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Updated: May 28, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Efficiency of Neurologist-Led Focused Cardiac Ultrasound in the Acute Stroke Pathway (S-FoCUS)
Eduardo Mariño1, Lara Pulido Fraiz1, Carlos Hervás-Testal1
1Department of Neurology , Stroke Center, La Paz University Hospital, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), 28046 Madrid, Spain.
Insights
Stroke-focused cardiac ultrasound (S-FoCUS) screening by neurologists significantly reduced hospital stay and transthoracic echocardiography (TTE) use in acute stroke patients. This efficient triage strategy optimizes cardiac evaluation and resource utilization in stroke care.
Area of Science:
- Neurology
- Cardiology
- Medical Ultrasound
- Health Services Research
Background:
- Comprehensive transthoracic echocardiography (TTE) is recommended for selected acute ischemic stroke patients but not cost-effective for all.
- Neurologist-led, stroke-focused cardiac ultrasound (S-FoCUS) is an emerging bedside screening tool for cardiac evaluation in acute stroke.
- S-FoCUS implementation may reduce hospital stay and TTE procedure utilization.
Purpose of the Study:
- To evaluate the impact of implementing a neurologist-led S-FoCUS screening protocol on resource utilization in acute stroke care.
- To compare time to first cardiac ultrasound assessment, length of stay, TTE procedures, and estimated in-hospital costs before and after S-FoCUS implementation.
Main Methods:
- Retrospective before-and-after cohort study of patients with suspected acute ischemic stroke or TIA.
- Comparison of two 6-month periods: pre-S-FoCUS (initial TTE) and post-S-FoCUS (initial S-FoCUS, TTE for abnormal findings or discretion).
- Analysis included time to first cardiac ultrasound, length of stay, TTE reduction, and estimated costs.
Main Results:
- S-FoCUS reduced median time to first cardiac ultrasound by 2 days (1 vs. 3 days) and median length of stay by 1 day (5 vs. 6 days).
- The protocol was associated with estimated lower in-hospital costs (€716 per patient), primarily due to shorter hospital stays.
- High agreement was observed between S-FoCUS and TTE findings for various cardiac conditions (e.g., mitral stenosis κ=0.78, LVEF κ=0.88).
Conclusions:
- Neurologist-led S-FoCUS is a feasible and effective triage strategy for acute stroke patients.
- Implementation of S-FoCUS improves efficiency in the acute stroke pathway by optimizing cardiac evaluation and reducing resource use.
- S-FoCUS demonstrates high agreement with TTE, supporting its role as a reliable initial screening tool.
Abstract:
Background/Objectives: Although comprehensive transthoracic echocardiography (TTE) is part of the diagnostic workup in acute ischemic stroke, it is not cost-effective to use it for all patients. Guidelines recommend using it only for selected patients to guide secondary prevention. Neurologist-led, stroke-focused cardiac ultrasound (S-FoCUS) is an emerging bedside screening tool that optimizes cardiac evaluation in acute stroke care. We hypothesize that the implementation of S-FoCUS screening may reduce resource utilization in terms of hospital stay and TTE procedures. Methods: We conducted a retrospective before-and-after cohort study of patients with suspected acute ischemic stroke or TIA admitted to our comprehensive stroke center. We compared two 6-month periods: the pre-S-FoCUS period, during which patients underwent TTE as the initial cardiac imaging modality; and the post-S-FoCUS period, during which patients initially underwent S-FoCUS, with subsequent TTE performed only in the presence of abnormal findings or at the clinician's discretion. We compared the time from admission to first cardiac ultrasound assessment, length of stay, relative reduction in TTE procedures and estimated in-hospital costs. Results: The pre-S-FoCUS period included 224 patients, and the post-S-FoCUS period included 229 patients. The S-FoCUS protocol reduced the median time to first cardiac ultrasound assessment by two days (median [IQR] 3 [2-5] vs. 1 [1-2], p < 0.001) and the median length of stay by one day (6 [4-9] vs. 5 [3-10], p = 0.014). Implementing the S-FoCUS protocol was associated with an exploratory estimate of lower in-hospital costs (approximately €716 per screened patient) driven mainly by a shorter length of stay. The distribution of the frequency of predefined cardioembolic sources was similar between both periods. There was a high agreement rate between the S-FoCUS and TTE findings in patients who underwent both tests: mitral stenosis (κ = 0.78), left atrial severe enlargement (κ = 0.74), left ventricular hypokinesia/akinesia (κ = 0.84), and depressed LVEF (κ = 0.88). Conclusions: Neurologist-led S-FoCUS is a feasible triage strategy to improve efficiency in the acute stroke pathway.
