Acute ischemic stroke--from symptom recognition to thrombolysis

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.

Health care providers' perceptions of factors that influence the provision of acute stroke care in urban and rural settings: A qualitative study

Objectives

Individuals living in rural areas have comparatively less access to acute stroke care than their urban counterparts. Understanding the local barriers and facilitators to the use of current best practice for acute stroke may inform efforts to reduce this disparity.

Methods

A qualitative study featuring semi-structured interviews and focus groups was conducted in the Australian state of Tasmania. Clinical staff from a range of disciplines involved in acute stroke care were recruited from three of the state's four major public hospitals (one urban and two rural). A semi-structured interview guide based on the findings of an earlier quantitative study was used to elicit discussion about the barriers and facilitators associated with providing acute stroke care. An inductive process of thematic analysis was then used to identify themes and subthemes across the data set.

Results

Two focus groups and five individual interviews were conducted. Four major themes were identified from analysis of the data: systemic issues, clinician factors, additional support and patient-related factors. Acute stroke care within the study's urban hospital was structured and comprehensive, aided by the hospital's acute stroke unit and specialist nursing support. In contrast, care provided in the study's rural hospitals was somewhat less comprehensive, and often constrained by an absence of infrastructure or poor access to existing resources.

Conclusion

The identified factors help to characterise acute stroke care within urban and rural hospitals and will assist quality improvement efforts in Tasmania's hospitals.

Brain computerized tomography reading in suspected acute ischemic stroke patients: what are essentials for medical students?

BACKGROUND

Few systematic methods prioritize the image education in medical students (MS). We hope to develop a checklist of brain computerized tomography (CT) reading in patients with suspected acute ischemic stroke (AIS) for MS and primary care (PC) physicians.

METHODS

Our pilot group generated the items indicating specific structures or signs for the checklist of brain CT reading in suspected AIS patients for MS and PC physicians. These items were used in a modified web-based Delphi process using the online software "SurveyMonkey". In total 15 panelists including neurologists, neurosurgeons, neuroradiologists, and emergency department physicians participated in the modified Delphi process. Each panelist was encouraged to express feedback, agreement or disagreement on the inclusion of each item using a 9-point Likert scale. Items with median scores of 7-9 were included in our final checklist.

RESULTS

Fifty-two items were initially provided for the first round of the Delphi process. Of these, 35 achieved general agreement of being an essential item for the MS and PC physicians. The other 17 of the 52 items in this round and another two added items suggested by the panelists were further rated in the next round. Finally, 38 items were included in the essential checklist items of brain CT reading in suspected AIS patients for MS and PC physicians.

CONCLUSIONS

We established a reference regarding the essential items of brain CT reading in suspected AIS patients. We hope this helps to minimize malpractice and a delayed diagnosis, and to improve competency-based medical education for MS and PC physicians.

Pre-hospital management of acute stroke patients eligible for thrombolysis - an evaluation of ambulance on-scene time

BACKGROUND

Stroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes. While door-to-needle time in hospital has been optimized for many years, little is known about the ambulance on-scene time (OST). OST has been reported to account for 44% of total alarm-to-door time, thereby being a major time component. We aimed to analyse ambulance OST in stroke patients eligible for thrombolysis and identify potential areas of time optimization.

METHODS

A study-specific registration form was developed to record detailed information about OST consumption in cases where the Emergency Medical Services (EMS) suspected a stroke from July 2014-May 2015. Registration forms were completed by ambulance personnel and included details on estimated time spent: 1) localising patient, 2) clinical examination, 3) consulting with the on-call neurologist, 4) mobilising patient to the ambulance, 5) treatment in ambulance before departure. Additionally, estimated total OST was noted. For patients found eligible for further evaluation at a stroke centre, time points were analysed using multivariate Poisson regressions.

RESULTS

A total of 520 cases were included. The median OST was 21 min (Interquartile Range (IQR) 16-27). Time consumption was significantly lower (17 vs 21 min, p = 0.0015) when electrocardiography (ECG) was obtained in-hospital instead of on-scene, when intravenous (IV) access was established during transportation instead of before transportation (17 vs 21 min, p < 0.0001), and when the quality of communication with the stroke centres was rated as "good" as opposed to "acceptable/poor" (21 vs 23 min, p = 0.014). Neither the presence of relatives nor ambulance trainees had a significant effect on OST.

CONCLUSIONS

In-hospital ECG recording and IV cannulation during transport were found to reduce OST, while "acceptable/poor" communication was found to prolong OST relative to "good" communication. These components of pre-hospital stroke management represent potential opportunities for lowering OST with relatively simple changes, which could ultimately lead to earlier treatment and better patient outcome.

TRIAL REGISTRATION

Unique identifier: NCT02191514 .

Glucagon-like receptor 1 agonists and DPP-4 inhibitors: Anti-diabetic drugs with anti-stroke potential

Stroke is one of the leading causes of death and serious disability in Westernized societies. The risk of stroke approximately doubles with each decade after the age of 55. Therefore, even though the incidence of stroke is declining, mostly because of the efforts to lower blood pressure and reduce smoking, the overall number of strokes is increasing due to the aging of the population. While stroke prevention by healthy lifestyle is effective in decreasing the risk of stroke, post stroke pharmacological strategies aimed at minimizing stroke-induced brain damage and promoting recovery are highly needed. Unfortunately, several candidate drugs that have shown significant neuroprotective efficacy in experimental models have failed in clinical trials and no treatment for stroke based on pharmacological neuroprotection is available today. Glucagon-like peptide 1 receptor (GLP-1R) agonists and dipeptidyl peptidase-4 inhibitors (DPP-4i) are clinically used against type 2 diabetes. Interestingly, these drugs have also shown promising effects in decreasing stroke incidence and increasing neuroprotection in clinical and preclinical studies, respectively. However, the mode of action of these drugs in the brain is largely unknown. Moreover, while it was previously thought that GLP-1R agonists and DPP-4i act via similar mechanisms of action, recent data argue against this hypothesis. Herein, we review this promising research area and highlight the main questions in the field whose answers could reveal important aiming to developing effective anti-stroke therapies. This article is part of the Special Issue entitled 'Metabolic Impairment as Risk Factors for Neurodegenerative Disorders.'

The golden hour of acute ischemic stroke

Background

Acute Ischemic Stroke (AIS) treatment has been revolutionised in the last two decades with the increasing use of Intravenous Thrombolysis (IVT) and with the advent of Endovascular therapy (EVT). AIS treatment and outcome are time dependant and time saving measures are being implemented at every step of the treatment chain. These changes have resulted in lower treatment times in-hospital, but it is unclear if this translates into more patients being treated within 60 min of symptom onset – the Golden Hour. The clinical outcome of IVT therapy in this patient group was our secondary outcome.

Methods

From 2009 onwards, systematic changes were made to the AIS treatment chain leading to a dramatic decrease in Door-to-Needle (DTN) time. Analyses were performed on the number of these treatments year on year and their clinical outcomes within the Golden Hour at Stavanger University Hospital (SUS).

Results

Six-hundred and thirteen patients were included; seventy-three were treated within the Golden Hour. The percentage of total IVT treatments occurring in the Golden Hour rose from 2.2% in 2009 to 14.5% in 2015 (p = 0.006) with a high of 18.3% in 2012 (p < 0.001). All of these patients had a Median NIHSS of 0 at discharge, irrespective of age and pre-existing comorbidity. There was no incidence of any ICH and in-hospital mortality was only 2.7% in this group.

Discussion

The time from AIS symptom onset to treatment is filled with delays. Despite the inherence of some delays,significant efforts on the part of the pre- and in- hospital treatment chain have made IVT therapy within 60 min a possibility. The allocation and use of resources in the setting of rapid AIS treatment is warrantedand yields unprecedented results.

Conclusions

Our study shows that improved treatment routines led to an increase in the number of patients treated within the Golden Hour. Treatment in the Golden Hour leads to excellent outcomes in all patients, irrespective of age and pre-existing comorbidity.

Help seeking behavior and onset-to-alarm time in patients with acute stroke: sub-study of the preventive antibiotics in stroke study

BACKGROUND

Patients with acute stroke often do not seek immediate medical help, which is assumed to be driven by lack of knowledge of stroke symptoms. We explored the process of help seeking behavior in patients with acute stroke, evaluating knowledge about stroke symptoms, socio-demographic and clinical characteristics, and onset-to-alarm time (OAT).

METHODS

In a sub-study of the Preventive Antibiotics in Stroke Study (PASS), 161 acute stroke patients were prospectively included in 3 Dutch hospitals. A semi-structured questionnaire was used to assess knowledge, recognition and interpretation of stroke symptoms. With in-depth interviews, response actions and reasons were explored. OAT was recorded and associations with socio-demographic, clinical parameters were assessed.

RESULTS

Knowledge about stroke symptoms does not always result in correct recognition of own stroke symptoms, neither into correct interpretation of the situation and subsequent action. In our study population of 161 patients with acute stroke, median OAT was 30 min (interquartile range [IQR] 10-150 min). Recognition of one-sided weakness and/or sensory loss (p = 0.046) and adequate interpretation of the stroke situation (p = 0.003), stroke at daytime (p = 0.002), severe stroke (p = 0.003), calling the emergency telephone number (p = 0.004), and transport by ambulance (p = 0.040) were associated with shorter OAT.

CONCLUSION

Help seeking behavior after acute stroke is a complex process. A shorter OAT after stroke is associated with correct recognition of one-sided weakness and/or sensory loss, adequate interpretation of the stroke situation by the patient and stroke characteristics and logistics of stroke care, but not by knowledge of stroke symptoms.

Organizational changes aiming to reduce iv tPA door-to-needle time

OBJECTIVES

To assess time trends in intravenous thrombolytic (iv tPA) treatment in a general local hospital during a period with organizational changes, especially how movement of treatment start from the emergency room (ER) to the CT laboratory, and changing method of administration of acute antihypertensive medication influenced on door-to-needle time (DNT).

MATERIALS AND METHODS

All stroke patients treated with iv tPA have been prospectively enrolled in the Safe Implementation of Treatments in Stroke (SITS) registry. Data from 2007 to 2011 were reviewed. Safety was evaluated by the incidence of symptomatic intracerebral hemorrhage (SICH). Predictors of DNT were assessed by multivariable regression.

RESULTS

Two hundred and forty-three patients were treated with iv tPA. The annual treatment rate reached 21.9% of patients with ischemic strokes admitted to the hospital. Median DNT decreased from 36 to 28 min (P ≤ 0.001). The incidence of SICH remained low and was throughout the period 2.5%. Treatment start in the CT laboratory vs in the ER was associated with a reduction in median DNT (P = 0.007). Acute antihypertensive treatment and treatment with warfarin were associated with increased DNT (P = 0.024 and P = 0.003, respectively). Age, gender, baseline NIHSS, onset-to-door time, comorbidity, and method of administration of acute antihypertensive treatment did not influence DNT significantly.

CONCLUSIONS

Streamlining of iv tPA logistics can reduce median DNT to <30 min in a general local hospital. Moving treatment start from the ER to the CT laboratory contributed to reduce DNT. Our organizational model was resistant to influence on DNT by patient age, gender, stroke severity, and time to hospital arrival. The incidence of SICH remained low.

GLP-1R activation for the treatment of stroke: updating and future perspectives

Stroke is the leading cause of adult disability in Westernized societies with increased incidence along ageing and it represents a major health and economical threat. Inactive lifestyle, smoking, hypertension, atherosclerosis, obesity and diabetes all dramatically increase the risk of stroke. While preventive strategies based on lifestyle changes and risk factor management can delay or decrease the likelihood of having a stroke, post stroke pharmacological strategies aimed at minimizing stroke-induced brain damage are highly needed. Unfortunately, several candidate drugs that have shown significant preclinical neuroprotective efficacy, have failed in clinical trials and no treatment for stroke based on neuroprotection is available today. Glucagon-like peptide 1 (GLP-1) is a peptide originating in the enteroendocrine L-cells of the intestine and secreted upon nutrient ingestion. The activation of the GLP-1R by GLP-1 enhances glucose-dependent insulin secretion, suppresses glucagon secretion and exerts multifarious extrapancreatic effects. Stable GLP-1 analogues and inhibitors of the proteolytic enzyme dipeptidyl peptidase 4 (DPP-4) (which counteract endogenous GLP-1 degradation) have been developed clinically for the treatment of type 2 diabetes. Besides their antidiabetic properties, experimental evidence has shown neurotrophic and neuroprotective effects of GLP-1R agonists and DPP-4 inhibitors in animal models of neurological disorders. Herein, we review recent experimental data on the neuroprotective effects mediated by GLP-1R activation in stroke. Due to the good safety profile of the drugs targeting the GLP-1R, we also discuss the high potential of GLP-1R stimulation in view of developing a safe clinical treatment against stroke based on neuroprotection in both diabetic and non-diabetic patients.

Evaluation of the implementation of a rapid response treatment protocol for patients with acute onset stroke: can we increase the number of patients treated and shorten the time needed?

Aims

This study aims to evaluate the implementation of a rapid response treatment protocol for patients presenting with acute onset ischemic stroke. Improvements of routines surrounding the admission and treatment of patients with intravenous thrombolysis (IVT), such as door-to-needle (DTN) times, and increasing the numbers of patients treated are discussed.

Methods

We conducted a retrospective analysis of all patients (n = 320) treated with IVT for acute onset ischemic stroke at the Stavanger University Hospital, Norway, between 2003 and 2012. In 2009, a succession of changes to pre- and intra-hospital routines were made as well as an improvement in the education of primary health care physicians, nurses and paramedics involved in the treatment of acute onset stroke patients (rapid response treatment protocol). Analyses of DTN times, onset-to-needle times and the number of patients treated per year were carried out to ascertain the effect of the changes made. The primary aim was to analyze DTN times to look for any changes, and the secondary aim was to analyze changes in the number of patients treated per year.

Results

In the years after the implementation of the rapid treatment protocol, we saw an improvement in the median DTN time with a decrease from 73 to 50 min in the first year (p = 0.03), a decrease of 45 min in the second year (p = 0.01) and a decrease of 31 min in the third year (p < 0.001). Similarly, an improvement in the number of patients treated per year was seen after enhancements in the treatment chain were made. A significant, 27-fold increase was shown when the number of patients treated in 2012 was compared with all patients treated in all years prior to the implementation of the rapid treatment protocol.

Conclusions

The implementation of the rapid treatment protocol for acute onset ischemic stroke patients led to a significant decrease in the DTN time at our center. These improvements also produced an increase in the number of patients treated per year. The extension of the therapeutic window from 3 to 4.5 h for the use of intravenous recombinant tissue plasminogen activator also played a role in the increased treatment numbers.

Inhibition of the membrane attack complex of the complement system reduces secondary neuroaxonal loss and promotes neurologic recovery after traumatic brain injury in mice

Traumatic brain injury (TBI) is the leading cause of disability and death in young adults. The secondary neuroinflammation and neuronal damage that follows the primary mechanical injury is an important cause of disability in affected people. The membrane attack complex (MAC) of the complement system is detected in the traumatized brain early after TBI; however, its role in the pathology and neurologic outcome of TBI has not yet been investigated. We generated a C6 antisense oligonucleotide that blocks MAC formation by inhibiting C6, and we compared its therapeutic effect to that of Ornithodoros moubata complement inhibitor (OmCI), a known inhibitor of C5 activation that blocks generation of the anaphylatoxin C5a and C5b, an essential component of MAC. Severe closed head injury in mice induced abundant MAC deposition in the brain. Treatment with C6 antisense reduced C6 synthesis (85%) and serum levels (90%), and inhibited MAC deposition in the injured brain (91-96%). Treatment also reduced accumulation of microglia/macrophages (50-88%), neuronal apoptosis, axonal loss and weight loss (54-93%), and enhanced neurologic performance (84-92%) compared with placebo-treated controls after injury. These data provide the first evidence, to our knowledge, that inhibition of MAC formation in otherwise complement-sufficient animals reduces neuropathology and promotes neurologic recovery after TBI. Given the importance of maintaining a functional complement opsonization system to fight infections, a critical complication in TBI patients, inhibition of the MAC should be considered to reduce posttraumatic neurologic damage. This work identifies a novel therapeutic target for TBI and will guide the development of new therapy for patients.

Agreement between ambulance nurses and physicians in assessing stroke patients

OBJECTIVES

If an ambulance nurse could bypass the emergency department (ED) and bring suspected stroke patients directly to a CT scanner, time to thrombolysis could be shortened. This study evaluates the level of agreement between ambulance nurses and emergency physicians in assessing the need for a CT scan, and interventions and monitoring beforehand, in patients with suspected stroke and/or a lowered level of consciousness.

METHODS

From October 2008 to June 2009, we compared the ambulance nurses' and ED physicians' judgement of 200 patients with stroke symptoms. Both groups answered identical questions on patients' need for a CT scan, and interventions and monitoring beforehand.

RESULTS

There was poor agreement between ambulance nurses and ED physicians in judging the need for a CT scan: κ = 0.22 (95% confidence interval (CI), 0.06-0.37). The nurses' ability to select the same patients as the physician for a CT scan had a sensitivity of 84% (95% CI, 77-89) and a specificity of 37% (95% CI, 23-53). Agreement concerning the need for interventions and monitoring was also low: κ = 0.32 (95% CI, 0.18-0.47). In 18% of cases, the nurses considered interventions before a CT scan unnecessary when the physicians' deemed them necessary.

CONCLUSIONS

Additional tools to support ambulance nurses decisions appear to be required before suspected stroke patients can be taken directly to a CT scanner.