Launching online education for 911 telecommunicators and EMS personnel: experiences from the North Carolina Rapid Response to Stroke Project

Acute ischemic stroke: improving access to intravenous tissue plasminogen activator

INTRODUCTION

Since approval by the United States Food and Drug Administration in 1996, alteplase utilization rates for acute ischemic stroke have increased. Despite its efficacy for improving stroke outcomes, however, the majority of ischemic stroke patients still do not receive alteplase. To address this issue, different methods for improving access to alteplase have been tested with varying degrees of success.

AREAS COVERED

This article gives an overview of the recent approaches pursued to improve access to alteplase for acute ischemic stroke patients. Utilization of stroke systems of care, quality metrics, and quality-improvement initiatives to improve alteplase treatment rates are discussed. The implementation of Telestroke networks to improve access and timely evaluation by a stroke specialist are also reviewed. Lastly, this review discusses the use of neuroimaging techniques to identify alteplase candidates in stroke of unknown symptom onset or beyond the 4.5-h treatment window.

EXPERT COMMENTARY

Expanding access to alteplase therapy for acute ischemic stroke is a multi-faceted approach. Specific considerations based on region, population, and health-care resources should be considered for each strategy. Neuroimaging approaches to identify alteplase-eligible patients beyond the 4.5-h treatment window are a recent development in acute stroke care that holds promise for increasing alteplase treatment rates.

Long-term prognosis of patients presenting first-ever vestibular symptoms in a community-based study

BACKGROUND

Vestibular symptoms (VSs) are frequent complaints in patients attending ambulatory care and the emergency room. They may represent a peripheral vestibular disorder or a stroke/transient ischemic attack (TIA), yet many patients have VSs that cannot be clearly classified at presentation. This study aims to characterize and determine the long-term prognosis of these patients.

METHODS

In a prospective community-based study involving 104,700 individuals registered at 4 health centers of Northern Portugal, patients with a first-ever-in-lifetime focal neurologic symptom (FNS) were ascertained using comprehensive methods, including referrals from physicians working in the study area and data retrieved from emergency/discharge records. Physicians were encouraged to report/notify any patient who might have experienced an FNS, including those with vertigo or vertigo-like symptoms, imbalance, presyncope, or nonspecific dizziness. After neurologic assessment patients were classified as having a peripheral vestibular symptom (pVS), a stroke/TIA, or an unclassified vestibular symptom (uVS). They were followed up 7 years after the index event at the outpatient clinic; predictors of survival free from stroke or vascular events were determined using Cox proportional hazards models.

RESULTS

Of the 1163 patients with an FNS, 360 (31.0%) were included, 16.7% had a stroke/TIA, 57.8% had pVS, and 25.6% had uVS. Most patients presented only isolated VSs (62.8%); 63% were women and mean age was 60.1 years (standard deviation = 16); hypertension (47.8%), hypercholesterolemia (41.9%), and diabetes (19.2%) were the most prevalent vascular risk factors (VRFs). Cranial computed tomography (CT) scan was performed in 63.3%. Adjusting for age, sex, VRFs, and diagnosis (TIA, pVS and uVS), the long-term risk of stroke was higher when CT showed silent infarctions (hazard rate [HR] = 3.96; 95% confidence interval [CI], 1.63-9.60) and the risk of vascular events (stroke, myocardial infarction, or vascular death) was higher in patients with 2 or more VRFs (HR = 2.70; 95% CI, 1.25-5.86). Identical results were obtained when restricting the model to patients with pVS or uVS.

CONCLUSIONS

First-ever-in-lifetime VSs are common in patients with FNS and may represent a good opportunity for preventing a serious vascular event, particularly in patients with vascular comorbidity (silent infarctions and VRFs).

Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition

BACKGROUND AND PURPOSE

The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience.

METHODS

We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices.

RESULTS

Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures.

CONCLUSIONS

Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Educational outreach to improve emergency medical services systems of care for stroke in Montana

OBJECTIVE

To improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support.

METHODS

Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n = 988) and 2009 (n = 944), overall and in rural and urban counties.

RESULTS

The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69% vs. 61%, p = 0.001), training in the use of a stroke screening tool (62% vs. 42%, p < 0.001), use of a stroke screening tool (62% vs. 40%, p < 0.001), and an adequate level of knowledge about stroke (81% vs. 66%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs.

CONCLUSIONS

Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care.

A comprehensive review of prehospital and in-hospital delay times in acute stroke care

The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (P<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from emergency department arrival to emergency department evaluation (3.1%, P=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from emergency department arrival to neurology evaluation or notification (P=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from emergency department arrival to initiation of computed tomography (P=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community-based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care.