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Effect of Sociodemographic Factors, Concomitant Disease States, and Measures Performed in the Emergency Department on Patient Disability in Ischemic Stroke: Retrospective Study from Lebanon. Stroke Res Treat 2021; 2021:5551558. [PMID: 34136116 PMCID: PMC8175140 DOI: 10.1155/2021/5551558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/30/2021] [Accepted: 05/10/2021] [Indexed: 12/05/2022] Open
Abstract
Background Stroke is a leading cause of death and disability in developed countries. The major factor affecting long-term survival other than age is the disability severity caused by stroke. The modified Rankin Scale (mRS) is a global functional endpoint measurement used in acute stroke to evaluate the degree of disability or dependence in daily life activities. The objective of this study was to assess the effects of sociodemographic factors, concomitant disease states, and some measures performed in the emergency department (ED) on patients' disability. Methods We conducted a retrospective study on ischemic stroke patients admitted to Intensive Care Unit of three Lebanese university hospitals between June and December 2016. Patients were excluded if they had been discharged from ED without hospital admission or if mRS was not performed. The mRS was further subdivided into two categories considered as “good prognosis” (0-2 or 0-3) and “poor prognosis” (>2 or > 3). Results 204 patients were included in the study with mean age of 65.4 ± 11.9 years, hypertension was the most previous concomitant past medical disease (77.1%), and 27.1% of these patients had previous history of stroke. No significant differences were found in both mRS categories for all sociodemographic factors, and past medical history except that arrhythmia was significantly more common in the higher mRS categories > 2 and > 3. Based on multivariable analysis, there was a trend for previous intake of calcium channel blocker to be associated with lower mRS at admission (beta -0.586). However, intracranial arterial stenosis, ED blood glucose > 180 mg/dL, and performing brain imaging above 20 minutes after patient presentation to ED were significantly associated with higher mRS scores at discharge with an ORa and (confidence interval) of 2.986 (0.814, 10.962), 3.301 (1.072, 1.261), and 1.138 (1.071, 9.080), respectively. Conclusion mRS is affected by previous disease states, prescribed medications, and acute measures performed in ED. It is also influenced by intracranial arterial stenosis etiology, which is associated with worse outcome.
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Lee JH, Jeong JH, Jeong YG, Kim DK, Lee NS, Na CS, Doh ES, Han SY. Platycarya strobilacea leaf extract protects mice brain with focal cerebral ischemia by antioxidative property. Anat Cell Biol 2020; 52:486-497. [PMID: 31949989 PMCID: PMC6952690 DOI: 10.5115/acb.19.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/24/2019] [Accepted: 09/16/2019] [Indexed: 11/27/2022] Open
Abstract
The leaf extract of Platycarya strobilacea (PSL) has long been recognized as possessing various health-promoting activities. However, information on its possible protective effects against ischemic stroke is currently lacking. Here, using a mouse model of focal cerebral ischemia (fCI), we studied the protective potential of an oral supplement of PSL. Mice were randomly divided into four groups: SO, a group subjected to a sham-operation; VEH, pretreated with distilled water and subjected to middle cerebral artery occlusion and reperfusion (MCAO/R); PSL-L and PSL-H, pretreated with low (20 mg/kg) and high (100 mg/kg) doses of PSL, respectively, and subjected to the MCAO/R procedure. PSL was administered via an oral route daily for 8 days prior to surgery. We then measured the infarct volumes and sensorimotor deficits and studied the underlying antioxidant mechanisms by quantifying apoptosis, reactive oxygen species (ROS) generation, oxidative damages, and antioxidant enzymes in the ischemic cortex. The results showed a marked attenuation in infarct volume and sensorimotor deficits in both the PSL-L and PSL-H groups when compared with VEH. The terminal deoxynucleotidyl transferase dUTP nick end labeling and the immunohistochemical detection of the cleaved caspase-3 revealed that PSL could reduce cellular apoptosis in the ischemic lesion in a dose-dependent manner. The dihydroethidium-fluorescence, 4-hydroxynonenal, and 8-hydroxyl-2'-deoxyguanosine immunoreactivities in the ischemic lesion were markedly attenuated in the PSL-L group compared with the VEH group, indicating that PSL could attenuate ROS generation and the associated oxidative damage in the ischemic cortex. Finally, western blot results indicated that PSL can upregulate levels of heme oxygenase-1 (HO-1), an antioxidant enzyme, in the lesion area. Together, these results suggest that PSL can exert protective effects against fCI, and the mechanism may involve HO-1 upregulation.
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Affiliation(s)
- Ji Hye Lee
- Department of Anatomy, Konyang University College of Medicine, Daejeon, Korea
| | - Ji Heun Jeong
- Department of Anatomy, Konyang University College of Medicine, Daejeon, Korea
| | - Young-Gil Jeong
- Department of Anatomy, Konyang University College of Medicine, Daejeon, Korea
| | - Do-Kyung Kim
- Department of Anatomy, Konyang University College of Medicine, Daejeon, Korea
| | - Nam-Seob Lee
- Department of Anatomy, Konyang University College of Medicine, Daejeon, Korea
| | | | - Eun Soo Doh
- Department of Herbal Health and Pharmacy, Joongbu University College of Health and Welfare, Geumsan, Korea
| | - Seung Yun Han
- Department of Anatomy, Konyang University College of Medicine, Daejeon, Korea
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Wei D, Xie D, Li H, Chen Y, Qi D, Wang Y, Zhang Y, Chen K, Li C, Zhang Z. The positive effects of Xueshuan Xinmai tablets on brain functional connectivity in acute ischemic stroke: a placebo controlled randomized trial. Sci Rep 2017; 7:15244. [PMID: 29127417 PMCID: PMC5681502 DOI: 10.1038/s41598-017-15456-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/25/2017] [Indexed: 11/09/2022] Open
Abstract
Through a placebo controlled randomized study, the purpose of this report was to investigate the effects of Xueshuan Xinmai tablets (XXMT) on neurologic deficits, quality of life and brain functional connectivity in acute ischemic stroke patients and to explore the mechanism of action of XXMT. In total, 44 acute ischemic stroke patients were randomly divided to the XXMT treatment group (n = 22) or the placebo group (n = 22) in a 2-week trial. Before and after the treatment, the neurological assessment and functional magnetic resonance imaging examinations were carried out. Compared to the placebo group, the scores of the National Institutes of Health Stroke Scale (NIHSS) and Stroke-Specific Quality of Life Scale (SSQOL) significantly improved in the treatment group. In addition, XXMT-treated patients demonstrated significantly enhanced functional connectivity within the default mode, frontal-parietal, and motor control networks. Furthermore, the changed connectivity in the left precuneus was positively correlated to the improvement of NIHSS and SSQOL scores. The present study indicated that XXMT treatment significantly improved the neurologic deficit and quality of life of acute ischemic stroke patients and that the therapeutic effect may be based on the modulation of XXMT on the functional connectivity of brain networks.
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Affiliation(s)
- Dongfeng Wei
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Daojun Xie
- The First Affiliated Hospital of Anhui University of traditional Chinese Medicine, Hefei, 230031, P.R. China
| | - He Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, 100700, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Yaojing Chen
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Di Qi
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Yujiao Wang
- Graduate School of Anhui University of traditional Chinese Medicine, Hefei, 230038, P.R. China
| | - Yangjun Zhang
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China.,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China
| | - Kewei Chen
- BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China.,Banner Alzheimer's Institute, Phoenix, Arizona, 85006, USA
| | - Chuanfu Li
- The First Affiliated Hospital of Anhui University of traditional Chinese Medicine, Hefei, 230031, P.R. China.
| | - Zhanjun Zhang
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, 100875, P.R. China. .,BABRI Centre, Beijing Normal University, Beijing, 100875, P.R. China.
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Mutgi SA, Behrouz R. Practice diversity among US stroke physicians with respect to the 3- to 4.5-h window. Int J Stroke 2016; 10:E24-5. [PMID: 25777833 DOI: 10.1111/ijs.12443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sunil A Mutgi
- Division of Cerebrovascular Diseases & Neurosciences Critical Care, Department of Neurology, Ohio State University College of Medicine, Columbus, Ohio, USA
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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.
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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
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Quality assurance monitoring of a citywide transportation protocol improves clinical indicators of intravenous tissue plasminogen activator therapy: a community-based, longitudinal study. J Stroke Cerebrovasc Dis 2014; 24:183-8. [PMID: 25440326 DOI: 10.1016/j.jstrokecerebrovasdis.2014.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 08/11/2014] [Accepted: 08/13/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Stroke-bypass transportation to the stroke center by paramedics is important to maximize the efficiency of intravenous tissue plasminogen activator (iv-tPA) therapy. To improve access to stroke thrombolysis, a citywide protocol was launched on January 2007 in Kawasaki City (population 1.4 million) using the Maria Prehospital Stroke Scale (MPSS), and quality assurance monitoring has been performed every 6 months. The aim was to identify whether the citywide quality assurance monitoring improves the process and outcome of iv-tPA therapy. METHODS All of the MPSS-based transportation data prospectively recorded by the Kawasaki City Fire Department and the associated clinical data in the 11 hospitals that accept stroke-bypass transfers were merged every 6 months for the quality assurance monitoring. Clinical indicators such as ambulance call-to-door time, onset-to-needle time, door-to-needle time, frequency of thrombolytic use, and outcome of thrombolytic therapy were analyzed. These clinical indicators were also compared between patients transferred on weekdays and on weekends. RESULTS A total of 2049 patients was registered from April 2009 to March 2013. Their mean age was 70.4 ± 13.2 (range, 24-98) years, and 64.3% were male. Ambulance call-to-door time decreased gradually from 37.5 ± 12.5 minutes to 33.9 ± 11.7 minutes over 4 years (P = .000, analysis of variance with the post hoc Dunnett test). Onset-to-needle time and door-to-needle time were similar over the 4 years. Good outcome (modified Rankin Scale score <2) after iv-tPA therapy increased from 24.1% to 35.3% (P = .045, 2010 vs. 2012). No deleterious effect of weekend admission was observed based on these clinical indicators. CONCLUSIONS A citywide MPSS-based transportation protocol significantly decreased the delay in the ambulance call-to-door time. The implementation of standardized cross-institutional quality assurance programs for acute stroke therapy may improve the process and outcome of iv-tPA therapy in the community.
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van Dishoeck AM, Dippel DWJ, Dirks M, Looman CWN, Mackenbach JP, Steyerberg EW. Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time. Cerebrovasc Dis Extra 2014; 4:149-55. [PMID: 25076959 PMCID: PMC4105950 DOI: 10.1159/000363535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/08/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator 'door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. METHODS We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. RESULTS Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. CONCLUSION AND IMPLICATIONS The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.
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Affiliation(s)
- Anne Margreet van Dishoeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maaike Dirks
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caspar W N Looman
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johan P Mackenbach
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Ruff IM, Ali SF, Goldstein JN, Lev M, Copen WA, McIntyre J, Rost NS, Schwamm LH. Improving door-to-needle times: a single center validation of the target stroke hypothesis. Stroke 2014; 45:504-8. [PMID: 24399372 DOI: 10.1161/strokeaha.113.004073] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE National guidelines recommend imaging within 25 minutes of emergency department arrival and intravenous tissue-type plasminogen activator within 60 minutes of emergency department arrival for patients with acute stroke. In 2007, we implemented a new institutional acute stroke care model to include 10 best practices and evaluated the effect of this intervention on improving door-to-computed tomography (CT) and door-to-needle (DTN) times at our hospital. METHODS We compared patients who presented directly to our hospital with acute ischemic stroke in the preintervention (2003-2006) and postintervention (2008-2011) periods. We did not include 2007, the year that the new protocol was established. Predictors of DTN ≤60 minutes before and after the intervention were assessed using χ(2) for categorical variables, and t test and Wilcoxon signed-rank test for continuous variables. RESULTS Among 2595 patients with acute stroke, 284 (11%) received intravenous tissue-type plasminogen activator. For patients arriving within an intravenous tissue-type plasminogen activator window, door-to-CT <25 improved from 26.7% pre intervention to 52.3% post intervention (P<0.001). Similarly, the percentage of patients with DTN <60 doubled from 32.4% to 70.3% (P<0.001). Patients with DTN ≤60 did not differ significantly with respect to demographics, comorbidities, or National Institutes of Health Stroke Scale score in comparison with those treated after 60 minutes. CONCLUSIONS Door-to-CT and DTN times improved dramatically after applying 10 best practices, all of which were later incorporated into the Target Stroke Guidelines created by the American Heart Association. The only factor that significantly affected DTN60 was the intervention itself, indicating that these best practices can result in improved DTN times.
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Affiliation(s)
- Ilana M Ruff
- From the Departments of Neurology (I.R., S.A., N.R., L.S.), Radiology (W.C., M.L.), and Emergency Medicine (J.G., J.M.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
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