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Background Endovascular thrombectomy is not available at all hospitals that offer intravenous thrombolysis, prompting debate regarding the preferred transport destination for acute ischemic stroke. This study aimed to quantify real-world travel time and distance of bypass and non-bypass transport models for large-vessel occlusion (LVO) and non-LVO stroke. Methods This cross-sectional study included population data of census tracts in the contiguous USA from the 2014-2018 United States Census Bureau's American Community Survey, stroke (thrombolysis-capable) and thrombectomy-capable centers certified by a state or national body, and road network data from a mapping service. Census tracts were categorized by urbanization level. Data were retrieved from March to November 2020. Travel times and distances were calculated for each census tract to each of the following: nearest stroke center (nearest), nearest thrombectomy-capable center (bypass), and nearest stroke center then to the nearest thrombectomy-capable center (transfer). Population-weighted median and IQR were calculated nationally and by urbanization. Results 72 538 census tracts, 2388 stroke hospitals, and 371 thrombectomy-capable centers were included. Nationally, population-weighted median travel time for nearest and bypass routing was 11.7 min (IQR 7.7-19.3) and 26.4 min (14.8-55.1), respectively. For transfer routing, the population-weighted median travel times with 60 min, 90 min, and 120 min door-in-door-out times were 94.1 min (78.5-127.7), 124.1 min (108.5-157.7), and 154.1 min (138.4-187.6), respectively. Conclusions Bypass routing offers modest travel time benefits for LVO patients and incurs modest penalties for non-LVO patients. Differences are greatest in rural areas. A majority of Americans live in areas for which current guidelines recommend bypass. [ABSTRACT FROM AUTHOR]

Since the publication of five large randomized controlled trials in 2015, endovascular thrombectomy (EVT) has become the standard of care for adult patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO).[1] However, AIS is also an important cause of mortality and long-term disability in children and teenagers.[2][3]-[2] Accordingly, there has been a trend toward offering adult interventions for AIS such as intravenous thrombolysis and EVT to pediatric patients.[5][6]-[5] Since few pediatric hospitals currently have the necessary infrastructure and expertise to provide EVT in-house, pediatric access to EVT often relies on proximity to adult EVT centers.[8] No studies to date characterize the proximity of pediatric hospitals to EVT centers. As a result, few pediatric hospitals currently provide EVT, and most instead rely upon inter-hospital transport to an EVT center.[8] Though this care paradigm is widely used, the proximity of EVT hospitals to pediatric hospitals has not previously been characterized. Hospital identification Pediatric hospitals were identified in January 2021 from the directory of the Children's Hospital Association, a national organization representing over 220 pediatric hospitals.[9] Pediatric acute care hospitals in the contiguous United States that were likely to have a pediatric emergency department were included. [Extracted from the article]

For more than a year, the SARS-CoV-2 pandemic has had a devastating effect on global health. High-, low-, and middle-income countries are struggling to cope with the spread of newer mutant strains of the virus. Delivery of acute stroke care remains a priority despite the pandemic. In order to maintain the time-dependent processes required to optimize delivery of intravenous thrombolysis and endovascular therapy, most countries have reorganized infrastructure to optimize human resources and critical services. Low-and-middle income countries (LMIC) have strained medical resources at baseline and often face challenges in the delivery of stroke systems of care (SSOC). This position statement aims to produce pragmatic recommendations on methods to preserve the existing SSOC during COVID-19 in LMIC and propose best stroke practices that may be low cost but high impact and commonly shared across the world. [ABSTRACT FROM AUTHOR]

The article explores how to access to comprehensive stroke care, and how among the different levels of hospitals providing stroke care, the comprehensive stroke center (CSC). Topics discussed include provide the most advanced stroke care, including therapies like endovascular clot retrieval; and the interaction of a constant transport threshold with variable resistance to transport from traffic.

Objective: It is unclear whether trauma center care is associated with improved outcomes in older adults with traumatic brain injury (TBI) compared to management at nontrauma centers. Our primary objectives were to describe the long‐term outcomes of older adults with TBI and to evaluate the association of trauma center transport with long‐term functional outcome. Methods: This was a prospective, observational study at five emergency medical services (EMS) agencies and 11 hospitals representing all 9‐1‐1 transfers within a county. Older adults (≥55 years) with TBI (defined as closed head injury associated with loss of consciousness and/or amnesia, abnormal Glasgow Coma Scale [GCS] score, or traumatic intracranial hemorrhage) and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and emergency department (ED) and hospital data were abstracted. Functional outcomes were measured using the Extended Glasgow Outcome Scale (GOS‐E) at 3‐ and 6‐month intervals by telephone follow‐up. Reasons for disabilities were coded as due to head injury, due to illness or injury to other part of body, or due to a mixture of both. To evaluate the association of trauma center transport and functional outcomes, we conducted multivariate ordinal logistic regression analyses on multiple imputed data for 1) all patients with TBI and 2) patients with traumatic intracranial hemorrhage. Results: We enrolled 350 patients with TBI; the median (Q1, Q3) age was 70 (61, 84) years, 187 (53%) were male, and 91 patients (26%) had traumatic intracranial hemorrhage on initial ED cranial computed tomography (CT) imaging. A total of 257 patients (73%) were transported by EMS to a Level I or II trauma center. Sixty‐nine patients (20%) did not complete follow‐up at 3 or 6 months. Of the patients with follow‐up, 119 of 260 patients (46%) had moderate disability or worse at 6 months, including 55 of 260 patients (21%) who were dead at 6‐month follow‐up. Death or severe disabilities were more commonly attributed to non‐TBI causes while moderate disabilities or better were more commonly due to TBI. On adjusted analysis, an abnormal GCS score, higher Charlson Comorbidity Index scores, and the presence of traumatic intracranial hemorrhage on initial ED cranial imaging were associated with worse GOS‐E scores at 6 months. Trauma center transport was not associated with GOS‐E scores at 6 months for TBI patients and in patients with traumatic intracranial hemorrhage on initial ED CT imaging. Conclusions: In older adults with TBI, moderate disability or worse is common 6 months after injury. Over one in five of older adults with TBI died by 6 months, usually due to nonhead causes. Patients with TBI or traumatic intracranial hemorrhage did not have improved functional outcomes with initial triage to a trauma center. [ABSTRACT FROM AUTHOR]

Objectives: Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening. Methods: Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)-documented isolated SDH presenting to a university-affiliated, urban, 100,000-annual-visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model. Results: A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors—SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127. Conclusion: Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers. [ABSTRACT FROM AUTHOR]

Background The acquisition of intravenous ( IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine ( BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity. Objective The objective was to assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non- IV BDZ efficacy in the real world with regard to failure rates (primary outcome), interval to seizure control, and observed complications (secondary outcomes). Methods A systematic review was performed using Medline, Embase, and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi-randomized controlled trials directly comparing IV to non- IV (buccal, rectal, intranasal, or intramuscular) BDZ were included. Results Our search strategy retrieved 2,604 citations for review. A total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non- IV BDZ was superior to IV BDZ (odd ratio [ OR] = 0.72; 95% confidence interval [ CI] = 0.56-0.92). However, no significant difference was found between the two treatments in the pediatric subgroup ( OR = 1.16; 95% CI = 0.74-1.81). Non- IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69-5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52-0.95 minutes). Respiratory complications requiring intervention were similar between non- IV BDZ and IV BDZ, regardless of administration route (risk difference = 0.00; 95% CI = -0.02 to 0.01). Conclusion Non- IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher-quality studies and further evaluation in different age groups are warranted. [ABSTRACT FROM AUTHOR]

Objectives A brain electrical activity biomarker for identifying traumatic brain injury ( TBI) in emergency department ( ED) patients presenting with high Glasgow Coma Scale ( GCS) after sustaining a head injury has shown promise for objective, rapid triage. The main objective of this study was to prospectively evaluate the efficacy of an automated classification algorithm to determine the likelihood of being computed tomography ( CT) positive, in high-functioning TBI patients in the acute state. Methods Adult patients admitted to the ED for evaluation within 72 hours of sustaining a closed head injury with GCS 12 to 15 were candidates for study. A total of 720 patients (18-85 years) meeting inclusion/exclusion criteria were enrolled in this observational, prospective validation trial, at 11 U.S. EDs. GCS was 15 in 97%, with the first and third quartiles being 15 (interquartile range = 0) in the study population at the time of the evaluation. Standard clinical evaluations were conducted and 5 to 10 minutes of electroencephalogram ( EEG) was acquired from frontal and frontal-temporal scalp locations. Using an a priori derived EEG-based classification algorithm developed on an independent population and applied to this validation population prospectively, the likelihood of each subject being CT+ was determined, and performance metrics were computed relative to adjudicated CT findings. Results Sensitivity of the binary classifier (likely CT+ or CT-) was 92.3% (95% confidence interval [ CI] = 87.8%-95.5%) for detection of any intracranial injury visible on CT ( CT+), with specificity of 51.6% (95% CI = 48.1%-55.1%) and negative predictive value ( NPV) of 96.0% (95% CI = 93.2%-97.9%). Using ternary classification (likely CT+, equivocal, likely CT-) demonstrated enhanced sensitivity to traumatic hematomas (≥1 mL of blood), 98.6% (95% CI = 92.6%-100.0%), and NPV of 98.2% (95% CI = 95.5%-99.5%). Conclusion Using an EEG-based biomarker high accuracy of predicting the likelihood of being CT+ was obtained, with high NPV and sensitivity to any traumatic bleeding and to hematomas. Specificity was significantly higher than standard CT decision rules. The short time to acquire results and the ease of use in the ED environment suggests that EEG-based classifier algorithms have potential to impact triage and clinical management of head-injured patients. [ABSTRACT FROM AUTHOR]

Objectives Computed tomography ( CT) is often used in the emergency department ( ED) evaluation of children with posttraumatic seizures ( PTS); however, the frequency of traumatic brain injuries ( TBIs) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED. Methods This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children < 18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions, and recurrent seizures within 1 week. Patients discharged from the ED were contacted by telephone 1 week to 3 months later. Results Of 42,424 children enrolled, 536 (1.3%, 95% confidence interval [ CI] = 1.2%-1.4%) had PTS. A total of 466 of 536 (86.9%, 95% CI = 83.8%-89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI = 12.3%-19.1%), of whom 20 (27.8%, 95% CI = 17.9%-39.6%) underwent neurosurgical intervention and 15 (20.8%, 95% CI = 12.2%-32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and five (1.1%, 95 CI = 0.4%-2.5%) had recurrent seizures; four of five presented with Glasgow Coma Scale scores < 15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p = 0.006) and longer duration of PTS (p < 0.001). Conclusions Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBIs on CT, however, are at low risk of short-term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT-negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED. [ABSTRACT FROM AUTHOR]

Large vessel ischemic stroke is a leading cause of morbidity and mortality throughout the world. Recent advances in endovascular stroke treatment are changing the treatment paradigm for these patients. This concepts article summarizes the time-dependent nature of stroke care and evaluates the recent advancements in endovascular treatment. These advancements have significant implications for out-of-hospital, hospital, and regional systems of stroke care. Emergency medicine clinicians have a central role in implementing these systems that will ensure timely treatment of patients and selection of those who may benefit from endovascular care. [ABSTRACT FROM AUTHOR]

Objective Missed diagnoses of acute ischemic stroke ( AIS) in the ED may result in lost opportunities to treat AIS. Our objectives were to describe the rate and clinical characteristics of missed AIS in the ED, to determine clinical predictors of missed AIS, and to report tissue plasminogen ( tPA) eligibility among those with missed strokes. Methods Among a population of 1.3 million in a five-county region of southwest Ohio and northern Kentucky, cases of AIS that presented to 16 EDs during 2010 were identified using ICD-9 codes followed by physician verification of cases. Missed ED diagnoses were physician-verified strokes that did not receive a diagnosis indicative of stroke in the ED. Bivariate analyses were used to compare clinical characteristics between patients with and without an ED diagnosis of AIS. Logistic regression was used to evaluate predictors of missed AIS diagnoses. Alternative diagnoses given to those with missed AIS were codified. Eligibility for tPA was reported between those with and without a missed stroke diagnosis. Results Of 2,027 AIS cases, 14.0% ( n = 283) were missed in the ED. Race, sex, and stroke subtypes were similar between those with missed AIS diagnoses and those identified in the ED. Hospital length of stay was longer in those with a missed diagnosis (5 days vs. 3 days, p < 0.0001). Younger age (adjusted odds ratio [ aOR] = 0.94, 95% confidence interval [ CI] = 0.89 to 0.98) and decreased level of consciousness ( LOC) ( aOR = 3.58, 95% CI = 2.63 to 4.87) were associated with higher odds of missed AIS. Altered mental status was the most common diagnosis among those with missed AIS. Only 1.1% of those with a missed stroke diagnosis were eligible for tPA. Conclusion In a large population-based sample of AIS cases, one in seven cases were not diagnosed as AIS in the ED, but the impact on acute treatment rates is likely small. Missed diagnosis was more common among those with decreased LOC, suggesting the need for improved diagnostic approaches in these patients. [ABSTRACT FROM AUTHOR]

Abstract: Many patients with transient ischemic attacks (TIA) are at high risk of stroke within the first few days of onset of symptoms. Emergency physicians and primary care physicians need to assess these patients quickly and initiate appropriate secondary stroke prevention strategies. Recent refinements in diagnostic imaging have produced valuable insight into risk stratification of patients with TIA. Clinical data regarding urgent initiation of antiplatelet therapy specifically in this patient population with non-cardioembolic TIA are limited but promising. This review outlines the diagnostic tools available for rapid assessment of patients presenting with symptoms of TIA and discusses clinical trials that apply to these vulnerable patients. [Copyright &y& Elsevier]

An executive summary of the 2011 guideline issued by organizations such as the American Heart Association (AHA), American Stroke Association (ASA), and the American College of Cardiology Foundation (ACCF) on the management of patients with extracranial carotid and vertebral artery disease (ECVD) is presented. It features sections that address the pathogenesis, epidemiology, diagnostic evaluation and management of patients with ECVD. It also covers the prevention of recurrent ischemic events.

The article offers information on the 2011 guidelines on the management of patients with vertebral artery and extracranial carotid disease. Duplex ultrasonography is accepted as an initial diagnostic test of patients with suspected or known carotid stenosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) is shown to determine carotid stenosis, while antihypertensive treatment is recommended for patients with hypertension and asymptomatic extracranial carotid.

Abstract: Stroke is a leading cause of death, disability, and dependence. Treatment of patients with acute stroke requires an integrated, systematic approach with thrombolysis, if indicated, and aggressive supportive care. Subacute treatment of patients with ischemic stroke should focus on the initiation of antithrombotic therapy and prevention of secondary stroke by risk factor modification. Treatment by emergency medicine physicians, who initiate thrombolysis and begin antiplatelet agents, and modification of preexisting risk factors are critical to patient outcome. Because few patients seen in the emergency department are eligible for thrombolysis because of the narrow timeframe for receiving treatment, most patients require antithrombotic therapy with aspirin, clopidogrel, or aspirin in combination with extended-release dipyridamole (ER-DP). Although aspirin, clopidogrel, and aspirin plus ER-DP effectively reduce the risk for recurrent stroke, according to treatment guidelines, clopidogrel alone (particularly in patients allergic to aspirin) and aspirin plus ER-DP are recommended over aspirin alone. Emergency medicine physicians should be aware of the available antiplatelet agents and the importance of antithrombotic therapy for prevention of secondary stroke. [Copyright &y& Elsevier]

This case series documents injury patterns related to beanbag and other less-lethal (LL) weapons during a period of civil unrest in a major U.S. city. A retrospective review of injuries related to LL weapons usage presenting to an urban Emergency Department (ED) from April 10, 2001 to April 18, 2001 was performed. Patients under 18 years of age and those without signed consent to treat were excluded. Twenty-seven patients were identified. Two were excluded due to lack of signed consent for treatment. Mean age was 28.4 ± 11.7 years; 76% of patients were male. Significant morbidity was found in 7 (28%) cases with no fatalities. Three (12%) individuals, with the diagnoses of pulmonary contusion, liver laceration, and Achilles tendon rupture, required admission. Two (8%) individuals had delayed complications of pneumonia and post-concussive syndrome. Reports of injury patterns associated with beanbag munitions in the medical literature are limited. Physicians should be aware of the injuries and delayed sequelae associated with their use. [Copyright &y& Elsevier]

A response by Peter D. Panagos to a letter to the editor about his article "Transient Ischemic Attack (TIA): The Initial Diagnostic and Therapeutic Dilemma" in the 2012 issue is presented.