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Kleinig TJ, McMullan P, Cloud GC, Bladin PC, Ranta A. Hyper-Acute Stroke Systems of Care and Workflow. Curr Neurol Neurosci Rep 2024; 24:495-505. [PMID: 39150649 DOI: 10.1007/s11910-024-01367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Recent stroke treatment advances have necessitated agile, broad-scale healthcare system redesign, to achieve optimal patient outcomes and access equity. Optimised hyperacute stroke care requires integrated pre-hospital, emergency department, stroke specialist, radiology, neurosurgical and endovascular neurointervention services, guided by a population-wide needs analysis. In this review, we survey system integration efforts, providing case studies, and identify common elements of successful initiatives. RECENT FINDINGS Different regions and nations have evolved varied acute stroke systems depending on geography, population density and workforce. However, common facilitators to these solutions have included stroke unit care as a foundation, government-clinician synergy, pre-hospital pathway coordination, service centralisation, and stroke data guiding system improvement. Further technological advantages will minimize the geographical distance disadvantages and facilitate virtual expertise redistribution to remote areas. Continued treatment advances necessitate an integrated, adaptable, population-wide trans-disciplinary approach. A well-designed clinician-led and government-supported system can facilitate hyperacute care and scaffold future system enhancements.
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Affiliation(s)
- Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia, 5000, Australia.
| | - Patrick McMullan
- Department of Neurology, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia, 5000, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Anna Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
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Man S, Bruckman D, Uchino K, Chen BY, Dalton JE, Fonarow GC. Rural Hospital Performance in Guideline-Recommended Ischemic Stroke Thrombolysis, Secondary Prevention, and Outcomes. Stroke 2024; 55:2472-2481. [PMID: 39234759 DOI: 10.1161/strokeaha.124.047071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Existing data suggested a rural-urban disparity in thrombolytic utilization for ischemic stroke. Here, we examined the use of guideline-recommended stroke care and outcomes in rural hospitals to identify targets for improvement. METHODS This retrospective cohort study included patients (aged ≥18 years) treated for acute ischemic stroke at Get With The Guidelines-Stroke hospitals from 2017 to 2019. Multivariable mixed-effect logistic regression was used to compare thrombolysis rates, speed of treatment, secondary stroke prevention metrics, and outcomes after adjusting for patient- and hospital-level characteristics and stroke severity. RESULTS Among the 1 127 607 patients admitted to Get With The Guidelines-Stroke hospitals in 2017 to 2019, 692 839 patients met the inclusion criteria. Patients who presented within 4.5 hours were less likely to receive thrombolysis in rural stroke centers compared with urban stroke centers (31.7% versus 43.5%; adjusted odds ratio [aOR], 0.72 [95% CI, 0.68-0.76]) but exceeded rural nonstroke centers (22.1%; aOR, 1.26 [95% CI, 1.15-1.37]). Rural stroke centers were less likely than urban stroke centers to achieve door-to-needle times of ≤45 minutes (33% versus 44.7%; aOR, 0.86 [95% CI, 0.76-0.96]) but more likely than rural nonstroke centers (aOR, 1.24 [95% CI, 1.04-1.49]). For secondary stroke prevention metrics, rural stroke centers were comparable to urban stroke centers but exceeded rural nonstroke centers (aOR of 1.66, 1.94, 2.44, 1.5, and 1.72, for antithrombotics within 48 hours of admission, antithrombotics at discharge, anticoagulation for atrial fibrillation/flutter, statin treatment, and smoking cessation, respectively). In-hospital mortality was similar between rural and urban stroke centers (aOR, 1.11 [95% CI, 0.99-1.24]) or nonstroke centers (aOR, 1.00 [95% CI, 0.84-1.18]). CONCLUSIONS Rural hospitals had lower thrombolysis utilization and slower treatment times than urban hospitals. Rural stroke centers provided comparable secondary stroke prevention treatment to urban stroke centers and exceeded rural nonstroke centers. These results reveal important opportunities and specific targets for rural health equity interventions.
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Affiliation(s)
- Shumei Man
- Department of Neurology, Neurological Institute (S.M.), Cleveland Clinic, OH
| | - David Bruckman
- Center for Populations Health Research, Department of Quantitative Health Sciences (D.B., J.E.D.), Cleveland Clinic, OH
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute (K.U., B.Y.C.), Cleveland Clinic, OH
| | - Bing Yu Chen
- Cerebrovascular Center, Neurological Institute (K.U., B.Y.C.), Cleveland Clinic, OH
| | - Jarrod E Dalton
- Center for Populations Health Research, Department of Quantitative Health Sciences (D.B., J.E.D.), Cleveland Clinic, OH
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles (G.C.F.)
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Chen CLH, Chai JH, Pokharkar YM, Venketasubramanian N. Cost-effectiveness of MLC601 in post-stroke functional recovery compared with placebo - the CHIMES & CHIMES-E studies. BMC Health Serv Res 2024; 24:1127. [PMID: 39334395 PMCID: PMC11430337 DOI: 10.1186/s12913-024-11618-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 09/19/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Despite progress in stroke therapy (e.g., revascularisation interventions by thrombolysis and/or thrombectomy, organised stroke care), many stroke survivors will have impairment of neurological function. We aimed to compare the cost-effectiveness of an oral natural formulation, MLC601, versus placebo in functional recovery among subjects receiving standard of care after an ischemic stroke of intermediate severity assessed with NIH Stroke Scale at baseline (b-NIHSS 8-14). METHODS A Markov cohort model with a 2-year time horizon was developed to simulate patients from a published randomised placebo-controlled clinical trial of MLC601 in their post-stroke functional recovery assessed by modified Rankin Score (mRS), from a health system perspective. Transition probabilities were derived from a multi-centre clinical trial in South East Asia. As cost and utility data were not collected in the trial, therefore we extracted them from the published literature. The main outcomes were incremental cost, incremental quality-adjusted life-year (QALY) gained, and incremental cost-effectiveness ratio (ICER). Besides base-case and sensitivity analyses, we performed subgroup analyses to explore the heterogeneity of patients with poor-prognosis factors (b-NIHSS 10-14, stroke onset to treatment time > 48 h, rehabilitation during first 3 month). All costs are expressed in 2022 Euro and USD, with an annual discount rate of 3% applied to costs and QALYs. RESULTS Base-case analysis showed that MLC601 was cost-effective compared with placebo, with €5,080 saved and 0.45 QALY gained, resulting in an ICER of -€11,352.50 per QALY gained. Similarly, results from subgroup analyses indicated that the use of MLC601 was a dominant strategy in all subgroups with poor-prognosis factors. Sensitivity analyses revealed the results were robust. CONCLUSION Compared with placebo on top of standard stroke care, MLC601 was cost-effective in post-stroke functional recovery over two years. Due to the lack of cost and utility data from the study population, the results might not be generalizable to other settings. Further studies with country-specific data are needed to confirm the results of this study. TRIAL REGISTRATION URL http://www. CLINICALTRIALS gov . Unique identifier NCT00554723 November 7, 2007.
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Affiliation(s)
- Christopher Li Hsian Chen
- Memory Aging and Cognition Centre, Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Blk MD3, 16 Medical Drive, #04-01, Singapore, 117600, Singapore.
| | - Jia Hui Chai
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation Singapore, 23 Rochester Park, Singapore, 139234, Singapore
| | - Yogesh Mahadev Pokharkar
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation Singapore, 23 Rochester Park, Singapore, 139234, Singapore
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Harbison J, McCormack J, Brych O, Collins R, Cassidy T. Hospital overcrowding and care of stroke patients: Irish national audit of stroke. BMC Health Serv Res 2024; 24:1075. [PMID: 39285299 PMCID: PMC11403833 DOI: 10.1186/s12913-024-11566-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/10/2024] [Indexed: 09/20/2024] Open
Abstract
INTRODUCTION Hospital overcrowding where patient admissions exceed capacity is associated with worse outcomes in Emergency Department. Developments in emergency stroke care have been associated with improvements in stroke outcome but are dependent on effective, organised care. We examined if overcrowding in the hospital system was associated with negative changes in stroke outcome. METHODS Data on overcrowding were obtained from the Irish Nurses and Midwives Organisation (INMO) 'Trolley Count' database recording the number of patients cared for on trolleys/chairs in all acute hospitals each midnight. These were compared with quarterly data from the Irish National Audit of Stroke from 2013 to 2021 inclusive. Variables analysed were inpatient mortality rate, thrombolysis rate for ischaemic stroke, median door to needle time and median length of stay. RESULTS 579449 patient episodes were recorded by Trolley Watch over the period, (Quarterly Median 16719.5, range 3389-27015). Average Quarterly Thrombolysis rate was 11.3% (sd 1.3%) Median Quarterly Inpatient Mortality rate was 11.8% (Range 8.9-14.0%). Median Quarterly Length of stay was 9 days (8-11 days). Median quarterly door to needle was 65 min (45-80 min). Q1 was typically the worst for overcrowding with on average 19777 incidences (sd 4786). This was significantly higher than for Q2 (mean 13540 (sd 4785) p = 0.005 t-test) and for Q3 (mean 14542 (sd 4753) p = 0.03). No significant correlation was found between quarterly Trolley watch episodes and inpatient mortality (r = 0.084, p = 0.63), median length of stay r=-0.15, p = 0.37) or thrombolysis rate (r = 0.089 p = 0.61). There was an unexpected significant negative correlation between trolley watch data and median door to needle time (r=-0.36, p = 0.03). CONCLUSION Despite increasing hospital overcrowding, stroke services still managed to preserve standard of care. We could find no association between levels of overcrowding and deterioration in selected indices of patient care.
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Affiliation(s)
- Joseph Harbison
- Irish National Audit of Stroke, National Office of Clinical Audit, St Stephen's Green, Dublin 2, Ireland.
- Dept of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland.
| | - Joan McCormack
- Irish National Audit of Stroke, National Office of Clinical Audit, St Stephen's Green, Dublin 2, Ireland
| | - Olga Brych
- Irish National Audit of Stroke, National Office of Clinical Audit, St Stephen's Green, Dublin 2, Ireland
| | - Ronan Collins
- Irish National Audit of Stroke, National Office of Clinical Audit, St Stephen's Green, Dublin 2, Ireland
- Dept of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Tim Cassidy
- Irish National Audit of Stroke, National Office of Clinical Audit, St Stephen's Green, Dublin 2, Ireland
- Acute Stroke Service, St Vincent's Hospital, Elm Park, Dublin 4, Ireland
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Popa DI, Buleu F, Williams C, Tudor A, Sutoi D, Trebuian CI, Ioan CC, Forțofoiu D, Badalica-Petrescu M, Petre I, Iancu A, Mederle OA. Evaluating Thrombolysis Rates and Emergency Department Time Targets in Acute Ischemic Stroke: Need for Personalized Medicine. J Pers Med 2024; 14:955. [PMID: 39338208 PMCID: PMC11433347 DOI: 10.3390/jpm14090955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 08/27/2024] [Accepted: 09/07/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In the era of personalized medicine, standard protocols regarding the management of acute ischemic stroke (AIS) focus on time targets alone without tailoring the protocol to the specific patient and hospital characteristics to increase IV thrombolysis rates and improve outcomes for these patients by considering organizational differences and patient-related factors that influence adherence to target times at the emergency department level. With this in mind, we evaluate the effect of achieving ED time targets from standard protocol and patient-related risk factors on the intravenous (IV) thrombolysis rate in patients with AIS in the therapeutic window. MATERIALS AND METHODS For our research, we enrolled people who arrived at the ED with signs of recent AIS with an onset of less than 4.5 h. Initially, 355 patients were included in the study, but through careful screening, only 258 were considered eligible to participate. Of the final group of 258 patients, only 46 received intravenous thrombolysis treatment. RESULTS In our study, when we are analyzing ED times in patients admitted with stroke symptoms in the therapeutic window, we found statistically significantly decreased ED times for patients that performed IV thrombolysis compared to patients not performing as follows: a median of 100 min in onset-to-ED door time (p < 0.001), a door-to-physician time (ED doctor) of 4 min (p = 0.009), door-to-blood-samples of 5 min (p = 0.026), a door-to-CT time of 15.5 min (p = 0.009), and door-to-CT results of 37 min (p < 0.001). In addition, patients who received intravenous thrombolysis were found to be significantly older (p < 0.001), with lower height and weight (p < 0.001 for both) and lower Glasgow Coma Scale (GCS) scores (9 ± 4.94 vs. 13.85 ± 2.41, p < 0.001). The logistic regression analysis indicated that the onset-to-ED time (p < 0.001) and the door-to-physician time (p = 0.014) for emergency medicine physicians are significant predictors of the likelihood of administering thrombolysis. By analyzing the impact of comorbidities, we observed that dyslipidemia, chronic arterial hypertension, and diabetes mellitus are significant predictive factors for performing IV thrombolysis (the presence of dyslipidemia and diabetes mellitus are predictive factors for performing IV thrombolysis, while the presence of arterial hypertension is not). CONCLUSIONS The ED time targets that significantly influenced IV thrombolysis in our study were the onset-to-ED door time and the time it takes for the ED doctor to assess the AIS patient (door-to-physician time). The IV thrombolysis rate for these patients was 17.83%, lower than expected despite achieving most ED time targets, with the presence of chronic arterial hypertension as a significant predictive patient-related factor for not performing it. Even though our reported hospital's thrombolysis rate is favorable compared to international reports, there is always room for improvement. Based on our study results, it is necessary that new protocols to customized standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right. Based on our study results, it is necessary that new protocols customize standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right.
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Affiliation(s)
- Daian Ionel Popa
- Doctoral School, Faculty of General Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Department of Surgery, Emergency Discipline, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Florina Buleu
- Department of Cardiology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Carmen Williams
- Emergency Municipal Clinical Hospital, 300254 Timisoara, Romania
| | - Anca Tudor
- Department of Functional Sciences, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Dumitru Sutoi
- Doctoral School, Faculty of General Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Department of Surgery, Emergency Discipline, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Cosmin Iosif Trebuian
- Doctoral School, Faculty of General Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Department of Surgery, Emergency Discipline, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | | | - Dragoș Forțofoiu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Marius Badalica-Petrescu
- Department of Cardiology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ion Petre
- Department of Functional Sciences, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Aida Iancu
- Department of Radiology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ovidiu Alexandru Mederle
- Department of Surgery, Emergency Discipline, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Emergency Municipal Clinical Hospital, 300254 Timisoara, Romania
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Lens C, Demeestere J, Casolla B, Christensen H, Fischer U, Kelly P, Molina C, Sacco S, Sandset EC, Strbian D, Thomalla G, Tsivgoulis G, Vanhaecht K, Weltens C, Coeckelberghs E, Lemmens R. From guidelines to clinical practice in care for ischaemic stroke patients: A systematic review and expert opinion. Eur J Neurol 2024:e16417. [PMID: 39236303 DOI: 10.1111/ene.16417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/25/2024] [Accepted: 07/07/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND AND PURPOSE Guidelines help physicians to provide optimal care for stroke patients, but implementation is challenging due to the quantity of recommendations. Therefore a practical overview related to applicability of recommendations can be of assistance. METHODS A systematic review was performed on ischaemic stroke guidelines published in scientific journals, covering the whole acute care process for patients with ischaemic stroke. After data extraction, experts rated the recommendations on dimensions of applicability, that is, actionability, feasibility and validity, on a 9-point Likert scale. Agreement was defined as a score of ≥8 by ≥80% of the experts. RESULTS Eighteen articles were identified and 48 recommendations were ultimately extracted. Papers were included only if they described the whole acute care process for patients with ischaemic stroke. Data extraction and analysis revealed variation in terms of both content and comprehensiveness of this description. Experts reached agreement on 34 of 48 (70.8%) recommendations in the dimension actionability, for 16 (33.3%) in feasibility and for 15 (31.3%) in validity. Agreement on all three dimensions was reached for seven (14.6%) recommendations: use of a stroke unit, exclusion of intracerebral haemorrhage as differential diagnosis, administration of intravenous thrombolysis, performance of electrocardiography/cardiac evaluation, non-invasive vascular examination, deep venous thrombosis prophylaxis and administration of statins if needed. DISCUSSION AND CONCLUSION Substantial variation in agreement was revealed on the three dimensions of the applicability of recommendations. This overview can guide stroke physicians in improving the care process and removing barriers where implementation may be hampered by validity and feasibility.
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Affiliation(s)
- Charlotte Lens
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium
| | - Jelle Demeestere
- Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Barbara Casolla
- Université Cote d'Azur UR2CA-URRIS, Unité Neurovasculaire, CHU Hôpital Pasteur 2, Nice, France
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Peter Kelly
- Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
- Department of Neurology, Mater University Hospital, Dublin, Ireland
| | - Carlos Molina
- Stroke Unit, Vall d'Hebron Hospital, Barcelona, Spain
| | - Simona Sacco
- Department of Neurology, University of L'Aquila, L'Aquila, Italy
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kris Vanhaecht
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
| | - Caroline Weltens
- Department of Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen Coeckelberghs
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
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Härkönen H, Myllykangas K, Gomes J, Immonen M, Kärppä M, Hyvämäki P, Jansson M. Challenges and needs in cerebrovascular disease pathway: A qualitative descriptive study from the patients' and healthcare professionals' perspectives. J Adv Nurs 2024; 80:3767-3780. [PMID: 38214101 DOI: 10.1111/jan.16055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/12/2023] [Accepted: 12/30/2023] [Indexed: 01/13/2024]
Abstract
AIM(S) To understand patients' and healthcare professionals' experiences to improve care in and across different domains of the cerebrovascular disease pathway. DESIGN A qualitative descriptive study. METHODS Semi-structured in-person interviews were conducted among 22 patients diagnosed with acute cerebrovascular disease and 26 healthcare professionals taking care of them in a single tertiary-level hospital from August 2021 to March 2022. Data were analysed using deductive and inductive content analysis. The consolidated criteria for reporting qualitative research was used to ensure reliable reporting. RESULTS Overall, 19 generic and 79 sub-categories describing perceived challenges with 17 generic and 62 sub-categories describing perceived needs were identified related to primary prevention, organization of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment, and life after stroke. CONCLUSION Several challenges and needs were identified in and across the different domains of the cerebrovascular disease pathway. There is a requirement for adequate resources, early initiation of treatment, early diagnostics and recanalization, dedicated rehabilitation services, long-term counselling and support, and impact evaluation of services to improve cerebrovascular disease care. Future research on caregivers', and clinical leadership experiences in and across the cerebrovascular disease pathway is needed to explore the provision of services. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The results of this study can be applied by organizations, managers and research for developing and improving services in the cerebrovascular disease pathway. IMPACT This study identified several patient-related, organizational and logistical needs and challenges, with suggestions for required actions, that can benefit the provision of effective, high-quality cerebrovascular disease care. REPORTING METHOD We have adhered to relevant EQUATOR guidelines with the COREQ reporting method. PATIENT OR PUBLIC CONTRIBUTION No patient or public involvement.
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Affiliation(s)
- Henna Härkönen
- Research Unit of Health Sciences and Technology (HST), University of Oulu/Faculty of Medicine, Oulu, Finland
| | - Kirsi Myllykangas
- Research Unit of Health Sciences and Technology (HST), University of Oulu/Faculty of Medicine, Oulu, Finland
| | | | - Milla Immonen
- VTT Technical Research Centre of Finland, Oulu, Finland
| | - Mikko Kärppä
- Neurocenter, Neurology, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, Neurology, University of Oulu/Faculty of Medicine, Oulu, Finland
| | - Piia Hyvämäki
- Research Unit of Health Sciences and Technology (HST), University of Oulu/Faculty of Medicine, Oulu, Finland
| | - Miia Jansson
- Research Unit of Health Sciences and Technology (HST), University of Oulu/Faculty of Medicine, Oulu, Finland
- RMIT University, Melbourne, Victoria, Australia
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Diaz ML, Carmona T, Requena M, Piñana C, Hernández D, Diana F, De Dios M, Farrero J, Ribo M, Fredes Araya A, Gramegna LL, Purroy F, Fernandez L, Villalba J, Quintana M, Tomasello A. Remote Teleproctoring with the TEGUS System for Mechanical Thrombectomy in a Non-Comprehensive Stroke Center: Initial Preliminary Data On Clinical Experience. Clin Neuroradiol 2024:10.1007/s00062-024-01440-0. [PMID: 39179879 DOI: 10.1007/s00062-024-01440-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 07/08/2024] [Indexed: 08/26/2024]
Abstract
PURPOSE Mechanical thrombectomy (MT) is typically performed by experienced neurointerventional radiologists. However, logistical and geographic limitations often hinder access to rapid MT. This study reports the first clinical experience using TEGUS teleproctoring to support MT conducted by general interventional radiologists (IR) at non-comprehensive stroke centers, compared to on-site proctoring outcomes. METHODS The Arnau de Vilanova Hospital in Spain used to transfer stroke patients requiring MT to a comprehensive Stroke Center 160 km away. To overcome COVID-19 mobility restrictions, the Tegus Teleproctoring System was installed. Before teleproctoring, the general interventional radiologist underwent six months of neurointerventional training at a primary stroke center. From April 2021 to May 2023, general IR conducted MT either with on-site proctor supervision or teleproctoring support. We aim to compare clinical outcome of patients receiving MT according to proctoring method. RESULTS During the study, 49 MTs were performed: 15 with TEGUS teleproctoring and 34 with on-site proctoring. Both groups had similar baseline characteristics, except for NIHSS scores (Tegus 9 [IQR 6-20] vs 18 [IQR 12-22], p = 0.034). No significant differences were found in door-to-revascularization time (82 ± 28.2 vs 84 ± 26.4) min, p = (0.895). The final mTICI distribution and 90-day mRS scores were comparable after adjusting by stroke severity. There were no reports of symptomatic intracranial hemorrhage in either group. CONCLUSION This study shows the feasibility of Tegus remote teleproctoring during emergent cases of MT in a remote hospital. It could improve the learning curve of interventional radiologists with limited experience in MT, and lower the territorial inequity associated to MT.
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Affiliation(s)
- Maria Lourdes Diaz
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
| | - Tomás Carmona
- Neurosurgey unit, Hospital San Pablo, Coquimbo, Chile
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manuel Requena
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Stroke unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carlos Piñana
- Interventional radiology unit, Hospital clínico Universitario, Valencia, Spain
| | - David Hernández
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francesco Diana
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Marta De Dios
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Farrero
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
| | - Marc Ribo
- Stroke unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Arturo Fredes Araya
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
| | - Laura Ludovica Gramegna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Leandro Fernandez
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
- Radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
| | - Jordi Villalba
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain
- Vascular interventional radiology unit, Santa Creu I Sant Pau Hospital, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Tomasello
- Vascular interventional radiology unit, Arnau de Vilanova Hospital, Lleida, Spain.
- Interventional Neuroradiology Section, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
- Departamento de Medicina (A.T.), Universitat Autònoma de Barcelona, Barcelona, Spain.
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9
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Bando K, Ohashi K, Fujiwara K, Osanai T, Morii Y, Tanikawa T, Fujimura M, Ogasawara K. The Capacitated Maximal Covering Location Problem Improves Access to Stroke Treatment: A Cross-Sectional Simulation Study. Health Serv Insights 2024; 17:11786329241263699. [PMID: 39092183 PMCID: PMC11292677 DOI: 10.1177/11786329241263699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/06/2024] [Indexed: 08/04/2024] Open
Abstract
Disparities in accessing advanced stroke treatment have been recognized as a policy challenge in multiple countries, including Japan, necessitating priority solutions. Nevertheless, more practical healthcare policies must be implemented due to the limited availability of healthcare staff and financial resources in most nations. This study aimed to evaluate the supply and demand balance of mechanical thrombectomy (MT) and identify areas with high priority for enhancing stroke centers. The target area of this study was Hokkaido, Japan. We adopted the capacitated maximal covering location problem (CMCLP) to propose an optimal allocation without increasing the number of medical facilities. Four realistic scenarios with varying levels of total MT supply capacity for Primary stroke centers and assuming a range of 90 minutes by car from the center were created and simulated. From scenarios 1 to 4, the coverage increased by approximately 53% to 85%, scenarios 2 and 3 had 5% oversupply, and scenario 4 had an oversupply of approximately 20%. When the supply capacity cap was eliminated and 8 PSCs received 31 or more patients, they became priority enhancement targets. The CMCLP estimates demand coverage considering the supply and demand balance and indicates areas and facilities where MT supply capacity enhancement is a priority.
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Affiliation(s)
- Kyohei Bando
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Kazuki Ohashi
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Kensuke Fujiwara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Graduate School of Commerce, Otaru University of Commerce, Otaru, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yasuhiro Morii
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Wako, Japan
| | - Takumi Tanikawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Faculty of Health Sciences, Hokkaido University of Science, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Katsuhiko Ogasawara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Faculty of Engineering, Muroran Institute of Technology, Muroran, Japan
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10
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Wang C, Dong J, Huang H, Zhou K, Liu Z, Milner R, Li L. Astrocyte-TREM2 alleviates brain injury by regulating reactive astrocyte states following ischemic stroke. Glia 2024. [PMID: 39056459 DOI: 10.1002/glia.24597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/08/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
Triggering receptor expressed on myeloid cells 2 (TREM2) has been shown to confer strong neuroprotective effects in acute ischemic stroke (AIS). However, as the vast majority of research findings to date are based on its functions in microglia, the precise role of TREM2 in astrocytes after AIS is unknown. Here, both loss- and gain-of-function experiments were employed to investigate how astrocytic TREM2 influences the pathogenesis of AIS in vivo and in vitro. Our results demonstrated that cerebral ischemia triggered induction of TREM2 expression on reactive astrocytes following AIS. In addition, astrocyte-specific TREM2 knockout mice exhibited much greater brain injury than TREM2 flox/flox controls following AIS, as evidenced by increased cerebral infarct volume, neuronal apoptosis and neurological deficit, which was associated with an increased expression of pro-inflammatory molecule complement component 3 (C3) on reactive astrocytes and activation of microglia/macrophages but decreased expression of S100 calcium binding protein A10 (S100A10) and arginase1 (Arg1) on reactive astrocytes. Mechanistic analyses revealed that astrocytic TREM2 alleviated brain injury by inhibiting detrimental actions of reactive astrocytes but promoting their neuro- and glioprotective actions via the kruppel-like transcription factor-4-nuclear factor-κB axis. Together, this study provides novel evidence for a critical protective role of astrocyte-derived TREM2 in AIS and highlights a potential therapeutic target for the treatment of AIS.
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Affiliation(s)
- Cong Wang
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- The Graduate School, Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China
| | - Jing Dong
- Department of Pharmacy, Gongli Hospital, Pudong New Area, Shanghai, Shanghai, People's Republic of China
| | - Heng Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Kegui Zhou
- The Graduate School, Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China
| | - Zhenguo Liu
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Richard Milner
- San Diego Biomedical Research Institute, San Diego, California, USA
| | - Longxuan Li
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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11
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O’Flaherty D, Ali K. Recommendations for Upper Limb Motor Recovery: An Overview of the UK and European Rehabilitation after Stroke Guidelines (2023). Healthcare (Basel) 2024; 12:1433. [PMID: 39057576 PMCID: PMC11276617 DOI: 10.3390/healthcare12141433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/01/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Upper limb impairment is common after stroke, with a significant impact on the stroke survivor's function, social participation and quality of life. Clinical guidelines are needed to inform clinical practise, tailor interventions to improve outcomes and address unresolved research questions. This review contributes to the evidence guiding clinical practise for upper limb motor recovery after stroke by summarising the recommendations from the UK rehabilitation guidelines (National Institute for Health and Care Excellence (NICE) and the Intercollegiate Stroke Working Party (ISWP)) and the European Stroke Organisation (ESO) guidelines, all published in 2023. All three guidelines target researchers, clinical practitioners, stroke survivors and their social networks. An important feature in all three guidelines was therapeutic intensity, with all guidelines recommending increased therapeutic intensity. Unlike the ESO, the NICE and ISWP additionally include specific research recommendations. While the NICE guidelines seem more holistic and target a wider audience, the three guidelines are complimentary. We recommend that a future consensus statement should be developed in partnership between all three organisations, agreeing on scope and using the same terminology, on recommendations to improve stroke rehabilitation in the UK and Europe.
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Affiliation(s)
- Daniel O’Flaherty
- University Hospital Southampton NHS Foundation Trust, Hampshire SO16 6YD, UK
| | - Khalid Ali
- Department of Geriatrics, Brighton and Sussex Medical School, Brighton BN1 9PX, UK
- University Hospitals Sussex NHS Foundation Trust, Princess Royal Hospital, Haywards Heath RH16 4EX, UK
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12
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Vandelanotte S, De Meyer SF. Acute Ischemic Stroke Thrombus Composition. Neuroscience 2024; 550:11-20. [PMID: 38185279 DOI: 10.1016/j.neuroscience.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
Ischemic stroke is caused by a thrombus blocking one or multiple arteries in the brain, resulting in irreversible damage in the associated brain tissue. The aim of therapy is to restore the blood flow as fast as possible. Two recanalization strategies are currently available: pharmacological thrombolysis using recombinant tissue plasminogen activator (rt-PA) and mechanical removal of the thrombus. Despite recent advancements, achieving efficient recanalization remains a challenge. The precise causes of therapy failure are not fully understood but thrombus composition is likely a key factor in successful recanalization. This review explores acute ischemic stroke thrombus composition, its recently identified components, and how it affects stroke treatment. It also discusses how new insights could enhance current recanalization strategies for ischemic stroke patients.
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Affiliation(s)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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13
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Hengel P, Nimptsch U, Blümel M, Achstetter K, Busse R. Regional variation in access to and quality of acute stroke care: results of Germany's Health System Performance Assessment pilot, 2014-2020. RESEARCH IN HEALTH SERVICES & REGIONS 2024; 3:9. [PMID: 39177921 PMCID: PMC11281753 DOI: 10.1007/s43999-024-00045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 06/18/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Health System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA's conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance. METHODS We use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany's 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities. RESULTS About 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74-98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0-9.7%, one outlier of 13.3%). CONCLUSIONS The results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.
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Affiliation(s)
- P Hengel
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany.
| | - U Nimptsch
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
| | - M Blümel
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
| | - K Achstetter
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
| | - R Busse
- Department of Health Care Management, Technische Universität Berlin, Str. des 17. Juni 135, Berlin, 10623, Germany
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14
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Babenko VA, Yakupova EI, Pevzner IB, Bocharnikov AD, Zorova LD, Fedulova KS, Grebenchikov OA, Kuzovlev AN, Grechko AV, Silachev DN, Rahimi-Moghaddam P, Plotnikov EY. Effects of Lithium Ions on tPA-Induced Hemorrhagic Transformation under Stroke. Biomedicines 2024; 12:1325. [PMID: 38927532 PMCID: PMC11201972 DOI: 10.3390/biomedicines12061325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Thrombolytic therapy with the tissue plasminogen activator (tPA) is a therapeutic option for acute ischemic stroke. However, this approach is subject to several limitations, particularly the increased risk of hemorrhagic transformation (HT). Lithium salts show neuroprotective effects in stroke, but their effects on HT mechanisms are still unknown. In our study, we use the models of photothrombosis (PT)-induced brain ischemia and oxygen-glucose deprivation (OGD) to investigate the effect of Li+ on tPA-induced changes in brain and endothelial cell cultures. We found that tPA did not affect lesion volume or exacerbate neurological deficits but disrupted the blood-brain barrier. We demonstrate that poststroke treatment with Li+ improves neurological status and increases blood-brain barrier integrity after thrombolytic therapy. Under conditions of OGD, tPA treatment increased MMP-2/9 levels in endothelial cells, and preincubation with LiCl abolished this MMP activation. Moreover, we observed the effect of Li+ on glycolysis in tPA-treated endothelial cells, which we hypothesized to have an effect on MMP expression.
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Affiliation(s)
- Valentina A. Babenko
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Elmira I. Yakupova
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
| | - Irina B. Pevzner
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Alexey D. Bocharnikov
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- Advanced Engineering School “Intelligent Theranostics Systems”, Sechenov First Moscow State Medical University, 119992 Moscow, Russia
| | - Ljubava D. Zorova
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Kseniya S. Fedulova
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
| | - Oleg A. Grebenchikov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (O.A.G.); (A.N.K.); (A.V.G.)
| | - Artem N. Kuzovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (O.A.G.); (A.N.K.); (A.V.G.)
| | - Andrey V. Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (O.A.G.); (A.N.K.); (A.V.G.)
| | - Denis N. Silachev
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Parvaneh Rahimi-Moghaddam
- Department of Pharmacology, School of Medicine, Iran University of Medical Sciences, Tehran 14496-14535, Iran;
| | - Egor Y. Plotnikov
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
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15
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Venketasubramanian N, Yeo TT, Chen CLH. Translational Medicine in Acute Ischemic Stroke and Traumatic Brain Injury-NeuroAiD Trials, from Traditional Beliefs to Evidence-Based Therapy. Biomolecules 2024; 14:680. [PMID: 38927083 PMCID: PMC11202287 DOI: 10.3390/biom14060680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/08/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Acute ischemic stroke (AIS) and traumatic brain injury (TBI) are two severe neurological events, both being major causes of death and prolonged impairment. Their incidence continues to rise due to the global increase in the number of people at risk, representing a significant burden on those remaining impaired, their families, and society. These molecular and cellular mechanisms of both stroke and TBI present similarities that can be targeted by treatments with a multimodal mode of action, such as traditional Chinese medicine. Therefore, we performed a detailed review of the preclinical and clinical development of MLC901 (NeuroAiDTMII), a natural multi-herbal formulation targeting several biological pathways at the origin of the clinical deficits. The endogenous neurobiological processes of self-repair initiated by the brain in response to the onset of brain injury are often insufficient to achieve complete recovery of impaired functions. This review of MLC901 and its parent formulation MLC601 confirms that it amplifies the natural self-repair process of brain tissue after AIS or TBI. Following AIS and TBI where "time is brain", many patients enter the post-acute phase with their functions still impaired, a period when "the brain needs time to repair itself". The treatment goal must be to accelerate recovery as much as possible. MLC901/601 demonstrated a significant reduction by 18 months of recovery time compared to a placebo, indicating strong potential for facilitating the improvement of health outcomes and the more efficient use of healthcare resources.
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Affiliation(s)
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore;
| | - Christopher Li Hsian Chen
- Memory Aging and Cognition Centre, Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Blk MD3, 16 Medical Drive, #04-01, Singapore 117600, Singapore;
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16
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Consoli A, Cancelliere NM, Charbonnier G, Spears J, Marotta TR, Pereira VM. Perspectives on Remote Robotic-Assisted Stroke Treatment: A Commentary Paper. AJNR Am J Neuroradiol 2024; 45:681-685. [PMID: 38216300 PMCID: PMC11288596 DOI: 10.3174/ajnr.a8085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 01/14/2024]
Abstract
The proved feasibility of robotic-assisted endovascular treatment of intracranial aneurysms has stimulated the idea of a potential application of remote robotics for the treatment of acute ischemic stroke. The possibility of developing a more advanced remote-controlled robotic system capable of performing a complete mechanical thrombectomy procedure would help bridge the health care gap of lack of technical expertise in isolated areas. This possibility could allow a more equitable access to mechanical thrombectomy to a larger number of patients and be a breakthrough for acute ischemic stroke care worldwide. Many aspects around the technical, human, financial, and regulatory requirements should be discussed to implement remote robotic-assisted procedures. In this State of Practice article, we aimed to outline the major challenges that must be considered, as well as proposed solutions. However, different solutions may be applied in different health care systems on the basis of the availability of human and financial resources.
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Affiliation(s)
- Arturo Consoli
- From the Diagnostic and Interventional Neuroradiology Department (A.C.), Foch Hospital, Suresnes, France
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nicole Mariantonia Cancelliere
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Guillaume Charbonnier
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Interventional Neuroradiology Department (G.C.), Besançon University Hospital, Besançon, France
| | - Julian Spears
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Thomas R Marotta
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology (T.R.M.), Department of Medical Imaging, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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17
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Checkouri T, Sablot D, Varnier Q, Fryder I, Collemiche FL, Azais B, Dargazanli C, Leibinger F, Cagnazzo F, Mahmoudi M, Lefevre PH, Van Damme L, Gascou G, Schmidt J, Arquizan C, Plantard C, Farouil G, Costalat V. Becoming a thrombectomy-capable stroke center: Clinical and medico-economical effectiveness at the hospital level. Eur Stroke J 2024:23969873241254239. [PMID: 38760934 DOI: 10.1177/23969873241254239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024] Open
Abstract
INTRODUCTION Too few patients benefit from endovascular therapy (EVT) in large vessel occlusion acute stroke (LVOS), and various acute stroke care paradigms are currently investigated to reduce these inequalities in health access. We aimed to investigate whether newly set-up thrombectomy-capable stroke centers (TSC) offered a safe, effective and cost-effective procedure. PATIENTS AND METHODS This French retrospective study compared the outcomes of LVOS patients with an indication for EVT and treated at the Perpignan hospital before on-site thrombectomy was available (Primary stroke center), and after formation of local radiology team for neurointervention (TSC). Primary endpoints were 3-months functional outcomes, assessed by the modified Rankin scale. Various safety endpoints for ischemic and hemorragic procedural complications were assessed. We conducted a medico-economic analysis to estimate the cost-benefit of becoming a TSC for the hospital. RESULTS The differences between 422 patients in the PSC and 266 in the TSC were adjusted by the means of weighted logistic regression. Patients treated in the TSC had higher odds of excellent functional outcome (aOR 1.77 [1.16-2.72], p = 0.008), with no significant differences in the rates of procedural complications. The TSC setting shortened onset-to-reperfusion times by 144 min (95% CI [131-155]; p < 0.0001), and was cost-effective after 21 treated LVOS patients. On-site thrombectomy saves 10.825€ per patient for the hospital. DISCUSSION Our results demonstrate that the TSC setting improves functional outcomes and reduces intra-hospital costs in LVOS patients. TSCs could play a major public health role in acute stroke care and access to EVT.
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Affiliation(s)
- Thomas Checkouri
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Denis Sablot
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Quentin Varnier
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Ivan Fryder
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | - Benoit Azais
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | | | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Mehdi Mahmoudi
- Department of Radiology, St. Jean Hospital, Perpignan, France
| | | | | | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
| | - Julia Schmidt
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
| | - Carole Plantard
- Department of Neurology, St. Jean Hospital, Perpignan, France
| | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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18
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Wang S, Pan Y, Zhang C, Zhao Y, Wang H, Ma H, Sun J, Zhang S, Yao J, Xie D, Zhang Y. Transcriptome Analysis Reveals Dynamic Microglial-Induced A1 Astrocyte Reactivity via C3/C3aR/NF-κB Signaling After Ischemic Stroke. Mol Neurobiol 2024:10.1007/s12035-024-04210-8. [PMID: 38713438 DOI: 10.1007/s12035-024-04210-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/26/2024] [Indexed: 05/08/2024]
Abstract
Microglia and astrocytes are key players in neuroinflammation and ischemic stroke. A1 astrocytes are a subtype of astrocytes that are extremely neurotoxic and quickly kill neurons. Although the detrimental A1 astrocytes are present in many neurodegenerative diseases and are considered to accelerate neurodegeneration, their role in the pathophysiology of ischemic stroke is poorly understood. Here, we combined RNA-seq, molecular and immunological techniques, and behavioral tests to investigate the role of A1 astrocytes in the pathophysiology of ischemic stroke. We found that astrocyte phenotypes change from a beneficial A2 type in the acute phase to a detrimental A1 type in the chronic phase following ischemic stroke. The activated microglial IL1α, TNF, and C1q prompt commitment of A1 astrocytes. Inhibition of A1 astrocytes induction attenuates reactive gliosis and ameliorates morphological and functional defects following ischemic stroke. The crosstalk between astrocytic C3 and microglial C3aR contributes to the formation of A1 astrocytes and morphological and functional defects. In addition, NF-κB is activated following ischemic stroke and governs the formation of A1 astrocytes via direct targeting of inflammatory cytokines and chemokines. Taken together, we discovered that A2 astrocytes and A1 astrocytes are enriched in the acute and chronic phases of ischemic stroke respectively, and that the C3/C3aR/NF-κB signaling leads to A1 astrocytes induction. Therefore, the C3/C3aR/NF-κB signaling is a novel therapeutic target for ischemic stroke treatment.
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Affiliation(s)
- Song Wang
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
- Beijing Clinical Research Institute, Beijing, 100050, China.
| | - Yuhualei Pan
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Beijing Clinical Research Institute, Beijing, 100050, China
- Immunology Research Center for Oral and Systemic Health, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Chengjie Zhang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yushang Zhao
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Beijing Clinical Research Institute, Beijing, 100050, China
| | - Huan Wang
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Beijing Clinical Research Institute, Beijing, 100050, China
| | - Huixuan Ma
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jinmei Sun
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Song Zhang
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Beijing Clinical Research Institute, Beijing, 100050, China
| | - Jingyi Yao
- Experimental and Translational Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Beijing Clinical Research Institute, Beijing, 100050, China
| | - Dan Xie
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
| | - Yongbo Zhang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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19
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Li J, Zhong Q, Yuan S, Zhu F. Global burden of stroke attributable to high systolic blood pressure in 204 countries and territories, 1990-2019. Front Cardiovasc Med 2024; 11:1339910. [PMID: 38737709 PMCID: PMC11084284 DOI: 10.3389/fcvm.2024.1339910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/04/2024] [Indexed: 05/14/2024] Open
Abstract
Background High systolic blood pressure (HSBP) is severely related to stroke, although the global burden of stroke associated with HSBP needs to be understood. Materials and methods Data derived from the Global Burden of Disease, Injuries, and Risk Factors Study were used to analyze deaths, disability-adjusted life years (DALYs), age-standardized rates of mortality (ASMR), age-standardized rates of DALY (ASDR), and estimated annual percentage change (EAPC). Results Globally, 52.57% of deaths and 55.54% of DALYs from stroke were attributable to HSBP in 2019, with higher levels in men; the ASMRs and ASDRs in 1990-2019 experienced a decline of 34.89% and 31.71%, respectively, with the highest ASMR- and ASDR-related EAPCs in women. The middle socio-demographic index (SDI) regions showed the most numbers of deaths and DALYs in 2019 and 1990, with a decline in ASMR and ASDR; East Asia shared over 33% of global deaths and DALYs; Central Asia shared the highest ASMR and ASDR; high-income Asia Pacific experienced the highest decline in the ASMR- and ASDR-related EAPCs. Central and Southeast Asia had the highest percentages for deaths and DALYs, respectively, with more ASMR in high-middle SDI; the SDI and human development index were negatively associated with ASMR/ASDR and ASMR/ASDR-related EAPCs in 2019. Conclusion Global deaths and DALYs of stroke attributable to HSBP but none of their age-standardized rates have been on the rise over the past three decades; its disease burden focused especially on men aged 70 years and older in East, Central, and Southeast Asia, and the middle to high SDI regions.
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Affiliation(s)
- Junxiao Li
- Central Laboratory, Guangzhou Twelfth People's Hospital, Guangzhou, China
- Departments of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
| | - Qiongqiong Zhong
- Central Laboratory, Guangzhou Twelfth People's Hospital, Guangzhou, China
- Departments of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
| | - Shixiang Yuan
- Department of Neurosurgery, Guangzhou Twelfth People’s Hospital, Guangzhou, China
| | - Feng Zhu
- Central Laboratory, Guangzhou Twelfth People's Hospital, Guangzhou, China
- Departments of Public Health and Preventive Medicine, Jinan University, Guangzhou, China
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Poll M, Martins RT, Anschau F, Jotz GP. Length of Hospitalization and Mortality among Stroke Patients before and after the Implementation of a Specialized Unit: A Retrospective Cohort Study Using Real-World Data from One Reference Hospital in Southern Brazil. Healthcare (Basel) 2024; 12:836. [PMID: 38667598 PMCID: PMC11050536 DOI: 10.3390/healthcare12080836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Stroke constitutes a significant global cause of mortality and disability. The implementation of stroke units influences hospital quality indicators, guiding care management. We aimed to compare hospital length of stay (LOS), in-hospital mortality, and post-discharge mortality between stroke patients admitted in the pre- and post-implementation periods of a stroke unit in a public hospital in southern Brazil. This retrospective cohort study used real-world data from one reference hospital, focusing on the intervention (stroke unit) and comparing it to the general ward (control). We analyzed the electronic medical records of 674 patients admitted from 2009 to 2012 in the general ward and 766 patients from 2013 to 2018 in the stroke unit. Admission to the stroke unit was associated with a 43% reduction in the likelihood of prolonged hospitalization. However, there was no significant difference in the risk of in-hospital mortality between the groups (Hazard ratio = 0.90; Interquartile range = 0.58 to 1.39). The incidence of death at three, six and twelve months post-discharge did not differ between the groups. Our study results indicate significant improvements in care processes for SU patients, including shorter LOS and better adherence to treatment protocols. However, our observations revealed no significant difference in mortality rates, either during hospitalization or after discharge, between the SU and GW groups. While SU implementation enhances efficiency in stroke care, further research is needed to explore long-term outcomes and optimize management strategies.
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Affiliation(s)
- Marcia Poll
- Graduate Program in Health Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, RS, Brazil
| | - Rodrigo Targa Martins
- Stroke Unit Coordination, Conceição Hospital Group, Porto Alegre 91350-200, RS, Brazil
| | - Fernando Anschau
- Conceição Hospital Group, Department of Education and Research Coordination, Porto Alegre 91350-200, RS, Brazil
| | - Geraldo Pereira Jotz
- Graduate Program in Health Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, RS, Brazil
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21
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Hernández-Bernal F, Estenoz-García D, Gutiérrez-Ronquillo JH, Martín-Bauta Y, Catasús-Álvarez K, Gutiérrez-Castillo M, Guevara-Rodríguez M, Castro-Jeréz A, Fuentes-González Y, Pinto-Cruz Y, Valenzuela-Silva C, Muzio-González VL, Pérez-Saad H, Subirós-Martínez N, Guillén-Nieto GE, Garcia-del-Barco-Herrera D. Combination therapy of Epidermal Growth Factor and Growth Hormone-Releasing Hexapeptide in acute ischemic stroke: a phase I/II non-blinded, randomized clinical trial. Front Neurol 2024; 15:1303402. [PMID: 38638315 PMCID: PMC11024445 DOI: 10.3389/fneur.2024.1303402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
Objective This study tested the hypothesis that a neuroprotective combined therapy based on epidermal growth factor (EGF) and growth hormone-releasing hexapeptide (GHRP6) could be safe for acute ischemic stroke patients, admitting up to 30% of serious adverse events (SAE) with proven causality. Methods A multi-centric, randomized, open-label, controlled, phase I-II clinical trial with parallel groups was conducted (July 2017 to January 2018). Patients aged 18-80 years with a computed tomography-confirmed ischemic stroke and less than 12 h from the onset of symptoms were randomly assigned to the study groups I (75 μg rEGF + 3.5 mg GHRP6 i.v., n=10), II (75 μg rEGF + 5 mg GHRP6 i.v., n=10), or III (standard care control, n=16). Combined therapy was given BID for 7 days. The primary endpoint was safety over 6 months. Secondary endpoints included neurological (NIHSS) and functional [Barthel index and modified Rankin scale (mRS)] outcomes. Results The study population had a mean age of 66 ± 11 years, with 21 men (58.3%), a baseline median NIHSS score of 9 (95% CI: 8-11), and a mean time to treatment of 7.3 ± 2.8 h. Analyses were conducted on an intention-to-treat basis. SAEs were reported in 9 of 16 (56.2%) patients in the control group, 3 of 10 (30%) patients in Group I (odds ratio (OR): 0.33; 95% CI: 0.06-1.78), and 2 of 10 (20%) patients in Group II (OR: 0.19; 95% CI: 0.03-1.22); only two events in one patient in Group I were attributed to the intervention treatment. Compliance with the study hypothesis was greater than 0.90 in each group. Patients treated with EGF + GHRP6 had a favorable neurological and functional evolution at both 90 and 180 days, as evidenced by the inferential analysis of NIHSS, Barthel, and mRS and by their moderate to strong effect size. At 6 months, proportion analysis evidenced a higher survival rate for patients treated with the combined therapy. Ancillary analysis including merged treated groups and utility-weighted mRS also showed a benefit of this combined therapy. Conclusion EGF + GHRP6 therapy was safe. The functional benefits of treatment in this study supported a Phase III study. Clinical Trial Registration RPCEC00000214 of the Cuban Public Registry of Clinical Trials, Unique identifier: IG/CIGB-845I/IC/1601.
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Affiliation(s)
- Francisco Hernández-Bernal
- Clinical Trial Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Department of Comprehensive General Medicine, Latin American School of Medicine (ELAM), Havana, Cuba
| | | | | | - Yenima Martín-Bauta
- Clinical Trial Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Karen Catasús-Álvarez
- Clinical Trial Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | | | | | | | | | | | | | | | - Héctor Pérez-Saad
- Neuroprotection Project, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Nelvys Subirós-Martínez
- Neuroprotection Project, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Gerardo E. Guillén-Nieto
- Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Department of Physiology, Latin American School of Medicine (ELAM), Havana, Cuba
| | - Diana Garcia-del-Barco-Herrera
- Neuroprotection Project, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Department of Physiology, Latin American School of Medicine (ELAM), Havana, Cuba
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22
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Grunwald IQ, Musialek P, Podlasek A, Sievert H, Mathias K, Guyler P, Hopkins LN. World Federation for Interventional Stroke Treatment (WIST) multispecialty training guidelines for endovascular stroke intervention: Time is brain! - Response to commentary by UKNG. Clin Radiol 2024; 79:e637-e639. [PMID: 38311524 DOI: 10.1016/j.crad.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 02/06/2024]
Affiliation(s)
- I Q Grunwald
- NHS Tayside, Dundee, UK; Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, School of Medicine, University of Dundee, UK; Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany.
| | - P Musialek
- Jagiellonian University, Krakow, Poland; Stroke Thrombectomy-Capable Center, John Paul II Hospital, Krakow, Poland
| | - A Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, School of Medicine, University of Dundee, UK
| | - H Sievert
- Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany; Goethe University Frankfurt, Frankfurt, Germany
| | - K Mathias
- Asklepios Clinik St Georg - Klinische und Interventionelle Angiologie, Hamburg, Germany
| | - P Guyler
- East of England Regional Stroke Network, UK; Mid and South Essex University Hospitals Group, Southend University Hospital, Westcliff-on-Sea, UK
| | - L N Hopkins
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA; Jacobs Institute, Buffalo, NY, USA
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23
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Meng TT, You YP, Li M, Guo JB, Song XB, Ding JY, Xie XL, Li AQ, Li SJ, Yin XJ, Wang P, Wang Z, Wang BL, He QY. Chinese herbal medicine Ginkgo biloba L. preparations for ischemic stroke: An overview of systematic reviews and meta-analyses. JOURNAL OF INTEGRATIVE MEDICINE 2024; 22:163-179. [PMID: 38519277 DOI: 10.1016/j.joim.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/25/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Ginkgo biloba L. preparations (GBLPs) are a class of Chinese herbal medicine used in the adjuvant treatment of ischemic stroke (IS). Recently, several systematic reviews (SRs) and meta-analyses (MAs) of GBLPs for IS have been published. OBJECTIVE This overview aims to assess the quality of related SRs and MAs. SEARCH STRATEGY PubMed, Embase, Cochrane Library, Web of Science, Chinese Biological Medicine, China National Knowledge Infrastructure, Wanfang, and Chinese Science and Technology Journals databases were searched from their inception to December 31, 2022. INCLUSION CRITERIA SRs and MAs of randomized controlled trials (RCTs) that explored the efficacy of GBLPs for patients with IS were included. DATA EXTRACTION AND ANALYSIS Two independent reviewers extracted data and assessed the methodological quality, risk of bias (ROB), reporting quality, and credibility of evidence of the included SRs and MAs using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), Risk of Bias in Systematic Reviews (ROBIS), the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and the Grading of Recommendations Assessment, Development and Evaluation (GRADE), respectively. Additionally, descriptive analysis and data synthesis were conducted. RESULTS Twenty-nine SRs/MAs involving 119 outcomes were included in this review. The overall methodological quality of all SRs/MAs was critically low based on AMSTAR 2, and 28 had a high ROB based on the ROBIS. According to the PRISMA statement, the reporting items of the included SRs/MAs are relatively complete. The results based on GRADE showed that of the 119 outcomes, 8 were rated as moderate quality, 24 as low quality, and 87 as very low quality. Based on the data synthesis, GBLPs used in conjunction with conventional treatment were superior to conventional treatment alone for decreasing neurological function scores. CONCLUSION GBLPs can be considered a beneficial supplemental therapy for IS. However, because of the low quality of the existing evidence, high-quality RCTs and SRs/MAs are warranted to further evaluate the benefits of GBLPs for treating IS. Please cite this article as: Meng TT, You YP, Li M, Guo JB, Song XB, Ding JY, Xie XL, Li AQ, Li SJ, Yin XJ, Wang P, Wang Z, Wang BL, He QY. Chinese herbal medicine Ginkgo biloba L. preparations for ischemic stroke: An overview of systematic reviews and meta-analyses. J Integr Med. 2024;22(2): 163-179.
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Affiliation(s)
- Tian-Tian Meng
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100032, China; Department of Rehabilitation, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing 100071, China
| | - Ya-Ping You
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100032, China
| | - Min Li
- School of Chemistry and Chemical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Jian-Bo Guo
- School of Chinese Medicine, the University of Hong Kong, Hong Kong, China
| | - Xin-Bin Song
- Graduate School, Henan University of Chinese Medicine, Zhengzhou 450008, Henan Province, China
| | - Jing-Yi Ding
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100032, China
| | - Xiao-Long Xie
- Department of Acupuncture and Moxibustion, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100010, China
| | - An-Qi Li
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100032, China
| | - Shang-Jin Li
- School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Xiang-Jun Yin
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Peng Wang
- Graduate School, Henan University of Chinese Medicine, Zhengzhou 450008, Henan Province, China
| | - Zhe Wang
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100032, China
| | - Bao-Liang Wang
- Department of Neurology, the First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450003, Henan Province, China.
| | - Qing-Yong He
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100032, China.
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24
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Harbison J, McCormack J, Brych O, Collins R, O'Connell N, Randles M, Kennedy C, Kelly PJ, Cassidy T. Changes in anticoagulation practice in subjects admitted with stroke associated with atrial fibrillation, following introduction of direct oral anticoagulants over 2013-2021. Int J Stroke 2024; 19:342-347. [PMID: 37771031 DOI: 10.1177/17474930231206680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND The adoption of direct oral anticoagulants (DOACs) has changed practice in prevention of stroke in atrial fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis. METHODS AF, anticoagulation, thrombolysis, and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021 were reviewed. The proportion of patients with ischemic stroke (IS) and intracerebral hemorrhage (IH) with known AF admitted on anticoagulation was determined. Effects on age distribution in the population and thrombolysis practice were assessed. RESULTS AF data were available on 34,630 of 35,241 individuals (98.3%) included in INAS; median age was 74 years and 56% were male. AF was found in 10,016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The proportion all total IS due to AF decreased by 15.3% (31.3%-26.5%, chi-square = 24.6, p < 0.0001). The proportion of IH did not change significantly (21.6%-20.2%, chi-square = 1.8, p = 0.18). Over the 9 years, 3875 (38.6%) of the subjects with AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF-associated strokes were admitted on a DOAC and 21.4% on warfarin; by 2021, 44.1% were receiving a DOAC and 6.2% warfarin. There was a strong inverse correlation between the proportion of anticoagulated stroke patients and the total proportion of AF-associated strokes over time (r = -0.82, p = 0.006). In contrast, no correlation was found between increasing DOAC usage and IH (r = 0.14, p = 0.71). Increased anticoagulation usage correlated with a reduction in patients ⩾ 80 years (r = -0.83, p = 0.006) and also correlated with a relative reduction of 30.1% in subjects thrombolysed <4 h from onset (r = -0.89, p = 0.001). CONCLUSION DOACs have led to increased use of anticoagulation, but warfarin use fell by two-thirds. There has been a reduction in the proportion of AF-associated IS without a noticeable increase in IH. Increased anticoagulation correlated with reduced numbers of strokes in those >80 years and in the proportion of patients thrombolysed.
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Affiliation(s)
- Joseph Harbison
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Joan McCormack
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
| | - Olga Brych
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
| | - Ronan Collins
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Niamh O'Connell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Mary Randles
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Cormac Kennedy
- Department of Pharmacology & Therapeutics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Peter J Kelly
- Department of Neurology, University College Dublin, Dublin, Ireland
- Institute of Neurology, The Mater Hospital, Dublin, Ireland
| | - Tim Cassidy
- Irish National Audit of Stroke, National Office of Clinical Audit, Dublin, Ireland
- Acute Stroke Service, St. Vincent's University Hospital, Dublin, Ireland
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Korompoki E, Ntaios G, Tountopoulou A, Mavraganis G, Tsampalas E, Kalliontzakis I, Vassilopoulou S, Manios E, Savopoulos C, Milionis H, Protogerou A, Kakaletsis N, Galanis P, Kaitelidou D, Siskou O, Vemmos K. Quality Indicators and Clinical Outcomes of Acute Stroke: Results from a Prospective Multicenter Registry in Greece (SUN4P). J Clin Med 2024; 13:917. [PMID: 38337611 PMCID: PMC10856279 DOI: 10.3390/jcm13030917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/21/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
AIM The Stroke Units Necessity for Patients (SUN4P) project aims to provide essential data on stroke healthcare in Greece. Herein, we present results on established quality indicators and outcomes after first-ever stroke occurrences. METHODS This prospective multicenter study included consecutive patients admitted to nine hospitals across Greece in 2019-2021. Descriptive statistics were used to present patients' characteristics, key performance measures and stroke outcomes. RESULTS Among 892 patients, 755 had ischemic stroke (IS) (mean age 75.6 ± 13.6, 48.7% males) and 137 had hemorrhagic stroke (HS) (mean age 75.8 ± 13.2, 57.7% males). Of those, 15.4% of IS and 8% of HS patients were treated in the acute stroke unit (ASU) and 20.7% and 33.8% were admitted to the intensive care unit (ICU) or high-dependency unit (HDU), respectively. A total of 35 (4.6%) out of 125 eligible patients received intravenous alteplase with a door-to needle time of 60 min (21-90). The time to first scan for IS patients was 60 min (31-105) with 53.2% undergoing a CT scan within 60 min post presentation. Furthermore, 94.4% were discharged on antiplatelets, 69.8% on lipid-lowering therapy and 61.6% on antihypertensives. Oral anticoagulants (OAC) were initiated in 73.2% of the 153 IS patients with atrial fibrillation (AF). Among the 687 IS patients who survived, 85.4% were discharged home, 12% were transferred to rehabilitation centers, 1.2% to nursing homes and 1.3% to another hospital. CONCLUSIONS The SUN4P Registry is the first study to provide data from a prospectively collected cohort of consecutive patients from nine representative national hospitals. It represents an important step in the evaluation and improvement of the quality of acute stroke care in Greece.
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Affiliation(s)
- Eleni Korompoki
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece; (G.M.); (E.M.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece;
| | - Argyro Tountopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.T.); (S.V.)
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece; (G.M.); (E.M.)
| | | | | | - Sofia Vassilopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.T.); (S.V.)
| | - Efstathios Manios
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece; (G.M.); (E.M.)
| | - Christos Savopoulos
- First Propaedeutic Internal Medicine Department, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece;
| | - Haralampos Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, 45500 Ioannina, Greece;
| | - Athanasios Protogerou
- Clinic-Laboratory of Pathophysiology, First Department of Propeadeutic Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Nikolaos Kakaletsis
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokrateion General Hospital of Thessaloniki, 54643 Thessaloniki, Greece;
| | - Petros Galanis
- Center for Health Services Management and Evaluation, Nursing Department, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.G.); (D.K.); (O.S.)
| | - Daphne Kaitelidou
- Center for Health Services Management and Evaluation, Nursing Department, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.G.); (D.K.); (O.S.)
| | - Olga Siskou
- Center for Health Services Management and Evaluation, Nursing Department, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.G.); (D.K.); (O.S.)
- Department of Tourism Studies, University of Piraeus, 18534 Piraeus, Greece
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Li S, Wang X, Jin A, Liu G, Gu H, Li H, Campbell BCV, Fisher M, Yang Y, Wei Y, Wang J, Wang Y, Zhao X, Liu L, Li Z, Meng X, Wang Y. Safety and Efficacy of Reteplase Versus Alteplase for Acute Ischemic Stroke: A Phase 2 Randomized Controlled Trial. Stroke 2024; 55:366-375. [PMID: 38152962 DOI: 10.1161/strokeaha.123.045193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Reteplase is a more affordable new-generation thrombolytic with a prolonged half-life. We aimed to determine the safety dose range of reteplase for patients with acute ischemic stroke within 4.5 hours of onset. METHODS This is a multicenter, prospective, randomized controlled, open-label, blinded-end point phase 2 clinical trial. Patients with acute ischemic stroke aged between 18 and 80 years who were eligible for standard intravenous thrombolysis were enrolled from 17 centers in China and randomly assigned (1:1:1) to receive intravenous reteplase 12+12 mg, intravenous reteplase 18+18 mg, or intravenous alteplase 0.9 mg/kg. The primary safety outcome was symptomatic intracranial hemorrhage (SITS definition) within 36 hours. The primary efficacy outcome was the proportion of patients with the National Institutes of Health Stroke Scale score of no more than 1 or a decrease of at least 4 points from the baseline at 14 days after thrombolysis. RESULTS Between August 2019 and May 2021, 180 patients were randomly assigned to reteplase 12+12 mg (n=61), reteplase 18+18 mg (n=67), or alteplase (n=52). Four patients did not receive the study agent. Symptomatic intracranial hemorrhage occurred in 3 of 60 (5.0%) in the reteplase 12+12 mg group, 1 of 66 (1.5%) in the reteplase 18+18 mg group, and 1 of 50 (2.0%) in the alteplase group (P=0.53). The primary efficacy outcome in the modified intention-to-treat population occurred in 45 of 60 (75.0%) in the reteplase 12+12 mg group (odds ratio, 0.85 [95% CI, 0.35-2.06]), 48 of 66 (72.7%) in the reteplase 18+18 mg group (odds ratio, 0.75 [95% CI, 0.32-1.78]), and 39 of 50 (78.0%) in alteplase group. CONCLUSIONS Reteplase was well tolerated in patients with acute ischemic stroke within 4.5 hours of onset in China with a similar efficacy profile to alteplase. The efficacy and appropriate dosage of reteplase for patients with acute ischemic stroke need prospective validation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04028518.
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Affiliation(s)
- Shuya Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xuechun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Aoming Jin
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Gaifen Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hongqiu Gu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (B.C.V.C.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China (Y.Y.)
| | - Yan Wei
- Department of Neurology, Halison International Peace Hospital of Hengshui City, China (Y.W.)
| | - Junhai Wang
- Department of Neurology, Sinopharm Tongmei General Hospital, Datong, China (J.W.)
| | - Yilong Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Liping Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Zixiao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xia Meng
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Yongjun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
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Prendes CF, Rantner B, Hamwi T, Stana J, Feigin VL, Stavroulakis K, Tsilimparis N. Burden of Stroke in Europe: An Analysis of the Global Burden of Disease Study Findings From 2010 to 2019. Stroke 2024; 55:432-442. [PMID: 38252754 DOI: 10.1161/strokeaha.122.042022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 09/21/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND While most European Regions perform well in global comparisons, large discrepancies within stroke epidemiological parameters exist across Europe. The objective of this analysis was to evaluate the stroke burden across European regions and countries in 2019 and its difference to 2010. METHODS The GBD 2019 analytical tools were used to evaluate regional and country-specific estimates of incidence, prevalence, deaths, and disability-adjusted life years of stroke for the European Region as defined by the World Health Organization, with its 53 member countries (EU-53) and for European Union as defined in 2019, with its 28 member countries (EU-28), between 2010 and 2019. Results were analyzed at a regional, subregional, and country level. RESULTS In EU-53, the absolute number of incident and prevalent strokes increased by 2% (uncertainty interval [UI], 0%-4%), from 1 767 280 to 1 802 559 new cases, and by 4% (UI, 3%-5%) between 2010 and 2019, respectively. In EU-28, the absolute number of prevalent strokes and stroke-related deaths increased by 4% (UI, 2%-5%) and by 6% (UI, 1%-10%), respectively. All-stroke age-standardized mortality rates, however, decreased by 18% (UI, -22% to -14%), from 82 to 67 per 100 000 people in the EU-53, and by 15% (UI, -18% to -11%), from 49.3 to 42.0 per 100 000 people in EU-28. Despite most countries presenting reductions in age-adjusted incidence, prevalence, mortality, and disability-adjusted life year rates, these rates remained 1.4×, 1.2×, 1.6×, and 1.7× higher in EU-53 in comparison to the EU-28. CONCLUSIONS EU-53 showed a 2% increase in incident strokes, while they remained stable in EU-28. Age-standardized rates were consistently lower for all-stroke burden parameters in EU-28 in comparison to EU-53, and huge discrepancies in incidence, prevalence, mortality, and disability-adjusted life-year rates were observed between individual countries.
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Affiliation(s)
- Carlota F Prendes
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Barbara Rantner
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Tarek Hamwi
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Jan Stana
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, New Zealand (V.L.F.)
- Institute for Health Metrics and Evaluation, University of Washington, Seattle (V.L.F.)
- Research Center of Neurology, Moscow, Russia (V.L.F.)
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilians University, Munich, Germany (C.F.P., B.R., T.H., J.S., K.S., N.T.)
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Ennab Vogel N, Wester P, Andersson Granberg T, Levin LÅ. Optimized density and locations of stroke centers for improved cost effectiveness of mechanical thrombectomy in patients with acute ischemic stroke. J Neurointerv Surg 2024; 16:156-162. [PMID: 37072170 PMCID: PMC10850679 DOI: 10.1136/jnis-2023-020299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/02/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Despite the proven cost effectiveness of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion, treatment within 6 hours from symptom onset remains inaccessible for many patients. We aimed to find the optimal number and location of treatment facilities with respect to the cost effectiveness of MT in patients with AIS, first by the most cost effective implementation of comprehensive stroke centers (CSCs), and second by the most cost effective addition of complementary thrombectomy capable stroke centers (TSCs). METHODS This study was based on nationwide observational data comprising 18 793 patients with suspected AIS potentially eligible for treatment with MT. The most cost effective solutions were attained by solving the p median facility location-allocation problem with the objective function of maximizing the incremental net monetary benefit (INMB) of MT compared with no MT in patients with AIS. Deterministic sensitivity analysis (DSA) was used as the basis of the results analysis. RESULTS The implementation strategy with seven CSCs produced the highest annual INMB per patient of all possible solutions in the base case scenario. The most cost effective implementation strategy of the extended scenario comprised seven CSCs and four TSCs. DSA revealed sensitivity to variability in MT rate and the maximum willingness to pay per quality adjusted life year gained. CONCLUSION The combination of optimization modeling and cost effectiveness analysis provides a powerful tool for configuring the extent and locations of CSCs (and TSCs). The most cost effective implementation of CSCs in Sweden entails 24/7 MT services at all seven university hospitals.
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Affiliation(s)
- Nicklas Ennab Vogel
- Department of Health, Medicine, and Caring Sciences, Linkoping University Faculty of Medicine, Linkoping, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden
- Department of Clinical Science, Karolinska Institute Danderyds Hospital, Stockholm, Sweden
| | - Tobias Andersson Granberg
- Communications and Transport Systems, Linköping University Department of Science and Technology, Norrköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine, and Caring Sciences, Linkoping University Faculty of Medicine, Linkoping, Sweden
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29
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Zheng Y, Zhu T, Li G, Xu L, Zhang Y. PCSK9 inhibitor protects against ischemic cerebral injury by attenuating inflammation via the GPNMB/CD44 pathway. Int Immunopharmacol 2024; 126:111195. [PMID: 38048667 DOI: 10.1016/j.intimp.2023.111195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/20/2023] [Accepted: 11/05/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Ischemic stroke is the second leading cause of death worldwide, and neuroinflammation has been recognized as a critical player in its progression. Meanwhile, proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) has been demonstrated to inhibit inflammatory response. However, the effects of PCSK9i on ischemic stroke remain unclear and require further investigation. METHODS Temporary middle cerebral artery occlusion (tMCAO) was performed to establish animal models of ischemic stroke in C57BL/6 mice. The PCSK9i were administered subcutaneously after 2 h tMCAO. Neurological function and cerebral infarct volume were measured by mNSS and TTC staining, respectively. RNA-seq was performed to investigate the changes in mechanistic pathways. Western blotting and immunofluorescence were applied to detect expression of GPNMB, CD44, IL-6, and iNOS. RESULTS Treatment with PCSK9i significantly improved neurological deficits and reduced the volume of cerebral infarction. PCSK9i suppressed neuroinflammation by activating the GPNMB/CD44 signaling pathway, further exerting their protective effects. CONCLUSION Taken together, treatment with PCSK9i is an effective way to prevent ischemic stroke-induced brain injury.
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Affiliation(s)
- Yaling Zheng
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tianrui Zhu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Luran Xu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China.
| | - Yue Zhang
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China.
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30
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Hwong WY, Ng SW, Tong SF, Ab Rahman N, Law WC, Wong SK, Puvanarajah SD, Mohd Norzi A, Lian FS, Sivasampu S. Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers' perspective. BMC Health Serv Res 2024; 24:34. [PMID: 38183003 PMCID: PMC10768456 DOI: 10.1186/s12913-023-10397-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/29/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia. METHODS A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings. RESULTS Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation. CONCLUSIONS In addition to the global effort to explore sustainable measures to improve patients' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.
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Affiliation(s)
- Wen Yea Hwong
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia.
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Sock Wen Ng
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Seng Fah Tong
- Department of Family Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Norazida Ab Rahman
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Wan Chung Law
- Neurology Unit, Department of Medicine, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Sarawak, Malaysia
| | - Sing Keat Wong
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Santhi Datuk Puvanarajah
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Aisyah Mohd Norzi
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Fiona Suling Lian
- Clinical Research Centre, Penang General Hospital, Ministry of Health Malaysia, Penang, Malaysia
| | - Sheamini Sivasampu
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
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Ishigami A, Toyoda K, Nakai M, Yoshimura S, Wada S, Sasahara Y, Sonoda K, Miwa K, Koge J, Shiozawa M, Iwanaga Y, Miyamoto Y, Nakahara J, Suzuki N, Kobayashi S, Minematsu K, Koga M. Improvement of Functional Outcomes in Patients with Stroke who Received Alteplase for Over 15 Years: Japan Stroke Data Bank. J Atheroscler Thromb 2024; 31:90-99. [PMID: 37587045 PMCID: PMC10776302 DOI: 10.5551/jat.64200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/12/2023] [Indexed: 08/18/2023] Open
Abstract
AIM The nationwide verification of intravenous thrombolysis (IVT) was rarely performed after the extension of the therapeutic time window of alteplase or after the expansion of mechanical thrombectomy (MT). We aimed to examine the long-term change in accurate real-world outcomes of IVT in patients with acute ischemic stroke (AIS) using the Japan Stroke Databank, a representative Japan-wide stroke database. METHODS We extracted all patients with AIS who received IVT with alteplase between October 11, 2005, the approval date for alteplase use for AIS in Japan, and December 31, 2020. Patients were categorized into three groups using two critical dates in Japan as cutoffs: the official extension date of the therapeutic time window for IVT to within 4.5 h of symptom onset and the publication date of the revised guideline, where the evidence level of MT was heightened. We assessed the yearly trend of IVT implementation rates and the secular changes and three-group changes in clinical outcomes at discharge. RESULTS Of 124,382 patients with AIS, 9,569 (7.7%) received IVT (females, 41%; median age, 75 years). The IVT implementation rate has generally increased over time and plateaued in recent years. The proportion of favorable outcomes (modified Rankin Scale score of 0-2) increased yearly over 15 years. The results of the changes in the outcomes of the three groups were similar to those of the annual changes. CONCLUSIONS We revealed that IVT implementation rates in patients with AIS increased, and the functional outcome in these patients improved over 15 years. Therefore, the Japanese IVT dissemination strategy is considered appropriate and effective.
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Affiliation(s)
- Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | | | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Fandler-Höfler S, Mikšová D, Deutschmann H, Kneihsl M, Mutzenbach S, Killer-Oberpfalzer M, Gizewski ER, Knoflach M, Kiechl S, Sonnberger M, Vosko MR, Weber J, Hausegger KA, Serles W, Werner P, Staykov D, Sykora M, Lang W, Ferrari J, Enzinger C, Gattringer T. Endovascular stroke therapy outside core working hours in a nationwide stroke system. J Neurointerv Surg 2023; 15:e402-e408. [PMID: 36813552 DOI: 10.1136/jnis-2022-020044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Endovascular therapy (EVT) has been established as a major component in the acute treatment of large vessel occlusion stroke. However, it is unclear whether outcome and other treatment-related factors differ if patients are treated within or outside core working hours. METHODS We analyzed data from the prospective nationwide Austrian Stroke Unit Registry capturing all consecutive stroke patients treated with EVT between 2016 and 2020. Patients were trichotomized according to the time of groin puncture into treatment within regular working hours (08:00-13:59), afternoon/evening (14:00-21:59) and night-time (22:00-07:59). Additionally, we analyzed 12 EVT treatment windows with equal patient numbers. Main outcome variables included favorable outcome (modified Rankin Scale scores of 0-2) 3 months post-stroke as well as procedural time metrics, recanalization status and complications. RESULTS We analyzed 2916 patients (median age 74 years, 50.7% female) who underwent EVT. Patients treated within core working hours more frequently had a favorable outcome (42.6% vs 36.1% treated in the afternoon/evening vs 35.8% treated at night-time; p=0.007). Similar results were found when analyzing 12 treatment windows. All these differences remained significant in multivariable analysis adjusting for outcome-relevant co-factors. Onset-to-recanalization time was considerably longer outside core working hours, which was mainly explained by longer door-to-groin time (p<0.001). There was no difference in the number of passes, recanalization status, groin-to-recanalization time and EVT-related complications. CONCLUSIONS The findings of delayed intrahospital EVT workflows and worse functional outcomes outside core working hours in this nationwide registry are relevant for optimization of stroke care, and might be applicable to other countries with similar settings.
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Affiliation(s)
| | | | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Sebastian Mutzenbach
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
- Institute of Neurointervention, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Sonnberger
- Institute of Neuroradiology, Kepler University Hospital Linz, Linz, Austria
| | - Milan R Vosko
- Department of Neurology, Kepler University Hospital Linz, Linz, Austria
| | - Jörg Weber
- Department of Neurology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Klaus A Hausegger
- Institute of Diagnostic and Interventional Radiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Philipp Werner
- Department of Neurology, State Hospital of Feldkirch/Rankweil, Rankweil, Austria
| | - Dimitre Staykov
- Department of Neurology, St. John's Hospital, Eisenstadt, Austria
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
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Oliveira M, Rocha A, Barbosa F, Barros P, Fonseca L, Ribeiro M, Afreixo V, Gregório T. Acute kidney injury after endovascular therapy in acute stroke patients: systematic review with meta-analysis. J Neurointerv Surg 2023; 15:e468-e474. [PMID: 36797049 DOI: 10.1136/jnis-2022-019955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/09/2023] [Indexed: 02/18/2023]
Abstract
AIMS Endovascular therapy (EVT) is a highly effective stroke treatment, but it requires the administration of contrast media which puts patients at risk of acute kidney injury (AKI). AKI is associated with increased morbidity and mortality in cardiovascular patients. METHODS PubMed, Scopus, ISI and the Cochrane Library were systematically searched for observational and experimental studies assessing the occurrence of AKI in adult acute stroke patients submitted to EVT. Two independent reviewers collected study data regarding study setting, period, source of data, and AKI definition and predictors, the outcomes of interest being AKI incidence and 90-day death or dependency (modified Rankin Scale score ≥3). These outcomes were pooled using random effect models, and heterogeneity was measured using the I2 statistic. RESULTS 22 studies were identified and included in the analysis, involving 32 034 patients. Pooled incidence of AKI was 7% (95% CI 5% to 10%), but heterogeneity was high across studies (I2=98%), and not accounted for by the definition of AKI used. The most frequently reported AKI predictors were impaired baseline renal function (5 studies) and diabetes (3 studies); 3 studies (2103 patients) reported data on death and 4 studies (2424 patients) reported data on dependency. Overall, AKI was associated with both outcomes, with ORs of 6.21 (95% CI 3.52 to 10.96) and 2.86 (95% CI 1.88 to 4.37), respectively. Heterogeneity was low for both analyses (I2=0%). CONCLUSIONS AKI affects 7% of acute stroke patients submitted to EVT and identifies a subgroup of patients for which treatment outcomes are suboptimal, with an increased risk of death and dependency.
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Affiliation(s)
- Marta Oliveira
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Ana Rocha
- Department of Medical Sciences, Universidade de Aveiro, Aveiro, Portugal
| | - Flávia Barbosa
- Department of Medical Sciences, Universidade de Aveiro, Aveiro, Portugal
| | - Pedro Barros
- Stroke Unit, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Porto, Portugal
- Neurology, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Porto, Portugal
| | - Luísa Fonseca
- Stroke Unit, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manuel Ribeiro
- Cerebrovascular Interventional Neuroradiology Unit, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Porto, Portugal
| | - Vera Afreixo
- Center for Research and Development in Mathematics and Applications, University of Aveiro, Aveiro, Portugal
| | - Tiago Gregório
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
- Stroke Unit, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Porto, Portugal
- MEDCIDS, Universidade do Porto Faculdade de Medicina, Porto, Portugal
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Popa D, Iancu A, Petrica A, Buleu F, Williams CG, Sutoi D, Trebuian C, Tudor A, Mederle OA. Emergency Department Time Targets for Interhospital Transfer of Patients with Acute Ischemic Stroke. J Pers Med 2023; 14:13. [PMID: 38276228 PMCID: PMC10820891 DOI: 10.3390/jpm14010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background and objectives: Although the intravenous tissue plasminogen activator (rt-PA) has been shown to be effective in the treatment of acute ischemic stroke (AIS), only a small proportion of stroke patients receive this drug. The low administration rate is mainly due to the delayed presentation of patients to the emergency department (ED) or the lack of a stroke team/unit in most of the hospitals. Thus, the aim of this study is to analyze ED time targets and the rate of rt-PA intravenous administration after the initial admission of patients with AIS in an ED from a traditional healthcare center (without a neurologist or stroke team/unit). Methods: To analyze which factors influence the administration of rt-PA, we split the general sample (n = 202) into two groups: group No rt-PA (n = 137) and group rt-PA (n = 65). This is based on the performing or no intravenous thrombolysis. Results: Analyzing ED time targets for all samples, we found that the median onset-to-ED door time was 180 min (IQR, 120-217.5 min), door-to-physician time was 4 min (IQR, 3-7 min), door-to-CT time was 52 min (IQR, 48-55 min), and door-in-door-out time was 61 min (IQR, 59-65 min). ED time targets such as door-to-physician time (p = 0.245), door-to-CT time (p = 0.219), door-in-door-out time (p = 0.24), NIHSS at admission to the Neurology department (p = 0.405), or NIHSS after 24 h (p = 0.9) did not have a statistically significant effect on the administration or no rt-PA treatment in patients included in our study. Only the highest door-to-CT time was statistically significantly correlated with the death outcome. Conclusion: In our study, the iv rt-PA administration rate was 32.18%. A statistically significant correlation between the highest door-to-CT time and death outcome was found.
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Affiliation(s)
- Daian Popa
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Aida Iancu
- Department of Radiology, “Victor Babes” University of Medicine and Pharmacy, E. Murgu Square no. 2, 300041 Timisoara, Romania
| | - Alina Petrica
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Florina Buleu
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, E. Murgu Square no. 2, 300041 Timisoara, Romania;
| | | | - Dumitru Sutoi
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Cosmin Trebuian
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
| | - Anca Tudor
- Department of Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, E. Murgu Square no. 2, 300041 Timisoara, Romania;
| | - Ovidiu Alexandru Mederle
- Department of Surgery, Emergency Discipline, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.P.); (A.P.); (D.S.); (C.T.)
- Department of Surgery, Multidisciplinary Center for Research, Evaluation, Diagnosis and Therapies in Oral Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Feigin VL, Owolabi MO. Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurol 2023; 22:1160-1206. [PMID: 37827183 PMCID: PMC10715732 DOI: 10.1016/s1474-4422(23)00277-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/14/2023] [Indexed: 10/14/2023]
Abstract
Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met. In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases. Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders. The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.
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Affiliation(s)
- Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.
| | - Mayowa O Owolabi
- Centre for Genomics and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria; Blossom Specialist Medical Centre, Ibadan, Nigeria.
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Pearn K, Allen M, Laws A, Monks T, Everson R, James M. What would other emergency stroke teams do? Using explainable machine learning to understand variation in thrombolysis practice. Eur Stroke J 2023; 8:956-965. [PMID: 37480324 PMCID: PMC10683721 DOI: 10.1177/23969873231189040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/03/2023] [Indexed: 07/24/2023] Open
Abstract
INTRODUCTION The aim of this work was to understand between-hospital variation in thrombolysis use among emergency stroke admissions in England and Wales. PATIENTS A total of 88,928 patients who arrived at all 132 emergency stroke hospitals in England Wales within 4 h of stroke onset, from 2016 to 2018. METHODS Machine learning was applied to the Sentinel Stroke National Audit Programme (SSNAP) data set, to learn which patients in each hospital would likely receive thrombolysis. We used XGBoost machine learning models, coupled with a SHAP model for explainability; Shapley (SHAP) values, providing estimates of how patient features, and hospital identity, influence the odds of receiving thrombolysis. RESULTS Thrombolysis use in patients arriving within 4 h of known or estimated stroke onset ranged 7% -49% between hospitals. The odds of receiving thrombolysis reduced 9-fold over the first 120 min of arrival-to-scan time, varied 30-fold with stroke severity, reduced 3-fold with estimated rather than precise stroke onset time, fell 6-fold with increasing pre-stroke disability, fell 4-fold with onset during sleep, fell 5-fold with use of anticoagulants, fell 2-fold between 80 and 110 years of age, reduced 3-fold between 120 and 240 min of onset-to-arrival time and varied 13-fold between hospitals. The majority of between-hospital variance was explained by the hospital, rather than the differences in local patient populations. CONCLUSIONS Using explainable machine learning, we identified that the majority of the between-hospital variation in thrombolysis use in England and Wales may be explained by differences in in-hospital processes and differences in attitudes to judging suitability for thrombolysis.
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Affiliation(s)
- Kerry Pearn
- University of Exeter Medical School, Exeter, UK
- NIHR South West Peninsula Applied Research Collaboration (ARC), Plymouth, UK
| | - Michael Allen
- University of Exeter Medical School, Exeter, UK
- NIHR South West Peninsula Applied Research Collaboration (ARC), Plymouth, UK
| | - Anna Laws
- University of Exeter Medical School, Exeter, UK
- NIHR South West Peninsula Applied Research Collaboration (ARC), Plymouth, UK
| | - Thomas Monks
- University of Exeter Medical School, Exeter, UK
- NIHR South West Peninsula Applied Research Collaboration (ARC), Plymouth, UK
| | | | - Martin James
- NIHR South West Peninsula Applied Research Collaboration (ARC), Plymouth, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
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Babaei HA, Ferdosi M, Masoumi G, Rezaei F. A comparative study on specialized services in pre-hospital emergencies in Iran and selected countries. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:414. [PMID: 38333162 PMCID: PMC10852191 DOI: 10.4103/jehp.jehp_232_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/01/2023] [Indexed: 02/10/2024]
Abstract
The quality of emergency services is one of the indicators describing the health status of countries. Moreover, the specialization of services and targeted response to any accident or disease has been the priority of pre-hospital emergency operations in some leading countries. This study aimed to compare the special services provided in the emergency department of several selected countries. This was a comparative study that was done in Isfahan in 2022. Data were collected by reviewing the literature provided by libraries and emergency websites of selected countries. We selected countries based on the accessibility of information in two groups of developed countries and countries with the same income and population as Iran including Germany, France, The United States, Australia, Britain, Malaysia, and Turkey. Data were classified and compared based on staff, vehicles, and specialized services. Emergency staffs in most countries were of different skill and training levels. Ambulances varied in equipment types in various land, air, and sea forms and dimensions. Developed countries had more modern ambulances and equipment. France and Germany were operating more especially. Specialized teams are dispatched only in the United States and Germany. Existing studies have shown the adequacy and effectiveness of these teams in reducing complications and mortality and improving the prognosis of patients. The use of specialized teams appropriate to each emergency based on the specific and targeted response is effective in improving the prognosis of patients. The results of this study are suggested to beneficiaries to improve the quality of emergency care and reduce complications and potential causalities.
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Affiliation(s)
- Habib Allah Babaei
- Department of Health in Disasters and Emergencies, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoud Ferdosi
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholamraza Masoumi
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
- Emergency Management Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Rezaei
- Department of Health in Disasters and Emergencies, Health Management and Economics Research Centers, Isfahan University of Medical Sciences, Isfahan, Iran
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Akay EMZ, Rieger J, Schöttler R, Behland J, Schymczyk R, Khalil AA, Galinovic I, Sobesky J, Fiebach JB, Madai VI, Hilbert A, Frey D. A deep learning analysis of stroke onset time prediction and comparison to DWI-FLAIR mismatch. Neuroimage Clin 2023; 40:103544. [PMID: 38000188 PMCID: PMC10709350 DOI: 10.1016/j.nicl.2023.103544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION When time since stroke onset is unknown, DWI-FLAIR mismatch rating is an established technique for patient stratification. A visible DWI lesion without corresponding parenchymal hyperintensity on FLAIR suggests time since onset of under 4.5 h and thus a potential benefit from intravenous thrombolysis. To improve accuracy and availability of the mismatch concept, deep learning might be able to augment human rating and support decision-making in these cases. METHODS We used unprocessed DWI and coregistered FLAIR imaging data to train a deep learning model to predict dichotomized time since ischemic stroke onset. We analyzed the performance of Group Convolutional Neural Networks compared to other deep learning methods. Unlabeled imaging data was used for pre-training. Prediction performance of the best deep learning model was compared to the performance of four independent junior and senior raters. Additionally, in cases deemed indeterminable by human raters, model ratings were used to augment human performance. Post-hoc gradient-based explanations were analyzed to gain insights into model predictions. RESULTS Our best predictive model performed comparably to human raters. Using model ratings in cases deemed indeterminable by human raters improved rating accuracy and interrater agreement for junior and senior ratings. Post-hoc explainability analyses showed that the model localized stroke lesions to derive predictions. DISCUSSION Our analysis shows that deep learning based clinical decision support has the potential to improve the accessibility of the DWI-FLAIR mismatch concept by supporting patient stratification.
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Affiliation(s)
- Ela Marie Z Akay
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Jana Rieger
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ricardo Schöttler
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Behland
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Raphael Schymczyk
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ahmed A Khalil
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Sobesky
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Vince I Madai
- QUEST Center for Responsible Research, Berlin Institute of Health (BIH), Charité Universitätsmedizin Berlin, Berlin, Germany; Faculty of Computing, Engineering and the Built Environment, School of Computing and Digital Technology, Birmingham City University, Birmingham, United Kingdom
| | - Adam Hilbert
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Frey
- Charité Lab for Artificial Intelligence in Medicine (CLAIM), Charité Universitätsmedizin Berlin, Berlin, Germany
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Deng X, Chu W, Zhang H, Peng Y. Nrf2 and Ferroptosis: A New Research Direction for Ischemic Stroke. Cell Mol Neurobiol 2023; 43:3885-3896. [PMID: 37728817 DOI: 10.1007/s10571-023-01411-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 09/04/2023] [Indexed: 09/21/2023]
Abstract
Ischemic stroke (IS) is one of the leading causes of death and morbidity worldwide. As a novel form of cell death, ferroptosis is an important mechanism of ischemic stroke. Nuclear factor E2-related factor 2 (Nrf2) is the primary regulator of cellular antioxidant response. In addition to alleviating ischemic stroke nerve damage by reducing oxidative stress, Nrf2 regulates genes associated with ferroptosis, suggesting that Nrf2 may inhibit ferroptosis after ischemic stroke. However, the specific pathway of Nrf2 on ferroptosis in the field of ischemic stroke remains unclear. Therefore, this paper provides a concise overview of the mechanisms underlying ferroptosis, with a particular focus on the regulatory role of Nrf2. The discussion highlights the potential connections between Nrf2 and the mitigation of oxidative stress, regulation of iron metabolism, modulation of the interplay between ferroptosis and inflammation, as well as apoptosis. This paper focuses on the specific pathway of Nrf2 regulation of ferroptosis after ischemic stroke, providing scientific research ideas for further research on the treatment of ischemic stroke.
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Affiliation(s)
- Xiaoman Deng
- Department of Acupuncture and Rehabilitation, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Wenming Chu
- Henan University of Chinese Medicine, Zhengzhou, 450000, Henan Province, China
| | - Hanrui Zhang
- Department of Acupuncture and Rehabilitation, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China
| | - Yongjun Peng
- Department of Acupuncture and Rehabilitation, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, Jiangsu Province, China.
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Guo X, Dye J. Modern Prehospital Screening Technology for Emergent Neurovascular Disorders. Adv Biol (Weinh) 2023; 7:e2300174. [PMID: 37357150 DOI: 10.1002/adbi.202300174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/14/2023] [Indexed: 06/27/2023]
Abstract
Stroke is a serious neurological disease and a significant contributor to disability worldwide. Traditional in-hospital imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) remain the standard modalities for diagnosing stroke. The development of prehospital stroke detection devices may facilitate earlier diagnosis, initiation of stroke care, and ultimately better patient outcomes. In this review, the authors summarize the features of eight stroke detection devices using noninvasive brain scanning technology. The review summarizes the features of stroke detection devices including portable CT, MRI, transcranial Doppler ultrasound , microwave tomographic imaging, electroencephalography, near-infrared spectroscopy, volumetric impedance phaseshift spectroscopy, and cranial accelerometry. The technologies utilized, the indications for application, the environments indicated for application, the physical features of the eight stroke detection devices, and current commercial products are discussed. As technology advances, multiple portable stroke detection instruments exhibit the promising potential to expedite the diagnosis of stroke and enhance the time taken for treatment, ultimately aiding in prehospital stroke triage.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurology, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, CA, 92354, USA
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Caso V, Martins S, Mikulik R, Middleton S, Groppa S, Pandian JD, Thang NH, Danays T, van der Merwe J, Fischer T, Hacke W. Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide. Int J Stroke 2023; 18:898-907. [PMID: 37226325 PMCID: PMC10507995 DOI: 10.1177/17474930231180067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.
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Affiliation(s)
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Robert Mikulik
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
| | - Sandy Middleton
- Australian Catholic University and St. Vincent’s Health Network Sydney, Sydney, NSW, Australia
| | - Stanislav Groppa
- State University of Medicine and Pharmacy ‘Nicolae Testemitanu,’ Chisinau, Moldova
| | | | | | | | - Jan van der Merwe
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Werner Hacke
- Ruprecht-Karl-University Heidelberg, Heidelberg, Germany
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Siskou O, Galanis P, Konstantakopoulou O, Stafylas P, Karagkouni I, Tsampalas E, Garefou D, Alexopoulou H, Gamvroula A, Lypiridou M, Kalliontzakis I, Fragkoulaki A, Kouridaki A, Tountopoulou A, Kouzi I, Vassilopoulou S, Manios E, Mavraganis G, Vemmou A, Karagkiozi E, Savopoulos C, Dimas G, Myrou A, Milionis H, Siopis G, Evaggelou H, Protogerou A, Samara S, Karapiperi A, Kakaletsis N, Papastefanatos G, Papastefanatos S, Sourtzi P, Ntaios G, Vemmos K, Korompoki E, Kaitelidou D. The Cost and the Value of Stroke Care in Greece: Results from the SUN4P Study. Healthcare (Basel) 2023; 11:2545. [PMID: 37761742 PMCID: PMC10530928 DOI: 10.3390/healthcare11182545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this study was to measure the one-year total cost of strokes and to investigate the value of stroke care, defined as cost per QALY. The study population included 892 patients with first-ever acute strokes, hemorrhagic strokes, and ischemic strokes, (ICD-10 codes: I61, I63, and I64) admitted within 48 h of symptoms onset to nine public hospitals located in six cities. We conducted a bottom-up cost analysis from the societal point of view. All cost components including direct medical costs, productivity losses due to morbidity and mortality, and informal care costs were considered. We used an annual time horizon, including all costs for 2021, irrespective of the time of disease onset. The average cost (direct and indirect) was extrapolated in order to estimate the national annual burden associated with stroke. We estimated the total cost of stroke in Greece at EUR 343.1 mil. a year in 2021, (EUR 10,722/patient or EUR 23,308 per QALY). Out of EUR 343.1 mil., 53.3% (EUR 182.9 mil.) consisted of direct healthcare costs, representing 1.1% of current health expenditure in 2021. Overall, productivity losses were calculated at EUR 160.2 mil. The mean productivity losses were estimated to be 116 work days with 55.1 days lost due to premature retirement and absenteeism from work, 18.5 days lost due to mortality, and 42.4 days lost due to informal caregiving by family members. This study highlights the burden of stroke and underlines the need for stakeholders and policymakers to re-organize stroke care and promote interventions that have been proven cost-effective.
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Affiliation(s)
- Olga Siskou
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
- Department of Tourism Studies University of Piraeus, 185 34 Piraeus, Greece
| | - Petros Galanis
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - Olympia Konstantakopoulou
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | | | - Iliana Karagkouni
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - Evangelos Tsampalas
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Dafni Garefou
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Helen Alexopoulou
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Anastasia Gamvroula
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | - Maria Lypiridou
- Department of Neurology, Panarkadikon General Hospital, 221 00 Tripoli, Greece
| | | | | | - Aspasia Kouridaki
- Department of Neurology, General Hospital of Chania, 733 00 Creta, Greece
| | - Argyro Tountopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (A.T.)
| | - Ioanna Kouzi
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (A.T.)
| | - Sofia Vassilopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (A.T.)
| | - Efstathios Manios
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
| | - Anastasia Vemmou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 413 34 Larissa, Greece (G.N.)
| | - Christos Savopoulos
- 1st Medical Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 546 36 Thessaloniki, Greece
| | - Gregorios Dimas
- 1st Medical Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 546 36 Thessaloniki, Greece
| | - Athina Myrou
- 1st Medical Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 546 36 Thessaloniki, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Georgios Siopis
- Department of Internal Medicine, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Hara Evaggelou
- Department of Internal Medicine, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Athanasios Protogerou
- Cardiovascular Prevention & Research Unit, Laiko General Hospital of Athens at the Medical School, National & Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Stamatina Samara
- Cardiovascular Prevention & Research Unit, Laiko General Hospital of Athens at the Medical School, National & Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Asteria Karapiperi
- Cardiovascular Prevention & Research Unit, Laiko General Hospital of Athens at the Medical School, National & Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Nikolaos Kakaletsis
- Second Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokrateion General Hospital of Thessaloniki, 546 42 Thessaloniki, Greece
| | - George Papastefanatos
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
- Information Management Systems Institute, ATHENA Research Center, 151 25 Athens, Greece
| | - Stefanos Papastefanatos
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - Panayota Sourtzi
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 413 34 Larissa, Greece (G.N.)
- Hellenic Stroke Organization, 115 28 Athens, Greece;
| | | | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece (E.K.)
- Hellenic Stroke Organization, 115 28 Athens, Greece;
| | - Daphne Kaitelidou
- Center for Health Services Management and Evaluation, Department of Nursing National and Kapodistrian, University of Athens, 115 27 Athens, Greece (D.K.)
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Ohashi K, Osanai T, Fujiwara K, Tanikawa T, Tani Y, Takamiya S, Sato H, Morii Y, Ogasawara K. Access to mechanical thrombectomy and ischemic stroke mortality in Japan: a spatial ecological study. Front Neurol 2023; 14:1209446. [PMID: 37731848 PMCID: PMC10507726 DOI: 10.3389/fneur.2023.1209446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023] Open
Abstract
Background Advances in stroke treatment have greatly improved outcomes; however, disparities in access to treatment might increase. Achieving equitable access to stroke treatment is a health policy challenge, as rapid treatment is essential for positive outcomes. This ecological cross-sectional study aimed to determine the relationship between the disparities in spatial accessibility to mechanical thrombectomy (SAMT) and stroke mortality rates in Japan, hypothesizing that disparities in SAMT may increase the differences in stroke mortality between regions. Methods We used the average number of ischemic stroke (IS) deaths between 2020 and 2021 as the response variable; and SAMT, medical resources, and socioeconomic characteristics of each municipality as explanatory variables. A conditional autoregressive model was used to examine the association between the risk of stroke mortality and SAMT. The standardized mortality ratio (SMR) was mapped to understand the nationwide disparities in stroke mortality risk. Results The median number of IS deaths was 17.5 persons per year in the municipalities (2020 to 2021). The study also found that municipalities with low SAMT were located in the northern part of Japan. The non-spatial regression model results indicated that poor accessibility, a small proportion of bachelor's degrees or higher, and a high proportion of workers in secondary industries were related to high IS mortality. Three models were evaluated using spatial analysis; Model 1 with accessibility indicators alone, Model 2 with medical resources added to Model 1, and Model 3 with socioeconomic characteristics added to Model 2. In Models 1 and 2, the population-weighted spatial accessibility index (PWSAI) showed a significant negative relationship with stroke mortality. However, this was not evident in Model 3. Mapping using Model 3 showed that the high-risk areas were predominantly located in northern Japan, excluding Hokkaido. Conclusion Access to mechanical thrombectomy was estimated, and regional differences were observed. The relationship between accessibility and IS mortality is unknown; however, regardless of accessibility, municipalities with a high proportion of workers in secondary industries and a small proportion with bachelor's degrees or above are at risk of death from stroke.
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Affiliation(s)
- Kazuki Ohashi
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kensuke Fujiwara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Graduate School of Commerce, Otaru University of Commerce, Otaru, Japan
| | - Takumi Tanikawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Faculty of Health Sciences, Hokkaido University of Science, Sapporo, Japan
| | - Yuji Tani
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Department of Medical Informatics and Hospital Management, Asahikawa Medical University, Asahikawa, Japan
| | - Soichiro Takamiya
- Department of Neurosurgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan
| | - Hirotaka Sato
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yasuhiro Morii
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Wako, Japan
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Mansour M. Reperfusion Therapies in Acute Ischemic Stroke Beyond the Conventional Time Window: A Narrative Review. Cureus 2023; 15:e45864. [PMID: 37881372 PMCID: PMC10597672 DOI: 10.7759/cureus.45864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
Stroke is the second most common cause of death worldwide, with 50% of survivors experiencing long-term disability. For more than two decades, treatment with intravenous thrombolysis (IVT) and mechanical endovascular thrombectomy (MET), the only approved stroke reperfusion therapies, was restricted to patients within the 4.5-6 hour time window, respectively. Therefore, patients who presented with acute ischemic stroke (AIS) beyond the conventional time window were excluded from reperfusion treatment. This narrative review aims to review the scientific literature on the possibilities of reperfusion therapies for patients who present with an unknown time of stroke onset, and those with stroke onset beyond the conventional 4.5-6 hour time window. Beyond the conventional time window, the eligibility of patients for IVT or MET, the two main therapeutic procedures, is decided based on the concept of penumbral imaging. Penumbral imaging identifies patients with hypoperfused but viable brain tissue, who could benefit from reperfusion. On the other hand, clock-based DWI-fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) can detect stroke that has occurred within 4.5 hours in patients with an unknown time of onset, including patients who awaken with stroke. The introduction of penumbral imaging and MRI-based tissue clocking as imaging biomarkers for stroke has revolutionized stroke therapy, potentially allowing for personalized treatment of eligible stroke patients.
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Affiliation(s)
- Mohammad Mansour
- Department of General Medicine, University of Debrecen, Debrecen, HUN
- Department of General Medicine, Jordan University Hospital, Amman, JOR
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Aguiar de Sousa D, Wilkie A, Norrving B, Macey C, Bassetti C, Tiu C, Roth G, Lunde G, Christensen H, Fiehler J, Pezzella FR, Dichgans M, Roaldsen MB, Kelly P, Mikulik R, Sacco S, Caso V, Fischer U. Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020. Eur Stroke J 2023; 8:618-628. [PMID: 37431768 PMCID: PMC10472963 DOI: 10.1177/23969873231186042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020. PATIENTS AND METHODS We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively. RESULTS The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90-4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63-26.43) per 100,000 and 17.14% (95% CI: 12.98-21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96-9.77) per 100,000 and 6.91% (95% CI: 5.15-8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016. CONCLUSION Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.
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Affiliation(s)
- Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital and Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Bo Norrving
- Department of Clinical Sciences, Section of Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Claudio Bassetti
- Department of Neurology, Inselspital Bern and Medical Faculty, University of Bern, Bern, Switzerland
| | - Cristina Tiu
- Department of Clinical Neurosciences, University of Medicine and Pharmacy ‘Carol Davila’ Bucharest, and Department of Neurology, University Hospital Bucharest, Romania
| | - Greg Roth
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Martin Dichgans
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilian University, Munich and German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Melinda B Roaldsen
- Center for Research and Education, University Hospital of North Norway and Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Peter Kelly
- Stroke and Neurology Department, Mater University Hospital and Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Robert Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czech Republic
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences University of L’Aquila, L’Aquila, Italy
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
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Grunwald IQ, Mathias K, Bertog S, Snyder KV, Sievert H, Siddiqui A, Musialek P, Hornung M, Papanagiotou P, Comelli S, Pillai S, Routledge H, Nizankowski RT, Ewart I, Fassbender K, Kühn AL, Alvarez CA, Alekyan B, Skrypnik D, Politi M, Tekieli L, Haldis T, Gaikwad S, Houston JG, Donald-Simpson H, Guyler P, Petrov I, Roffe C, Abelson M, Hargroves D, Mani S, Podlasek A, Witkowski A, Sievert K, Pawlowski K, Dziadkiewicz A, Hopkins NL. World Federation for Interventional Stroke Treatment (WIST) Multispecialty Training Guidelines for Endovascular Stroke Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 53:67-72. [PMID: 37012107 DOI: 10.1016/j.carrev.2023.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/09/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Today, endovascular treatment (EVT) is the therapy of choice for strokes due to acute large vessel occlusion, irrespective of prior thrombolysis. This necessitates fast, coordinated multi-specialty collaboration. Currently, in most countries, the number of physicians and centres with expertise in EVT is limited. Thus, only a small proportion of eligible patients receive this potentially life-saving therapy, often after significant delays. Hence, there is an unmet need to train a sufficient number of physicians and centres in acute stroke intervention in order to allow widespread and timely access to EVT. AIM To provide multi-specialty training guidelines for competency, accreditation and certification of centres and physicians in EVT for acute large vessel occlusion strokes. MATERIAL AND METHODS The World Federation for Interventional Stroke Treatment (WIST) consists of experts in the field of endovascular stroke treatment. This interdisciplinary working group developed competency - rather than time-based - guidelines for operator training, taking into consideration trainees' previous skillsets and experience. Existing training concepts from mostly single specialty organizations were analysed and incorporated. RESULTS The WIST establishes an individualized approach to acquiring clinical knowledge and procedural skills to meet the competency requirements for certification of interventionalists of various disciplines and stroke centres in EVT. WIST guidelines encourage acquisition of skills using innovative training methods such as structured supervised high-fidelity simulation and procedural performance on human perfused cadaveric models. CONCLUSIONS WIST multispecialty guidelines outline competency and quality standards for physicians and centres to perform safe and effective EVT. The role of quality control and quality assurance is highlighted. SUMMARY The World Federation for Interventional Stroke Treatment (WIST) establishes an individualized approach to acquiring clinical knowledge and procedural skills to meet the competency requirements for certification of interventionalists of various disciplines and stroke centres in endovascular treatment (EVT). WIST guidelines encourage acquisition of skills using innovative training methods such as structured supervised high-fidelity simulation and procedural performance on human perfused cadaveric models. WIST multispecialty guidelines outline competency and quality standards for physicians and centers to perform safe and effective EVT. The role of quality control and quality assurance is highlighted. SIMULTANEOUS PUBLICATION The WIST 2023 Guidelines are published simultaneously in Europe (Adv Interv Cardiol 2023).
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Affiliation(s)
- Iris Q Grunwald
- Department of Radiology, NHS Tayside, Dundee, UK; Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, School of Medicine, University of Dundee, UK; Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany.
| | - Klaus Mathias
- Asklepios Clinik St. Georg-Klinische und Interventionelle Angiologie, Hamburg, Germany
| | - Stefan Bertog
- Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany; Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA; Jacobs Institute, Buffalo, NY
| | - Horst Sievert
- Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany
| | - Adnan Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA; Jacobs Institute, Buffalo, NY
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Marius Hornung
- Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany; SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Panagiotes Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Bremen, Germany; First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, Athens, Greece
| | - Simone Comelli
- S. C. Neuroradiologia ed Interventistica Vascolare, Ospedale S. Michele, Cagliari, Italy
| | | | - Helen Routledge
- Worcestershire Royal Hospital, Cardiology Department, Worcester, United Kingdom
| | - Rafal T Nizankowski
- Accreditation Council, National Centre for Health Quality Assessment, Krakow, Poland
| | - Ian Ewart
- Mid and South Essex NHS Foundation Trust, United Kingdom
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Anna L Kühn
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, USA
| | - Carlos A Alvarez
- Hospital Italiano Regional Del Sur, Hospital Privado Del Sur and Hospital Regional Español, Bahia Blanca, Argentina
| | | | - Dmitry Skrypnik
- I.V. Davidovsky City Hospital, Moscow State University and Dentistry, Moscow, Russia
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Bremen, Germany
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | | | - Shailesh Gaikwad
- Department of Neuroimaging and Interventional Neuroradiology, Neurosciences Center, Ansari Nagar, All India Institute of Medical Sciences (A.I.I.M.S), New Delhi, India
| | - John Graeme Houston
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, School of Medicine, University of Dundee, UK
| | - Helen Donald-Simpson
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, School of Medicine, University of Dundee, UK
| | - Paul Guyler
- Mid and South Essex NHS Foundation Trust, United Kingdom
| | - Ivo Petrov
- Department of Cardiology and Angiology, Acibadem City Clinic-Cardiovascular Center, Sofia, Bulgaria
| | - Christine Roffe
- University Hospital of North Midlands, Keele University, Stoke-on-Trent, UK
| | - Mark Abelson
- Vergelegen MediClinic, Somerset West, University of Cape Town, South Africa
| | - David Hargroves
- East Kent Hospitals University NHS Foundation Trust, Ashford, United Kingdom
| | | | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, School of Medicine, University of Dundee, UK; Precision Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Adam Witkowski
- Deptartment of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Kolja Sievert
- Cardiovascular Center Frankfurt, Sankt Katharinen, Frankfurt, Germany
| | - Krzysztof Pawlowski
- Department of Cardiology and Interventional Angiology, Kashubian Center for Heart and Vascular Diseases, Pomeranian Hospitals, Wejherowo, Poland
| | - Artur Dziadkiewicz
- Department of Neurology and Stroke, Pomeranian Hospitals, Wejherowo, Poland
| | - Nelson L Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA; Jacobs Institute, Buffalo, NY
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Aref H, El Nahas N, Alrukn SA, Khan M, Kesraoui S, Alnidawi F, Hokmabadi ES, Farhoudi M, Fairooz M, Batayha W, Salmeen A, Abdulrahman H, Belahsen MF, Al Hashmi AM, Akhtar N, Al-Johani M, Seidi OA, Jouhar A, Mhiri C, Elbassiouny A, Shokri H, Roushdy T. Stroke services in MENA: What is there and what is needed. PLoS One 2023; 18:e0288030. [PMID: 37471350 PMCID: PMC10358887 DOI: 10.1371/journal.pone.0288030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 06/16/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVES Stroke represents a health care challenge to most parts of the world including the Middle East and North Africa (MENA) region. The MENA represents 6% of the world population with an age-standardized stroke rate of 87.7 (78.2-97.6) per 100,000 population. This number is subject to increase given that the cause of morbidity has recently shifted from infectious diseases to non-communicable diseases. Thus, in the coming years, treatment of stroke will pose a major burden on MENA countries which mostly lie in the low to middle income economies. Accordingly, we need to study the state of MENA stroke services in order to recognize and further inform policy makers about any gaps that need to be bridged in this domain. METHODS AND RESULTS Stroke specialists representing 16 countries filled an online survey that included: screening for risk factors, acute management, diagnostics, medications, post-discharge services, and stroke registries. Results showed that 11 countries screen for risk factors, 16 have neuroimaging studies, 15 provide intravenous thrombolysis (IVT), 13 mechanical thrombectomy (MT) while medications for secondary prevention are available in all countries. However, stroke units are not equally available and even absent in 4 countries, and despite the availability of IVT yet, the rate of administration is still low in 6 countries (<5%), and ranges from 5-20% in 7 countries. Stroke registries and training still need to be implemented in most countries. CONCLUSION Although imaging, revascularization therapies and medications for secondary prevention are available in most MENA countries, yet the rate of revascularization is low, so is the number of stroke units insufficient in some countries. Additionally, registries and structured training are still defective. Further field studies are required for more accurate determination of the status of stroke services in the MENA region.
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Affiliation(s)
- Hany Aref
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nevine El Nahas
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Maria Khan
- Neurology Department, Rashid Hospital, Dubai, United Arab Emirates
| | - Selma Kesraoui
- Neurology Department, Blida Hospital University, Blida, Algeria
| | - Firas Alnidawi
- Neurology Department, Salmaniyah Medical Complex, Manama, Bahrain
| | | | - Mehdi Farhoudi
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Muataz Fairooz
- Neurology Department, Sa’ad Al-Witry Neurosciences Hospital, Baghdad, Iraq
| | - Waleed Batayha
- Neurology Department, Basma Teaching Hospital, Irbid, Jordan
| | - Athari Salmeen
- Neurology Department, Jaber AlAhmad Hospital, Kuwait, Kuwait
| | | | - Mohammed Faouzi Belahsen
- Neurology Department, Hassan II University Hospital, Sidi Mohamed Ben Abdellah University, Fez, Morocco
| | - Amal M. Al Hashmi
- Central Stroke Unit, Neuroscience Directorate, Khoula Hospital, Muscat, Oman
| | - Naveed Akhtar
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Al-Johani
- Neurology Department, King Salman ibn Abdulaziz Medical City, Madinah, Saudi Arabia
| | - Osheik Abu’Asha Seidi
- Neurology Department, Faculty of Medicine and Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | - Anas Jouhar
- Neurology and Neurophysiology Department, Damascus Hospital, Damascus, Syria
| | - Chokri Mhiri
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Ahmed Elbassiouny
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hossam Shokri
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tamer Roushdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Vilionskis A, Korv J. Editorial: Quality of stroke care: what could be improved, and how? Front Neurol 2023; 14:1250872. [PMID: 37497011 PMCID: PMC10368399 DOI: 10.3389/fneur.2023.1250872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
| | - Janika Korv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
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Abstract
PURPOSE OF REVIEW This review aims to summarize the therapeutic advances and evidence in the medical management of acute ischemic stroke (AIS). Recent evidence comparing the efficacy and safety of tenecteplase (TNK) with alteplase for intravenous thrombolysis (IVT) in AIS will be highlighted. Recent advances and evidence on improving micro-circulation following endovascular procedures and neuroprotection will be reviewed. RECENT FINDINGS A significant number of randomized control studies now support the use of tenecteplase for IVT in AIS. TNK 0.25 mg/kg single bolus is as effective and well tolerated as alteplase 0.9 mg/kg infusion for IVT in AIS. Evidence from randomized control trials (RCTs) has shown effective and well tolerated expansion of the therapeutic window of IVT in the wake-up stroke and up to 9 h after last seen well, using advanced neuroimaging with computed tomography perfusion/MRI. Early evidence suggests that intra-arterial alteplase may help improve microcirculation in patients with large vessel occlusion following successful thrombectomy. However, more trials are required to confirm the results. Similarly, early evidence from a recent RCT showed that remote ischemic conditioning confers potential neuroprotection and improves outcomes in AIS. SUMMARY Converging evidence has demonstrated that for patients with ischemic stroke presenting at under 4.5 h from the onset, TNK is comparable to alteplase. These data along with the practical advantages of TNK have resulted in a shift to replace intravenous TNK as the standard for thrombolysis. Ongoing studies of IVT with TNK are focussed on defining the optimal dose, expanding the time window with multimodal imaging and defining the role of thrombolysis for bridging patients with stroke due to large vessel occlusion.
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Affiliation(s)
- Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Urbanek C, Jung J, Güney R, Potreck A, Nagel S, Grau AJ, Boujan T, Luckscheiter A, Bendszus M, Möhlenbruch MA, Seker F. Clinical outcome, recanalization success, and time metrics in drip-and-ship vs. drive-the-doctor: A retrospective analysis of the HEI-LU-Stroke registry. Front Neurol 2023; 14:1142983. [PMID: 36970521 PMCID: PMC10035332 DOI: 10.3389/fneur.2023.1142983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
PurposeThis study aimed at comparing clinical outcome, recanalization success and time metrics in the “drip and ship” (DS) vs. “drive the doctor” (DD) concept in a comparable setting.MethodsThis is a retrospective analysis of thrombectomy registries of a comprehensive stroke center (CSC) and a thrombectomy-capable stroke center (TSC). Patients, who were transferred from the TSC to the CSC, were classified as DS. Patients treated at the TSC by an interventionalist transferred from the CSC were classified as DD. Good outcome was defined as mRS 0–2 or equivalent to premorbid mRS at discharge. Recanalization (TICI 2b-3 or equivalent) and time metrics were compared in both groups.ResultsIn total, 295 patients were included, of which 116 (39.3%) were treated in the DS concept and 179 (60.7%) in the DD concept. Good clinical outcome was similarly achieved in DS and DD (DS 25.0% vs. DD 31.3%, P = 0.293). mRS on discharge (DS median 4, DD median 4, P = 0.686), NIHSS improvement (DS median 4, DD median 5, P = 0.582) and NIHSS on discharge (DS median 9, DD median 7, P = 0.231) were similar in both groups. Successful reperfusion was achieved similarly in DS (75.9%) and DD as well (81.0%, P = 0.375). Time from onset to reperfusion (median DS 379 vs. DD 286 min, P = 0.076) and time from initial imaging to reperfusion were longer in DS compared to DD (median DS 246 vs. DD 162 min, P < 0.001).ConclusionThe DD concept is time saving while achieving similar clinical outcome and recanalization results.
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Affiliation(s)
- Christian Urbanek
- Department of Neurology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Jasmin Jung
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Resul Güney
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Armin J. Grau
- Department of Neurology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Timan Boujan
- Department of Radiology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Andre Luckscheiter
- Department of Anaesthesiology, Clinical Centre of the City of Ludwigshafen, Ludwigshafen, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
- *Correspondence: Fatih Seker
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