Treating patients with suspected stroke in a mobile stroke unit (MSU) instead of a hospital can substantially reduce the time to treatment decision and thrombolysis, researchers reported in the April 11 online Lancet Neurology.
The median time between emergency call and treatment decision, the researchers’ primary outcome, was 35 minutes for patients received in an MSU, compared with 76 minutes for patients received at the hospital. The median time from symptom onset to thrombolysis was 72 minutes for patients received in an MSU, compared with 153 minutes for patients thrombolyzed at the hospital.
To assess the efficacy of diagnosing and treating patients with suspected stroke at the emergency site, Silke Walter, MD, a scientist at the Neurology Clinic of the University Hospital of the Saarland in Homburg, Germany, and colleagues studied patients between ages 18 and 80 who had one or more stroke symptoms that had begun within the previous 2.5 hours. A total of 53 patients were randomly assigned to prehospital stroke treatment in an MSU. The control group consisted of 47 patients who were treated at a hospital. Patients’ mean age was about 71, and 63% of patients were male. Patients were followed up for seven days.
The two groups’ neurologic outcome indicators (eg, NIH Stroke Scale score and Barthel index) did not differ significantly at day 1 or at day 7. The authors noted, however, that their study lacked power for this and other secondary end points. Nevertheless, stroke management in an MSU “substantially breaks, to our knowledge, all reported times for stroke management,” said Dr. Walter.
The researchers’ main finding is “probably valid,” but their method could have biased the secondary clinical outcomes, wrote Peter M. Rothwell, MD, Professor of Clinical Neurology at Oxford University in the United Kingdom, and Alastair M. Buchan, head of the Medical Sciences Division at John Radcliffe Hospital in Oxford, United Kingdom, in an accompanying editorial. Allocating intervention in the MSU on the basis of a time period, as the researchers did, “would not achieve the main purpose of randomization, allocation concealment,” observed Dr. Rothwell.
The reduction in the delay before treatment did not result in the expected lower death rate among treated patients, noted Drs. Rothwell and Buchan. “Although these numbers are too small to allow reliable interpretation, they highlight the need for larger trials with sufficient power to establish the effect of the MSU intervention on clinical outcome,” they added.
Prognostic Models May Predict Treatment Failure and Seizure Remission in Patients With Epilepsy
New prognostic models could predict the time to treatment failure and the time to 12 months of remission for patients with epilepsy, according to research published in the April issue of Lancet Neurology.
Treatment history, age, total number of seizures before randomization, and treatment were significant variables in the model for treatment failure because of inadequate seizure control. Sex, treatment history, age, seizure type, and treatment were predictors of treatment failure because of unacceptable adverse events. Factors significantly associated with time to 12 months of remission were sex, treatment history, age, time from first seizure to randomization, neurologic insult, total number of seizures before randomization, CT or MRI scan results, and treatment.
Laura Bonnett, a biostatistics research assistant at the University of Liverpool in the United Kingdom, and her colleagues used regression multivariable modeling to perform a post hoc analysis of data from patients with epilepsy in Arm A of the Standard and New Antiepileptic Drug (SANAD) trial. In this prospective trial, a heterogeneous group of 1,721 patients for whom physicians considered carbamazepine to be the first-line treatment were randomly assigned treatment with carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate.
Approximately 89% of patients had focal epilepsy. A total of 1,608 patients were included in the analysis of time to treatment failure, and 1,588 were included in the analysis of time to 12 months of remission. All patients had had at least two clinically definite unprovoked epileptic seizures in the year before enrollment.
“The SANAD study is the largest randomized controlled trial in epilepsy and includes data for long-term treatment outcomes, which is essential to inform the management of this chronic condition,” observed Ms. Bonnett. The researchers’ models could “inform patient counseling and treatment decisions,” she added. “If validated, our results might improve predictions of outcome for patients and enable identification of patients more likely to have a poor treatment outcome who might need to be followed up more regularly. The models might also help identify patients “who might be eligible to participate in trials of new treatments,” concluded Ms. Bonnett.
Bonnett L, Smith CT, Smith D, et al. Prognostic factors for time to treatment failure and time to 12 months of remission for patients with focal epilepsy: post-hoc, subgroup analyses of data from the SANAD trial. Lancet Neurol. 2012;11(4):331-340.