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Research Article| Volume 32, ISSUE 3, 106975, March 2023

Using the ICH score during acute telestroke consults to triage transfer to tertiary centers

Published:January 04, 2023DOI:https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106975
Using the ICH score during acute telestroke consults to triage transfer to tertiary centers
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      Abstract

      Objective

      Constrained resources at tertiary centers indicate a need for re-exploration of the practice of routinely transferring all community hospital patients with complex conditions such as hemorrhagic stroke (ICH). We addressed the clinical question of whether information available during acute care telestroke consults could identify ICH patients not requiring specialty services or neurosurgical intervention who could safely remain at the local center for care.

      Design

      Retrospective cohort analysis abstracting clinical factors to identify ICH patients associated with need for tertiary care or neurosurgical intervention.

      Setting

      The Duke Telestroke Network (DTN) in Central NC and Southern Virginia.

      Patients

      All DTN transferred ICH patients January 1, 2017 to December 31, 2018.

      Interventions

      We defined neurosurgical intervention as craniotomy, digital subtraction angiography, or external ventricular drain placement.

      Measurements and results

      We identified 116 transferred ICH patients. Sixty-two were female, the median Glasgow coma score (GCS) was 13, and the median ICU and hospital length of stay were 2 and 7 days respectively. Thirty of the patients were offered and 27 ultimately received neurosurgical intervention. Using inclusion/exclusion criteria from two ICH surgical trials would have increased the intervention group to 35 patients (30%). Components of the ICH score differentiated surgical from non-surgical patients; patients with an ICH score of <2 and GCS ≥13 received no interventions. Nearly 50% of patients could receive medical management locally.

      Conclusions

      Coupling the ICH score and GCS can provide triage guidance identifying patients for retention at the referring center. This retained population is distinct from patients eligible for current or novel surgical interventions. This approach provides a framework for assessment of transfers across specialty areas and furthers the value of telehealth networks.

      Keywords

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      References

        • Institute Of M.
        IOM report: the future of emergency care in the United States health system.
        Acad Emerg Med. 2006; 13: 1081-1085
        View in Article
        • Byrne R.W.
        • Bagan B.T.
        • Slavin K.V.
        • et al.
        Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study.
        Neurosurgery. 2008; 62 (discussion 709-16): 709-716
        View in Article
        • Hemphill 3rd, J.C.
        • Greenberg S.M.
        • Anderson C.S.
        • et al.
        Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association.
        Stroke,. 2015; 46: 2032-2060
        View in Article
        • Holland C.M.
        • McClure E.W.
        • Howard B.M.
        • et al.
        Interhospital transfer of neurosurgical patients to a high-volume tertiary care center: opportunities for improvement.
        Neurosurgery. 2015; 77 (discussion 206-7): 200-206
        View in Article
        • Man S.
        • Zhao X.
        • Uchino K.
        • et al.
        Comparison of acute ischemic stroke care and outcomes between comprehensive stroke centers and primary stroke centers in the United States.
        Circ Cardiovasc Qual Outcomes. 2018; 11e004512
        View in Article
        • Sheth K.N.
        • Smith E.E.
        • Grau-Sepulveda M.V.
        • et al.
        Drip and ship thrombolytic therapy for acute ischemic stroke: use, temporal trends, and outcomes.
        Stroke. 2015; 46: 732-739
        View in Article
        • Kolls B.J.
        • Mace B.E.
        • Dombrowski K.E.
        Implementation of continuous video-electroencephalography at a community hospital enhances care and reduces costs.
        Neurocrit Care. 2018; 28: 229-238
        View in Article
        • Reinhardt U.E.
        The pricing of U.S. hospital services: chaos behind a veil of secrecy.
        Health Aff (Millwood). 2006; 25: 57-69
        View in Article
        • Chen S.
        • Zeng L.
        • Hu Z.
        Progressing haemorrhagic stroke: categories, causes, mechanisms and managements.
        J Neurol. 2014; 261: 2061-2078
        View in Article
        • Virani S.S.
        • Alonso A.
        • Benjamin E.J.
        • et al.
        Heart disease and stroke statistics-2020 update: a report from the American heart association.
        Circulation. 2020; 141: e139-e596
        View in Article
        • Mendelow A.D.
        • Gregson B.A.
        • Rowan E.N.
        • et al.
        Early surgery versus initial conservative treatment in patients with traumatic intracerebral hemorrhage (STITCH[Trauma]): the first randomized trial.
        J Neurotrauma. 2015; 32: 1312-1323
        View in Article
        • Mendelow A.D.
        • Gregson B.A.
        • Rowan E.N.
        • et al.
        Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial.
        Lancet. 2013; 382: 397-408
        View in Article
        • de Havenon A.
        • Joyce E.
        • Yaghi S.
        • et al.
        End-of-treatment intracerebral and ventricular hemorrhage volume predicts outcome: a secondary analysis of MISTIE III.
        Stroke. 2020; 51: 652-654
        View in Article
        • Fiorella D.
        • Arthur A.
        • Bain M.
        • et al.
        Minimally invasive surgery for intracerebral and intraventricular hemorrhage: rationale, review of existing data and emerging technologies.
        Stroke. 2016; 47: 1399-1406
        View in Article
        • Hanley D.F.
        • Thompson R.E.
        • Muschelli J.
        • et al.
        Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial.
        Lancet Neurol. 2016; 15: 1228-1237
        View in Article
        • Hanley D.F.
        • Thompson R.E.
        • Rosenblum M.
        • et al.
        Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial.
        Lancet. 2019; 393: 1021-1032
        View in Article
        • Phillips V.L.
        • Roy A.K.
        • Ratcliff J.
        • et al.
        Minimally invasive parafascicular surgery (MIPS) for spontaneous intracerebral hemorrhage compared to medical management: a case series comparison for a single institution.
        Stroke Res Treat. 2020; 20206503038
        View in Article

      18. ENRICH: Early MiNimally-invasive Removal of IntraCerebral Hemorrhage (ICH) (ENRICH). 2016 [cited 2021 August 20, 2021]; The ENRICH trial will compare the outcomes between early surgical intervention using the BrainPath® Approach (i.e., MIPS) and a medically managed cohort. The integrated surgical approach includes a combination of available technologies, including the FDA-cleared NICO BrainPath® for non-disruptive access and NICO Myriad® to achieve the goal of maximum clot evacuation. The medically managed cohort will be treated according the Clinical Standardization Guidelines (CSG) as adapted by Emory University from the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Clinical efficacy will be determined by demonstrating a 10% improvement in functional outcome, as determined by a blinded-assessment of the 180-day utility-weighted modified Rankin Scale (mRS). Data suggests improved mortality rates and potential functional benefits of surgical ICH evacuation. The methodology proposed for this trial was tested in a preliminary series of 39 patients treated for supratentorial spontaneous ICH and retrospectively reviewed (Labib et al.). These results were replicated in a single center retrospective series of 18 patients (Bauer et al.). Despite positive results of both studies and the widely accepted benefit of the BrainPath Approach (i.e., MIPS) for subcortical lesions, stronger evidence supporting the use of these techniques in ICH is needed for the technique to become universally validated.]. Available from: https://clinicaltrials.gov/ct2/show/record/NCT02880878

        View in Article

      19. INVEST Feasibility - Minimally Invasive Endoscopic Surgery With Apollo in Patients With Brain Hemorrhage. 2016 [cited 2021 August 20, 2021]; Objective: The primary objective of this multicenter single arm feasibility study is to provide an assessment of enrollment and follow up feasibility for this patient population being treated with the Apollo or Artemis Minimally Invasive Surgical Treatment (MIES). Patients who do not qualify for the INVEST Feasibility Study will be referred to the INVEST Registry study. Study Design: This study will be a prospective, multi-centered trial that will enroll 50 patients at up to 10 United States (US) centers. Patient Population: Patients with moderate-large volume (20-80 cc) supratentorial intracerebral hemorrhage (ICH) who present within 24 hours of symptom onset. Enrolled patients will receive minimally invasive endoscopic evacuation with the Apollo system or Artemis Device. Indication: The Artemis Neuro Evacuation Device is used for the controlled aspiration of tissue and/or fluid during surgery of the Ventricular System or Cerebrum in conjunction with a Penumbra Aspiration Pump. The Penumbra Aspiration Pump is indicated as a vacuum source for the Penumbra Aspiration Systems. The Apollo system has been cleared for the controlled aspiration of soft tissue and/or fluid during endoscopically guided neurosurgery of the ventricular system or cerebrum. In the present study, the researchers propose to investigate the feasibility of studying this patient population for eventual implementation of efficacy trials.]. Available from: https://clinicaltrials.gov/ct2/show/record/NCT02654015

        View in Article

      20. MIND: Artemis in the Removal of Intracerebral Hemorrhage. 2017 [cited 2021; Subjects will be randomized to either minimally invasive hematoma evacuation with the Artemis Neuro Evacuation Device with medical management (MIS group) or best medical management alone (2:1) (MM).]. Available from: https://clinicaltrials.gov/ct2/show/record/NCT03342664

        View in Article
        • Catalano A.R.
        • Winn H.R.
        • Gordon E.
        • et al.
        Impact of interhospital transfer on complications and outcome after intracranial hemorrhage.
        Neurocrit Care. 2012; 17: 324-333
        View in Article
        • Finn E.B.
        • Campbell Britton M.J.
        • Rosenberg A.P.
        • et al.
        A qualitative study of risks related to interhospital transfer of patients with nontraumatic intracranial hemorrhage.
        J Stroke Cerebrovasc Dis. 2019; 28: 1759-1766
        View in Article
        • Vahidy F.S.
        • Meyer E.G.
        • Bambhroliya A.B.
        • et al.
        Rationale and design of a statewide cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH).
        BMC Neurol. 2018; 18: 31
        View in Article
        • Hemphill 3rd, J.C.
        • Bonovich D.C.
        • Besmertis L.
        • et al.
        The ICH score: a simple, reliable grading scale for intracerebral hemorrhage.
        Stroke. 2001; 32: 891-897
        View in Article
        • Clarke J.L.
        • Johnston S.C.
        • Farrant M.
        • et al.
        External validation of the ICH score.
        Neurocrit Care. 2004; 1: 53-60
        View in Article
        • Hemphill 3rd, J.C.
        • Farrant M.
        • Neill Jr., T.A.
        Prospective validation of the ICH Score for 12-month functional outcome.
        Neurology. 2009; 73: 1088-1094
        View in Article
        • Klaas J.P.
        • Braksick S.
        • Mandrekar J.
        • et al.
        Factors associated with the need for intensive care unit admission following supratentorial intracerebral hemorrhage: the triage ICH model.
        Neurocrit Care. 2017; 27: 75-81
        View in Article
        • Zachrison K.S.
        • Aaronson E.
        • Mahmood S.
        • et al.
        Resource utilisation among patients transferred for intracerebral haemorrhage.
        Stroke Vasc Neurol. 2019; 4: 223-226
        View in Article
        • Kilbourn K.J.
        • Levy S.
        • Staff I.
        • et al.
        Clinical characteristics and outcomes of neurogenic stress cadiomyopathy in aneurysmal subarachnoid hemorrhage.
        Clin Neurol Neurosurg. 2013; 115: 909-914
        View in Article
        • Nguyen C.
        • Mir O.
        • Vahidy F.
        • et al.
        Resource utilization for patients with intracerebral hemorrhage transferred to a comprehensive stroke center.
        J Stroke Cerebrovas Dis. 2015; 24: 2866-2874
        View in Article
        • Vahidy F.
        • Albright K.
        • Donnelly J.P.
        • et al.
        National trends in transfer of patients with intracerebral hemorrhage to teaching hospitals.
        Stroke. 2016; : 47
        View in Article

      Article info

      Publication history

      Published online: January 04, 2023
      Accepted: December 29, 2022
      Received in revised form: December 15, 2022
      Received: October 17, 2022

      Identification

      DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106975

      Copyright

      © 2023 Elsevier Inc. All rights reserved.

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