Translation of the 'time is brain' concept into clinical practice: focus on prehospital stroke management

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

Background

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

Methods

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

Results

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

Conclusions

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

Interventions to Support the Return to Work for Individuals with Stroke: A Systematic Review and Meta-analysis

PURPOSE

An increasing number of individuals with stroke are having difficulties in returning to work, having a significant impact on both individuals and society. The aims of this meta-analysis were to summarize the interventions to support the return to work (RTW) for individuals with stroke and to quantitatively evaluate the efficacy of each type of intervention.

METHODS

A systematic review and meta-analysis were conducted according to PRISMA guidelines. PubMed, Embase, Cochrane Library, CINAHL, and PsycINFO were searched until 26 June 2023, and the list of references of the initially included articles was also searched. Two researchers independently performed the search, screening, selection, and data extraction. The primary outcome was RTW rate (the RTW rate was defined as the proportion of individuals who returned to work in each group (intervention and control) at the endpoint). Pooled risk ratio (RR) was estimated using a random-effects model with 95% confidence intervals (CIs).

RESULTS

A total of 13 studies representing 4,282 individuals with stroke were included in our study. Results showed that physiological interventions could improve the RTW rate of individuals with stroke (RR: 1.19, 95% CI: 1.01 to 1.42, I2 = 72%). And receiving intravenous thrombolytic therapy was beneficial in promoting the RTW in individuals with stroke. Subgroup analysis and meta-regression analysis showed that the individuals' functional status during hospitalization was the only source of heterogeneity. Psychological interventions had little or no effect on the RTW rate of individuals with stroke (RR: 1.20, 95% CI: 0.58 to 2.51, I2 = 30%). Work-related interventions had little or no effect on the RTW rate of the individuals with stroke (RR:1.36,95%CI: 0.99 to 1.88, I2 = 73%). The subgroup analysis showed that country, age, and follow-up method were the sources of heterogeneity.

CONCLUSION

Physiological intervention promoted the RTW of individuals with stroke. But, the effect of psychological and work-related interventions in promoting the RTW of individuals with stroke was not significant. We anticipate that these findings may inform the design of future interventions. For future research, we recommend that more high-quality randomized controlled trials be conducted to further promote the RTW of individuals with stroke.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration Number, CRD42023443668.

[Comparison of acute stroke care pathways-A qualitative multicenter study in three referring hospitals of a stroke network]

BACKGROUND

In stroke networks, hospitals that do not provide thrombectomy (referring hospitals) refer patients to specialized hospitals (receiving hospitals) for this specific intervention. In order to improve the access and management of thrombectomy, the focus of research needs to be not only on the receiving hospitals but also on the prior stroke care pathways in referring hospitals.

OBJECTIVE

The purpose of this study was to investigate the stroke care pathways in different referring hospitals as well as the advantages and disadvantages associated with these pathways.

METHODS

A qualitative multicenter study was carried out in three referring hospitals of a stroke network. Stroke care was assessed and analyzed by using non-participant observations and 15 semi-structured interviews with employees in various health professions.

RESULTS

The following aspects were reported as advantageous within the stroke care pathways: (1) a structured and personal prenotification of the patient by the emergency medical service (EMS) members; (2) a more efficiently organized teleneurology workflow; (3) the provision of the secondary referral to thrombectomy by the same EMS members of the primary referral and (4) the integration of external neurologists into in-house structures.

CONCLUSION

The study provides insights into different stroke care pathways of three different referring hospitals of a stroke network. The results can be used to derive potentials for improvement of other referring hospitals; however, this study is too small to provide reliable information about their potential effectiveness. Future studies should investigate whether implementation of these recommendations actually leads to improvements and under which conditions they are successful. To ensure patient-centeredness, the perspectives of patients and relatives should also be included.

Recognition, reaction, risk factors and adequate knowledge of stroke: A Brazilian populational survey

INTRODUCTION

General population proper knowledge about stroke can improve stroke outcomes. We aimed to assess the awareness levels of laypeople regarding stroke recognition, reaction, risk factors, and adequate general knowledge (correct answers for those three questions) of stroke.

METHODS

Cross-sectional survey-based study enrolling community population from 12 cities of Brazil's Northeast. The volunteers were verbally exposed to a typical case of stroke and then responded to an open-ended semi-structured questionnaire to evaluate their stroke knowledge.

RESULTS

A total of 1475 subjects enrolled in this study (52.6% of women, mean±SD 36.2±15.3 years-old, 13.0±4.4 years of formal schooling). 1220/1475 (82.7%) recognized the situation as a stroke; 1148/1475 (77.8%) would react to it by taking the patient to the emergency department or calling for emergency medical assistance; 844/1475 (57.2%) knew at least one risk factor; and 190/1475 (12.9%) stated that symptoms could be reversed if the patient was treated "as soon as possible". Adequate general knowledge was found in 622/1475 (42,2%) of participants. Notably, among those who recognized the stroke, 19.9% (243/1220) would not react appropriately to it. The multivariate analysis showed that factors independently related to stroke recognition were female sex, higher education levels, private health insurance and previous experience with a similar situation. Adequate general knowledge was associated with longer school years and health insurance.

CONCLUSIONS

The frequency of stroke recognition and appropriate reaction were acceptable, however the general knowledge, knowledge of risk factors and notion that stroke treatment is time-sensitive were insufficient. Addressing the recognition-reaction gap requires targeted campaigns focusing on stroke treatment awareness.

Study on the Effect of Prehospital Emergency Nursing Model Based on Network Information Sharing Platform in Acute Ischemic Stroke

Background

Acute ischemic stroke is one of the most common emergencies in clinical medicine. Prehospital first aid of ischemic stroke has become the focus and focus of the global medical community. The combination of network information technology and prehospital first aid can better serve the treatment of ischemic stroke.

Objective

To explore the effect of prehospital emergency nursing model based on network information sharing platform in acute ischemic stroke.

Methods

78 patients with acute ischemic stroke from February 2020 to October 2021 were studied. Patients were randomly divided into study group (n = 39) and control group (n = 39). The control group was given routine first aid nursing. Prehospital first aid nursing based on network information sharing platform was used in the study group. Alarm response time, on-site first aid response time, hospital handover time, National Institutes of Health Stroke scale (NIHSS) at 12 and 24 hours after admission, Glasgow coma scale (GCS) at 12 and 24 hours after admission, incidence of poor prognosis, and nursing satisfaction score at 24 hours after admission were recorded.

Results

The emergency response time and hospital handover time in the study group were significantly shorter than those in the control group (P < 0.05). The NIHSS score and the incidence of poor prognosis at 12 and 24 hours after admission in the study group were lower than those in the control group (P < 0.05). The GCS scores at 12 hours and 24 hours after admission in the study group were higher than those in the control group (P < 0.05). The NSNS score of the study group was higher than that of the control group.

Conclusion

Prehospital first aid nursing based on network information sharing platform has great application value in patients with acute ischemic stroke. It can shorten the time of first aid, improve patients' consciousness, and reduce the incidence of poor prognosis.

Stroke in Djibouti

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Sub-Saharan Africa is experiencing an increasing burden of stroke, with current prevalence as high as 1.46 per 1000 population.

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Limited cohort studies exist to profile the epidemiological, clinical and paraclinical characteristics of stroke in this setting.

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Identifying the most at-risk population for ischemic and haemorrhagic stroke can improve approaches for prevention in this setting.

Background

Stroke is a neurological emergency affecting both developed and developing countries. In Djibouti, stroke is the fourth leading cause of death. Our objective was to describe the demographic, clinical, paraclinical profile of stroke in Djibouti and identify the possible underlying risk factors.

Methods

We conducted a cross-sectional multicentre study carried out over a period of 6 months in the medical services of the Soudano-Djibouti military hospital, the General Peltier hospital and the emergency department of the National fund for social security health centre.

Results

A total of seventy patients were included. The mean age was 59.61 years with a male predominance (sex ratio: 2.5) and a statistically significant female-related difference beyond the age of 60 years (p <10⁻³). Cardiovascular risk factors were mainly hypertension (73%), khat chewing (64%) and tobacco use (50%). Khat chewing and tobacco use were associated with a younger age of occurrence of stroke (p=0.020 and p=0.004, respectively). Diabetes mellitus and hypercholesterolemia were found respectively in 30% and 19% of cases, and were more associated with ischemic stroke. Coronary disease (11%), heart failure (3%) and obesity (4%) (significantly associated with the female gender; p= 0,021) were less common. Motor deficits (94%) were the most common clinical manifestations, followed by sensory deficits (51%) and alteration of consciousness (37%). Stroke was ischemic in 61.5% of patients. The most affected territory in ischemic stroke was the territory of the middle cerebral artery, and capsulo-thalamic involvement in haemorrhagic stroke which was significantly associated with the alteration of consciousness(p=0,003).

Discussion

Stroke had primarily modifiable risk factors in Djiboutian patients dominated by high blood pressure, tobacco use and khat chewing especially in the male population under the age of 60 years. These findings could have implications on future preventive measures and a better approach to public health policy.

Artificial intelligence in Emergency Medical Services dispatching: assessing the potential impact of an automatic speech recognition software on stroke detection taking the Capital Region of Denmark as case in point

BACKGROUND AND PURPOSE

Stroke recognition at the Emergency Medical Services (EMS) impacts the stroke treatment and thus the related health outcome. At the EMS Copenhagen 66.2% of strokes are detected by the Emergency Medical Dispatcher (EMD) and in Denmark approximately 50% of stroke patients arrive at the hospital within the time-to-treatment. An automatic speech recognition software (ASR) can increase the recognition of Out-of-Hospital cardiac arrest (OHCA) at the EMS by 16%. This research aims to analyse the potential impact an ASR could have on stroke recognition at the EMS Copenhagen and the related treatment.

METHODS

Stroke patient data (n = 9049) from the years 2016-2018 were analysed retrospectively, regarding correlations between stroke detection at the EMS and stroke specific, as well as personal characteristics such as stroke type, sex, age, weekday, time of day, year, EMS number contacted, and treatment. The possible increase in stroke detection through an ASR and the effect on stroke treatment was calculated based on the impact of an existing ASR to detect OHCA from CORTI AI.

RESULTS

The Chi-Square test with the respective post-hoc test identified a negative correlation between stroke detection and females, the 1813-Medical Helpline, as well as weekends, and a positive correlation between stroke detection and treatment and thrombolysis. While the association analysis showed a moderate correlation between stroke detection and treatment the correlation to the other treatment options was weak or very weak. A potential increase in stroke detection to 61.19% with an ASR and hence an increase of thrombolysis by 5% in stroke patients calling within time-to-treatment was predicted.

CONCLUSIONS

An ASR can potentially improve stroke recognition by EMDs and subsequent stroke treatment at the EMS Copenhagen. Based on the analysis results improvement of stroke recognition is particularly relevant for females, younger stroke patients, calls received through the 1813-Medical Helpline, and on weekends.

TRIAL REGISTRATION

This study was registered at the Danish Data Protection Agency (PVH-2014-002) and the Danish Patient Safety Authority (R-21013122).

Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.

Multimodality Imaging in Acute Ischemic Stroke

Stroke is the most common cause of mortality and morbidity worldwide. The prognosis of stroke depends upon the area affected and its early treatment. Time is of the essence in the care of stroke patients as it is estimated that approximately 1.9 million neurons, 14 billion synapses, and 12 km myelinated nerve fibers are lost per minute. Therefore, early diagnosis and prompt treatment are necessary. The primary goal of imaging in acute stroke is to diagnose the underlying cause, estimate the area affected, predict response towards thrombolytic therapy and to exclude the conditions mimicking stroke. With advancements in radiology, multiple imaging modalities are available for diagnosis and predicting prognosis. None of them is considered alone to be perfect. In this era of multimodality imaging, the decision of choosing appropriate techniques depends upon purpose and availability. Non-Contrast Computed Tomography is time effective, and helps in excluding other causes, Trans Cranial Doppler is time-effective and cost-effective with wide availability, however, is operator dependent and less sensitive. It holds a great future in sonothrombolysis. Magnetic Resonance Imaging is so far considered to be the most superior one in terms of early diagnosis, planning for interventional treatment and predicting the response of treatment. However, it is limited due to high cost and lack of availability. The current review gives a detailed account of all imaging modalities available for imaging stroke and their associated pros and cons.

Impact of mobile stroke units

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Impact of a theory-informed and user-centered stroke information campaign on the public's behaviors, attitudes, and knowledge when facing acute stroke: a controlled before-and-after study

Background

Public awareness of stroke symptoms is a key factor to ensure access to reperfusion strategies in due time. We designed and launched a regional theory-informed and user-centered information campaign and assessed its impact on emergency medical services (EMS) calls for stroke suspicion, time-to-call, and public attitudes and awareness concerning stroke.

Methods

A controlled before-and-after study was conducted during 3 sequential time-periods in 2 separate counties. Key messages of the campaign were underpinned by stroke representations and the theory of planned behavior, and focused on recognition of stroke warning signs and the need to call EMS urgently. The campaign included posters, leaflets, adverts and films displayed in bus and subway stations, internet, social networks, and local radio. Outcome measures on behavior, attitudes, and knowledge were assessed before the launch of the campaign, at 3 months, and 12 months.

Results

The number of EMS calls for stroke suspicion increased by 21% at 12 months in the intervention county and this change was significantly different to that observed in the control county (p = 0.02). No significant changes were observed regarding self-reported attitudes in case of stroke. An 8% significant increase in recognizing at least 2 stroke warning signs was observed in the intervention county (p = 0.04) at 3 months, while it did not change significantly in the control county (p = 0.6). However, there was no significant difference in warning sign recognition between both counties (p = 0.16).

Conclusion

The campaign significantly improved public’s behavior of calling EMS, although stroke knowledge was not improved as much as expected. Repeating these campaigns over time might further help improve timeliness and access to reperfusion strategies.

Trial registration

Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT02846363.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09795-y.

Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke

BACKGROUND

Despite recent advances in acute stroke care, only 1-8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD).

OBJECTIVE

This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital.

METHODS

A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital (Burgos, Spain). Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses.

RESULTS

The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms (OR 10.36; 95% confidence interval (CI) 4.47-23.99), onset of stroke during the daytime (OR 7.73; 95% CI 3.09-19.34) and the weekend (OR 2.64; 95% CI 1.19-5.85), occurrence of stroke outside the home (OR 7.09; 95% CI 1.97-25.55), using a prenotification system (OR 6.46; 95% CI 1.71-8.39), patient's perception of being unable to control symptoms without assistance (OR 5.14; 95% CI 2.60-10.16), previous knowledge of stroke as a medical emergency (OR 3.20; 95% CI 1.38-7.40), call to emergency medical services as the first medical contact (OR 2.77; 95% CI 1.32-5.88), speech/language difficulties experienced by the patient (OR 2.21; 95% CI 1.16-4.36), and the identification of stroke symptoms by the patient (OR 1.98; 95% CI 1.03-3.82).

CONCLUSIONS

The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns.

Neighborhood-level stroke hot spots within major United States cities

OBJECTIVE

Identifying communities at high risk of stroke is an important step in improving systems of stroke care. Stroke is known to show spatial clustering at the state and county levels, but it is not known if clusters are present within city boundaries.

METHODS

We performed a geospatial analysis of the prevalence of stroke within 500 major cities in the United States using the Centers for Disease Control and Prevention 500 Cities Project. For each city, we calculated the Moran's I statistic, which looks for evidence of spatial clustering, and used Monte Carlo simulation to assess for clustering significance.

RESULTS

The mean overall crude prevalence of self-reported history of stroke at the city level was 2.8% (IQR 2.4-3.2%). Monte Carlo simulations of spatial patterns of stroke were successfully performed for 497 cities, of which 136 (27.3%) showed significant spatial clustering at the neighborhood level. All nine cities with more than one million inhabitants in 2010 showed significant spatial clustering.

CONCLUSIONS

This is the first study to demonstrate that stroke shows clustering at the neighborhood level within many major cities in the United States and within all of the largest cities. Understanding where stroke clusters exist within cities can form the basis of optimizing emergency medical services deployment and improving systems of stroke care.

Understanding delays in acute stroke care: a systematic review of reviews

Background

Stroke is the leading cause of adult long-term disability in Western countries. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator is safe and effective within the first 4.5 h after the onset of stroke. Various factors delaying acute stroke care have been identified in the literature. This review aimed to provide an overview of factors delaying acute stroke care and attempted to show how they interact in a synthetic framework.

Methods

We conducted a systematic review of literature reviews published in Medline and DORIS until 2016 on factors influencing acute stroke pathway timeframe.

Results

We analyzed 31 reviews that cover all factors of delays from stroke onset to treatment. We identified 27 factors that had a significant impact on acute stroke care and can be categorized into four distinct categories: patient-related factors, training, resources and lack of coordination. We also reported associations between factors observed in both between categories (mainly between patients and organizational/logistical factors) and within categories.

Conclusion

This review provides a wide overview of factors influencing acute stroke pathway. Since it was observed that the identified factors were interrelated, they needed to be analyzed in a systematic way. We hence created a synthetic framework that combines several categories of factors while assuming that factor weight varies from a study context to another. Better knowledge on underlying mechanisms between factors would provide crucial improvement of the interventions aiming at reducing delays in both pre-hospital and inhospital stages. For future research, we recommend adopting a systemic perspective on factors influencing acute stroke pathway.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Air-Mobile Stroke Unit for access to stroke treatment in rural regions

Background

In recent years, important progress has been made in effective stroke treatment, however, patients living in rural and remote areas have nil or very limited access to timely reperfusion therapies.

Aims

Novel systems of care to overcome the detrimental treatment gap for stroke patients living in rural and remote regions need to be developed.

Summary of review

A possible solution to the treatment disparity between stroke patients living in metropolitan and rural areas may involve the use of specially designed aircrafts equipped with the ability to diagnose and treat acute stroke at remote emergency sites. We describe technical solutions for an Air-Mobile Stroke Unit (Air-MSU) concept, where an aircraft is customized with the ability to perform multimodal computed tomography, in addition to onboard laboratory equipment and telemedicine connection. The Air-MSU is envisioned not only to allow intravenous thrombolysis in the field but also to allow prehospital triage to a comprehensive stroke center through use of contrast intracerebral vascular imaging. Several options for the Air-MSU approach are described, and issues regarding the potential medical benefit, optimal operating environment, technical realization, and integration in pre-existing solutions (e.g., flying doctor service) are addressed.

Conclusion

The Air-MSU may represent a novel tool to reduce treatment disparity for stroke patients in rural and remote areas. However, this approach requires further implementation research to determine the overall benefit to these communities.

Prehospital notification can effectively reduce in-hospital delay for thrombolysis in acute stroke

Aim: To reduce in-hospital intervals by developing a prehospital notification (PHN) protocol which directly notifies a neurologist to prepare for possible treatment. Methods: A 24/7 connection was established between emergency medical services dispatch and the on-call neurologist. A database of all patients with in-hospital stroke code activation was developed, door-to-computed tomography (CT) time and door-to-needle time was recorded from January 2013 to December 2016. The statistical results were considered significant at p < 0.05. Result: PHN resulted in a significant reduction in door-to-CT time (median 14 vs 20; p < 0.001). Among patients who were treated with intravenous thrombolysis, door-to-needle time was significantly shorter in patients with PHN compared with non-PHN group (median 42 vs 70; p < 0.001). Conclusion: PHN effectively reduced door-to-CT and door-to-needle times.

Improving Access to Thrombolysis and Inhospital Management Times in Ischemic Stroke: A Stepped-Wedge Randomized Trial

BACKGROUND AND PURPOSE

A suboptimal number of ischemic stroke patients eligible for thrombolysis actually receive it, partly because of extended inhospital delays. We developed a comprehensive program designed for emergency unit staff and evaluated its effectiveness for reducing intrahospital times and improving access to thrombolysis.

METHODS

We conducted a randomized stepped-wedge controlled trial in 18 emergency unit. The sequentially implemented training intervention, targeting emergency physicians and nurses, was based on specifically designed videos and interactive simulation workshops on intrahospital management optimization. The effectiveness was assessed on intrahospital times and thrombolysis proportion. During the study period, all consecutive patients with confirmed ischemic stroke and no contraindications to thrombolysis were included.

RESULTS

A total of 328 patients were enrolled in the control group and 363 in the intervention group. Mean age was 73.6 years. Overall thrombolysis proportion was 34.2% in the intervention group versus 25.6% in the control group (adjusted odds ratio, 1.42; 95% confidence interval, 1.01-2.01), thrombolysis proportion within 4 hours 30 minutes almost doubled (adjusted odds ratio, 1.9; 95% confidence interval, 1.32-2.73). Although imaging-to-stroke unit time was significantly decreased in the intervention group (39 versus 53 minutes; P=0.03), median door-to-imaging and door-to-needle times were not different between groups (P=0.70 and P=0.40, respectively).

CONCLUSIONS

An interactive and multifaceted training program targeting emergency professionals was significantly associated with an increased access to thrombolysis, especially within 4 hours and 30 minutes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02814760.

Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review

Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.

Response to Symptoms and Prehospital Delay in Stroke Patients. Is It Time to Reconsider Stroke Awareness Campaigns?

BACKGROUND

Despite recent advances in acute stroke care, reperfusion therapies are given to only 1%-8% of patients. Previous studies have focused on prehospital or decision delay. We aim to give a more comprehensive view by addressing different time delays and decisions.

METHODS

A total of 382 patients with either acute stroke or transient ischemic attack were prospectively included. Sociodemographic and clinical parameters and data on decision delay, prehospital delay, and first medical contact were recorded. Multivariate logistic regression analyses were conducted to identify factors related to decision delay of 15 minutes or shorter, calling the Extrahospital Emergency Services, and prehospital delay of 60 minutes or shorter and 180 minutes or shorter.

RESULTS

Prehospital delay was 60 minutes or shorter in 11.3% of our patients and 180 minutes or shorter in 48.7%. Major vascular risk factors were present in 89.8% of patients. Severity was associated with decision delay of 15 minutes or shorter (odds ratio [OR] 1.08; confidence interval [CI] 1.04-1.13), calling the Extrahospital Emergency Services (OR 1.17; CI 1.12-1.23), and prehospital delay of 180 minutes or shorter (OR 1.08; CI 1.01-1.15). Adult children as witnesses favored a decision delay of 15 minutes or shorter (OR 3.44; CI 95% 1.88-6.27; P < .001) and calling the Extrahospital Emergency Services (OR 2.24; IC 95% 1.20-4.22; P = .012). Calling the Extrahospital Emergency Services favored prehospital delay of 60 minutes or shorter (OR 5.69; CI 95% 2.41-13.45; P < .001) and prehospital delay of 180 minutes or shorter (OR 3.86; CI 95% 1.47-10.11; P = .006).

CONCLUSIONS

Severity and the bystander play a critical role in the response to stroke. Calling the Extrahospital Emergency Services promotes shorter delays. Future interventions should encourage immediately calling the Extrahospital Emergency Services, but the target should be redirected to those with known risk factors and their caregivers.

Vectorized nanodelivery systems for ischemic stroke: a concept and a need

Neurological diseases of diverse aetiologies have significant effects on the quality of life of patients. The limited self-repairing capacity of the brain is considered to be the origin of the irreversible and progressive nature of many neurological diseases. Therefore, neuroprotection is an important goal shared by many clinical neurologists and neuroscientists. In this review, we discuss the main obstacles that have prevented the implementation of experimental neuroprotective strategies in humans and propose alternative avenues for the use of neuroprotection as a feasible therapeutic approach. Special attention is devoted to nanotechnology, which is a new approach for developing highly specific and localized biomedical solutions for the study of the multiple mechanisms involved in stroke. Nanotechnology is contributing to personalized neuroprotection by allowing us to identify mechanisms, determine optimal therapeutic windows, and protect patients from brain damage. In summary, multiple aspects of these new players in biomedicine should be considered in future in vivo and in vitro studies with the aim of improving their applicability to clinical studies.

Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden

OBJECTIVES

Ambulance services and stroke alerts reduce the time from stroke onset to acute stroke diagnosis. We describe the use of stroke alerts and ambulance services in different hospitals and patient groups and their relationship with reperfusion therapy.

METHODS

This nationwide study included 49,907 patients admitted with acute stroke who were registered in The Swedish Stroke Register (Riksstroke) in 2011-2012.

RESULTS

The proportions of patients admitted as stroke alerts out of all acute stroke admissions varied from 12.2% to 45.7% in university hospitals (n = 9), 0.5% to 38.7% in specialized nonuniversity hospitals (n = 22), and 4.2% to 40.3% in community hospitals (n = 41). Younger age, atrial fibrillation (AF), living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were factors associated with a higher probability of stroke alerts. Living alone, primary school education, non-European origin, previous stroke, diabetes, smoking, and dependency in activities of daily living (ADL) were associated with a lower probability of stroke alert. The proportion of patients arriving at the hospital by ambulance varied from 60.3% to 94.5%. Older age, living alone, primary school education, being born in a European country, previous stroke, AF, dependency in ADL, living in an institution, reduced consciousness upon admission, and hemorrhagic stroke were associated with ambulance services. Hospital stroke alert frequencies correlated strongly with reperfusion rates (r = .75).

CONCLUSION

Acute stroke alerts have a significant potential to improve stroke reperfusion rates. Prehospital stroke management varies conspicuously between hospitals and patient groups, and the elderly and patients living alone have a markedly reduced likelihood of stroke alerts.

Prehospital Identification of Stroke Subtypes in Chinese Rural Areas

Background:

Differentiating intracerebral hemorrhage (ICH) from cerebral infarction as early as possible is vital for the timely initiation of different treatments. This study developed an applicable model for the ambulance system to differentiate stroke subtypes.

Methods:

From 26,163 patients initially screened over 4 years, this study comprised 1989 consecutive patients with potential first-ever acute stroke with sudden onset of the focal neurological deficit, conscious or not, and given ambulance transport for admission to two county hospitals in Yutian County of Hebei Province. All the patients underwent cranial computed tomography (CT) or magnetic resonance imaging to confirm the final diagnosis based on stroke criteria. Correlation with stroke subtype clinical features was calculated and Bayes’ discriminant model was applied to discriminate stroke subtypes.

Results:

Among the 1989 patients, 797, 689, 109, and 394 received diagnoses of cerebral infarction, ICH, subarachnoid hemorrhage, and other forms of nonstroke, respectively. A history of atrial fibrillation, vomiting, and diabetes mellitus were associated with cerebral infarction, while vomiting, systolic blood pressure ≥180 mmHg, and age <65 years were more typical of ICH. For noncomatose stroke patients, Bayes’ discriminant model for stroke subtype yielded a combination of multiple items that provided 72.3% agreement in the test model and 79.3% in the validation model; for comatose patients, corresponding agreement rates were 75.4% and 73.5%.

Conclusions:

The model herein presented, with multiple parameters, can predict stroke subtypes with acceptable sensitivity and specificity before CT scanning, either in alert or comatose patients. This may facilitate prehospital management for patients with stroke.

Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges

In acute stroke management, time is brain. Bringing swift treatment to the patient, instead of the conventional approach of awaiting the patient's arrival at the hospital for treatment, is a potential strategy to improve clinical outcomes after stroke. This strategy is based on the use of an ambulance (mobile stroke unit) equipped with an imaging system, a point-of-care laboratory, a telemedicine connection to the hospital, and appropriate medication. Studies of prehospital stroke treatment consistently report a reduction in delays before thrombolysis and cause-based triage in regard to the appropriate target hospital (eg, primary vs comprehensive stroke centre). Moreover, novel medical options for the treatment of stroke patients are also under investigation, such as prehospital differential blood pressure management, reversal of warfarin effects in haemorrhagic stroke, and management of cerebral emergencies other than stroke. However, crucial concerns regarding safety, clinical efficacy, best setting, and cost-effectiveness remain to be addressed in further studies. In the future, mobile stroke units might allow the investigation of novel diagnostic (eg, biomarkers and automated imaging evaluation) and therapeutic (eg, neuroprotective drugs and treatments for haemorrhagic stroke) options in the prehospital setting, thus functioning as a tool for research on prehospital stroke management.

Hackathon as a way to raise awareness and foster innovation for stroke

The 'Time is Brain" concept has been a major focus in the World Stroke Awareness Campaign.

OBJECTIVE

We describe our experience with a Hackathon (junction of hack+marathon), a 24 hour event of innovation- and technology-based project development, focused around detecting stroke.

METHOD

The Hackathon was held during a Brazilian Student's union (BRASA) congress involving students from engineering and other technological disciplines.

RESULTS

Four teamscompleted the 24-hour challenge; two teams opted the stroke challenge. One team proposed improving detection using a mobile sensor Fit-Bit combined with a smart-phone to contact emergency dispatch. The other team developed a game, in which kids would play a role as a neurologist; to diagnosis stroke with objective to increase awareness.

CONCLUSION

Hackathons can focus attention on innovation and improvement opportunities to support the World Stroke Campaign, as well as other campaigns to raise awareness for other health or social problems.

Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions

Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.

Use of a SmartPhone/Tablet-Based Bidirectional Telemedicine Disease Management Program Facilitates Early Detection and Treatment of COPD Exacerbation Symptoms

INTRODUCTION

Early treatment of worsening chronic obstructive pulmonary disease (COPD) symptoms speeds recovery, improves quality of life, and reduces the need for hospitalization. Patients may fail to recognize worsening symptoms leading to delays in treatment. A telemedicine application could facilitate detection and treatment of worsening symptoms. To work, such an application requires consistent use by patients and quick responses from healthcare providers. We conducted a quality assurance assessment of our system to see if we were meeting these goals.

MATERIALS AND METHODS

Thirty patients were provided a smartphone application for daily COPD symptom reporting. Reports between November 2012 and September 2013 were reviewed. Symptoms reports and interventions were time-stamped by the application. Adherence reporting was calculated as the number of reports made divided by the number of days enrolled in the program for each patient. Time to intervention was calculated as the time a report was submitted to the time a treatment recommendation was sent to the patient.

RESULTS

There were 4,434 symptom reports made over 5,178 patient-days of observation for an average reporting compliance of 85.6%. Median reporting compliance was 90.7% (interquartile range, 83.8-98%). Four hundred seventy-five symptom reports resulted in an alert. The average response time for all alerts was 6.64 h, with a median response time of 5.75 h.

CONCLUSIONS

From this quality assessment we were able to conclude that patient adherence to the reporting system exceeded 90% for over half of the participants. Furthermore, over 50% of worsening COPD symptom reports were responded to in less than 6 h with patient-specific treatment recommendations.

Assessment of acute stroke cerebral CT examinations by anaesthesiologists

Background and purpose

It is essential to diagnose ischaemic stroke as soon as possible after symptom onset, so that thrombolytic treatment can be initiated as quickly as possible. This might be greatly facilitated if cerebral CT could be carried out in a pre‐hospital setting. The aim of this study was to evaluate if anaesthesiologists, who in Norway provide pre‐hospital medical care, could be trained to assess cerebral CT scans to exclude radiological contraindications for thrombolytic stroke treatment.

Methods

Thirteen anaesthesiologists attended an 8‐h course in acute stroke assessment, including a 2‐h introduction to the neuroradiology of acute stroke. Each participant then assessed 12 non‐contrast cerebral CT examinations of acute stroke patients with specific regard to radiological contraindications for thrombolytic therapy. Test results were compared with those of three experienced neuroradiologists. Inter‐rater agreement between anaesthesiologists and neuroradiologists was calculated using Cohen's Kappa statistics. Robustness of the results was assessed using the non‐parametric bootstrap.

Results

Among the neuroradiologists, Kappa was 1 for detecting radiological contraindications for thrombolytic therapy. Twelve of the 13 anaesthesiologists showed good or excellent agreement (Kappa > 0.60) with the neuroradiologists. The anaesthesiologists spent a median time of 2 min and 18 s on each CT scan.

Conclusions

This study suggests that anaesthesiologists who are experienced in pre‐hospital care may be quickly trained to assess cerebral CT examinations in acute stroke patients with regard to radiological contraindications for thrombolytic therapy.

Teleneurocritical care and telestroke

Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients.

Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial

BACKGROUND

Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs.

METHODS

We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed.

RESULTS

Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km2 (202 inhabitants per square mile).

CONCLUSION

This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.