO) study.Discussion: If association between proteolytic response to rt-PA and recanalization is confirmed, future clinical treatment may customize thrombolytic therapy to maximize outcomes and minimize adverse effects for individual patients.

Background and Purpose: Telestroke aims to increase access to endovascular clot retrieval (ECR) for rural areas. There is limited information on transfer workflow for ECR in rural settings. We sought to describe the transfer metrics for ECR in a rural telestroke network with respect to decision making.Methods: A retrospective cohort study was employed on consecutive patients transferred to the comprehensive stroke center (CSC) for ECR in a rural hub-and-spoke telestroke network between April 2013 and October 2019, by road or air. Key time-based metrics were analyzed.Results: Sixty-two patients were included. Mean age was 66 years [standard deviation (SD), 14] and median National Institutes of Health Stroke Scale 13 [interquartile range (IQR), 8–18]. Median rural-hospital-door-to-CSC-door (D2D) was 308 min (IQR, 254–351), of which 68% was spent at rural hospitals [door-in-door-out (DIDO); 214 min; IQR, 171–247]. DIDO was longer for air transfers than road (P = 0.004), primarily because of a median 87 min greater decision-to-departure time (Decision-DO, P < 0.001). In multiple linear regression analysis, intubation but not thrombolysis was associated with significantly longer DIDO. The distance at which the extra speed of an aircraft made up for the delays involved in booking an aircraft was 299 km from the CSC.Conclusions: DIDO is longer for air retrievals compared with road. Decision-DO represents the most important component of DIDO, being longer for air transfers. Systems for rapid transportation of rural ECR candidates need optimization for best patient outcomes, with decision support seen as a potential tool to achieve this.

Background: Transient ischemic attack (TIA) and minor stroke (TIAMS) are risk factors for stroke recurrence. Some TIAMS may be preventable by appropriate primary prevention. We aimed to recruit “possible-TIAMS” patients in the INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study.Methods: A prospective inception cohort study performed across 16 Hunter–Manning region, Australia, general practices in the catchment of one secondary-care acute neurovascular clinic. Possible-TIAMS patients were recruited from August 2012 to August 2016. We describe the baseline demographics, risk factors and pre-event medications of participating patients.Results: There were 613 participants (mean age; 69 ± 12 years, 335 women), and 604 (99%) were Caucasian. Hypertension was the most common risk factor (69%) followed by hyperlipidemia (52%), diabetes mellitus (17%), atrial fibrillation (AF) (17%), prior TIA (13%) or stroke (10%). Eighty-nine (36%) of the 249 participants taking antiplatelet therapy had no known history of cardiovascular morbidity. Of 102 participants with known AF, 91 (89%) had a CHA2DS2-VASc score ≥ 2 but only 47 (46%) were taking anticoagulation therapy. Among 304 participants taking an antiplatelet or anticoagulant agent, 30 (10%) had stopped taking these in the month prior to the index event.Conclusion: This study provides the first contemporary data on TIAMS or TIAMS-mimics in Australia. Community and health provider education is required to address the under-use of anticoagulation therapy in patients with known AF, possibly inappropriate use of antiplatelet therapy and possibly inappropriate discontinuation of antiplatelet or anticoagulation therapy.

Background: Admission outside normal business hours has been associated with prolonged door-to-treatment times and poorer patient outcomes, the so called “weekend effect. ” This is the first examination of the weekend effect in a telestroke service that uses multi-modal computed tomography.Aims: To examine differences in workflow and triage between in-hours and out-of-hours calls to a telestroke service.Methods: All patients assessed using the Northern New South Wales (N-NSW) telestroke service from April 2013 to January 2019 were eligible for inclusion (674 in total; 539 with complete data). The primary outcomes measured were differences between in-hours and out-of-hours in door-to-call-to-decision-to-needle times, differences in the proportion of patients confirmed to have strokes or of patients selected for reperfusion therapies or patients with a modified Rankin Score (mRS ≤ 2) at 90 days.Results: There were no significant differences between in-hours and out-of-hours in any of the measured times, nor in the proportions of patients confirmed to have strokes (67.6 and 69.6%, respectively, p = 0.93); selected for reperfusion therapies (22.7 and 22.6%, respectively, p = 0.56); or independent at 3 months (34.8 and 33.6%, respectively, p = 0.770). There were significant differences in times between individual hospitals, and patient presentation more than 4.5 h after symptom onset was associated with slower times (21 minute delay in door-to-call, p = 0.002 and 22 min delay in door-to-image, p = 0.001).Conclusions: The weekend effect is not evident in the Northern NSW telestroke network experience, though this study did identify some opportunities for improvement in the delivery of acute stroke therapies.

Imaging protocols for acute ischemic stroke varies significantly from center to center leading to challenges in research translation. We aimed to assess the inter-rater reliability of collateral grading systems derived from dynamic computed tomography angiography (CTA) and an optimized multiphase CTA and, to analyze the association of the two CTA modalities with CT perfusion (CTP) compartments by comparing the accuracy of dynamic CTA (dCTA) and optimized multiphase CTA (omCTA) in identifying CT perfusion (CTP) target mismatch patients. Acute ischemic stroke patients with a proximal large vessel occlusion who underwent whole brain CTP were included in the study. Collateral status were assessed using ASPECTS collaterals (Alberta Stroke Program Early CT Score on Collaterals) and ASITN/SIR collateral system (the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology) on dCTA and omCTA. Eighty-one patients were assessed, with a median ischemic core volume of 29 mL. The collateral assessment with ASPECTS collaterals using dCTA have a similar inter-rater agreement (K-alpha: 0.71) compared to omCTA (K-alpha: 0.69). However, the agreement between dCTA and CTP in classifying patients with target mismatch was higher compared to omCTA (Kappa, dCTA: 0.81; omCTA: 0.64). We found dCTA was more accurate than omCTA in identifying target mismatch patients with proximal large vessel occlusion.

Introduction: The incidence of pituitary dysfunction after severe ischemic stroke is unknown, however given the increasing attention to pituitary dysfunction after neurological injuries such as traumatic brain injury, this may represent a novel area of research in stroke.Methods: We perform an arginine and human growth hormone releasing hormone challenge on ischemic stroke patients within a week of symptom onset.Results: Over the study period, 13 patients were successfully tested within a week of stroke (baseline NIHSS 10, range 7–16). Overall, 9(69%) patients had a poor response, with 7(54%) of these patients meeting the criteria for had human growth hormone deficiency. Other measures of pituitary function were within normal ranges.Conclusion: After major ischemic stroke, low GH levels are common and may play a role in stroke recovery.