Reasons for Prehospital Delay in Acute Ischemic Stroke

Development of an Acute Stroke Care Seeking Framework

ABSTRACT

BACKGROUND: A multitude of variables influence an individual's decision to seek care in emergency situations. By recognizing these variables and their impact on the timeline of an individual seeking care for a stroke, nurses have an opportunity to positively affect the outcomes of stroke within the community. The purpose of this narrative review was to develop a research framework describing the variables involved in care seeking during an acute stroke. METHODS: Using a theory synthesis methodology that included variable identification and the establishment of relationships between variables based on existing literature, a framework describing variables relevant to acute stroke care seeking behavior was developed. RESULTS: Fourteen recently published studies reported significant variables related to seeking emergency medical care during the hyperacute phase of a stroke. Eight variables were identified and characterized as either promoters or distractors. Promoters led an individual to seek acute stroke care earlier, such as perceived symptom severity, stroke knowledge, and the presence of others. Distractors led an individual to delay seeking acute stroke care and resulted in later hospital arrival times, such as a lack of social network or resources, comorbid conditions, and incongruity with the local health system. CONCLUSION: Although individual decision making is exceedingly complex and varies by individual and situation, the developed acute stroke care seeking framework may provide a basis on which to develop stroke awareness programs and interventions targeted at individuals at risk for delayed acute stroke care.

Factors affecting stroke pre-hospital delay behavioral intention among community residents: A path analysis

BACKGROUND

Pre-hospital delay is the major cause of stroke treatment delay, and behavioral intention is considered to be the most direct predictor of behavior. Therefore, to effectively reduce stroke pre-hospital delay, it is essential to further understand the relationship between stroke pre-hospital delay intention (SPDBI) and its social-psychological influencing factors, namely personality traits, social support and coping style.

AIM

This study aims at examining the relationships among personality traits, coping style, social support, and SPDBI.

METHODS

A cross-sectional, self-administered questionnaire was distributed to 845 residents. The content of the questionnaire included demographic information, the knowledge of "Stroke 120", Ten-Item Personality Inventory-Chinese version, Simplified Coping Style Questionnaire, Perceived Social Support Scale and SPDBI Scale. Path analysis was used to investigate the relationship among SPDBI and its psychosocial influencing factors.

RESULTS

The final path model showed a good fit to the data (χ2/df = 2.981, RMSEA = 0.048, GFI = 0.936, CFI = 0.941). Extroversion (β = 0.106), positive coping (β = -0.110), negative coping (β = 0.150) and the knowledge of "Stroke 120" (β = -0.152) had only direct effects on SPDBI. While agreeableness (β = 0.113), openness (β = -0.121) and social support (β = -0.118) had direct effects on SPDBI, they also had indirect effects (β = -0.009; -0.022; -0.049) on SPDBI though positive coping.

CONCLUSIONS

Adequate social support and positive coping of health threat may reduce residents' SPDBI. Meanwhile, the interventions to reduce SPDBI should take personality differences into consideration.

Impact of demographic and clinical factors on in-hospital delays in acute ischemic stroke treatment

BACKGROUND

Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear.

METHOD

This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed.

RESULTS

Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups.

CONCLUSION

Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

Impact of Gender and Marital Status on Door-To-Treatment (DTT) Time and Acute Stroke Outcome

OBJECTIVES

Delays in acute stroke treatment lead to poor outcomes. Women can present with atypical stroke symptoms, are older at the time of stroke, and tend to be living alone, causing delays in pre-hospital diagnosis and seeking care. It is unclear if gender disparities in ED arrival and stroke assessment are compounded by gender differences after ED arrival. Therefore, we sought to identify if gender and marital status were associated with faster door-to-treatment (DTT) time.

METHODS

Our single-center stroke database was queried for adults presenting to ED with acute stroke between January 1, 2018 and January 30, 2023 treated with IV thrombolytics (IVT)+/- endovascular thrombectomy (EVT) and a known DTT time. The primary outcome was DTT (door-to-needle+door-to-puncture) time. Data collected includes the National Institutes of Health Stroke Scale (NIHSS) at presentation and discharge, gender, marital status, age, and intervention (IVT alone or IVT+/- EVT).

RESULTS

Among 674 patients identified, 35 patients were excluded due to missing data. Of 639 patients (median age 66 y), 25%/18% of patients were married men/women, respectively, and 22%/35% were single men/women. Median DTN time, DTP time, and discharge NIHSS score were 36, 79, and 4 mins, respectively. On multivariable analysis, neither DTT time nor NIHSS score at discharge improved among married men relative to any other combination of gender and marital status.

CONCLUSIONS

Gender differences in the knowledge of stroke warning signs and gender disparities in ED assessment did not translate into faster DTT time. More work is needed to find ways to accelerate stroke care after ED arrival.

Multicenter Validation of lncRNA and Target mRNA Diagnostic and Prognostic Biomarkers of Acute Ischemic Stroke From Peripheral Blood Leukocytes

BACKGROUND

Long noncoding RNA (lncRNA) and mRNA profiles in leukocytes have shown potential as biomarkers for acute ischemic stroke (AIS). This study aimed to identify altered lncRNA and target mRNA profiles in peripheral blood leukocytes as biomarkers and to assess the diagnostic value and association with AIS prognosis.

METHODS AND RESULTS

Differentially expressed lncRNAs (DElncRNAs) and differentially expressed target mRNAs (DEmRNAs) were screened by RNA sequencing in the discovery set, which consisted of 10 patients with AIS and 20 controls. Validation sets consisted of a multicenter (311 AIS versus 303 controls) and a nested case-control study (351 AIS versus 352 controls). The discriminative value of DElncRNAs and DEmRNAs added to the traditional risk factors was estimated with the area under the curve. NAMPT-AS, FARP1-AS1, FTH1, and NAMPT were identified in the multicenter case-control study (P<0.05). LncRNA NAMPT-AS was associated with cis-target mRNA NAMPT and trans-target mRNA FTH1 in all validation sets (P<0.001). Similarly, AIS cases exhibited upregulated lncRNA FARP-AS1 and FTH1 expression (P<0.001) in the nested case-control study (P<0.001). Furthermore, lncRNA FARP1-AS1 expression was upregulated in AIS patients at discharge with an unfavorable outcome (P<0.001). Positive correlations were found between NAMPT expression level and NIHSS scores of AIS patients (P<0.05). Adding 2 lncRNAs and 2 target mRNAs to the traditional risk factor model improved area under the curve by 22.8% and 5.2% in the multicenter and the nested case-control studies, respectively.

CONCLUSIONS

lncRNA NAMPT-AS and FARP1-AS1 have potential as diagnostic biomarkers for AIS and exhibit good performance when combined with target mRNA NAMPT and FTH1.

Regional Disparities in Prehospital Delay of Acute Ischemic Stroke: The Korean Stroke Registry

BACKGROUND

Late hospital arrival keeps patients with stroke from receiving recanalization therapy and is associated with poor outcomes. This study used a nationwide acute stroke registry to investigate the trends and regional disparities in prehospital delay and analyze the significant factors associated with late arrivals.

METHODS

Patients with acute ischemic stroke or transient ischemic attack between January 2012 and December 2021 were included. The prehospital delay was identified, and its regional disparity was evaluated using the Gini coefficient for nine administrative regions. Multivariate models were used to identify factors significantly associated with prehospital delays of >4.5 h.

RESULTS

A total of 144,014 patients from 61 hospitals were included. The median prehospital delay was 460 min (interquartile range, 116-1912), and only 36.8% of patients arrived at hospitals within 4.5 h. Long prehospital delays and high regional inequality (Gini coefficient > 0.3) persisted throughout the observation period. After adjusting for confounders, age > 65 years old (adjusted odds ratio [aOR] = 1.23; 95% confidence interval [CI], 1.19-1.27), female sex (aOR = 1.09; 95% CI, 1.05-1.13), hypertension (aOR = 1.12; 95% CI, 1.08-1.16), diabetes mellitus (aOR = 1.38; 95% CI, 1.33-1.43), smoking (aOR = 1.15, 95% CI, 1.11-1.20), premorbid disability (aOR = 1.44; 95% CI, 1.37-1.52), and mild stroke severity (aOR = 1.55; 95% CI, 1.50-1.61) were found to independently predict prehospital delays of >4.5 h.

CONCLUSION

Prehospital delays were lengthy and had not improved in Korea, and there was a high regional disparity. To overcome these inequalities, a deeper understanding of regional characteristics and further research is warranted to address the vulnerabilities identified.

The potential of virtual triage AI to improve early detection, care acuity alignment, and emergent care referral of life-threatening conditions

Objective

To evaluate the extent to which patient-users reporting symptoms of five severe/acute conditions requiring emergency care to an AI-based virtual triage (VT) engine had no intention to get such care, and whose acuity perception was misaligned or decoupled from actual risk of life-threatening symptoms.

Methods

A dataset of 3,022,882 VT interviews conducted over 16 months was evaluated to quantify and describe patient-users reporting symptoms of five potentially life-threatening conditions whose pre-triage healthcare intention was other than seeking urgent care, including myocardial infarction, stroke, asthma exacerbation, pneumonia, and pulmonary embolism.

Results

Healthcare intent data was obtained for 12,101 VT patient-user interviews. Across all five conditions a weighted mean of 38.5% of individuals whose VT indicated a condition requiring emergency care had no pre-triage intent to consult a physician. Furthermore, 61.5% intending to possibly consult a physician had no intent to seek emergency medical care. After adjustment for 13% VT safety over-triage/referral to ED, a weighted mean of 33.5% of patient-users had no intent to seek professional care, and 53.5% had no intent to seek emergency care.

Conclusion

AI-based VT may offer a vehicle for early detection and care acuity alignment of severe evolving pathology by engaging patients who believe their symptoms are not serious, and for accelerating care referral and delivery for life-threatening conditions where patient misunderstanding of risk, or indecision, causes care delay. A next step will be clinical confirmation that when decoupling of patient care intent from emergent care need occurs, VT can influence patient behavior to accelerate care engagement and/or emergency care dispatch and treatment to improve clinical outcomes.

Symptoms at stroke onset as described by patients: a qualitative study

BACKGROUND

Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sided weakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke can present with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the National Institutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed to investigate how patients describe their symptoms at the onset of a first-time stroke.

METHODS

The study used a qualitative descriptive design and conventional content analysis. Data were collected through recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke between October 2018 and April 2020. Data were analysed on a manifest level.

RESULTS

Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed Body Functions and described in five categories. Various types of symptoms were found. All symptoms were perceived as sudden, persistent, and never experienced before and this appear as a "red thread" in the result. Regardless of symptom expressions, no specific symptom was described as more severe than another.

CONCLUSIONS

Stroke symptoms were described with a variety of expressions. Many described complex symptoms not typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Public stroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke and could be designed to help achieve this.

Delays in receiving Alteplase and related factors in patients with stroke referred to Shahid Beheshti Hospital in Kashan-Iran in 2020-2021

BACKGROUND

The benefits of using Alteplase are time-dependent. This study aimed to evaluate delays between the onset of symptoms and the administration of Alteplase and related factors in patients with acute ischemic stroke (AIS).

MATERIALS AND METHODS

In this cross-sectional study, 60 AIS patients receiving Alteplase were selected by census sampling from July 2020 to July 2021 from the eligible patients referred to Shahid Beheshti Hospital in Kashan, Iran. The data collection tool was a researcher-made questionnaire containing demographic information, time periods from the onset of symptoms to the injection of Alteplase, and associated factors. The required information was collected from the patients, their relatives, their health records, and Kashan Emergency Medical Service (EMS) information system. Data were analyzed in SPSS-16.

RESULTS

Eighty-five percent of the 60 patients participating in the study were transferred to the hospital by EMS ambulances. The mean time intervals between different phases were as follows: Onset-To-Door (OTD) time 81.35 ± 33.76 minutes; Door-To-CT (DTC) scan time 16.12 ± 17.46 minutes; Door-To-Needle (DNT) time 51.30 ± 26.14 minutes; and the overall Onset-To-Needle (ONT) time 133.75 ± 39.17 minutes. Also, the mean ONT in people transferred by EMS was about 129 minutes, and the longest prehospital delay in these patients was related to the time between the arrival of the EMS ambulance to the hospital. Marital status and geographical location where the stroke had occurred showed a significant relationship with prehospital delay and pre-hospital notification (PHN) by EMS But there was no relationship between underlying diseases or economic status and prehospital delays; also, the patient's diastolic blood pressure at the time of receiving Alteplase showed a significant relationship with in-hospital delay.

CONCLUSION

The findings of the study showed that the majority of people trust and use EMS ambulances to transfer to the hospital and the time spent in different stages, from the onset of symptoms to the injection of the thrombolytic drug, was in an acceptable range in the patients.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

Prehospital Factors Associated with Delayed Hospital Arrival of Stroke Patients: A Regional Single-Center Study from India

Background

Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously conducted the first regional study to assess the factors delaying acute stroke care in India. The present study aims to understand and describe in depth the variables associated with prehospital delay among patients admitted with an acute ischemic stroke.

Methods

Data were prospectively collected by conducting an in-depth interview of 470 acute ischemic stroke patients and their bystanders, aged above 18 years, presenting to the Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur. Patients who arrived within 4.5 h of symptom onset were considered as "early arrival" and those who arrived after 4.5 h were considered as "delayed arrival." Univariate and multivariate analyses were undertaken to determine associations between variables of interest and delays to hospital presentation.

Results

Of the 470 patients who met the inclusion criteria, 73 patients reached within 4.5 h (15.5%), whereas 397 patients arrived after 4.5 h. The mean age of acute stroke patients who reached within 4.5 h was 63 ± 13.7 years, whereas the mean age of those who reached after 4.5 h was 63 ± 12.1 years. Binary logistic regression performed to quantify the associations of prehospital factors showed an increased risk of prehospital delay among individuals with lack of awareness (odds ratio [OR] = 5.16 [3.040-8.757], P < 0.001), followed by those for whom a vehicle was not available at the site of event (OR = 3.745 [1.864-7.522], P < 0.001). Within the predefined socioeconomic strata, compared to lower class, upper middle class had less risk (OR = 0.135 [0.018-1.035], P = 0.054), whereas the distance from first medical contact to emergency department contributed moderate risk (OR = 1.071 [1.028-1.116], P < 0.001) for prehospital delay.

Conclusions

Health promotion techniques that increase public knowledge about the early signs of stroke, transferring patients directly to hospitals with thrombolysis capabilities, and making ambulance services more widely available are appropriate measures to reduce prehospital delay.

Efficacy of endovascular therapy for stroke in developing country: A single-centre retrospective observational study in Indonesia from 2017 to 2021

Background

Indonesia as a developing nation faces a plethora of challenges in applying endovascular therapy (EVT), mostly due to the lack of physicians specialized in neuro-intervention, high operational cost, and time limitation. The efficacy of EVT in improving functional outcomes of stroke in developing countries has not been previously studied.

Methods

This retrospective cohort study was conducted at Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) from January 2017 to December 2021. Large vessel occlusion (LVO) diagnosis was established based on a combination of clinical and imaging characteristics. We assessed patients' functional independence on day-90 based on modified Rankin Scale (mRS) between the endovascular treatment group and the conservative group (those receiving intravascular thrombolysis or medical treatment only). Functional independence was defined as mRS ≤2.

Results

Among 111 stroke patients with LVO, we included 32 patients in the EVT group and 50 patients in the conservative group for this study. Patients with younger age (p = 0.004), lower hypertension rate (p < 0.001), higher intubation rate (p = 0.014), and earlier onset of stroke were observed in the EVT group. The proportion of mRS ≤2 at day-90 in the EVT group was higher than the conservative group (28.1 % vs. 18.0 %; p = 0.280). Patients within mRS ≤2 group had earlier onset-to-puncture time (p = 0.198), onset-to-recanalization time (p = 0.341), lower NIHSS (p = 0.026) and higher ASPECTS (p = 0.001) on admission. In multivariate analysis, ASPECTS (aOR 2.43; 95%CI 1.26-4.70; p = 0.008) defined functional independence in the EVT group.

Conclusion

The endovascular therapy group had a higher proportion of mRS ≤2 at day-90 than the conservative group despite its statistical insignificance.

Two stroke education programs designed for older adults

Stroke is an important public health problem worldwide and in Korea causing death and serious long-term disability. This study tested the feasibility, acceptability, and preliminary efficacy of two stroke education programs. The pictogram-based education program was administered to 118 participants, and the PowerPoint-based education program was administered to 108 participants. Stroke knowledge (stroke definition, risk factors, warning signs) and first action knowledge in the event of stroke were assessed among all participants prior to and following completion of their respective programs. Both stroke education programs showed similar, significant improvements in stroke knowledge and first action knowledge from baseline to posttest. Also, feasibility (81-88 % participation and 96 % completion) and acceptability (86-97 % satisfaction) of both stroke education programs were supported. These findings indicate that healthcare professionals can use either of the education programs to improve stroke knowledge and first action knowledge among older adults who are at high risk for stroke.

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.

Association of Neighborhood Deprivation With Thrombolysis and Thrombectomy for Acute Stroke in a Health System With Universal Access

BACKGROUND AND OBJECTIVES

The association between socioeconomic status and acute ischemic stroke treatments remain uncertain, particularly in countries with universal health care systems. This study aimed to investigate the association between neighborhood-level material deprivation and the odds of receiving IV thrombolysis or thrombectomy for acute ischemic stroke within a single-payer, government-funded health care system.

METHODS

We conducted a population-based cohort study using linked administrative data from Ontario, Canada. This study involved all community-dwelling adult Ontario residents hospitalized with acute ischemic stroke between 2017 and 2022. Neighborhood-level material deprivation, measured in quintiles from least to most deprived, was our main exposure. We considered the receipt of thrombolysis or thrombectomy as the primary outcome. We used multivariable logistic regression models adjusted for baseline differences to estimate the association between material deprivation and outcomes. We performed a sensitivity analysis by additionally adjusting for hospital type at initial assessment. Furthermore, we tested whether hospital type modified the associations between deprivation and outcomes.

RESULTS

Among 57,704 patients, those in the most materially deprived group (quintile 5) were less likely to be treated with thrombolysis or thrombectomy compared with those in the least deprived group (quintile 1) (16.6% vs 19.6%, adjusted odds ratio [aOR] 0.76, 95% CI 0.63-0.93). The association was consistent when evaluating thrombolysis (13.0% vs 15.3%, aOR 0.78, 95% CI 0.64-0.96) and thrombectomy (6.4 vs 7.8%, aOR 0.73, 95% CI 0.59-0.90) separately. There were no statistically significant differences between the middle 3 quintiles and the least deprived group. These associations persisted after additional adjustment for hospital type, and there was no interaction between material deprivation and hospital type (p interaction >0.1).

DISCUSSION

We observed disparities in the use of thrombolysis or thrombectomy for acute ischemic stroke by socioeconomic status despite access to universal health care. Targeted health care policies, public health messaging, and resource allocation are needed to ensure equitable access to acute stroke treatments for all patients.

Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke

To investigate the association between the Emergency Medical Service dispatcher's initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017-2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1-76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was - 33.2 min (95% CI - 44.4; - 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI - 18.9; - 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.

Real-time video analysis allows the identification of large vessel occlusion in patients with suspected stroke: feasibility trial of a "telestroke" pathway in Northwestern Switzerland

Background and aim

Loss of time is a major obstacle to efficient stroke treatment. Our telestroke path intends to optimize prehospital triage using a video link connecting ambulance personnel and a stroke physician. The objectives were as follows: (1) To identify patients suffering a stroke and (2) in particular large vessel occlusion (LVO) strokes as candidates for endovascular treatment. We have chosen the Rapid Arterial Occlusion Evaluation (RACE) scale for this purpose.

Methods

This analysis aimed to verify the feasibility of prehospital stroke identification by video assessment. In this prospective telestroke cohort study, we included 97 subjects, in which the RACE score (items: facial palsy, arm and leg motor function, head and gaze deviation, and aphasia or agnosia) was applied, and the assessment videotaped by a trained member of the Emergency Medical Services (EMS) in the field using a mobile device. Each recorded patient video was independently assessed by three experienced stroke physicians from a certified stroke center and compared to the neuroimaging gold standard. Within this feasibility study, the stroke code was not altered by the outcome of the RACE assessment, and all patients underwent the standard procedures within the emergency unit.

Results

We analyzed 97 patients (median age 78 years, 53% women), of whom 51 (52.6%) suffered an acute stroke, 12 (23.5%) of which were due to an LVO and 46 patients had symptoms mimicking a stroke. The sensitivity of stroke identification was 77.8%, and specificity was 53.6%. In regard to the identification of an LVO, sensitivity was 69.4% and specificity was 84.3%. The inter-rater agreement in the RACE-score assessment was ICC = 0.82 (intraclass-correlation coefficient).

Conclusion

These results confirm our hypothesis that the local telestroke concept is feasible. It allows correct (i) stroke and (ii) LVO identification in the majority of the cases and thus has the potential to assist in efficient prehospital triage.

Prevalence and factors associated with pre-hospital delay among acute stroke patients at Mulago and Kiruddu national referral hospitals, Kampala: a cross-sectional study

BACKGROUND

Despite advancements in acute stroke care, acute stroke patients present late for care resulting in high mortality and poor functional outcomes. This study determined the prevalence of pre-hospital delay and associated factors among adult acute stroke patients in Uganda.

METHODS

In a hospital based, cross-sectional study, one hundred and forty-three study participants with confirmed acute stroke presenting to the emergency units of Mulago and Kiruddu national referral hospitals were enrolled. Using an interviewer-administered questionnaire, details on sociodemographics, onset of stroke, arrival at the tertiary facility, health system and clinical factors were collected. Descriptive statistics and modified Poisson regression analyses were performed to determine factors associated with prehospital delay.

RESULTS

Among the 143 study participants, nearly two-thirds (79/146) had ischemic stroke while a third (59/143) had haemorrhagic stroke. The mean age was 59 years (SD 16) and 51.7% of acute stroke patients were males. Ninety one percent (130/143) presented to the emergency unit after 3 hours. The majority (124/143) reported visiting lower-level facilities prior to referral to the tertiary facility. Staying outside Kampala district (PR: 1.28 (1.22-1.34), p < 0.001), and using hired or government ambulance for transport to tertiary facility (PR: 1.17 (1.13-1.20), p < 0.001) were associated with pre-hospital delay.

CONCLUSIONS

Prevalence of pre-hospital delay among acute stroke patients presenting to public tertiary hospitals in Uganda is very high. The causes of pre hospital delay should be further explored qualitatively. Efforts to reduce prehospital delay should include improving pre-hospital transport systems for stroke patients.

Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide

The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.

Perceived performance of activities of daily living by stroke patients: key in decision to call EMS and outcomes

Background

Until recently, public education campaigns aimed at improving help-seeking behavior by acute stroke patients have achieved only limited or even no effects. Better understanding of psychological factors determining help-seeking behavior may be relevant in the design of more effective future campaigns.

Methods

In this prospective, cross-sectional study, we interviewed 669 acute stroke patients within 72 h after hospital admission. The primary endpoint was the effect of psychological factors on the decision to call emergency medical services (EMS). Secondary endpoints were the effects of such factors on treatment rates and clinical improvement (difference between modified Rankin scale (MRS) scores at admission and at discharge).

Results

Only 48.7% of the study population called the EMS. Multivariate logistic and linear regression analyses revealed that perception of unimpaired performance of activities of daily living (ADL) was the only psychological factor that predicted EMS use and outcomes. Thus, patients who perceived only minor impairment in performing ADL were less likely to use EMS (odds ratio, 0.54 [95% confidence interval, 0.38-0.76]; p = 0.001), had lower treatment rates, and had less improvement in MRS scores (b = 0.40, p = 0.004). Additional serial mediation analyses involving ischemic stroke patients showed that perception of low impairment in ADL decreased the likelihood of EMS notification, thereby increasing prehospital delays, leading to reduced thrombolysis rates and, finally, to reduced clinical improvement.

Conclusion

Perception of unimpaired performance of ADL is a crucial barrier to appropriate help-seeking behavior after acute stroke, leading to undertreatment and less improvement in clinical symptoms. Thus, beyond improving the public's knowledge of stroke symptoms, future public education campaigns should focus on the need for calling the EMS in case of stroke symptoms even if daily activities do not seem to be severely impaired.

Are digital social media campaigns the key to raise stroke awareness in low-and middle-income countries? A study of feasibility and cost-effectiveness in Nepal

BACKGROUND

Stroke is a major global health problem and was the second leading cause of death worldwide in 2020. However, the lack of public stroke awareness especially in low- and middle-income countries (LMICs) such as Nepal severely hinders the effective provision of stroke care. Efficient and cost-effective strategies to raise stroke awareness in LMICs are still lacking. This study aims to (a) explore the feasibility of a social media-based stroke awareness campaign in Nepal using a cost-benefit analysis and (b) identify best practices for social media health education campaigns.

METHODS

We performed a stroke awareness campaign over a period of 6 months as part of a Stroke Project in Nepal on four social media platforms (Facebook, Instagram, Twitter, TikTok) with organic traffic and paid advertisements. Adapted material based on the World Stroke Day Campaign and specifically created videos for TikTok were used. Performance of the campaign was analyzed with established quantitative social media metrics (impressions, reach, engagement, costs).

RESULTS

Campaign posts were displayed 7.5 million times to users in Nepal. 2.5 million individual social media users in Nepal were exposed to the campaign on average three times, which equals 8.6% of Nepal's total population. Of those, 250,000 users actively engaged with the posts. Paid advertisement on Facebook and Instagram proved to be more effective in terms of reach and cost than organic traffic. The total campaign cost was low with a "Cost to reach 1,000 users" of 0.24 EUR and a "Cost Per Click" of 0.01 EUR.

DISCUSSION

Social media-based campaigns using paid advertisement provide a feasible and, compared to classical mass medias, a very cost-effective approach to inform large parts of the population about stroke awareness in LMICs. Future research needs to further analyze the impact of social media campaigns on stroke knowledge.

Prehospital screening of acute stroke with the National Institutes of Health Stroke Scale (ParaNASPP): a stepped-wedge, cluster-randomised controlled trial

BACKGROUND

Timely treatment of acute stroke depends on early identification and triage. Improved methods for recognition of stroke in the prehospital setting are needed. We aimed to assess whether use of the National Institutes of Health Stroke Scale (NIHSS) by paramedics in the ambulance could improve communication with the hospital, augment triage, and enhance diagnostic accuracy of acute stroke.

METHODS

The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge, single-blind, cluster-randomised controlled trial. Patients with suspected acute stroke, who were evaluated by paramedics from five ambulance stations in Oslo, Norway, were eligible for inclusion. The five ambulance stations (defined as clusters) all initially managed patients according to a standard stroke protocol (control group), with randomised sequential crossover of each station to the intervention group. The intervention consisted of supervised training on NIHSS scoring, a mobile application to aid scoring, and standardised communication with stroke physicians. Random allocation was done via a simple lottery draw by administrators at Oslo University Hospital, who were independent of the research team. Allocation concealment was not possible due to the nature of the intervention. The primary outcome was the positive predictive value (PPV) for prehospital identification of patients with a final discharge diagnosis of acute stroke, analysed by intention to treat. Prespecified secondary safety outcomes were median prehospital on-scene time and median door-to-needle time. This trial is registered with ClinicalTrials.gov, NCT04137874, and is completed.

FINDINGS

Between June 3, 2019, and July 1, 2021, 935 patients were evaluated by paramedics for suspected acute stroke. 134 patients met exclusion criteria or did not consent to participate. The primary analysis included 447 patients in the intervention group and 354 in the control group. There was no difference in PPV for prehospital identification of patients with a final discharge diagnosis of acute stroke between the intervention group (48·1%, 95% CI 43·4-52·8) and control group (45·8%, 40·5-51·1), with an estimated percentage points difference between groups of 2·3 (95% CI -4·6 to 9·3; p=0·51). Median prehospital on-scene time increased by 5 min in the intervention group (29 min [IQR 23-36] vs 24 min [19-31]; p<0·0001), whereas median door-to-needle time was similar between groups (26 min [21-36] vs 27 min [20-36]; p=0·90). No prehospital deaths were reported in either group.

INTERPRETATION

The intervention did not improve diagnostic accuracy in patients with suspected stroke. A general increase in prehospital time during the pandemic and the identification of smaller strokes that require more deliberation are possible explanations for the increased on-scene time. The ParaNASPP model is to be implemented in Norway from 2023, and will provide real-life data for further research.

FUNDING

Norwegian Air Ambulance Foundation and Oslo University Hospital.

Prediction of Late Hospital Arrival in Patients with Mild and Rapidly Improving Acute Ischemic Stroke in a Rural Area of China

Purpose

Among all ischemic stroke patients, more than half are mild and rapidly improving acute ischemic stroke (MaRAIS) patients. However, many MaRAIS patients do not recognize the disease early on, and thus they delay access to the treatment that would be most effective if provided earlier. This is especially true in rural areas. The aim of this study was to develop and validate a late hospital arrival risk nomogram in a rural Chinese population of patients with MaRAIS.

Methods

We developed a prediction model based on a training dataset of 173 MaRAIS patients collected from September 9, 2019 to May 13, 2020. Data analyzed included demographics and disease characteristics. A least absolute shrinkage and selection operator (LASSO) regression model was used to optimize feature selection for the late hospital arrival risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the features selected in the LASSO regression models. The discrimination, calibration, and clinical usefulness of the prediction model were assessed using the C-index, calibration plot, and decision curve analysis, respectively. Internal validation was then assessed using bootstrapping validation.

Results

Variables contained in the prediction nomogram included transportation mode, history of diabetes, knowledge of stroke symptoms, and thrombolytic therapy. The model had moderate predictive power with a C-index of 0.709 (95% confidence interval: 0.636-0.783) and good calibration. In the internal validation, the C-index reached 0.692. The risk threshold was 30-97% according to the analysis of the decision curve, and the nomogram could be applied in clinical practice.

Conclusion

This novel nomogram, which incorporates transportation mode, history of diabetes, knowledge of stroke symptoms, and thrombolytic therapy, was conveniently applied to facilitate individual late hospital arrival risk prediction among MaRAIS patients in a rural area of Shanghai, China.

Recurrent stroke arrival time

BACKGROUND

Stroke patients and family members should receive stroke education including recognition of stroke symptoms and prompt activation of emergency medical services (EMS). The impact of this education is unclear. We aimed to measure the associations between EMS use and timing of hospital arrival and first-ever and recurrent strokes as a proxy for stroke education.

METHODS

The study analyzed data from validated strokes identified by the Brain Attack Surveillance in Corpus Christi (BASIC) project between 1/1/2000-1/1/2020. We analyzed 5,617 first-ever strokes, 259 instances of recurrent stroke within 1 year of the first (early recurrence), and 451 recurrent strokes over 1 year from the first (late recurrence). Following imputation, associations of both EMS arrival (available starting late 2011) and early arrival (< 3 hours) with first-ever versus recurrent stroke (early and late) were assessed with logistic models, accounting for the clustering of multiple strokes per participant with generalized estimating equations. Full model covariates included stroke type, initial stroke severity, marital status, race/ethnicity, gender, age, insurance, education, and EMS use (early arrival model only).

RESULTS

Compared to first-ever stroke, there were significantly higher unadjusted odds of arrival by EMS for the late recurrence group (late recurrence OR = 1.54, 95% CI = 1.18-1.99; early arrival OR = 1.24, 95% CI = 0.87-1.76). The association for late recurrence remained significant after adjustment (aOR = 1.46, 95% CI = 1.09-1.95). The pre-2010 unadjusted odds of early arrival were non-significant for both early and late recurrence groups (late recurrence OR = 1.05, CI = 0.70-1.56; early recurrence OR = 0.85, CI = 0.54-1.33), while late recurrence was associated with early arrival after 2010 (OR = 1.32, 95% CI = 1.03-1.69). After full adjustment, it was no longer significant (aOR = 1.25, 95% CI = 0.96-1.62). Higher initial stroke severity, married status, and EMS use were associated with higher odds of early arrival, while African Americans (AAs) had lower odds than non-Hispanic Whites (NHWs). However, AAs did have higher odds of EMS use relative to NHWs. Those who were married and living together had borderline significant lower odds of EMS use compared to those who were not.

CONCLUSIONS

Our study examines the association of repeat stroke on early arrival and EMS use as a surrogate for adequate stroke education. Recurrence at least one year after the first stroke was associated with higher EMS usage, but there was not enough evidence to establish a relationship with early arrival after accounting for EMS usage and possible confounders. By examining subsets, we can identify groups that would benefit from targeted education. For example, younger, non-AA patients with smaller strokes would benefit from more education on EMS use and African American patients would benefit from education related to faster recognition or urgency of presentation.

Trends in Prehospital Visits as a Cause of Delayed Admission in Korean Stroke Patients over a 10-Year Period: A National Health Insurance Claims Data Study

Background

A prehospital delay from symptom onset to hospital arrival resulted in stroke-related complications or in-hospital deaths in acute stroke patients. We aimed to investigate trends in prehospital visits as a cause of prehospital delay using data from the Korean Health Insurance Service.

Methods

This nationwide, population-based, retrospective cohort study included 524,524 newly-diagnosed stroke patients admitted via the emergency departments of secondary and tertiary hospitals. We obtained the prehospital visits rate from 2010 to 2019 and identified the related characteristics.

Results

Prehospital visits were observed in 111,465 patients (21.3%). The prehospital visits rate decreased from 25.1% in 2010 to 17.8% in 2019, but the number of patients increased from 11,255 cases in 2010 to 11,747 cases in 2019. Fortunately, the rate of delayed admission for more than one day decreased from 26.7% to 21.3%. However, 10.4% of patients were diagnosed more than two days later. Young, females, or patients with higher income status and living in low urbanization areas exhibited a higher rate of prehospital visits.

Conclusions

Prehospital visits in Korean stroke patients decreased from 25.1% in 2010 to 17.8% in 2019. However, more than 10,000 patients still visited other medical institutions before admission to treatment.

Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center

Background

Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.

Methods

This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.

Results

One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).

Conclusions

Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.

Factors affecting the presentation time of patients with acute stroke to hospital and level of awareness of thrombolytic therapy

Introduction In this study, it was aimed to reveal the factors affecting the time of presentation of patients with acute stroke to the hospital, determine the rates of benefiting from thrombolytic therapy and assess the thrombolytic therapy awareness of patients. Materials and Methods 276 patients with acute stroke were included in our study. Standard structured questionnaire was administered to the patients. Patients were asked about the time of onset of stroke, age, place of residence, level of education, whether they received thrombolytic therapy, what was done as the first intervention, and whether they had information about thrombolytic therapy. Stroke severity was also evaluated by applying the National Institutes of Health Stroke Scale (NIHSS) to the patients. Results Of the patients included in the study, 218 (79%) had ischemic stroke, 26 (9.4%) had intracerebral hemorrhage and 32 (11.6%) had TIA. The mean NIHH score of the patients was 6.7±6.2. Stroke onset time was mainly between 18.00-24.00 with a rate of 28.3%. It was understood that 83.1% of the patients came to the emergency department by ambulance and 16.9% came by their own vehicle. When the groups of patients who received and did not receive thrombolytic therapy were compared, no significant difference was found between who the patient lived with at home and the groups of the level of education. Statistical significance was found with symptom onset time (p

The PRESTO study: awareness of stroke symptoms and time from onset to intervention

Timely access to medical assistance is the first crucial step to improving clinical outcomes of stroke patients. Many educational campaigns have been organized with the purpose of making people aware of what a stroke is and what is necessary to do after its clinical onset. The PRESTO campaign was organized in Genoa (Italy) to spread easy messages regarding the management of the acute phase of stroke. Educational material was disseminated to educate people to call the emergency medical services as soon as symptoms appear. Data collected were analyzed in three different phases of the campaign: before the beginning, during, and after the end. We enrolled 1,132 patients with ischemic stroke admitted to hospital within 24 hours of symptoms onset. Our data showed a mild reduction in onset-to-door time (24 minutes) during the months following the end of the campaign and a slight increase in number of patients who arrived at hospitals, in particular with milder symptoms and transient ischemic attack, as opposed to the same period before the campaign. Interestingly, in the months after the end of the campaign, we observed a slight reduction of the percentage of patients who accessed hospitals after 4.5 hours from symptoms onset. In conclusion, our results may suggest that an informative campaign can be successful in making people rapidly aware of stroke onset, with the consequent rapid access to hospitals. Considering the changing of way of access to information, we think that an extensive multimedia campaign should be evaluated in the next future.

Factors Associated with Prehospital Delay in Patients with Acute Stroke in South India

Background

Early hospital presentation is critical in the management of acute ischemic stroke. The effectiveness of stroke treatment is highly dependent on the amount of time lapsed between onset of symptoms and treatment. This study was aimed to identify the factors associated with prehospital delay in patients with acute stroke.

Material and Methods

A cross-sectional descriptive study was conducted in Sri Ramachandra University Hospital, India. A total of 210 patients hospitalized in the stroke unit were included. Patients' data were obtained by interviewing the patient and/or accompanying family member and by reviewing their medical records using a standard questionnaire. Associations were determined between prehospital delay (≥4.5 h) and variables of interest by using univariate and multivariate logistic regression analyses.

Results

The prehospital delay was observed in 154 patients (73.3%) and the median prehospital delay was 11.30 h. The following are the factors significantly (P < 0.05) attributed for the delay in presenting to the hospital: contextual factors like using public transport (bus), taxi, time of onset of symptoms, 7 pm-3 am; family history of stroke, perceived cognitive and behavioral factors like, wishing or praying for the symptoms to subside on its own, hesitation to travel due to long distance, delay in arranging transport, and arranging money for admission and wasting time by shopping for general practitioners, nursing homes, and hospitals. The presence of stroke symptom, headache, significantly decreased the prehospital delay.

Conclusions

Prehospital delay is high in South India and influenced by clinical, contextual, and cognitive/behavioral factors.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Comparison of Factors Associated With Direct Versus Transferred-in Admission to Government-Designated Regional Centers Between Acute Ischemic Stroke and Myocardial Infarction in Korea

BACKGROUND

There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI.

METHODS

Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed.

RESULTS

Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI; additionally, age (65-74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI.

CONCLUSIONS

Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses

BACKGROUND AND OBJECTIVES

Early access to hospital for diagnosis and treatment is strongly recommended for patients with acute stroke. Unfortunately, prehospital delay frequently occurs. The aim of the current study was to gain in-depth insight into patient experience and behavior in the prehospital phase of a stroke.

METHODS

We conducted qualitative interviews with a purposive sample of 11 patients and six witnesses within four weeks post stroke. The interviews were audio recorded, transcribed, and analyzed utilizing Systematic Text Condensation.

RESULTS

The material was classified according to two main categories each containing three subgroups. The first category contained the diversity of sudden changes that all participants noticed. The subgroups were confusing functional changes, distinct bodily changes and witnesses' observations of abnormal behavior or signs. The second category was delaying and facilitating factors. To trivialize or deny stroke symptoms, or having a high threshold for contacting emergency services, led to time delay. Factors facilitating early contact were severe stroke symptoms, awareness of the consequences of stroke or a witness standing by when the stroke occurred.

CONCLUSIONS

Prehospital delays involved interrelated elements: (1) Difficulties in recognition of a stroke when symptoms were mild, odd and/or puzzling; (2) Recognition of a stroke or need for medical assistance were facilitated by interaction/communication; (3) High threshold for calling emergency medical services, except when symptoms were severe. The findings may be helpful in planning future public stroke campaigns and in education and training programs for health personnel.

Using Multiple Logistic Regression to Determine Factors Affecting Delaying Hospital Arrival of Patients with Acute Ischemic Stroke

Background

Early treatment of ischemic stroke patients who arrive at the hospital ≤4.5 hours after the onset of symptoms with recombinant tissue plasminogen activator is more beneficial and very important.

Objective

This study is aimed to investigate the factors delaying the hospital arrival of patients with acute ischemic stroke by using multiple logistic regression analysis.

Methods and Materials

This descriptive cross-sectional study was done on patients diagnosed with acute ischemic stroke who were referred to Ardabil city Training and Research hospital at 2018. All patients and/or patient relatives were interviewed and data were collected through a checklist including demographic and clinical data of patients to explore the involved factors delaying hospital arrival of patients and then analyzed using multiple logistic regression analysis.

Results

Of all included patients, only 25.3% arrived at the hospital in ≤ 4.5 hours. By using multivariate logistic regression analysis, living in cities (P = 0.007), cigarette consumption (P = 0.032), having valvular heart disease (P = 0.008), and gender (P = 0.049) were factors associated with an early arrival to the hospital.

Conclusions

Results showed that most of the patients had a considerable delay in arriving at the hospital in ≤ 4.5 hours. Thus, providing health promotion strategies to improve society awareness of early symptoms of stroke, training of local physicians about the importance of early arrival of stroke patients, and more extended ambulance services in all cities and rural areas are necessary for better management of acute stroke patients in this area.

Awareness towards stroke among high school students in Brazil: a cross-sectional study

BACKGROUND

Stroke is one of the main causes of death worldwide. Educational interventions on stroke are potentially effective in reducing the period between the onset of symptoms and the initial emergency medical assistance.

OBJECTIVES

To assess high school students' knowledge of stroke.

DESIGN AND SETTING

Cross-sectional study conducted in high schools in northeastern Brazil.

METHODS

A self-structured questionnaire survey regarding stroke awareness was applied among high school students in northeastern Brazil. Data were collected between 2018 and 2019. The chi-square test and other descriptive statistics were used. Univariate and multivariate analyses were performed using logistic regression.

RESULTS

A total of 1,788 students were analyzed. Eighty percent (n = 1430) of them did not have the minimum knowledge on how to act in a stroke situation. Only 10% (n = 179) presented the ideal knowledge on how to act. Males presented lower levels of knowledge on risk factors (odds ratio, OR: 0.62%; 95% confidence interval, CI: 0.49-0.79) and signs and symptoms of stroke (OR: 0.63%; 95% CI: 0.52-0.77). Students with ≥ 10 years of schooling (OR: 1.64%; 95% CI: 1.30-2.07) demonstrated greater knowledge of signs and symptoms of stroke. Students aged 18 years (OR: 1.70%; 95% CI: 1.14-2.52) demonstrated greater knowledge than other ages regarding the telephone number of the emergency medical services.

CONCLUSIONS

There was a knowledge deficit with regard to recognizing stroke and activating the emergency medical services. The findings apply to the sample investigated and suggest that there is a need for stroke educational interventions, starting in high school.

Analysis of Time to the Hospital and Ambulance Use Following a Stroke Community Education Intervention in China

Importance

Prehospital delay (time from symptom onset of stroke to the door of a hospital) in patients with stroke is long in China. With the goal of improving public awareness and knowledge of stroke recognition, Stroke 1-2-0 was developed in China as an education program to prompt rapid response to the onset of stroke based on clinical practice in China, and examination of its outcomes is needed.

Objective

To investigate the association of the Stroke 1-2-0 educational campaign with prehospital delay for patients with ischemic stroke.

Design, Setting, and Participants

In a population-based cross-sectional study, all patients with ischemic stroke events were admitted to the Minhang Hospital, which is the only tertiary care hospital with a stroke center that provides acute stroke care in Xinzhuang county, Shanghai, China. The study period was from January 1, 2016, to December 31, 2019, and data analysis was performed from January 1 to July 31, 2021.

Exposures

A multifaceted Stroke 1-2-0 educational campaign comprising slides, videos, brochures, and posters distributed in the community.

Main Outcomes and Measures

Proportion of patients with hospital arrival within 3 hours and use of an ambulance to seek medical care, as well as the odds of seeking medical attention within 3 hours after the stroke before vs after initiation of the multifaceted educational campaign.

Results

A total of 2857 patients (1774 men [62.1%]; mean [SD] age, 69.83 [12.66] years) with stroke were identified, including 503 in the precampaign period and 2354 in the postcampaign period. Following the multifaceted campaign, the median (IQR) prehospital delay time decreased from 18.72 (7.44-27.84) hours to 6.00 (2.00-16.35) hours (P < .001). After the implementation of the Stroke 1-2-0 campaign, the proportion of patients with hospital arrival time within 3 hours increased from 5.8% to 33.4% (P < .001) and use of an ambulance increased from 3.2% to 30.6% (P < .001). In an interrupted time series analysis, the initiation of the Stroke 1-2-0 campaign was associated with significantly increased odds of arriving at the hospital within 3 hours (odds ratio, 8.01; 95% CI, 7.17-8.95; P < .001) and use of an ambulance (odds ratio, 9.41; 95% CI, 8.24-10.74; P < .001).

Conclusions and Relevance

The persistent multifaceted campaign using the Stroke 1-2-0 program was associated with reduced prehospital delay and improved timely arrival rate and ambulance arrival rate for patients with stroke. These findings suggest that Stroke 1-2-0 can be adopted in other regions of China to possibly improve health outcomes and reduce clinical burdens for all patients with stroke.

Developing a conceptual model for studying various points of delays and underlying factors in the emergency healthcare system

To review various literature related to emergency healthcarerelated delays and synthesize a conceptual framework for future research. Critical Interpretative Synthesis is employed to analyze and develop themes from selected articles. A total of 25 articles were selected for analysis after the careful selection process. Diseases including acute heart disease, stroke, pneumonia, infections, and gastrointestinal disorders were included. During analysis, three major phases of delays emerged: pre-hospital delay, inhospital delay, and ambulance off-load delay. Various factors, including socioeconomic factors, health system factors, organizational level factors, etc., are related to delays in emergency care settings. The model evolved from this literature analysis is similar to the 3 delays model. This review identified three significant delay segments related to emergency health care management.

Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association

Patients with premorbid disability or dementia have generally been excluded from randomized controlled trials of reperfusion therapies such as thrombolysis and endovascular therapy for acute ischemic stroke. Consequently, stroke physicians face treatment dilemmas in caring for such patients. In this scientific statement, we review the literature on acute ischemic stroke in patients with premorbid disability or dementia and propose principles to guide clinicians, clinician-scientists, and policymakers on the use of acute stroke therapies in these populations. Recent clinical-epidemiological studies have demonstrated challenges in our concept and measurement of premorbid disability or dementia while highlighting the significant proportion of the general stroke population that falls under this umbrella, risking exclusion from therapies. Such studies have also helped clarify the adverse long-term clinical and health economic consequences with each increment of additional poststroke disability in these patients, underscoring the importance of finding strategies to mitigate such additional disability. Several observational studies, both case series and registry-based studies, have helped demonstrate the comparable safety of endovascular therapy in patients with premorbid disability or dementia and in those without, complementing similar data on thrombolysis. These data also suggest that such patients have a substantial potential to retain their prestroke level of disability when treated, despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials. By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population.

Sex and Age Differences in Patient-Reported Acute Stroke Symptoms

Background

Identification of sex- and age-related differences in the presentation of atypical symptoms at stroke onset may reduce prehospital delay and improve stroke treatment if acknowledged at first contact.

Aim

To explore sex- and age-related differences in patient-reported typical and atypical symptoms of a stroke.

Methods

We used data from a cross-sectional survey at two non-comprehensive stroke units in the Capital Region of Denmark. Patient-reported symptoms, stroke knowledge, and behavioral response were analyzed by the Chi-square test or a Fisher's exact test separated by sex. Multivariable logistic regression adjusted for covariates were used to explore sex- and age-related differences according to each patient-reported typical or atypical symptoms.

Results

In total, 479 patients with acute stroke were included (median age 74 years [25th to 75th percentile: 64–80], and 40.1% were women). Female sex was associated with higher odds of presenting with atypical symptoms, such as loss of consciousness (OR 2.12 [95% CI 1.08–4.18]) and nausea/vomiting (OR 2.33 [95% CI 1.24–4.37]), and lower odds of presenting with lower extremity paresis (OR 0.59 [95% CI 0.39–0.89). With each year of age, the odds decreased of presenting with sensory changes (OR 0.95 [95% CI 0.94–0.97]) and upper extremity paresis (OR 0.98 [95% CI 0.96–0.99]), whereas odds of presenting with dysphagia (OR 1.06 [95% CI 1.02–1.11]) increased.

Conclusions

Patients of female sex and younger age reported on admission more frequently atypical stroke symptoms. Attention should be drawn to this possible atypical first presentation to facilitate correct identification and early stroke revascularization treatment to improve the outcome for both sexes.

Pre-Hospital Delay in Patients With Acute Stroke During the Initial Phase of the Coronavirus Disease 2019 Outbreak

BACKGROUND

When a sudden outbreak of an infectious disease occurs, emergency medical services (EMS) response could be negatively affected. The poor prognosis of acute stroke may be largely attributed to delays in treatment. This study aimed to identify the impact of the sudden outbreak of coronavirus disease 2019 (COVID-19) on EMS response for patients with acute stroke.

METHODS

This comparative cross-sectional study was conducted in 25 safety centers in Seoul, Korea. We enrolled patients with acute stroke who were transferred to the emergency department by EMS. The study period was from February-April 2020 and the same period in 2019. Patients were divided into two groups, pre-COVID-19 period and early-COVID-19 period, and previously collected patient data were analyzed. We performed comparative analyses of EMS response and clinical outcomes between the groups.

RESULTS

Of 465 patients, 231 (49.7%) had an acute stroke during the study period. There was no significant difference between clinical characteristics of patients with acute stroke before and after the COVID-19 outbreak. EMS response times increased significantly during the early COVID-19 outbreak. The intensive care unit admission rate and mortality rate increased during the early COVID-19 outbreak.

CONCLUSION

In the initial phase after the sudden COVID-19 outbreak, EMS response times for acute stroke were delayed and the clinical outcomes of patients with acute stroke deteriorated.

Help-seeking behaviour and subsequent patient and system delays in stroke

OBJECTIVES

Prehospital delay is the main reason why only a limited number of stroke patients receive reperfusion therapy. We aimed to investigate help-seeking behaviour in patients and bystanders after onset of stroke and subsequent patient and system delay.

MATERIALS & METHODS

We conducted a cross-sectional study of 332 patients with stroke. We performed structured interviews and used data from the medical records and the Danish Stroke Registry. Primary outcomes were patient delay and system delay.

RESULTS

The median patient delay was 280 min, and the median system delay was 97 min. For a patient delay of <3 h, an additional non-significant system delay of median 30 min was seen for a first contact to a general practitioner (GP), and an additional significant delay of median 490 min was seen for the small group of patients with a first contact to 'other' healthcare professionals compared to the Emergency Medical Services (EMS). For a patient delay of more than 3 h, an additional system delay of median 78 min was found when the first contact was directed to the out-of-hours primary care (OOH-PC). A total of 17% of patients were admitted to another hospital or department before arrival at the stroke centre; this resulted in a substantially prolonged system delay of a median of 431 min.

CONCLUSIONS

Patient delay remains the main reason for delayed arrival at the stroke centre. Appropriate help-seeking behaviour and efficient pre-hospital triage are essential for reducing the prehospital delay and increasing the proportion of patients receiving reperfusion therapy.

Educational Program Improved Senior Preparedness to Call 911 as a Response to Stroke

OBJECTIVES

Stroke predominantly affects the elderly. Universities of the Third Age (U3A) are presented with an opportunity to target them. The goal of our study was to improve older adults' preparedness to call 911 as a response to symptoms of stroke.

MATERIALS AND METHODS

Participants were recruited from U3A in Brno, Czech Republic in year 2018. The program included an educational movie about stroke and testing with pretest posttest design. Stroke awareness was measured by Stroke Action Test and video-clips portraying stroke and stroke mimicking symptoms. Respondents had to answer close-ended questions. Composite scores were compared using paired t-test.

RESULTS

Data were obtained from 206 attendees of the program, that is 2% of all students, from 4 of 5 U3A in Brno. The mean test score improved from 80% to 87% (paired p < 0.001). Participants with a lower baseline knowledge improved by 12% (95% CI 9% to 16%) and with a higher baseline knowledge by 0% (95% CI 3% to 4%). The score for calling 911 for stroke mimicking symptoms improved from 29% to 20% (paired p < 0.001).

CONCLUSIONS

Video-based educational program improved senior preparedness to call 911 as a response to stroke. The improvement was mild, which is at least partly due to a high baseline level of preparedness of seniors active in U3A. A lower baseline knowledge was however associated with a bigger improvement, which might be important for use in a less active/educated population. Educational intervention also decreased intention to call 911 for stroke mimicking symptoms, which could have important implications for decreasing unnecessary activation of pre-hospital services.

Development of a machine learning-based real-time location system to streamline acute endovascular intervention in acute stroke: a proof-of-concept study

BACKGROUND

Delivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether WiFi fingerprinting is a feasible machine learning (ML)-based real-time location system (RTLS) technology that can provide accurate real-time location information within a hospital setting, and (b) hypothesize its potential application in streamlining acute stroke endovascular intervention.

METHODS

We conducted our study in a comprehensive stroke care unit in Melbourne, Australia that offers a 24-hour mechanical thrombectomy service. ML algorithms including K-nearest neighbors, decision tree, random forest, support vector machine and ensemble models were trained and tested on a public WiFi dataset and the study hospital WiFi dataset. The hospital dataset was collected using the WiFi explorer software (version 3.0.2) on a MacBook Pro (AirPort Extreme, Broadcom BCM43x×1.0). Data analysis was implemented in the Python programming environment using the scikit-learn package. The primary statistical measure for algorithm performance was the accuracy of location prediction.

RESULTS

ML-based WiFi fingerprinting can accurately predict the different hospital zones relevant in the acute endovascular intervention workflow such as emergency department, CT room and angiography suite. The most accurate algorithms were random forest and support vector machine, both of which were 98% accurate. The algorithms remain robust when new data points, which were distinct from the training dataset, were tested.

CONCLUSIONS

ML-based RTLS technology using WiFi fingerprinting has the potential to streamline delivery of acute stroke endovascular intervention by efficiently tracking patient and staff movement during stroke calls.

Knowledge, Prevention Practice and Associated Factors of Stroke Among Hypertensive and Diabetic Patients - A Systematic Review

INTRODUCTION

Because of the inadequate level of public awareness of the disease, the incidence of stroke has been sharply rising. Eventually, due to the prehospital delay, many stroke cases could not be eligible for thrombolysis thereby poor rehabilitative outcome has been tremendously increased. Thus, this study aimed to review the level of knowledge, prevention practice, and associated factors of stroke among hypertensive and diabetic patients.

METHODS

A systematic review of primarily published articles (2010-2020) related to knowledge and prevention practices of stroke was performed by searching online electronic databases like PubMed, Google Scholar, Refseek, Science direct, ResearchGate, and manual Google search by using the keywords and MeSH terms. Studies conducted on knowledge and prevention practices amongst hypertensive and/or diabetic patients were included.

RESULTS

Out of 531 searched studies, 42 articles were identified to be reviewed. The reported overall knowledge of stroke was ranging from 4.4% to 79%. Knowledge to the signs/symptoms of stroke was 23.6% to 87%. However, 15% to 77% of subjects were also reported that they did not know any sign of stroke. The range of risk factor knowledge was 10.5% to 86.6%. The reported level of stroke prevention practice was 2.4% to 72% but physical activity and weight reduction practice were relatively low. Inadequate level of knowledge and prevention practice of stroke was related to elderly, female gender, uneducated, unmarried, rural residents, economically low, comorbidity and unemployed individuals.

CONCLUSION

The current finding revealed that the level of knowledge and prevention practice of stroke was inadequate. Hence, the finding highlights health educational programs should be planned as an important avenue to enhance stroke awareness among the high-risk populations.

Patient-reported factors associated with early arrival for stroke treatment

OBJECTIVE

Timely evaluation and initiation of treatment is the key for improving stroke outcomes, although minimizing the time from symptom onset to the first contact with healthcare professionals remains a challenge. We aimed to identify patient-related factors associated with early hospital arrival.

MATERIALS AND METHODS

In this cross-sectional survey, we included patients with stroke or transient ischemic attack admitted directly to one of two noncomprehensive stroke units or transferred to the units from comprehensive stroke centers in the Capital Region of Denmark. Patient-reported factors associated with early hospital arrival were analyzed using multivariable logistic regression analysis adjusted for age, sex, education, living arrangement, brain location of the stroke, stroke severity, patient-perceived symptom severity, history of prior stroke, stroke risk factors, and knowledge of stroke symptoms.

RESULTS

In total, 479 patients with acute stroke were included (median age 74 (25th-75th percentile, 64-80), 40% women), of whom 46.4% arrived within 180 min of symptom onset. Factors associated with early hospital arrival were patients or bystanders choosing emergency medical service (EMS) for the first contact with a medical professional (adjusted odds ratio (OR), 3.41; 95% confidence interval, CI [1.57, 7.35]) or the patient's perceived symptom severity above the median score of 25 on a 100-point verbal scale (adjusted OR, 2.44; 95% CI [1.57, 3.82]). Living alone reduced the likelihood of early arrival (adjusted OR, 0.53; 95% CI [0.33, 0.86]).

CONCLUSIONS

Only when patients perceived symptoms as severe or when EMS was selected as the first contact, early arrival for stroke treatment was ensured.

Pre-hospital causes for delayed arrival in acute ischemic stroke before and during the COVID-19 pandemic: A study at two stroke centers in Egypt

BACKGROUND

In the current study we investigated the causes of pre-hospital delay as this can compromise the patient's chance to receive thrombolytic therapy and thus impact stroke outcome.

METHODS

We surveyed 254 patients regarding reasons for delayed and early arrival to hospital after acute ischemic stroke. The survey was performed over five months, spanning a period pre- and during COVID-19 (between December 7, 2019 and May 10, 2020).

RESULTS

A total of 71.2% of patients arrived beyond four hours of onset of ischemic stroke. The commonest cause for delay pre-Covid-19 was receiving treatment in a non-stroke hospital, while that during COVID-19 was fear of infection and lock down issues. Not realizing the urgency of the condition and stroke during sleep were common in both periods. Early arrival because of the patient's previous experience with stroke accounted for approximately 25% of cases in both periods. The effect of media was more evident during COVID-19, accounting for 47.7% of cases.

CONCLUSION

Pre-hospital delay secondary to misperception of the urgency of stroke and management in a non-stroke hospital reflect the lack of awareness among the public and medical staff. This concept is emphasized by early arrival secondary to previous experience with stroke and the pronounced effect of media in the time of COVID-19.

Translation, cross-cultural adaptation and validation of the Cincinnati prehospital stroke scale in Brazil

BACKGROUND

Use of internationally standardized instruments to assist healthcare professionals in accurately recognizing stroke early is recommended. The process of translation and cross-cultural adaptation is important for ensuring that scales are interpreted in the same way in different languages, thus ensuring applicability in several countries.

OBJECTIVE

To translate into Brazilian Portuguese, cross-culturally adapt and validate the Cincinnati Prehospital Stroke Scale, using a representative sample of the Brazilian population.

METHOD

The present study included patients with suspected stroke who were treated at a Brazilian emergency medical service and referred to a stroke center. A systematic process of translation and cross-cultural adaptation of the original scale and application of the final instrument was performed. Statistical analysis was used to assess the sensitivity, specificity and accuracy of the scale. Cohen's kappa coefficient was used to assess inter-rater reliability.

RESULTS

After translation and cross-cultural adaptation, the scale was applied to 64 patients. It showed 93.0% accuracy and 92.4% sensitivity in relation to the final "gold standard" diagnosis. Cohen's kappa coefficient was calculated using data from 26 patients (40.6%) and showed excellent inter-rater reliability between items on the scale (0.8385 to 1.0000).

CONCLUSION

The scale demonstrated excellent accuracy, sensitivity and inter-rater reliability. It was a useful tool for assisting healthcare professionals during initial assessments on patients with suspected stroke and significantly contributed to early recognition of stroke in a simple and quick manner.

Time for a prehospital-modified sequential organ failure assessment score: An ambulance-Based cohort study

BACKGROUND

To adapt the Sequential Organ Failure Assessment (SOFA) score to fit the prehospital care needs; to do that, the SOFA was modified by replacing platelets and bilirubin, by lactate, and tested this modified SOFA (mSOFA) score in its prognostic capacity to assess the mortality-risk at 2 days since the first Emergency Medical Service (EMS) contact.

METHODS

Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of adults with acute diseases, referred to two tertiary care hospitals (Spain), between January 1st and December 31st, 2020. The discriminative power of the predictive variable was assessed through a prediction model trained using the derivation cohort and evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) on the validation cohort.

RESULTS

A total of 1114 participants comprised two separated cohorts recruited from 15 ambulance stations. The 2-day mortality rate (from any cause) was 5.9% (66 cases). The predictive validity of the mSOFA score was assessed by the calculation of the AUC of ROC in the validation cohort, resulting in an AUC of 0.946 (95% CI, 0.913-0.978, p < .001), with a positive likelihood ratio was 23.3 (95% CI, 0.32-46.2).

CONCLUSIONS

Scoring systems are now a reality in prehospital care, and the mSOFA score assesses multiorgan dysfunction in a simple and agile manner either bedside or en route. Patients with acute disease and an mSOFA score greater than 6 points transferred with high priority by EMS represent a high early mortality group.

TRIAL REGISTRATION

ISRCTN48326533, Registered Octuber 312,019, Prospectively registered (doi:https://doi.org/10.1186/ISRCTN48326533).