Hospital Arrival Time and Intravenous t-PA Use in US Academic Medical Centers, 2001–2004

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.

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

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

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.

Transcranial Doppler Ultrasonography in Pre-hospital Management of Stroke: Can it make a Difference?

The aim of this paper is to discuss the use of transcranial doppler in the pre-hospital management of stroke. In the pre-hospital organization, neurological defect scales are used, but they are often indicative of the occlusions of anterior circulation and not of the posterior circulation. Patients with posterior circulation stroke are sometimes not diagnosed and clinically treated. In the pre-hospital phase, the transcranial doppler may identify an occlusion of the large cerebral vessels and be useful for stroke patients, in particular those with posterior occlusions, for a more precise diagnosis and consequently for adequate treatment in the excellence centers for stroke.

Mobile Stroke Units: Current and Future Impact on Stroke Care

Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.

Association of chronic kidney disease with in-hospital outcomes of endovascular stroke interventions

BACKGROUND

Data on the differential impact of chronic kidney disease (CKD) on the outcomes of endovascular stroke interventions (ESI) for acute ischemic stroke (AIS) are limited.

METHODS

Adult patients who underwent ESI for AIS between October 1st, 2015 and September 30th, 2019, were identified in a national multicenter database. The primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints included intracranial hemorrhage, mechanical ventilation, pneumonia, myocardial infarction, blood transfusion, length of stay, and cost. A multilevel mixed-effects regression model was used to derive adjusted outcomes.

RESULTS

A total of 22,193 AIS patients who underwent ESI at 99 centers were included. Among those, 18,881 (85%) had no CKD, and 3312 (15%) had CKD. Patients with CKD were older and had a higher prevalence of key comorbidities. After multivariable risk adjustment, patients with CKD had significantly higher in-hospital mortality (Odds Ratio [OR] 1.55 [95% Confidence Interval] [CI] 1.40-1.73, p < 0.01), and poor functional outcomes (OR 1.38, 95%CI 1.26-1.50, p < 0.01). Major complications, including mechanical ventilation, pneumonia, blood transfusion, and myocardial infarction, were more common among CKD patients, who also had longer hospitalizations and accrued higher cost.

CONCLUSION

The presence of CKD in patients with AIS treated with ESI is an independent predictor of in-hospital mortality and poor functional outcomes at discharge.

Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention

Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.

Clinical Outcomes of On-Site Versus Off-Site Endovascular Stroke Interventions

OBJECTIVES

The aim of this study was to assess whether offering local endovascular stroke therapy (EST) rather than transferring patients off-site to receive EST would improve outcomes.

BACKGROUND

There are limited data to determine whether offering EST on-site rather than transferring patients to receive EST off-site improves clinical outcomes.

METHODS

A large academic consortium database was queried to identify patients with acute ischemic stroke who received EST between October 2015 and September 2019. Primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints were major complications, length of stay, and cost. Baseline characteristics were adjusted for using propensity score matching and multivariate risk adjustment.

RESULTS

A total of 22,193 patients with acute ischemic stroke who underwent EST (50.8% on-site, 49.2% off-site) were included. Mean ages were 67.9 ± 15.5 years and 68.4 ± 15.5 years, respectively (p = 0.03). In the propensity score matching analysis, mortality and poor functional outcomes were higher in the off-site EST group (14.7% vs. 11.2% and 40.7% vs. 35.9%, respectively; p < 0.001). In the risk-adjusted analyses with different models, in-hospital mortality and poor functional outcomes remained significantly higher in the off-site EST group. In the most comprehensive model (adjusting for age, sex, demographics, risk factors, tissue plasminogen activator use, and institutional EST volume), in-hospital mortality and poor functional outcomes were significantly higher in the off-site EST group, with odds ratios of 1.38 (95% confidence interval: 1.26 to 1.51) and 1.26 (95% confidence interval: 1.18 to 1.34), respectively (p < 0.001). The incidence of intracranial hemorrhage and mechanical ventilation was higher in the off-site group, but cost was higher in the on-site group in both the propensity score matching and risk-adjusted analyses.

CONCLUSIONS

In contemporary U.S. practice, patients with acute ischemic stroke treated with EST on-site had lower in-hospital mortality and better functional outcomes compared with those transferred off-site for EST.

Factors affecting the arrival time to hospital of patients with acute ischemic stroke

Objective: It is known that intravenous thrombolytic therapy in ischemic stroke is beneficial in selected patients who arrived within the first 4.5 hours after the onset of the symptoms and the effectiveness of the treatment depends on early arrival to the hospital. The more patients arrival to the hospital within this time zone, the more they will have the chance to receive thrombolytic therapy. This study aims to investigate the factors that cause delay in the arrival of patients with ischemic stroke to the hospital. Methods: Patients diagnosed with acute ischemic stroke who applied to the neurology outpatient clinic and emergency room between February and May 2019 were included in the study. A direct interview survey was conducted to investigate the factors that delay the arrival to patients or relatives of the patients arrival to Bursa Yuksek Ihtisas Training and Research Hospital due to acute stroke. According to the time of arrival to the hospital after the onset of stroke symptoms, patients were classified as early ( 4.5 hours) and late arrival (> 4.5 hours). Based on this grouping, factors causing delay in patients' access to hospital were compared statistically. Results: A total of 251 patients and / or patient relatives who arrived to the emergency and neurology outpatient clinic were interviewed. Of the 251 patients included in the study, 119 (47.4%) were female and the mean age was 70 (34-94) years. Approximately 72.5% of the patients were arrived in the first 4.5-hour slice after the onset of stroke symptoms. Factors causing late arrival were determined as being female, having low NIHSS score and not using ambulance in transportation. Conclusion: Due to the delay in arrival of 27.5% of the patients, there is no chance to apply thrombolytic therapy to eligible ones. The factors resulting in the delay were discovered as female gender, low severity of the stroke and transportation without ambulance. In this respect, community-oriented trainings are required.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Multimodal MRI-Based Triage for Acute Stroke Therapy: Challenges and Progress

Revascularization therapies have been established as the treatment mainstay for acute ischemic stroke. However, a substantial number of patients are either ineligible for revascularization therapy, or the treatment fails or is futile. At present, non-contrast computed tomography is the first-line neuroimaging modality for patients with acute stroke. The use of magnetic resonance imaging (MRI) to predict the response to early revascularization therapy and to identify patients for delayed treatment is desirable. MRI could provide information on stroke pathophysiologies, including the ischemic core, perfusion, collaterals, clot, and blood–brain barrier status. During the past 20 years, there have been significant advances in neuroimaging as well as in revascularization strategies for treating patients with acute ischemic stroke. In this review, we discuss the role of MRI and post-processing, including machine-learning techniques, and recent advances in MRI-based triage for revascularization therapies in acute ischemic stroke.

The Effect of Being Found with Stroke Symptoms on Predictors of Hospital Arrival

BACKGROUND

Studies examining predictors of delay in hospital arrival after stroke symptom onset have not accounted for patients who are found with their symptoms and cannot seek help independently. Our objective is to show that inclusion of patients who are "found down" in studies of prehospital delay biases the estimated association of sociodemographic and clinical variables with time of hospital arrival.

METHODS

We performed a retrospective analysis of sociodemographic and clinical characteristics of patients with acute ischemic stroke presenting to a tertiary care hospital in the Bronx, New York.

RESULTS

Compared with all other patients with acute ischemic stroke (N = 1784), patients who were found down (N = 120) were more likely to be older (75  ± 13 years versus 68 ± 14 years, P < .0001), female (68% versus 53%, P = .003), Caucasian race (P < .001), have higher socioeconomic status (P = .001), more severe stroke deficits (P < .0001), use emergency medical services (P < .001), and arrive to the hospital more than 3 hours after symptom onset (P < .001). Inclusion of patients who were found down in a model predicting delay in hospital arrival decreased the strength of the association between the predictors and the outcome.

CONCLUSIONS

Being found with stroke symptoms confounds the association of sociodemographic and clinical variables with time of hospital arrival. Studies of predictors of prehospital delay should therefore exclude patients who are found down.

If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke?

Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.

If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke?

Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.

Intra-arterial verapamil post-thrombectomy is feasible, safe, and neuroprotective in stroke

Large vessel ischemic stroke represents the most disabling subtype. While t-PA and endovascular thrombectomy can recanalize the occluded vessel, good clinical outcomes are not uniformly achieved. We propose that supplementing endovascular thrombectomy with superselective intra-arterial (IA) verapamil immediately following recanalization could be safe and effective. Verapamil, a calcium channel blocker, has been shown to be an effective IA adjunct in a pre-clinical mouse focal ischemia model. To demonstrate translational efficacy, mechanism, feasibility, and safety, we conducted a group of translational experiments. We performed in vivo IA dose-response evaluation in our animal stroke model with C57/Bl6 mice. We evaluated neuroprotective mechanism through in vitro primary cortical neuron (PCN) cultures. Finally, we performed a Phase I trial, SAVER-I, to evaluate feasibility and safety of administration in the human condition. IA verapamil has a likely plateau or inverted-U dose-response with a defined toxicity level in mice (LD₅₀ 16-17.5 mg/kg). Verapamil significantly prevented PCN death and deleterious ischemic effects. Finally, the SAVER-I clinical trial showed no evidence that IA verapamil increased the risk of intracranial hemorrhage or other adverse effect/procedural complication in human subjects. We conclude that superselective IA verapamil administration immediately following thrombectomy is safe and feasible, and has direct, dose-response-related benefits in ischemia.

Application of emerging technologies to improve access to ischemic stroke care

During the past 20 years, the traditional supportive treatment for stroke has been radically transformed by advances in catheter technologies and a cohort of prominent randomized controlled trials that unequivocally demonstrated significant improvement in stroke outcomes with timely endovascular intervention. However, substantial limitations to treatment remain, among the most important being timely access to care. Nonetheless, stroke care has continued its evolution by incorporating technological advances from various fields that can further reduce patients' morbidity and mortality. In this paper the authors discuss the importance of emerging technologies—mobile stroke treatment units, telemedicine, and robotically assisted angiography—as future tools for expanding access to the diagnosis and treatment of acute ischemic stroke.

Race-Ethnic Disparities in Hospital Arrival Time after Ischemic Stroke

OBJECTIVE

Conflicting reports exist about hospital arrival time after stroke onset in Hispanics compared with African Americans and Caucasians. Our current study investigates race-ethnic disparities in hospital arrival times after stroke onset.

METHODS

We performed a retrospective analysis of hospital arrival times in Hispanic, African American, and Caucasian acute ischemic stroke patients (N=1790) presenting to a tertiary-care hospital in the Bronx, New York. A multivariable logistic regression model was used to identify the association between race-ethnicity and hospital arrival time adjusting for age, sex, socioeconomic status (SES), NIH stroke scale (NIHSS), history of stroke, preferred language and transportation mode to the hospital.

RESULTS

There were 338 Caucasians, 662 Hispanics, and 790 African Americans in the cohort. Compared with Caucasians, African Americans and Hispanics were younger (P<.0001 respectively), had lower SES (P<.001 respectively) and were less likely to use EMS (P=.003 and P=.001, respectively). A greater proportion of Hispanic and African American women had delayed hospital arrival times (≥3 hours) after onset of stroke symptoms compared with Caucasian women (74% of Hispanic, 72% of African American, and 59% of Caucasian women), but this difference between race-ethnicities is no longer present after adjusting for socioeconomic status. Compared with Caucasian men, hospital arrival ≥3 hours after symptom onset was more likely for African American men (OR 1.72, 95% CI:1.05-2.79) but not Hispanic men (OR .80, 95% CI .49-1.30).

CONCLUSIONS

African American men and socially disadvantaged women delay in presenting to the hospital after stroke onset. Future research should focus on identifying the factors contributing to pre-hospital delay among race-ethnic minorities.

Emerging temporal trends in tissue plasminogen activator use: Results from the BASIC project

OBJECTIVE

To explore temporal trends in tissue plasminogen activator (tPA) administration for acute ischemic stroke (AIS) in a biethnic community without an academic medical center and variation in trends by age, sex, ethnicity, and stroke severity.

METHODS

Cases of AIS were identified from 7 hospitals in the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based surveillance study between January 1, 2000, and June 30, 2012. tPA, demographics, and stroke severity as assessed by the NIH Stroke Scale (NIHSS) were ascertained from medical records. Temporal trends were explored using generalized estimating equations, and adjustment made for age, sex, ethnicity, and NIHSS. Interaction terms were included to test for effect modification.

RESULTS

There were 5,277 AIS cases identified from 4,589 unique individuals. tPA use was steady at 2% and began increasing in 2006, reaching 11% in subsequent years. Stroke severity modified temporal trends (p = 0.003) such that cases in the highest severity quartile (NIHSS > 8) had larger increases in tPA use than those in lower severity quartiles. Although ethnicity did not modify the temporal trend, Mexican Americans (MAs) were less likely to receive tPA than non-Hispanic whites (NHWs) due to emerging ethnic differences in later years.

CONCLUSIONS

Dramatic increases in tPA use were apparent in this community without an academic medical center. Primary stroke center certification likely contributed to this rise. Results suggest that increases in tPA use were greater in higher severity patients compared to lower severity patients, and a gap between MAs and NHWs in tPA administration may be emerging.

Stroke Knowledge in African Americans: A Narrative Review

OBJECTIVE

The purpose of this review is to evaluate the state of knowledge in regard to stroke literacy in African Americans. This topic is important for assessing the specific gaps in stroke knowledge for this population, as well as to evaluate the methodology that has been used to assess stroke literacy.

METHODS

This narrative review includes studies that evaluated and reported stroke knowledge in African Americans and were published between January 2000 and October 2015.

RESULTS

Our review revealed that disparities may exist in recognition of headache and visual symptoms, knowledge of the organ in which stroke occurs, and identification of tobacco use as a risk factor. Stress may be perceived as a more important risk factor among African Americans than among White Americans. The literature does not suggest disparities in knowledge of the appropriate action to take for stroke.

CONCLUSIONS

Racial disparities may exist for specific domains of stroke knowledge. Future studies should explore specific gaps in knowledge to be addressed in stroke prevention interventions for African Americans. Standardization of methods is needed to aid comparisons across populations. The relationship between stroke knowledge and clinical outcomes also needs to be evaluated.

Brain Imaging Using Mobile CT: Current Status and Future Prospects

Computed tomography (CT) is an invaluable tool in the diagnosis of many clinical conditions. Several advancements in biomedical engineering have achieved increase in speed, improvements in low-contrast detectability and image quality, and lower radiation. Portable or mobile CT constituted one such important advancement. It is especially useful in evaluating critically ill, intensive care unit patients by scanning them at bedside. A paradigm shift in utilization of mobile CT was its installation in ambulances for the management of acute stroke. Given the time sensitive nature of acute ischemic stroke, Mobile stroke units (MSU) were developed in Germany consisting of an ambulance equipped with a CT scanner, point of care laboratory system, along with teleradiological support. In a radical reconfiguration of stroke care, the MSU would bring the CT scanner to the stroke patient, without waiting for the patient at the emergency room. Two separate MSU projects in Saarland and Berlin demonstrated the safety and feasibility of this concept for prehospital stroke care, showing increased rate of intravenous thrombolysis and significant reduction in time to treatment compared to conventional care. MSU also improved the triage of patients to appropriate and specialized hospitals. Although multiple issues remain yet unanswered with the MSU concept including clinical outcome and cost-effectiveness, the MSU venture is visionary and enables delivery of life-saving and enhancing treatment for ischemic and hemorrhagic stroke. In this review, we discuss the development of mobile CT and its applications, with specific focus on its use in MSUs along with our institution's MSU experience.

Imaging of prehospital stroke therapeutics

Despite significant quality improvement efforts to streamline in-hospital acute stroke care in the conventional model, there remain inherent layers of treatment delays, which could be eliminated with prehospital diagnostics and therapeutics administered in a mobile stroke unit. Early diagnosis using telestroke and neuroimaging while in the ambulance may enable targeted routing to hospitals with specialized care, which will likely improve patient outcomes. Key clinical trials in telestroke, mobile stroke units with prehospital neuroimaging capability, prehospital ultrasound and co-administration of various classes of neuroprotectives, antiplatelets and antithrombin agents with intravenous thrombolysis are discussed in this article.

Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial

BACKGROUND

Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs.

METHODS

We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed.

RESULTS

Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km2 (202 inhabitants per square mile).

CONCLUSION

This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.

Selective intra-arterial drug administration in a model of large vessel ischemia

With continuing disconnect between laboratory stroke treatment models and clinical stroke therapy, we propose a novel experimental model to study stroke and vessel recanalization that mirrors acute management of large vessel stroke, with concomitant directed pharmacotherapy. Using the tandem transient ipsilateral common carotid/middle cerebral artery occlusion (MCAO) model to induce stroke in mice we then added selective intra-arterial (IA) drug administration for directed pharmacotherapy. The IA model uses micro-angio tubing placed at the bifurcation of the CCA to selectively administer the drug to the internal carotid distribution. We have shown that delivery of pharmacotherapy agents selectively through an IA injection is feasible in a mouse model, which will permit studies involving pharmacotherapy, transgenic modification, and/or a combination. Our IA model has similarities to previously published models of IA injection but differs in that we do not leave an indwelling micro-port or catheter in our animals, which is not clinically relevant as it does not reflect the human condition or current clinical management. Furthermore, we optimized our model to selectively direct therapy to the ipsilateral, stroke affected hemisphere. By developing an IA drug delivery model that mirrors clinical conditions, we are bridging the gap between basic stroke research and what is standard practice in acute ischemic stroke intervention. The IA model of drug delivery can target agents directly to the site of injury while blunting systemic effects, dose penetration issues, and administration delay that have plagued the intraperitoneal and oral drug administration models.

Clinical trials in acute ischemic stroke

Acute ischemic stroke (AIS) is a major cause of mortality and disability and remains a serious and significant global health problem. The development of neurovascular protectants to treat AIS successfully has been beset by disappointments and setbacks. Many promising candidates have lacked significant pleiotropic protective activity for brain tissue and cerebral blood vessels in clinical trials, while those with protective activity have had poor bioavailability or high toxicity. Moreover, the majority of agents did not confer significant neurovascular protection or clinical efficacy, as measured by standard behavioral endpoints in clinical trials of heterogeneous populations of patients with AIS. The recombinant tissue plasminogen activator alteplase is approved in many countries for the treatment of AIS in the first 3 h after symptom onset. Many drug candidates have been subject to clinical trials, including those with anti-excitotoxic, anti-inflammatory, antioxidant, antiapoptotic/regenerative, calcium/adrenergic-modulating/antihypertensive, thrombolytic, nootropic/stimulant, fluid regulatory, or oxygen-delivering mechanisms of action. Some agents, such as tenecteplase, edaravone and minocycline, may be approved for global use in the future. This review evaluates almost all neurovascular protectants subject to clinical trial evaluation for the treatment of AIS, and includes 241 studies conducted between 1978 and 2014. The development of agents that reduce brain injury after AIS will require new and different approaches based on a deeper understanding of the pathophysiology of AIS. Moreover, the future treatment for AIS is likely to lie in combination therapy rather than monotherapy. Additional approaches to the testing and use of neurovascular protectants should be considered.

Geographic access to acute stroke care in the United States

BACKGROUND AND PURPOSE

Only 3% to 5% of patients with acute ischemic stroke receive intravenous recombinant tissue-type plasminogen activator (r-tPA) and <1% receive endovascular therapy. We describe access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke.

METHODS

We used US demographic data and intravenous r-tPA and endovascular therapy rates in the 2011 US Medicare Provider and Analysis Review data set. International Classification of Diseases-Ninth Revision codes 433.xx, 434.xx and 436 identified acute ischemic stroke cases. International Classification of Diseases-Ninth Revision code 99.10 defined intravenous r-tPA treatment and International Classification of Diseases-Ninth Revision code 39.74 defined endovascular therapy. We estimated ambulance response times using arc-Geographic Information System's network analyst and helicopter transport times using validated models. Population access to care was determined by summing the population contained within travel sheds that could reach capable hospitals within 60 and 120 minutes.

RESULTS

Of 370,351 acute ischemic stroke primary diagnosis discharges, 14,926 (4%) received intravenous r-tPA and 1889 (0.5%) had endovascular therapy. By ground, 81% of the US population had access to intravenous-capable hospitals within 60 minutes and 56% had access to endovascular-capable hospitals. By air, 97% had access to intravenous-capable hospitals within 60 minutes and 85% had access to endovascular hospitals. Within 120 minutes, 99% of the population had access to both intravenous and endovascular hospitals.

CONCLUSIONS

More than half of the US population has geographic access to hospitals that actually deliver acute stroke care but treatment rates remain low. These data provide a national perspective on acute stroke care and should inform the planning and optimization of stroke systems in the United States.

Compliance with acute stroke care quality measures in hospitals with and without primary stroke center certification: the North Carolina Stroke Care Collaborative

Background

Organized stroke care is associated with improved outcomes. Data are limited on differences in changes in the quality of acute stroke care at The Joint Commission–certified Primary Stroke Centers (PSCs) versus non‐PSCs over time.

Methods and Results

We compared compliance with the Joint Commission's 10 acute stroke care performance measures and defect‐free care in PSCs and non‐PSCs participating in the Registry of the North Carolina Stroke Care Collaborative from January 2005 through February 2010. We included 29 654 cases presenting at 47 hospitals—10 PSCs, 8 preparing for certification, and 29 non‐PSCs—representing 43% of North Carolina's non–Veterans Affairs, acute care hospitals. Using a non‐PSC referent, odds ratios and 95% CIs were calculated using logistic regression and generalized estimating equations accounting for clustering of cases within hospitals. Time trends were presented graphically using simple linear regression. Performance measure compliance increased for all measures for all 3 groups in 2005–2010, with the exception of discharge on antithrombotics, which remained consistently high. PSCs and hospitals preparing for certification had better compliance with all but 2 performance measures compared with non‐PSCs (each P<0.01). Defect‐free care was delivered most consistently at hospitals preparing for certification (52.8%), followed by PSCs (45.0%) and non‐PSCs (21.9%). Between 2005 and 2010, PSCs and hospitals preparing for certification had a higher average annual percent increase in the provision of defect‐free care (P=0.01 and 0.04, respectively) compared with non‐PSCs.

Conclusions

PSC certification is associated with an overall improvement in the quality of stroke care in North Carolina; however, room for improvement remains.

Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound

BACKGROUND

Transcranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination.

METHODS

Following a '911 stroke code' call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care.

RESULTS

We enrolled '232 stroke code' patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as 'stroke mimics'. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis 'any stroke' showed a sensitivity of 94% and a specificity of 48%. 'Major MCA or ICA stroke' diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%.

CONCLUSIONS

The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment.

Compliance with joint commission measures in state-designated stroke centers

BACKGROUND

Comparison of state-designated primary and comprehensive stroke centers (PSCs and CSCs) with regard to adherence to nationally accepted performance standards are scarce. The objective of this study was to examine if a significant association exists between level of designation and fulfillment of Joint Commission (JC) stroke core measures.

METHODS

A retrospective comparative data analysis of the New Jersey acute stroke registry for the calendar years 2010 and 2011 was performed. JC core measures were compared by hospital level (PSCs vs CSCs). Adjusted odds ratios (aOR) were estimated for association between hospital levels and fulfillment of JC core measures. Median door-to-thrombolytic time was also compared.

RESULTS

There were 36,892 acute stroke admissions. PSCs had 60% of the patients, whereas CSCs had 40%. Hemorrhagic stroke admissions were about 2 times more frequent at CSCs than PSCs (13.3% and 7.1%, respectively). CSCs adhered better to 6 of the 8 JC measures than PSCs. Of eligible patients, 19.5% received thrombolytic therapy at CSCs compared to 9.6% at PSCs, with a 44% difference in provision of thrombolytic therapy (aOR = 0.28, 95% confidence interval: 0.24-0.34). Median door-to-thrombolytic drug times was 65 minutes at CSCs compared to 74.0 minutes at PSCs (P < 0.0001).

CONCLUSIONS

New Jersey state-designated CSCs are better at adhering to the JC core stroke measures and have shorter door-to-thrombolytic drug times.

Stroke: prospective evaluation of a prehospital management process based on rescuers under medical direction

BACKGROUND

Improving access to thrombolytic therapy for patients with ischemic stroke is challenging. We assessed a prehospital process based on firemen rescuers under strict medical direction, aimed at facilitating thrombolysis of eligible patients.

METHODS

This was a prospective observational study conducted over 4 months in Paris, France. Prehospital patients with suspected stroke were included after telephone consultation with a physician. If the time since the onset of symptoms was less than 6 hours, patients were transported directly to a neurovascular unit (NVU); if symptom onset was more than 6 hours ago, they were transported to an emergency department (ED). Confirmation of stroke diagnosis, the rate of thrombolysis, and the time intervals between the call and hospital arrival and imaging were assessed. Comparison used Fisher exact test.

RESULTS

Of the 271 patients transported to an NVU, 218 were diagnosed with a stroke (166 with ischemic stroke), 69 received thrombolytic therapy, and the mean stroke-thrombolysis interval was 150 minutes. Of 64 patients admitted to the ED, 36 patients had a stroke (ischemic, 24). None were thrombolysed. Globally, 36% of ischemic strokes were thrombolysed (27% of all strokes diagnosed). The mean interval call-hospital was 65 minutes (ED vs NVU, P = .61). The interval call-imaging was 202 minutes (interquartile range, 105.5-254.5) for ED and 92 minutes (interquartile range, 77-116) for NVU (P < .001).

CONCLUSIONS

The prehospital management of stroke by rescuers, under strict medical direction, seemed to be feasible and effective for selection of patients with stroke in an urban environment and may improve the access to thrombolysis.

Current Reperfusion Strategies for Acute Stroke

Stroke is the most common cause of permanent disability, the second most common cause of dementia, and the third most common cause of death in the Western world. The treatment of affected patients is a challenge because intravenous (IV) thrombolysis is often ineffective. IV thrombolysis on its own leads to a favorable clinical outcome in only 15% to 25% in patients with large-artery occlusion. Current reperfusion therapies enable high recanalization rates, high rate of favorable clinical outcome, and low complication rates. However, to achieve good clinical results, appropriate patient selection and the use of optimized stroke management system are obligate.

Thrombolytic utilization for ischemic stroke in US hospitals with neurology residency program

OBJECTIVE

We aimed to compare the rates of thrombolysis utilization for acute ischemic stroke in hospitals with neurology residency (NR) to those of other teaching (OT) and nonteaching (NT) hospitals.

METHODS

A retrospective serial cross-sectional cohort study of a nationally representative sample of stroke patients was conducted. Accreditation Council for Graduate Medical Education-accredited NR program-affiliated hospitals in the United States were cross-matched to the hospitals in the Nationwide Inpatient Sample from 2000 to 2010. ICD-9-CM codes were used for case ascertainment.

RESULTS

A total of 712,433 adult ischemic stroke patients from 6,839 hospital samples were included, of whom 10.1%, 29.1%, and 60.8% were treated in NR, OT, and NT hospitals, respectively. Stroke patients in NR received thrombolysis more frequently (3.74% ± 0.24% [standard error]) than in OT (2.28% ± 0.11%, p < 0.001) and NT hospitals (1.44% ± 0.06%, p < 0.001). The adjusted odds ratios (ORs) of thrombolysis rates in NR vs OT and NR vs NT increased with each decade increment in age. In multivariate analysis, NR was independently predictive of higher thrombolysis rate (adjusted OR 1.51; 95% confidence interval [CI] 1.44-1.59 [NR vs OT], and adjusted OR 1.82; 95% CI 1.73-1.91 [NR vs NT]).

CONCLUSIONS

Acute stroke care in NR hospitals is associated with an increased thrombolytic utilization. The disparities between the thrombolysis rate in NR and that in OT and NT hospitals are greater among elderly patients.

Association of geographical factors with administration of tissue plasminogen activator for acute ischemic stroke

BACKGROUND

Intravenous tissue plasminogen activator (tPA) is an effective treatment for acute ischemic stroke if administered within a few hours of stroke onset. Because of this time restriction, tPA administration remains infrequent. Ambulance use is an effective strategy for increasing tPA administration but may be influenced by geographical factors. The objectives of this study are to investigate the relationship between tPA administration and ambulance use and to examine how patient travel distance and population density affect tPA utilization.

METHODS AND RESULTS

We analyzed administrative claims data from 114,194 acute ischemic stroke cases admitted to 603 hospitals between July 2010 and March 2012. Mixed-effects logistic regression models of patients nested within hospitals with a random intercept were generated to analyze possible predictive factors (including patient characteristics, ambulance use, and driving time from home to hospital) of tPA administration for different population density categories to investigate differences in these factors in various regional backgrounds. Approximately 5.1% (5797/114,194) of patients received tPA. The composition of baseline characteristics varied among the population density categories, but adjustment for covariates resulted in all factors having similar associations with tPA administration in every category. The administration of tPA was associated with patient age and severity of stroke symptoms, but driving time showed no association. Ambulance use was significantly associated with tPA administration even after adjustment for covariates.

CONCLUSION

The association between ambulance use and tPA administration suggests the importance of calling an ambulance for suspected stroke. Promoting ambulance use for acute ischemic stroke patients may increase tPA use.

A review of current imaging methods used in stroke research

Stroke is a serious healthcare problem with high mortality and long-term disability. However, to date, our ability to prevent and cure stroke remains limited. One important goal in stroke research is to identify the extent and location of lesion for treatment. In addition, accurately differentiating salvageable tissue from infarct and evaluating therapeutic efficacies are indispensible. These objectives could potentially be met with the assistance of modern neuroimaging techniques. This paper reviews current imaging methods commonly used in ischemic stroke research. These methods include positron emission tomography, computed tomography, T1 MRI, T2 MRI, diffusion and perfusion MRI, diffusion tensor imaging, blood-brain barrier permeability MRI, pH-weighted MRI, and functional MRI.

Factors associated with the administration of tissue plasminogen activator for acute ischemic stroke

BACKGROUND

The use of intravenous tissue plasminogen activator (t-PA) can be an effective treatment for acute ischemic stroke if administered promptly. Despite its clinical effectiveness, overall use in Japan remains low, and regional variations have been reported. Factors such as ambulance utilization and geographical distance from patients' residences to hospitals may influence t-PA administration rates. The aim of this study is to identify factors associated with the administration of t-PA for acute ischemic stroke while adjusting for casemix using a large-scale administrative database in Japan.

METHODS

We analyzed acute ischemic stroke patients admitted to acute care hospitals between July 2010 and March 2011 using a nationwide database. A logistic regression model was used to analyze the factors influencing t-PA administration. Candidate factors included patient gender, age, stroke severity, direct distance between each patient's residence and admitting hospital, and ambulance utilization.

RESULTS

Of the 10,615 ischemic stroke patients from 89 hospitals analyzed, 557 (5.2%) received t-PA treatment. Patients aged 75 years and older were found to be associated with decreased t-PA administration. In contrast, severe stroke and ambulance utilization were associated with increased t-PA administration. Distance was not significantly associated with the use of t-PA.

CONCLUSIONS

Our findings suggest that ambulance utilization is an important factor for improving the likelihood of t-PA administration in patients with stroke and may underline a need for educational programs to the general public that promote the use of ambulances for suspected stroke patients.

Delay in presentation after acute ischemic stroke: the Careggi Hospital Stroke Registry

Intravenous thrombolysis with recombinant tissue-type plasminogen activator is the approved treatment for acute ischemic stroke within 4.5 h from symptoms onset. Evidence suggests the earlier treatment was given, the greater the chance of a favorable outcome. We investigated if the delay in hospital presentation has been modified in the past 8 years. Acute ischemic strokes admitted to the Emergency Department of the Careggi Hospital, Florence from March 2004 to December 2012 were prospectively collected in the Careggi Hospital Stroke Registry. Proportion of patients presenting ≤ 2 h, 2-3.5, 3.5-6, and >6 h from symptom onset or with awakening stroke were compared. From March 2004 to December 2012, 3,856 patients with acute ischemic stroke arrived to the Careggi Emergency Department. During the period, 28.3 % of patients arrived ≤ 2 h from symptoms onset and 9.8 % between 2 and 3.5 h. The proportion of time-eligible patients is steady in the first years with a slight increase in 2011 and 2012. Early presentation is significantly associated with younger age, intracerebral hemorrhage, and stroke severity. In this study, about one-third of acute ischemic strokes arrived at the Emergency Department within the therapeutic time-window for intravenous thrombolysis. There is only a slight increase in early presentation through the period, mainly in the last 2 years. Additional efforts are required to impact deeply on the rates of time-eligible patients.

Thrombolysis for acute ischemic stroke in Joint Commission-certified and -noncertified hospitals in Michigan

BACKGROUND

The Joint Commission (JC) for Accreditation of Healthcare Organizations has devised disease specific certification programs for hospitals, including stroke. JC certification as a primary stroke center (PSC) suggests that the hospital has critical measures in place to ensure improving stroke outcomes over the long term. In this study, we focused on the delivery of care for patients with acute ischemic and compared differences in JC-certified and -noncertified centers in Michigan.

METHODS

We performed a systematic chart review of patients with acute ischemic stroke from 10 Michigan hospitals, half of whom were JC-certified PSCs. Sixty charts were randomly chosen from 1 calendar year from each hospital. An experienced nurse performed the data abstraction, and data analysis was performed with the Fisher exact test.

RESULTS

A total of 602 charts--of which 302 were from JC-certified PSCs--were chosen for the study. The 2 groups were similar with regard to stroke risk factors except that there were significantly more patients with atrial fibrillation in noncertified centers and there were more African American patients in JC-certified PSCs. Significantly more patients were considered for thrombolytic therapy in JC-certified PSCs compared to noncertified centers (90.4% v 66%; P = .0001). Overall, 3.8% of patients had received thrombolytic therapy without any significant difference between JC-certified PSCs and noncertified centers (4.6% v 3%; adjusted odds ratio 1.64; 95% confidence interval 0.64-4.19; P = .87). However, thrombolysis rates among eligible patients was significantly higher in the JC-certified PSCs (48.2% v 8.8%; P = .0001). The most common reason documented for not giving thrombolytic therapy was late arrival outside the therapeutic window, which was more common in JC-certified PSCs (72.8% v 55.6%; P = .0001) compared to noncertified centers. Seventy-four percent of patients from JC-certified PSCs were discharged home or to inpatient rehabilitation facility compared to 71% (P = .38) from noncertified hospitals. The mean length of stay was marginally shorter in JC-certified PSCs compared to noncertified centers (5.53 v 6.25 days; P = .08).

CONCLUSIONS

Rates of thrombolysis administration for acute stroke patients across Michigan were low in both JC-certified and noncertified hospitals, although better processes were in place in JC-certified PSCs. While there was no overall difference in the administration of thrombolytic treatment, a greater number of the eligible patients received thrombolysis in the certified centers. There was a tendency to shorter lengths of stay at JC-certified PSCs, but there was no significant difference in discharge to home, inpatient rehabilitation, or inpatient mortality in this study.

Genes involved in hemorrhagic transformations that follow recombinant t-PA treatment in stroke patients

Aim: Despite the benefits of recombinant t-PA (rt-PA) for stroke patients some of them suffer from adverse hemorrhagic transformations (HTs) following treatment. Our objective is to study the transcriptomics of HTs patients. Methods: We studied by microarrays 11 blood samples from patients with stroke that had received rt-PA of whom six of them had suffered a HT. For replication step RNA was collected from 14 new subjects (seven with HT, seven without) and then analyzed by real-time PCR. Four proteins were measured by ELISA in 72 new subjects to analyze their role as potential protein biomarkers. Results: The microarray analysis revealed that 14 genes were altered among the HT patients. The replication study confirmed these results for six genes. Two of them (BCL2 and OLFM4) are associated with apoptosis, whereas the other four (LTF, LCN2 [also known as NGAL], CEACAM8 and CRISP3) are involved in the regulation of neutrophil processes. Conclusion: Our data revealed that genes related to apoptosis and neutrophil regulation pathways could be associated with HTs after rt-PA.

Original submitted 7 September 2012; Revision submitted 23 January 2013

Thrombolytic therapy for acute ischaemic stroke: what can we do to improve outcomes?

Constant efforts are being made in the stroke community to aim for maximum benefit from thrombolytic therapy since the approval of intravenous recombinant tissue plasminogen activator (rt-PA; alteplase) for the management of acute ischaemic stroke. However, fear of symptomatic haemorrhage secondary to thrombolytic therapy has been a major concern for treating physicians. Certain imaging and clinical variables may help guide the clinician towards better treatment decision making. Aggressive management of some predictive variables that have been shown to be surrogate outcome measures has been related to better clinical outcomes. Achieving faster, safer and complete recanalization with evolving endovascular techniques is routinely practiced to achieve better clinical outcomes. Selection of an 'ideal candidate' for thrombolysis can maximize functional outcomes in these patients. Although speed and safety are the key factors in acute management of stroke patients, there must also be a systematic and organized pattern to assist the stroke physician in making decisions to select the 'ideal candidate' for treatment to maximize results.

Edaravone (Radicut), a free radical scavenger, is a potentially useful addition to thrombolytic therapy in patients with acute ischemic stroke

Acute ischemic stroke (AIS) is a major cause of morbidity and mortality in the aging population worldwide. Alteplase, a recombinant tissue plasminogen activator, is the only Food and Drug Administration-approved thrombolytic agent for the treatment of AIS. Only 2-5% of patients with stroke receive thrombolytic treatment, mainly due to delay in reaching the hospital. Edaravone is a free radical scavenger marketed in Japan to treat patients with AIS, who present within 24 h of the onset of symptoms. When used in combination with alteplase, edaravone may have three useful effects: enhancement of early recanalization, inhibition of alteplase-induced hemorrhagic transformation and extension of the therapeutic time window for alteplase. This is the first review of the literature evaluating the clinical efficacy of edaravone, aiming to clarify whether edaravone should be further evaluated for clinical use worldwide. This review covers both clinical and experimental studies conducted between 1994 and 2012. Edaravone is a potentially useful neurovascular protective agent, used in combination with thrombolytic agents to treat >15 million patients devastated by stroke worldwide annually. Additional clinical studies are necessary to verify the efficacy of edaravone when used in combination with a thrombolytic agent.

Regional Variation in Recommended Treatments for Ischemic Stroke and TIA

Background and Purpose—

Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get With The Guidelines-Stroke.

Methods—

Receipt of 8 guideline-recommended treatments (intravenous tissue-type plasminogen activator, antihypertensives, antithrombotics, anticoagulants for atrial fibrillation, deep vein thrombosis prophylaxis, lipid-lowering medications at discharge, smoking cessation counseling, weight loss education) and defect-free care were compared in 4 US regions among eligible patients with ischemic stroke and transient ischemic attack; there was adjustment for patient demographics, medical history, and hospital characteristics.

Results—

Among 991 995 admissions (South, 37%; Northeast, 27.6%; Midwest, 19.3%; West, 15.9%). Receipt varied regionally for tissue-type plasminogen activator (58.2%–67.8%), lipid-lowering medications (72.5%–75.7%), antihypertensives (80.1%–83.6%), antithrombotics (95.6%–96.8%), deep vein thrombosis prophylaxis (88.0%–91.4%), weight loss education (49.3%–54.7%), and defect-free care (72.1%–76.5%). In adjusted analyses, patients in the South had lower odds of use of intravenous tissue-type plasminogen activator (OR [95% CI]; 0.82 [0.69–0.97]), antihypertensives (0.82 [0.67–0.99]), and defect-free care (0.83 [0.75–0.92]); but, they were more likely to receive lipid-lowering medications (1.28 [1.05–1.54]) compared with those in the Northeast. Patients in the Midwest had lower odds of intravenous tissue-type plasminogen activator administration (0.82 [0.68–0.99]) and defect-free care (0.81 [0.72–0.92]). Those in the West had lower odds of antihypertensives (0.81 [0.67–0.99]), but had greater odds of receiving lipid-lowering medications (1.26 [1.03–1.53]).

Conclusions—

Despite relatively high rates of adherence to stroke-related therapies in Get With The Guidelines-Stroke hospitals, regional variations exist, with over one quarter of patients receiving suboptimal care. Systematic improvements may lead to better patient outcomes.

Times From Symptom Onset to Hospital Arrival in the Get With The Guidelines–Stroke Program 2002 to 2009

Background and Purpose—

Time from symptom onset to hospital arrival is the most important factor in determining eligibility for intravenous tissue-type plasminogen activator. We used data from a large contemporary nationwide study to determine temporal trends in the proportions of patients arriving within time windows for potential acute ischemic stroke therapies.

Methods—

Trends in symptom onset to hospital arrival time (“onset-to-door time”) for patients with acute ischemic stroke in the Get With The Guidelines–Stroke (GWTG-Stroke) program were analyzed between 2003 and 2009. Factors associated with early onset-to-door time (≤2 hours) were also examined.

Results—

Between April 2003 and March 2009, 1287 hospitals submitted data on 413 147 patients with acute ischemic stroke of whom 194 352 (47.0%) had a specific onset time documented. Among all 413 147 patients, onset-to-door time was documented as ≤2 hours in 20.6%, ≤3 hours in 25.1%, ≤3.5 hours in 26.8%, and ≤8 hours in 35.8%. Early arrival within 2 hours was significantly associated with emergency medical services transport ( P <0.0001). There was no substantial change in onset-to-door time over the 6-year study period. Expansion of the tissue-type plasminogen activator treatment window from 3 to 4.5 hours (allowing 60 minutes for provision of tissue-type plasminogen activator) increases the pool of potentially eligible patients by 6.3% (30.1% relative increase).

Conclusions—

More than one fourth of patients with ischemic stroke arrive within the time window for tissue-type plasminogen activator therapy; however, this percentage has remained unchanged over recent years. Further efforts are needed to increase the portion of patients with acute ischemic stroke presenting within the time window for acute interventions.

Delay in presentation after an acute stroke in a multiethnic population in South london: the South london stroke register

BACKGROUND

Delayed presentation to hospital after an acute stroke is a major explanation given for low thrombolysis rates. This study aimed to investigate the factors associated with delays in presentation after an acute stroke and changes after a mass media campaign.

METHODS AND RESULTS

Data were from a population-based study involving 1392 patients with first-ever strokes between 2002 and 2010 in a multiethnic South London population. Associations were determined between prehospital delay (≥3 hours) and variables of interest, including ethnicity, by using multivariate logistic regression analyses. Differences in prehospital delay and thrombolysis rates were determined for the period immediately before and after the FAST mass media campaign (2007/2008 versus 2009/2010). The median (Q(1) to Q(3)) time to presentation was 4.73 (1.55 to 12.70) hours, and 550 (39.5%) presented within 3 hours of symptom onset. In multivariate analysis, patients of black ethnicity had increased odds of delay (odds ratio: 1.63; 95% confidence interval, 1.11 to 2.38), whereas those with more severe strokes characterized by a higher National Institutes of Health Stroke Scale score (odds ratio: 0.35; 95% confidence interval, 0.20 to 0.61) had reduced odds of delay. There was no difference in the proportion of patients who arrived within 3 hours (P=0.30) in the period immediately before and after the FAST campaign (40.7% in 2007/2008 versus 44.9% in 2009/2010). Among patients with ischemic stroke, 119 (11.0%) received thrombolysis between 2002 and 2010, with no difference observed between the pre- and postcampaign periods (16.9% versus 16.4%).

CONCLUSION

Significant delays in seeking care after stroke still occur in this population despite efforts to increase public awareness. Future educational programs must identify and specifically address factors that influence behavior and should target those at higher risk of delay. (J Am Heart Assoc. 2012;1:e001685 doi: 10.1161/JAHA.112.001685.).

Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial

BACKGROUND

Only 2-5% of patients who have a stroke receive thrombolytic treatment, mainly because of delay in reaching the hospital. We aimed to assess the efficacy of a new approach of diagnosis and treatment starting at the emergency site, rather than after hospital arrival, in reducing delay in stroke therapy.

METHODS

We did a randomised single-centre controlled trial to compare the time from alarm (emergency call) to therapy decision between mobile stroke unit (MSU) and hospital intervention. For inclusion in our study patients needed to be aged 18-80 years and have one or more stroke symptoms that started within the previous 2·5 h. In accordance with our week-wise randomisation plan, patients received either prehospital stroke treatment in a specialised ambulance (equipped with a CT scanner, point-of-care laboratory, and telemedicine connection) or optimised conventional hospital-based stroke treatment (control group) with a 7 day follow-up. Allocation was not masked from patients and investigators. Our primary endpoint was time from alarm to therapy decision, which was analysed with the Mann-Whitney U test. Our secondary endpoints included times from alarm to end of CT and to end of laboratory analysis, number of patients receiving intravenous thrombolysis, time from alarm to intravenous thrombolysis, and neurological outcome. We also assessed safety endpoints. This study is registered with ClinicalTrials.gov, number NCT00153036.

FINDINGS

We stopped the trial after our planned interim analysis at 100 of 200 planned patients (53 in the prehospital stroke treatment group, 47 in the control group), because we had met our prespecified criteria for study termination. Prehospital stroke treatment reduced the median time from alarm to therapy decision substantially: 35 min (IQR 31-39) versus 76 min (63-94), p<0·0001; median difference 41 min (95% CI 36-48 min). We also detected similar gains regarding times from alarm to end of CT, and alarm to end of laboratory analysis, and to intravenous thrombolysis for eligible ischaemic stroke patients, although there was no substantial difference in number of patients who received intravenous thrombolysis or in neurological outcome. Safety endpoints seemed similar across the groups.

INTERPRETATION

For patients with suspected stroke, treatment by the MSU substantially reduced median time from alarm to therapy decision. The MSU strategy offers a potential solution to the medical problem of the arrival of most stroke patients at the hospital too late for treatment.

FUNDING

Ministry of Health of the Saarland, Germany, the Werner-Jackstädt Foundation, the Else-Kröner-Fresenius Foundation, and the Rettungsstiftung Saar.

Role of the MMP9 gene in hemorrhagic transformations after tissue-type plasminogen activator treatment in stroke patients

BACKGROUND AND PURPOSE

Despite the benefits of tissue-type plasminogen activator treatment, some stroke patients experience adverse hemorrhagic transformations (HT). Plasma protein levels of MMP9 have been associated with HT occurrence. We aimed to analyze the association of the MMP9 gene with HT occurrence.

METHODS

We analyzed the MMP9 gene in blood samples from 885 stroke patients treated with tissue-type plasminogen activator by tag-SNP, imputed SNP, direct sequencing, and RNA expression.

RESULTS

We did not observe any significant association between MMP9 genetic variations or MMP9 expression and HT occurrence. Moreover, no association was found between MMP9 expression and MMP9 polymorphisms.

CONCLUSIONS

Genetic variations in the MMP9 gene are not associated with HT occurrence in tissue-type plasminogen activator-treated patients.