Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.)

Development of endothelial-targeted CD39 as a therapy for ischemic stroke

BACKGROUND

Ischemic stroke is characterized by a necrotic lesion in the brain surrounded by an area of dying cells termed the penumbra. Salvaging the penumbra either with thrombolysis or mechanical retrieval is the cornerstone of stroke management. At-risk neuronal cells release extracellular adenosine triphosphate, triggering microglial activation and causing a thromboinflammatory response, culminating in endothelial activation and vascular disruption. This is further aggravated by ischemia-reperfusion injury that follows all reperfusion therapies. The ecto-enzyme CD39 regulates extracellular adenosine triphosphate by hydrolyzing it to adenosine, which has antithrombotic and anti-inflammatory properties and reverses ischemia-reperfusion injury.

OBJECTIVES

The objective off the study was to determine the efficacy of our therapeutic, anti-VCAM-CD39 in ischaemic stroke.

METHODS

We developed anti-VCAM-CD39 that targets the antithrombotic and anti-inflammatory properties of recombinant CD39 to the activated endothelium of the penumbra by binding to vascular cell adhesion molecule (VCAM)-1. Mice were subjected to 30 minutes of middle cerebral artery occlusion and analyzed at 24 hours. Anti-VCAM-CD39 or control agents (saline, nontargeted CD39, or anti-VCAM-inactive CD39) were given at 3 hours after middle cerebral artery occlusion.

RESULTS

Anti-VCAM-CD39 treatment reduced neurologic deficit; magnetic resonance imaging confirmed significantly smaller infarcts together with an increase in cerebrovascular perfusion. Anti-VCAM-CD39 also restored blood-brain barrier integrity and reduced microglial activation. Coadministration of anti-VCAM-CD39 with thrombolytics (tissue plasminogen activator [tPA]) further reduced infarct volumes and attenuated blood-brain barrier permeability with no associated increase in intracranial hemorrhage.

CONCLUSION

Anti-VCAM-CD39, uniquely targeted to endothelial cells, could be a new stroke therapy even when administered 3 hours postischemia and may further synergize with thrombolytic therapy to improve stroke outcomes.

Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis

BACKGROUND

We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window.

METHODS

Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals.

RESULTS

608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke.

CONCLUSION

Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.

Association of Neighborhood-Level Socioeconomic Factors With Delay to Hospital Arrival in Patients With Acute Stroke

BACKGROUND AND OBJECTIVES

Delivery of acute ischemic stroke (AIS) therapies is contingent on the duration from last known well (LKW) to emergency department arrival time (EDAT). One reason for treatment ineligibility is delay in presentation to the hospital. We evaluate patient and neighborhood characteristics associated with time from LKW to EDAT.

METHODS

This was a retrospective observational study of patients presenting to the Yale New Haven Hospital in the AIS code pathway from 2010 to 2020. Patients presenting within 4.5 hours from LKW who were recorded in the institutional Get With the Guidelines Stroke registry were classified as early while those presenting beyond 4.5 hours were designated as late. Temporal trends in late presentation were explored by univariate logistic regression. Using variables significant in univariate analysis at p < 0.05, we developed a mixed-effect logistic regression model to estimate the probability of late presentation as a function of patient-level and neighborhood (ZIP)-level characteristics (area deprivation index [ADI] derived from the Health Resources and Services Administration), adjusted for calendar year and geographic distance from the centroid of the ZIP code to the hospital.

RESULTS

A total of 2,643 patients with AIS from 2010 to 2020 were included (63.4% presented late and 36.6% presented early). The frequency of late presentation increased significantly from 68% in 2010 to 71% in 2020 (p = 0.002) and only among non-White patients. Patients presenting late were more likely to be non-White (37.1% vs 26.9%, p < 0.0001), arrive by means other than emergency medical services (EMS) (32.7% vs 16.1%, p < 0.0001), have an NIHSS <6 (68.7% vs 55.2%, p < 0.0001), and present from a neighborhood with a higher ADI category (p = 0.0001) that was nearer to the hospital (median 5.8 vs 7.7 miles, p = 0.0032). In the mixed model, the ADI by units of 10 (odds ratio [OR] 1.022, 95% confidence interval [CI] 1.020-1.024), non-White race (OR 1.083, 95% CI 1.039-1.127), arrival by means other than EMS (OR 1.193, 95% CI 1.145-1.124), and an NIHSS <6 (OR 1.085, 95% CI 1.041-1.129) were associated with late presentation.

DISCUSSION

In addition to patient-level factors, socioeconomic deprivation of neighborhood of residence contributes to delays in hospital presentation for AIS. These findings may provide opportunities for targeted interventions to improve presentation times in at-risk communities.

Non-compliance with medical recommendations results in delayed hospitalization and poorer prognosis in patients with cerebral ischemic stroke in Poland: Non-compliance effects on post-ischemic stroke prognosis

OBJECTIVES

This study aimed to reveal and analyze the causes of delays in reaching the hospital of patients with cerebral ischemic stroke and to assess their clinical picture.

MATERIAL AND METHODS

The study group included 161 patients with stroke, who reported to the hospital beyond the thrombolytic treatment therapeutic window. The control group consisted of 85 patients recruited consecutively with stroke who received thrombolytic treatment per eligibility criteria. Laboratory and medical imaging tests essential for neurological condition assessment were conducted in the study group. Control group research was based on retrospective analysis of medical records.

RESULTS

The rate of deaths during hospitalization was lower in the control group (4.7%) compared to the study group (14.9%). In the study group, more patients (16.8%) admitted to non-compliance with medical recommendations than in the control group (5.9%). There were no statistically significant differences in nicotinism and alcohol dependence syndrome frequency between both groups.

CONCLUSIONS

Based on each group inclusion criteria, a lower mortality rate in the control group indicates a crucial role of the therapeutic window in cerebral stroke treatment. Analysis of reasons for delay points out that efficient prophylaxis is the education of patients with stroke risk factors and their families.

Inhibition of insulin-regulated aminopeptidase confers neuroprotection in a conscious model of ischemic stroke

Stroke is a leading cause of mortality and morbidity with a paucity of effective pharmacological treatments. We have previously identified insulin-regulated aminopeptidase (IRAP) as a potential target for the development of a new class of drugs for the treatment of stroke, as global deletion of this gene in mice significantly protected against ischemic damage. In the current study, we demonstrate that small molecular weight IRAP inhibitors reduce infarct volume and improve neurological outcome in a hypertensive animal model of ischemic stroke. The effects of two structurally distinct IRAP inhibitors (HFI419 or SJM164) were investigated in a model of stroke where the middle cerebral artery was transiently occluded with endothelin-1 in the conscious spontaneously hypertensive rat. IRAP inhibitor was administered into the lateral ventricle at 2 or 6 h after stroke, with subsequent doses delivered at 24, 48 and 70 h post-stroke. Functional outcomes were assessed prior to drug treatment, and on day 1 and 3 post-stroke. Histological analyses and neuroinflammatory cytokine profiling were conducted at 72 and 24 h post-stroke respectively. IRAP inhibitor treatment following stroke significantly reduced infarct volume and improved neurological and motor deficits. These protective effects were maintained even when the therapeutic window was extended to 6 h. Examination of the cellular architecture at 72 h post-stroke demonstrated that IRAP expression was upregulated in CD11b positive cells and activated astrocytes. Furthermore, IRAP inhibitor treatment significantly increased gene expression for interleukin 6 and C-C motif chemokine ligand 2 in the ischemic core. This study provides proof-of-principle that selective inhibition of IRAP activity with two structurally distinct IRAP inhibitors reduces infarct volume and improves functional outcome even when the first dose is administered 6 h post-stroke. This is the first direct evidence that IRAP inhibitors are a class of drug with potential use in the treatment of ischemic stroke.

Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review

BACKGROUND

Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms.

METHODS

We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12-1.24) to 4.5 (1.8-11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies.

CONCLUSIONS

This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations.

TRIAL REGISTRATION NUMBER

The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.

Hospital admission from the emergency department for selected emergent diagnoses during the first year of the COVID-19 pandemic in Ontario: a retrospective population-based study

BACKGROUND

Avoidance of care during the pandemic may have contributed to delays in care, and as a result, worse patient outcomes. We evaluated markers of illness acuity on presentation to the emergency department among patients with non-COVID-19-related emergent diagnoses and associated outcomes.

METHODS

We conducted a retrospective study using linked administrative data from Ontario. We selected 4 emergent diagnoses, namely appendicitis, ectopic pregnancy, renal failure and diabetic ketoacidosis. We used the nonemergent diagnosis of cellulitis as a control. Our primary outcome of interest was hospital admission. Secondary outcomes were ambulance arrival, surgical intervention, subsequent hospital admission within 30 days of discharge from the emergency department or hospital and 30-day mortality. We compared outcomes during the first year of the COVID-19 pandemic (Mar. 15-Dec. 31, 2020) with a control period (Mar. 15-Dec. 31, 2018, and Mar. 15-Dec. 31, 2019).

RESULTS

Emergency department visits for all conditions initially decreased during the pandemic. During this period, patients across all study diagnoses were more likely to arrive to the emergency department via ambulance. Patients with an ectopic pregnancy had higher odds of surgery in the pandemic period (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.04-1.55) but this was not observed among patients with appendicitis. Patients with renal failure had increased odds of hospital admission (OR 1.14, 95% CI 1.04-1.24) and 30-day mortality (OR 1.17, 95% CI 1.04-1.31) during the pandemic period.

INTERPRETATION

The pandemic period was associated with increased arrival to the emergency department via ambulance across all study diagnoses. Although patients with renal failure had increased hospital admission and death, and patients with ectopic pregnancy had an increased risk of surgery, there were no differences in outcomes for other populations, suggesting the health care system was able to care for these patients effectively.

Community Socioeconomic and Urban-Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina

OBJECTIVES

Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality.

METHODS

Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban-rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation.

RESULTS

The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67-0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52-0.77) tracts.

CONCLUSIONS

Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.

Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients

INTRODUCTION

Several reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA.

METHODS

We analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis.

RESULTS

Five patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups.

CONCLUSION

Approximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.

An analysis of racial inequities in emergency department triage among patients with stroke-like symptoms in the United States

BACKGROUND

Racial inequities exist in treatment and outcomes in patients with acute stroke.

OBJECTIVES

Our objective was to determine if racial inequities exist in the time-lapse between patient presentation and provider assessment in patients with stroke-like symptoms in Emergency Departments (ED) across the U.S.

METHODS

This study is a retrospective, observational study of the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2014-2018. We identified visits with stroke-like symptoms and stratified the proportion of door-to-provider (DTP) times by racial groups. We used broad and narrow definitions of stroke-like symptoms. We performed bivariate and multivariate analyses using race and clinical and demographic characteristics as covariates.

RESULTS

Between 2014-2018, there were an average of 138.58 million annual ED visits. Of the total ED visits, 0.36% to 7.39% of the ED visits presented with stroke-like symptoms, and the average DTP time ranged from 39 to 49 min. The proportion of the visits with a triage level of 1 (immediate) or 2 (emergent) ranged from 16.03% to 23.27% for stroke-like symptoms. We did not find statistically significant racial inequities in DTP or ED triage level. We found significantly longer DTP times in non-Hispanic blacks (15.88 min, 95% CI: 4.29-27.48) and Hispanics (by 14.77 min, 95% CI: 3.37-26.16) than non-Hispanic whites that presented with atypical stroke-like symptoms. We observed that non-Hispanic whites were significantly more diagnosed with a stroke/TIA than other racial minority groups (p = 0.045) for atypical stroke-like symptoms.

CONCLUSION

In our population-based analysis, we did not identify systemic racial inequities in the DTP times or ED triage level at ED triage for stroke-like symptoms.

Evaluation of Pattern of Lesions Depicted on Brain Computed Tomography Scan of Patients Presenting with Stroke in Zaria, Nigeria

Introduction

Stroke is a major public health problem worldwide and it is the third leading cause of death in industrialized countries and ranks among the five most common causes of hospital deaths in adults in Africa. Accurate stroke diagnosis has a high significance for patient's outcome. Computed tomography (CT) brain scan is the imaging of choice for patients presenting to the emergency department with stroke.

Aim and Objectives

The study aimed at evaluating the pattern of lesion depicted on CT brain of patients presenting with stroke in ABUTH, Zaria.

Materials and Methods

A prospective review of CT findings in 155 patients who presented in the Radiology Department of Ahmadu Bello University Teaching Hospital (ABUTH) with clinical diagnosis of stroke was undertaken over a period of six months (from October 2017 to April 2018)..

Results

Of the 155 patients seen within the period under review, 88 (56.8%) were males while 67 (43.2%) were females. Age range was 11-90 years (mean 56, standard deviation (SD) 16, 44(28.4%) of patients were in the age group of 61-70 years. Ninety six patients (61.9%) had ischaemic stroke, 27(17.4%) had hemorrhagic stroke, eight (5.2%) was stroke mimic, six patients (3.9%) mixed lesions (ie both ischaemic and haemorrhagic). Eighteen patients (11.6%) had normal brain CT findings. The region most affected by stroke was the parietal region 52(38%).

Conclusion

Ischaemic stroke is the most common form of stroke in this study.

Causes of Pre-hospital Delay in Acute Stroke in Punjab

Background Pre-hospital delay, which refers to the time delay between the development of symptoms in the patient and the start of treatment, is one of the major factors impacting the treatment of stroke. This study aimed to identify patient characteristics and factors causing a pre-hospital delay in acute stroke (both ischemic and hemorrhagic) cases. Methodology This prospective follow-up study included 100 patients who presented with clinical features of acute stroke within 48 hours of symptom onset. A pre-designed questionnaire was administered within 72 hours of hospital admission to every patient. Results The mean time to hospital presentation was 7.73 hours. Only 2% of patients were thrombolysed. Age group, gender, education status, occupation, and socioeconomic status were not significantly (p > 0.05) associated with the mean symptom onset time to hospital arrival. Rural area (p < 0.001), nuclear family (p = 0.004), distance from the tertiary care center (p < 0.001), being alone at the time of symptom onset (p < 0.001), lack of knowledge about symptoms of stroke in patient/attendant (p < 0.001), and mode of transport were the factors that emerged as significant predictors of pre-hospital delay on univariate analysis. Living in a nuclear family, distance from the tertiary care center, and mode of transport were the factors that emerged as independent predictors of pre-hospital delay on multiple linear regression analysis. Conclusions In this study, factors associated with delayed hospital presentation including living in a nuclear family, distance from the tertiary care center, and use of public transport to reach the hospital emerged as independent predictors of pre-hospital delay.

Age and geographic disparities in acute ischaemic stroke prehospital delays in China: a cross-sectional study using national stroke registry data

Background

Stroke has been the leading cause of death in China for decades. The extremely low intravenous thrombolysis rate is largely due to the prehospital delays that make patients ineligible for the time-sensitive therapy. Limited studies evaluated prehospital delays across China. We investigated prehospital delays in the stroke population across China and the associated age, rurality, and geographic disparities.

Methods

A cross-sectional study design was employed using the Bigdata Observatory platform for Stroke of China in 2020, the nationwide, prospective, multicentre registry of patients with acute ischaemic stroke (AIS). Mixed-effect regression models were used to account for the clustered data.

Findings

The sample contained 78,389 AIS patients. The median onset-to-door (OTD) time was 24 h, with only 11.79% (95% confidence interval [CI]: 11.56-12.02%) patients arriving at hospitals within 3 h. About 12.43% (95% CI: 12.11-12.74%) of patients 65 years or older arrived at hospitals within 3 h, which was significantly higher than the young and middle-aged patients (11.03%; 95% CI: 10.71-11.36%). After controlling for potential confounders, young and middle-aged patients were less likely to present to hospitals within 3 h (adjusted odds ratio: 0.95; 95% CI: 0.90-0.99) compared to patients 65 years or older. The 3-h hospital arrival rate was the highest in Beijing (18.40%, 95% CI: 16.01-20.79%), which was almost 5 times higher than that in Gansu (3.45%, 95% CI: 2.69-4.20%). The arrival rate in urban areas was almost 2 times higher than that in rural areas (13.35% versus. 7.66%).

Interpretation

We found that the low rates of timely arrival at hospitals after a stroke is more salient in the younger population, rural settings, or those residing in less developed geographic regions. This study calls for more tailored interventions focusing on younger people, rural areas, and less developed geographic regions.

Funding

The National Natural Science Foundation of China; CIHR, Grant/Award Number: 81973157, PI: JZ. Natural Science Foundation of Shanghai; CIHR, Grant/Award Number: 17dz2308400, PI: JZ. Funding from the University of Pennsylvania; Grant/Award Number: CREF-030, PI: RL.

Using qualitative data to inform the adaptation of a stroke preparedness health intervention

Qualitative research methods are often used to develop health interventions, but few researchers report how their qualitative data informed intervention development. Improved completeness of reporting may facilitate the development of effective behavior change interventions. Our objective was to describe how we used qualitative data to develop our stroke education intervention consisting of a pamphlet and video. First, we created a questionnaire grounded in the theory of planned behavior to determine reasons people delay in activating emergency medical services and presenting to the hospital after stroke symptom onset. From our questionnaire data, we identified theoretical constructs that affect behavior which informed the active components of our intervention. We then conducted cognitive interviews to determine emergency department patients’ understanding of the intervention pamphlet and video. Our cognitive interview data provided insight into how our intervention might produce behavior change. Our hope is that other researchers will similarly reflect upon and report on how they used their qualitative data to develop health interventions.

In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways

Introduction

Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals.

Methods

Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome.

Results

Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays.

Conclusion

In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.

Evaluation of stroke pre-hospital management in Lebanon from symptoms onset to hospital arrival and impact on patients' status at discharge: a pilot study

BACKGROUND

Hospital arrival time after acute ischemic stroke onset is the major factor limiting the eligibility of patients to receive intravenous thrombolysis. Shortening the prehospital delay is crucial to reducing morbidity and mortality for stroke patients. The study was conducted to investigate the factors that influence hospital arrival time after acute stroke onset in the Lebanese population and to assess the effect of the prehospital phase on patients' prognosis at discharge.

METHOD

A prospective cross-sectional study was performed in eleven hospitals from April to July 2021 including 100 patients having stroke symptoms or transient ischemic attack (TIA). Two questionnaires were used to collect data addressing patient management in the pre-hospital phase and the in-hospital phase. Descriptive and bivariate analyses were done to evaluate the potential associations between prognosis, pre-hospital characteristics, and other factors.

RESULTS

The patients' mean age was 70.36 ± 12.25 years, 43 (53.8%) of them were females, and 79 (85%) arrived within 3 hours after symptoms onset. Diabetic patients had a significant delay in hospital arrival compared with non-diabetics (27.0%vs.7.1%, p-value = 0.009). Moreover, 37 (75.5%) of school-level education patients arrived early at the hospital compared to 7 (100%) of university-level education (p-value = 0.009). The modified Rankin Scale (mRS) at discharge in patients with hemorrhagic stroke (10 (90%)) was worse than that in patients with ischemic stroke (38 (80%)) or TIA (3 (15%)) (p-value< 0.001).

CONCLUSION

The study findings make it imperative to raise awareness about stroke symptoms among the Lebanese population. Emergency Medical Services should be utilized appropriately in the transportation of stroke patients to achieve optimal patient outcomes.

Factors Influencing Early Hospital Arrival of Patients with Acute Ischemic Stroke, Cross-Sectional Study at Teaching Hospital in Mogadishu Somalia

Background and Purpose

The low rates of thrombolysis for ischemic stroke in our country and other developing countries can be attributed to delays in arrival at the hospital. This study aims to investigate the factors that influence the early hospital arrival of patients with acute ischemic stroke to the hospital in Mogadishu, Somalia.

Methods

This is a cross-sectional study conducted at a teaching hospital in Mogadishu, Somalia. Adult patients with acute ischemic stroke admitted to the emergency department (ED) between June 2021 and May 2022 were included in the study. A questionnaire-based interview was administered to adult patients or their relatives to assess the factors contributing to hospital delay.

Results

Of the 212 patients in the study, 113 (53.3%) were male, while 99 (46.7%) were female. The mean age of the patients was 62±10. Hypertension was the most common risk factor among patients 121 (57%), followed by diabetes and hyperlipidemia. One hundred and forty (66%) patients lived in the city, while 72 (34%) lived outside of the city. About 53 (25%) of the patients were brought to the ED by ambulance, and only 32 (15%) reached the hospital in less than 4 hours. The majority of patients had no idea about stroke symptoms and thrombolytic treatment. In univariate and binary logistic regression analysis, delays in hospital arrivals were associated with a travel distance of more than 10 km, transportation via non-ambulance means, living alone, lack of recognition of stroke symptoms, night-time stroke onset, lack of knowledge about thrombolytic treatment, and non-hemiplegic presentation.

Conclusion

This study demonstrates factors delaying early hospital arrivals of patients with ischemic stroke. Improving the modifiable factors through public education will prevent delays in the early hospital arrival of stroke patients and will improve early thrombolytic intervention and the overall outcome of these patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

Therapeutic hypothermia for stroke: Unique challenges at the bedside

Therapeutic hypothermia has shown promise as a means to improving neurological outcomes at several neurological conditions. At the clinical level, it has been shown to improve outcomes in comatose survivors of cardiac arrest and in neonatal hypoxic ischemic encephalopathy, but has yet to be convincingly demonstrated in stroke. While numerous preclinical studies have shown benefit in stroke models, translating this to the clinical level has proven challenging. Major obstacles include cooling patients with typical stroke who are awake and breathing spontaneously but often have significant comorbidities. Solutions around these problems include selective brain cooling and cooling to lesser depths or avoiding hyperthermia. This review will cover the mechanisms of protection by therapeutic hypothermia, as well as recent progress made in selective brain cooling and the neuroprotective effects of only slightly lowering brain temperature. Therapeutic hypothermia for stroke has been shown to be feasible, but has yet to be definitively proven effective. There is clearly much work to be undertaken in this area.

Time to hospital presentation following intracerebral haemorrhage: Proportion of patients presenting within eight hours and factors associated with delayed presentation

PURPOSE

Prolonged time to diagnosis of primary intracerebral haemorrhage (ICH) can result in delays in obtaining appropriate blood pressure control, reversal of coagulopathy or surgical intervention in select cases. We sought to characterise the time to diagnosis in a cohort of patients with ICH and identify factors associated with delayed diagnosis.

METHODOLOGY

The stroke database of our hospital was retrospectively reviewed to identify patients presenting to our hospitals emergency department with ICH over two years (January 2017-December 2018.) Data collected included demographics (age and sex), comorbidities, anticoagulation status, clinical scores (NIHSS, GCS, ICH score), and imaging (anatomical site, haematoma size). Time from symptom onset to diagnosis and hospital presentation were recorded. Factors associated with diagnosis >8 h post ictus were assessed using a univariate and then multivariable analysis.

RESULTS

235 patients were identified with 125 males (53%) and a median age of 76 (range 40-98). For the 200 patients that initially presented to our hospital, median time to presentation was 179 min (IQR 77-584 min), and median time from ictus to imaging diagnosis was 268 min (IQR 114-717 min). 139 (70%) presented within 8 h of symptom onset, and 129 (65%) patients had imaging of the brain performed within 8 h of symptom onset. Factors associated with presentation >8 h post symptom onset included wake up stroke (OR 5.31, 95% confidence interval (CI) 2.36-11.96, p < 0.0001) and age (OR 1.04, 95% CI 1.01-1.08, p = 0.01). Patients with hemiplegia were less likely to present >8 h following ictus (OR 0.41, 95% CI 0.21-0.84, p = 0.01).

CONCLUSIONS

The majority of patients with ICH presented within 8 h of ictus. Cases of delayed diagnosis involved patients who had not incurred hemiplegia.

Public and outpatients’ awareness of calling emergency medical services immediately by acute stroke in an upper middle-income country: a cross-sectional questionnaire study in greater Gaborone, Botswana

Objectives

In this cross-sectional study from Botswana, we investigated awareness of calling emergency medical services (EMS) and seeking immediate medical assistance by acute stroke among stroke risk outpatients and public.

Method

Closed-ended questionnaires on awareness of calling EMS and seeking immediate medical assistance by acute stroke, were administered by research assistants to a representative selection of outpatients and public.

Results

The response rate was 96.0% (93.0% for public (2013) and 96.6% for outpatients (795)). Public respondents had mean age of 36.1 ± 14.5 years (age range 18–90 years) and 54.5% were females, while outpatients had mean age of 37.4 ± 12.7 years (age range 18–80 years) and 58.1% were females.

Awareness of calling EMS (78.3%), and of seeking immediate medical assistance (93.1%) by stroke attack was adequate. For calling EMS by acute stroke, outpatients had higher awareness than the public (p < 0.05) among those with unhealthy diet (90.9% vs 71.1%), family history of both stroke and heart diseases (90.7% vs 61.2%), no history of psychiatric diseases (93.2% vs 76.0%) and sedentary lifestyle (87.5% vs 74.8%).

Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight.

Male gender, ≥50 years age, primary education, family history of both stroke and heart diseases, current smoking, no history of HIV/AIDS, and light physical activity were predictors of low awareness of need for calling EMS.

Conclusion

Results call for educational campaigns on awareness of calling EMS and seeking immediate medical assistance among those with high risk factor levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02859-z.

• This is the first study comparing awareness of calling EMS among outpatients and public in sub-Saharan Africa

• Awareness of calling EMS or seeking immediate medical services by acute stroke was adequate among both outpatients and public

• Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight

• Results call for educational campaigns on awareness of calling EMS/ seeking immediate medical assistance by stroke.

Time Window for Acute Stroke Treatment: Current Practice in King Abdullah Medical City Specialist Hospital in Makkah, Saudi Arabia

Introduction

Stroke has become one of the most severe causes of long-term neurological impairment and disability and is considered one of the leading causes of mortality worldwide. This study aimed to determine time delays in stroke patients from symptoms onset to treatment with tissue plasminogen activator (tPA) initiation in King Abdullah Medical City Specialist Hospital, Makkah, Saudi Arabia.

Patients and methods

We reviewed 81 patients who suffered from acute stroke. The data were collected from patients’ electronic and paper files. Patients were divided into two main categories based on interval time from recognition of symptoms to tPA treatment. Patients were divided into early treatment, if the duration was less than or equal to 120 minutes, and delayed treatment, if the interval time was more than 120 minutes.

Results

Nearly two-thirds (64.2%) were males, and more than half (5.6%) were in the older age group (>65 years). Patients who underwent thrombectomy were 7.4%. The mean value of the National Institutes of Health Stroke Scale (NIHSS) score was 10.7 (SD: 7.14). The mean time from symptoms onset to arrival at the hospital was 82.4 (SD: 44.1) minutes, while the total time from recognition of symptoms to tPA treatment was 154 (SD: 50.8) minutes. The prevalence of patients with delayed treatment was 72.8%, and the rest were assumed to have early treatment (27.2%). None of the socio-demographic variables were predicted to influence delayed treatment.

Conclusion

A significant number of patients were delayed in treatment. Patients' socio-demographic data and NIHSS scores seem to have no significant effect on delayed treatment. Further research is needed to establish the delay in time for pre-hospital and in-hospital treatment of stroke patients.

Analysis of the demographic characteristics and clinical profile of acute ischemic strokes admitted to the emergency centre in the Somalia population

Background

Stroke is a leading cause of death and chronic disability worldwide. In Sub-Saharan Africa (SSA), which includes Somalia, stroke represents a significant part of the chronic disease burden. However, there is relatively little data on risk factors, demographics, and clinical profiles. This study aimed to define the etiological, demographic characteristics, classification of stroke and functional status of patients with acute ischemic stroke (AIS) admitted to the emergency centre, and to create projections to evaluate the incidence and genetic aspects of stroke.

Methods

The study population consisted of patients who applied to the emergency centre between 1 May 2017 and 1 May 2021 and were diagnosed with acute ischemic stroke (AIS). Patient demographics, season of onset, risk factors, laboratory data, imaging results, infarct location, AIS subtype and treatment outcomes were collected, and compared.

Results

A total of 3,968 patients diagnosed with ischemia stroke were included in the study. The mean age was 51.12 ± 16.43 years, and we reported male predominance (65.7%). While hypertension, hyperlipidaemia, Diabetes mellitus (DM) were more frequent among the risk factors, smoking history and alcohol consumption history were very low. HIV-infected ischemic stroke was detected at a high rate (20.9%) and was common in a relatively young age group (31.8 ± 14.3). Large-artery atherosclerosis (LAA) subtype was detected with a high rate of 67.7%. The most common clot localization was in Supratentorial location (74.3%), and according to OSCP classification, partial anterior circulation infarcts (PACI) subtype (56.3%) was the most common. And these results were again different from other studies.

Discussion

While the incidence of stroke and especially HIV-associated youthful ischemic stroke continues to increase rapidly in developing countries such as Somalia, with the addition of inadequate primary health care services, stroke has become a major public health problem in African countries regarding its costs at social, psychological, and economic levels.

Uncharted territory: The feasibility of serial computerised cognitive assessment the first week post-stroke

BACKGROUND

Cognitive impairment is common and problematic post-stroke, yet vital information to understand early cognitive recovery is lacking. To examine early cognitive recovery, it is first necessary to establish the feasibility of repeat cognitive assessment during the acute post-stroke phase.

OBJECTIVE

To determine if serial computerised testing is feasible for cognitive assessment in an acute post-stroke phase, measured by assessment completion rates.

METHOD

An observational cohort study recruited consecutive stroke patients admitted to an acute stroke unit within 48 hours of onset. Daily assessment with the Cambridge Neuropsychological Test Automated Battery (CANTAB) was performed for seven days, and single Montreal Cognitive Assessment (MoCA).

RESULTS

Seventy-one participants were recruited, mean age 74 years, with 67 completing daily testing. Participants had predominantly mild (85%; NIHSS ≤6), ischemic (90%) stroke, 32% demonstrated clinical delirium. The first day of testing, 76% of participants completed CANTAB batteries. Eighty-seven percent of participants completed MoCA a mean of 3.4 days post-stroke. The proportion of CANTAB batteries completed improved significantly from day 2 to day 3 post-stroke with test completion rates stabilizing ≥ 92% by day 4. Participants with incomplete CANTAB were older, with persisting delirium, and longer stay in acute care.

CONCLUSION

Serial computerised cognitive assessments are feasible the first week post-stroke and provide a novel approach to measuring cognitive change for both clinical and research purposes. Maximum completion rates by day four have clinical implications for optimal timing of cognitive testing.

Comparisons of Prehospital Delay and Related Factors Between Acute Ischemic Stroke and Acute Myocardial Infarction

Background

Prehospital delay is an important contributor to poor outcomes in both acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We aimed to compare the prehospital delay and related factors between AIS and AMI.

Methods and Results

We identified patients with AIS and AMI who were admitted to the 11 Korean Regional Cardiocerebrovascular Centers via the emergency room between July 2016 and December 2018. Delayed arrival was defined as a prehospital delay of >3 hours, and the generalized linear mixed‐effects model was applied to explore the effects of potential predictors on delayed arrival. This study included 17 895 and 8322 patients with AIS and AMI, respectively. The median value of prehospital delay was 6.05 hours in AIS and 3.00 hours in AMI. The use of emergency medical services was the key determinant of delayed arrival in both groups. Previous history, 1‐person household, weekday presentation, and interhospital transfer had higher odds of delayed arrival in both groups. Age and sex had no or minimal effects on delayed arrival in AIS; however, age and female sex were associated with higher odds of delayed arrival in AMI. More severe symptoms had lower odds of delayed arrival in AIS, whereas no significant effect was observed in AMI. Off‐hour presentation had higher and prehospital awareness had lower odds of delayed arrival; however, the magnitude of their effects differed quantitatively between AIS and AMI.

Conclusions

The effects of some nonmodifiable and modifiable factors on prehospital delay differed between AIS and AMI. A differentiated strategy might be required to reduce prehospital delay.

Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review

Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.

Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration

BACKGROUND

Unprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown.

METHODS

We performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment.

RESULTS

Of the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7-21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (βadj=-73.2, 95% CI -153.8-7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (βadj=-3.85, 95% CI -36.9-29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (βadj=-46.44, 95% CI -62.8 to - -30.0, P<0.01) and higher NIHSS (βadj=-2.15, 95% CI -4.2to - -0.1, P=0.05).

CONCLUSIONS

In this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.

Impact of COVID-19 on Emergency Medical Services for Patients with Acute Stroke Presentation in Busan, South Korea

The purpose of this retrospective observational study was to identify the impact of COVID-19 on emergency medical services (EMS) processing times and transfers to the emergency department (ED) among patients with acute stroke symptoms before and during the COVID-19 pandemic in Busan, South Korea. The total number of patients using EMS for acute stroke symptoms decreased by 8.2% from 1570 in the pre-COVID-19 period to 1441 during the COVID-19 period. The median (interquartile range) EMS processing time was 29.0 (23–37) min in the pre-COVID-19 period and 33.0 (25–41) minutes in the COVID-19 period (p < 0.001). There was a significant decrease in the number of patients transferred to an ED with a comprehensive stroke center (CSC) (6.37%, p < 0.001) and an increase in the number of patients transferred to two EDs nearby (2.77%, p = 0.018; 3.22%, p < 0.001). During the COVID-19 pandemic, EMS processing time increased. The number of patients transferred to ED with CSC was significantly reduced and dispersed. COVID-19 appears to have affected the stroke chain of survival by hindering entry into EDs with stroke centers, the gateway for acute stroke patients.

Social Determinants of Health in Neurology

Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.

Socioeconomic Influence on Emergency Medical Services Utilization for Acute Stroke: Think Nationally, Act Locally

Background and Purpose

Rates of emergency medical services (EMS) utilization for acute stroke remain low nationwide, despite the time-sensitive nature of the disease. Prior research suggests several demographic and social factors are associated with EMS use. We sought to evaluate which demographic or socioeconomic factors are associated with EMS utilization in our region, thereby informing future education efforts.

Methods

We performed a retrospective analysis of patients for whom the stroke code system was activated at 2 hospitals in our region. Univariate and logistic regression analysis was performed to identify factors associated with use of EMS versus private vehicle.

Results

EMS use was lower in patients who were younger, had higher income, were married, more educated and in those who identified as Hispanic. Those arriving by EMS had significantly faster arrival to code, arrival to imaging, and arrival to thrombolytic treatment times.

Conclusion

Analysis of regional data can identify specific populations underutilizing EMS services for acute stroke symptoms. Factors effecting EMS utilization varies by region and this information may be useful for targeted education programs promoting EMS use for acute stroke symptoms. EMS use results in more rapid evaluation and treatment of stroke patients.

CE: Acute Ischemic Stroke

ABSTRACT

Stroke, the most common form of cerebrovascular disease, is a leading cause of death and disability throughout the world. There have been no significant advances in the development of effective therapeutics for hemorrhagic stroke, and for ischemic stroke highly effective, evidence-based therapies such as alteplase and mechanical thrombectomy are widely underutilized. Improving outcomes for patients experiencing ischemic stroke requires faster recognition and appropriate intervention within the treatment window (the first 24 hours after symptom onset). This article discusses the pathophysiology underlying the various types of ischemic stroke; the risk factors for ischemic stroke; stroke presentation; and the evidence-based treatments, nursing assessments, and monitoring protocols that are critical to patient recovery.

Characterization of a Temporal Profile of Biomarkers as an Index for Ischemic Stroke Onset Definition

Background and purpose: Stroke is a dynamic process in terms of molecular mechanisms, with prominent glutamate-mediated excitotoxicity at the onset of symptoms followed by IL-6-mediated inflammation. Our aim was to study a serum glutamate/IL-6 ratio as an index for stroke onset definition. Methods: A total of 4408 ischemic stroke patients were recruited and then subdivided into four quartiles according to latency time in minutes (0–121, 121–185, 185–277 and >277). Latency time is defined as the time between stroke onset and treatment at the neurological unit. The primary endpoint of the study was the association of early latency times with different clinical aspects and serum markers. Serum glutamate and interleukin-6 (IL-6) levels at admission were selected as the main markers for excitotoxicity and inflammation, respectively. Results: Glutamate serum levels were significantly higher in the earlier latency time compared with the higher latency times (p < 0.0001). IL-6 levels were lower in early latency times (p < 0.0001). Patients with a glutamate/IL-6 index on admission of >5 were associated with a latency time of <121 min from the onset of symptoms with a sensitivity of 88% and a specificity of 80%. Conclusions: The glutamate/IL-6 index allows the development of a ratio for an easy, non-invasive early identification of the onset of ischemic stroke symptoms, thus offering a new tool for selecting early stroke patient candidates for reperfusion therapies.

Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

OBJECTIVES

Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.

DESIGN

A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.

SETTING

This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.

PARTICIPANTS

Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.

RESULTS

Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).

CONCLUSIONS

The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

Early Hospital Arrival After Acute Ischemic Stroke Is Associated With Family Members' Knowledge About Stroke

Background and Purpose: Prehospital delay is the major factor limiting intravenous thrombolysis and mechanical thrombectomy in acute ischemic stroke (AIS). This study aimed to: (1) identify factors related to prehospital delay and (2) determine the impact of recognition and behavior of family members on patient delay. Methods: A cross-sectional, multicenter study was conducted at six teaching hospitals in China between December 1, 2018 and November 30, 2019. Patients who experienced AIS within 7 days of onset were interviewed. Results: Of 1,782 consecutive patients (male, 57.97%; mean age, 66.3 ± 9.65 years) who had an AIS, 267 (14.98%) patients arrived within 4.5 h and 722 (40.52%) patients arrived within 6 h of stroke onset. Among patients who arrived within 4.5 h, 103 (38.6%) received thrombolysis. Age over 65 years (OR, 2.009; 95% CI, 1.014-3.982), prior stroke (OR, 3.478; 95% CI, 1.311-9.229), blurred vision (OR, 3.95; 95% CI, 1.71-9.123), and patients deciding to seek medical help (OR, 3.097; 95% CI, 1.417-6.769) were independently associated with late arrival. In contrast, sudden onset of symptoms (OR, 0.075; 95% CI, 0.028-0.196), the National Institutes of Health Stroke Scale 7-15 (OR, 0.093; 95% CI, 0.035-0.251), consciousness disturbance (OR, 0.258; 95% CI, 0.091-0.734), weakness (OR, 0.265; 95% CI, 0.09-0.784), arrival by ambulance (OR, 0.102; 95% CI, 0.049-0.211), decision time <30 min (OR, 0.008; 95% CI, 0.003-0.018), and family member understanding stroke requires early treatment (OR, 0.224; 95% CI, 0.109-0.462) were independently associated with early arrival. Conclusions: The prehospital delay in China lags behind Western countries. Recognition and behavior of stroke patients' family members may play a key role in early arrival.

Sex Differences in Risk Factors for Transient Ischemic Attack in a Chinese Population

Introduction: This study aimed to collect and evaluate basic information of a stroke screening population in eastern China and to compare distribution differences in risk factors between males and females in a transient ischemic attack (TIA) population. Methods: A standardization of the risk factors for stroke was performed according to an implementation plan of stroke in a high-risk population screening and intervention project in Shandong Province. Of the 231,289 residents, 8,603 patients with a previous TIA were identified and risk factors in this cohort were analyzed for sex differences. Results: In our initial cohort of 231,289 residents, we found 3,390 men and 5,213 women with TIA, accounting for a prevalence of 3.1 and 4.2%, respectively. Risk factors for TIA were hypertension, atrial fibrillation, diabetes, smoking, lack of exercise, overweight, and family history of stroke. In our TIA cohort, we found that the prevalence of smoking was significantly higher in men (41.3%) compared with that found in women (4.2%). Further, hypertension (58.8 vs. 55.5%) and family history of stroke (22.3 vs. 20.0%) were more prevalent in men compared with women, whereas atrial fibrillation (AF) (14.7 vs. 16.4%), diabetes (11.1 vs. 13.2%), lack of exercise (27.2 vs. 28.0%), and overweight (29.5 vs. 35.7%) were less prevalent. Conclusions: In our TIA cohort from eastern China, we found significant sex differences for the risk factors of hypertension, atrial fibrillation, smoking, diabetes, and overweight.

Factors Associated With Emergency Department Length of Stay and In-hospital Mortality in Intracerebral Hemorrhage Patients

ABSTRACT

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a medical emergency that requires rapid identification and focused assessment early to ensure the best possible outcomes. The purpose of this study is to evaluate the associations between system and patient factors and emergency department (ED) length of stay and in-hospital mortality in patients given a diagnosis of ICH. METHODS: A sample of 3108 ICH patients was selected from a statewide administrative database for cross-sectional retrospective analysis. System characteristic (hospital stroke certification), patient characteristics (age, sex, and race), and covariate conditions (stroke severity and comorbidities) were analyzed using descriptive statistics and hierarchical logistic regression models to address the study questions. RESULTS: The mean ED length of stay is 2.9 ± 3 hours (range, 0-42 hours) before admission to an inpatient unit. Inpatient mortality is 14.9%. Stroke center certification (P < .000) and stroke severity (P ≤ .000) are significant predictors of ED length of stay, whereas age (P < .000), stroke severity (P < .000), comorbidities (P = .047), and ED length of stay (P = .04) are significant predictors of in-hospital mortality. Most notably, an ED length of stay of 3 hours or longer has a 37% increase in the odds of in-hospital mortality. CONCLUSION: Our findings support age, stroke severity, and ED length of stay as predictors of in-hospital mortality for ICH patients. The importance of timely admission to an inpatient unit is emphasized. Optimal systems of care and expedited inpatient admission are vital to reduce morbidity and mortality for ICH stroke patients.

Cue responsiveness as a measure of emerging language ability in aphasia

Background: Prior research suggests that initial aphasia severity, lesion size, and lesion location are the most salient factors in predicting recovery outcomes. While these factors provide important prognostic information, information that is individualized and readily available to clinicians is limited. Deficits in naming are common to all aphasia types and are routinely targeted in aphasia assessment and treatment, with cues provided to facilitate lexical retrieval.Objectives: In this study, we examine aphasia recovery factors that are readily available to clinicians, examining whether a person's ability to improve naming with cues, indicating "stimulability," will be predictive of future word retrieval.Methods: Ten participants with aphasia following a left-hemisphere stroke participated in initial assessment, seven of whom met criteria for longitudinal assessment. Stroke and early clinical recovery data were collected for all participants. At four timepoints over one year we evaluated longitudinal participants' naming ability and measured the proportion of successful lexical retrieval with the presentation of phonemic, feature, and sentence cues.Results: For all participants, multiple descriptive factors regarding recovery, including lesion information, information from the acute inpatient timeframe, and communication opportunities, were examined. For individuals followed longitudinally, naming stimulability did not consistently predict naming accuracy at the subsequent assessment timepoint. Individuals' attempts at naming emerged as a metric related to future naming performance warranting further evaluation.Conclusions: Multiple factors related to recovery must be considered when providing prognostic information. Naming stimulability and attempts at naming provide some information regarding future performance, but are not consistently reliable across timepoints.

Mapping access to endovascular stroke care in the USA and implications for transport models

BACKGROUND

The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive.

METHODS

Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated.

RESULTS

Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive.

CONCLUSION

Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.

Lack of racial and ethnic-based differences in acute care delivery in intracerebral hemorrhage

Background and aim

Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH.

Methods

We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale.

Results

Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (β = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (β = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome.

Conclusions

We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

Stroke Awareness among Elderly Hypertensives in a Rural Area of Bangalore District, India

OBJECTIVES

India faces a high and growing burden of hypertension, which is an important cerebrovascular risk factor, especially in elderly persons. Poor awareness contributes to delays in seeking health care, which is undesirable given the emergent nature of stroke. Literature regarding awareness in this subgroup of the population is scarce. Our objective was to assess awareness regarding cerebrovascular disease among elderly persons with hypertension residing in a rural area of Bangalore district, and estimate their individual risk of stroke.

MATERIAL & METHODS

We randomly selected 144 elderly hypertensives residing in a rural area in Bangalore district from a list of known hypertensives maintained as part of a population-based senior citizen health service. We developed an open-ended, face-validated questionnaire, which was administered following informed consent, to assess stroke awareness. We defined good awareness as knowing at least one risk factor, one warning sign, and having the knowledge that stroke requires immediate treatment. Univariate and multivariate analyses were performed to assess factors associated with good or poor awareness.

RESULTS

40% of the study population had not heard of the term 'stroke'. Only 22% could identify the brain as the organ affected. 51% could name at least one symptom. 45% of males and 24% of females believed that their hypertension predisposed them to stroke. 56% could not name a single risk factor. Only 37% of the males and 18% of the females had good overall awareness. Female gender and low literacy were associated with poor overall awareness, while being gainfully employed, a history of alcohol use and doing higher levels of exercise were associated with greater awareness on univariate analysis. None of these factors were statistically significantly related to stroke awareness on multivariate analysis.

CONCLUSIONS

Awareness of different aspects of stroke was very poor, highlighting the need for stroke education at all levels of care.

Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics within a Tele-Stroke Network

INTRODUCTION

Differences in access to stroke care and compliance with standard of care stroke management among patients of varying racial and ethnic backgrounds and sex are well-characterized. However, little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care.

METHODS

We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke.

RESULTS

Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration, or incidence of MT utilization.

CONCLUSION

We did not find racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.

Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults

BACKGROUND AND PURPOSE

Despite declining stroke rates in the general population, stroke incidence and hospitalizations are rising among younger individuals. Awareness of and prompt response to stroke symptoms are crucial components of a timely diagnosis and disease management. We assessed awareness of stroke symptoms and response to a perceived stroke among young adults in the United States.

METHODS

Using data from the 2017 National Health Interview Survey, we assessed awareness of 5 common stroke symptoms and the knowledge of planned response (ie, calling emergency medical services) among young adults (<45 years) across diverse sociodemographic groups. Common stroke symptoms included: (1) numbness of face/arm/leg, (2) confusion/trouble speaking, (3) difficulty walking/dizziness/loss of balance, (4) trouble seeing in one/both eyes, and (5) severe headache.

RESULTS

Our study population included 24 769 adults, of which 9844 (39.7%) were young adults who were included in our primary analysis, and represented 107.2 million US young adults (mean age 31.3 [±7.5] years, 50.6% women, and 62.2% non-Hispanic White). Overall, 2718 young adults (28.9%) were not aware of all 5 stroke symptoms, whereas 242 individuals (2.7%; representing 2.9 million young adults in the United States) were not aware of a single symptom. After adjusting for confounders, Hispanic ethnicity (odds ratio, 1.96 [95% CI, 1.17-3.28]), non-US born immigration status (odds ratio, 2.02 [95% CI, 1.31-3.11]), and lower education level (odds ratio, 2.77 [95% CI, 1.76-4.35]), were significantly associated with lack of symptom awareness. Individuals with 5 high-risk characteristics (non-White, non-US born, low income, uninsured, and high school educated or lower) had nearly a 4-fold higher odds of not being aware of all symptoms (odds ratio, 3.70 [95% CI, 2.43-5.62]).

CONCLUSIONS

Based on data from the National Health Interview Survey, a large proportion of young adults may not be aware of stroke symptoms. Certain sociodemographic subgroups with decreased awareness may benefit from focused public health interventions.

Sex-Related Differences after Endovascular Treatment of Acute Ischemic Stroke in the 'Real World'

BACKGROUND

Gender differences are often reported in the field of ischemic stroke, although most of such discrepancies were observed in randomized trials involving highly selected populations. We therefore explored gender differences regarding 90-day outcomes in large vessel occlusion (LVO) strokes receiving endovascular treatment in a real world setting.

METHODS

This prospective registry included anterior and/or posterior circulation LVO strokes admitted between January 2014 and December 2019 who received mechanical thrombectomy up to 24 hours from symptoms onset or last known to be well. We explored sex-related differences in rates of functional independence (modified Rankin Scale, mRS, ≤2) at 90 days. Secondary outcomes included "National Institutes of Health Stroke Scale" (NIHSS) at 24 hours, successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, death, and symptomatic intracranial hemorrhage (sICH).

RESULTS

A total of 288 LVO stroke patients comprised the study population, involving 148 (51.4%) women. Females were older (71.4±15.7 vs. 66.1±14.0 years, p=0.003) and had lower rates of coronary artery disease (15% vs. 24%, p=0.05). The median time from symptoms onset to hospital arrival was 315 min (IQR 139.5-495.0) in females and 255.0 (IQR 117.0-405.0) in males (p=0.052). Rates of mRS ≤2 at 90 days were comparable (females 46% vs. males 49%, p=0.50). Successful reperfusion was achieved in 82% of females and 89% of males (p=0.10). Rates of sICH (females 10% vs. males 13%, p=0.47) and death (females 18% vs. males 21%, p=0.50) at 90 days were similar. NIHSS at 24 hours was the strongest predictor of functional independence at 90 days (area under ROC curve 0.92 (95%CI 0.87; 0.95)].

CONCLUSIONS

Our prospective registry involving a real world setting suggests that females are equally likely to achieve good outcomes after endovascular treatment despite being older and having delayed hospital arrival compared to males. In addition, we found that NIHSS at 24 hours was the strongest predictor of functional independence at 90 days, sICH, and death.

Association between Area-Level Socioeconomic Deprivation and Prehospital Delay in Acute Ischemic Stroke Patients: An Ecological Study

We analyzed the associations between area-level socioeconomic status (SES) and prehospital delay in acute ischemic stroke (AIS) patients by degree of urbanization with the use of an ecological framework. The participants were 13,637 patients over 18 years of age who experienced AIS from 2007 to 2012 and were admitted to any of the 29 hospitals in South Korea. Area-level SES was determined using 11 variables from the 2010 Korean census. The primary outcome was a prehospital delay (more than three hours from AIS onset time). Multilevel logistic regression was conducted to define the associations of individual- and area-level SES with prehospital delay after adjusting for confounders, which includes the use of emergency medical services (EMS) and individual SES. After adjusting for covariates, it was found that the area-level SES and urbanization were not associated with prehospital delay and EMS use was beneficial in both urban and rural areas. However, after stratification by urbanization, low area-level SES was significantly associated with a prehospital delay in urban areas (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 1.04–1.47) but not in rural areas (aOR 1.04, 95% CI 0.78–1.38). Therefore, we posit that area-level SES in urban areas might be a significant barrier to improving prehospital delay in AIS patients.

Disentangling Sex Differences in Use of Reperfusion Therapy in Patients With Acute Ischemic Stroke

Background and Purpose:

Previous studies from local settings have reported that women with acute ischemic stroke have a lower chance of receiving reperfusion therapy treatment, including intravenous thrombolysis and thrombectomy, than men, but the underlying mechanisms of this disparity have not been identified. We aimed to examine sex differences in the utilization of reperfusion therapy focusing on all the phases of pre- and in-hospital time delay in a nationwide population-based cohort.

Methods:

This study was based on data from nationwide public registries. The study population included patients aged at least 18 years admitted with acute ischemic stroke using emergency medical services in Denmark dispatched after an emergency call in the period 2016 to 2017. Study outcomes included time delays from symptom onset to start of reperfusion therapy and use of reperfusion therapy. Data were analyzed using multivariable quantile regression and logistic regression.

Results:

A total of 5356 stroke events fulfilled the inclusion criteria. Women (26.6%) were less likely to receive intravenous thrombolysis than men (30.2 %), corresponding to an unadjusted odds ratio of 0.84 (95% CI, 0.74–0.95). In addition, women experienced a 20 minutes longer median time delay from stroke symptom onset to stroke unit arrival than men. Adjusting for onset-to-door time only appeared to have a limited effect on the sex differences in use of intravenous thrombolysis, whereas the odds ratio was 1.06 (95% CI, 0.93–1.21) when adjusting for age at stroke, stroke severity, and cohabitation status. No sex difference was observed for the use of thrombectomy.

Conclusions:

Women received less reperfusion therapy than men and had a longer time delay from symptom onset to stroke unit arrival, primarily due to a longer delay from symptom onset to emergency medical services call. These differences appeared to be due to the higher age and the higher proportion of women living alone at the time of the stroke.

Emergency medical services use and its association with acute ischaemic stroke evaluation and treatment in Singapore

Background

Emergency medical services (EMS) is a critical link in the chain of stroke survival. We aimed to assess EMS use for stroke in Singapore, identify characteristics associated with EMS use and the association of EMS use with stroke evaluation and treatment.

Methods

The Singapore Stroke Registry combines nationwide EMS and public hospital data for stroke cases in Singapore. Multivariate regressions with the generalised estimating equations were performed to examine the association between EMS use and timely stroke evaluation and treatment.

Results

Of 3555 acute ischaemic patients with symptom onset within 24 hours admitted to all five public hospitals between 2015 and 2016, 68% arrived via EMS. Patients who used EMS were older, were less likely to be female, had higher stroke severity by National Institute of Health Stroke Scale and had a higher prevalence of atrial fibrillation or peripheral arterial disease. Patients transported by EMS were more likely to receive rapid evaluation (door-to-imaging time ≤25 min 34.3% vs 11.1%, OR=2.74 (95% CI 1.40 to 5.38)) and were more likely to receive intravenous tissue plasminogen activator (tPA, 22.8% vs 4.6%, OR=4.61 (95% CI 3.52 to 6.03)). Among patients treated with tPA, patients who arrived via EMS were more likely to receive timely treatment than self-transported patients (door-to-needle time ≤60 min 52.6% vs 29.4%, OR=2.58 (95% CI 1.35 to 4.92)).

Conclusions

EMS use is associated with timely stroke evaluation and treatment in Singapore. Seamless EMS-Hospital stroke pathways and targeted public campaigns to advocate for appropriate EMS use have the potential to improve acute stroke care.