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Jia W, Jiang Y, Ma R, Huang X, Gu H, Meng X, Li H, Zhao X, Wang Y, Wang Y, Li Z, Wang C. 10-year Temporal Trends of Intravenous Thrombolysis in Acute Ischemic Stroke: Analysis of the China National Stroke Registry I-Ⅲ. J Stroke Cerebrovasc Dis 2024; 33:107431. [PMID: 37951082 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 11/13/2023] Open
Abstract
OBJECTIVES To investigate the 10-year trend in healthcare quality of intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator in acute ischemic stroke (AIS) in China. MATERIALS AND METHODS We analyzed 42,188 AIS within 7 days of onset from the China National Stroke Registry (CNSR) Ⅰ-Ⅲ. Primary outcomes were temporal changes in the proportion of patients arriving at the hospital within 3.5 hours (and 2 hours) of onset and receiving IVT within 4.5 hours (and 3 hours), stratified by region and hospital tier. Secondary outcomes included temporal changes in door-to-needle time (DNT), DNT ≤60 min and favorable outcome defined as a 90-day modified Rankin Scale (mRS) of 0-1. RESULTS Among patients arriving at the hospital within 3.5 hours of onset, 13.5%, 7.1% and 33.4% patients received IVT within 4.5 hours in CNSR Ⅰ, Ⅱ and Ⅲ, respectively, including a higher proportion from eastern China (37.0%) and tertiary hospitals (36.5%). The median DNT was shorter in CNSR Ⅲ (60.0 min) than those in Ⅱ (95.0 min) and I (94.0 min). The proportion of patients with DNT ≤60 min was greater in Ⅲ (53.4%) than those in Ⅱ (26.7%) and Ⅰ (13.4%). The proportion of favorable outcomes was higher in CNSR Ⅲ (72.8%) than those in Ⅱ (49.6%) and Ⅰ (49.4%). Similar trends were observed for patients arriving at the hospital within 2 hours and receiving IVT within 3 hours of onset. CONCLUSIONS The healthcare quality of IVT has improved remarkably in the past decade, notably in eastern China and tertiary hospitals.
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Affiliation(s)
- Weili Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Ruihua Ma
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Xinying Huang
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Center of Stroke, Beijing Institute for Brain Disorders; Advanced Innovation Center for Human Brain Protection, Capital Medical University; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Center of Stroke, Beijing Institute for Brain Disorders; Advanced Innovation Center for Human Brain Protection, Capital Medical University; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences; Chinese Institute for Brain Research, Beijing, China.
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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di Biase L, Bonura A, Caminiti ML, Pecoraro PM, Di Lazzaro V. Neurophysiology tools to lower the stroke onset to treatment time during the golden hour: microwaves, bioelectrical impedance and near infrared spectroscopy. Ann Med 2022; 54:2658-2671. [PMID: 36154386 PMCID: PMC9542520 DOI: 10.1080/07853890.2022.2124448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reperfusion therapy administration timing in acute ischaemic stroke is the main determinant of patients' mortality and long-term disability. Indeed, the first hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects. Delayed ambulance transport, inappropriate triage and difficulty in accessing CT scans lead to delayed onset to treatment time (OTT) in clinical practice. To date brain CT scan is needed to rule out intracranial haemorrhage, which is a major contraindication to thrombolytic therapy. The availability, dimension and portability make CT suitable mainly for intrahospital use, determining further delays in the therapies administration. This review aims at evaluating portable neurophysiology technologies developed with the scope of speeding up the diagnostic phase of acute stroke and, therefore, the initiation of intravenous thrombolysis. Medline databases were explored for studies concerning near infrared spectroscopy (NIRS), bioelectrical impedance spectroscopy (BIS) and Microwave imaging (MWI) as methods for stroke diagnosis. A total of 1368 articles were found, and 12 of these fit with our criteria and were included in the review. For each technology, the following parameters were evaluated: diagnostic accuracy, ability to differentiate ischaemic and haemorrhagic stroke, diagnosis time from stroke onset, portability and technology readiness level (TRL). All the described methods seem to be able to identify acute stroke even though the number of studies is very limited. Low cost and portability make them potentially usable during ambulance transport, possibly leading to a reduction of stroke OTT along with the related huge benefits in terms of patients outcome and health care costs. In addition, unlike standard imaging techniques, neurophysiological techniques could allow continuous monitoring of patients for timely intrahospital stroke diagnosis.KEY MESSAGESFirst hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects.The delay for stroke onset to brain imaging time is one of the major reasons why only a minority of patients with acute ischaemic stroke are eligible to reperfusion therapies.Neurophysiology techniques (NIRS, BIS and MWI) could have a potential high impact in reducing the time to treatment in stroke patients.
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Affiliation(s)
- Lazzaro di Biase
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy.,Brain Innovations Laboratory, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Adriano Bonura
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Maria Letizia Caminiti
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Pasquale Maria Pecoraro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico di Roma, Roma, Italy.,Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
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Mikulík R, Bar M, Bělašková S, Černík D, Fiksa J, Herzig R, Jura R, Jurák L, Klečka L, Neumann J, Ostrý S, Šaňák D, Ševčík P, Škoda O, Šrámek M, Tomek A, Václavík D. Ultrashort Door‐to‐Needle Time for Intravenous Thrombolysis Is Safer and Improves Outcome in the Czech Republic: Nationwide Study 2004 to 2019. J Am Heart Assoc 2022; 11:e023524. [PMID: 35574953 PMCID: PMC9238542 DOI: 10.1161/jaha.121.023524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The benefit of intravenous thrombolysis is time dependent. It remains unclear, however, whether dramatic shortening of door‐to‐needle time (DNT) among different types of hospitals nationwide does not compromise safety and still improves outcome. Methods and Results Multifaceted intervention to shorten DNT was introduced at a national level, and prospectively collected data from a registry between 2004 and 2019 were analyzed. Generalized estimating equation was used to identify the association between DNT and outcomes independently from prespecified baseline variables. The primary outcome was modified Rankin score 0 to 1 at 3 months, and secondary outcomes were parenchymal hemorrhage/intracerebral hemorrhage (ICH), any ICH, and death. Of 31 316 patients treated with intravenous thrombolysis alone, 18 861 (60%) had available data: age 70±13 years, National Institutes of Health Stroke Scale at baseline (median, 8; interquartile range, 5–14), and 45% men. DNT groups 0 to 20 minutes, 21 to 40 minutes, 41 to 60 minutes, and >60 minutes had 3536 (19%), 5333 (28%), 4856 (26%), and 5136 (27%) patients. National median DNT dropped from 74 minutes in 2004 to 22 minutes in 2019. Shorter DNT had proportional benefit: it increased the odds of achieving modified Rankin score 0 to 1 and decreased the odds of parenchymal hemorrhage/ICH, any ICH, and mortality. Patients with DNT ≤20 minutes, 21 to 40 minutes, and 41 to 60 minutes as compared with DNT >60 minutes had adjusted odds ratios for modified Rankin score 0 to 1 of the following: 1.30 (95% CI, 1.12–1.51), 1.33 (95% CI, 1.15–1.54), and 1.15 (95% CI, 1.02–1.29), and for parenchymal hemorrhage/ICH: 0.57 (95% CI, 0.45–0.71), 0.76 (95% CI, 0.61–0.94), 0.83 (95% CI, 0.70–0.99), respectively. Conclusions Ultrashort initiation of thrombolysis is feasible, improves outcome, and makes treatments safer because of fewer intracerebral hemorrhages. Stroke management should be optimized to initiate thrombolysis as soon as possible optimally within 20 minutes from arrival to a hospital.
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Affiliation(s)
- Robert Mikulík
- International Clinical Research Center and Department of Neurology St. Anne’s University Hospital in Brno Czech Republic
- Faculty of Medicine at Masaryk University Brno Czech Republic
| | - Michal Bar
- Department of Neurology University Hospital Ostrava and Faculty of Medicine at University Ostrava Ostrava Czech Republic
| | - Silvie Bělašková
- International Clinical Research Center and Department of Neurology St. Anne’s University Hospital in Brno Czech Republic
| | - David Černík
- Comprehensive Stroke Center ‐ Department of Neurology Masaryk Hospital Ustí nad Labem ‐ KZ a.s. Ustí nad Labem Czech Republic
| | - Jan Fiksa
- Department of Neurology First Faculty of Medicine and General University Hospital, Charles University Prague Czech Republic
| | - Roman Herzig
- Comprehensive Stroke Center University Hospital Hradec KrálovéCharles University Faculty of Medicine in Hradec Králové Czech Republic
| | - René Jura
- Faculty of Medicine at Masaryk University Brno Czech Republic
- Department of Neurology University Hospital Brno Brno Czech Republic
| | - Lubomír Jurák
- Neurocenter Regional Hospital Liberec Liberec Czech Republic
| | - Lukáš Klečka
- Department of Neurology Town Hospital Ostrava Ostrava Czech Republic
| | - Jiří Neumann
- Department of Neurology Chomutov Hospital, KZ a.s. Chomutov Czech Republic
| | - Svatopluk Ostrý
- Comprehensive Stroke Center Hospital České Budějovice, a.s. České Budějovice Czech Republic
- Department of Neurosurgery and Neurooncology First Faculty of Medicine Charles University in Prague Czech Republic
- Military University Hospital Prague Prague Czech Republic
| | - Daniel Šaňák
- Comprehensive Stroke Center in Department of Neurology Palacký Medical School and University Hospital Olomouc Czech Republic
| | - Petr Ševčík
- Department of Neurology Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
- Department of Neurology University Hospital Pilsen Pilsen Czech Republic
| | - Ondřej Škoda
- Department of Neurology Hospital Jihlava Jihlava Czech Republic
- Department of Neurology 3rd Medical School of Charles University and Vinohrady University Hospital Prague Czech Republic
| | - Martin Šrámek
- Department of Neurology Central Military University Hospital Prague and Motol University Hospital Prague Czech Republic
| | - Aleš Tomek
- Department of Neurology 2nd Medical School of Charles University and Motol University Hospital Prague Czech Republic
| | - Daniel Václavík
- Department of Neurology and AGEL Research and Training Institute Ostrava Vítkovice Hospital Ostrava Czech Republic
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4
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Mikulik R, Bar M, Cernik D, Herzig R, Jura R, Jurak L, Neumann J, Sanak D, Ostry S, Sevcik P, Skoda O, Skoloudik D, Vaclavik D, Tomek A. Stroke 20 20: Implementation goals for intravenous thrombolysis. Eur Stroke J 2021; 6:151-159. [PMID: 34414290 DOI: 10.1177/23969873211007684] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis. Material and Method Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004. Results Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients. Discussion Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes. Conclusion Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.
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Affiliation(s)
- Robert Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne's University Hospital Brno, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Faculty Hospital Ostrava and Faculty of Medicine, University Ostrava, Ostrava, Czech Republic
| | - David Cernik
- Department of Neurology, Masaryk Hospital Usti nad Labem - KZ a.s., Comprehensive Stroke Center, Usti nad Labem, Czech Republic
| | - Roman Herzig
- Comprehensive Stroke Center, University Hospital Hradec Kralove and Charles University Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | - Lubomir Jurak
- Neurocenter, Regional Hospital Liberec, Liberec, Czech Republic
| | - Jiri Neumann
- Department of Neurology, County Hospital Chomutov, Chomutov, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Comprehensive Stroke Center, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Svatopluk Ostry
- Department of Neurology, Hospital Ceske Budejovice, a.s., Ceske Budejovice, Czech Republic.,Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, Prague, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Charles University Faculty of Medicine in Pilsen, Pilsen, Czech Republic.,Department of Neurology, University Hospital Pilsen, Pilsen, Czech Republic
| | - Ondrej Skoda
- Department of Neurology, Hospital Jihlava, Jihlava, Czech Republic.,Department of Neurology, 3rd Medical School of Charles University and Vinohrady University Hospital, Prague, Czech Republic
| | - David Skoloudik
- Department of Nursing, Faculty of Health Science, Palacký University Olomouc, Olomouc, Czech Republic
| | - Daniel Vaclavik
- Department of Neurology and AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
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5
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Nordanstig A, Curtze S, Gensicke H, Zinkstok SM, Erdur H, Karlsson C, Karlsson JE, Martinez-Majander N, Sibolt G, Lyrer P, Traenka C, Baharoglu MI, Scheitz JF, Bricout N, Hénon H, Leys D, Eskandari A, Michel P, Hametner C, Ringleb PA, Arnold M, Fischer U, Sarikaya H, Seiffge DJ, Pezzini A, Zini A, Padjen V, Jovanovic DR, Luft A, Wegener S, Kellert L, Feil K, Kägi G, Rentzos A, Lappalainen K, Leker RR, Cohen JE, Gomori J, Brehm A, Liman J, Psychogios M, Kastrup A, Papanagiotou P, Gralla J, Magoni M, Majoie CBLM, Bohner G, Vukasinovic I, Cvetic V, Weber J, Kulcsar Z, Bendszus M, Möhlenbruch M, Ntaios G, Kapsalaki E, Jood K, Nolte CH, Nederkoorn PJJ, Engelter S, Strbian D, Tatlisumak T. EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry. BMJ Open 2021; 11:e042211. [PMID: 34373287 PMCID: PMC8354282 DOI: 10.1136/bmjopen-2020-042211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry. PARTICIPANTS All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS). FINDINGS TO DATE Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups. FUTURE PLANS This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.
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Affiliation(s)
- Annika Nordanstig
- Department of Clinical Neurosciences Sahlgrenska Academy at University of Gothenburg, Sahlgrenska Academy, Goteborg, Sweden,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Sanne M Zinkstok
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Hebun Erdur
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Camilla Karlsson
- Department of Clinical Neurosciences Sahlgrenska Academy at University of Gothenburg, Sahlgrenska Academy, Goteborg, Sweden
| | - Jan-Erik Karlsson
- Department of Clinical Neurosciences Sahlgrenska Academy at University of Gothenburg, Sahlgrenska Academy, Goteborg, Sweden,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Gerli Sibolt
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Merih I Baharoglu
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Jan F Scheitz
- Department of Neurology and Center for Stroke Research, Charite Universitatsmedizin Berlin Klinik fur Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Hilde Hénon
- Department of Neurology, University of Lille, Lille, France
| | - Didier Leys
- Department of Neurology, University of Lille, Lille, France
| | - Ashraf Eskandari
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Marcel Arnold
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia, Belgrade, Clinical Center of Serbia, Beograd, Serbia
| | - Dejana R Jovanovic
- Neurology Clinic, Clinical Centre of Serbia, Belgrade, Clinical Center of Serbia, Beograd, Serbia,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andreas Luft
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Katharina Feil
- Neurology and German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Georg Kägi
- Department of Neurology, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Alexandros Rentzos
- Department of Radiology, Institute of clinical sciences, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden,Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kimmo Lappalainen
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Ronen R Leker
- Department of Neurology, Hebrew University Hadassah Medical School, Yerushalayim, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hebrew University Hadassah Medical School, Yerushalayim, Israel
| | - John Gomori
- Department of Radiology, Hebrew University Hadassah Medical School, Yerushalayim, Israel
| | - Alex Brehm
- Department of Neurology, Georg-August-Universitat Gottingen Universitatsmedizin, Gottingen, Germany
| | - Jan Liman
- Department of Neurology, Georg-August-Universitat Gottingen Universitatsmedizin, Gottingen, Germany
| | - Marios Psychogios
- Department of Neuroradiology, Georg-August-Universitat Gottingen Universitatsmedizin, Gottingen, Germany,Neuroradiology and Stroke Center Basel, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Andreas Kastrup
- Department of Neurology, University Hospitals Bremen-Mitte and Bremen-Ost, Bremen, Germany
| | - Panagiotis Papanagiotou
- Clinic for Diagnostic and Interventional Neuroradiology, University Hospitals Bremen-Mitte and Bremen-Ost, University of Bremen, Bremen, Germany,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mauro Magoni
- USD Stroke Unit and Vascular Neurology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Charles B L M Majoie
- Department of Neuroradiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Georg Bohner
- Institute of Neuroradiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Ivan Vukasinovic
- Clinic of Neurosurgery, Clinical Center of Serbia, Beograd, Serbia
| | - Vladimir Cvetic
- Faculty of Medicine, University of Belgrade, Beograd, Serbia,Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | - Johannes Weber
- Department of Radiology and Nuclear Medicine, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, UniversitatsKlinikum Heidelberg, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, UniversitatsKlinikum Heidelberg, Heidelberg, Germany
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Volos, Thessaly, Greece
| | - Eftychia Kapsalaki
- Department of Radiology, University Hospital of Larissa, School of Medicine, University of Thessaly, Volos, Thessaly, Greece
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden,Department for Clinical Neuroscience and Rehabilitation, Sahlgrenska Academy, Goteborg, Sweden
| | - Christian H Nolte
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Paul J J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University of Basel, Basel, Switzerland,Deptartment of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athen, Greece
| | - Daniel Strbian
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neurosciences, Sahlgrenska University Hospital, Goteborg, Sweden,Department of Neurology, University of Helsinki, Helsinki, Finland
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Sobolewski P, Brola W, Wilczyński J, Szczuchniak W, Wójcik T, Wach-Klink A, Kos M, Kozera G. Cerebral Thrombolysis in Rural Residents Aged ≥ 80. Clin Interv Aging 2020; 15:1737-1751. [PMID: 33061326 PMCID: PMC7522422 DOI: 10.2147/cia.s256070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/05/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers. Patients and Methods This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed. Results The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients’ conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04–5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21–10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03–6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01–1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10–0.62, p = 0.003) were associated with mortality in rural patients over 80. Conclusion We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.
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Affiliation(s)
- Piotr Sobolewski
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland.,Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Waldemar Brola
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland.,Department of Neurology and Stroke Unit, Saint Lukas Hospital in Końskie, Końskie, Poland
| | | | - Wiktor Szczuchniak
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Tomasz Wójcik
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Aleksandra Wach-Klink
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland
| | - Marek Kos
- Department of Neurology and Stroke Unit, Holy Spirit Specialist Hospital in Sandomierz, Sandomierz, Poland.,Department of Public Health, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Kozera
- Medical Simulation Center, Medical University of Gdańsk, Gdańsk, Poland
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7
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Utilization of Intravenous Tissue Plasminogen Activator and Reasons for Nonuse in Acute Ischemic Stroke in Saudi Arabia. J Stroke Cerebrovasc Dis 2020; 29:104761. [PMID: 32173225 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104761] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/11/2020] [Accepted: 02/14/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recombinant tissue plasminogen activator (rt-PA, alteplase) within 4.5 hours of symptom onset decreases the rate of disability after acute ischemic stroke (AIS). Due to various reasons, alteplase remains underutilized in certain regions (∼3% in low- and middle-income countries). AIMS We aimed to estimate the alteplase utilization rate and identify the reasons for nonuse in Saudi Arabia. METHODS We retrospectively reviewed all patients admitted with suspected stroke in the past 24 hours to the stroke unit at King Abdulaziz Medical City, Riyadh, Saudi Arabia from February 2016 to July 2018. We estimated the alteplase utilization rate among patients with AIS who could be treated within 4.5 hours of symptoms onset (≤225 minutes, allowing 45 minutes for door to needle time). We examined potential predictors of alteplase use using multivariable logistic regression analyses. Study was approved by local IRB. RESULTS Of 1366 patients with suspected stroke, 819 (60%) had AIS. The alteplase utilization rates were 8.6% and 29% for all AIS and AIS arrived within the therapeutic window, respectively. The most common reason for no alteplase treatment was late arrival. Only 244 (29.8%) of AIS patients arrived within the time window for treatment. Among patients with sudden neurological deficit who arrived within the therapeutic time window, the most common reasons were mild neurological deficit (National Institutes of Health Stroke Scale score <5, 29.9%), stroke mimics (16.6%), and hemorrhagic stroke (8.1%). CONCLUSIONS Our study showed a comparable alteplase utilization rate with most international estimates. The low utilization rate was mainly attributed to late patient arrival. Urgent interventions are needed to improve public awareness of stroke recognition and prehospital stroke care.
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8
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Abstract
BACKGROUND Prehospital delay remains an important reason for low intravenous tissue plasminogen activator administration rates. Study of ischemic stroke patients' responses to stroke onset may be hampered by lack of a questionnaire designed specifically to examine their cognitive, emotional, and behavioral responses to symptoms. METHODS We provide evidence for content validity and reliability for the Responses to Ischemic Stroke Symptoms Questionnaire (RISQ) through, expert panel review and calculation of a content validity index and a study to examine stability reliability among hospitalized acute ischemic stroke patients. RESULTS Expert panel review demonstrated agreement on the relevance of questionnaire items and an overall content validity index of 0.97. The study to examine stability reliability demonstrated acceptable stability of the items on the RISQ over the short term in a sample of white and black stroke patients. CONCLUSION Preliminary evidence was gathered to support the content validity and stability reliability of the RISQ. Study of the RISQ with other population groups is needed.
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9
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Tong X, Wiltz JL, George MG, Odom EC, Coleman King SM, Chang T, Yin X, Merritt RK. A Decade of Improvement in Door-to-Needle Time Among Acute Ischemic Stroke Patients, 2008 to 2017. Circ Cardiovasc Qual Outcomes 2019; 11:e004981. [PMID: 30557047 DOI: 10.1161/circoutcomes.118.004981] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The clinical benefit of intravenous (IV) alteplase in acute ischemic stroke is time dependent. We assessed the overall temporal changes in door-to-needle (DTN) time and examine the factors associated with DTN time ≤60 and ≤45 minutes. METHODS AND RESULTS A total of 496 336 acute ischemic stroke admissions were identified in the Paul Coverdell National Acute Stroke Program from 2008 to 2017. We used generalized estimating equations models to examine the factors associated with DTN time ≤60 and ≤45 minutes, and calculated adjusted odds ratios and 95% CI. Between 2008 and 2017, the percentage of acute ischemic stroke patients who received IV alteplase including those transferred, increased from 6.4% to 15.3%. After excluding those who received IV alteplase at an outside hospital, a total of 39 737 (8%) acute ischemic stroke patients received IV alteplase within 4.5 hours of the time the patient last known to be well. Significant increases were seen in DTN time ≤60 minutes (26.4% in 2008 to 66.2% in 2017, P<0.001), as well as DTN time ≤45 minutes (10.7% in 2008 to 40.5% in 2017, P<0.001). Patients aged 55 to 84 years were more likely to receive IV alteplase within 60 minutes, while those aged 55 to 74 years were more likely to receive IV alteplase within 45 minutes, as compared with those aged 18 to 54 years. Arrival by emergency medical service, and patients with severe stroke were more likely to receive IV alteplase within 60 and 45 minutes. Conversely, women, black patients as compared with white, and patients with a medical history of diseases associated with stroke were less likely to receive DTN time ≤60 or 45 minutes. CONCLUSIONS Rapid improvements in DTN time were observed in the Paul Coverdell National Acute Stroke Program; however, opportunities to reduce disparities remain.
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Affiliation(s)
- Xin Tong
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.)
| | - Jennifer L Wiltz
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,United States Public Health Service, Atlanta, GA (J.L.W., E.C.O., S.M.C.K.)
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.)
| | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,United States Public Health Service, Atlanta, GA (J.L.W., E.C.O., S.M.C.K.)
| | - Sallyann M Coleman King
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,United States Public Health Service, Atlanta, GA (J.L.W., E.C.O., S.M.C.K.)
| | - Tiffany Chang
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,IHRC, Inc., Atlanta, GA (T.C., X.Y.)
| | - Xiaoping Yin
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.).,IHRC, Inc., Atlanta, GA (T.C., X.Y.)
| | | | - Robert K Merritt
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (X.T., J.L.W., M.G.G., E.C.O., S.M.C.K., T.C., X.Y., R.K.M.)
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10
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Paul C, D'Este C, Ryan A, Jayakody A, Attia J, Oldmeadow C, Kerr E, Henskens F, Grady A, Levi CR. Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke. SAGE Open Med 2019; 7:2050312119865656. [PMID: 31384464 PMCID: PMC6647204 DOI: 10.1177/2050312119865656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/01/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Intravenous thrombolysis is one of few evidence-based treatments for acute
stroke. Treatment uptake is low outside major stroke care centres. There is
a need for greater understanding of barriers encountered by clinicians when
seeking to increase thrombolysis rates. Aim: The aim of this study is to describe physicians’ and nurses’ perceptions
regarding thrombolysis for acute stroke at hospitals in the earlier stages
of thrombolysis implementation. Methods: A cross-sectional paper survey completed by physicians’ and nurses’ was
distributed to 1127 staff at stroke care units, emergency departments or
equivalent stroke care facilities at 19 Australian hospitals, as part of a
cluster randomised controlled trial for thrombolysis implementation and
systems improvement. Results: Of 1127 potential participants, 503 (148 physicians and 355 nurses) completed
surveys (45% response rate). Over 90% agreed that thrombolysis improved the
odds of independent survival. However, 42% to 58% agreed that there were
limitations in the evidence base. A small proportion of staff indicated
deficits in technical competencies. Interactive or competency-based training
was reported by less than two-thirds of the sample. Challenges such as quick
bed availability were identified. Emergency department physicians were less
positive towards the treatment compared with nurses (p < 0.001), stroke
care unit physicians were more positive than nurses (p = 0.047) and older
clinicians were more positive than younger clinicians (p = 0.007). Conclusion: Australian hospitals seeking to address barriers to stroke thrombolysis
implementation may benefit from the availability of interactive and
competency-based training, staff performance feedback, support to make beds
available quickly and bypass arrangements to quickly deliver acute stroke
patients to appropriate facilities.
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Affiliation(s)
- Christine Paul
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Catherine D'Este
- National Centre for Epidemiology & Population Health, The Australian National University, Canberra, ACT, Australia
| | - Annika Ryan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Amanda Jayakody
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Christopher Oldmeadow
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Erin Kerr
- Hunter New England Health, New Lambton Heights, NSW, Australia
| | - Frans Henskens
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia
| | - Alice Grady
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.,Hunter New England Health, New Lambton Heights, NSW, Australia.,Priority Research Centre for Health Behaviour, The University of Newcastle, Callaghan, NSW, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW, Australia.,Hunter New England Health, New Lambton Heights, NSW, Australia
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11
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Nicastro N, Eger AF, Boukrid II, Mueller HFG, Machi P, Vargas MI, Poletti PA, Platon A, Sztajzel RF. Earlier IV thrombolysis and mechanical thrombectomy in acute ischemic stroke are associated with a better recanalization. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x19855602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Combined intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the recommended treatment options for acute ischemic stroke (AIS). It is unclear whether earlier IVT and MT management can predict complete vessel recanalization. Methods: In this single-center retrospective observational study, we included 81 consecutive subjects with proximal middle cerebral artery AIS (age 70.5 ± 14.2 years, 53% female) who had both IVT and MT. We assessed recanalization after mechanical procedure according to modified thrombolysis in cerebral infarction (TICI) score as well as the National Institute of Health Stroke Scale (NIHSS) score at 24 h. Outcomes were modified Rankin Scale (mRS) at discharge, mRS at 3 months, death at 3 months, and prevalence of intracerebral hemorrhage during hospitalization. Results: Multinomial logistic regression ( χ 2 = 49.4, p = 0.0075, pseudo- R 2 = 0.26) showed that complete recanalization (TICI score = 3) was predicted by lower door-to-MT time ( p = 0.014, 95% confidence interval (CI) = −0.09 to −0.01) and lower symptoms-to-IVT time ( p = 0.045, 95% CI = −0.038 to −0.0004). An NIHSS score ≥10 at 24 h was predicted by higher baseline NIHSS ( p < 0.0001) and lower TICI score ( p = 0.009). Lower NIHSS at 24 h predicted a good outcome according to mRS at 3 months ( p = 0.006). Similarly, higher NIHSS at 24 h was a predictor of death at 3 months ( p = 0.013). Conclusions: The present study suggests that bridging therapy may improve vascular recanalization when both IVT and MT are performed earlier.
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Affiliation(s)
- Nicolas Nicastro
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Division of Neurorehabilitation, Geneva University Hospitals, Geneva, Switzerland
| | - Antoine F Eger
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Iman I Boukrid
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Paolo Machi
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Alexandra Platon
- Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
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12
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Ageron FX, Gayet-Ageron A, Steyerberg E, Bouzat P, Roberts I. Prognostic model for traumatic death due to bleeding: cross-sectional international study. BMJ Open 2019; 9:e026823. [PMID: 31142526 PMCID: PMC6549712 DOI: 10.1136/bmjopen-2018-026823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To develop and validate a prognostic model and a simple model to predict death due to bleeding in trauma patients. DESIGN Cross-sectional study with multivariable logistic regression using data from two large trauma cohorts. SETTING 274 hospitals from 40 countries in the Clinical Randomisation of Anti-fibrinolytic in Significant Haemorrhage (CRASH-2) trial and 24 hospitals in the Northern French Alps Trauma registry. PARTICIPANTS 13 485 trauma patients in the CRASH-2 trial and 9945 patients in the Northern French Alps Trauma registry who were admitted to hospital within 3 hours of injury. MAIN OUTCOME MEASURE In-hospital death due to bleeding within 28 days. RESULTS There were 815 (6%) deaths from bleeding in the CRASH-2 trial and 102 (1%) in the Northern French Alps Trauma registry. The full model included age, systolic blood pressure (SBP), Glasgow Coma Scale (GCS), heart rate, respiratory rate and type of injury (penetrating). The simple model included age, SBP and GCS. In a cross-validation procedure by country, discrimination and calibration were adequate (pooled C-statistic 0.85 (95% CI 0.81 to 0.88) for the full model and 0.84 (95% CI 0.80 to 0.88) for the simple model). CONCLUSION This prognostic model can identify trauma patients at risk of death due to bleeding in a wide range of settings and can support prehospital triage and trauma audit, including audit of tranexamic acid use.
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Affiliation(s)
- Francois-Xavier Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
- Emergency Department and Northern French Alps Emergency Network, Hospital Annecy Genevois, Annecy, France
| | - Angele Gayet-Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Research Center and Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospital Geneva, Geneva, Switzerland
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Pierre Bouzat
- Grenoble Alpes Trauma Center, Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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13
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Scheitz JF, Gensicke H, Zinkstok SM, Curtze S, Arnold M, Hametner C, Pezzini A, Turc G, Zini A, Padjen V, Wegener S, Nordanstig A, Kellert L, Kägi G, Bejot Y, Michel P, Leys D, Nolte CH, Nederkoorn PJ, Engelter ST. Cohort profile: Thrombolysis in Ischemic Stroke Patients (TRISP): a multicentre research collaboration. BMJ Open 2018; 8:e023265. [PMID: 30224398 PMCID: PMC6150152 DOI: 10.1136/bmjopen-2018-023265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/06/2018] [Accepted: 08/04/2018] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration aims to address clinically relevant questions about safety and outcomes of intravenous thrombolysis (IVT) and endovascular thrombectomy. The findings can provide observational information on treatment of patients derived from everyday clinical practice. PARTICIPANTS TRISP is an open, investigator-driven collaborative research initiative of European stroke centres with expertise in treatment with revascularisation therapies and maintenance of hospital-based registries. All participating centres made a commitment to prospectively collect data on consecutive patients with stroke treated with IVT using standardised definitions of variables and outcomes, to assure accuracy and completeness of the data and to adapt their local databases to answer novel research questions. FINDINGS TO DATE Currently, TRISP comprises 18 centres and registers >10 000 IVT-treated patients. Prior TRISP projects provided evidence on the safety and functional outcome in relevant subgroups of patients who were excluded, under-represented or not specifically addressed in randomised controlled trials (ie, pre-existing disability, cervical artery dissections, stroke mimics, prior statin use), demonstrated deficits in organisation of acute stroke care (ie, IVT during non-working hours, effects of onset-to-door time on onset-to-needle time), evaluated the association between laboratory findings on outcome after IVT and served to develop risk estimation tools for prediction of haemorrhagic complications and functional outcome after IVT. FUTURE PLANS Further TRISP projects to increase knowledge of the effect and safety of revascularisation therapies in acute stroke are ongoing. TRISP welcomes participation and project proposals of further centres fulfilling the outlined requirements. In the future, TRISP will be extended to include patients undergoing endovascular thrombectomy.
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Affiliation(s)
- Jan F Scheitz
- Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Sanne M Zinkstok
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland
| | - Marcel Arnold
- Department of Neurology, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Guillaume Turc
- Université Paris Descartes Sorbonne Paris Cité, Centre Hospitalier Sainte-Anne, Paris, France
| | - Andrea Zini
- Stroke Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital, Modena, Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia, Belgrad, Serbia
| | - Susanne Wegener
- Department of Neurology, University of Zürich, Zürich, Switzerland
| | - Annika Nordanstig
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Kellert
- Department of Neurology, Klinikum der Universität München, Ludwig-Maximilians University, München, Germany
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Yannick Bejot
- Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Didier Leys
- Department of Neurology, University of Lille, Lille, France
| | - Christian H Nolte
- Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University of Basel and University Hospital Basel, Basel, Switzerland
- Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
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14
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Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017. [PMID: 29209269 DOI: 10.3389/fneur.2017.00617/full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
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Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
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15
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Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017; 8:617. [PMID: 29209269 PMCID: PMC5701972 DOI: 10.3389/fneur.2017.00617] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/06/2017] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
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Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
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16
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Positive impact of the participation in the ENCHANTED trial in reducing Door-to-Needle Time. Sci Rep 2017; 7:14168. [PMID: 29074964 PMCID: PMC5658430 DOI: 10.1038/s41598-017-14164-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/05/2017] [Indexed: 11/09/2022] Open
Abstract
Door-to-needle time (DNT) is a key performance indicator for efficient use of intravenous thrombolysis in acute ischemic stroke (AIS). We aimed to determine whether DNT improved over time in the Enhanced Control of Hypertension and Acute Stroke Study (ENCHANTED) and the clinical predictors of DNT. Temporal trends in DNT were assessed across fourths of time since activation of study centers using generalized linear model. Predictors of long DNT (>60 min) were determined in logistic regression models. Overall mean DNT (min) was 71.8 (95% confidence interval [CI] 70.4–73.2), but decreased significantly over time (fourths): 77.9 (74.9–80.9), 69.3 (66.7–72.0), 69.1 (66.5–71.8) and 71.4 (68.7–74.2) (P for trend, 0.003). The reduction in DNT was particularly marked in China (P for trend, 0.001), but was not significant across the other participating countries (P for trend, 0.065). Independent predictors of long DNT were recruitment from China, short onset-to-door time, lower numbers of patients treated per center, higher diastolic blood pressure, off-hour admission, and absence of proximal clot occlusion. DNT in ENCHANTED declined progressively during the trial, especially in China. However, DNT in China is still longer than the key performance parameter of ≤60 minutes recommended in guidelines. Effective national programs are needed to improve DNT in China.
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17
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Length of stay in emergency department and cerebral intravenous thrombolysis in community hospitals. Eur J Emerg Med 2017; 24:208-216. [DOI: 10.1097/mej.0000000000000330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Advani R, Naess H, Kurz MW. The golden hour of acute ischemic stroke. Scand J Trauma Resusc Emerg Med 2017; 25:54. [PMID: 28532498 PMCID: PMC5440901 DOI: 10.1186/s13049-017-0398-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/12/2017] [Indexed: 11/30/2022] Open
Abstract
Background Acute Ischemic Stroke (AIS) treatment has been revolutionised in the last two decades with the increasing use of Intravenous Thrombolysis (IVT) and with the advent of Endovascular therapy (EVT). AIS treatment and outcome are time dependant and time saving measures are being implemented at every step of the treatment chain. These changes have resulted in lower treatment times in-hospital, but it is unclear if this translates into more patients being treated within 60 min of symptom onset – the Golden Hour. The clinical outcome of IVT therapy in this patient group was our secondary outcome. Methods From 2009 onwards, systematic changes were made to the AIS treatment chain leading to a dramatic decrease in Door-to-Needle (DTN) time. Analyses were performed on the number of these treatments year on year and their clinical outcomes within the Golden Hour at Stavanger University Hospital (SUS). Results Six-hundred and thirteen patients were included; seventy-three were treated within the Golden Hour. The percentage of total IVT treatments occurring in the Golden Hour rose from 2.2% in 2009 to 14.5% in 2015 (p = 0.006) with a high of 18.3% in 2012 (p < 0.001). All of these patients had a Median NIHSS of 0 at discharge, irrespective of age and pre-existing comorbidity. There was no incidence of any ICH and in-hospital mortality was only 2.7% in this group. Discussion The time from AIS symptom onset to treatment is filled with delays. Despite the inherence of some delays,significant efforts on the part of the pre- and in- hospital treatment chain have made IVT therapy within 60 min a possibility. The allocation and use of resources in the setting of rapid AIS treatment is warrantedand yields unprecedented results. Conclusions Our study shows that improved treatment routines led to an increase in the number of patients treated within the Golden Hour. Treatment in the Golden Hour leads to excellent outcomes in all patients, irrespective of age and pre-existing comorbidity.
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Affiliation(s)
- Rajiv Advani
- Department of Neurology, Stavanger University Hospital, Postboks 8100, Stavanger, 4068, Norway. .,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway.
| | - Halvor Naess
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Martin W Kurz
- Department of Neurology, Stavanger University Hospital, Postboks 8100, Stavanger, 4068, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
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19
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Tsivgoulis G, Katsanos AH, Kadlecová P, Czlonkowska A, Kobayashi A, Brozman M, Švigelj V, Csiba L, Fekete K, Kõrv J, Demarin V, Vilionskis A, Jatuzis D, Krespi Y, Liantinioti C, Giannopoulos S, Mikulik R. Intravenous thrombolysis for ischemic stroke in the golden hour: propensity-matched analysis from the SITS-EAST registry. J Neurol 2017; 264:912-920. [PMID: 28315960 DOI: 10.1007/s00415-017-8461-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/06/2017] [Accepted: 03/13/2017] [Indexed: 01/20/2023]
Abstract
As there are scarce data regarding the outcomes of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) within 60 min from symptom onset ("golden hour"), we sought to compare outcomes between AIS patients treated within [GH(+)] and outside [GH(-)] the "golden hour" by analyzing propensity score matched data from the SITS-EAST registry. Clinical recovery (CR) at 2 and 24 h was defined as a reduction of ≥10 points on NIHSS-score or a total NIHSS-score of ≤3 at 2 and 24 h, respectively. A relative reduction in NIHSS-score of ≥40% at 2 h was considered predictive of complete recanalization (CREC). Symptomatic intracranial hemorrhage (sICH) was defined using SITS-MOST criteria. Favorable functional outcome (FFO) was defined as a mRS-score of 0-1 at 3 months. Out of 19,077 IVT-treated AIS patients, 71 GH(+) patients were matched to 6882 GH(-) patients, with no differences in baseline characteristics (p > 0.1). GH(+) had higher rates of CR at 2 (31.0 vs. 12.4%; p < 0.001) and 24 h (41 vs. 27%; p = 0.010), CREC at 2 h (39 vs. 21%; p < 0.001) and FFO (46.5 vs. 34.0%; p = 0.028) at 3 months. The rates of sICH and 3-month mortality did not differ (p > 0.2) between the two groups. GH(+) was associated with 2-h CR (OR: 5.34; 95% CI 2.53-11.03) and CREC (OR: 2.38; 95% CI 1.38-4.09), 24-h CR (OR: 1.88; 95% CI 1.08-3.26) and 3-month FFO (OR: 2.02; 95% CI 1.15-3.54) in multivariable logistic regression models adjusting for potential confounders. In conclusion, AIS treated with IVT within the GH seems to have substantially higher odds of early neurological recovery, CREC, 3-month FFO and functional improvement.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece. .,International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic.
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece.,Department of Neurology, University of Ioannina, Ioannina, Greece
| | - Pavla Kadlecová
- International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic
| | - Anna Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Adam Kobayashi
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Miroslav Brozman
- Neurology Department, University Hospital Nitra, Nitra, Slovakia
| | - Viktor Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Laszlo Csiba
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Klara Fekete
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Vida Demarin
- Department of Neurology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Aleksandras Vilionskis
- Department of Neurology and Neurosurgery, Vilnius University and Republican Vilnius University Hospital, Vilnius, Lithuania
| | - Dalius Jatuzis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Yakup Krespi
- Neurology Department and Stroke Center, Memorial Şişli Hospital, Istanbul, Turkey
| | - Chrissoula Liantinioti
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Iras 39, Gerakas Attikis, 15344, Athens, Greece
| | | | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St. Anne's Hospital, Brno, Czech Republic.,Medical Faculty of Masaryk University, Brno, Czech Republic
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20
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Sommer P, Seyfang L, Posekany A, Ferrari J, Lang W, Fertl E, Serles W, Töll T, Kiechl S, Greisenegger S. Prehospital and intra-hospital time delays in posterior circulation stroke: results from the Austrian Stroke Unit Registry. J Neurol 2016; 264:131-138. [PMID: 27822599 PMCID: PMC5225195 DOI: 10.1007/s00415-016-8330-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/25/2016] [Accepted: 10/26/2016] [Indexed: 01/17/2023]
Abstract
Therapeutic effect of recombinant tissue-plasminogen activator (rt-PA) is time dependent. There is limited evidence whether localization of stroke within the posterior circulation (PCS) is associated with a treatment delay. We aimed to analyze within a nationwide multicenter cohort whether duration of pre- and intra-hospital patient management differs between patients with PCS and anterior circulation strokes (ACS). We studied onset-to-door-times (ODT) and door-to-needle-times (DNT) of all patients with acute ischemic stroke (IS) enrolled in the Austrian Stroke Unit Registry according to infarct localization. Classification into PCS and ACS was based on clinical presentation applying the criteria used in the Oxfordshire Community Stroke Project. Relationships between ODT, respectively, DNT and explanatory variables were modeled by multivariate linear regression. Between 2003 and 2015, 71010 patients with IS were enrolled, 11,924 with PCS and 59,086 with ACS. Overall, the ODT was significantly longer in PCS: median (IQR): 170 (25th, 75th‰: 79,420) min versus 110 (60,240); p < 0.001; this finding held true in multivariable analysis. In 10535 rt-PA-treated patients (1022 PCS/9832 ACS), ODT and DNT were significantly longer among those with PCS: ODT: median: 80 min (55,120) versus 72 (50,110), p < 0.001; DNT: 57 (35.90) versus 45 (30.67), p < 0.001. In the multivariate model, PCS was significantly associated with delay in the DNT. In conclusion, in this large nationwide cohort, patient management was significantly slower in PCS as compared to ACS. Increasing awareness about these delays and further elaboration of the underlying causes may translate into higher proportions of patients with PCS receiving rt-PA.
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Affiliation(s)
- Peter Sommer
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Leonhard Seyfang
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - Alexandra Posekany
- Danube University Krems and Gesundheit Österreich GmbH/BIQG, Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - Elisabeth Fertl
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Töll
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Greisenegger
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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21
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Palazón-Cabanes B, López-Picazo-Ferrer JJ, Morales-Ortiz A, Tomás-García N. [Why is reperfusion therapy delayed in stroke code patients? A qualitative analysis]. ACTA ACUST UNITED AC 2016; 31:347-355. [PMID: 27084299 DOI: 10.1016/j.cali.2016.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/14/2016] [Accepted: 01/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Efficacy and safety of reperfusion therapy in acute ischaemic stroke is time-dependent and has a limited therapeutic window, which is, in fact, the main exclusion criterion. Initiatives to evaluate the quality of care are essential to design future interventions and ensure the shortest management times and application of such treatments. OBJECTIVE The aim of the study is to identify and classify potential causes of delay in the administration of reperfusion therapy in a tertiary hospital, a reference for the comprehensive treatment of acute ischaemic stroke. MATERIAL AND METHODS The project was developed in Hospital Universitario Virgen de la Arrixaca, Murcia, Spain. A total of 337 patients with acute ischaemic stroke treated with reperfusion therapies were evaluated. For qualitative analysis, 2 working groups were formed: an advocacy group that designed and directed the entire project, and a multidisciplinary one, which served as a source of information and a mechanism for active involvement of all professionals in the stroke-care chain. Information was collected in 3 meetings and then, both the flowcharts and the cause-effect diagram were prepared. RESULTS Based on the above tools, potential causes of delay were identified and classified according to an operational criterion into unmodified structures, and modifiable ones with known evidence and hypothetical repercussions. Modifiable ones are noted for their importance in the design of future improvement interventions in stroke care. Some of them are: Variability in following established protocols, lack of procedures in some parts of the stroke-care chain, etc. CONCLUSION Knowledge of the current situation has just been the starting point, but it has been an essential requisite for the design and implementation of a quality improvement program to shorten in-hospital stroke code times.
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Affiliation(s)
- B Palazón-Cabanes
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España.
| | - J J López-Picazo-Ferrer
- Unidad de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - A Morales-Ortiz
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - N Tomás-García
- Unidad de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
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22
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Ahmed N, Hermansson K, Bluhmki E, Danays T, Nunes AP, Kenton A, Lakshmanan S, Toni D, Mikulik R, Ford GA, Lees KR, Wahlgren N. The SITS-UTMOST: A registry-based prospective study in Europe investigating the impact of regulatory approval of intravenous Actilyse in the extended time window (3-4.5 h) in acute ischaemic stroke. Eur Stroke J 2016; 1:213-221. [PMID: 31008282 DOI: 10.1177/2396987316661890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction The SITS-UTMOST (Safe Implementation of Thrombolysis in Upper Time window Monitoring Study) was a registry-based prospective study of intravenous alteplase used in the extended time window (3-4.5 h) in acute ischaemic stroke to evaluate the impact of the approval of the extended time window on routine clinical practice. Patients and methods Inclusion of at least 1000 patients treated within 3-4.5 h according to the licensed criteria and actively registered in the SITS-International Stroke Thrombolysis Registry was planned. Prospective data collection started 2 May 2012 and ended 2 November 2014. A historical cohort was identified for 2 years preceding May 2012. Clinical management and outcome were contrasted between patients treated within 3 h versus 3-4.5 h in the prospective cohort and between historical and prospective cohorts for the 3 h time window. Outcomes were functional independency (modified Rankin scale, mRS) 0-2, favourable outcome (mRS 0-1), and death at 3 months and symptomatic intracerebral haemorrhage (SICH) per SITS. Results 4157 patients from 81 centres in 12 EU countries were entered prospectively (N = 1118 in the 3-4.5 h, N = 3039 in the 0-3 h time window) and 3454 retrospective patients in the 0-3 h time window who met the marketing approval conditions. In the prospective cohort, median arrival to treatment time was longer in the 3-4.5 h than 3 h window (79 vs. 55 min). Within the 3 h time window, treatment delays were shorter for prospective than historical patients (55 vs. 63). There was no significant difference between the 3-4.5 h versus 3 h prospective cohort with regard to percentage of reported SICH (1.6 vs. 1.7), death (11.6 vs. 11.1), functional independency (66 vs. 65) at 3 months or favourable outcome (51 vs. 50). Discussion Main weakness is the observational design of the study. Conclusion This study neither identified negative impact on treatment delay, nor on outcome, following extension of the approved time window to 4.5 h for use of alteplase in stroke.
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Affiliation(s)
- Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden
| | - Karin Hermansson
- Boehringer Ingelheim Medical Department, Boehringer Ingelheim AB, Stockholm, Sweden
| | - Erich Bluhmki
- Biostatistics, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - Thierry Danays
- Medical Department, Boehringer Ingelheim France S.A.S., Reims, France
| | - Ana Paiva Nunes
- Unidade CerebroVascular, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Anthony Kenton
- University Hospitals Coventry and Warwickshire NHS Trust, UK
| | | | - Danilo Toni
- Department of Neurology and Psychiatry, Sapienza University of Rome, Italy
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St. Anne's Hospital in Brno, Czech Republic and Masaryk University, Brno, Czech Republic
| | - Gary A Ford
- Medical Sciences Division, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kennedy R Lees
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden
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23
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Barrett KM, Pizzi MA, Kesari V, TerKonda SP, Mauricio EA, Silvers SM, Habash R, Brown BL, Tawk RG, Meschia JF, Wharen R, Freeman WD. Ambulance-based assessment of NIH Stroke Scale with telemedicine: A feasibility pilot study. J Telemed Telecare 2016; 23:476-483. [PMID: 27177870 DOI: 10.1177/1357633x16648490] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Ischemic stroke is a time-sensitive disease, with improved outcomes associated with decreased time from onset to treatment. It was hypothesised that ambulance-based assessment of the National Institutes of Health Stroke Scale (NIHSS) using a Health Insurance Portability and Accountability Act (HIPAA)-compliant mobile platform immediately prior to arrival is feasible. Methods This is a proof-of-concept feasibility pilot study in two phases. The first phase consisted of an ambulance-equipped HIPAA-compliant video platform for remote NIHSS assessment of a simulated stroke patient. The second phase consisted of remote NIHSS assessment by a hospital-based neurologist of acute stroke patients en route to our facility. Five ambulances were equipped with a 4G/LTE-enabled tablet preloaded with a secure HIPAA-compliant telemedicine application. Secondary outcomes assessed satisfaction of staff with the remote platform. Results Phase one was successful in the assessment of three out of three simulated patients. Phase two was successful in the assessment of 10 out of 11 (91%) cases. One video attempt was unsuccessful because local LTE was turned off on the device. The video signal was dropped transiently due to weather, which delayed NIHSS assessment in one case. Average NIHSS assessment time was 7.6 minutes (range 3-9.8 minutes). Neurologists rated 83% of encounters as 'satisfied' to 'very satisfied', and the emergency medical service (EMS) rated 90% of encounters as 'satisfied' to 'very satisfied'. The one failed video attempt was associated with 'poor' EMS satisfaction. Conclusion This proof-of-concept pilot demonstrates that remote ambulance-based NIHSS assessment is feasible. This model could reduce door-to-needle times by conducting prehospital data collection.
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Affiliation(s)
| | - Michael A Pizzi
- 1 Department of Neurology, Mayo Clinic, USA.,2 Department of Critical Care, Mayo Clinic, USA
| | | | - Sarvam P TerKonda
- 4 Connected Care, Mayo Clinic, USA.,5 Department of Plastic Surgery, Mayo Clinic, USA
| | | | | | - Ranya Habash
- 7 Everbridge (HipaaBridge, formerly e-HipaaChat), Everbridge-USA, USA
| | | | | | | | | | - William D Freeman
- 1 Department of Neurology, Mayo Clinic, USA.,2 Department of Critical Care, Mayo Clinic, USA.,3 Department of Neurosurgery, Mayo Clinic, USA
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Paul CL, Ryan A, Rose S, Attia JR, Kerr E, Koller C, Levi CR. How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care. Implement Sci 2016; 11:51. [PMID: 27059183 PMCID: PMC4825073 DOI: 10.1186/s13012-016-0414-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 03/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke. METHODS Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted. RESULTS Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05). CONCLUSIONS In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.
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Affiliation(s)
- Christine L Paul
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
| | - Annika Ryan
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Shiho Rose
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - John R Attia
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Erin Kerr
- Hunter New England Health, Lookout Road, New Lambton Heights, NSW, 2305, Australia
| | - Claudia Koller
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Christopher R Levi
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Hunter New England Health, Lookout Road, New Lambton Heights, NSW, 2305, Australia.,Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
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25
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Burton KR, Kapral MK, Li S, Fang J, Moody AR, Krahn M, Laupacis A. Predictors of diagnostic neuroimaging delays among adults presenting with symptoms suggestive of acute stroke in Ontario: a prospective cohort study. CMAJ Open 2016; 4:E331-7. [PMID: 27398382 PMCID: PMC4933639 DOI: 10.9778/cmajo.20150110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many studies have examined the timeliness of thrombolysis for acute ischemic stroke, but less is known about door-to-imaging time. We conducted a prospective cohort study to assess the timing of neuroimaging among patients with suspected acute stroke in the province of Ontario, Canada, and to examine factors associated with delays in neuroimaging. METHODS We included all patients 18 years and older with suspected acute stroke seen at hospitals with neuroimaging capacity within the Ontario Stroke Registry between Apr. 1, 2010, and Mar. 31, 2011. We used a hierarchical, multivariable Cox proportional hazards model to evaluate the association between patient and hospital factors and the likelihood of receiving timely neuroimaging (≤ 25 min) after arrival in the emergency department. RESULTS A total of 13 250 patients presented to an emergency department with stroke-like symptoms during the study period. Of the 3984 who arrived within 4 hours after symptom onset, 1087 (27.3%) had timely neuroimaging. The factors independently associated with an increased likelihood of timely neuroimaging were less time from symptom onset to presentation, more severe stroke, male sex, no history of stroke or transient ischemic attack, arrival to hospital from a setting other than home and presentation to a designated stroke centre or an urban hospital. INTERPRETATION A minority of patients with stroke-like symptoms who presented within the 4-hour thrombolytic treatment window received timely neuroimaging. Neuroimaging delays were influenced by various patient and hospital factors, some of which are modifiable.
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Affiliation(s)
- Kirsteen R Burton
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Shudong Li
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Jiming Fang
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Alan R Moody
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Murray Krahn
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation (Burton, Kapral, Krahn, Laupacis), University of Toronto; Departments of Medical Imaging (Burton, Moody) and Medicine (Kapral, Krahn, Laupacis), University of Toronto; Institute for Clinical Evaluative Sciences (Kapral, Li, Fang); Institute of Medical Sciences (Moody), University of Toronto; Toronto Health Economics and Technology Assessment Collaborative (Krahn), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis), St. Michael's Hospital, Toronto, Ont
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26
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Ido MS, Okosun IS, Bayakly R, Clarkson L, Lugtu J, Floyd S, Krompf K, Frankel M. Door to Intravenous Tissue Plasminogen Activator Time and Hospital Length of Stay in Acute Ischemic Stroke Patients, Georgia, 2007-2013. J Stroke Cerebrovasc Dis 2016; 25:866-71. [PMID: 26853143 DOI: 10.1016/j.jstrokecerebrovasdis.2015.12.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 12/17/2015] [Accepted: 12/22/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Ischemic stroke patients benefit most from intravenous thrombolysis when they receive the treatment as quickly as possible after symptom onset. Hospitals participating in the Georgia Coverdell Acute Stroke Registry reduced the time from patient arrival to administration of intravenous tissue plasminogen activator. This study evaluates the benefit of reducing door-to-treatment (DTT) time as measured by hospital length of stay (LOS). METHODS Data from 3154 ischemic stroke patients treated with intravenous thrombolysis from 2007 to 2013 were analyzed. The impact of door-to-treatment time on patients' length of hospital stay, discharge disposition, ambulatory status at discharge, and bleeding complications was assessed, controlling for patient-, hospital- and event-related characteristics. RESULTS Patients who received intravenous thrombolysis within 30 minutes of hospital arrival had a 19% shorter (95% confidence interval [CI]: 2%-32%, P value = .04) hospital LOS than those treated for more than 120 minutes after arrival. Patients treated within 60 minutes of arrival were 27% more likely (odds ratio = 1.28, 95% CI: 1.06-1.56, P = .01) to have a better discharge disposition than patients treated after 60 minutes of arrival while having a similar rate of bleeding complications. CONCLUSIONS Shortening the door-to-treatment time is associated with a decrease in patient LOS and better patient outcomes. Hospitals should be encouraged to measure, monitor, and reduce DTT time progressively for a better patient outcome.
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Affiliation(s)
- Moges Seyoum Ido
- Division of Epidemiology & Biostatistics, School of Public Health, Georgia State University, Atlanta, Georgia; Georgia Department of Public Health, Atlanta, Georgia.
| | - Ike S Okosun
- Division of Epidemiology & Biostatistics, School of Public Health, Georgia State University, Atlanta, Georgia
| | - Rana Bayakly
- Georgia Department of Public Health, Atlanta, Georgia
| | | | - James Lugtu
- Georgia Department of Public Health, Atlanta, Georgia
| | - Sanita Floyd
- Georgia Department of Public Health, Atlanta, Georgia
| | - Kerrie Krompf
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, School of Medicine, Emory University, Atlanta, Georgia
| | - Michael Frankel
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, School of Medicine, Emory University, Atlanta, Georgia
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27
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Speirs L, Mitchell A. Meet Me in Computed Tomography Suite: Decreasing Tissue Plasminogen Activator Door-to-Needle Time for Acute Ischemic Stroke Patients. J Emerg Nurs 2015; 41:381-6. [DOI: 10.1016/j.jen.2015.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/09/2015] [Accepted: 01/16/2015] [Indexed: 11/25/2022]
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28
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Strbian D, Ahmed N, Wahlgren N, Lees KR, Toni D, Roffe C, Surakka IL, Tatlisumak T. Trends in Door-to-Thrombolysis Time in the Safe Implementation of Stroke Thrombolysis Registry. Stroke 2015; 46:1275-80. [DOI: 10.1161/strokeaha.114.007170] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 01/28/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Shorter delays between symptom onset and treatment translate into better outcomes after ischemic stroke thrombolysis. There are considerable intercenter variations in treatment delivery. We analyzed the trends of door-to-needle times (DNTs) in the Safe Implementation of Thrombolysis in Stroke registry between 2003 and 2011.
Methods—
We extracted from the Safe Implementation of Thrombolysis in Stroke registry (n=45 079) year of treatment, center code, DNT, sex, age, National Institutes of Health Stroke Scale, and comorbidity. For each center, the year they joined the registry and the annual volume of patients were determined (<5, 5–24, 25–49, 50–74, 75–99, and ≥100 patients/y).
Results—
DNT was not available for 720 (1.6%) patients. The overall mean (SD) DNT was 73 (37) minutes with a median (interquartile range) of 67 (47–91) minutes. The DNT was 65 (46–90), 68 (50–92), and 72 (51–98) minutes for centers joined early (2003–2005), later (2006–2009), and recently (2009–2011), respectively. Center volume had more robust effect on DNT than year of treatment, and the shortest DNTs were seen in centers with volumes ≥100 patients/y. Earlier enrollment period was also associated with shorter delays.
Conclusions—
Centers that joined the registry earlier and those with high annual volume achieved shorter DNT than centers that joined later and low-volume centers. However, in most of the centers, DNT did not change much during the registry period. A multicenter project aiming to reduce DNT is warranted.
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Affiliation(s)
- Daniel Strbian
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Niaz Ahmed
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Nils Wahlgren
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Kennedy R. Lees
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Danilo Toni
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Christine Roffe
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Ida L. Surakka
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
| | - Turgut Tatlisumak
- From the Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., T.T.); Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., N.W.); Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom (K.R.L.); Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, “Sapienza” University of Rome, Rome, Italy (D.T.); University Hospital of North Staffordshire,
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29
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Baird AE, Soper SA, Pullagurla SR, Adamski MG. Recent and near-future advances in nucleic acid-based diagnosis of stroke. Expert Rev Mol Diagn 2015; 15:665-79. [PMID: 25837776 DOI: 10.1586/14737159.2015.1024660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Stroke is a leading cause of death and disability in adults, but at present, treatment for ischemic stroke reaches only a small percentage of patients. This is because of the very short time window for treatment and the time-consuming evaluation involved. Intense efforts are underway to find novel approaches to expedite stroke diagnosis and treatment. In this review, we provide the rationale for the use of blood-based nucleic acid biomarkers to advance stroke diagnosis. We describe mRNA markers identified in genomic profiling of circulating leukocytes and then outline technological issues involved in the application of these results. We then describe the novel point-of-care technology that is in development for the rapid detection of multiple mRNA molecules in circulating leukocytes.
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Affiliation(s)
- Alison E Baird
- Department of Neurology, SUNY Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203, USA
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30
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Cho HJ, Lee KY, Nam HS, Kim YD, Song TJ, Jung YH, Choi HY, Heo JH. Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment. J Clin Neurol 2014; 10:328-33. [PMID: 25324882 PMCID: PMC4198714 DOI: 10.3988/jcn.2014.10.4.328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/11/2014] [Accepted: 03/13/2014] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose Process improvement (PI) is an approach for enhancing the existing quality improvement process by making changes while keeping the existing process. We have shown that implementation of a stroke code program using a computerized physician order entry system is effective in reducing the in-hospital time delay to thrombolysis in acute stroke patients. We investigated whether implementation of this PI could further reduce the time delays by continuous improvement of the existing process. Methods After determining a key indicator [time interval from emergency department (ED) arrival to intravenous (IV) thrombolysis] and conducting data analysis, the target time from ED arrival to IV thrombolysis in acute stroke patients was set at 40 min. The key indicator was monitored continuously at a weekly stroke conference. The possible reasons for the delay were determined in cases for which IV thrombolysis was not administered within the target time and, where possible, the problems were corrected. The time intervals from ED arrival to the various evaluation steps and treatment before and after implementation of the PI were compared. Results The median time interval from ED arrival to IV thrombolysis in acute stroke patients was significantly reduced after implementation of the PI (from 63.5 to 45 min, p=0.001). The variation in the time interval was also reduced. A reduction in the evaluation time intervals was achieved after the PI [from 23 to 17 min for computed tomography scanning (p=0.003) and from 35 to 29 min for complete blood counts (p=0.006)]. Conclusions PI is effective for continuous improvement of the existing process by reducing the time delays between ED arrival and IV thrombolysis in acute stroke patients.
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Affiliation(s)
- Han-Jin Cho
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Kyung Yul Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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31
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Abou-Chebl A, Zaidat OO, Castonguay AC, Gupta R, Sun CHJ, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Linfante I, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi M, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Nogueira RG. North American SOLITAIRE Stent-Retriever Acute Stroke Registry. Stroke 2014; 45:1396-401. [DOI: 10.1161/strokeaha.113.003698] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Previous work that predated the availability of the safer stent-retriever devices has suggested that general anesthesia (GA) may have a negative impact on outcomes in patients with acute ischemic stroke undergoing endovascular therapy.
Methods—
We reviewed demographic, clinical, procedural (GA versus local anesthesia [LA], etc), and site-adjudicated angiographic and clinical outcomes data from consecutive patients treated with the Solitaire FR device in the investigator-initiated North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry. The primary outcomes were 90-day modified Rankin Scale, mortality, and symptomatic intracranial hemorrhage.
Results—
A total of 281 patients from 18 centers were enrolled. GA was used in 69.8% (196/281) of patients. Baseline demographic and procedural factors were comparable between the LA and GA groups, except the former demonstrated longer time-to-groin puncture (395.4±254 versus 337.4±208 min;
P
=0.04), lower National Institutes of Health Stroke Scale (NIHSS; 16.2±5.8 versus 18.8±6.9;
P
=0.002), lower balloon-guide catheter usage (22.4% versus 49.2%;
P
=0.0001), and longer fluoroscopy times (39.5±33 versus 28±22.8 min;
P
=0.008). Recanalization (thrombolysis in cerebral infarction ≥2b; 72.94% versus 73.6%;
P
=0.9) and rate of symptomatic intracranial hemorrhage (7.1% versus 11.2%;
P
=0.4) were similar but modified Rankin Scale ≤2 was achieved in more LA patients, 52.6% versus 35.6% (odds ratio, 1.4 [1.1–1.8];
P
=0.01). In multivariate analysis, hypertension, NIHSS, unsuccessful revascularization, and GA use (odds ratio, 3.3 [1.6–7.1];
P
=0.001) were associated with death. When only anterior circulation and elective GA patients were included, there was a persistent difference in good outcomes in favor of LA patients (50.7% versus 35.5%; odds ratio, 1.3 [1.01–1.6];
P
=0.04).
Conclusions—
The NASA Registry has demonstrated that clinical outcomes and survival are significantly better in patients treated with LA, without increased symptomatic intracranial hemorrhage risk. Future trials should prospectively evaluate the effect of GA on outcomes.
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Affiliation(s)
- Alex Abou-Chebl
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Ossama O. Zaidat
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Alicia C. Castonguay
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Rishi Gupta
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Chung-Huan J. Sun
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Coleman O. Martin
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - William E. Holloway
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Nils Mueller-Kronast
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Joey D. English
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Italo Linfante
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Guilherme Dabus
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Timothy W. Malisch
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Franklin A. Marden
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Hormozd Bozorgchami
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Andrew Xavier
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Ansaar T. Rai
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Micahel T. Froehler
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Aamir Badruddin
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Thanh N. Nguyen
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Muhammad Taqi
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Michael G. Abraham
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Vallabh Janardhan
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Hashem Shaltoni
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Roberta Novakovic
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Albert J. Yoo
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Peng R. Chen
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Gavin W. Britz
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Ritesh Kaushal
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Ashish Nanda
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Mohammad A. Issa
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
| | - Raul G. Nogueira
- From the Texas Stroke Institute, Plano, TX (A.A.-C., V.J.); Departments of Neurology, Neurosurgery, and Radiology, Medical College of Wisconsin/Froedtert Hospital, Atlanta, GA (O.O.Z., A.C.C., M.A.I.); Wellstar Neurosurgery Kennestone Hospital, Atlanta, GA (R.G.); Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.-H.J.S. R.G.N.); Saint Luke’s Kansas City, Kansas City, MO (C.O.M., W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K.)
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