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Dagonnier M, Donnan GA, Davis SM, Dewey HM, Howells DW. Acute Stroke Biomarkers: Are We There Yet? Front Neurol 2021; 12:619721. [PMID: 33633673 PMCID: PMC7902038 DOI: 10.3389/fneur.2021.619721] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Distinguishing between stroke subtypes and knowing the time of stroke onset are critical in clinical practice. Thrombolysis and thrombectomy are very effective treatments in selected patients with acute ischemic stroke. Neuroimaging helps decide who should be treated and how they should be treated but is expensive, not always available and can have contraindications. These limitations contribute to the under use of these reperfusion therapies. Aim: An alternative approach in acute stroke diagnosis is to identify blood biomarkers which reflect the body's response to the damage caused by the different types of stroke. Specific blood biomarkers capable of differentiating ischemic from hemorrhagic stroke and mimics, identifying large vessel occlusion and capable of predicting stroke onset time would expedite diagnosis and increase eligibility for reperfusion therapies. Summary of Review: To date, measurements of candidate biomarkers have usually occurred beyond the time window for thrombolysis. Nevertheless, some candidate markers of brain tissue damage, particularly the highly abundant glial structural proteins like GFAP and S100β and the matrix protein MMP-9 offer promising results. Grouping of biomarkers in panels can offer additional specificity and sensitivity for ischemic stroke diagnosis. Unbiased “omics” approaches have great potential for biomarker identification because of greater gene, protein, and metabolite coverage but seem unlikely to be the detection methodology of choice because of their inherent cost. Conclusion: To date, despite the evolution of the techniques used in their evaluation, no individual candidate or multimarker panel has proven to have adequate performance for use in an acute clinical setting where decisions about an individual patient are being made. Timing of biomarker measurement, particularly early when decision making is most important, requires urgent and systematic study.
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Affiliation(s)
- Marie Dagonnier
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Department of Neurology, Ambroise Paré Hospital, Mons, Belgium
| | - Geoffrey A Donnan
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Helen M Dewey
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - David W Howells
- Stroke Division, Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia.,Faculty of Health, School of Medicine, University of Tasmania, Hobart, TAS, Australia
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2
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Gorlicki J, Adnet F, Bouamra B, D’Araujo L, L’hermitte Y, Deltour S. Prise en charge en phase aiguë des patients suspects d’accident vasculaire cérébral : étude EpisignAVC. ANNALES FRANCAISES DE MEDECINE D URGENCE 2021. [DOI: 10.3166/afmu-2020-0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectif : Les patients présentant des signes d’accident vasculaire cérébral (AVC) nécessitent une prise en charge rapide. En France, il a été mis en place une filière « neurovasculaire » dédiée à ces patients. L’objectif de cette étude était de décrire la filière de prise en charge des patients présentant des signes évocateurs d’AVC dans le système de soins français.
Méthodes : Étude prospective observationnelle de courte durée pendant trois jours dans 35 régulations Samu, 27 Smur et 85 services d’urgences en France, incluant tout patient de plus de 18 ans présentant un signe évocateur d’AVC ou d’accident ischémique transitoire (AIT). Les patients suivaient ou non la filière neurovasculaire définie au préalable.
Résultats : Du 29 novembre au 1er décembre 2016, 827 patients ont été inclus, d’âge moyen 68 ans. Parmi eux, 418 avaient un AVC confirmé, dont 231 accidents ischémiques constitués. La filière UNVa été suivie pour 279 patients (44 %). Le délai médian de prise en charge médicale était de 3 heures 49. Pour les patients avec AVC confirmé, ce délai était significativement plus court dans la filière neurovasculaire (2 heures 45 vs 5 heures 56 ; p < 0,001).
Conclusion : En France, la prise en charge dans une filière dédiée des patients suspects d’AVC n’est actuellement effective que dans la moitié des cas. Cette filière nécessite d’être promue.
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Lachkhem Y, Rican S, Minvielle É. Understanding delays in acute stroke care: a systematic review of reviews. Eur J Public Health 2019; 28:426-433. [PMID: 29790991 DOI: 10.1093/eurpub/cky066] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Stroke is the leading cause of adult long-term disability in Western countries. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator is safe and effective within the first 4.5 h after the onset of stroke. Various factors delaying acute stroke care have been identified in the literature. This review aimed to provide an overview of factors delaying acute stroke care and attempted to show how they interact in a synthetic framework. Methods We conducted a systematic review of literature reviews published in Medline and DORIS until 2016 on factors influencing acute stroke pathway timeframe. Results We analyzed 31 reviews that cover all factors of delays from stroke onset to treatment. We identified 27 factors that had a significant impact on acute stroke care and can be categorized into four distinct categories: patient-related factors, training, resources and lack of coordination. We also reported associations between factors observed in both between categories (mainly between patients and organizational/logistical factors) and within categories. Conclusion This review provides a wide overview of factors influencing acute stroke pathway. Since it was observed that the identified factors were interrelated, they needed to be analyzed in a systematic way. We hence created a synthetic framework that combines several categories of factors while assuming that factor weight varies from a study context to another. Better knowledge on underlying mechanisms between factors would provide crucial improvement of the interventions aiming at reducing delays in both pre-hospital and inhospital stages. For future research, we recommend adopting a systemic perspective on factors influencing acute stroke pathway.
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Affiliation(s)
- Yacine Lachkhem
- Equipe d'Accueil Management des Organisations de Santé, French School of Public Health, Rennes, France
| | | | - Étienne Minvielle
- Equipe d'Accueil Management des Organisations de Santé, French School of Public Health, Rennes, France.,Gustave Roussy Cancer Center, Villejuif, France
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4
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Olascoaga Arrate A, Freijo Guerrero M, Fernández Maiztegi C, Azkune Calle I, Silvariño Fernández R, Fernández Rodríguez M, Vazquez Naveira P, Anievas Elena A, Iturraspe González I, Pérez Díez Y, Ruiz Fernández R. Use of emergency medical transport and impact on time to care in patients with ischaemic stroke. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2016.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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5
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Jallow E, Al Hail H, Han TS, Sharma S, Deleu D, Ali M, Al Hussein H, Abuzaid HO, Sharif K, Khan FY, Sharma P. Current status of stroke in Qatar: Including data from the BRAINS study. JRSM Cardiovasc Dis 2019; 8:2048004019869160. [PMID: 31452875 PMCID: PMC6700866 DOI: 10.1177/2048004019869160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/06/2019] [Accepted: 07/18/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Qatar is located on the north-eastern coast of the Arabian Peninsula. Qatari natives account for less than 15% of the population while the largest migrant group comprising 60% derives from South Asia. Despite projections that stroke burden in Qatar will increase with population ageing, epidemiological studies focusing on stroke in Qatar are relatively scarce. METHOD We reviewed the available epidemiological publications relating to Qatar. In addition, we have added to this knowledge by incorporating Qatari data from the on-going Bio-Repository of DNA in Stroke, an independent multinational database of stroke patients. RESULTS Qatar has low reported incidence and mortality rates of 58 and 9.17 per 100,000 per year, respectively, which may be explained by its middle-aged migrant worker majority population. Correspondingly, South Asian migrants in Qatar suffered younger strokes than Qatari natives (48.7 vs 63.4 years, P < 0.001). Among the most common risk factors identified in stroke patients were hypertension (77.9%), diabetes (43.8%) and hypercholesterolemia (28.5%). Ischaemic stroke was the most frequent subtype amongst migrant South Asians (71.1%). The majority of stroke cases had computed tomography and/or magnetic resonance imaging scans, but only 11.1% of ischaemic strokes were thrombolysed. Qataris on one-year follow up were more often found to have died (6.5% vs 0.3%) and had further stroke/transient ischaemic attack events (17.4% vs 6.4%, P = 0.009) compared to South Asians. CONCLUSION The burden of stroke is increasing in Qatar, and considerable disparities are observed between the native and migrant populations which likely will require different approaches to management by its healthcare system.
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Affiliation(s)
- Ebrima Jallow
- Institute of Cardiovascular Research, Royal Holloway University of London , London, UK
| | | | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway University of London , London, UK
| | - Sapna Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London , London, UK
| | | | - Musab Ali
- Hamad Medical Corporation, Doha, Qatar
| | | | | | | | | | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London , London, UK
- Ashford & St Peters Hospital NHS Foundation Trust, Surrey, UK
- Imperial College Healthcare NHS Trust, London, UK
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6
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Abstract
The present study was conducted to assess stroke care and outcomes in two Lebanese hospitals. Patients admitted in 2012 and 2013 were retrospectively selected. Data were extracted from medical records for time to hospital arrival, stroke severity, management, and discharge outcomes. A Cox regression analysis was then conducted to predict time to in-hospital death. A total of 201 patients were included (mean age = 69.2 years), among whom 50% arrived within a delay of 3.75 hours. Half underwent brain imaging in the first hour, and nine patients received an acute intervention. Forty-four patients died at the hospital; 142 were discharged home, among whom 98 patients were dependent in their daily activities. Stroke severity on admission and time from onset to arrival were found to be significantly associated to the time to in-hospital death (adjusted hazard ratio [HRa] = 1.13 and HRa = 0.98 respectively; p < 0.05). The study sheds light on high case fatality and dependency rates at discharge among stroke patients in Lebanese hospitals.
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7
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Gerschenfeld G, Muresan IP, Blanc R, Obadia M, Abrivard M, Piotin M, Alamowitch S. Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke. JAMA Neurol 2017; 74:549-556. [PMID: 28319240 DOI: 10.1001/jamaneurol.2016.5823] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome. Objective To compare the functional independence at 3 months between patients treated under the drip-and-ship paradigm and those treated on site (mothership). Design, Setting, and Participants This study used a prospectively gathered registry of patients with AIS to select patients admitted through the Saint-Antoine and Tenon (drip and ship) or the Fondation Rothschild (mothership) hospitals from January 1, 2013, through April 30, 2016. The study included patients older than 18 years treated with bridging therapy for AIS with LVO of the anterior circulation. Among the 159 patients who received MT at the mothership, 100 had been transferred after IVT from the drip-and-ship hospitals and 59 had received IVT on site. Main Outcomes and Measures The main outcome was 3-month functional independence (modified Rankin scale score ≤2). Both groups were compared using a multivariate linear model, including variables that were significantly different in the 2 groups. Results During the study period, 497 patients were hospitalized at the drip-and-ship and mothership hospitals for an AIS eligible to reperfusion therapy; 11 patients had a basilar artery occlusion and were excluded, leaving 100 patients in the drip-and-ship group (mean age, 73 years; age range, 60-81 years; 57 men [57.0%]) and 59 in the mothership group (mean age, 70 years; age range, 58-82 years; 29 men [49.2%]). The proportion of patients with a favorable neurologic outcome at 3 months was similar in both groups (drip and ship, 61 [61.0%]; mothership, 30 [50.8%]; P = .26), even after adjusting the analysis for the baseline National Institutes of Health Stroke Scale score, diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, and general anesthesia (P = .82). Patients had less severe conditions in the drip-and-ship group (median baseline National Institutes of Health Stroke Scale score, 15 vs 17 [P = .03]; median diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, 7.5 vs 7 [P = .05]). Process times were longer in the drip-and-ship group (onset-to-needle time, 150 vs 135 minutes; onset-to-puncture time, 248 vs 189 minutes; and onset-to-recanalization time, 297 vs 240 minutes; P < .001). Both groups were similar in terms of substantial recanalization (Thrombolysis in Cerebral Ischemia scores 2B to 3; drip and ship, 84 [84.0%]; mothership, 47 [79.7%]; P = .49) and symptomatic hemorrhagic transformation (drip and ship, 2 [2.0%]; mothership, 2 [3.4%]; P = .63). Conclusions and Relevance This study found that patients treated under the drip-and-ship paradigm also benefit from bridging therapy, with no statistically significant difference compared with those treated directly in a comprehensive stroke center.
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Affiliation(s)
- Gaspard Gerschenfeld
- Service de Neurologie et d'Urgences Neurovasculaires, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - Ioan-Paul Muresan
- Service de Neurologie et d'Urgences Neurovasculaires, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - Raphael Blanc
- Service de Neuroradiologie Interventionnelle, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Michael Obadia
- Service de Neurologie, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Marie Abrivard
- Service de Neuroradiologie Interventionnelle, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Michel Piotin
- Service de Neuroradiologie Interventionnelle, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Sonia Alamowitch
- Service de Neurologie et d'Urgences Neurovasculaires, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France4Université Pierre et Marie Curie, INSERM, Système Immunitaire, Neuroinflammation et Maladies Neurodégénératives, Hôpital Saint-Antoine, Paris, France
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8
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Olascoaga Arrate A, Freijo Guerrero MM, Fernández Maiztegi C, Azkune Calle I, Silvariño Fernández R, Fernández Rodríguez M, Vazquez Naveira P, Anievas Elena A, Iturraspe González I, Pérez Díez Y, Ruiz Fernández R. Use of emergency medical transport and impact on time to care in patients with ischaemic stroke. Neurologia 2017; 34:80-88. [PMID: 28094089 DOI: 10.1016/j.nrl.2016.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/07/2016] [Accepted: 11/12/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION According to numerous studies, using emergency medical services (EMS) to transport stroke patients to hospitals decreases diagnostic and treatment delays. OBJECTIVES To determine the frequency of use of EMS by stroke patients in Bizkaia (Spain), analyse the factors associated with using EMS, and study the impact of EMS on time to care. METHODS We gathered data from 545 patients hospitalised for acute ischaemic stroke and recruited consecutively. Data were obtained from the patients' medical histories and interviews with the patients themselves or their companions. We studied the following variables: previous health status, stroke symptoms and severity (NIHSS), type of transport, and time to medical care. Univariate and multivariate analyses were performed to identify factors associated with use of EMS and care delays. RESULTS Patients transported to hospital by the EMS accounted for 47.2% of the total. Greater stroke severity, arriving at the hospital at night, and poor functional status at baseline were found to be independently associated with use of EMS. Use of EMS was linked to earlier arrival at the hospital. Door-to-imaging times were shorter in the EMS group; however, this association disappeared after adjusting for stroke severity. Revascularisation was more frequent among patients transported by the EMS. CONCLUSIONS EMS transport was associated with shorter prehospital delays. Effective health education programmes should be developed to promote EMS transport for patients with stroke symptoms. In-hospital stroke management should also be improved to reduce time to medical care.
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Affiliation(s)
- A Olascoaga Arrate
- Delegación Territorial de Bizkaia, Departamento de Salud del Gobierno Vasco, Bilbao, Bizkaia, España.
| | - M M Freijo Guerrero
- Servicio de Neurología, Hospital Universitario Basurto, Osakidetza, Bilbao, Bizkaia, España
| | - C Fernández Maiztegi
- Servicio de Neurología, Hospital Universitario Cruces, Osakidetza, Barakaldo, Bizkaia, España
| | - I Azkune Calle
- Servicio de Neurología, Hospital Galdakao-Usansolo, Osakidetza, Galdakao, Bizkaia, España
| | - R Silvariño Fernández
- Servicio de Medicina Interna, Servicio de Urgencias, Hospital San Eloy, Osakidetza, Barakaldo, Bizkaia, España
| | - M Fernández Rodríguez
- Servicio de Medicina Interna, Servicio de Urgencias, Hospital San Eloy, Osakidetza, Barakaldo, Bizkaia, España
| | - P Vazquez Naveira
- Emergencias de Osakidetza, Servicio Vasco de Salud, Bilbao, Bizkaia, España
| | - A Anievas Elena
- Delegación Territorial de Bizkaia, Departamento de Salud del Gobierno Vasco, Bilbao, Bizkaia, España
| | - I Iturraspe González
- Delegación Territorial de Bizkaia, Departamento de Salud del Gobierno Vasco, Bilbao, Bizkaia, España
| | - Y Pérez Díez
- Delegación Territorial de Bizkaia, Departamento de Salud del Gobierno Vasco, Bilbao, Bizkaia, España
| | - R Ruiz Fernández
- Delegación Territorial de Bizkaia, Departamento de Salud del Gobierno Vasco, Bilbao, Bizkaia, España
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Mouthon-Reignier C, Bonnaud I, Gaudron M, Vannier-Bernard S, Bodin JF, Cottier JP, De Toffol B, Debiais S. Impact of a direct-admission stroke pathway on delays of admission, care, and rates of intravenous thrombolysis. Rev Neurol (Paris) 2016; 172:756-760. [DOI: 10.1016/j.neurol.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 08/23/2016] [Accepted: 10/14/2016] [Indexed: 11/27/2022]
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10
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Guillon B, Bourcier R, Toulgoat F, de Gaalon S, Gaultier-Lintia A, Sévin M. Gestione dell’infarto cerebrale acuto. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)80382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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Kawano H, Levi C, Inatomi Y, Pagram H, Kerr E, Bivard A, Spratt N, Miteff F, Yonehara T, Ando Y, Parsons M. International benchmarking for acute thrombolytic therapy implementation in Australia and Japan. J Clin Neurosci 2016; 29:87-91. [PMID: 26928157 DOI: 10.1016/j.jocn.2015.10.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/25/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
Although a wide range of strategies have been established to improve intravenous tissue plasminogen activator (IV-tPA) treatment rates, international benchmarking has not been regularly used as a systems improvement tool. We compared acute stroke codes (ASC) between two hospitals in Australia and Japan to study the activation process and potentially improve the implementation of thrombolysis. Consecutive patients who were admitted to each hospital via ASC were prospectively collected. We compared IV-tPA rates, factors contributing to exclusion from IV-tPA, and pre- and in-hospital process of care. IV-tPA treatment rates were significantly higher in the Australian hospital than in the Japanese (41% versus 25% of acute ischaemic stroke patients, p=0.0016). In both hospitals, reasons for exclusion from IV-tPA treatment were intracerebral haemorrhage, mild symptoms, and stroke mimic. Patients with baseline National Institutes of Health Stroke Scale score⩽5 were more likely to be excluded from IV-tPA in the Japanese hospital. Of patients treated with IV-tPA, the door-to-needle time (median, 63 versus 54minutes, p=0.0355) and imaging-to-needle time (34 versus 27minutes, p=0.0220) were longer in the Australian hospital. Through international benchmarking using cohorts captured under ASC, significant differences were noted in rates of IV-tPA treatment and workflow speed. This variation highlights opportunity to improve and areas to focus targeted practice improvement strategies.
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Affiliation(s)
- Hiroyuki Kawano
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia.
| | - Yuichiro Inatomi
- Department of Neurology, Stroke Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Heather Pagram
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Erin Kerr
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Toshiro Yonehara
- Department of Neurology, Stroke Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mark Parsons
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and The University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia
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13
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Masingue M, Alamowitch S. [An update on limitations of intravenous thrombolysis to treat acute ischemic stroke]. Presse Med 2015; 44:515-25. [PMID: 25697630 DOI: 10.1016/j.lpm.2014.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/06/2014] [Accepted: 07/08/2014] [Indexed: 11/15/2022] Open
Abstract
The benefit of intravenous thrombolysis with rt-pa has been demonstrated in acute ischemic stroke up to 4 h 30 after the first symptoms. The number of patients with stroke treated by rt-pa remains low at less than 5%. In the license of rt-pa in acute ischemic stroke, there are numerous contra-indications explained by the fear of cerebral hemorrhagic complications. These contra-indications are based on the first therapeutic trials published more than 15 years ago, but are not all evidence-based. Large post-marketing registers and new randomized trials have shown a favorable ratio benefit/risk of rt-pa in acute ischemic strokes in some classical contra-indications. Reconsidering some of the official contra-indications would increase the target population with treatable acute ischemic stroke using rt-pa to 20%.
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Affiliation(s)
- Marion Masingue
- Hôpital Saint-Antoine, service de neurologie et d'urgences neuro-vasculaires, 75012 Paris, France
| | - Sonia Alamowitch
- Hôpital Saint-Antoine, service de neurologie et d'urgences neuro-vasculaires, 75012 Paris, France; Université Pierre-et-Marie-Curie, Paris VI, 75005 Paris, France.
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14
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Eadie L, Regan L, Mort A, Shannon H, Walker J, MacAden A, Wilson P. Telestroke Assessment on the Move. Stroke 2015; 46:e38-40. [DOI: 10.1161/strokeaha.114.007475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leila Eadie
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
| | - Luke Regan
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
| | - Alasdair Mort
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
| | - Helen Shannon
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
| | - Jason Walker
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
| | - Ashish MacAden
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
| | - Philip Wilson
- From the Centre for Rural Health, University of Aberdeen, Centre for Health Science, Inverness, United Kingdom (L.E., A. Mort, P.W.) and NHS Highland, Raigmore Hospital, Inverness, United Kingdom (L.R., H.S., J.W., A. MacAden)
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Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Republished: Society for Neuroscience in Anesthesiology and Critical Care expert consensus statement: Anesthetic management of endovascular treatment for acute ischemic stroke. Stroke 2014; 45:e138-50. [PMID: 25070964 DOI: 10.1161/strokeaha.113.003412] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Literature on the anesthetic management of endovascular treatment of acute ischemic stroke (AIS) is limited. Anesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Thus, the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) created a task force to provide expert consensus recommendations on anesthetic management of endovascular treatment of AIS. The task force conducted a systematic literature review (up to August 2012). Because of the limited number of research articles relating to this subject, the task force solicited opinions from experts in this area. The task force created a draft consensus statement based on the available data. Classes of recommendations and levels of evidence were assigned to articles specifically addressing anesthetic management during endovascular treatment of stroke using the standard American Heart Association evidence rating scheme. The draft consensus statement was reviewed by the Task Force, SNACC Executive Committee and representatives of Society of NeuroInterventional Surgery (SNIS) and Neurocritical Care Society (NCS) reaching consensus on the final document. For this consensus statement the anesthetic management of endovascular treatment of AIS was subdivided into 12 topics. Each topic includes a summary of available data followed by recommendations. This consensus statement is intended for use by individuals involved in the care of patients with acute ischemic stroke, such as anesthesiologists, interventional neuroradiologists, neurologists, neurointensivists and neurosurgeons.
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Affiliation(s)
- Pekka O Talke
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.
| | - Deepak Sharma
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Eric J Heyer
- Departments of Anesthesiology and Neurology, Columbia University, New York, NY
| | - Sergio D Bergese
- Departments of Anesthesiology and Neurological Surgery, The Ohio State University, Columbus (on behalf of Society for Neuroscience in Anesthesiology and Critical Care [SNACC])
| | - Kristine A Blackham
- Department of Radiology, Case Western Reserve University, Cleveland, OH (representing the Society of NeuroInterventional Surgery [SNIS])
| | - Robert D Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery and Radiology, Hopkins University School of Medicine, Baltimore, MD (representing the Neurocritical Care Society [NCS])
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Tai YJ, Yan B. Minimising time to treatment: targeted strategies to minimise time to thrombolysis for acute ischaemic stroke. Intern Med J 2014; 43:1176-82. [PMID: 23734983 DOI: 10.1111/imj.12204] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/22/2013] [Indexed: 12/01/2022]
Abstract
Time to thrombolysis is a critical determinant of favourable outcomes in acute ischaemic stroke. It is not infrequent that patient outcomes are compromised due to out-of-hospital and in-hospital time delays. On the other hand, time delays could be minimised through the identification of barriers and the implementation of targeted solutions. This review outlines the different strategies in minimising treatment delays and offers recommendations. Literature search in PubMed, Medline and EBSCO Host was conducted to identify studies that are relevant to reduction of time to treatment from January 1995 to December 2012. Strategies to reduce time to thrombolysis are categorised into pre-hospital strategies, in-hospital strategies and post-treatment decision strategies. Proposed pre-hospital strategies include public education on stroke symptoms awareness, prioritising stroke by emergency medical services, increasing ease of access to medical records, pre-hospital notification, and mobile computed tomography scanning. In-hospital strategies include a streamlined code stroke system, computed tomography scanner co-location with emergency department, 24/7 availability of stroke physicians, point-of-care laboratory testing and access to expert neuroimaging interpretation. Post-decision strategies include increasing availability of intravenous thrombolysis and simplification of informed consent procurement. Time to thrombolysis delays is multifactorial. Effective reduction of time delays for acute ischaemic stroke requires the correct identification of and targeted strategies to overcome time barriers.
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Affiliation(s)
- Y J Tai
- Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Chen CH, Tang SC, Tsai LK, Hsieh MJ, Yeh SJ, Huang KY, Jeng JS. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS One 2014; 9:e104862. [PMID: 25111200 PMCID: PMC4128738 DOI: 10.1371/journal.pone.0104862] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/12/2014] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Timely intravenous (IV) thrombolysis for acute ischemic stroke is associated with better clinical outcomes. Acute stroke care implemented with “Stroke Code” (SC) may increase IV tissue plasminogen activator (tPA) administration. The present study aimed to investigate the impact of SC on thrombolysis. Methods The study period was divided into the “pre-SC era” (January 2006 to July 2010) and “SC era” (August 2010 to July 2013). Demographics, critical times (stroke symptom onset, presentation to the emergency department, neuroimaging, thrombolysis), stroke severity, and clinical outcomes were recorded and compared between the two eras. Results During the study period, 5957 patients with acute ischemic stroke were admitted; of these, 1301 (21.8%) arrived at the emergency department within 3 h of stroke onset and 307 (5.2%) received IV-tPA. The number and frequency of IV-tPA treatments for patients with an onset-to-door time of <3 h increased from the pre-SC era (n = 91, 13.9%) to the SC era (n = 216, 33.3%) (P<0.001). SC also improved the efficiency of IV-tPA administration; the median door-to-needle time decreased (88 to 51 min, P<0.001) and the percentage of door-to-needle times ≤60 min increased (14.3% to 71.3%, P<0.001). The SC era group tended to have more patients with good outcome (modified Rankin Scale ≤2) at discharge (49.5 vs. 39.6%, P = 0.11), with no difference in symptomatic hemorrhage events or in-hospital mortality. Conclusion The SC protocol increases the percentage of acute ischemic stroke patients receiving IV-tPA and decreases door-to-needle time.
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Affiliation(s)
- Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurology, Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Yu Huang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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18
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van Dishoeck AM, Dippel DWJ, Dirks M, Looman CWN, Mackenbach JP, Steyerberg EW. Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time. Cerebrovasc Dis Extra 2014; 4:149-55. [PMID: 25076959 PMCID: PMC4105950 DOI: 10.1159/000363535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/08/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator 'door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. METHODS We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. RESULTS Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. CONCLUSION AND IMPLICATIONS The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.
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Affiliation(s)
- Anne Margreet van Dishoeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maaike Dirks
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caspar W N Looman
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan P Mackenbach
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Society for Neuroscience in Anesthesiology and Critical Care Expert Consensus Statement. J Neurosurg Anesthesiol 2014; 26:95-108. [DOI: 10.1097/ana.0000000000000042] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Dagonnier M, Howells DW, Donnan GA, Dewey HM. Recruitment to trials of late thrombolysis: lessons from the EXTEND study. J Clin Neurosci 2014; 21:1215-9. [PMID: 24583057 DOI: 10.1016/j.jocn.2013.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 10/25/2013] [Indexed: 10/25/2022]
Abstract
To increase the percentage of acute stroke patients benefiting from thrombolysis, the utility of expanding the time window of treatment beyond 4.5 hours after stroke onset needs to be investigated. We aimed to identify the target population and the challenges of recruitment of patients for the time window beyond 4.5 hours. Extending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND), a multicentre randomised controlled trial testing the efficacy of thrombolytic therapy in patients with clinically significant ischaemic penumbra between 4.5 to 9 hours after stroke onset, was used as a model to evaluate inclusion and exclusion criteria for late thrombolysis trials. Data from all stroke patients admitted to Austin Health over a 1 year period were retrospectively analysed. Case notes were examined to determine potential trial eligibility. Of 556 patients assessed, 95 (17%) presented during the EXTEND time window. Sixty-seven of these (70.5%) were wake-up strokes (WUS) and 28 (29.5%) arrived between 4.5 and 9 hours after symptoms onset. At least one exclusion criterion was found for 78 (82%) of them. Hence, 17 (3%) patients arrived within an appropriate time frame for the study without any exclusion criteria. Most of these (13) arrived outside routine MRI hours. The number of patients recruited would have increased more than three-fold if imaging had been available 24 hours, 7 days a week. A significant proportion (17%) of ischaemic stroke patients presented between 4.5 and 9 hours after stroke onset. The majority of these were WUS. The major challenge identified for patient recruitment was imaging availability.
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Affiliation(s)
- Marie Dagonnier
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia; University of Melbourne, Melbourne, VIC, Australia.
| | - David W Howells
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia
| | - Geoffrey A Donnan
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia; University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Helen M Dewey
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia; University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
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Casolla B, Bodenant M, Girot M, Cordonnier C, Pruvo JP, Wiel E, Leys D, Goldstein P. Intra-hospital delays in stroke patients treated with rt-PA: impact of preadmission notification. J Neurol 2012; 260:635-9. [PMID: 23052603 DOI: 10.1007/s00415-012-6693-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Revised: 09/08/2012] [Accepted: 09/25/2012] [Indexed: 11/26/2022]
Abstract
Pre-hospital notification enhances thrombolysis rate and improves intra-hospital delays, but the impact of the notification to the neurologist by the emergency medical system (EMS) call centre remains unknown. Our objective was to compare pre-hospital and in-hospital delays in stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA), with and without pre-hospital notification. We compared baseline characteristics and in-hospital delays in stroke patients treated by rt-PA with a high-level notification (call to EMS and EMS-neurologist discussion), a low-level notification (call to EMS without EMS-neurologist discussion ) and no pre-hospital notification. Of 302 consecutive patients [165 women, 54.6 %; median age 74 years, interquartile range (IQR) 59-83], patients with high-level, low-level and no notification differed for the severity at admission (median National Institutes of Health Stroke Scale scores, respectively, of: 12, IQR 7-17; 9, IQR 6-15, and 8, IQR 6-14, p = 0.029). Patients with high-level notification had shorter (1) admission-to-completion of imaging times (27 min, IQR 14-35) than patients with low-level notification (35 min, IQR 17-54) or no notification (36 min, IQR 30-58) (p < 0.01); (2) door-to-needle times (49 min, IQR 39-62 vs. 57 min, IQR 39-81 vs. 63 min, IQR 51-97; p = 0.003); and (3) onset-to-needle times (140 min, IQR 110-175 vs. 155 min, IQR 106-230 vs. 182 min, IQR 131-234; p < 0.001). They did not differ for onset-to-admission time and imaging-to-needle time. Pre-hospital notification by the EMS reduces intra-hospital delays in patients eligible for rt-PA, but the benefit is higher in the case of discussion between the EMS and the neurologist before admission.
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Affiliation(s)
- Barbara Casolla
- Department of Neurology, Univ Lille Nord de France, CHU Lille, EA 1046, 59000 Lille, France
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Code stroke: a mismatch between number of activation and number of thrombolysis. J Formos Med Assoc 2012; 113:442-6. [PMID: 24961186 DOI: 10.1016/j.jfma.2012.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 06/22/2012] [Accepted: 07/23/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/PURPOSE Code stroke systems are widely implemented to expedite acute stroke treatment. Although this system requires considerable resources, so far no reimbursement has been provided by the Bureau of National Health Insurance (BNHI) in Taiwan. We investigated how often a code stroke was initiated and the percentage of patients treated with intravenous (IV) tissue plasminogen activator, and draw attention to the resulting mismatch. METHODS From January 2010 to September 2011, we prospectively registered all consecutive code stroke patients. Patient characteristics, including demographic data, medical history, comorbidity conditions, treatments, and discharge diagnosis were collected, together with the exact time of onset (or last known normal time) and management. The eligibility of thrombolysis for each patient recorded originally on the chart was reviewed retrospectively on the basis of two sets of criteria, namely, the BNHI reimbursement criteria and the Taiwan Stroke Society (TSS) guideline. RESULTS During the study period, code strokes were activated for 419 patients at an average of around 20 patients per month. About 57% of code strokes were initiated outside of office hours. Stroke was diagnosed in 377 (90%) patients and 304 (73%) patients had ischemic stroke or transient ischemic attack. A total of 42 (10%) patients according to the BNHI reimbursement criteria and 101 (24%) patients by the TSS guideline were eligible for IV thrombolytic therapy. Of all the code stroke patients, only 49 (12%) were actually treated. Before each additional patient was thrombolysed, about eight patients had been evaluated and excluded from treatment. CONCLUSION The majority of code stroke patients were stroke patients; however, most of them could not be treated with thrombolytic therapy. These findings underscore the need for further support from the BNHI in order for health-care providers to implement the code stroke systems successfully.
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