Early management and outcome of acute stroke in Auckland

A multidisciplinary guideline for the acute phase of stroke: barriers perceived by Dutch neurologists

RATIONALE, AIMS AND OBJECTIVES

Guidelines for stroke management should improve quality of care. Dissemination of guidelines, however, does not guarantee guideline adherence. The aim of this paper is to investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies.

METHOD

Questionnaire survey among all Dutch neurologists working on neurology wards in general hospitals during the year 2000 in The Netherlands.

RESULTS

The neurologists expressed a high degree of agreement with the diagnostic and preventive recommendations, but expressed doubts with regard to the therapeutic recommendations, especially for the recombinant tissue plasminogen activator therapy. In general, barriers at the organizational and the multidisciplinary team level were most prominent.

CONCLUSIONS

Active implementation of the guidelines seems necessary. Implementation strategies should be focused on the different sources of barriers: the caregiver, the patient and the organization of care.

Modern stroke unit

The modern stroke unit is making significant contributions to the care of stroke victims and is proving to be an effective, cost-saving enterprise. The precise factors that contribute to the efficacy of these units have yet to be identified, but a combination of protocolized approaches to patient care, critical paths, a focus of expertise, and heightened index of suspicion for comorbidities all probably play a role. This article outlines the basic features of a modern stroke unit and surveys the literature on stroke unit outcomes.

Relation between troponin T concentration and mortality in patients presenting with an acute stroke: observational study

OBJECTIVE

To assess whether a raised serum troponin T concentration would be an independent predictor of death in patients with an acute ischaemic stroke.

DESIGN

Observational study.

SETTING

Auckland Hospital, Auckland, New Zealand.

SUBJECTS

All 181 patients with an acute ischaemic stroke admitted over nine months in 1997-8, from a total of 8057 patients admitted to the acute medical service.

MAIN OUTCOME MEASURES

Blood samples for measuring troponin T concentration were collected 12-72 hours after admission; other variables previously associated with severity of stroke were also recorded and assessed as independent predictors of inpatient mortality.

RESULTS

Troponin T concentration was raised (>0.1 microgram/l) in 17% (30) of patients admitted with an acute ischaemic stroke. Thirty one patients died in hospital (12/30 (40%) patients with a raised troponin T concentration v 19/151 (13%) patients with a normal concentration (relative risk 3.2 (95% confidence 1.7 to 5. 8; P=0.0025)). Of 17 possible predictors of death, assessed in a multivariate stepwise model, only a raised troponin T concentration (P=0.0002), age (P=0.0008), and an altered level of consciousness at presentation (P=0.0074) independently predicted an adverse outcome.

CONCLUSIONS

Serum troponin T concentration at hospital admission is a powerful predictor of mortality in patients admitted with an acute ischaemic stroke.

Opinion of New Zealand physicians on management of acute ischaemic stroke: results of a national survey

BACKGROUND

Randomised trials have evaluated various treatments for acute ischaemic stroke, but it is unclear how the results of these studies are used in everyday practice.

AIMS

To obtain the opinions of physicians on the management of acute ischaemic stroke.

METHODS

A questionnaire was sent to 368 New Zealand Fellows of the Royal Australasian College of Physicians. The survey included questions about the availability of hospital services for stroke patients, management of acute ischaemic stroke and opinion on the efficacy of treatments used in acute ischaemic stroke.

RESULTS

Of the 293 physicians who responded to the questionnaire, 171 managed patients in the first week after stroke. Forty-seven per cent of these physicians were general physicians. Ninety-five per cent usually managed these patients in a general medical ward. Only five physicians admitted patients to an acute stroke unit and only 57% considered acute stroke units were beneficial. Aspirin was usually or sometimes used for patients with acute ischaemic stroke by 92% of physicians, intravenous heparin by 43%, low-dose subcutaneous heparin by 41%, low-molecular-weight heparin by 25% and tissue-plasminogen activator (t-PA) by 3%. Two thirds considered that aspirin was definitely beneficial, but most were uncertain about the efficacy of intravenous heparin, low-dose subcutaneous heparin, low-molecular-weight heparin and t-PA. Sixty-two per cent were prepared to begin aspirin and 21% subcutaneous heparin before computerised tomography (CT). Twenty-three per cent used anti-hypertensive treatment in the first few hours after an ischaemic stroke.

CONCLUSIONS

Several common deficiencies in the management of acute ischaemic stroke were identified. The widespread lack of stroke units, use of aspirin and heparin before CT, and lowering of blood pressure after an acute ischaemic stroke differed from accepted guidelines. Many physicians used heparin despite lack of evidence from randomised trials that it is beneficial. The development of stroke units and the appointment of physicians with a special interest in the management of stroke may improve the management of patients with acute stroke.