Worldwide Reported Use of IV Tissue Plasminogen Activator for Acute Ischemic Stroke

USP18 Stabilized FTO Protein to Activate Mitophagy in Ischemic Stroke Through Repressing m6A Modification of SIRT6

Ischemic stroke (IS) is a dangerous cerebrovascular disorder with a significant incidence and death rate. Ubiquitin-specific peptidase 18 (USP18) has been proven to mitigate ischemic brain damage; however, its potential regulatory mechanisms remain unclear. In vivo and in vitro models of IS were established by middle cerebral artery occlusion (MCAO) and oxygen-glucose deprivation/reoxygenation (OGD/R). Neurocyte injury was detected by MTT, LDH, ROS level, mitochondrial membrane potential (Δψm), and flow cytometry. Molecular expression was evaluated by qPCR, Western blotting, and immunofluorescence staining. Molecular mechanisms were determined by Co-IP, RIP, and MeRIP. IS injury was determined by neurological behavior score and TTC staining. Mitophagy was observed by TEM. USP18 and fat mass and obesity-associated protein (FTO) expression declined after OGD/R. Dysfunctional mitochondrial and apoptosis in OGD/R-stimulated neurocytes were eliminated by USP18/FTO overexpression via mitophagy activation. USP18-mediated de-ubiquitination was responsible for increasing FTO protein stability. Up-regulation of FTO protein restrained m6A modification of sirtuin6 (SIRT6) in a YTHDF2-dependent manner to enhance SIRT6 expression and subsequent activation of AMPK/PGC-1α/AKT signaling. FTO induced mitophagy to ameliorate nerve cell damage through SIRT6/AMPK/PGC-1α/AKT pathway. Finally, USP18/FTO overexpression relieved IS in rats via triggering SIRT6/AMPK/PGC-1α/AKT axis-mediated mitophagy. USP18 increased FTO protein stability to trigger SIRT6-induced mitophagy, thus mitigating IS. Our data unravel the novel neuroprotective mechanism of USP18 and suggest its potential as a promising treatment target for IS.

Integrated single cell-RNA sequencing and Mendelian randomization for ischemic stroke and metabolic syndrome

Although more and more evidence has supported that metabolic syndrome (MS) is linked to ischemic stroke (IS), the molecular mechanism and genetic association between them has not been investigated. Here, we combined the existing single-cell RNA sequencing (scRNA-seq) data and mendelian randomization (MR) for stroke to understand the role of dysregulated metabolism in stroke. The shared hub genes were identified with machine learning and WGCNA. A total of six upregulated DEGs and five downregulated genes were selected for subsequent analyses. Nine genes were finally identified with random forest, Lasso regression, and XGBoost method as a potential diagnostic model. scRNA-seq also show the abnormal glycolysis level in most cell clusters in stroke and associated with the expression level of hub genes. The genetic relationship between IS and MS was verified with MR analysis. Our study reveals the common molecular profile and genetic association between ischemic stroke and metabolic syndrome.

Integrated analysis of single cell-RNA sequencing and Mendelian randomization identifies lactate dehydrogenase B as a target of melatonin in ischemic stroke

AIMS

Despite the success of single-cell RNA sequencing in identifying cellular heterogeneity in ischemic stroke, clarifying the mechanisms underlying these associations of differently expressed genes remains challenging. Several studies that integrate gene expression and gene expression quantitative trait loci (eQTLs) with genome wide-association study (GWAS) data to determine their causal role have been proposed.

METHODS

Here, we combined Mendelian randomization (MR) framework and single cell (sc) RNA sequencing to study how differently expressed genes (DEGs) mediating the effect of gene expression on ischemic stroke. The hub gene was further validated in the in vitro model.

RESULTS

We identified 2339 DEGs in 10 cell clusters. Among these DEGs, 58 genes were associated with the risk of ischemic stroke. After external validation with eQTL dataset, lactate dehydrogenase B (LDHB) is identified to be positively associated with ischemic stroke. The expression of LDHB has also been validated in sc RNA-seq with dominant expression in microglia and astrocytes, and melatonin is able to reduce the LDHB expression and activity in vitro ischemic models.

CONCLUSION

Our study identifies LDHB as a novel biomarker for ischemic stroke via combining the sc RNA-seq and MR analysis.

Developing Systems of Care for Stroke in Resource-limited Settings

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India

BACKGROUND

India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges.

AIM

This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study.

METHODS

A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken.

RESULTS

In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal.

CONCLUSION

This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

Explainable machine learning for long-term outcome prediction in two-center stroke patients after intravenous thrombolysis

Objective

Neurological outcome prediction in patients with ischemic stroke is very critical in treatment strategy and post-stroke management. Machine learning techniques with high accuracy are increasingly being developed in the medical field. We studied the application of machine learning models to predict long-term neurological outcomes in patients with after intravenous thrombolysis.

Methods

A retrospective cohort study was performed to review all stroke patients with intravenous thrombolysis. Patients with modified Rankin Score (mRs) less than two at three months post-thrombolysis were considered as good outcome. The clinical features between stroke patients with good and with poor outcomes were compared using three different machine learning models (Random Forest, Support Vector Machine and Logistic Regression) to identify which performed best. Two datasets from the other stroke center were included accordingly for external verification and performed with explainable AI models.

Results

Of the 488 patients enrolled in this study, and 374 (76.6%) patients had favorable outcomes. Patients with higher mRs at 3 months had increased systolic pressure, blood glucose, cholesterol (TC), and 7-day National Institute of Health Stroke Scale (NIHSS) score compared to those with lower mRs. The predictability and the areas under the curves (AUC) for the random forest model was relatively higher than support vector machine and LR models. These findings were further validated in the external dataset and similar results were obtained. The explainable AI model identified the risk factors as well.

Conclusion

Explainable AI model is able to identify NIHSS_Day7 is independently efficient in predicting neurological outcomes in patients with ischemic stroke after intravenous thrombolysis.

Safety and efficacy of low-cost alternative urokinase in acute ischemic stroke: A systematic review and meta-analysis

INTRODUCTION

Use of intravenous thrombolysis (IVT) for treatment of acute ischemic stroke (AIS) varies greatly between countries, ranging from 10% to 15% in high-income countries to less than 2% in low- and middle income countries (LMICs). This is because alteplase is expensive and has been cited as one of the most common barriers to IVT in LMICs. Urokinase (UK) is a thrombolytic agent which is almost 50 times cheaper with easier production and purification than alteplase. UK may become a cost-effective option for IVT in LMICs if it is found to be safe and effective. We conducted this study to assess the existing evidence on the safety and efficacy of UK vs alteplase for IVT in AIS.

METHODS

The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Systematic literature search was done in PubMed, EMBASE, and Google Scholar for English literature published from 2010 to 2021.

RESULTS

A total of 4061 participants in the alteplase and 2062 participants in the UK group were included in the final statistical analysis. After IVT, a good functional outcome at last follow-up was found among 80.57 % of patients in the alteplase group compared to 73.79 % of patients in the UK group (OR: 1.11; 95 % CI: 0.95- 1.31; I2 = 0 %; P = 0.18). Symptomatic Intracerebral Hemorrhage (sICH) was found among 1.77 % of patients in the alteplase group compared to 2.83 % of patients in the UK group (OR: 0.84; 95 % CI: 0.56- 1.26; I2 = 0 %; P = 0.41). Similarly, mortality was found among 5.03 % of patients in the alteplase group compared to 5.42 % of patients in the UK group (OR: 0.87; 95 % CI: 0.66-1.14; I2 = 0 %; P = 0.30).

CONCLUSION

Our meta-analysis found that intravenous UK is not inferior to alteplase in terms of safety and efficacy and can be a viable alternative for IVT in AIS patients in LMICs.

Identification of high-risk factors for prehospital delay for patients with stroke using the risk matrix methods

Background

Stroke has become a leading cause of mortality and adult disability in China. The key to treating acute ischemic stroke (AIS) is to open the obstructed blood vessels as soon as possible and save the ischemic penumbra. However, the thrombolytic rate in China is only 2.5%. Research has been devoted to investigating the causes of prehospital delay, but the exact controllable risk factors for prehospital delay remain uncertain, and a consensus is lacking. We aimed to develop a risk assessment tool to identify the most critical risk factors for prehospital delay for AIS patients.

Methods

From November 2018 to July 2019, 450 patients with AIS were recruited. Both qualitative and quantitative data were collected. The Delphi technique was used to obtain expert opinions about the importance of the risk indices in two rounds of Delphi consultation. Then, we used the risk matrix to identify high-risk factors for prehospital delay for AIS patients.

Results

The risk matrix identified the following five critical risk factors that account for prehospital delay after AIS: living in a rural area; no bystanders when stroke occurs; patients and their families lacking an understanding of the urgency of stroke treatment; patients and their families not knowing that stroke requires thrombolysis or that there is a thrombolysis time window; and the patient self-medicating, unaware of the seriousness of the symptoms, and waiting for spontaneous remission.

Conclusions

The risk analysis tool used during this study may help prevent prehospital delays for patients with AIS.

The Next Frontier in Neurocritical Care in Resource-Constrained Settings

Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.

Economic evaluation of endovascular treatment for acute ischaemic stroke in Thailand

OBJECTIVES

Endovascular therapy (EVT) has proven to be clinically effective in treating large vessel occlusion acute ischaemic stroke (AIS), either alone or in combination with intravenous alteplase. Despite this, there is a limited evidence on the cost-effectiveness of EVT in Thailand and other low-income and middle-income countries. This study aims to assess whether EVT is a cost-effective therapy for AIS, and to estimate the fiscal burden to the Thai government through budget impact analysis.

METHODS

An economic evaluation was performed to compare AIS therapy with and without EVT from a societal perspective. The primary outcome was incremental cost-effectiveness per quality-adjusted life year (QALY) gained. Clinical parameters were derived from both national and international literature, while cost and utility data were collected locally. The analysis applied a cost-effectiveness threshold of 160 000 Baht (~$5000) per QALY, as set by the Thai government.

RESULTS

Both EVT alone and EVT combined with intravenous alteplase, among patients who are ineligible and eligible for intravenous alteplase, respectively, improved health outcomes but incurred additional cost. The combination of EVT and intravenous alteplase was associated with an incremental cost-effectiveness ratio (ICER) of 146 800 THB per QALY gained compared with intravenous alteplase alone, and the ICER of EVT alone compared with supportive care among patients ineligible for intravenous alteplase was estimated at 115 000 THB per QALY gained. Sensitivity analysis showed that the price of EVT has the greatest impact on model outcomes. Over a time horizon of 5 years, the introduction of EVT into the Thai health benefit package would require an additional budget of 887 million THB, assuming 2000 new cases per year.

CONCLUSIONS

EVT represents good value for money in the Thai context, both when provided to patients eligible for intravenous alteplase, and when provided alone to those who are ineligible for intravenous alteplase.

Novel Therapeutic Strategies for Ischemic Stroke: Recent Insights into Autophagy

Stroke is one of the leading causes of death and disability worldwide. Autophagy is a conserved cellular catabolic pathway that maintains cellular homeostasis by removal of damaged proteins and organelles, which is critical for the maintenance of energy and function homeostasis of cells. Accumulating evidence demonstrates that autophagy plays important roles in pathophysiological mechanisms under ischemic stroke. Previous investigations show that autophagy serves as a “double-edged sword” in ischemic stroke as it can either promote the survival of neuronal cells or induce cell death in special conditions. Following ischemic stroke, autophagy is activated or inhibited in several cell types in brain, including neurons, astrocytes, and microglia, as well as microvascular endothelial cells, which involves in inflammatory activation, modulation of microglial phenotypes, and blood-brain barrier permeability. However, the exact mechanisms of underlying the role of autophagy in ischemic stroke are not fully understood. This review focuses on the recent advances regarding potential molecular mechanisms of autophagy in different cell types. The focus is also on discussing the “double-edged sword” effect of autophagy in ischemic stroke and its possible underlying mechanisms. In addition, potential therapeutic strategies for ischemic stroke targeting autophagy are also reviewed.

Sex and Economic Disparity Related to Reperfusion Therapies for Patients with Acute Ischemic Stroke in South Korea across a 10-Year Period: A Nationwide Population-Based Study Using the National Health Insurance Database

A complete enumeration study was conducted to evaluate trends related to reperfusion therapies (intravenous thrombolysis (IVT) and endovascular treatment (EVT)) in acute ischemic stroke (AIS) in South Korea, according to sex, economic status, and age, over a 10-year period retrospectively, using the National Health Information Database (NHIS-2020-1-481). This study included AIS patients aged ≥20 years who were hospitalized in a general hospital or tertiary hospital for ≥4 days and underwent brain imaging during the same period. Study participants were classified by sex, economic status (Medical Aid beneficiaries and National Health Insurance beneficiaries) and age (20-44, 45-64, 65-79, and ≥80 years). Women showed a significantly lower OR (Odds ratio) than men in IVT (OR: 0.75; 95% CI: 0.73-0.77), EVT (OR: 0.96; 95% CI: 0.93-0.99), and any therapy (OR: 0.82; 95% CI: 0.80-0.84). The Medical Aid beneficiaries showed significantly lower OR in IVT (OR 0.91, 95% CI 0.88-0.95), EVT (OR 0.93, 95% CI 0.89-0.98), and either therapy (OR 0.92, 95% CI 0.90-0.95) than the National Health Insurance beneficiaries. This study showed sex and economic disparity related to reperfusion therapies in patients with AIS in Korea.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil

Objectives

Cerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke.

Materials and Methods

This retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments.

Results

Patients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069-13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376-9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients.

Conclusion

Altogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability and coverage

BACKGROUND

Major disparities have been reported in recombinant tissue Plasminogen Activator (rtPA) availability among countries of different socioeconomic status.

AIMS

To characterize variability of rtPA price, its availability, and its association with and impact on each country's health expenditure (HE) resources.

METHODS

We conducted a global survey to obtain information on rtPA price (50mg vial, 2020 US Dollars) and availability. Country-specific data, including Low, Lower Middle (LMIC), Upper Middle (UMIC) and High-Income Country (HIC) classifications, and Gross Domestic Product (GDP) and HE, both nominally and adjusted for purchasing power parity (PPP), were obtained from World Bank Open Data. To assess the impact of rtPA cost, we computed the rtPA price as percentage of per capita GDP and HE and examined its association with the country income classification.

RESULTS

rtPA is approved and available in 109 countries. We received surveys from 59 countries: 27 (46%) HIC, 20 (34%) UMIC and 12 (20%) LMIC. Although HIC have significantly higher per capita GDP and HE compared to UMIC and LMIC (p<0.0001), the median price of rtPA is non-significantly higher in LMICs [USD 755, IQR (575-1300)] compared to UMICs [USD 544, IQR (400-815)] and HIC [USD 600, IQR (526-1000)]. In LMIC, rtPA cost accounts for 217.4% (IQR (27.1-340.6%) of PPP-adjusted per capita HE, compared to 17.6% (IQR [11.2-28.7%], p<0.0001) for HICs.

CONCLUSIONS

We documented significant rtPA availability and variability in its price among countries. Relative costs are higher in lower income countries, exceeding the available HE. Concerted efforts to improve rtPA affordability in low-income settings are necessary.

Clinical-epidemiological and radiological characteristics of stroke patients: A multicentre study

INTRODUCTION AND AIM

Stroke is the leading cause of disability in adults and the second most common cause of death, at a rate of 11.8% worldwide. The purpose of this study was to examine the aetiological, demographic, and clinical characteristics of patients admitted to hospital because of acute strokes.

MATERIALS AND METHODS

This multicentre study retrieved information for all patients admitted to hospital because of an acute cerebrovascular event over a six-month period, and sociodemographic, aetiological, and clinical characteristics were recorded.

RESULTS

A total of 1136 patients, 520 of whom were women (45.7%), with a mean age of 70.3 ± 12.8 years, were included in the study. Of these, 967 were diagnosed with ischaemic stroke (IS) (85.1%), 99 with haemorrhagic stroke (HS) (8.7%), and 70 with transient ischaemic attack (6.1%). The most common risk factor for stroke was hypertension (73%). Carotid disease and hyperlipidaemia rates were higher in patients with HS. Numbers of functionally dependent patients with severe neurological status according to the National Institutes of Health Stroke Scale and modified Rankin scale were significantly higher in the HS group (P < .001). When IS was classified according to the Trial of Org 10172 in Acute Stroke Treatment, small vessel disease emerged as the most common cause (41%). The most common lesion localisations were the parietal lobe (23%) in the IS group and the thalamus (35.3%) in the HS group. Eighty-eight patients (7.7%), 62 (6.4%) in the ischaemic subgroup, and 26 (26.3%) in the haemorrhagic subgroup, died within the first month.

CONCLUSION

Current and accurate evaluations of stroke aetiology are essential for stroke prevention and treatment planning. This study, shows that no change occurred in the aetiology of stroke and epidemiological characteristics and that accurate identification of modifiable stroke risk factors is still a major goal.

The Role of Mitophagy in Ischemic Stroke

Mitochondria are important places for eukaryotes to carry out energy metabolism and participate in the processes of cell differentiation, cell information transmission, and cell apoptosis. Autophagy is a programmed intracellular degradation process. Mitophagy, as a selective autophagy, is an evolutionarily conserved cellular process to eliminate dysfunctional or redundant mitochondria, thereby fine-tuning the number of mitochondria and maintaining energy metabolism. Many stimuli could activate mitophagy to regulate related physiological processes, which could ultimately reduce or aggravate the damage caused by stimulation. Stroke is a common disease that seriously affects the health and lives of people around the world, and ischemic stroke, which is caused by cerebral vascular stenosis or obstruction, accounts for the vast majority of stroke. Abnormal mitophagy is closely related to the occurrence, development and pathological mechanism of ischemic stroke. However, the exact mechanism of mitophagy involved in ischemic stroke has not been fully elucidated. In this review, we discuss the process and signal pathways of mitophagy, the potential role of mitophagy in ischemic stroke and the possible signal transduction pathways. It will help deepen the understanding of mitophagy and provide new ideas for the treatment of ischemic stroke.

Stroke systems of care in low-income and middle-income countries: challenges and opportunities

The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs-eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.

The Role of Dual Energy CT in Evaluating Hemorrhagic Complications at Different Stages After Thrombectomy

Background: Contrast media extravasation can mimic hemorrhage after endovascular thrombectomy (EVT). Dual energy CT (DECT) has the potential to distinguish hemorrhage from iodine contrast.

Methods: We retrospectively examined clinical and radiological data from 106 consecutive acute ischemic stroke patients who received EVT and underwent DECT immediately and 24 h after EVT. Iodine overlay map, virtual non-contrast, and mixed images are reconstructed.

Results: With the use of DECT, the proportion of all patients diagnosed with hemorrhagic transformation on mixed images immediately after EVT was reduced from 74.5% (79 of 106) to 10.4% (11 of 106), with a very poor consistency (κ = 0.076, p = 0.041). Correspondingly, hemorrhagic transformation on mixed images 24 h after EVT was reduced from 41.5% (44 of 106) to 30.2% (32 of 106), with a moderate consistency (κ = 0.757, p < 0.001).

Conclusions: The use of DECT both immediately and 24 h after EVT changes the diagnosis of hemorrhagic transformation in a considerable proportion of acute ischemic stroke patients with EVT. This could affect decision making with respect to antithrombotic strategy.

Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries

Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti

INTRODUCTION

In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.

METHODS

We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.

RESULTS

Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).

CONCLUSION

Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

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.

Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru

BACKGROUND

The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest.

AIMS

To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases.

METHODS

We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression.

RESULTS

Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity.

CONCLUSIONS

Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

MAMBO: Measuring ambulation, motor, and behavioral outcomes with post-stroke fluoxetine in Tanzania: Protocol of a phase II clinical trial

BACKGROUND

SSA has a high stroke incidence and post-stroke morbidity. An inexpensive pharmacological treatment for stroke recovery would be beneficial to patients in the region. Fluoxetine, currently on the World Health Organization Essential Medicines List, holds promise as a treatment for motor recovery after ischemic stroke, but its effectiveness is controversial and untested in this context in SSA.

AIM

To determine if fluoxetine 20 mg by mouth daily, given within 14 days of acute ischemic stroke, and taken for 90 days, is well-tolerated and safe with adequate adherence to justify a future randomized, controlled trial of fluoxetine in the United Republic of Tanzania.

METHODS

Open-label, phase II clinical trial enrolling up to 120 patients. Participants will be recruited from the Muhimbili National Hospital in Dar es Salaam, Tanzania, and followed for 90 days. The primary outcomes are: 1) safety, including serum sodium and hepatic enzyme levels; and 2) tolerability, as measured through study case report forms. The secondary outcomes are: 1) change in motor strength, as measured through the Fugl-Meyer Motor Scale; 2) adherence, as measured with electronic pill bottles; and 3) participant depressive symptom burden measured via standard questionnaires.

CONCLUSIONS

Expanding the evidence base for fluoxetine for Sub-Saharan African stroke survivors requires testing of its safety, tolerability, and adherence. Compared to prior studies in France and the United Kingdom, the patient characteristics, health infrastructure, and usual care for stroke recovery differ substantially in Tanzania. If fluoxetine reveals favorable endpoints, scale up of its use post-stroke is possible.

Randomization of endovascular treatment with stent-retriever and/or thromboaspiration versus best medical therapy in acute ischemic stroke due to large vessel occlusion trial: Rationale and design

BACKGROUND

RESILIENT is a prospective, multicenter, randomized phase III trial to test the safety, efficacy, and cost-effectiveness of mechanical thrombectomy as compared to medical treatment alone in patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country.

METHODS

Subjects must fulfill the following main inclusion criteria: symptom onset ≤8 h, age ≥18 years, baseline NIHSS ≥8, evidence of intracranial ICA or proximal MCA (M1 segment) occlusion, ASPECTS ≥6 on CT or >5 on DWI-MRI and be either ineligible for or unresponsive to intravenous alteplase. The primary end-point is the distribution of disability levels (on the modified Rankin Scale, mRS) at 90 days under the intention-to-treat principle.

RANDOMIZATION

Randomization is performed under a minimization process using age, baseline NIHSS, intravenous alteplase use, occlusion site and center.

DESIGN

The trial is designed with an expectation of a 10% difference in the proportion of favorable outcome (mRS 0-2 at 90 days) common odds ratio of 1.615.

PRIMARY OUTCOME

Projected sample size is 690 subjects with pre-planned interim analyses at 174, 346, and 518 subjects.

SECONDARY OUTCOMES

Secondary end-points include: 90-day functional independence (mRS ≤2), mRS shift stratified for treatment with IV rt-PA at 90 days, infarct volume on 24 h CT or MRI, early dramatic response (NIHSS 0-2 or improvement ≥8 points) at 24 h, vessel recanalization evaluated by CTA or MRA at 24 h, and the post-procedure rate of successful reperfusion (defined as a modified Treatment in Cerebral Infarction 2b or greater). Safety variables are mortality at 90 days, symptomatic intracranial hemorrhage at 24 h and procedure-related complications.

Mitophagy, a potential therapeutic target for stroke

Mitochondria autophagy, termed as mitophagy, is a mechanism of specific autophagic elimination of mitochondria. Mitophagy controls the quality and the number of mitochondria, eliminating dysfunctional or excessive mitochondria that can generate reactive oxygen species (ROS) and cause cell death. Mitochondria are centrally implicated in neuron and tissue injury after stroke, due to the function of supplying adenosine triphosphate (ATP) to the tissue, regulating oxidative metabolism during the pathologic process, and contribution to apoptotic cell death after stroke. As a catabolic mechanism, mitophagy links numbers of a complex network of mitochondria, and affects mitochondrial dynamic process, fusion and fission, reducing mitochondrial production of ROS, mediated by the mitochondrial permeability transition pore (MPTP). The precise nature of mitophagy’s involvement in stroke, and its underlying molecular mechanisms, have yet to be fully clarified. This review aims to provide a comprehensive overview of the integration of mitochondria with mitophagy, also to introduce and discuss recent advances in the understanding of the potential role, and possible signaling pathway, of mitophagy in the pathological processes of both hemorrhagic and ischemic stroke. The author also provides evidence to explain the dual role of mitophagy in stroke.

Treatment Delays for Patients With Acute Ischemic Stroke in an Iranian Emergency Department: A Retrospective Chart Review

STUDY OBJECTIVE

We evaluate the extent and nature of treatment delays and the contributing factors influencing them for patients with acute ischemic stroke, as well as main barriers to stroke care in an Iranian emergency department (ED).

METHODS

A retrospective chart review was conducted on 394 patients with acute ischemic stroke who were referred to the ED of a tertiary academic medical center in northwest Iran from March 21 to June 21, 2017. The steps of this review process included instrument development, medical records retrieval, data extraction, and data verification. Primary outcomes were identified treatment delays and causes of loss of eligibility for intravenous recombinant tissue plasminogen activator (r-tPA).

RESULTS

Of patients with acute ischemic stroke, 80.2% did not meet intravenous r-tPA eligibility; the most common cause was delayed (>4.5 hours) ED arrival after symptom onset (71.82%; n=283). Of 19.8% of subjects for whom the stroke code was activated, intravenous r-tPA was administered in only 5.3%. The average time from patients' arrival to first emergency medicine resident visit, notification of acute stroke team, presence of neurology resident, and computed tomography scan interpretation was lower for patients who met criteria of intravenous r-tPA than for those who lost eligibility for fibrinolytic therapy. The average door-to-needle time was 69 minutes (interquartile range 46 to 91 minutes).

CONCLUSION

Our ED and acute stroke team had a favorable clinical performance meeting established critical time goals of inhospital care for potentially eligible patients, but a poor clinical performance for the majority of patients who were not candidates for fibrinolytic therapy.

Essential medicines for emergency care in Africa

OBJECTIVES

Essential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications. The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries have implemented national EMLs based on the WHO EML. Although EMLs have given careful consideration to many public health priorities, they have yet to comprehensively address the importance of medicines for treating acute illness and injury.

METHODS

We undertook a multi-step consensus process to establish an EML for emergency care in Africa. After a review of existing literature and international EMLs, we generated a candidate list for emergency care. This list was reviewed by expert clinicians who ranked the medicines for overall inclusion and strength of recommendation. These medications and recommendations were then evaluated by an expert group. Medications that reached consensus in both the online survey and expert review were included in a draft emergency care EML, which underwent a final in-person consensus process.

RESULTS

The final emergency care EML included 213 medicines, 25 of which are not in the 2017 WHO EML but were deemed essential for clinical practice by regional emergency providers. The final EML has associated recommendations of desirable or essential, and is subdivided by facility level. Thirty-nine medicines were recommended for basic facilities, an additional 96 for intermediate facilities (e.g. district hospitals), and an additional 78 for advanced facilities (e.g. tertiary centres).

CONCLUSION

The 25 novel medications not currently on the WHO EML should be considered by planners when making rational formularies for developing emergency care systems. It is our hope that these resource-stratified lists will allow for easier implementation, and will be a useful tool for practical expansion of emergency care delivery in Africa.

Stroke care in Africa: A systematic review of the literature

Background

Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited.

Aim

To describe the status of stroke care in Africa.

Summary of review

We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa.

Conclusions

This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice.

Essential medicines for emergency care in Africa

OBJECTIVES

Essential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications. The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries have implemented national EMLs based on the WHO EML. Although EMLs have given careful consideration to many public health priorities, they have yet to comprehensively address the importance of medicines for treating acute illness and injury.

METHODS

We undertook a multistep consensus process to establish an EML for emergency care in Africa. After a review of existing literature and international EMLs, we generated a candidate list for emergency care. This list was reviewed by expert clinicians who ranked the medicines for overall inclusion and strength of recommendation. These medications and recommendations were then evaluated by an expert group. Medications that reached consensus in both the online survey and expert review were included in a draft emergency care EML, which underwent a final inperson consensus process.

RESULTS

The final emergency care EML included 213 medicines, 25 of which are not in the 2017 WHO EML, but were deemed essential for clinical practice by regional emergency providers. The final EML has associated recommendations of desirable or essential and is subdivided by facility level. Thirty-nine medicines were recommended for basic facilities, an additional 96 for intermediate facilities (eg, district hospitals) and an additional 78 for advanced facilities (eg, tertiary centres).

CONCLUSION

The 25 novel medications not currently on the WHO EML should be considered by planners when making rational formularies for developing emergency care systems. It is our hope that these resource-stratified lists will allow for easier implementation and will be a useful tool for practical expansion of emergency care delivery in Africa.

Stroke

Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.

Interventions for acute stroke management in Africa: a systematic review of the evidence

BACKGROUND

The past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship.

RESULTS

Initially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa.

CONCLUSION

Evidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients' outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016051566.

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose

Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes.

Method

We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up.

Findings

We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit.

Discussion

Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke.

Conclusion

Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.

Controversies in Thrombolysis

PURPOSE OF REVIEW

The purpose of the review is to examine recent evidence on the effects of intravenous thrombolysis and identify the remaining uncertainties.

RECENT FINDINGS

We review the results of two large trials (the third International Stroke Trial (IST-3) and The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED)) and the publications from the individual patient data analyses of the trials of alteplase conducted by the Stroke Thrombolysis Trialists Collaboration. Despite about a 2% risk of fatal intracerebral haemorrhage, on average, adult patients of all ages treated with 0.9 mg/kg alteplase within 4.5 h will have better long-term functional outcome. The use of a lower dose of alteplase (0.6 mg/kg) is associated with a lower risk of haemorrhage but its effect on functional outcome has not been proven to be non-inferior to standard dose therapy. Some clinicians feel confident to treat selected patients who present beyond 4.5 h or have unknown time of onset, but many also agree that the current trials and other research is needed to reliably define the optimum imaging methods and treatment eligibility criteria.

Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review

BACKGROUND

Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings.

METHODOLOGY

A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used.

RESULTS

Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers.

CONCLUSIONS

Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings.

TRIAL REGISTRATION

The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

OBJECTIVE

Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.

DESIGN

A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.

SETTING

A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.

PARTICIPANTS

A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.

RESULTS

Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.

CONCLUSION

Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

Towards best practice in acute stroke care in Ghana: a survey of hospital services

Background

Stroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice.

Methods

A multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards.

Results

Availability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care.

Conclusion

This study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2061-2) contains supplementary material, which is available to authorized users.

Desfechos clínicos de pacientes com acidente vascular cerebral isquêmico após terapia trombolítica

Resumo Objetivo Analisar desfechos e fatores associados em pacientes com acidente vascular cerebral isquêmico após terapia trombolítica. Métodos Estudo do tipo coorte retrospectivo de pacientes com acidente vascular cerebral isquêmico submetidos à terapia trombolítica. Foram descritas as comorbidades; os défices neurológicos e os tempos de atendimento. Utilizou-se o teste qui quadrado para associação entre comorbidades, tempos de atendimento e ocorrência de transformação hemorrágica. Resultados Houve elevada frequência de comorbidades. Défices neurológicos pontuaram média de 15 pontos. A janela de tempo obteve média de 98 minutos e o tempo porta-agulha, 89,8 minutos. Observou-se transformação hemorrágica em 20 pacientes. Na análise bivariada, a ocorrência de transformação hemorrágica esteve associada com maior défice neurológico, fibrilação atrial e cardiopatia. Houve redução dos défices neurológicos de 51% para 12,5 entre a admissão e alta. Conclusão A terapia trombolítica apresentou resultados positivos, apesar de tempos de atendimento elevados e pacientes com défices neurológicos com elevada pontuação.

Aspirin for secondary prevention after stroke of unknown etiology in resource-limited settings

OBJECTIVE

To analyze the potential impact of aspirin therapy for long-term secondary prevention after stroke of undetermined etiology in resource-limited settings without access to neuroimaging to distinguish ischemic stroke from intracerebral hemorrhage (ICH).

METHODS

We conducted a decision analysis using a Markov state transition model. Sensitivity analyses were performed across the worldwide reported range of the proportion of strokes due to ICH and the 95% confidence intervals (CIs) of aspirin-associated relative risks in patients with ICH.

RESULTS

For patients with stroke of undetermined etiology, long-term aspirin was the preferred treatment strategy across the worldwide reported range of the proportion of strokes due to ICH. At 34% of strokes due to ICH (the highest proportion reported in a large epidemiologic study), the benefit of aspirin remained beyond the upper bounds of the 95% CIs of aspirin-associated post-ICH relative risks most concerning to clinicians (ICH recurrence risk and mortality risk if ICH recurs on aspirin). Based on the estimated 11,590,204 strokes in low- and middle-income countries in 2010, our model predicts that aspirin therapy for secondary stroke prevention in all patients with stroke in these countries could lead to an estimated yearly decrease of 84,492 recurrent strokes and 4,056 stroke-related mortalities.

CONCLUSIONS

The concern that the risks of aspirin in patients with stroke of unknown etiology could outweigh the benefits is not supported by our model, which predicts that aspirin for secondary prevention in patients with stroke of undetermined etiology in resource-limited settings could lead to decreased stroke-related mortality and stroke recurrence.

Aspirin for acute stroke of unknown etiology in resource-limited settings: a decision analysis

OBJECTIVE

To analyze the potential impact of aspirin on outcome at hospital discharge after acute stroke in resource-limited settings without access to neuroimaging to distinguish ischemic stroke from intracerebral hemorrhage (ICH).

METHODS

A decision analysis was conducted to evaluate aspirin use in all patients with acute stroke of unknown type for the duration of initial hospitalization. Data were obtained from the International Stroke Trial and Chinese Acute Stroke Trial. Predicted in-hospital mortality and stroke recurrence risk were determined across the worldwide reported range of the proportion of strokes caused by ICH. Sensitivity analyses were performed on aspirin-associated relative risks in patients with ICH.

RESULTS

At the highest reported proportion of strokes due to ICH from a large epidemiologic study (34% in sub-Saharan Africa), aspirin initiation after acute stroke of undetermined etiology is predicted to reduce in-hospital mortality (from 85/1,000 without treatment to 81/1,000 with treatment), in-hospital stroke recurrence (58/1,000 to 50/1,000), and combined risk of in-hospital mortality or stroke recurrence (127/1,000 to 114/1,000). Benefits of aspirin therapy remained in sensitivity analyses across a range of plausible parameter estimates for relative risks associated with aspirin initiation after ICH.

CONCLUSION

Aspirin treatment for the period of initial hospitalization after acute stroke of undetermined etiology is predicted to decrease acute stroke-related mortality and in-hospital stroke recurrence even at the highest reported proportion of acute strokes due to ICH. In the absence of clinical trials to test this approach empirically, clinical decisions require patient-specific evaluation of risks and benefits of aspirin in this context.