A nationwide study on topography and efficacy of the stroke treatment network in the Czech republic

Comparative effects of low-dose versus standard-dose alteplase in ischemic patients with prior stroke and/or diabetes mellitus: The ENCHANTED trial

BACKGROUND AND PURPOSE

History of prior stroke (PS) and diabetes mellitus (DM) are considered relative contraindications to the use of intravenous alteplase in patients with acute ischemic stroke (AIS). We aimed to assess whether a history of PS and DM modified the comparative effects of low- versus standard-dose alteplase in patients who participated in the alteplase-dose arm of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

METHODS

Data from an international, multi-center, prospective, randomized, open-label, blinded-endpoint trial were used to assess the benefits and risks of low (0.6mg/kg) versus standard-dose (0.9mg/kg) intravenous alteplase in thrombolysis-eligible AIS patients. Logistic regression was used for analysis of patient subgroups defined by history of PS and DM on efficacy and safety outcomes, adjusted for confounding variables.

RESULTS

After adjusting for baseline characteristics and management variables over the first seven days in 3288 AIS patients (431 PS, 489 DM, and 157 with both), history of PS and DM were not associated with poor outcome at 90-days: whether defined by modified Rankin scale (mRS) scores 2-6 (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.55-1.32; P=0.476) or mortality (OR 1.25, 95%CI 0.62-2.52; P=0.533). There was no differential effect of low-versus standard-dose alteplase on dichotomized mRS (0-1 vs. 2-6), ordinal shift in mRS scores, mortality, or symptomatic intracerebral hemorrhage, by a history of PS and DM.

CONCLUSIONS

A history of PS and DM was not an independent predictor of poor outcome in thrombolysis-treated AIS patients. We were not able to demonstrate any effect of these variables in modifying the differences in effects of low- versus standard-dose alteplase.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov.

UNIQUE IDENTIFIER

NCT01422616.

Interrater variability for CT angiography evaluation between neurologists and neuroradiologist in acute stroke patients

Objective:

The diagnosis of arterial occlusion has a considerable impact on the indication of mechanical thrombectomy, and CT angiography (CTA) is recommended in the management of acute stroke. The goal of the present study is to assess the interrater agreement in the diagnosis of occlusion of intracranial arteries on CTA between a neuroradiologist and neurologists.

Methods:

CTA images of 75 acute stroke patients were evaluated for occlusion of intracranial arteries by an experienced interventional neuroradiologist, and stroke and general neurologists.

Results:

75 patients who were treated by intravenous thrombolysis were enrolled in the study. CTA images were available for all 75 patients (34 females; mean age ± SD, 72 ± 14 years; National Institutes of Health Stroke Scale 10; median 8–14; and Alberta Stroke Program Early CT mean 9.7). The agreement between the neuroradiologist and neurologists in evaluation of intracranial artery occlusion was as follows: occlusion of the middle cerebral artery segment M1: observer agreement 77%, kappa (κ) = 0.61 and middle cerebral artery M2: observer agreement 77%, κ 0.48; internal carotid artery: observer agreement 92%, κ 0.84; T occlusion: observer agreement 90.0%, κ 0.33; posterior cerebral artery segments P1 and P2: observer agreement 98%, κ 0.97; basilar artery: observer agreement 96%, κ 0.92; and vertebral artery segment V4: observer agreement 88%, κ 0.48.

Conclusion:

Interrater agreement of CTA evaluation of occlusion between the neurologists and the neuroradiologist was very strong. The ability of the trained neurologists to read an intracranial large vessel occlusion correctly may improve the door-to-needle times in acute stroke.

Advances in knowledge:

In this study, the neurologists were able to recognize occlusion of intracranial arteries. This could accelerate the management of acute stroke care.

Incidence of Hospitalized Stroke in the Czech Republic: The National Registry of Hospitalized Patients

BACKGROUND

Contemporary stroke incidence data are not available in some countries and regions, including in Eastern Europe. Based on previous validation of the accuracy of the National Registry of Hospitalized Patients (NRHOSP), we report the incidence of hospitalized stroke in the Czech Republic (CR) using the NRHOSP.

METHODS

The results of the prior validation study assessing the accuracy of coding of stroke diagnoses in the NRHOSP were applied, and we calculated (1) the overall incidence of hospitalized stroke and (2) the incidence rates of hospitalized stroke for the three main stroke types: cerebral infarction (International Classification of Diseases Tenth Revision, CI I63), subarachnoid hemorrhage (SAH I60), and intracerebral hemorrhage (ICH I61). We calculated the average annual age- and sex-standardized incidence.

RESULTS

The overall incidence of hospitalized stroke was 241 out of 100,000 individuals. The incidence of hospitalized stroke for the main stroke types was 8.2 cases in SAH, 29.5 in ICH, and 211 in CI per 100,000 individuals. The standardized annual stroke incidence adjusted to the 2000 World Health Organization population for overall stroke incidence of hospitalized stroke was 131 per 100,000 individuals. Standardized stroke incidence for stroke subtypes was 5.7 cases in SAH, 16.7 in ICH, and 113 in CI per 100,000 individuals.

CONCLUSIONS

These studies provide an initial assessment of the burden of stroke in this part of the world. The estimates of hospitalized stroke in the CR and Eastern Europe suggest that ICH is about three times more common than SAH, and hemorrhagic stroke makes up about 18% of strokes.

The High Frequency of Guideline-Approved and Guideline-Disapproved Medication Use in Stroke and Transient Ischemic Attack

BACKGROUND AND PURPOSE

Administration of evidence-based pharmacotherapy improves stroke outcome while the use of non-evidence-based medications may not be of benefit and leads to unnecessary patient care costs. The aim of our study was to determine the frequency of guideline-approved and guideline-disapproved pharmacotherapy use in acute stroke management in the Czech Republic (CR).

METHODS

Using the ICD-10 codes, 500 stroke and transient ischemic attack (TIA) patients were randomly selected (random selection of 10 hospitals and then 50 patients from each hospital) from the National Registry of Hospitalized Patients for strokes occurring in 2011. Discharge summaries were reviewed for medications prescribed during hospitalization and at discharge.

RESULTS

Of the 500 requested discharge summaries, 484 were available for review (response rate 97%). Up to 479 (96%) summaries were sufficient for evaluation and of these, 393 were confirmed to have a stroke or TIA diagnosis. Brain imaging (computed tomography or magnetic resonance imaging) was performed in 97% of the 393 cases. Intravenous thrombolysis was administered to 7% of patients with ischemic stroke (rate was 0%-25% in different hospitals). Up to 97% of patients with ischemic events (TIA or ischemic stroke) were treated with antiplatelets or anticoagulants. At least 1 non-evidence-based medication was administered to 28% of the 393 patients (rate was 5%-89% in different hospitals).

CONCLUSIONS

Guideline-disapproved pharmacotherapy is common in stroke and TIA patients in the CR and processes should be put into place to lessen the frequency of their use. The use of guideline-approved medications is also high and should be further promoted.

Predictors of noticing stroke educational campaign

BACKGROUND

Long-term campaigns to improve stroke awareness, such as the campaign conducted in the Czech Republic since 2006, have not been effective. However, the small subpopulation that noticed the campaign had better stroke awareness than the population that did not. To better understand this awareness campaign responsiveness and to design more successful future campaigns, predictors of noticing campaigns were identified.

MATERIALS AND METHODS

This study is a secondary analysis of cross-sectional nationwide survey data of the Czech population older than 40 years, collected in 2009. The survey used a 3-stage random sampling method (area, household, and household member) and personal semistructured interview questionnaires concerning participants' stroke knowledge, demographic characteristics, medical history, and stroke information sources. To identify the association between these variables and whether the campaign was noticed (the primary outcome of the study), multivariate binary logistic regression analysis was used.

RESULTS

A total of 601 participants were surveyed (90% response rate), 19% of them stated that they noticed the stroke awareness campaign. Primary independent predictors of campaign efficiency were heart disease (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.2), obesity (OR, 2.4; 95% CI, 1.3-4.7), and current smoking (OR, .4; 95% CI, .3-.7).

CONCLUSIONS

Tobacco smokers in particular should be targeted by stroke awareness campaigns, for example, through health warning labels on cigarette packs. People with some stroke risk factors, such as heart disease and obesity, are responsive to information about stroke. Therefore, educational campaigns should target the groups with increased risk of stroke.

Stroke care in Central Eastern Europe: current problems and call for action

Stroke is a major medical problem and one of the leading causes of mortality and disability all over in Europe. However, there are significant East-West differences in stroke care as well as in stroke mortality and morbidity rates. Central and Eastern European countries that formerly had centralized and socialist health care systems have serious and similar problems in organizing health and stroke care 20 years after the political transition. In Central and Eastern Europe, stroke is more frequent, the mortality rate is higher, and the victims are younger than in Western Europe. High-risk patients live in worse environmental conditions, and the socioeconomic consequences of stroke further weaken the economic development of these countries. To address these issues, a round table conference was organized. The main aim of this conference was to discuss problems to be solved related to acute and chronic stroke care in Central and Eastern European countries, and also, to exchange ideas on possible solutions. In this article, the discussed problems and possible solutions will be summarized, and introduce 'The Budapest Statement of Stroke Experts of Central and Eastern European countries'.

Intravenous Alteplase in Ischemic Stroke Patients not Fully Adhering to the Current Drug License in Central and Eastern Europe

Background

The current European license for alteplase in acute ischemic stroke excludes from treatment large groups of patients. Nevertheless, in everyday practice, many patients receive off-label thrombolysis at the physician's discretion.

Aim

Our aim was to evaluate safety and effectiveness of intravenous alteplase in patients not fully adhering to the drug license compared with those treated strictly according to the license in Central and Eastern Europe.

Methods

We analyzed the data contributed to Safe Implementation of Thrombolysis in Stroke registry from nine countries between February 2003 and February 2010. Statistical analysis included multivariate logistic regression.

Results

Of 5594 consecutive patients, 1919 patients (34·3%) not fully adhered to the license. The most frequent deviations were: time-to-treatment >3 h (13·1%), use of intravenous antihypertensives (8·3%), age >80 years (7·3%), oral anticoagulation (4·2%), a previous stroke with concomitant diabetes (3·9%), and previous stroke <three-months (2·7%). The off-label group showed a significantly higher rate of symptomatic intracranial haemorrhage, which was not confirmed in the multivariate analysis. License nonadherence significantly increased the risk of death or dependency (odds ratio 1·26; 95% confidence interval: 1·08–1·48), with a trend for increased mortality (odds ratio 1·17; 95% confidence interval: 0·97–1·42). Isolated time-to-treatment >3 h was an independent predictor of unfavorable outcome (odds ratio 1·32; 95% confidence interval: 1·01–1·71).

Conclusion

Our findings show that patients not fully adhering to the European license are not at increased risk of symptomatic intracranial haemorrhage but achieve less favorable outcome. Some contraindications appear more redundant than others. However, the final conclusions about safety and effectiveness should be based on the results of ongoing randomized trials.