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Objectives: Telemedicine is frequently used to provide remote neurological expertise for acute stroke workup and was associated with better functional outcomes when combined with a stroke unit system‐of‐care. We investigated whether such system‐of‐care yields additional benefits when implemented on top of neurological competence already available onsite. Methods: Quality improvement measures were implemented within a "hub‐and‐spoke" teleneurology network in 11 hospitals already provided with onsite or telestroke expertise. Measures included dedicated units for neurological emergencies, standardization of procedures, multiprofessional training, and quality‐of‐care monitoring. Intervention effects were investigated in a controlled study enrolling patients insured at 3 participating statutory health insurances diagnosed with acute stroke or other neurological emergencies. Outcomes during the intervention period between November 2017 and February 2020 were compared with those pre‐intervention between October 2014 and March 2017. To control for temporal trends, we compared outcomes of patients with respective diagnoses in 11 hospitals of the same region. Primary outcome was the composite of up‐to‐90‐day death, new disability with the need of ambulatory or nursing home care, expressed by adjusted hazard ratio (aHR). Results: We included 1,418 patients post‐implementation (55% female, mean age 76.7 ± 12.8 year) and 2,306 patients pre‐implementation (56%, 75.8 ± 13.0 year, respectively). The primary outcome occurred in 479/1,418 (33.8%) patients post‐implementation and in 829/2,306 (35.9%) pre‐implementation. The aHR for the primary outcome was 0.89 (95% confidence interval [CI]: 0.79–0.99, p = 0.04) with no improvement seen in non‐participating hospitals between post‐ versus pre‐implementation periods (aHR 1.04; 95% CI: 0.95–1.15). Interpretation: Implementation of a multicomponent system‐of‐care was associated with a lower risk of poor outcomes. ANN NEUROL 2023;93:511–521 [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of additional mobile stroke unit (MSU) dispatch on functional outcomes among the full spectrum of stroke patients, regardless of subtype or potential contraindications to reperfusion therapies. Methods: We used data from the nonrandomized Berlin‐based B_PROUD study (02/2017 to 05/2019), in which MSUs were dispatched based solely on availability, and the linked B‐SPATIAL stroke registry. All patients with final stroke or transient ischemic attack (TIA) diagnoses were eligible. The intervention under study was the additional dispatch of an MSU, an emergency physician‐staffed ambulance equipped to provide prehospital imaging and thrombolytic treatment, compared to conventional ambulance alone. The primary outcome was the 3‐month modified Rankin Scale (mRS) score, and the co‐primary outcome was a 3‐tiered disability scale. We identified confounders using directed acyclic graphs and obtained adjusted effect estimates using inverse probability of treatment weighting. Results: MSUs were dispatched to 1,125 patients (mean age: 74 years, 46.5% female), while for 1,141 patients only conventional ambulances were dispatched (75 years, 49.9% female). After confounding adjustment, MSU dispatch was associated with more favorable 3‐month mRS scores (common odds ratio [cOR] = 0.82; 95% confidence interval [CI]: 0.71–0.94). No statistically significant association was found with the co‐primary outcome (cOR = 0.86; 9% CI: 0.72–1.01) or 7‐day mortality (OR = 0.94; 95% CI: 0.59–1.48). Interpretation: When considering the entire population of stroke/TIA patients, MSU dispatch improved 3‐month functional outcomes without evidence of compromised safety. Our results are relevant for decision‐makers since stroke subtype and treatment eligibility are unknown at time of dispatch. ANN NEUROL 2023;93:50–63 [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to investigate whether high‐sensitivity cardiac troponin T (hs‐cTnT) is associated with major adverse cardiovascular events (MACE) in patients with minor stroke or transient ischemic attack (TIA), and whether this association differs after risk stratification based on the Age, Blood Pressure, Clinical Features, Duration of Symptoms, Diabetes (ABCD2) score. Methods: INSPiRE‐TMS was a randomized controlled trial allocating patients with minor stroke or TIA to an intensified support program or conventional care. In this post hoc analysis, participants were categorized using hs‐cTnT levels (5th generation; Roche Diagnostics, Manheim, Germany; 99th percentile upper reference limit [URL] = 14ng/l). Vascular risk was stratified using the ABCD2 score (lower risk = 0–5 vs higher risk = 6–7). Cox proportional hazard regression was performed using covariate adjustment and propensity score matching (PSM) for the association between hs‐cTnT and MACE (stroke/nonfatal coronary event/vascular death). Results: Among 889 patients (mean age = 70 years, 37% female), MACE occurred in 153 patients (17.2%) during a mean follow‐up of 3.2 years. hs‐cTnT was associated with MACE (9.3%/yr, >URL vs 4.4%/yr, ≤URL, adjusted hazard ratio [HR] = 1.63 [95% confidence interval (CI) = 1.13–2.35], adjusted HR [Q4 vs Q1] = 2.57 [95% CI = 1.35–4.97], adjusted HR [log‐transformed] = 2.31 [95% CI = 1.37–3.89]). This association remained after PSM (adjusted HR = 1.76 [95% CI = 1.14–2.72]). There was a significant interaction between hs‐cTnT and ABCD2 category for MACE occurrence (pinteraction = 0.04). In the lower risk category, MACE rate was 9.5%/yr in patients with hs‐cTnT > URL, which was higher than in those ≤URL (3.8%/yr) and similar to the overall rate in the higher risk category. Interpretation: hs‐cTnT levels are associated with incident MACE within 3 years after minor stroke or TIA and may help to identify high‐risk individuals otherwise deemed at lower risk based on the ABCD2 score. If confirmed in independent validation studies, this might warrant intensified secondary prevention measures and cardiac diagnostics in stroke patients with elevated hs‐cTnT. ANN NEUROL 2021;90:901–912 [ABSTRACT FROM AUTHOR]