Late Hospital Arrival for Thrombolysis after Stroke in Southern Portugal: Who Is at Risk?

Analyzing prehospital delays in recurrent acute ischemic stroke: Insights from interpretable machine learning

OBJECTIVE

This study investigates prehospital delays in recurrent Acute Ischemic Stroke (AIS) patients, aiming to identify key factors contributing to these delays to inform effective interventions.

METHODS

A retrospective cohort analysis of 1419 AIS patients in Shenzhen from December 2021 to August 2023 was performed. The study applied the Extreme Gradient Boosting (XGBoost) algorithm and SHapley Additive exPlanations (SHAP) for identifying determinants of delay.

RESULTS

Living with others and lack of stroke knowledge emerged as significant risk factors for delayed hospital presentation in recurrent AIS patients. Key features impacting delay times included residential status, awareness of stroke symptoms, presence of conscious disturbance, diabetes mellitus awareness, physical weakness, mode of hospital presentation, type of stroke, and presence of coronary artery disease.

CONCLUSION

Prehospital delays are similarly prevalent among both recurrent and first-time AIS patients, highlighting a pronounced knowledge gap in the former group. This discovery underscores the urgent need for enhanced stroke education and management.

PRACTICE IMPLICATION

The similarity in prehospital delay patterns between recurrent and first-time AIS patients emphasizes the necessity for public health initiatives and tailored educational programs. These strategies aim to improve stroke response times and outcomes for all patients.

Stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in Kinshasa

Background

Rapid recognition and early medical intervention are essential to reduce stroke-related mortality and long-term disability. This study aimed to evaluate awareness of stroke symptoms/signs and determine factors delaying the hospital arrival of patients with acute stroke in Kinshasa.

Methods

Patients with stroke and/or accompanying family members were interviewed using a standard questionnaire, and their medical records were reviewed. Factors independently associated with a late arrival (≥4.5 h) to the hospital were identified using the logistic regression test in forward multivariate analysis.

Results

Overall, 202 patients with an average age of 57.9 ± 13.1 years were included. Only 27 (13.4%) patients immediately associated the initial symptoms with a stroke episode. Delayed hospital arrival was observed in 180 (89.1%) patients. Unmarried status (adjusted odds ratio [aOR], 2.29; 95% confidence interval [CI], 1.17-4.88; p = 0.007), low education level (aOR, 2.29; 95% CI, (1.12-5.10; p = 0,014), absence of impaired consciousness (aOR, 3.12; 95% CI, 1.52-4.43; p = 0.005), absence of a history of hypertention (aOR, 1.85; 95% CI, 1.18-3.78; p = 0.041), absence of a history of diabetes (aOR, 1.93; 95% CI, 1.15-4.58; p = 0.013), heavy alcohol consumption (aOR, 1.83; 95% CI, 1.12-2.83; p = 0.045), absence of a severe to very severe stroke (aOR, 4.93; 95% CI, 0.82-1.01; p = 0.002), and presence of ischemic stroke (aOR, 2.93; 95% CI, 1.54-4.59; p = 0.001) were identified as independent determinants of delayed hospital arrival.

Conclusions

This study depicted a low stroke awareness rate and a much longer prehospital delay than evidence-based guidelines recommend and identified eight factors that public health actions could target to promote the earliest management of stroke.

Global stroke statistics 2023: Availability of reperfusion services around the world

BACKGROUND

Disparities in the availability of reperfusion services for acute ischemic stroke are considerable globally and require urgent attention. Contemporary data on the availability of reperfusion services in different countries are used to provide the necessary evidence to prioritize where access to acute stroke treatment is needed.

AIMS

To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services.

METHODS

We searched PubMed to identify original articles, published up to January 2023 for the most recent, representative, and relevant patient-level data for each country. Keywords included thrombolysis, endovascular thrombectomy and telemedicine. We also screened reference lists of review articles, citation history of articles, and the gray literature. The information is provided as a narrative summary.

RESULTS

Of 11,222 potentially eligible articles retrieved, 148 were included for review following de-duplications and full-text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and PRE-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (63% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulance services (80% in HICs) around the world.

CONCLUSION

Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available patient-level data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.

Healthcare-Seeking Delays in Acute Ischemic Stroke Patients: The Influence of Gender, Immigrant Status, and Educational Background

Purpose

Timely medical attention is crucial for patients with Acute Ischemic Stroke (AIS), as delays can significantly impact therapeutic outcomes. These delays are influenced by a combination of socio-cultural, educational, and clinical factors.

Patients and Methods

An in-depth analysis was conducted to assess the prevalence and median duration of healthcare-seeking delays in AIS patients. The study specifically investigated the independent impacts of sociocultural and clinical determinants on these delays, with a focus on immigrant status, gender disparities, and educational levels. Multivariate regression analysis was employed to identify these independent effects while controlling for potential confounding factors.

Results

Among 1419 AIS patients, 82.52% (n = 1171) experienced delays exceeding 2 hours from symptom onset of symptoms to hospital arrival. The median delay was 12.3 hours. Immigrant populations encountering longer delays compared to native groups. Younger males (<45 years) and elderly females were more prone to delay in healthcare-seeking. Identified independent risk factors for delay included male gender (OR = 1.65 [95% CI:1.14-2.48]), self-acknowledged diabetes (OR = 2.50 [95% CI:1.21-5.17]), small vessel (OR = 2.07 [95% CI:1.27-3.36]), and wake stroke (OR = 7.04 [95% CI:3.69-13.44]). Educational background (high school and above), GCS score with 3-8 points (OR = 0.52 [95% CI:0.09-0.69]), understanding stroke-related knowledge (OR = 0.26 [95% CI:0.09-0.44]), conscious disturbance (OR = 0.25 [95% CI:0.10-0.62]) and limb weakness (OR=0.21[95% CI:0.21-0.49]) are protective factors for timely treatment.

Conclusion

Immigrant populations experienced longer delays from symptom onset to hospital arrival. The crucial roles of education and knowledge about stroke underscore the need for enhanced health literacy campaigns and public awareness, with a targeted focus on younger males and elderly females.

Posterior Circulation Stroke Patients Receive Less Reperfusion Therapy Because of Late Arrival and Relative Contraindications: A Retrospective Study

BACKGROUND

Reperfusion treatment (RT) is administered to individuals with posterior circulation strokes (PCS) later and less frequently. We aimed to study the impact of demographic and clinical factors on the decision for RT in PCS.

METHODS

We conducted a retrospective analysis of the data from 500 subjects admitted to the tertiary stroke centre's emergency department between 2018 and 2020 due to PCS. Demographic and clinical factors were analysed among three groups: the RT group, the group with no RT because of absolute contraindications (ACI), and the group with no RT because of relative contraindications (RCI).

RESULTS

Of the patients, 202 (40.3%) were female. The median NIHSS was four (4), and the subjects' median age was 69 (18). RT was performed on 120 (24%) subjects. FAST symptoms (OR-5.62, 95% CI [2.90-12.28]) and higher NIHSS (OR-1.13, 95% CI [1.09-1.18]) at presentation, atrial fibrillation (OR-1.56, 95% CI [1.02-2.38]), hypertension (OR-2.19, 95% CI [1.17-4.53]) and diabetes (OR-1.70, 95% CI [1.06-2.71]) increased the chance of RT. Late arrival was the most prevalent ACI for 291 (58.2%) patients. FAST-negative subjects (OR-2.92, 95% CI [1.84-4.77]) and males (OR-1.58, 95% CI [1.11-2.28]) had a higher risk of arriving late. Because of RCI, 50 (10%) subjects did not receive RT; the majority were above 80 and had NIHSS ≤ 5. Subjects with RCI who received the RT had a higher NIHSS (4 vs. 3, p < 0.001), higher hypertension (59 (92.2%) vs. 35 (77.8%), p = 0.032) and heart failure (23 (35.9%) vs. 7 (15.6%), p = 0.018) prevalence. There was a trend for less RT in females with RCI.

CONCLUSIONS

Late arrival was the most common barrier to RT, and the male gender increased this risk. because of relative contraindications, 10% of subjects were not considered for RT. The presence of FAST symptoms, vascular risk factors, and a higher NIHSS increased the chance of RT.

Prediction of Late Hospital Arrival in Patients with Mild and Rapidly Improving Acute Ischemic Stroke in a Rural Area of China

Purpose

Among all ischemic stroke patients, more than half are mild and rapidly improving acute ischemic stroke (MaRAIS) patients. However, many MaRAIS patients do not recognize the disease early on, and thus they delay access to the treatment that would be most effective if provided earlier. This is especially true in rural areas. The aim of this study was to develop and validate a late hospital arrival risk nomogram in a rural Chinese population of patients with MaRAIS.

Methods

We developed a prediction model based on a training dataset of 173 MaRAIS patients collected from September 9, 2019 to May 13, 2020. Data analyzed included demographics and disease characteristics. A least absolute shrinkage and selection operator (LASSO) regression model was used to optimize feature selection for the late hospital arrival risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the features selected in the LASSO regression models. The discrimination, calibration, and clinical usefulness of the prediction model were assessed using the C-index, calibration plot, and decision curve analysis, respectively. Internal validation was then assessed using bootstrapping validation.

Results

Variables contained in the prediction nomogram included transportation mode, history of diabetes, knowledge of stroke symptoms, and thrombolytic therapy. The model had moderate predictive power with a C-index of 0.709 (95% confidence interval: 0.636-0.783) and good calibration. In the internal validation, the C-index reached 0.692. The risk threshold was 30-97% according to the analysis of the decision curve, and the nomogram could be applied in clinical practice.

Conclusion

This novel nomogram, which incorporates transportation mode, history of diabetes, knowledge of stroke symptoms, and thrombolytic therapy, was conveniently applied to facilitate individual late hospital arrival risk prediction among MaRAIS patients in a rural area of Shanghai, China.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Factors Affecting Pre-Hospital and In-Hospital Delays in Treatment of Ischemic Stroke; a Prospective Cohort Study

Introducion:

The outcomes of acute ischemic stroke (AIS) are highly affected by time-to-treatment. The present study aimed to determine the factors affecting in-hospital and pre-hospital delays in treatmentof AIS.

Methods:

This prospective study was carried out on 204 AIS patients referring to the stroke care unit in Zanjan (Iran) in 2019. The required data were collected by interviewing the patients and families and using patients’ records and observations.

Results:

The maximum delay was related to onset-to-arrival time (288.19 ± 339.02 minutes). The logistic regression analysis indicated a statistically significant decline in the treatment delay via consultation after the initiation of symptoms (p< 0.001), transferring the patient through emergency medical service to the hospital (p<0.001), and patients’ perception regarding AIS symptoms (P< 0.001).

Conclusion:

It is essential to inform people regarding AIS symptoms and referring to AIS treatment units to reduce the treatment time.

Ischemic stroke in Morocco: Prehospital delay and associated factors

OBJECTIVES

This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco.

PATIENTS AND METHODS

An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department.

RESULTS

A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI_95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI_95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI_95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI_95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI_95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI_95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI_95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI_95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI_95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI_95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI_95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke.

CONCLUSION

Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.

Factors affecting prehospital delay in rural and urban patients with stroke: a prospective survey-based study in Southwest Germany

Background

Reducing prehospital delay plays an important role in increasing the thrombolysis rate in patients with stroke. Several studies have identified predictors for presentation ≤4.5 h, but few compared these predictors in urban and rural communities. We aimed to identify predictors of timely presentation to the hospital and identify possible differences between the urban and rural populations.

Methods

From January to June 2017, we conducted a prospective survey of patients with stroke admitted to an urban comprehensive stroke centre (CSC) and a rural primary care centre (PCC). Predictors were identified using binary logistical regression. Predictors and patient characteristics were then compared between the CSC and PCC.

Results

Overall, 459 patients were included in our study. We identified hesitation before seeking help, awareness of the existence of a time-window, type of admission and having talked about stroke symptoms with friends/relatives who had previously had a stroke as the strongest predictors for presentation to the emergency room ≤4.5 h. Patients admitted to the rural PCC were more hesitant to seek help and less likely to contact emergency services, even though patients had comparable knowledge pertaining to stroke care concepts.

Conclusions

Patients from rural areas were more likely to be hesitant to seek help and contacted the EMS less frequently, despite similar self-awareness of having a stroke.

Educational campaigns should focus on addressing these disparities in rural populations. Affected patients should also be encouraged to talk about their symptoms and take part in educational campaigns.

Machine learning is a valid method for predicting prehospital delay after acute ischemic stroke

OBJECTIVES

This study aimed to identify the influencing factors associated with long onset-to-door time and establish predictive models that could help to assess the probability of prehospital delay in populations with a high risk for stroke.

MATERIALS AND METHODS

Patients who were diagnosed with acute ischemic stroke (AIS) and hospitalized between 1 November 2018 and 31 July 2019 were interviewed, and their medical records were extracted for data analysis. Two machine learning algorithms (support vector machine and Bayesian network) were applied in this study, and their predictive performance was compared with that of the classical logistic regression models after using several variable selection methods. Timely admission (onset-to-door time < 3 hr) and prehospital delay (onset-to-door time ≥ 3 hr) were the outcome variables. We computed the area under curve (AUC) and the difference in the mean AUC values between the models.

RESULTS

A total of 450 patients with AIS were enrolled; 57 (12.7%) with timely admission and 393 (87.3%) patients with prehospital delay. All models, both those constructed by logistic regression and those by machine learning, performed well in predicting prehospital delay (range mean AUC: 0.800-0.846). The difference in the mean AUC values between the best performing machine learning model and the best performing logistic regression model was negligible (0.014; 95% CI: 0.013-0.015).

CONCLUSIONS

Machine learning algorithms were not inferior to logistic regression models for prediction of prehospital delay after stroke. All models provided good discrimination, thereby creating valuable diagnostic programs for prehospital delay prediction.

Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature

BACKGROUND/AIMS

This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery.

METHODS

A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy.

RESULTS

One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model.

CONCLUSION

Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.

Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhage

OBJECTIVES

The case fatality from spontaneous ICH (SICH) remains high. The quality and intensity of early treatment is one of the determinants of the outcome. We aimed to study the association of early intensive care, using the Intracerebral Hemorrhage-Specific Intensity of Care Quality Metrics (IHSICQM) with the 30-day in-hospital mortality in Algarve, Portugal.

PATIENTS AND METHODS

analysis of prospective collected data of 157 consecutive SICH patients (2014-2016). Logistic regression was performed to assess the role of IHSICQM on the 30-day in-hospital mortality controlling for the most common clinical and radiological predictors of death. Receiver operating characteristic (ROC) curve was developed to evaluate the prediction accuracy of the IHSICQM score (C-statistics).

RESULTS

forty-five (29 %) patients died. The group of deceased patients had lower intensity of care (lower IHSICQM score) and higher proportion of poor prognosis associated factors (pre-ICH functional dependency, intraventricular dissection/glycaemia). On the multivariate analysis, higher IHSICQM was associated with reduction of the odds of death, 0.27 (0.14-0.50) per each increasing point. The ROC curve showed a high discriminating ability of isolated IHSICQM in predicting the 30-day mortality (AUC = 0,95; 95 % CI = [0,86; 0,95]).

CONCLUSION

the early intensity of quality of care independently predicts the 30-day in-hospital mortality. Quantification of the intensity of SICH is a valid tool to persuade improvement of SICH care, as well to help comparison of performances within and between hospitals.

High-resolution mapping of epilepsy prevalence, ambulance use, and socioeconomic deprivation in an urban area of Sweden

OBJECTIVE

Geographic differences in epilepsy prevalence between areas of different socioeconomic standing have been demonstrated in the United Kingdom, but knowledge from other health care systems is scarce. Our objective was to compare epilepsy prevalence and emergency medical service (EMS) assignments for seizures in areas of different socioeconomic standings in the urban area of Gothenburg.

METHODS

Register-based study in Gothenburg (population 690 000), the second largest city in Sweden. Epilepsy cases were identified in the comprehensive national patient register in 2014-2015. EMS assignments were identified in the EMS dispatch system in 2013-2018. Socioeconomic variables were mean income and proportion of welfare recipients.

RESULTS

Significant correlations were seen between epilepsy prevalence and the proportion of welfare recipients (r = .49, P = .0014) and annual income per capita (r = -.42, P = .0071). There were 7907 assignments for seizures during the study years. GPS-based analysis showed that most assignments occurred in the city center. In addition, several high-density areas correlated with areas with a high proportion of inhabitants receiving welfare. Correlation analysis showed significant associations between the number of EMS assignments per capita and the proportion of welfare recipients (r = .31, P < .0001) and income (r = -.19, P < .0001). When comparing representative areas, a greater proportion of assignments was given the highest priority in high status areas compared to low status areas, both by the dispatch center and EMS clinicians on scene.

SIGNIFICANCE

Our findings that epilepsy prevalence and seizure frequency differ with socioeconomic status on a microgeographic level considerably strengthen the generalizability of previous observations across different health care systems. Differences in priority may reflect health utilization behavior or access to neurologic care.