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Brunser AM, Nuñez JC, Mansilla E, Cavada G, Olavarría V, Muñoz Venturelli P, Lavados PM. Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience. ARQUIVOS DE NEURO-PSIQUIATRIA 2023. [PMID: 37402398 PMCID: PMC10371412 DOI: 10.1055/s-0043-1768672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND The efficacy of intravenous thrombolysis (IVT) is time-dependent. OBJECTIVE To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. METHODS Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. RESULTS A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant. CONCLUSION Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.
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Affiliation(s)
- Alejandro M Brunser
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
| | - Juan-Cristobal Nuñez
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Emergencias Generales, Santiago, Chile
| | - Eloy Mansilla
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
| | - Gabriel Cavada
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Cuidados Críticos, Santiago, Chile
| | - Verónica Olavarría
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Cuidados Críticos, Santiago, Chile
| | - Paula Muñoz Venturelli
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Instituto de Ciencias e Innovación en Medicina, Centro de Estudios Clínicos, Santiago, Chile
- University of New South Wales, Faculty of Medicine, The George Institute for Global Health, Sydney, Australia
| | - Pablo M Lavados
- Clínica Alemana Universidad del Desarrollo, Facultad de Medicina, Departamento de Neurología y Psiquiatría Santiago, Servicio de Neurología, Unidad de Neurología, Santiago, Chile
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Olavarría VV, Hoffmeister L, Vidal C, Brunser AM, Hoppe A, Lavados PM. Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression. Front Neurol 2022; 13:851498. [PMID: 35463124 PMCID: PMC9028765 DOI: 10.3389/fneur.2022.851498] [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] [Received: 01/10/2022] [Accepted: 03/02/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions. Methods We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria. Results A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4–15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1–10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window. Conclusions The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.
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Affiliation(s)
- Verónica V. Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Lorena Hoffmeister
- Escuela de Salud Pública, Facultad de Medicina, Universidad Mayor, Santiago, Chile
| | - Carolina Vidal
- Escuela de Salud Pública, Facultad de Medicina, Universidad Mayor, Santiago, Chile
| | - Alejandro M. Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Arnold Hoppe
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Pablo M. Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
- Unidad de Investigación y Ensayos Clínicos, Departamento de Desarrollo Académico e Investigación, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Santiago, Universidad del Desarrollo, Santiago, Chile
- *Correspondence: Pablo M. Lavados
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The burden of stroke and its attributable risk factors in the Middle East and North Africa region, 1990-2019. Sci Rep 2022; 12:2700. [PMID: 35177688 PMCID: PMC8854638 DOI: 10.1038/s41598-022-06418-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/31/2022] [Indexed: 01/25/2023] Open
Abstract
Stroke is one of the leading causes of mortality and morbidity across the globe. Providing comprehensive data on the burden of stroke in the Middle East and North Africa (MENA) could be useful for health policy makers in the region. Therefore, this article reported the burden of stroke and its attributable risk factors between 1990 and 2019 by age, sex, type of stroke, and socio-demographic index. Data on the point prevalence, death, and disability-adjusted life-years (DALYs), due to stroke, were retrieved from the Global Burden of Disease study 2019 for the 21 countries located in the MENA region from 1990 to 2019. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals (UIs). In 2019, the regional age-standardised point prevalence and death rates of stroke were 1537.5 (95% UI: 1421.9–1659.9) and 87.7 (78.2–97.6) per 100,000, which represent a 0.5% (− 2.3 to 1.1) and 27.8% (− 35.4 to − 16) decrease since 1990, respectively. Moreover, the regional age-standardised DALY rate in 2019 was 1826.2 (1635.3–2026.2) per 100,000, a 32.0% (− 39.1 to − 23.3) decrease since 1990. In 2019, Afghanistan [3498.2 (2508.8–4500.4)] and Lebanon [752.9 (593.3–935.9)] had the highest and lowest age-standardised DALY rates, respectively. Regionally, the total number of stroke cases were highest in the 60–64 age group and was more prevalent in women in all age groups. In addition, there was a general negative association between SDI and the burden of stoke from 1990 to 2019. Also, in 2019, high systolic blood pressure [53.5%], high body mass index [39.4%] and ambient particulate air pollution [27.1%] made the three largest contributions to the burden of stroke in the MENA region. The stroke burden has decreased in the MENA region over the last three decades, although there are large inter-country differences. Preventive programs should be implemented which focus on metabolic risk factors, especially among older females in low SDI countries.
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CJEM Debate Series: #TPA should be the initial treatment in eligible patients presenting with an acute ischemic stroke. CAN J EMERG MED 2021; 22:142-148. [PMID: 32209153 DOI: 10.1017/cem.2020.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Outcome predictors of intravenous thrombolytic therapy in acute ischemic stroke patients: an Egyptian center experiences. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00229-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intravenous thrombolytic therapy remains the guideline-recommended treatment to improve outcomes after acute ischemic stroke. However, the functional outcome among patients with acute ischemic stroke after receiving intravenous thrombolytic therapy is influenced by huge variety of factors, and this was the aim of our study to evaluate the outcome predictors of intravenous thrombolytic therapy in a sample of Egyptian patients with acute ischemic stroke.
Methods
We enrolled 183 acute ischemic stroke patients who were treated with intravenous recombinant tissue plasminogen activator (IV rtPA) according to the last updated guidelines of American Heart Association and American Stroke Association (AHA/ASA) from February 2018 to February 2020; however, only 150 patients of them completed our study plan till the end. Data of study variables were collected, analyzed statistically and correlated with the functional outcome 3 months after receiving IV rtPA using the modified Rankin Scale (mRS).
Results
Good functional outcome was seen in 98 (65.3%) patients and poor functional outcome was seen in 52 (34.7%) patients. Multivariate analysis of the study variables was done to detect the significant independent predictors of the functional outcome. Atrial fibrillation (AF) (P value < 0.001*OR 6.28* (95% C.I)), hypertension (P value 0.001*OR 3.65*(95% C.I)), diabetes mellitus (DM) (P value 0.009*OR 2.805*(95% C.I)), increased National Institute of Health Stroke Scale (NIHSS) score 24 h after receiving IV rtPA (P value 0.003* OR 8.039* (95% C.I)), increased pulsatility index (PI) value in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of poor functional outcome. On the other hand decreased NIHSS score 24 h after receiving IV rtPA (P value 0.003* OR 0.124*(95% C.I)), Normal value of PI in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of good functional outcome.
Conclusion
Intravenous thrombolytic therapy improves the functional outcome of acute ischemic stroke patients. Also, AF, hypertension, DM, NIHSS 24 h after receiving IV rtPA and PI could be used as independent predictors of the functional outcome.
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Jillella DV, Calder CS, Uchino K, Qeadan F, Ikram A, Casul YR, Tran HQ. Blood Pressure and Hospital Discharge Outcomes in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy. J Stroke Cerebrovasc Dis 2020; 29:105211. [PMID: 33066897 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/20/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Acute management of blood pressure in ischemic stroke treated with reperfusion therapy remains uncertain. We evaluated blood pressures during the first 24-hours after reperfusion therapy in relation to in-hospital outcomes. METHODS We conducted a single-center retrospective study of blood pressure in the first 24 hours among ischemic stroke patients who underwent reperfusion therapy with intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) at a tertiary referral center. Blood pressure variability was expressed as the range between the highest and the lowest pressures. Outcomes of interest were discharge disposition and in-hospital mortality. Favorable outcome was defined as a discharge destination to home or inpatient rehabilitation facility (IRF). Multivariable logistic regression analysis was performed with adjustment for age, National Institutes of Health Stroke Scale score, and patients receiving reperfusion therapy. RESULTS Among the 140 ischemic stroke patients (117 IVT, 84 MT and 61 both), 95 (67.8%) had favorable discharge disposition and 24 (17.1%) died. Higher 24-hour peak systolic blood pressures (SBPs) and peak mean arterial pressures (MAPs) were independently associated with a lower likelihood of favorable discharge disposition, with an adjusted odds ratio (aOR) 0.868, 95 % CI 0.760 - 0.990 per 10 mm Hg for SBP and aOR 0.710, 95% CI 0.515 - 0.980 for MAP, and with increased odds of death aOR 1.244, 95% CI 1.056-1.467 and aOR 1.760, 95% CI 1.119 - 2.769 respectively. Greater variability of SBP and MAP was also associated with odds of death aOR 1.327, 95% CI 1.104 - 1.595 and aOR 1.577, 95% CI 1.060- 2.345 respectively, without a significant effect on discharge disposition. CONCLUSION In the first 24 hours after reperfusion therapy, higher peak and variable blood pressures are associated with unfavorable discharge outcomes and increased in-hospital mortality. Further studies in stroke patients undergoing reperfusion therapy might target blood pressure reduction and variability to improve patient outcomes.
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Affiliation(s)
- Dinesh V Jillella
- Department of Neurology, Emory University School of Medicine and Grady Memorial Hospital, 49 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, USA.
| | - Christopher S Calder
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fares Qeadan
- Division of Public Health, Department of Family and Preventive Medicine, Health University of Utah, Salt Lake City, UT, USA
| | - Asad Ikram
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Yoram Roman Casul
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Huy Q Tran
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA; Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
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