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Al-Ajlan FS, Alkhiri A, Alamri AF, Alghamdi BA, Almaghrabi AA, Alharbi AR, Alansari N, Almilibari AZ, Hussain MS, Audebert HJ, Grotta JC, Shuaib A, Saver JL, Alhazzani A. Golden Hour Intravenous Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Ann Neurol 2024. [PMID: 38922985 DOI: 10.1002/ana.27007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 04/30/2024] [Accepted: 05/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES The benefits of intravenous thrombolysis are time-dependent, with maximum efficacy when administered within the first "golden" hour after onset. Nevertheless, the impact of golden hour thrombolysis has not been well quantified. METHODS Medline, Embase, and Web of Science databases were systematically searched from inception to August 27, 2023. We included studies that reported safety and efficacy outcomes of ischemic stroke patients treated with intravenous thrombolysis in the golden hour versus later treatment window. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0-1 at 90 days. The secondary efficacy outcome was a good functional outcome (defined as modified Rankin Scale score of 0-2). The main safety outcome was symptomatic intracerebral hemorrhage. RESULTS Seven studies involving 78,826 patients met the selection criteria. Golden hour thrombolysis was associated with higher odds of 90-day excellent functional outcomes (OR 1.40, 95% CI 1.16-1.67) and 90-day good functional outcomes (OR 1.38, 95% CI 1.13-1.69) compared with thrombolysis outside the golden hour. The number needed to treat to benefit for golden hour thrombolysis to reduce disability by at least 1 level on the modified Rankin Scale per patient was 2.6. Rates of symptomatic intracerebral hemorrhage and mortality were similar between groups. INTERPRETATION Golden hour thrombolysis significantly improved acute ischemic stroke outcomes. The findings provide rationale for intensive efforts aimed at expediting thrombolytic therapy within the golden hour window following the onset of acute ischemic stroke. ANN NEUROL 2024.
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Affiliation(s)
- Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah R Alharbi
- Department of Neurology, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Nayef Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed Z Almilibari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - M Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - James C Grotta
- Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Ashfaq Shuaib
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Gude MF, Valentin JB, Christensen HC, Mikkelsen S, Søvsø MB, Andersen G, Kirkegaard H, Johnsen SP. Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. Intern Emerg Med 2023; 18:2355-2365. [PMID: 37369888 PMCID: PMC10635938 DOI: 10.1007/s11739-023-03349-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
To investigate the association between the Emergency Medical Service dispatcher's initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017-2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1-76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was - 33.2 min (95% CI - 44.4; - 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI - 18.9; - 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.
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Affiliation(s)
- Martin F Gude
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark.
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Central Denmark Region, Aarhus, Denmark.
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helle C Christensen
- Copenhagen Emergency Medical Services, Capital Region of Denmark, Copenhagen, Denmark
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Morten B Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Tsivgoulis G, Palaiodimou L, Stefanou MI, Theodorou A, Kõrv J, Nunes AP, Candelaresi P, Dall'Ora E, Sariaslani P, Provinciali L, Conforto AB, Cidrao AADL, Karapanayiotides T, Ahmed N. Predictors of functional outcome after symptomatic intracranial hemorrhage complicating intravenous thrombolysis: results from the SITS-ISTR. Eur J Neurol 2023; 30:3161-3171. [PMID: 37410547 DOI: 10.1111/ene.15968] [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: 05/20/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND PURPOSE Several risk factors of symptomatic intracerebral hemorrhage (SICH) following intravenous thrombolysis for acute ischaemic stroke have been established. However, potential predictors of good functional outcome post-SICH have been less studied. METHODS Patient data registered in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) from 2005 to 2021 were used. Acute ischaemic stroke patients who developed post intravenous thrombolysis SICH according to the SITS Monitoring Study definition were analyzed to identify predictors of functional outcomes. RESULTS A total of 1679 patients with reported SICH were included, out of which only 2.8% achieved good functional outcome (modified Rankin Scale scores of 0-2), whilst 80.9% died at 3 months. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score and 24-h ΔNIHSS score were independently associated with a lower likelihood of achieving both good and excellent functional outcomes at 3 months. Baseline NIHSS and hematoma location (presence of both SICHs, defined as remote and local SICH concurrently; n = 478) were predictors of early mortality within 24 h. Independent predictors of 3-month mortality were age, baseline NIHSS, 24-h ΔNIHSS, admission serum glucose values and hematoma location (both SICHs). Age, baseline NIHSS score, 24-h ΔNIHSS, hyperlipidemia, prior stroke/transient ischaemic attack, antiplatelet treatment, diastolic blood pressure at admission, glucose values on admission and SICH location (both SICHs) were associated with reduced disability at 3 months (≥1-point reduction across all modified Rankin Scale scores). Patients with remote SICH (n = 219) and local SICH (n = 964) had comparable clinical outcomes, both before and after propensity score matching. CONCLUSIONS Symptomatic intracerebral hemorrhage presents an alarmingly high prevalence of adverse clinical outcomes, with no difference in clinical outcomes between remote and local SICH.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ana Paiva Nunes
- Stroke Unit, Hospital São José, Lisbon Central University Hospital Center, Lisbon, Portugal
| | | | - Elisa Dall'Ora
- Stroke Unit, Department of Neurology, Bolzano Central Hospital, Bolzano, Italy
| | - Payam Sariaslani
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Leandro Provinciali
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Adriana B Conforto
- Divisão de Neurologia Clínica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | - Theodore Karapanayiotides
- Second Department of Neurology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Zhai M, Cao S, Yang J, Cao X, Dong Z, Liu W, Fu Y, Guan Q, Wang Y, Liu H. Effect of Intravenous Thrombolytic Dose of Alteplase on Long-Term Prognosis in Patients with Acute Ischemic Stroke. Neurol Ther 2023; 12:1105-1118. [PMID: 37166676 PMCID: PMC10310604 DOI: 10.1007/s40120-023-00488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/21/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the long-term prognostic effects of different alteplase doses on patients with acute ischemic stroke (AIS). METHODS In this cohort study, we enrolled 501 patients with AIS treated with intravenous thrombolysis with alteplase, with the primary endpoint event of recurrence of ischemic stroke and the secondary endpoint event of death. The effects of different doses of alteplase on recurrence of ischemic stroke and death were analyzed using a Cox proportional risk model. RESULTS Among 501 patients with AIS treated with thrombolysis, 295 patients (58.9%) and 206 patients (41.1%) were treated with low-dose and standard-dose alteplase, respectively. During the study period, 61 patients (12.2%) had a confirmed recurrence of ischemic stroke. Multivariate Cox proportional risk analysis showed that standard-dose alteplase thrombolysis (HR 0.511, 95% CI 0.288-0.905, P = 0.021) was significantly associated with a reduced risk of long-term recurrence of AIS, whereas atrial fibrillation was associated with an increased risk of long-term recurrence of AIS. Thirty-nine (7.8%) patients died during the study period. Multivariate Cox proportional risk analysis showed that age, baseline National Institutes of Health Stroke Scale (NIHSS) score, and symptomatic steno-occlusion were associated with an increased long-term risk of death from AIS. The alteplase dose was not associated with the risk of death from AIS. CONCLUSIONS Standard-dose alteplase treatment reduced the risk of long-term recurrence of AIS after hospital discharge and the alteplase dose was not associated with the long-term risk of death from AIS.
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Affiliation(s)
- Mingfeng Zhai
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Shugang Cao
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, The Second People's Hospital of Hefei, Hefei, China
| | - Jinwei Yang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Xiaoyan Cao
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Zhong Dong
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Anhui Public Health Clinical Center, Hefei, China
| | - Wanyin Liu
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Yongzhan Fu
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Qiyue Guan
- Department of Neurology, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
- Anhui Public Health Clinical Center, Hefei, China.
| | - Hongbo Liu
- Department of Emergency, The Affiliated Fuyang People's Hospital of Anhui Medical University, Fuyang People's Hospital, Fuyang, 236000, China.
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Palaiodimou L, Kargiotis O, Katsanos AH, Kiamili A, Bakola E, Komnos A, Zisimopoulou V, Natsis K, Papagiannopoulou G, Theodorou A, Zompola C, Safouris A, Psychogios K, Ntais E, Plomaritis P, Karamatzianni G, Mavriki A, Koutsokera M, Lykou C, Koutroulou I, Gourbali V, Skafida A, Roussopoulou A, Kourtesi G, Papamichalis P, Papagiannopoulos S, Gryllia M, Tavernarakis A, Kazis D, Karapanayiotides T, Magoufis G, Giannopoulos S, Tsivgoulis G. Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation. Eur Stroke J 2023; 8:5-15. [PMID: 36793743 PMCID: PMC9923128 DOI: 10.1177/23969873221103474] [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: 03/13/2022] [Accepted: 05/09/2022] [Indexed: 02/12/2023] Open
Abstract
Introduction Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset. Methods Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented. Results A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001). Conclusions Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Lina Palaiodimou, Second Department of
Neurology, “Attikon” University Hospital, School of Medicine, National and
Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece.
| | | | - Aristeidis H Katsanos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Argyro Kiamili
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Eleni Bakola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Apostolos Komnos
- Intensive Care Unit, General Hospital
of Larissa, Larissa, Greece
| | - Vaso Zisimopoulou
- Stroke Unit, Athens Euroclinic, Athens,
Greece
- Department of Neurology, 251 Hellenic
Air Force & VA General Hospital, Athens, Greece
| | | | - Georgia Papagiannopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Christina Zompola
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | | | | | - Evangelos Ntais
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Panagiotis Plomaritis
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Georgia Karamatzianni
- Department of Neurology,
Korgialenio-Benakio Greek Red Cross General Hospital of Athens, Athens, Greece
| | - Andriana Mavriki
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Maria Koutsokera
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Christina Lykou
- Department of Neurology, General
Hospital Eleusina Thriassio, Eleusina, Greece
| | - Ioanna Koutroulou
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | | | - Andromachi Roussopoulou
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, Tzaneio
General Hospital, Pireaus, Greece
| | - Georgia Kourtesi
- Department of Neurology, General
Hospital of Serres, Serres, Greece
| | | | - Sotirios Papagiannopoulos
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Maria Gryllia
- Department of Neurology, Athens
General Hospital G. Gennimatas, Athens, Greece
| | | | - Dimitrios Kazis
- Third Department of Neurology,
Aristotle University of Thessaloniki, Papanikolaou Hospital, Thessaloniki,
Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology,
Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital,
Thessaloniki, Greece
| | | | - Sotirios Giannopoulos
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, School of
Medicine, University of Ioannina, Ioannina, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology,
“Attikon” University Hospital, School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
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Muacevic A, Adler JR, Alves M, Papoila AL, Nunes AP. Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region. Cureus 2022; 14:e32659. [PMID: 36660499 PMCID: PMC9844243 DOI: 10.7759/cureus.32659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Endovascular treatment (EVT) with mechanical thrombectomy and acute carotid stenting has become an integral part of the treatment of acute ischemic stroke with large vessel occlusion. Despite being included in the most recent stroke guidelines, only comprehensive centers can offer EVT and thus patients frequently need to be transferred from primary hospitals. We aimed to assess which pre-hospital model of care - direct admission to a comprehensive stroke center (mothership) or transfer to a comprehensive stroke center after the first admission to the nearest hospital (drip-and-ship) - had the most benefit in stroke patients in a Portuguese urban region. Methods We selected patients admitted to a comprehensive stroke center who underwent EVTs between January 2018 and December 2020, in Lisbon, Portugal. We used data from the Safe Implementation of Treatments in Stroke (SITS) International registry on stroke severity, previous modified Rankin Scale (mRS), time from symptom onset to the first admission, time from symptom onset to the procedure, and mRS three months post stroke. We defined an unfavorable outcome as having an mRS >2 at three months post stroke. For patients with previous mRS >2, an unfavorable outcome was defined as any increase in mRS at three months post stroke. Results We analyzed the data of 1154 patients, of which 407 were admitted through a mothership approach and 747 through a drip-and-ship approach. Both groups were similar regarding sociodemographic characteristics, stroke risk factors, previous disability, and stroke severity. Median onset-to-door time was higher (126 vs 110 minutes, p-value=0.002) but onset-to-procedure time was lower (199 vs 339 minutes, p-value<0.001) in the mothership group. The mothership group had a higher proportion of patients with mRS <3 at three months post stroke than the drip-and-ship group (41.3% vs 34.9%, p-value=0.035). Mortality was similar in both groups. A multivariate logistic regression model confirmed a lower probability of unfavorable outcomes with the mothership approach (OR = 0.677, 95% CI 0.514-0.892, p-value=0.006). Surprisingly, onset-to-procedure time did not have an impact on functional outcomes. Conclusion Our findings show that the mothership model results in better functional outcomes for patients with acute ischemic stroke with large vessel occlusion. Further studies are needed to better define patient selection for this strategy and the impact of a mothership model in comprehensive stroke centers.
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7
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Lund UH, Stoinska-Schneider A, Larsen K, Bache KG, Robberstad B. Cost-Effectiveness of Mobile Stroke Unit Care in Norway. Stroke 2022; 53:3173-3181. [PMID: 35862205 PMCID: PMC9508956 DOI: 10.1161/strokeaha.121.037491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project).
METHODS:
We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway.
RESULTS:
MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated.
CONCLUSIONS:
MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.
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Affiliation(s)
- Ulrikke Højslev Lund
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Anna Stoinska-Schneider
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
| | - Kristi G. Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., K.G.B.)
- Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., K.G.B.)
- Research and Dissemination, Østfold University College, Halden, Norway (K.G.B.)
| | - Bjarne Robberstad
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway (U.H.L., A.S.-S., B.R.)
- Department of Global Public Health and Primary Care, University of Bergen, Norway (B.R.)
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8
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Li H, Xu D, Xu Y, Wei L. Impact of Medical Community Model on Intravenous Alteplase Door-to-Needle Times and Prognosis of Patients With Acute Ischemic Stroke. Front Surg 2022; 9:888015. [PMID: 35574548 PMCID: PMC9091958 DOI: 10.3389/fsurg.2022.888015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
Objective In this study, we retrospectively analyzed 795 AIS patients who received intravenous alteplase for thrombolytic therapy in one third-class hospital or three second-class hospitals in Dongyang City and sought to evaluate the effects of the medical community model on intravenous alteplase door-to-needle time (DNT) and prognosis of patients with acute ischemic stroke. Methods According to whether the medical community model is established or not, 303 AIS patients (204 cases from the third-class hospital and 99 cases from three second-class hospitals) were assigned to control group unavailable to the medical community model and 492 AIS patients (297 cases from the third-class hospital, and 195 cases from three second-class hospitals) into observational group available to the medical community model. Results A higher thrombolysis rate, a shorter DNT, more patients with DNT ≤ 60 min and DNT ≤ 45 min, a shorter ONT, lower National Institutes of Health Stroke Scale (NIHSS) scores at 24 h, 7 d, 14 d, and modified Rankin scale (mRS) scores at 3 months after thrombolytic therapy, a shorter length of hospital stay, and less hospitalization expense were found in the observational group than the control group. Subgroup analysis based on different-class hospitals revealed that the medical community model could reduce the DNT and ONT to increase the thrombolysis rate of AIS patients, especially in low-class hospitals. After the establishment of the medical community model, the AIS patients whether from the third-class hospital or three second-class hospitals exhibited lower NIHSS scores at 24 h, 7 d, 14 d after thrombolytic therapy (p < 0.05). After a 90-day follow-up for mRS scores, a significant difference was only noted in the mRS scores of AIS patients from the third-class hospital after establishing the medical community model (p < 0.05). It was also found that the medical community model led to reduced length of hospital stay and hospitalization expenses for AIS patients, especially for the second-class hospitals. Conclusion The data suggest that the medical community model could significantly reduce intravenous alteplase DNT and improve the prognosis of patients with AIS.
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - 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, TN, USA
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10
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Di Lorenzo R, Saqqur M, Buletko AB, Handshoe LS, Mulpur B, Hardman J, Donohue M, Wisco D, Uchino K, Hussain MS. IV tPA given in the golden hour for emergent large vessel occlusion stroke improves recanalization rates and clinical outcomes. J Neurol Sci 2021; 428:117580. [PMID: 34280605 DOI: 10.1016/j.jns.2021.117580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Early thrombolysis for acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) is associated with better clinical outcome. This is thought to be due to greater tissue salvage with earlier recanalization. We explored whether ultra-early administration of intravenous tissue plasminogen activator (IV tPA) within 60 min (Golden Hour) of symptom onset for AIS due to ELVO is associated with a higher rate of recanalization. METHODS We performed a retrospective analysis of recanalization rates and clinical outcomes in patients with AIS due to ELVO treated with IV tPA, comparing patients who received IV tPA within 60 min of stroke symptom onset with those treated beyond 60 min. RESULTS Between January 2013 and December 2016, 158 patients with AIS due to ELVO were treated with IV tPA. Of these, 25 (15.8%) patients received IV tPA within 60 min of stroke symptom onset, while the remaining 133 (84.2%) patients received IV tPA beyond 60 min. The ultra-early treatment group was found to have a higher rate of complete recanalization (28.0% vs 6.8%, 95% CI 1.78-16.63), better chance of early neurological improvement (76.0% vs 50.4%, 95% CI 1.16-8.65), favorable clinical outcomes (mRS ≤ 2 or return to premorbid mRS) (65.0% vs 36.8%, 95% CI 1.42-9.34), and lower mortality (5% vs 31.1%, 95% CI 0.01-0.74) at 90-day follow-up compared to the later treatment group. CONCLUSION Our data suggest that ultra-early administration of IV tPA significantly improves recanalization rates and clinical outcomes in patients with AIS due to ELVO.
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Affiliation(s)
- Rodica Di Lorenzo
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Maher Saqqur
- Division of Neurology, Trillium Hospital, Toronto, Canada
| | - Andrew Blake Buletko
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Lacy Sam Handshoe
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Bhageeradh Mulpur
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Julian Hardman
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Megan Donohue
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Dolora Wisco
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - M Shazam Hussain
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, USA.
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11
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Circulating Extracellular Vesicle Proteins and MicroRNA Profiles in Subcortical and Cortical-Subcortical Ischaemic Stroke. Biomedicines 2021; 9:biomedicines9070786. [PMID: 34356850 PMCID: PMC8301391 DOI: 10.3390/biomedicines9070786] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/28/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022] Open
Abstract
In order to investigate the role of circulating extracellular vesicles (EVs), proteins, and microRNAs as damage and repair markers in ischaemic stroke depending on its topography, subcortical (SC), and cortical-subcortical (CSC) involvement, we quantified the total amount of EVs using an enzyme-linked immunosorbent assay technique and analysed their global protein content using proteomics. We also employed a polymerase chain reaction to evaluate the circulating microRNA profile. The study included 81 patients with ischaemic stroke (26 SC and 55 CSC) and 22 healthy controls (HCs). No differences were found in circulating EV levels between the SC, CSC, and HC groups. We detected the specific expression of C1QA and Casp14 in the EVs of patients with CSC ischaemic stroke and the specific expression of ANXA2 in the EVs of patients with SC involvement. Patients with CSC ischaemic stroke showed a lower expression of miR-15a, miR-424, miR-100, and miR-339 compared with those with SC ischaemic stroke, and the levels of miR-339, miR-100, miR-199a, miR-369a, miR-424, and miR-15a were lower than those of the HCs. Circulating EV proteins and microRNAs from patients with CSC ischaemic stroke could be considered markers of neurite outgrowth, neurogenesis, inflammation process, and atherosclerosis. On the other hand, EV proteins and microRNAs from patients with SC ischaemic stroke might be markers of an anti-inflammatory process and blood–brain barrier disruption reduction.
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12
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Larsen K, Jaeger HS, Tveit LH, Hov MR, Thorsen K, Røislien J, Solyga V, Lund CG, Bache KG. Ultraearly thrombolysis by an anesthesiologist in a mobile stroke unit: A prospective, controlled intervention study. Eur J Neurol 2021; 28:2488-2496. [PMID: 33890385 DOI: 10.1111/ene.14877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute stroke treatment in mobile stroke units (MSU) is feasible and reduces time-to-treatment, but the optimal staffing model is unknown. We wanted to explore if integrating thrombolysis of acute ischemic stroke (AIS) in an anesthesiologist-based emergency medical services (EMS) reduces time-to-treatment and is safe. METHODS A nonrandomized, prospective, controlled intervention study. INCLUSION CRITERIA age ≥18 years, nonpregnant, stroke symptoms with onset ≤4 h. The MSU staffing is inspired by the Norwegian Helicopter Emergency Medical Services crew with an anesthesiologist, a paramedic-nurse and a paramedic. Controls were included by conventional ambulances in the same catchment area. Primary outcome was onset-to-treatment time. Secondary outcomes were alarm-to-treatment time, thrombolytic rate and functional outcome. Safety outcomes were symptomatic intracranial hemorrhage and mortality. RESULTS We included 440 patients. MSU median (IQR) onset-to-treatment time was 101 (71-155) minutes versus 118 (90-176) minutes in controls, p = 0.007. MSU median (IQR) alarm-to-treatment time was 53 (44-65) minutes versus 74 (63-95) minutes in controls, p < 0.001. Golden hour treatment was achieved in 15.2% of the MSU patients versus 3.7% in the controls, p = 0.005. The thrombolytic rate was higher in the MSU (81% vs 59%, p = 0.001). MSU patients were more often discharged home (adjusted OR [95% CI]: 2.36 [1.11-5.03]). There were no other significant differences in outcomes. CONCLUSIONS Integrating thrombolysis of AIS in the anesthesiologist-based EMS reduces time-to-treatment without negatively affecting outcomes. An MSU based on the EMS enables prehospital assessment of acute stroke in addition to other medical and traumatic emergencies and may facilitate future implementation.
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Affiliation(s)
- Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Henriette S Jaeger
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Lars H Tveit
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maren R Hov
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | - Jo Røislien
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Volker Solyga
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
| | | | - Kristi G Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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13
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Kim H, Kim JT, Lee JS, Kim BJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kwon JH, Kim WJ, Shin DI, Sohn SI, Hong JH, Park MS, Choi KH, Cho KH, Lee J, Bae HJ. Golden Hour Thrombolysis in Acute Ischemic Stroke: The Changing Pattern in South Korea. J Stroke 2021; 23:135-138. [PMID: 33600712 PMCID: PMC7900393 DOI: 10.5853/jos.2020.04658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/14/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hyunsoo Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong-Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
| | - Jae Guk Kim
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jee-Hyun Kwon
- Department of Neurology, University of Ulsan College of Medicine, Ulsan, Korea
| | - Wook-Joo Kim
- Department of Neurology, University of Ulsan College of Medicine, Ulsan, Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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14
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Zhang T, Zhang X, Sun H, Zhou F, Lin S, Sang H, Zheng N, Zhao Z, Shi J, Li W. Improving timely treatment with a stroke emergency map: The case of northern China. Brain Behav 2020; 10:e01743. [PMID: 32652889 PMCID: PMC7428498 DOI: 10.1002/brb3.1743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The Chinese stroke emergency map (SEM) was implemented in 2017 to reduce prehospital and hospital delays for acute ischemic stroke (AIS) patients suitable for intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. However, data on the time delay following the implementation of an SEM in China are limited. METHODS Data for suspected stroke patients from the SEM registry center of Taiyuan, Shanxi Province, from August 2017 to July 2019, patients' characteristics, thrombolysis rate, and functional outcome at 90 days were analyzed. RESULTS One thousand seven hundred and eighty six patients who arrived at hospitals within 4.5 hr of onset were included; 35.9% arrived by emergency medical services (EMSs), and 1,207 (67.6%) of the population received intravenous rt-PA. As a result of the SEM, the number of patients treated with rt-PA increased from 63.9% in phase 1 (August 2017 to July 2018) to 70.5% in phase 2 (August 2018 to July 2019). The median onset-to-door and onset-to-needle times decreased by five minutes (100 [IQR: 62-135] vs. 105 [IQR: 70-145], p = .005) and nine minutes (158 [IQR: 124-197] vs. 167 [IQR: 132-214], p = .001), respectively. Patients in phase 2 achieved greater independent function outcome at 90 days (79.9% vs. 72.1%; adjusted odds ratio, 2.010; 95% confidence interval, 1.444-2.798). The binary logistic regression models revealed that shorter onset-to-needle time (OR: 0.994; 95% CI: 0.992-0.997; p < .001) and lower baseline NIHSS scores (OR: 39.120; 95% CI: 23.477-65.188; p < .001 and OR: 18.324; 95% CI: 11.425-29.388; p < .001 and OR: 3.123; 95% CI: 2.044-4.773; p < .001) were significant predictors for the independent function outcome. CONCLUSION The implementation of a stroke emergency map is more likely to reduce prehospital delays and improve function outcomes. Future efforts should attempt to increase EMS usage.
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Affiliation(s)
- Tianli Zhang
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Xiaodong Zhang
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Huisheng Sun
- Administration officeTaiyuan Health CommissionTaiyuanChina
| | - Feng Zhou
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Shiqin Lin
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Hui Sang
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Nannan Zheng
- Department of NeurologyChangzhi Medical College Affiliated Heping HospitalChangzhiChina
| | - Ziyi Zhao
- Medical Records Statistics OfficeShanxi Bethune HospitalTaiyuanChina
| | - Jing Shi
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Weirong Li
- Department of NeurologyTaiyuan Central Hospital of Shanxi Medical UniversityTaiyuanChina
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15
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Cappellari M, Bonetti B, Forlivesi S, Sajeva G, Naccarato M, Caruso P, Lorenzut S, Merlino G, Viaro F, Pieroni A, Giometto B, Bignamini V, Perini F, De Boni A, Morra M, Critelli A, Tamborino C, Tonello S, Guidoni SV, L'Erario R, Russo M, Burlina A, Turinese E, Passadore P, Zanet L, Polo A, Turazzini M, Basile AM, Atzori M, Marini B, Bruno M, Carella S, Campagnaro A, Baldi A, Corazza E, Zanette G, Idone D, Gaudenzi A, Bombardi R, Cadaldini M, Lanzafame S, Ferracci F, Zambito S, Ruzza G, Simonetto M, Menegazzo E, Masato M, Padoan R, Bozzato G, Paladin F, Tonon A, Bovi P. Acute revascularization treatments for ischemic stroke in the Stroke Units of Triveneto, northeast Italy: time to treatment and functional outcomes. J Thromb Thrombolysis 2020; 51:159-167. [PMID: 32424778 DOI: 10.1007/s11239-020-02142-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
It is not known whether the current territorial organization for acute revascularization treatments in ischemic stroke patients guarantees similar time to treatment and functional outcomes among different levels of institutional stroke care. We aimed to assess the impact of time to treatment on functional outcomes in ischemic stroke patients who received intravenous thrombolysis (IVT) alone, bridging (IVT plus thrombectomy), or primary thrombectomy in level 1 and level 2 Stroke Units (SUs) in Triveneto, a geographical macroarea in Northeast of Italy. We conducted an analysis of data prospectively collected from 512 consecutive ischemic stroke patients who received IVT and/or mechanical thrombectomy in 25 SUs from September 17th to December 9th 2018. The favorable outcome measures were mRS score 0-1 and 0-2 at 3 months. The unfavorable outcome measures were mRS score 3-5 and death at 3 months. We estimated separately the possible association of each variable for time to treatment (onset-to-door, door-to-needle, onset-to-needle, door-to-groin puncture, needle-to-groin puncture, and onset-to-groin puncture) with 3-month outcome measures by calculating the odds ratios (ORs) with two-sided 95% confidence intervals (CI) after adjustment for pre-defined variables and variables with a probability value ≤ 0.10 in the univariate analysis for each outcome measure. Distribution of acute revascularization treatments was different between level 1 and level 2 SUs (p < 0.001). Among 182 patients admitted to level 1 SUs (n = 16), treatments were IVT alone in 164 (90.1%), bridging in 12 (6.6%), and primary thrombectomy in 6 (3.3%) patients. Among 330 patients admitted to level 2 SUs (n = 9), treatments were IVT alone in 219 (66.4%), bridging in 74 (22.4%), and primary thrombectomy in 37 (11.2%) patients. Rates of excellent outcome (51.4% vs 45.9%), favorable outcome (60.1% vs 58.7%), unfavorable outcome (33.3% vs 33.8%), and death (9.8% vs 11.3%) at 3 months were similar between level 1 and 2 SUs. No significant association was found between time to IVT alone (onset-to-door, door-to-needle, and onset-to-needle) and functional outcomes. After adjustment, door-to-needle time ≤ 60 min (OR 4.005, 95% CI 1.232-13.016), shorter door-to-groin time (OR 0.991, 95% CI 0.983-0.999), shorter needle-to-groin time (OR 0.986, 95% CI 0.975-0.997), and shorter onset-to-groin time (OR 0.994, 95% CI 0.988-1.000) were associated with mRS 0-1. Shorter door-to-groin time (OR 0.991, 95% CI 0.984-0.998), door-to-groin time ≤ 90 min (OR 12.146, 95% CI 2.193-67.280), shorter needle-to-groin time (OR 0.983, 95% CI 0.972-0.995), and shorter onset-to-groin time (OR 0.993, 95% CI 0.987-0.999) were associated with mRS 0-2. Longer door-to-groin time (OR 1.007, 95% CI 1.001-1.014) and longer needle-to-groin time (OR 1.019, 95% CI 1.005-1.034) were associated with mRS 3-5, while door-to-groin time ≤ 90 min (OR 0.229, 95% CI 0.065-0.808) was inversely associated with mRS 3-5. Longer onset-to-needle time (OR 1.025, 95% CI 1.002-1.048) was associated with death. Times to treatment influenced the 3-month outcomes in patients treated with thrombectomy (bridging or primary). A revision of the current territorial organization for acute stroke treatments in Triveneto is needed to reduce transfer time and to increase the proportion of patients transferred from a level 1 SU to a level 2 SU to perform thrombectomy.
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Affiliation(s)
- Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy. .,USD Stroke Unit, DAI Di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale Aristide Stefani, 1, 37126, Verona, Italy.
| | - Bruno Bonetti
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stefano Forlivesi
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giulia Sajeva
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Marcello Naccarato
- Stroke Unit, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Paola Caruso
- Stroke Unit, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Simone Lorenzut
- Stroke Unit, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Giovanni Merlino
- Stroke Unit, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Federica Viaro
- Stroke Unit, Azienda Ospedaliera Università di Padova, Padova, Italy
| | - Alessio Pieroni
- Stroke Unit, Azienda Ospedaliera Università di Padova, Padova, Italy
| | | | | | | | | | | | | | | | | | | | - Roberto L'Erario
- Stroke Unit, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Monia Russo
- Stroke Unit, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | | | | | - Paolo Passadore
- Stroke Unit, Ospedale Santa Maria degli Angeli, Pordenone, Italy
| | - Luca Zanet
- Stroke Unit, Ospedale Santa Maria degli Angeli, Pordenone, Italy
| | - Alberto Polo
- Stroke Unit, Ospedale Mater Salutis, Legnago, Italy
| | | | | | | | - Bruno Marini
- Stroke Unit, Ospedale San Giacomo Apostolo, Castelfranco Veneto, Italy
| | - Martina Bruno
- Stroke Unit, Ospedale San Giacomo Apostolo, Castelfranco Veneto, Italy
| | | | | | - Antonio Baldi
- Stroke Unit, Ospedale Di Portogruaro, Portogruaro, Italy
| | - Elisa Corazza
- Stroke Unit, Ospedale Di Portogruaro, Portogruaro, Italy
| | | | - Domenico Idone
- Stroke Unit, Ospedale Pederzoli, Peschiera del Garda, Italy
| | - Anna Gaudenzi
- Stroke Unit, Ospedale Santa Maria dei Battuti, Conegliano, Italy
| | - Roberto Bombardi
- Stroke Unit, Ospedale Santa Maria dei Battuti, Conegliano, Italy
| | - Morena Cadaldini
- Stroke Unit, Ospedali Riuniti Padova Sud Madre Teresa di Calcutta, Monselice, Italy
| | - Salvatore Lanzafame
- Stroke Unit, Ospedali Riuniti Padova Sud Madre Teresa di Calcutta, Monselice, Italy
| | | | | | | | | | | | | | - Roberta Padoan
- Stroke Unit, Ospedale Santa Maria del Prato, Feltre, Italy
| | - Giulio Bozzato
- Stroke Unit, Ospedale Santa Maria del Prato, Feltre, Italy
| | | | - Agnese Tonon
- Stroke Unit, Ospedale Santi Giovanni e Paolo, Venezia, Italy
| | - Paolo Bovi
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Tsivgoulis G, Saqqur M, Sharma VK, Brunser A, Eggers J, Mikulik R, Katsanos AH, Sergentanis TN, Vadikolias K, Perren F, Rubiera M, Bavarsad Shahripour R, Nguyen HT, Martínez-Sánchez P, Safouris A, Heliopoulos I, Shuaib A, Derksen C, Voumvourakis K, Psaltopoulou T, Alexandrov AW, Alexandrov AV. Timing of Recanalization and Functional Recovery in Acute Ischemic Stroke. J Stroke 2020; 22:130-140. [PMID: 32027798 PMCID: PMC7005347 DOI: 10.5853/jos.2019.01648] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/23/2019] [Indexed: 01/11/2023] Open
Abstract
Background and Purpose Although onset-to-treatment time is associated with early clinical recovery in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (tPA), the effect of the timing of tPA-induced recanalization on functional outcomes remains debatable.
Methods We conducted a multicenter, prospective observational cohort study to determine whether early (within 1-hour from tPA-bolus) complete or partial recanalization assessed during 2-hour real-time transcranial Doppler monitoring is associated with improved outcomes in patients with proximal occlusions. Outcome events included dramatic clinical recovery (DCR) within 2 and 24-hours from tPA-bolus, 3-month mortality, favorable functional outcome (FFO) and functional independence (FI) defined as modified Rankin Scale (mRS) scores of 0–1 and 0–2 respectively.
Results We enrolled 480 AIS patients (mean age 66±15 years, 60% men, baseline National Institutes of Health Stroke Scale score 15). Patients with early recanalization (53%) had significantly (jos-2019-01648P<0.001) higher rates of DCR at 2-hour (54% vs. 10%) and 24-hour (63% vs. 22%), 3-month FFO (67% vs. 28%) and FI (81% vs. 39%). Three-month mortality rates (6% vs. 17%) and distribution of 3-month mRS scores were significantly lower in the early recanalization group. After adjusting for potential confounders, early recanalization was independently associated with higher odds of 3-month FFO (odds ratio [OR], 6.19; 95% confidence interval [CI], 3.88 to 9.88) and lower likelihood of 3-month mortality (OR, 0.34; 95% CI, 0.17 to 0.67). Onset to treatment time correlated to the elapsed time between tPA-bolus and recanalization (unstandardized linear regression coefficient, 0.13; 95% CI, 0.06 to 0.19).
Conclusions Earlier tPA treatment after stroke onset is associated with faster tPA-induced recanalization. Earlier onset-to-recanalization time results in improved functional recovery and survival in AIS patients with proximal intracranial occlusions.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maher Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neuroscience, Hamad General Hospital, Doha, Qatar
| | - Vijay K Sharma
- Division of Neurology, National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alejandro Brunser
- Vascular Neurology Program, Neurology Service, Department of Medicine, Clinica Alemana of Santiago, University of Desarrollo, Santiago, Chile.,Department of Emergency Medicine, Clinica Alemana of Santiago, University of Desarrollo, Santiago, Chile
| | - Jürgen Eggers
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Lubeck, Lübeck, Germany.,Department of Neurology, Sana Hospital Lubeck, Lübeck, Germany
| | - Robert Mikulik
- Neurology Department and International Clinical Research Center, St. Anne's Hospital, Brno, Czech Republic.,Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Aristeidis H Katsanos
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Theodore N Sergentanis
- Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Fabienne Perren
- Stroke Unit, Department of Neurological Sciences, LUNIC Laboratory, HUG, University Hospital and Medical Faculty of Geneva, Geneva, Switzerland
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Reza Bavarsad Shahripour
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Huy Thang Nguyen
- Department of Cerebrovascular Disease, 115 The People Hospital, Ho Chi Minh, Vietnam
| | - Patricia Martínez-Sánchez
- Department of Neurology and Stroke Center, IdiPAZ Health Research Institute, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain.,Torrecardenas Hospital, University of Almeria School of Health Sciences, Almeria, Spain
| | - Apostolos Safouris
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Stroke Unit, Department of Neurology, Brugmann University Hospital, Brussels, Belgium
| | - Ioannis Heliopoulos
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Carol Derksen
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Lahr MMH, van der Zee DJ, Luijckx GJ, Buskens E. Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains. BMJ Open 2020; 10:e032780. [PMID: 31964668 PMCID: PMC7045180 DOI: 10.1136/bmjopen-2019-032780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To assess potential increases in intravenous thrombolysis (IVT) rates given particular interventions in the stroke care pathway. DESIGN Simulation modelling was used to compare the performance of the current pathway, best practices based on literature review and an optimised model. SETTING Four hospitals located in the North of the Netherlands, as part of a centralised organisational model. PARTICIPANTS Ischaemic stroke patients prospectively ascertained from February to August 2010. INTERVENTION The interventions investigated included efforts aimed at patient response and mode of referral, prehospital triage and intrahospital delays. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was thrombolysis utilisation. Secondary measures were onset-treatment time (OTT) and the proportion of patients with excellent functional outcome (modified Rankin scale (mRS) 0-1) at 90 days. RESULTS Of 280 patients with ischaemic stroke, 125 (44.6%) arrived at the hospital within 4.5 hours, and 61 (21.8%) received IVT. The largest improvements in IVT treatment rates, OTT and the proportion of patients with mRS scores of 0-1 can be expected when patient response is limited to 15 min (IVT rate +5.8%; OTT -6 min; excellent mRS scores +0.2%), door-to-needle time to 20 min (IVT rate +4.8%; OTT -28 min; excellent mRS scores+3.2%) and 911 calls are increased to 60% (IVT rate +2.9%; OTT -2 min; excellent mRS scores+0.2%). The combined implementation of all potential best practices could increase IVT rates by 19.7% and reduce OTT by 56 min. CONCLUSIONS Improving IVT rates to well above 30% appears possible if all known best practices are implemented.
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Affiliation(s)
- Maarten M H Lahr
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Gert-Jan Luijckx
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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18
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Huang Q, Song HQ, Ma QF, Song XW, Wu J. Effects of time delays on the therapeutic outcomes of intravenous thrombolysis for acute ischemic stroke in the posterior circulation: An observational study. Brain Behav 2019; 9:e01189. [PMID: 30614220 PMCID: PMC6379513 DOI: 10.1002/brb3.1189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/16/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We aim to demonstrate the effects of time delays on the therapeutic outcomes of intravenous thrombolysis (IVT) in acute posterior circulation stroke (PCS) patients. METHODS Consecutive PCS cases treated with IVT alone were retrospectively examined. The primary end point was set to be a favorable outcome (modified Rankin Scale [mRS] ≤2) at 3 months, and angiographic recanalization was set to be the secondary outcome. RESULTS A total of 95 PCS cases with IVT were recruited. The patients with favorable outcomes and those without favorable outcomes had similar baseline characteristics, except for significantly lower National Institute of Health Stroke Scale (NIHSS) scores (5 vs. 12, respectively; p < 0.001) and less hyperdense basilar artery signs in head CTs (26.5% vs. 70.4%, respectively; p < 0.001) for those with favorable outcomes. For patients with an onset-to-treatment time (OTT) of 0-90 min (n = 5), 91-180 min (n = 38), 181-270 min (n = 37), or ≧271 min (n = 15), the rate of favorable outcome was 100.0%, 71.1%, 67.6%, or 73.3%, respectively, and the Cochran-Armitage trend test showed no linear trend between the OTT and the clinical prognosis of IVT in PCS (p = 0.501) patients. In addition, the rates of recanalization were 100.0%, 68.4%, 64.9%, and 46.7%, and the Cochran-Armitage trend test suggested a linear trend between the OTT and recanalization (p = 0.046); that is, the proportion of PCS patients who underwent recanalization decreased with increasing OTTs. In the multivariate logistic regression analysis, after adjusting for confounding factors with p ≦ 0.20 in the univariate analysis, baseline NIHSS scores and hyperdense basilar artery signs were negatively associated with favorable outcomes, with odds ratios (OR) of 0.884 (95% confidence interval [CI], 0.804-0.971; p = 0.010) and 0.208 (95% CI, 0.062-0.693; p = 0.011), respectively. In addition, there was a negative association between recanalization, OTTs (OR, 0.993, 95% CI, 0.987-0.999; p = 0.029), and baseline NIHSS scores (OR, 0.881, 95% CI, 0.802-0.967; p = 0.008). CONCLUSION Irrespective of stroke severity, the therapeutic effects of recanalization after IVT decreased significantly with longer time delays in PCS patients.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hai-Qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing-Feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Song
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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19
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Tsivgoulis G, Geisler F, Katsanos AH, Kõrv J, Kunz A, Mikulik R, Rozanski M, Wendt M, Audebert HJ. Ultraearly Intravenous Thrombolysis for Acute Ischemic Stroke in Mobile Stroke Unit and Hospital Settings. Stroke 2018; 49:1996-1999. [DOI: 10.1161/strokeaha.118.021536] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Georgios Tsivgoulis
- From the Second Department of Neurology, “Attikon” Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., A.H.K.)
- Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Frederik Geisler
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany (F.G., A.K., M.R., H.J.A.)
| | - Aristeidis H. Katsanos
- From the Second Department of Neurology, “Attikon” Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T., A.H.K.)
- Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.)
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Estonia (J.K.)
| | - Alexander Kunz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany (F.G., A.K., M.R., H.J.A.)
| | - Robert Mikulik
- Neurology Department and International Clinical Research Center, St. Anne’s Hospital, Brno, Czech Republic (R.M.)
- Medical Faculty of Masaryk University, Brno, Czech Republic (R.M.)
| | - Michal Rozanski
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany (F.G., A.K., M.R., H.J.A.)
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Germany (M.W.)
| | - Heinrich J. Audebert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany (F.G., A.K., M.R., H.J.A.)
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.)
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20
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Tsivgoulis G, Kargiotis O, Rudolf J, Komnos A, Tavernarakis A, Karapanayiotides T, Ellul J, Katsanos AH, Giannopoulos S, Gryllia M, Safouris A, Papamichalis P, Vadikolias K, Mitsias P, Hadjigeorgiou G. Intravenous thrombolysis for acute ischemic stroke in Greece: the Safe Implementation of Thrombolysis in Stroke registry 15-year experience. Ther Adv Neurol Disord 2018; 11:1756286418783578. [PMID: 30034535 PMCID: PMC6048606 DOI: 10.1177/1756286418783578] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/06/2018] [Indexed: 01/08/2023] Open
Abstract
Background: Intravenous thrombolysis (IVT) remains the only approved systemic reperfusion
treatment for acute ischemic stroke (AIS), however there are scarce data
regarding outcomes and complications of IVT in Greece. We evaluated safety
and efficacy outcomes of IVT for AIS in Greece using the Safe Implementation
of Thrombolysis in Stroke: International Stroke Thrombolysis Register
(SITS-ISTR) dataset. Methods: All AIS patients treated with IVT in Greece between December 2002 and July
2017 and recorded in the SITS-ISTR were evaluated. Demographics, risk
factors, baseline stroke severity [defined using National Institutes of
Health Stroke Scale (NIHSS)], and onset-to-treatment time (OTT) were
recorded. Safety outcomes included symptomatic intracranial hemorrhage
(sICH) and 3-month mortality rates. The efficacy outcomes evaluated a
reduction in baseline NIHSS score at 2 and 24 h following IVT onset, 3-month
favorable functional outcome [FFO; modified Rankin scale (mRS) scores of
0–1] and 3-month functional independence (FI; mRS-scores of 0–2). The safety
and efficacy outcomes were assessed comparatively with previously published
data from SITS national and international registries. Results: A total of 523 AIS patients were treated with IVT in 12 Greek centers
participating in the SITS-ISTR during the study period (mean age 62.4 ±
12.7; 34.6% women; median baseline NIHSS score: 11 points; median OTT: 150
min). The rates of sICH were 1.4%, 2.3%, and 3.8% according to the
SIST-MOST, ECASS II, and NINDS criteria respectively. The median reduction
in NIHSS score at 2 and 24 h was 3 [interquartile range (IQR): 1–5] and 5
(IQR: 2–8) points respectively. The 3-month FI, FFO and mortality were
66.5%, 55.6% and 7.9%. All safety and efficacy outcomes were comparable with
available data from SITS-ISTR in other European countries. Conclusions: Our study underscores the safety and efficacy of IVT for AIS in Greece.
Additional action is necessary in order to increase the availability of IVT
in the Greek population and to include more centers in the SITS-ISTR.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Jobst Rudolf
- Department of Neurology, Papageorgiou Hospital, Thessaloniki, Greece
| | | | | | - Theodoros Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Aristeidis H Katsanos
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Gryllia
- Department of Neurology, Athens General Hospital G. Gennimatas, Athens, Greece
| | - Apostolos Safouris
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
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21
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Tsivgoulis G, Kargiotis O, Alexandrov AV. Intravenous thrombolysis for acute ischemic stroke: a bridge between two centuries. Expert Rev Neurother 2018. [PMID: 28644924 DOI: 10.1080/14737175.2017.1347039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intravenous tissue-plasminogen activator (tPA) remains the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke. Accumulating real-word experience for over 20 years regarding tPA safety and effectiveness led to re-appraisal of original contraindications for intravenous thrombolysis (IVT). Areas covered: This narrative review focuses on fast yet appropriate selection of patients for safe administration of tPA per recently expanded indications. Novel strategies for rapid patient assessment will be discussed. The potential for mobile stroke units (MSU) that shorten onset-to-needle time and increase tPA treatment rates is addressed. The use of IVT in the era of non-vitamin K antagonist oral anticoagulants (NOACs) is highlighted. The continuing role of IVT in large vessel occlusion (LVO) patients eligible for mechanical thrombectomy (MT) is discussed with regards to 'drip and ship' vs. 'mothership' treatment paradigms. Promising studies of penumbral imaging to extend IVT beyond the 4.5-hour window and in wake-up strokes are summarized. Expert commentary: This review provides an update on the role of IVT in specific conditions originally considered tPA contraindications. Novel practice challenges including NOAC's, MSU proliferation and bridging therapy (IVT&MT) for LVO patients, and the potential extension of IVT time-window using penumbral imaging are emerging as safe and potentially effective IVT applications.
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Affiliation(s)
- Georgios Tsivgoulis
- a Second Department of Neurology , National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital , Athens , Greece.,b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
| | | | - Andrei V Alexandrov
- b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
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22
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Sadeghi-Hokmabadi E, Farhoudi M, Taheraghdam A, Rikhtegar R, Ghafouri RR, Asadi R, Far EM, Ghaemian N, Mehrara M, Mirnour R. Prehospital notification can effectively reduce in-hospital delay for thrombolysis in acute stroke. FUTURE NEUROLOGY 2018. [DOI: 10.2217/fnl-2017-0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To reduce in-hospital intervals by developing a prehospital notification (PHN) protocol which directly notifies a neurologist to prepare for possible treatment. Methods: A 24/7 connection was established between emergency medical services dispatch and the on-call neurologist. A database of all patients with in-hospital stroke code activation was developed, door-to-computed tomography (CT) time and door-to-needle time was recorded from January 2013 to December 2016. The statistical results were considered significant at p < 0.05. Result: PHN resulted in a significant reduction in door-to-CT time (median 14 vs 20; p < 0.001). Among patients who were treated with intravenous thrombolysis, door-to-needle time was significantly shorter in patients with PHN compared with non-PHN group (median 42 vs 70; p < 0.001). Conclusion: PHN effectively reduced door-to-CT and door-to-needle times.
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Affiliation(s)
- Elyar Sadeghi-Hokmabadi
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Farhoudi
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aliakbar Taheraghdam
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Rikhtegar
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rouzbeh Rajaei Ghafouri
- Emergency medicine research team, Emergency Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rogayyeh Asadi
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elham Mehdizadeh Far
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Ghaemian
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrdad Mehrara
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reshad Mirnour
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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23
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Grenzen und Herausforderungen der Triage in der Notfall- und Rettungsmedizin. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0354-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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24
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Tsivgoulis G, Katsanos AH, Kadlecová P, Czlonkowska A, Kobayashi A, Brozman M, Švigelj V, Csiba L, Fekete K, Kõrv J, Demarin V, Vilionskis A, Jatuzis D, Krespi Y, Karapanayiotides T, Giannopoulos S, Mikulik R. Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry. Eur J Neurol 2017; 24:1493-1498. [PMID: 28888075 DOI: 10.1111/ene.13450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/04/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry. METHODS We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality. RESULTS Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273). CONCLUSIONS Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.
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Affiliation(s)
- G Tsivgoulis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,International Clinical Research Center and Neurology Department, St Anne's Hospital, Brno, Czech Republic
| | - A H Katsanos
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina, Ioannina, Greece
| | - P Kadlecová
- International Clinical Research Center and Neurology Department, St Anne's Hospital, Brno, Czech Republic
| | - A Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw
| | - A Kobayashi
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw.,Department of Neuroradiology, Interventional Stroke and Cerebrovascular Disease Treatment Centre, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - M Brozman
- Department of Neurology, Faculty Hospital Nitra, Constantine University Nitra, Nitra, Slovakia
| | - V Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - L Csiba
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - K Fekete
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - J Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - V Demarin
- Department of Neurology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - A Vilionskis
- Department of Neurology and Neurosurgery, Vilnius University and Republican Vilnius University Hospital, Vilnius
| | - D Jatuzis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Y Krespi
- Neurology Department and Stroke Center, Memorial Sisli Hospital Istanbul, Istanbul, Turkey
| | - T Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - S Giannopoulos
- Department of Neurology, University of Ioannina, Ioannina, Greece
| | - R Mikulik
- International Clinical Research Center and Neurology Department, St Anne's Hospital, Brno, Czech Republic.,Medical Faculty of Masaryk University, Brno, Czech Republic
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