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MIST: A novel stroke service delivery mode

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Dr A.V. Srinivasan Emeritus Prof., The Tamil Nadu Dr. M.G.R. Medical University    12 August 2021

A pilot program “MIST” has shown that stroke patients are much less likely to have disability if a specialized mobile interventional stroke team travelled to the patient to perform emergency stroke surgery compared to patients who were transferred to a stroke center.

Stroke specialists at Mount Sinai Health System in New York City developed a model called mobile interventional stroke team (MIST) to bring endovascular thrombectomy to the patient. The interventional team comprising of a neuro-interventionalist, a fellow in training or a physician assistant and a radiologic technologist travelled to the patient to perform endovascular thrombectomy.

Researchers analysed the NYC MIST Trial data and a prospectively collected stroke database for patients who received endovascular thrombectomy between January 2017 and February 2020 at four hospitals within the Mount Sinai Health System (one certified comprehensive stroke center and three thrombectomy-capable stroke centers). Of these, 106 were managed by the MIST team, while the remaining 120 patients had to be shifted to specialized stroke centers (drip-and-ship (DS) model) equipped to perform endovascular thrombectomy. The DS model requires a transfer to a comprehensive stroke center from a primary stroke center (or other referring center), following potential intravenous thrombolysis

Outcomes of patients who were seen within 6 hours of stroke-symptom onset (early therapeutic window) and after 6 hours of stroke symptoms (late window) were analysed. The modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale were used to assess their 90-day functional outcomes.

Analysis of data showed that patients managed within 6 hours of stroke by the MIST team were more functionally independent i.e. they were more mobile and could perform daily tasks three months after the acute event compared to those patients who were shifted to a stroke center and therefore lost valuable time in the process; 54% vs 28%, respectively. On a similar note, among patients treated during the early window, functional outcomes at discharge were significantly better among the MIST patients than the transferred patients. However, the outcomes were comparable in patients treated outside of 6 hours i.e. in the late window period; 35% in MIST vs 41% in transferred patients.

Most acute emergencies need to be managed well in time to have favorable outcomes for the patient. Any delay in treatment can be potentially life-threatening.

The concept of golden hour first came up in context to trauma victims. It was coined in 1975 by R Adams Cowley, founder of Shock Trauma Institute in Baltimore, who said that “the first hour after injury will largely determine a critically injured person’s chances for survival”. Prompt resuscitative care during the first hour after trauma can reduce the chances of death.

This concept also applies to other medical emergencies.

Door-to-Doctor Time has been defined for stroke patients. Endovascular thrombectomy is a time-sensitive intervention and shorter door-to-skin puncture interval improves long-term outcomes.

The 2018 American Heart Association/American Stroke Association (AHA/ASA) stroke early management guidelines recommend a goal “door-to-CT scan” time of within 20 minutes of arrival in ≥50% of stroke patients who may be candidates for IV tPA or mechanical thrombectomy and a “door-to-needle” times of <60 minutes in ≥50% of stroke patients treated with IV tPA.

Treatment within the Golden hour leads to improved patient outcomes. This study again highlights that “time is brain.”

MIST Is time efficient and has improved clinical outcome compared to DS (Drip and Ship)and other Models

(Source: AHA news release, Aug. 5, 2021; Stroke. 2021 Aug 5, doi: 10.1161/STROKEAHA.121.034222)

Dr A.V. Srinivasan

Emeritus Prof., The Tamil Nadu Dr. M.G.R. Medical University; Former President, Indian Academy Of Neurology

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