1
|
Buus SMØ, Behrndtz AB, Schmitz ML, Hedegaard JN, Cordsen P, Johnsen SP, Phan T, Andersen G, Simonsen CZ. Urban-rural inequalities in IV thrombolysis for acute ischemic stroke: A nationwide study. Eur Stroke J 2024; 9:722-731. [PMID: 38600682 PMCID: PMC11418494 DOI: 10.1177/23969873241244591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Rural residency has been associated with lower reperfusion treatment rates for acute ischemic stroke in many countries. We aimed to explore urban-rural differences in IV thrombolysis rates in a small country with universal health care, and short transport times to stroke units. PATIENTS AND METHODS In this nationwide cohort study, adult ischemic stroke patients registered in the Danish Stroke Registry (DSR) between 2015 and 2020 were included. The exposure was defined by residence rurality. Data from the DSR, Statistics Denmark, and the Danish Health Data Authority, were linked on the individual level using the Civil Registration Number. Adjusted treatment rates were calculated by balancing baseline characteristics using inverse probability of treatment weights. RESULTS Among the included 56,175 patients, prehospital delays were shortest for patients residing in capital municipalities (median 4.7 h), and longest for large town residents (median 7.1 h). Large town residents were predominantly admitted directly to a comprehensive stroke center (98.5%), whereas 30.9% of capital residents were admitted to a hospital with no reperfusion therapy available (non-RT unit). Treatment rates were similar among all non-rural residents (18.5%-18.7%), but slightly lower among rural residents (17.2% [95% CI 16.5-17.8]). After adjusting for age, sex, immigrant status, and educational attainment, rural residents reached treatment rates comparable to capital and large town residents at 18.5% (95% CI 17.7-19.4). DISCUSSION AND CONCLUSION While treatment rates varied minimally by urban-rural residency, substantial differences in median prehospital delay and admission to non-RT units underscored marked urban-rural differences in potential obstacles to reperfusion therapies.
Collapse
Affiliation(s)
| | | | | | | | - Pia Cordsen
- Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thanh Phan
- Department of Medicine, School of Clinical Sciences at Monash health, Monash University, Melbourne, VIC, Australia
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
2
|
Liao Y, Qi W, Li S, Shi X, Wu X, Chi F, Xia R, Qin L, Cao L, Ren L. Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study. BMC Health Serv Res 2024; 24:615. [PMID: 38730381 PMCID: PMC11084012 DOI: 10.1186/s12913-024-11088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors. METHODS We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay. RESULTS In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908). CONCLUSIONS Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.
Collapse
Affiliation(s)
- Yuqi Liao
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Wenwei Qi
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuting Li
- School of Statistics, Shandong Technology and Business University, Yantai, China
| | - Xin Shi
- School of Statistics, Shandong Technology and Business University, Yantai, China
- School of Health Management, China Medical University, Shenyang, China
| | - Xiaohong Wu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Feng Chi
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Runyu Xia
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Limin Qin
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| |
Collapse
|
3
|
Czap AL, Harmel P, Audebert H, Grotta JC. Stroke Systems of Care and Impact on Acute Stroke Treatment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
4
|
Al Kasab S, Almallouhi E, Grant C, Hewitt D, Hewitt J, Baki M, Sabatino P, Jones D, Holmstedt CA. Telestroke Consultation in the Emergency Medical Services Unit: A Novel Approach to Improve Thrombolysis Times. J Stroke Cerebrovasc Dis 2021; 30:105710. [PMID: 33690029 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105710] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/07/2021] [Accepted: 02/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Faster treatment times are associated with improved outcomes in patients with acute ischemic stroke. In this prospective pilot study, we assess the feasibility of initiating telestroke consultation in emergency medical services unit (TEMS). METHODS Patients with stroke symptoms were evaluated via TEMS using a video-call with a stroke provider. After TEMS evaluation, patients were transferred to the nearest stroke center (NSC) or thrombectomy capable center (TCS) depending on stroke severity and symptom onset time. We compared time metrics between patients evaluated via TEMS to those via standard telestroke (STS) consultation. RESULTS 49 patients were evaluated via TEMS between May 2017 and March 2020. Median age was 66, 24 (49%) were females, 15 (30.6%) received intravenous alteplase (tPA) after arrival to a local hospital, and 3 (6.1%) underwent mechanical thrombectomy (MT) after bypassing the NSC. Compared to 52 tPA patients treated through STS consultation, TEMS patients had shorter door to needle (DTN) time (21 vs. 38 min, p < 0.001). In addition, patients who received MT after bypassing the NSC had shorter onset to groin time compared to those transferred from NSC (216 vs. 293 min, P = 0.04). CONCLUSION Prehospital stroke triaging using TEMS is feasible, and could result in shorter DTN and onset to groin times.
Collapse
Affiliation(s)
- Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, SC, United States; Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, SC, United States.
| | - Cheryl Grant
- Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Dale Hewitt
- Georgetown County Fire/EMS, Georgetown, SC, United States
| | - Jessica Hewitt
- Georgetown Memorial Hospital, Georgetown, SC, United States
| | - Morgan Baki
- Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Perette Sabatino
- Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - David Jones
- Neurology, Medical University of South Carolina, Charleston, SC, United States
| | | |
Collapse
|
5
|
Abstract
Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.
Collapse
Affiliation(s)
- Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center-Houston, Houston, Texas
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| |
Collapse
|
6
|
Zheng S, Lyu TJ, Li Z, Gu H, Yang X, Wang C, Li H, Jiang Y, Shen H, Wang Y. GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate: evidence from the Chinese Stroke Center Alliance. Stroke Vasc Neurol 2021; 6:337-343. [PMID: 33431514 PMCID: PMC8485228 DOI: 10.1136/svn-2020-000633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Background Timely delivery of intravenous tissue plasminogen activator (IV-rt PA) is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic. This paper focuses on investigating influential factors associated with the administration of IV-rt PA, primarily per capita gross regional product (GRP) and healthcare system factors. Methods The study included 980 hospitals in the Chinese Stroke Center Alliance where 158 003 patients who had an acute ischaemic stroke received IV-rt PA between August 2015 and August 2019. The adherence rate to IV-rt PA within 4.5 hours time window in each hospital was the primary outcome. Influential factors were grouped into two categories: macroeconomic status and hospital characteristics. The outcome was analysed using multivariable linear regression. Results GRP per capita (β=2.37, p<0.001), hospital stroke centre certification (β=3.77, p<0.001), number of neurologists (β=0.12, p<0.001), existence of emergency services for neurological treatment (β=7.43, p=0.014), presence of emergency department (β=10.03, p=0.019) and cooperating with emergency centre (β=4.65, p=0.029) were significantly positively associated with the adherence rate to IV-rt PA. Conclusions Higher GRP per capita, affluent neurological personnel, well-equipped emergency services for neurological treatment and routine cooperation with the emergency centre were important for enhancing the adherence rate to IV-rt PA among patients who had an acute ischaemic stroke in China.
Collapse
Affiliation(s)
- Suxi Zheng
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China
| | - Tian Jie Lyu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Chinese Institute for Brain Research, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haipeng Shen
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China .,Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
7
|
Sobolewski P, Brola W, Wilczyński J, Szczuchniak W, Wójcik T, Wach-Klink A, Kos M, Kozera G. Cerebral Thrombolysis in Rural Residents Aged ≥ 80. Clin Interv Aging 2020; 15:1737-1751. [PMID: 33061326 PMCID: PMC7522422 DOI: 10.2147/cia.s256070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/05/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers. Patients and Methods This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed. Results The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients’ conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04–5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21–10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03–6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01–1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10–0.62, p = 0.003) were associated with mortality in rural patients over 80. Conclusion We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.
Collapse
Affiliation(s)
- Piotr Sobolewski
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland.,Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Waldemar Brola
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland.,Department of Neurology and Stroke Unit, Saint Lukas Hospital in Końskie, Końskie, Poland
| | | | - Wiktor Szczuchniak
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Tomasz Wójcik
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Aleksandra Wach-Klink
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Marek Kos
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland.,Department of Public Health, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Kozera
- Medical Simulation Center, Medical University of Gdańsk, Gdańsk, Poland
| |
Collapse
|
8
|
Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
Collapse
|
9
|
Fladt J, Meier N, Thilemann S, Polymeris A, Traenka C, Seiffge DJ, Sutter R, Peters N, Gensicke H, Flückiger B, de Hoogh K, Künzli N, Bringolf-Isler B, Bonati LH, Engelter ST, Lyrer PA, De Marchis GM. Reasons for Prehospital Delay in Acute Ischemic Stroke. J Am Heart Assoc 2019; 8:e013101. [PMID: 31576773 PMCID: PMC6818040 DOI: 10.1161/jaha.119.013101] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Prehospital delay reduces the proportion of patients with stroke treated with recanalization therapies. We aimed to identify novel and modifiable risk factors for prehospital delay. Methods and Results We included patients with an ischemic stroke confirmed by diffusion-weighted magnetic resonance imaging, symptom onset within 24 hours and hospitalized in the Stroke Center of the University Hospital Basel, Switzerland. Trained study nurses interviewed patients and proxies along a standardized questionnaire. Prehospital delay was defined as >4.5 hours between stroke onset-or time point of wake-up-and admission. Overall, 336 patients were enrolled. Prehospital delay was observed in 140 patients (42%). The first healthcare professionals to be alarmed were family doctors for 29% of patients (97/336), and a quarter of these patients had a baseline National Institute of Health Stroke Scale score of 4 or higher. The main modifiable risk factor for prehospital delay was a face-to-face visit to the family doctor (adjusted odds ratio, 4.19; 95% CI, 1.85-9.46). Despite transport by emergency medical services being associated with less prehospital delay (adjusted odds ratio, 0.41; 95% CI, 0.24-0.71), a minority of patients (39%) who first called their family doctor were transported by emergency medical services to the hospital. The second risk factor was lack of awareness of stroke symptoms (adjusted odds ratio, 4.14; 95% CI, 2.36-7.24). Conclusions Almost 1 in 3 patients with a diffusion-weighted magnetic resonance imaging-confirmed ischemic stroke first called the family doctor practice. Face-to-face visits to the family doctor quadrupled the odds of prehospital delay. Efforts to reduce prehospital delay should address family doctors and their staffs as important partners in the prehospital pathway. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02798770.
Collapse
Affiliation(s)
- Joachim Fladt
- Department of Neurology University Hospital Basel Basel Switzerland
| | | | | | | | - Christopher Traenka
- Department of Neurology University Hospital Basel Basel Switzerland.,Neurorehabilitation Unit University of Basel and University Center for Medicine of Aging and Rehabilitation Felix Platter Hospital Basel Switzerland
| | - David J Seiffge
- Department of Neurology University Hospital Basel Basel Switzerland
| | - Raoul Sutter
- Department of Neurology University Hospital Basel Basel Switzerland.,Department of Intensive Care Medicine University Hospital Basel Basel Switzerland.,University of Basel Switzerland
| | - Nils Peters
- Department of Neurology University Hospital Basel Basel Switzerland.,Neurorehabilitation Unit University of Basel and University Center for Medicine of Aging and Rehabilitation Felix Platter Hospital Basel Switzerland.,University of Basel Switzerland
| | - Henrik Gensicke
- Department of Neurology University Hospital Basel Basel Switzerland.,Neurorehabilitation Unit University of Basel and University Center for Medicine of Aging and Rehabilitation Felix Platter Hospital Basel Switzerland.,University of Basel Switzerland
| | - Benjamin Flückiger
- Swiss Tropical and Public Health Institute Basel Switzerland.,University of Basel Switzerland
| | - Kees de Hoogh
- Swiss Tropical and Public Health Institute Basel Switzerland.,University of Basel Switzerland
| | - Nino Künzli
- Swiss Tropical and Public Health Institute Basel Switzerland.,University of Basel Switzerland
| | - Bettina Bringolf-Isler
- Swiss Tropical and Public Health Institute Basel Switzerland.,University of Basel Switzerland
| | - Leo H Bonati
- Department of Neurology University Hospital Basel Basel Switzerland.,University of Basel Switzerland
| | - Stefan T Engelter
- Department of Neurology University Hospital Basel Basel Switzerland.,Neurorehabilitation Unit University of Basel and University Center for Medicine of Aging and Rehabilitation Felix Platter Hospital Basel Switzerland.,University of Basel Switzerland
| | - Philippe A Lyrer
- Department of Neurology University Hospital Basel Basel Switzerland.,University of Basel Switzerland
| | - Gian Marco De Marchis
- Department of Neurology University Hospital Basel Basel Switzerland.,University of Basel Switzerland
| |
Collapse
|
10
|
Urban Versus Rural Egypt: Stroke Risk Factors and Clinical Profile: Cross-Sectional Observational Study. J Stroke Cerebrovasc Dis 2019; 28:104316. [PMID: 31416762 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/19/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Egypt is a densely populated country with living habits and health care services that differ from urban to rural regions. We aimed to study how characteristics of stroke vary among these regions. METHODS This is a cross-sectional observational study of ischemic stroke, thus hemorrhagic and venous strokes were excluded. A total of 1475 ischemic stroke patients were recruited for analysis from a tertiary hospital in Cairo representing urban area and from a secondary care hospital in Suhag representing rural region. RESULTS Analysis was done for 1143 ischemic stroke patients from urban and 332 from rural area. Onset to door was shorter in urban. Urban patients showed an older age and higher prevalence of hypertension and diabetes (65.9%, 48.6% respectively), while rural patients were characterized by female preponderance (51.5%), more dyslipidemia, smoking 44.6%, stroke in young 20.5%, atrial fibrillation 23.8% % and recurrent stroke 44.3%. Rural cases showed a severer deficit at onset and poorer outcome. CONCLUSION Vascular risk factors, stroke type, and presentation tend to differ in Egypt according to the geographic distribution whether urban or rural. Studying patterns of such difference may aid in planning specific targeted preventive and therapeutic strategies for stroke in urban and rural Egypt.
Collapse
|
11
|
Mathur S, Walter S, Grunwald IQ, Helwig SA, Lesmeister M, Fassbender K. Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units. Front Neurol 2019; 10:159. [PMID: 30881334 PMCID: PMC6407433 DOI: 10.3389/fneur.2019.00159] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/07/2019] [Indexed: 12/11/2022] Open
Abstract
In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.
Collapse
Affiliation(s)
- Shrey Mathur
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Iris Q. Grunwald
- Neuroscience Unit, Faculty of Medicine, Anglia Ruskin University, Chelmsford, United Kingdom
- Department of Medicine, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, United Kingdom
| | - Stefan A. Helwig
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| |
Collapse
|
12
|
Cerebral thrombolysis in patients with ischemic stroke and heart failure. Neurol Neurochir Pol 2018; 52:593-598. [DOI: 10.1016/j.pjnns.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/10/2018] [Accepted: 08/03/2018] [Indexed: 11/20/2022]
|
13
|
Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017. [PMID: 29209269 DOI: 10.3389/fneur.2017.00617/full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
Collapse
Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| |
Collapse
|
14
|
Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017; 8:617. [PMID: 29209269 PMCID: PMC5701972 DOI: 10.3389/fneur.2017.00617] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/06/2017] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
Collapse
Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| |
Collapse
|
15
|
Length of stay in emergency department and cerebral intravenous thrombolysis in community hospitals. Eur J Emerg Med 2017; 24:208-216. [DOI: 10.1097/mej.0000000000000330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Chwojnicki K, Kozera G, Sobolewski P, Fryze W, Nyka WM. Intravenous thrombolysis and three-year ischemic stroke mortality. Acta Neurol Scand 2017; 135:540-545. [PMID: 27334369 DOI: 10.1111/ane.12625] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) in ischemic stroke (IS) does not reduce three-month mortality; however, longer-term survival after IVT has not been clearly established. Thus, we aimed to compare three-year mortality after IS in IVT-treated vs non-treated patients and to indicate predictors of long-term mortality after IVT. METHODS We have evaluated data of 366 subjects with IS (196 treated with IVT and 170 non-treated with IVT, whose age, sex, and calendar time of IS occurrence matched the control group) collected via the Pomeranian Stroke Register. We estimated the three-year survival and its determinants in both groups. RESULTS In univariate analysis, IVT was not associated with three-year mortality (OR 0.68; 95% CI 0.44-1.05). Independent predictors for unfavorable long-term outcome in a Cox regression model were older age, parenchymal hemorrhage type 2 (ph2), and modified Rankin scale >2 points at discharge from the hospital. IVT was strongly associated with a lower risk of death in the period 0-36 months from IS (HR 0.44, 95% CI 0.28-0.69, P<.001). CONCLUSIONS Treatment of IS with intravenous recombinant tissue plasminogen activator was associated with increased survival during the three-year follow-up.
Collapse
Affiliation(s)
- K. Chwojnicki
- Department of Neurology; Medical University of Gdańsk; Gdańsk Poland
| | - G. Kozera
- Department of Neurology; Medical University of Gdańsk; Gdańsk Poland
- Department of Neurology; Nicolaus Copernicus University Collegium Medicum in Bydgoszcz; Poland
| | - P. Sobolewski
- Department of Neurology and Stroke Unit; Hospital of Sandomierz; Sandomierz Poland
| | - W. Fryze
- Nicolaus Copernicus Pomeranian Traumatology Centre; Gdańsk Poland
| | - W. M. Nyka
- Department of Neurology; Medical University of Gdańsk; Gdańsk Poland
| |
Collapse
|
17
|
Abstract
BACKGROUND The presence of chronic kidney disease (CKD) is an indicator of a worse long-term prognosis in patients with ischemic stroke (IS). Unfortunately, not much is known about renal function in the population of post-IS subjects. The aim of our study was to assess the prevalence of renal damage and impaired renal function (IRF) in the population of post-IS subjects. METHODS This prospective analysis concerned 352 consecutive post-IS survivors hospitalized in Pomeranian stroke centers (Poland) in 2009. In this group estimated glomerular filtration rate (eGFR) according to MDRD (modification of diet in renal diseases) and CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formulas and urine albumin/creatinine ratio (ACR) were determined. RESULTS Among survivors decreased eGFR (<60 mL/min./1.73m2 according to MDRD or CKD-EPI) or ACR≥30mg/g were detected in 40.38% (23.07% Men, 55.32% Women; P<0.01). The highest prevalence of IRF was noted in post-IS subjects with atheromatic and lacunar IS. In multivariate analysis the ACR≥30mg/g was predicted by older age, diabetes mellitus (DM) and physical disability (modified Rankin scale 3-5 pts.). The association with reduced eGFR was proved for sex (female), DM and physical disability. CONCLUSIONS CKD is a frequently occurring problem in the group of post-IS subjects, especially after lacunar and atheromatic IS. Post-IS patients, mainly the elderly women, with physical disability and diabetes mellitus, should be regularly screened for CKD. This could reduce the risk of further cardiovascular events and delay the progression of IRF.
Collapse
|
18
|
Paul CL, Ryan A, Rose S, Attia JR, Kerr E, Koller C, Levi CR. How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care. Implement Sci 2016; 11:51. [PMID: 27059183 PMCID: PMC4825073 DOI: 10.1186/s13012-016-0414-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 03/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke. METHODS Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted. RESULTS Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05). CONCLUSIONS In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.
Collapse
Affiliation(s)
- Christine L Paul
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
| | - Annika Ryan
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Shiho Rose
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - John R Attia
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Erin Kerr
- Hunter New England Health, Lookout Road, New Lambton Heights, NSW, 2305, Australia
| | - Claudia Koller
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Christopher R Levi
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter New England Health, Lookout Road, New Lambton Heights, NSW, 2305, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| |
Collapse
|
19
|
Burton KR, Kapral MK, Li S, Fang J, Moody AR, Krahn M, Laupacis A. Predictors of diagnostic neuroimaging delays among adults presenting with symptoms suggestive of acute stroke in Ontario: a prospective cohort study. CMAJ Open 2016; 4:E331-7. [PMID: 27398382 PMCID: PMC4933639 DOI: 10.9778/cmajo.20150110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many studies have examined the timeliness of thrombolysis for acute ischemic stroke, but less is known about door-to-imaging time. We conducted a prospective cohort study to assess the timing of neuroimaging among patients with suspected acute stroke in the province of Ontario, Canada, and to examine factors associated with delays in neuroimaging. METHODS We included all patients 18 years and older with suspected acute stroke seen at hospitals with neuroimaging capacity within the Ontario Stroke Registry between Apr. 1, 2010, and Mar. 31, 2011. We used a hierarchical, multivariable Cox proportional hazards model to evaluate the association between patient and hospital factors and the likelihood of receiving timely neuroimaging (≤ 25 min) after arrival in the emergency department. RESULTS A total of 13 250 patients presented to an emergency department with stroke-like symptoms during the study period. Of the 3984 who arrived within 4 hours after symptom onset, 1087 (27.3%) had timely neuroimaging. The factors independently associated with an increased likelihood of timely neuroimaging were less time from symptom onset to presentation, more severe stroke, male sex, no history of stroke or transient ischemic attack, arrival to hospital from a setting other than home and presentation to a designated stroke centre or an urban hospital. INTERPRETATION A minority of patients with stroke-like symptoms who presented within the 4-hour thrombolytic treatment window received timely neuroimaging. Neuroimaging delays were influenced by various patient and hospital factors, some of which are modifiable.
Collapse
Affiliation(s)
- Kirsteen R Burton
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Shudong Li
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Jiming Fang
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Alan R Moody
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Murray Krahn
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| |
Collapse
|
20
|
Sheppard JP, Lindenmeyer A, Mellor RM, Greenfield S, Mant J, Quinn T, Rosser A, Sandler D, Sims D, Ward M, McManus RJ. Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study. Emerg Med J 2016; 33:482-8. [PMID: 26949969 PMCID: PMC4941194 DOI: 10.1136/emermed-2014-204392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/26/2015] [Indexed: 01/12/2023]
Abstract
Background Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a ‘prealert’ message can significantly improve the timeliness of treatment. Objective Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert. Methods Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke. Results Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p<0.001; 3 symptoms, OR 75.84, 95% CI 24.68 to 233.03, p<0.001) and EMS contact within 5 h of symptom onset (OR 2.99, 95% CI 1.37 to 6.50 p=0.006) were key predictors of prealerting but eligibility for prealert as a whole was not (OR 1.92, 95% CI 0.85 to 4.34 p=0.12). In qualitative interviews, EMS staff displayed varying understanding of prealert protocols and described frustration when their interpretation of the prealert criteria was not shared by ED staff. Conclusions Up to half of the patients presenting with suspected stroke in this study were prealerted by EMS staff, regardless of eligibility, resulting in disagreements with ED staff during handover. Aligning the expectations of EMS and ED staff, perhaps through simplified prealert protocols, could be considered to facilitate more appropriate use of hospital prealerting in acute stroke.
Collapse
Affiliation(s)
- J P Sheppard
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford, Oxfordshire, UK
| | - A Lindenmeyer
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Birmingham, West Midlands, UK
| | - R M Mellor
- Department of Public Health, NHS Lanarkshire, Bothwell, UK
| | - S Greenfield
- Department of Public Health, NHS Lanarkshire, Bothwell, UK
| | - J Mant
- Primary Care Unit, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - T Quinn
- Faculty of Health, Social Care and Education, St George's, University of London & Kingston University, London, UK
| | - A Rosser
- West Midlands Ambulance Service NHS Trust, Regional Ambulance Headquarters, Dudley, West Midlands, UK
| | - D Sandler
- Heart of England NHS Foundation Trust, Birmingham, West Midlands, UK
| | - D Sims
- Queen Elizabeth Hospital Birmingham Elderly Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, West Midlands, UK
| | - M Ward
- West Midlands Ambulance Service NHS Trust, Regional Ambulance Headquarters, Dudley, West Midlands, UK
| | - R J McManus
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford, Oxfordshire, UK
| | | |
Collapse
|
21
|
Sobolewski P, Kozera G, Szczuchniak W, Nyka WM. The role of additional computed tomography in the decision-making process on the secondary prevention in patients after systemic cerebral thrombolysis. Ther Clin Risk Manag 2015; 12:5-10. [PMID: 26730196 PMCID: PMC4694680 DOI: 10.2147/tcrm.s91119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Patients with ischemic stroke undergoing intravenous (iv)-thrombolysis are routinely controlled with computed tomography on the second day to assess stroke evolution and hemorrhagic transformation (HT). However, the benefits of an additional computed tomography (aCT) performed over the next days after iv-thrombolysis have not been determined. METHODS We retrospectively screened 287 Caucasian patients with ischemic stroke who were consecutively treated with iv-thrombolysis from 2008 to 2012. The results of computed tomography performed on the second (control computed tomography) and seventh (aCT) day after iv-thrombolysis were compared in 274 patients (95.5%); 13 subjects (4.5%), who died before the seventh day from admission were excluded from the analysis. RESULTS aCTs revealed a higher incidence of HT than control computed tomographies (14.2% vs 6.6%; P=0.003). Patients with HT in aCT showed higher median of National Institutes of Health Stroke Scale score on admission than those without HT (13.0 vs 10.0; P=0.01) and higher presence of ischemic changes >1/3 middle cerebral artery territory (66.7% vs 35.2%; P<0.01). Correlations between presence of HT in aCT and National Institutes of Health Stroke Scale score on admission (rpbi 0.15; P<0.01), and the ischemic changes >1/3 middle cerebral artery (phi=0.03) existed, and the presence of HT in aCT was associated with 3-month mortality (phi=0.03). CONCLUSION aCT after iv-thrombolysis enables higher detection of HT, which is related to higher 3-month mortality. Thus, patients with severe middle cerebral artery infarction may benefit from aCT in the decision-making process on the secondary prophylaxis.
Collapse
Affiliation(s)
- Piotr Sobolewski
- Department of Neurology and Stroke, Unit of Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Grzegorz Kozera
- Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Wiktor Szczuchniak
- Department of Neurology and Stroke, Unit of Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Walenty M Nyka
- Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland
| |
Collapse
|
22
|
Sobolewski P, Kozera G, Kaźmierski R, Michalak S, Szczuchniak W, Nyka W. Efficacy of cerebral thrombolysis in an extended 'time window'. J Clin Pharm Ther 2015; 40:472-6. [PMID: 26059848 DOI: 10.1111/jcpt.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/29/2015] [Indexed: 01/23/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Cerebral systemic thrombolysis (i.v. thrombolysis) with tissue-type plasminogen activator (rt-PA) is the only proven medical therapy for ischaemic stroke. The use of i.v. thrombolysis up to 4·5 h from stroke onset was approved in certain countries in 2008, but its safety and efficacy have not been fully determined to date. OBJECTIVE To assess the long-term outcome and complication rate of i.v. thrombolysis performed in the extended 'time window'. METHODS The study included 403 ischaemic stroke patients consecutively treated with i.v. thrombolysis from 2006 to 2012 at three comprehensive stroke centres in Poland. The long-term outcome and the haemorrhagic complications' (HC) rate were compared between subgroups of patients treated within 3 vs. 3-4·5 h from stroke onset. RESULTS AND DISCUSSION About 132 (32·75%) patients were treated between 3 and 4·5 h from stroke onset. Neurological deficits tended to be more severe in patients treated ≤3 than in those treated 3-4·5 h (National Institutes of Health Stroke Scale, NIHSS 12 vs.10 points; P = 0·053); however, the ratio of patients with a favourable outcome (mRS 0-2 points) and mortality did not differ between the two groups (53·9 vs. 58·3, P = 0·39 and 17·7 vs. 21·2, P = 0·39, respectively). The rate of HC also did not differ between the two groups (18·8% vs. 15·1%, P = 0·46). WHAT IS NEW AND CONCLUSION The efficacy of i.v. thrombolysis routinely performed in an extended 'time window' is not reduced when compared to procedures performed within 3 h from symptom onset.
Collapse
Affiliation(s)
- P Sobolewski
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - G Kozera
- Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - R Kaźmierski
- Department of Neurology and Cerebrovascular Disorders, Poznań University of Medical Sciences, Poznań, Poland
| | - S Michalak
- Department of Neurochemistry and Neuropathology, Poznań University of Medical Sciences, Poznań, Poland
| | - W Szczuchniak
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - W Nyka
- Department of Neurology, Medical University of Gdańsk, Gdańsk, Poland
| |
Collapse
|
23
|
Zhao Q, Yang L, Zuo Q, Zhu X, Zhang X, Wu Y, Yang L, Gao W, Li M. Instrument development and validation of the stroke pre-hospital delay behavior intention scale in a Chinese urban population. Health Qual Life Outcomes 2014; 12:170. [PMID: 25432795 PMCID: PMC4264611 DOI: 10.1186/s12955-014-0170-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/12/2014] [Indexed: 01/12/2023] Open
Abstract
Background Several stroke impairment scales are currently available for stroke patients but none of them provide information regarding the pre-stroke behavioral intentions of high-risk stroke patients and their relatives. This study’s objective was to generate and validate a new written tool, the Stroke Pre-hospital Delay Behavior Intention (SPDBI) scale. It is suitable for use with high-risk stroke patients and their relatives to predict the likelihood of pre-hospital delay. Methods From a review of related studies, we formulated a prototype scale. We interviewed ten stroke patients in a semi-structured iterative process that included interviews with experts, high-risk patients, and their family members. Then, we pretested and filtered items. We next used a large sample size and factor analysis to determine the scale’s structure. Finally, we checked the reliability and validity of the scale. Results We identified five sub-domains (stroke warning signs, non-treatment justification, symptom attributions, habitual response style, and emergency system use). The SPDBI demonstrated good internal consistency and test-retest reliability (Cronbach’s α =0.808; Intraclass Correlation Coefficient [ICC] =0.797). Conclusions This SPDBI scale is a reliable, and valid measure of the likeliness of pre-hospital delay in high-risk stroke patients and their family members. It may provide scientific assessment for targeted health education intervention. Electronic supplementary material The online version of this article (doi:10.1186/s12955-014-0170-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Qiuli Zhao
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Li Yang
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Qingqing Zuo
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Xuemei Zhu
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Xiao Zhang
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Yanni Wu
- Department of Nephrology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, HeiLongJiang Province, 150086, China.
| | - Liu Yang
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Wei Gao
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| | - Minghui Li
- School of Nursing, The 2nd Affiliated Hospital of Harbin Medical University, Harbin Medical University, 246 Xuefu Road, Harbin, HeiLongJiang Province, 150086, China.
| |
Collapse
|
24
|
Cortijo E, García-Bermejo P, Calleja AI, Pérez-Fernández S, Gómez R, del Monte JM, Reyes J, Arenillas JF. Intravenous thrombolysis in ischemic stroke with unknown onset using CT perfusion. Acta Neurol Scand 2014; 129:178-83. [PMID: 23848212 DOI: 10.1111/ane.12160] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute ischemic stroke patients with unclear onset time presenting >4.5 h from last-seen-normal (LSN) time are considered late patients and excluded from i.v. thrombolysis. We aimed to evaluate whether this subgroup of patients is different from patients presenting >4.5 h from a witnessed onset, in terms of eligibility and response to computed tomography perfusion (CTP)-guided i.v. thrombolysis. METHODS We prospectively studied consecutive acute non-lacunar middle cerebral artery (MCA) ischemic stroke patients presenting >4.5 h from LSN. All patients underwent multimodal CT and were considered eligible for i.v. thrombolysis according to CTP criteria. Two patient groups were established based on the knowledge of the stroke onset time. We compared the proportion of candidates suitable for intravenous thrombolysis between both groups, and their outcome after thrombolytic therapy. RESULTS Among 147 MCA ischemic stroke patients presenting >4.5 h from LSN, stroke onset was witnessed in 74 and unknown in 73. Thirty-seven (50%) patients in the first group and 32 (44%) in the second met CTP criteria for thrombolysis (P = 0.7). Baseline variables were comparable between both groups with the exception of age, which was higher in the unclear onset group. The rates of early neurological improvement (54.1% vs 46.9%), 2-h MCA recanalization (43.5% vs 37%), symptomatic hemorrhagic transformation (3% vs 0%) and good 3-month functional outcome (62.2% vs 56.3%) did not differ significantly between both groups. CONCLUSION Delayed stroke patients with unknown onset time were no different than patients >4.5 h regarding eligibility and response to CTP-based i.v. thrombolysis.
Collapse
Affiliation(s)
- E. Cortijo
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - P. García-Bermejo
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - A. I. Calleja
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - S. Pérez-Fernández
- Section of Neuroradiology; Department of Radiology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - R. Gómez
- Section of Neuroradiology; Department of Radiology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - J. M. del Monte
- Section of Neuroradiology; Department of Radiology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - J. Reyes
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| | - J. F. Arenillas
- Stroke Unit; Department of Neurology and Medicine; Hospital Clínico Universitario; Universidad de Valladolid; Valladolid Spain
| |
Collapse
|
25
|
Penaloza-Ramos MC, Sheppard JP, Jowett S, Barton P, Mant J, Quinn T, Mellor RM, Sims D, Sandler D, McManus RJ, Carr P, Greenfield S, Helliwell B, Nand C, Phillips N, Scott R, Singh S, Ward M. Cost-Effectiveness of Optimizing Acute Stroke Care Services for Thrombolysis. Stroke 2014; 45:553-62. [DOI: 10.1161/strokeaha.113.003216] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Cristina Penaloza-Ramos
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - James P. Sheppard
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Sue Jowett
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Pelham Barton
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Jonathan Mant
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Tom Quinn
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Ruth M. Mellor
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Don Sims
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - David Sandler
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | - Richard J. McManus
- From the Health Economics Unit (M.C.P.-R., S.J., P.B.) and Primary Care Clinical Sciences (J.P.S., R.M.M.), University of Birmingham, Edgbaston, Birmingham, UK; Department of Primary Care Health Sciences, University of Oxford, Oxford, UK (J.P.S., R.J.M.); Primary Care Unit, University of Cambridge, Cambridge, UK (J.M.); Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK (T.Q.); University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK (D. Sims); and Heart of
| | | | | | | | | | | | | | - Satinder Singh
- Primary Care Clinical Sciences, University of Birmingham
| | | | | |
Collapse
|
26
|
Sobolewski P, Brola W, Stoiński J, Szczuchniak W, Fudala M, Hatalska-Żerebiec R, Śledzińska-Dźwigał M. Intravenous thrombolysis in patients aged more than 80 years in the three rural hospitals in southeast Poland: An observational study. Geriatr Gerontol Int 2013; 14:689-94. [DOI: 10.1111/ggi.12135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Piotr Sobolewski
- Department of Neurology and Stroke Unit; Holy Spirit Specialist Hospital in Sandomierz; Sandomierz Poland
| | - Waldemar Brola
- Department of Neurology and Stroke Unit; Saint Luke's Hospital in Końskie; Końskie Poland
| | - Jan Stoiński
- Department of Neurology and Stroke Unit; Hospital in Skarżysko-Kamienna; Skarżysko-Kamienna Poland
| | - Wiktor Szczuchniak
- Department of Neurology and Stroke Unit; Holy Spirit Specialist Hospital in Sandomierz; Sandomierz Poland
| | - Malgorzata Fudala
- Department of Neurology and Stroke Unit; Saint Luke's Hospital in Końskie; Końskie Poland
| | - Renata Hatalska-Żerebiec
- Department of Neurology and Stroke Unit; Holy Spirit Specialist Hospital in Sandomierz; Sandomierz Poland
| | - Monika Śledzińska-Dźwigał
- Department of Neurology and Stroke Unit; Holy Spirit Specialist Hospital in Sandomierz; Sandomierz Poland
| |
Collapse
|
27
|
Gache K, Couralet M, Nitenberg G, Leleu H, Minvielle E. The Role of Calling EMS Versus Using Private Transportation in Improving the Management of Stroke in France. PREHOSP EMERG CARE 2013; 17:217-22. [DOI: 10.3109/10903127.2012.755584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Kristel Gache
- From the INSERM-COMPAQ-HPST Project, Institut de Cancérologie Gustave Roussy,
Villejuif, France
| | - Melanie Couralet
- From the INSERM-COMPAQ-HPST Project, Institut de Cancérologie Gustave Roussy,
Villejuif, France
| | - Gérard Nitenberg
- From the INSERM-COMPAQ-HPST Project, Institut de Cancérologie Gustave Roussy,
Villejuif, France
| | - Henri Leleu
- From the INSERM-COMPAQ-HPST Project, Institut de Cancérologie Gustave Roussy,
Villejuif, France
| | - Etienne Minvielle
- From the INSERM-COMPAQ-HPST Project, Institut de Cancérologie Gustave Roussy,
Villejuif, France
| |
Collapse
|
28
|
Vidale S, Agostoni E. Time is brain: optimizing acute stroke management to reduce time delay. Acta Neurol Scand 2013; 127:e13-4. [PMID: 23410066 DOI: 10.1111/ane.12057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
29
|
Kozera G, Chwojnicki K, Gójska-Grymajło A, Gąsecki D, Schminke U, Nyka WM. Authors' response to a letter from Vidale and Agostoni. Acta Neurol Scand 2013; 127:e15-6. [PMID: 23410067 DOI: 10.1111/ane.12056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
30
|
Kurz MW, Kurz KD, Farbu E. Acute ischemic stroke--from symptom recognition to thrombolysis. Acta Neurol Scand 2012. [PMID: 23190293 DOI: 10.1111/ane.12051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The understanding of stroke has changed in the recent years from rehabilitation to an emergency approach. We review existing data from symptom recognition to thrombolysis and identify challenges in the different phases of patient treatment. RESULTS Implementation of treatment in dedicated stroke units with a multidisciplinary team exclusively treating stroke patients has led to significant reduction of stroke morbidity and mortality. Yet, first the introduction of treatment with intravenous rtPA (IVT) has led to the 'time is brain' concept where stroke is conceived as an emergency. As neuronal death in stroke is time dependent, all effort should be laid on immediate symptom recognition, rapid transport to the nearest hospital with a stroke treatment facility and diagnosis and treatment as soon as possible. The main cause of prehospital delay is that patients do not recognize that they suffered a stroke or out of other reasons do not call the Emergency Medical Services immediately. Educational stroke awareness campaigns may have an impact in increasing the number of patients eligible for rtPA treatment and can decrease the prehospital times if they are directed both to the public and to the medical divisions treating stroke. Stroke transport times can be shortened by the use of helicopter and a stroke mobile--an ambulance equipped with a CT scanner--may be helpful to decrease time from onset to treatment start in the future. Yet, IVT has several limitations such as a narrow time window and a weak effect in ischemic strokes caused by large vessel occlusions. In these cases, interventional procedures and the concept of bridging therapy, a combined approach of IVT and intraarterial thrombolysis or mechanical thrombectomy, might improve recanalization rates and patient outcome. CONCLUSIONS As neuronal death in stroke patients occurs in a time-dependent fashion, all effort should be made to decrease time from symptom onset to treatment start with rtPA: major challenges are stroke recognition in the public, transport times to hospital and an efficient stroke triage in the hospital.
Collapse
Affiliation(s)
| | - K. D. Kurz
- Department of Radiology; Stavanger University Hospital; Stavanger; Norway
| | | |
Collapse
|