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Marti-Fabregas J, Ramos-Pachón A, Prats-Sanchez L, Núñez-Guillén A, Rodríguez BL, Rodriguez-Luna D, Amaro S, Silva Y, Rodriguez-Campello A, Puig I, Gomez-Choco M, Vázquez-Justes D, Guanyabens N, Cocho D, Cánovas D, Steinhauer EG, Llull L, Guasch-Jiménez M, Martinez-Domeño A, Marin R, Lambea-Gil Á, Díaz GE, Paipa-Merchan A, Quesada H, Casadevall MP, Wenger D, Pancorbo O, Seró L, Pérez J, Costa X, Zaragoza J, Rodríguez-Villatoro N, Catena E, Calvo NM, Krupinski J, De La Ossa NP, Abilleira S, Salvat-Planas M, Fagundez O, Camps-Renom P. Influence of Hospital Type on Outcomes of Patients With Acute Spontaneous Intracerebral Hemorrhage: A Population-Based Study. Neurology 2024; 103:e209539. [PMID: 38875516 DOI: 10.1212/wnl.0000000000209539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Whether the outcome of patients with spontaneous intracerebral hemorrhage (ICH) differs depending on the type of hospital where they are admitted is uncertain. The objective of this study was to determine influence of hospital type at admission (telestroke center [TSC], primary stroke center [PSC], or comprehensive stroke center [CSC]) on outcome for patients with ICH. We hypothesized that outcomes may be better for patients admitted to a CSC. METHODS This is a multicenter prospective observational and population-based study of a cohort of consecutively recruited patients with ICH (March 2020-March 2022). We included all patients with spontaneous ICH in Catalonia (Spain) who had a pre-ICH modified Rankin scale (mRS) score of 0-3 and who were admitted to the hospital within 24 hours of onset. We compared patients admitted to a TSC/PSC (n = 641) or a CSC (n = 1,320) and also analyzed the subgroup of patients transferred (n = 331) or not transferred (n = 310) from a TSC/PSC to a CSC. The main outcome was the 3-month mRS score obtained by blinded investigators. Outcomes were compared using adjusted ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI for a shift in mRS scores. A propensity score matching (PSM) analysis was performed for the subgroup of transferred patients. RESULTS Relevant data were obtained from 1961 of a total of 2,230 patients, with the mean (SD) age of 70 (14.1) years, and 713 (38%) patients were women. After adjusting for confounders (age, NIH Stroke Scale score, intraventricular hemorrhage, hematoma volume, and pre-ICH mRS score), type of hospital of initial admission (CSC vs TSC/PSC) was not associated with outcome (adjusted common OR 1.13, 95% CI 0.93-1.38). A PSM analysis indicated that transfer to a CSC was not associated with more favorable outcomes (OR 0.77, 95% CI 0.55-1.10; p = 0.16). DISCUSSION In this population-based study, we found that, after adjusting for confounders, hospital types were not associated with functional outcomes. In addition, for patients who were transferred from a TSC/PSC to a CSC, PSM indicated that outcomes were similar to nontransferred patients. Our findings suggest that patient characteristics are more important than hospital characteristics in determining outcome after ICH. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03956485.
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Affiliation(s)
- Joan Marti-Fabregas
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Anna Ramos-Pachón
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Luis Prats-Sanchez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Ana Núñez-Guillén
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Blanca Lara Rodríguez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - David Rodriguez-Luna
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sergio Amaro
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Yolanda Silva
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Ana Rodriguez-Campello
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Isabel Puig
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Manuel Gomez-Choco
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Daniel Vázquez-Justes
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Nicolau Guanyabens
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Dolores Cocho
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - David Cánovas
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Eva Giralt Steinhauer
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Laura Llull
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Marina Guasch-Jiménez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Alejandro Martinez-Domeño
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Rebeca Marin
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Álvaro Lambea-Gil
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Garbiñe Ezcurra Díaz
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Andrés Paipa-Merchan
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Helena Quesada
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Marc Puig Casadevall
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Denisse Wenger
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Olalla Pancorbo
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Laia Seró
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Jordi Pérez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Xavier Costa
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Jose Zaragoza
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Esther Catena
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Núria Matos Calvo
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Jerzy Krupinski
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Natalia Pérez De La Ossa
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sònia Abilleira
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Mercè Salvat-Planas
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Olga Fagundez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Pol Camps-Renom
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
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Loggini A, Hornik J, Hornik A, Braksick SA, Klaas JP. Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis. Neurocrit Care 2024:10.1007/s12028-024-02044-9. [PMID: 38955932 DOI: 10.1007/s12028-024-02044-9] [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: 03/14/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87 days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.
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Affiliation(s)
- Andrea Loggini
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA.
- Southern Illinois University School of Medicine, Carbondale, IL, USA.
| | - Jonatan Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- Southern Illinois University School of Medicine, Carbondale, IL, USA
| | - Alejandro Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- Southern Illinois University School of Medicine, Carbondale, IL, USA
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Ruff IM, de Havenon A, Bergman DL, Dugue R, Frontera JA, Goldstein JN, Hemphill JC, Marulanda-Londono E, Prabhakaran S, Richards CT, Sunmonu NA, Vilar P, Wolfe SQ. 2024 AHA/ASA Performance and Quality Measures for Spontaneous Intracerebral Hemorrhage: A Report From the American Heart Association/American Stroke Association. Stroke 2024; 55:e199-e230. [PMID: 38695183 DOI: 10.1161/str.0000000000000464] [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] [Indexed: 06/26/2024]
Abstract
The American Heart Association/American Stroke Association released a revised spontaneous intracerebral hemorrhage guideline in 2022. A working group of stroke experts reviewed this guideline and identified a subset of recommendations that were deemed suitable for creating performance measures. These 15 performance measures encompass a wide spectrum of intracerebral hemorrhage patient care, from prehospital to posthospital settings, highlighting the importance of timely interventions. The measures also include 5 quality measures and address potential challenges in data collection, with the aim of future improvements.
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Morán Gallego FJ, Sanchez Casado M, López de Toro Martin Consuegra I, Marina Martinez L, Alvarez Fernandez J, Sánchez Carretero MJ. Evaluation of the last 2 decades in the characteristics of presentation, management and prognosis of serious spontaneous intracerebral hemorrhage in a third level hospital. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:169-176. [PMID: 38295901 DOI: 10.1016/j.neucie.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/12/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To analyze the change in the characteristics of presentation, evolution and treatment in the ICU, as well as the functional evolution at 12 months of spontaneous intracranial hemorrhages (ICHs) treated in an ICU reference center. PATIENT AND METHODS Descriptive, retrospective study in a Neurocritical Reference Hospital. All admissions of patients with HICE during three periods are studied: 1999-2001 (I), 2015-2016 (II) and 2020-2021 (III). Evolution in the three periods of demographic variables, baseline characteristics of the patients, clinical variables and characteristics of bleeding, evolutionary data in the ICU are studied. At one year we assessed the GOS scale (Glasgow Outcome Score) according to whether they had a poor (GOS 1-3) or good (GOS 4-5) prognosis. RESULTS 300 admitted patients, distributed in periods: I: 28.7%, II: 36.3% and III: 35%. 56.7% were males aged 66 (55.5-74) years; ICH score 2 (1-3). The ICU stay was 5 (2-14) days with a mortality of 36.8%. GOS 1-3 a year in 67.3% and GOS 4-5 in 32.7%. Comparing the three periods, we observed a higher prevalence in women, and the presence of cardiovascular factors; no changes in etiology; in relation to the location, it increases cerebellar hemorrhage and in the brainstem. Although the severity was greater, the stay in the ICU, the use of invasive mechanical ventilation and tracheostomy were lower. Open surgery has decreased its use by 50%. Mortality continues to be high, stagnating in the ICU at 35% and entails a high degree of disability one year after assessment. CONCLUSIONS Severe ICH is a complex pathology that has changed some characteristics in the last two decades, with more severe patients, with more cardiovascular history and a greater predominance of brainstem and cerebellar hemorrhage. Despite the increase in severity, better parameters during the ICU stay, with open surgery used 50% less. Mortality remains stagnant at 35% with high disability per year.
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Parry-Jones AR, Järhult SJ, Kreitzer N, Morotti A, Toni D, Seiffge D, Mendelow AD, Patel H, Brouwers HB, Klijn CJ, Steiner T, Gibler WB, Goldstein JN. Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement. Eur Stroke J 2024; 9:295-302. [PMID: 38149323 DOI: 10.1177/23969873231220235] [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] [Indexed: 12/28/2023] Open
Abstract
PURPOSE Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase. METHODS We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems. FINDINGS In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy. DISCUSSION There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.
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Affiliation(s)
- Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Susann J Järhult
- Department of Medical Sciences, Uppsala University, Emergency Department, Uppsala University Hospital, Uppsala, Sweden
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, University La Sapienza Rome, Italy
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Hiren Patel
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Hens Bart Brouwers
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | - Walter Brian Gibler
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Klijn CJ, Dammers R, Sprigg N. Decompressive craniectomy for deep intracerebral haemorrhage: a SWITCH towards better outcomes? Lancet 2024; 403:2351-2353. [PMID: 38761809 DOI: 10.1016/s0140-6736(24)00703-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/05/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Catharina Jm Klijn
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, 6525 GC Nijmegen, Netherlands.
| | - Ruben Dammers
- Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Nikola Sprigg
- Stroke Trials Unit Nottingham, University of Nottingham, Nottingham, UK
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Adeniji O, Adeleye O, Akinyemi J, Otubogun F, Ogunde G, Ogunrombi M, Adesina D, Wahab A, Ogunlana M, Alimi T, Akinyemi R. Organized multi-disciplinary stroke team care improves acute stroke outcomes in resource limited settings; Results of a retrospective study from a Nigerian tertiary hospital. J Stroke Cerebrovasc Dis 2023; 32:107307. [PMID: 37633206 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Evidence for the impact of organized stroke multidisciplinary teams (MDTs) on outcomes in Africa is sparse. AIM To compare stroke outcomes, before and after the establishment (September 16, 2016) of a pioneer MDT at a tertiary hospital in southern Nigeria. METHODS Using a retrospective, observational study design, the in-patient record of all stroke patients admitted between September 2014 to September 2018 was retrieved and rigorously reviewed. 155 patients seen 2 years before the MDT were compared with 169 stroke patients seen 2 years after the MDT. Stroke severity at admission and functioning at discharge were assessed using the Stroke Levity Scale (SLS) and the modified Rankin scale (mRS). RESULTS Mean ages (in years) were 60 pre-MDT vs 59.57 post MDT (p = 0.754). There were more males, 51% pre-MDT vs 54.2% post MDT (p = 0.565). SLS and mRS were not significantly different; severe SLS and mRS pre-MDT, 52.9% vs post-MDT, 49.4% (p = 0.727) and pre-MDT 19.4% vs post-MDT 19.5% (p = 0.685) respectively. More post-MDT patients were discharged alive, pre-MDT,56.8% vs 79.2% post MDT (p < 0.001); had swallow tests, pre-MDT 9.23% vs post-MDT 33.5% (p < 0.001); on secondary prevention, pre-MDT 67.7% vs post-MDT 78.9% (p = 0.023); had more clinic visits, pre-MDT,0.7% vs post-MDT 38.3% (p < 0.001). MDT was independently associated with lower in-hospital mortality on multivariable regression, adjusted odds ratio (OR) (95% Confidence interval CI) 0.17 (0.09-0.32). CONCLUSION Our results suggest that an organized MDT may improve acute outcomes and reduce mortality in resource constrained settings where there may be no stroke units. These findings need further prospective validation.
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Affiliation(s)
- Olaleye Adeniji
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria.
| | - Osi Adeleye
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Joshua Akinyemi
- Department of Medical Statistics and Epidemiology, College of Medicine, University College hospital Ibadan, Oyo State, Nigeria
| | - Folajimi Otubogun
- Neurology unit, Federal Medical center, Ebute Meta, Lagos State, Nigeria
| | - Gabriel Ogunde
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Postal Address: PMB 017 GPO, General Post Office, Ibadan, Oyo State, Nigeria
| | - Mayowa Ogunrombi
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Deborah Adesina
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Ahmed Wahab
- Neurology Unit, Department of Medicine, Federal Medical Center, Postal Address- P.M.B 3031, Sapon Post Office, Abeokuta, Ogun State, Nigeria
| | - Michael Ogunlana
- Department of Physiotherapy, Federal Medical Center, Abeokuta, Ogun State, Nigeria
| | - Talayo Alimi
- Department of Physiotherapy, Federal Medical Center, Abeokuta, Ogun State, Nigeria
| | - Rufus Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Postal Address: PMB 017 GPO, General Post Office, Ibadan, Oyo State, Nigeria
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Scholte M, Marchau VAWJ, Kwakkel JH, Klijn CJM, Rovers MM, Grutters JPC. Dealing With Uncertainty in Early Health Technology Assessment: An Exploration of Methods for Decision Making Under Deep Uncertainty. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:694-703. [PMID: 36253242 DOI: 10.1016/j.jval.2022.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/18/2022] [Accepted: 08/31/2022] [Indexed: 05/03/2023]
Abstract
OBJECTIVES In early stages, the consequences of innovations are often unknown or deeply uncertain, which complicates early health economic modeling (EHEM). The field of decision making under deep uncertainty uses exploratory modeling (EM) in situations when the system model, input probabilities/distributions, and consequences are unknown or debated. Our aim was to evaluate the use of EM for early evaluation of health technologies. METHODS We applied EM and EHEM to an early evaluation of minimally invasive endoscopy-guided surgery (MIS) for acute intracerebral hemorrhage and compared these models to derive differences, merits, and drawbacks of EM. RESULTS EHEM and EM differ fundamentally in how uncertainty is handled. Where in EHEM the focus is on the value of technology, while accounting for the uncertainty, EM focuses on the uncertainty. EM aims to find robust strategies, which give relatively good outcomes over a wide range of plausible futures. This was reflected in our case study. EHEM provided cost-effectiveness thresholds for MIS effectiveness, assuming fixed MIS costs. EM showed that a policy with a population in which most patients had severe intracerebral hemorrhage was most robust, regardless of MIS effectiveness, complications, and costs. CONCLUSIONS EHEM and EM were found to complement each other. EM seems most suited in the very early phases of innovation to explore existing uncertainty and many potential strategies. EHEM seems most useful to optimize promising strategies, yet EM methods are complex and might only add value when stakeholders are willing to consider multiple solutions to a problem and adopt flexible research and adoption strategies.
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Affiliation(s)
- Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Jan H Kwakkel
- Faculty of Technology, Policy and Management, Delft, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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9
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Mazzoleni V, Padovani A, Morotti A. Emergency management of intracerebral hemorrhage. J Crit Care 2023; 74:154232. [PMID: 36565647 DOI: 10.1016/j.jcrc.2022.154232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Acute intracerebral hemorrhage is a medical emergency with high mortality and morbidity. Neuroimaging has a fundamental role in the etiological diagnosis, patients monitoring and in the risk stratification of hematoma expansion and poor outcome. The cornerstones of medical treatment in the acute phase are blood pressure lowering and coagulopathy reversal. Prevention of hematoma expansion is the main goal of these therapies and their efficacy is strongly time-dependent with a narrow time window. This review provides an update on the etiological diagnostic workup, acute treatment and prognosis of intracerebral hemorrhage.
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Affiliation(s)
- Valentina Mazzoleni
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy; Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
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10
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Puy L, Parry-Jones AR, Sandset EC, Dowlatshahi D, Ziai W, Cordonnier C. Intracerebral haemorrhage. Nat Rev Dis Primers 2023; 9:14. [PMID: 36928219 DOI: 10.1038/s41572-023-00424-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/18/2023]
Abstract
Intracerebral haemorrhage (ICH) is a dramatic condition caused by the rupture of a cerebral vessel and the entry of blood into the brain parenchyma. ICH is a major contributor to stroke-related mortality and dependency: only half of patients survive for 1 year after ICH, and patients who survive have sequelae that affect their quality of life. The incidence of ICH has increased in the past few decades with shifts in the underlying vessel disease over time as vascular prevention has improved and use of antithrombotic agents has increased. The pathophysiology of ICH is complex and encompasses mechanical mass effect, haematoma expansion and secondary injury. Identifying the causes of ICH and predicting the vital and functional outcome of patients and their long-term vascular risk have improved in the past decade; however, no specific treatment is available for ICH. ICH remains a medical emergency, with prevention of haematoma expansion as the key therapeutic target. After discharge, secondary prevention and management of vascular risk factors in patients remains challenging and is based on an individual benefit-risk balance evaluation.
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Affiliation(s)
- Laurent Puy
- Lille Neuroscience & Cognition (LilNCog) - U1172, University of Lille, Inserm, CHU Lille, Lille, France
| | - Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust & University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wendy Ziai
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charlotte Cordonnier
- Lille Neuroscience & Cognition (LilNCog) - U1172, University of Lille, Inserm, CHU Lille, Lille, France.
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11
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De Rosa L, Manara R, Vodret F, Kulyk C, Montano F, Pieroni A, Viaro F, Zedde ML, Napoletano R, Ermani M, Baracchini C. The "SALPARE study" of spontaneous intracerebral hemorrhage: part 1. Neurol Res Pract 2023; 5:5. [PMID: 36726162 PMCID: PMC9893659 DOI: 10.1186/s42466-023-00231-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is a devastating type of stroke with a huge impact on patients and families. Expanded use of oral anticoagulants and ageing population might contribute to an epidemiological change. In view of these trends, we planned a study to obtain a contemporary picture and identify early prognostic factors to improve secondary prevention. METHODS This multicenter prospective cohort study included consecutive adult patients with non-traumatic ICH admitted to three academic Italian hospitals (Salerno, Padova, Reggio Emilia) over a 2-year period. Demographic characteristics, vascular risk profile, clinical data and main radiological characteristics were correlated to 90-day clinical outcome. RESULTS Out of 682 patients [mean age: 73 ± 14 years; 316 (46.3%) females] enrolled in this study, 40% died [86/180 (47.8%) in Salerno, 120/320 (37.5%) in Padova, 67/182 (36.8%) in Reggio Emilia; p < 0.05)] and 36% were severely disabled at 90 days. Several factors were associated with a higher risk of poor functional outcome such as antithrombotic drug use, hyperglycemia, previous cerebrovascular accident, low platelet count, and pontine/massive/intraventricular hemorrhage. However, at multivariate analysis only pre-ICH mRS score (OR 30.84), GCS score at presentation (OR 11.88), initial hematoma volume (OR 29.71), and NIHSS score at presentation (OR 25.89) were independent predictors of death and poor functional outcome. CONCLUSION Despite the heterogeneity among centers, this study on ICH has identified four simple prognostic factors that can independently predict patients outcome, stratify their risk, and guide their management.
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Affiliation(s)
- Ludovica De Rosa
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Renzo Manara
- grid.411474.30000 0004 1760 2630Neuroradiology Unit, Padua University Hospital, Padua, Italy
| | - Francesca Vodret
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Caterina Kulyk
- grid.9970.70000 0001 1941 5140Stroke Unit and Neurosonology Laboratory, Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Florian Montano
- grid.11780.3f0000 0004 1937 0335Neuroradiology, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Alessio Pieroni
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Federica Viaro
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Maria Luisa Zedde
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Rosa Napoletano
- UOC Neurologia AOU S. Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Mario Ermani
- grid.411474.30000 0004 1760 2630Service of Medical Statistics, Department of Neurology, Padua University Hospital, Padua, Italy
| | - Claudio Baracchini
- grid.411474.30000 0004 1760 2630Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
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12
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Li Z, Khan S, Liu Y, Wei R, Yong VW, Xue M. Therapeutic strategies for intracerebral hemorrhage. Front Neurol 2022; 13:1032343. [PMID: 36408517 PMCID: PMC9672341 DOI: 10.3389/fneur.2022.1032343] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 09/03/2023] Open
Abstract
Stroke is the second highest cause of death globally, with an increasing incidence in developing countries. Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes. ICH is associated with poor neurological outcomes and high mortality due to the combination of primary and secondary injury. Fortunately, experimental therapies are available that may improve functional outcomes in patients with ICH. These therapies targeting secondary brain injury have attracted substantial attention in their translational potential. Here, we summarize recent advances in therapeutic strategies and directions for ICH and discuss the barriers and issues that need to be overcome to improve ICH prognosis.
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Affiliation(s)
- Zhe Li
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - Suliman Khan
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - Yang Liu
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - Ruixue Wei
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
| | - V. Wee Yong
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, Zhengzhou, China
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13
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Viarasilpa T. Implementation of neurocritical care in Thailand. Front Neurol 2022; 13:990294. [PMID: 36330426 PMCID: PMC9622761 DOI: 10.3389/fneur.2022.990294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/29/2022] [Indexed: 11/23/2022] Open
Abstract
Dedicated neurointensive care units and neurointensivists are rarely available in Thailand, a developing country, despite the high burden of life-threatening neurologic illness, including strokes, post-cardiac arrest brain injury, status epilepticus, and cerebral edema from various etiologies. Therefore, the implementation of neurocritical care is essential to improve patient outcomes. With the resource-limited circumstances, the integration of neurocritical care service by collaboration between intensivists, neurologists, neurosurgeons, and other multidisciplinary care teams into the current institutional practice to take care of critically-ill neurologic patients is more suitable than building a new neurointensive care unit since this approach can promptly be made without reorganization of the hospital system. Providing neurocritical care knowledge to internal medicine and neurology residents and critical care fellows and developing a research system will lead to sustainable quality improvement in patient care. This review article will describe our current situation and strategies to implement neurocritical care in Thailand.
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14
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Peter-Derex L, Philippeau F, Garnier P, André-Obadia N, Boulogne S, Catenoix H, Convers P, Mazzola L, Gouttard M, Esteban M, Fontaine J, Mechtouff L, Ong E, Cho TH, Nighoghossian N, Perreton N, Termoz A, Haesebaert J, Schott AM, Rabilloud M, Pivot C, Dhelens C, Filip A, Berthezène Y, Rheims S, Boutitie F, Derex L. Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:781-791. [PMID: 35963261 DOI: 10.1016/s1474-4422(22)00235-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The incidence of early seizures (occurring within 7 days of stroke onset) after intracerebral haemorrhage reaches 30% when subclinical seizures are diagnosed by continuous EEG. Early seizures might be associated with haematoma expansion and worse neurological outcomes. Current guidelines do not recommend prophylactic antiseizure treatment in this setting. We aimed to assess whether prophylactic levetiracetam would reduce the risk of acute seizures in patients with intracerebral haemorrhage. METHODS The double-blind, randomised, placebo-controlled, phase 3 PEACH trial was conducted at three stroke units in France. Patients (aged 18 years or older) who presented with a non-traumatic intracerebral haemorrhage within 24 h after onset were randomly assigned (1:1) to levetiracetam (intravenous 500 mg every 12 h) or matching placebo. Randomisation was done with a web-based system and stratified by centre and National Institutes of Health Stroke Scale (NIHSS) score at baseline. Treatment was continued for 6 weeks. Continuous EEG was started within 24 h after inclusion and recorded over 48 h. The primary endpoint was the occurrence of at least one clinical seizure within 72 h of inclusion or at least one electrographic seizure recorded on continuous EEG, analysed in the modified intention-to-treat population, which comprised all patients who were randomly assigned to treatment and who had a continuous EEG performed. This trial was registered at ClinicalTrials.gov, NCT02631759, and is now closed. Recruitment was prematurely stopped after 48% of the recruitment target was reached due to a low recruitment rate and cessation of funding. FINDINGS Between June 1, 2017, and April 14, 2020, 50 patients with mild-to-moderate severity intracerebral haemorrhage were included: 24 were assigned to levetiracetam and 26 to placebo. During the first 72 h, a clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (odds ratio 0·16, 95% CI 0·03-0·94, p=0·043). All seizures in the first 72 h were electrographic seizures only. No difference in depression or anxiety reporting was observed between the groups at 1 month or 3 months. Depression was recorded in three (13%) patients who received levetiracetam versus four (15%) patients who received placebo, and anxiety was reported for two (8%) patients versus one (4%) patient. The most common treatment-emergent adverse events in the levetiracetam group versus the placebo group were headache (nine [39%] vs six [24%]), pain (three [13%] vs ten [40%]), and falls (seven [30%] vs four [16%]). The most frequent serious adverse events were neurological deterioration due to the intracerebral haemorrhage (one [4%] vs four [16%]) and severe pneumonia (two [9%] vs two [8%]). No treatment-related death was reported in either group. INTERPRETATION Levetiracetam might be effective in preventing acute seizures in intracerebral haemorrhage. Larger studies are needed to determine whether seizure prophylaxis improves functional outcome in patients with intracerebral haemorrhage. FUNDING French Ministry of Health.
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Affiliation(s)
- Laure Peter-Derex
- Centre for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France.
| | - Frédéric Philippeau
- Stroke Unit, Department of Neurology, Fleyriat Hospital, Bourg en Bresse, France
| | - Pierre Garnier
- Stroke Centre, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nathalie André-Obadia
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Sébastien Boulogne
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Hélène Catenoix
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Philippe Convers
- Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France; Clinical Neurophysiology Unit, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Laure Mazzola
- Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France; Clinical Neurophysiology Unit, Department of Neurology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Michel Gouttard
- Stroke Unit, Department of Neurology, Fleyriat Hospital, Bourg en Bresse, France
| | - Maud Esteban
- Stroke Centre, Lyon University Hospital, Lyon, France
| | | | | | - Elodie Ong
- Stroke Centre, Lyon University Hospital, Lyon, France
| | - Tae-Hee Cho
- Stroke Centre, Lyon University Hospital, Lyon, France
| | | | - Nathalie Perreton
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne Termoz
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Julie Haesebaert
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne-Marie Schott
- Public Health Unit, Clinical Research and Epidemiology Department, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Muriel Rabilloud
- Department of Biostatistics, Lyon University Hospital, Lyon, France; Biometry and Evolutionary Biology Laboratory, CNRS UMR 5558, Biostatistics Health Team, Villeurbanne, France
| | - Christine Pivot
- Pharmacy, FRIPHARM, Edouard Herriot Hospital, Lyon University Hospital, Lyon, France
| | - Carole Dhelens
- Pharmacy, FRIPHARM, Edouard Herriot Hospital, Lyon University Hospital, Lyon, France
| | - Andrea Filip
- Department of Neuroradiology, Neurological Hospital, Lyon University Hospital, Lyon, France
| | - Yves Berthezène
- Department of Neuroradiology, Neurological Hospital, Lyon University Hospital, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Lyon University Hospital, Lyon, France; Lyon Neuroscience Research Centre, CNRS UMR 5292, INSERM U1028, Lyon, France
| | - Florent Boutitie
- Department of Biostatistics, Lyon University Hospital, Lyon, France; Biometry and Evolutionary Biology Laboratory, CNRS UMR 5558, Biostatistics Health Team, Villeurbanne, France
| | - Laurent Derex
- Stroke Centre, Lyon University Hospital, Lyon, France; University Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
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15
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Alexandrov AW. The Sky's the Limit: Expanding Nursing's Contribution to Acute Stroke Science. Am J Crit Care 2022; 31:266-274. [PMID: 35773192 DOI: 10.4037/ajcc2022109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Stroke is the number one cause of preventable disability in adults in the United States. Significant advances have occurred in medications and technology supporting rapid stroke diagnosis and treatment during the past 30 years, along with blurring of the lines of what traditionally constituted nursing or medical research. Ischemic stroke is a disease of vascular insufficiency that mirrors myocardial infarction more than any other neurologic diagnosis. My primary program of research is focused on exploration of methods to improve intracranial blood flow in patients with hyperacute ischemic stroke who have viable, yet vulnerable, brain tissue to prevent worsening or enable improvement of stroke symptoms. I am also examining augmentation of recombinant tissue plasminogen activator treatment and stimulation of both arteriogenesis and angiogenesis with external counter-pulsation in patients with intracranial atherosclerosis. My secondary program of research focuses on methods to improve stroke systems of care, including improvement of advance practice providers' contributions to acute stroke care, use of innovative mobile stroke units, and improvement of quality core measure processes. Lessons learned along the way are highlighted, along with the value of interdisciplinary "team science" to build knowledge and enhance the care of highly vulnerable patients with acute stroke.
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Affiliation(s)
- Anne W Alexandrov
- Anne W. Alexandrov is a professor of nursing and neurology and chief nurse practitioner, Acute Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center, Memphis, Tennessee; a principal partner at Health Outcomes Institute, LLC, and a professor, NET SMART Program, Fountain Hills, Arizona
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16
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Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal. J Clin Neurosci 2022; 101:259-263. [PMID: 35660959 DOI: 10.1016/j.jocn.2022.05.021] [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: 02/26/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH. PATIENTS AND METHODS Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death. RESULTS Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002). CONCLUSION The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 333] [Impact Index Per Article: 166.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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18
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Outcomes of a Stroke Response Team on the Emergent Management of Intracerebral Hemorrhage. Dimens Crit Care Nurs 2022; 41:157-163. [PMID: 36749865 DOI: 10.1097/dcc.0000000000000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage results in high patient mortality or poor functional outcomes. Early access to specialty care allows for rapid implementation of evidence-based strategies that improve the patient's long-term outcomes. OBJECTIVES The aim of this study was to determine the impact of a dedicated stroke response team on timeliness of blood pressure control, administration of anticoagulation reversal agents, and emergency department arrival to a critical care bed. METHODS A stroke response team was developed from the neuro intensive care unit that compliments the hospital's current rapid response team. Development of an algorithm guides the implementation of key interventions for intracerebral hemorrhages. Widespread education targeting care of patients with hemorrhagic stroke provided the stroke response team and emergency department staff with knowledge to implement the plan of care. RESULTS Baseline time interval data were collected on 70 consecutive patients with intracerebral hemorrhage. After implementation of a dedicated stroke response team, time interval data on 70 consecutive patients with intracerebral hemorrhage were collected for comparison with the baseline measurement. A significant decrease was seen in the time to control the patient's systolic blood pressure (median of 130 to 56 minutes, P = .000) and emergency department arrival to a critical care bed (240 to 132 minutes, P = .000). Patient arrival to anticoagulation reversal agent administration decreased from a mean of 98 to 72 minutes (P = .32). DISCUSSION Implementation of a stroke response team increased the knowledge of the care team, improved the timeliness of blood pressure control, and decreased the time for emergency department arrival to a critical care bed, and to anticoagulation reversal agent administration.
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Advancing the Surgical Treatment of Intracerebral Hemorrhage: Study Design and Research Directions. World Neurosurg 2022; 161:367-375. [DOI: 10.1016/j.wneu.2022.01.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 12/23/2022]
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Lip GYH, Lane DA, Lenarczyk R, Boriani G, Doehner W, Benjamin LA, Fisher M, Lowe D, Sacco RL, Schnabel R, Watkins C, Ntaios G, Potpara T. OUP accepted manuscript. Eur Heart J 2022; 43:2442-2460. [PMID: 35552401 PMCID: PMC9259378 DOI: 10.1093/eurheartj/ehac245] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:
A: Appropriate Antithrombotic therapy. B: Better functional and psychological status. C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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Affiliation(s)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, The Medical University of Silesia, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Laura A Benjamin
- Laboratory of Molecular and Cell Biology, University College London National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deborah Lowe
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral CH49 5PE, UK
| | - Ralph L Sacco
- UM Clinical & Translational Science Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Renate Schnabel
- University Heart & Vascular Center Hamburg Eppendorf, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston PR1 2HE, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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21
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Anderson CS. Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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22
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Yassi N, Zhao H, Churilov L, Campbell BCV, Wu T, Ma H, Cheung A, Kleinig T, Brown H, Choi P, Jeng JS, Ranta A, Wang HK, Cloud GC, Grimley R, Shah D, Spratt N, Cho DY, Mahawish K, Sanders L, Worthington J, Clissold B, Meretoja A, Yogendrakumar V, Ton MD, Dang DP, Phuong NTM, Nguyen HT, Hsu CY, Sharma G, Mitchell PJ, Yan B, Parsons MW, Levi C, Donnan GA, Davis SM. Tranexamic acid for intracerebral haemorrhage within 2 hours of onset: protocol of a phase II randomised placebo-controlled double-blind multicentre trial. Stroke Vasc Neurol 2021; 7:158-165. [PMID: 34848566 PMCID: PMC9067256 DOI: 10.1136/svn-2021-001070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Rationale Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth. Methods and design Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework. Hypothesis In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo. Sample size estimates A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients. Intervention Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo. Primary efficacy measure The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan. Discussion We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia .,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, Victoria, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Annemarei Ranta
- Department of Medicine, Dunedin School of Medicine, University of Otago, Wellington, New Zealand
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, Yanchao, Kaohsiung, Taiwan
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Clinical Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Nambour, Queensland, Australia
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Lauren Sanders
- Department of Neurology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - John Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Ben Clissold
- Department of Neurology, Geelong Hospital, Geelong, Victoria, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi, Viet Nam
| | - Duc Phuc Dang
- Stroke Department, 103 Military Hospital, Hanoi, Hanoi, Viet Nam
| | | | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Chung Y Hsu
- Department of Neurology, China Medical University, Taichung, Taiwan
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Sydney, New South Wales, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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Pedersen TGB, Vinter N, Schmidt M, Frost L, Cordsen P, Andersen G, Johnsen SP. Trends in the incidence and mortality of intracerebral hemorrhage, and the associated risk factors, in Denmark from 2004 to 2017. Eur J Neurol 2021; 29:168-177. [PMID: 34528344 DOI: 10.1111/ene.15110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The distribution of the major modifiable risk factors for intracerebral hemorrhage (ICH) changes rapidly. These changes call for contemporary data from large-scale population-based studies. The aim of the present study was to examine trends in incidence, risk factors, and mortality in ICH patients from 2004 to 2017. METHODS In a population-based cohort study, we calculated age- and sex-standardized incidence rates (SIRs), incidence rates (IRs) stratified by age and sex per 100,000 person-years, and trends in risk profiles. We estimated absolute mortality risk, and the Cox proportional hazards regression multivariable-adjusted hazard ratios for 30-day and 1-year mortality. RESULTS We included 16,902 patients (53% men; median age 75 years) from 2004 to 2017. The SIR of ICH decreased from 33 (95% confidence interval [CI] 32-34) in 2004/2005 to 28 (95% CI 27-29) in 2016/2017. Among patients aged ≥70 years, the IR decreased from 137 (95% CI 130-144) in 2004/2005 to 112 (95% CI 106-117) in 2016/2017. The IR in patients aged <70 years was unchanged. From 2004 to 2017, the proportion of patients with hypertension increased from 49% to 66%, the use of oral anticoagulants increased from 7% to 18%, and the use of platelet inhibitors decreased from 40% to 28%. The adjusted hazard ratio for 30-day mortality in 2016/2017 was 0.94 (95% CI 0.89-1.01) and 1-year mortality was 0.98 (95% CI 0.93-1.04) compared with 2004/2005. CONCLUSION The incidence of spontaneous ICH decreased from 2004 to 2017, with no clear trend in mortality. The risk profile of ICH patients changed substantially, with increasing proportions of hypertension and anticoagulant treatment. Given the high mortality rate of ICH, further advances in prevention and treatment are urgently needed.
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Affiliation(s)
- Tine Glavind Bülow Pedersen
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Morten Schmidt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark
| | - Lars Frost
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Grethe Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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25
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Sondag L, Jacobs FA, Schreuder FH, Boogaarts JD, Peter Vandertop W, Dammers R, Klijn CJ. Variation in medical management and neurosurgical treatment of patients with supratentorial spontaneous intracerebral haemorrhage. Eur Stroke J 2021; 6:134-142. [PMID: 34414288 PMCID: PMC8370071 DOI: 10.1177/23969873211005915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The role of surgery in spontaneous intracerebral haemorrhage (sICH) remains controversial. This leads to variation in the percentage of patients who are treated with surgery between countries. Patients and methods We sent an online survey to all neurosurgeons (n = 140) and to a sample of neurologists (n = 378) in Dutch hospitals, with questions on management in supratentorial sICH in general, and on treatment in six patients, to explore current variation in medical and neurosurgical management. We assessed patient and haemorrhage characteristics influencing treatment decisions. Results Twenty-nine (21%) neurosurgeons and 92 (24%) neurologists responded. Prior to surgery, neurosurgeons would more frequently administer platelet-transfusion in patients on clopidogrel (64% versus 13%; p = 0.000) or acetylsalicylic acid (61% versus 11%; p = 0.000) than neurologists. In the cases, neurosurgeons and neurologists were similar in their choice for surgery as initial treatment (24% and 31%; p = 0.12), however variation existed amongst physicians in specific cases. Neurosurgeons preferred craniotomy with haematoma evacuation (74%) above minimally-invasive techniques (5%). Age, Glasgow Coma Scale score and ICH location were important factors influencing decisions on treatment for neurosurgeons and neurologists. 69% of neurosurgeons and 80% of neurologists would randomise patients in a trial evaluating the effect of minimally-invasive surgery on functional outcome. Discussion Our results reflect the lack of evidence about the right treatment strategy in patients with sICH. Conclusion New high quality evidence is needed to guide treatment decisions for patients with ICH. The willingness to randomise patients into a clinical trial on minimally-invasive surgery, contributes to the feasibility of such studies in the future.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Floor Ae Jacobs
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Floris Hbm Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jeroen D Boogaarts
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, the Netherlands.,Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Academic Medical Centre, Amsterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
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Maljaars J, Garg A, Molian V, Leira EC, Adams HP, Shaban A. The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults. J Stroke Cerebrovasc Dis 2021; 30:105963. [PMID: 34247055 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105963] [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: 03/26/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates. METHODS We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality. RESULTS We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality. CONCLUSIONS The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.
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Affiliation(s)
- Jason Maljaars
- Departments of Neurology, Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242, USA.
| | - Aayushi Garg
- Departments of Neurology, Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242, USA.
| | - Vaelan Molian
- Departments of Neurology, Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242, USA.
| | - Enrique C Leira
- Departments of Neurology, Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242, USA; Neurosurgery, Carver College of Medicine, USA; Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA..
| | - Harold P Adams
- Departments of Neurology, Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242, USA.
| | - Amir Shaban
- Departments of Neurology, Carver College of Medicine, 200 Hawkins Dr., Iowa City, IA 52242, USA.
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Li L, Zuurbier SM, Kuker W, Warlow CP, Rothwell PM. Blood Pressure Control and Recurrent Stroke After Intracerebral Hemorrhage in 2002 to 2018 Versus 1981 to 1986: Population-Based Study. Stroke 2021; 52:3243-3248. [PMID: 34233466 PMCID: PMC8478103 DOI: 10.1161/strokeaha.121.034432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. The PROGRESS trial (Perindopril Protection Against Recurrent Stroke Study) conducted in the early 1990s showed that blood pressure (BP) lowering therapy reduced the risks of recurrent stroke by about 50% after spontaneous intracerebral hemorrhage (ICH). However, the ICH subgroup was a minority, and trial cohorts are invariably selective. Therefore, it is unclear whether the impact of BP control on risk of recurrent stroke in ICH observed in PROGRESS would be as great in real-world practice.
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Affiliation(s)
- Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
| | - Susanna M Zuurbier
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
| | - Wilhelm Kuker
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
| | - Charles P Warlow
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.).,Department of Clinical Neurosciences, University of Edinburgh, United Kingdom (C.P.W.)
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom (L.L., S.M.Z., W.K., C.P.W., P.M.R.)
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VAN DER Linden MC, VAN DER Linden N, Lam RC, Stap P, VAN DEN Brand CL, Vermeulen T, Jellema K, VAN DEN Wijngaard IR. Impact of ongoing centralization of acute stroke care from "drip and ship" into "direct-to-mothership" model in a Dutch urban area. Health Policy 2021; 125:1040-1046. [PMID: 34162490 DOI: 10.1016/j.healthpol.2021.06.003] [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: 05/03/2020] [Revised: 04/25/2021] [Accepted: 06/06/2021] [Indexed: 11/30/2022]
Abstract
When acute stroke care is organised using a "drip-and-ship" model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the "direct-to-mothership" model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from "drip and ship" into "direct-to-mothership". Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.
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Affiliation(s)
- M Christien VAN DER Linden
- Clinical Epidemiologist, Haaglanden Medical Centre (HMC), P.O. Box 432, 2501 CK The Hague, the Netherlands.
| | - Naomi VAN DER Linden
- Assistant Professor, Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE Enschede, the Netherlands
| | - Rianne C Lam
- Emergency Nurse Practitioner, Emergency Department, HMC, P.O. Box 432, 2501 CK The Hague, the Netherlands.
| | - Peter Stap
- Emergency Nurse Practitioner, Emergency Department, HMC, P.O. Box 432, 2501 CK The Hague, the Netherlands.
| | - Crispijn L VAN DEN Brand
- Emergency Physician, HMC and Scientific Lead at Dutch Institute for Clinical Auditing, P.O. Box 432, 2501 CK The Hague, the Netherlands.
| | - Tamara Vermeulen
- Nurse Practitioner Neurology, Department of Neurology, HMC, P.O.Box 432, 2501 CK The Hague, the Netherlands.
| | - Korné Jellema
- Neurologist, Department of Neurology, HMC, P.O. Box 432, 2501 CK The Hague, the Netherlands.
| | - Ido R VAN DEN Wijngaard
- Neurologist, Department of Neurology, HMC, P.O. Box 432, 2501 CK The Hague, the Netherlands, and Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, the Netherlands.
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Tu WJ, Yan F, Chao BH, Ji XM, Wang L. Stroke-unit care for stroke patients in China: the results from Bigdata Observatory platform for Stroke of China. J Neurol 2021; 268:4213-4220. [PMID: 33885974 DOI: 10.1007/s00415-021-10532-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND To assess whether stroke patients admitted to stroke units (SU) have a better short-term outcome than those treated in conventional wards (CW). METHODS A total of 20 hospitals from 16 provinces in China were initially selected in this study. Finally, 24,090 consecutive admissions in 2013-2015 treated in CW and 21,332 consecutive entries in 2017-2019 treated in SU were included. The primary endpoint of this study was the all-cause death or dependency condition three months after admission. RESULTS Patients in the SU group were more likely receiving thrombolytic therapy (3.9 vs 2.1%) and intravascular treatment (1.2 and 0.7%). In-hospital death were lower in the SU group than the CW group (SU vs CW: 2.93 vs 4.58% [absolute difference, - 2.28% {95% CI, - 3.32% to - 0.93%}, odd ratio {OR}, 0.72{95% CI, 0.61 to 0.82}]. Death after discharge was also lower in the SU group than the CW (SU vs CW: 5.07 vs 6.72% [absolute difference, - 2.33% {95% CI, - 3.39% to - 0.90%}, odd ratio {OR}, 0.75{95% CI, 0.68 to 0.84}]. In addition, patients who received SU care were less likely to be dead or disabled than those patients who received CW care after adjusting for other variability (SU vs CW: 36.20 vs 44.33% [absolute difference, - 11.33% {95% CI, - 15.32% to - 7.14%}, odd ratio {OR}, 0.78{95% CI, 0.80 to 0.85}]. CONCLUSIONS Among patients with stroke, admission to a designated SU was associated with modestly lower mortality at discharge, reduced probability of death, or being disabled at the end of follow-up.
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Affiliation(s)
- Wen-Jun Tu
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China.,Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Yan
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Bao-Hua Chao
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
| | - Xun-Ming Ji
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China. .,, No 45, Changchun Street, Xicheng District, Beijing, 100053, China.
| | - Longde Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China. .,, No. 118, Guang'anmen Inner Street, Beijing, 100053, People's Republic of China.
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D'Souza A, Dave KM, Stetler RA, S. Manickam D. Targeting the blood-brain barrier for the delivery of stroke therapies. Adv Drug Deliv Rev 2021; 171:332-351. [PMID: 33497734 DOI: 10.1016/j.addr.2021.01.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 02/06/2023]
Abstract
A variety of neuroprotectants have shown promise in treating ischemic stroke, yet their delivery to the brain remains a challenge. The endothelial cells lining the blood-brain barrier (BBB) are emerging as a dynamic factor in the response to neurological injury and disease, and the endothelial-neuronal matrix coupling is fundamentally neuroprotective. In this review, we discuss approaches that target the endothelium for drug delivery both across the BBB and to the BBB as a viable strategy to facilitate neuroprotective effects, using the example of brain-derived neurotrophic factor (BDNF). We highlight the advances in cell-derived extracellular vesicles (EVs) used for CNS targeting and drug delivery. We also discuss the potential of engineered EVs as a potent strategy to deliver BDNF or other drug candidates to the ischemic brain, particularly when coupled with internal components like mitochondria that may increase cellular energetics in injured endothelial cells.
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31
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Raychev R, Lo WD. The Phial of Galadriel. Neurology 2021; 96:729-730. [PMID: 33970882 DOI: 10.1212/wnl.0000000000011824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Radoslav Raychev
- From the Department of Neurology (R.R.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Pediatrics and Neurology (W.D.L.), Nationwide Children's Hospital and The Ohio State University, Columbus
| | - Warren D Lo
- From the Department of Neurology (R.R.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Pediatrics and Neurology (W.D.L.), Nationwide Children's Hospital and The Ohio State University, Columbus.
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Joundi RA, Smith EE, Yu AYX, Rashid M, Fang J, Kapral MK. Temporal Trends in Case Fatality, Discharge Destination, and Admission to Long-term Care After Acute Stroke. Neurology 2021; 96:e2037-e2047. [PMID: 33970881 DOI: 10.1212/wnl.0000000000011791] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/13/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine contemporary trends in case fatality, discharge destination, and admission to long-term care after acute ischemic stroke and intracerebral hemorrhage (ICH) using a large, population-based cohort. METHODS We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever ischemic stroke or ICH in Ontario, Canada, from 2003 to 2017. We calculated crude and age-/sex-standardized risk of death at 30 days and 1 year from stroke onset. We stratified crude trends by stroke type, age, and sex and used the Kendall τ-b correlation coefficient to evaluate the significance of trends. We determined trends in discharge home and to rehabilitation and admission to long-term care at 1 year. We used Cox proportional hazard and logistic regression models to assess whether trends in outcomes persisted after adjustment for baseline factors, estimated stroke severity, and use of life-sustaining care. RESULTS There were 163,574 people with acute ischemic stroke or ICH across the study period. Between 2003 and 2017, age-/sex-standardized 30-day stroke case fatality decreased from 20.5% to 13.2% (7.3% absolute and 36% relative reduction) while that at 1 year decreased from 32.2% to 22.8% (9.3% absolute and 29% relative reduction). Findings were consistent across age, sex, and stroke type, and after adjustment for comorbid conditions, stroke severity, and use of life-sustaining care. There was a reduction in long-term care admission after ischemic stroke and an increase in discharge home or to rehabilitation for both stroke types. CONCLUSION We observed substantial reductions in acute stroke case fatality from 2003 to 2017 with a concurrent increase in discharge to home or rehabilitation and a decrease in long-term care admissions, suggesting continuous improvements in stroke systems of care.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Amy Y X Yu
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Mohammed Rashid
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Jiming Fang
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Moira K Kapral
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada.
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Fernando SM, Qureshi D, Talarico R, Tanuseputro P, Dowlatshahi D, Sood MM, Smith EE, Hill MD, McCredie VA, Scales DC, English SW, Rochwerg B, Kyeremanteng K. Intracerebral Hemorrhage Incidence, Mortality, and Association With Oral Anticoagulation Use: A Population Study. Stroke 2021; 52:1673-1681. [PMID: 33685222 DOI: 10.1161/strokeaha.120.032550] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke associated with significant morbidity and mortality. Recent epidemiological data on incidence, mortality, and association with oral anticoagulation are needed. METHODS Retrospective cohort study of adult patients (≥18 years) with ICH in the entire population of Ontario, Canada (April 1, 2009-March 30, 2019). We captured outcome data using linked health administrative databases. The primary outcome was mortality during hospitalization, as well as at 1 year following ICH. RESULTS We included 20 738 patients with ICH. Mean (SD) age was 71.3 (15.1) years, and 52.6% of patients were male. Overall incidence of ICH throughout the study period was 19.1/100 000 person-years and did not markedly change over the study period. In-hospital and 1-year mortality were high (32.4% and 45.4%, respectively). Mortality at 2 years was 49.5%. Only 14.5% of patients were discharged home independently. Over the study period, both in-hospital and 1-year mortality reduced by 10.4% (37.5% to 27.1%, P<0.001) and 7.6% (50.0% to 42.4%, P<0.001), respectively. Use of oral anticoagulation was associated with both in-hospital mortality (adjusted odds ratio 1.37 [95% CI, 1.26-1.49]) and 1-year mortality (hazard ratio, 1.18 [95% CI, 1.12-1.25]) following ICH. CONCLUSIONS Both short- and long-term mortality have decreased in the past decade. Most survivors from ICH are likely to be discharged to long-term care. Oral anticoagulation is associated with both short- and long-term mortality following ICH. These findings highlight the devastating nature of ICH, but also identify significant improvement in outcomes over time.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine (S.M.F., S.W.E., K.K.), University of Ottawa, ON, Canada.,Department of Emergency Medicine (S.M.F.), University of Ottawa, ON, Canada
| | - Danial Qureshi
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.).,Bruyère Research Institute, Ottawa, ON, Canada (D.Q., P.T.)
| | - Robert Talarico
- ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Peter Tanuseputro
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine (P.T., K.K.), University of Ottawa, ON, Canada.,ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.).,Bruyère Research Institute, Ottawa, ON, Canada (D.Q., P.T.)
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Division of Neurology, Department of Medicine (D.D.), University of Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Manish M Sood
- School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Division of Nephrology, Department of Medicine (M.M.S.), University of Ottawa, ON, Canada.,ICES, Toronto, ON, Canada (D.Q., R.T., P.T., M.M.S., P.T.).,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Eric E Smith
- Calgary Stroke Program, Hotchkiss Brain Institute (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Michael D Hill
- Calgary Stroke Program, Hotchkiss Brain Institute (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Clinical Neurosciences (E.E.S., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (V.A.M., D.C.S.).,Krembil Research Institute, Toronto Western Hospital, University Health Network, ON, Canada (V.A.M.).,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (V.A.M., D.C.S.)
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (V.A.M., D.C.S.).,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (V.A.M., D.C.S.).,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada (D.C.S.)
| | - Shane W English
- Division of Critical Care, Department of Medicine (S.M.F., S.W.E., K.K.), University of Ottawa, ON, Canada.,School of Epidemiology and Public Health (D.Q., P.T., D.D., M.M.S., S.W.E.), University of Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.)
| | - Bram Rochwerg
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (V.A.M., D.C.S.).,Department of Medicine, Division of Critical Care (B.R.), McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine (S.M.F., S.W.E., K.K.), University of Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine (P.T., K.K.), University of Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (D.Q., R.T., P.T., D.D., M.M.S., S.W.E., K.K.).,Institut du Savoir Montfort, Ottawa, ON, Canada (K.K.)
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Guasch-Jiménez M, Prats-Sánchez L, Martínez-Domeño A, Delgado-Mederos R, Camps-Renom P, Guisado-Alonso D, Abilleira S, Martí-Fàbregas J. Patterns of Admission and Outcomes for Patients with Intracranial Hemorrhage in Catalonia, Spain. World Neurosurg 2021; 149:e1123-e1127. [PMID: 33412328 DOI: 10.1016/j.wneu.2020.12.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Limited information is available about the hospital types to which patients with intracerebral hemorrhage (ICH) are admitted and treated. This could be important because some effective therapeutic measures can only be administered at comprehensive stroke centers (CSCs). METHODS Using the Acute Hospitals Discharge database, which provides population-based information, we identified ICH patients admitted to 7 CSCs and 53 non-CSCs (from January 2015 to December 2016) in Catalonia. CSCs were defined as centers with an emergency department ready to assess and treat code stroke patients around the clock, 24-hour availability of neurology, neurosurgery, and neuroradiology services, and admission to the stroke unit and/or intensive care unit. The database provided the demographics, admitting hospital, and interhospital transfers. Vital status was retrieved from the Central Registry of the Catalan Public Health Insurance. RESULTS A total of 3339 ICH patients were identified (mean age, 72.2 ± 14.6 years; 56.8% men). Of the 3339 patients, 45.7% were admitted to a CSC and 54.3% to a non-CSC. Transfer from a non-CSC to a CSC occurred for 1.97% of the patients. In-hospital mortality was similar between the CSCs and non-CSCs (30.2% vs. 27.5%; P = 0.09). The long-term mortality was also comparable between the CSC and non-CSC groups (45.4% vs. 47%; P = 0.34). CONCLUSIONS Despite a considerable proportion of ICH patients remaining at a non-CSC for their entire hospitalization, the short- and long-term mortality were comparable between the 2 hospital types. More studies are required to determine whether outcomes other than mortality might be related to the admitting hospital type and whether the routing protocols for ICH patients should be modified.
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Affiliation(s)
- Marina Guasch-Jiménez
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Luis Prats-Sánchez
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Raquel Delgado-Mederos
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pol Camps-Renom
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Daniel Guisado-Alonso
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sònia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Centro de Investigación Biomédica en Red Epidemiología y Salud Pública, Madrid, Spain
| | - Joan Martí-Fàbregas
- Department of Neurology, Biomedical Research Institute Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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McGurgan IJ, Ziai WC, Werring DJ, Al-Shahi Salman R, Parry-Jones AR. Acute intracerebral haemorrhage: diagnosis and management. Pract Neurol 2020; 21:practneurol-2020-002763. [PMID: 33288539 PMCID: PMC7982923 DOI: 10.1136/practneurol-2020-002763] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 12/11/2022]
Abstract
Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome. Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Department of Neurology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, UCL, London, UK
| | | | - Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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Kuohn LR, Leasure AC, Acosta JN, Vanent K, Murthy SB, Kamel H, Matouk CC, Sansing LH, Falcone GJ, Sheth KN. Cause of death in spontaneous intracerebral hemorrhage survivors: Multistate longitudinal study. Neurology 2020; 95:e2736-e2745. [PMID: 32917797 PMCID: PMC7734723 DOI: 10.1212/wnl.0000000000010736] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/18/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the leading causes of death in intracerebral hemorrhage (ICH) survivors, we used administrative data from 3 large US states to identify adult survivors of a first-time spontaneous ICH and track all hospital readmissions resulting in death. METHODS We performed a longitudinal analysis of prospectively collected claims data from hospitalizations in California (2005-2011), New York (2005-2014), and Florida (2005-2014). Adult residents admitted with a nontraumatic ICH who survived to discharge were included. Patients were followed for a primary outcome of any readmission resulting in death. The cause of death was defined as the primary diagnosis assigned at discharge. Multivariable Cox proportional hazards and multinomial logistic regression were used to determine factors associated with the risk for and cause of death. RESULTS Of 72,432 ICH survivors (mean age 68 years [SD 16], 48% female), 12,753 (18%) died during a median follow-up period of 4.0 years (interquartile range 2.3-6.3). The leading causes of death were infection (34%), recurrent intracranial hemorrhage (14%), cardiac disease (8%), respiratory failure (8%), and ischemic stroke (5%). Death in patients with atrial fibrillation (AF) was more likely to be caused by ischemic stroke (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.9-2.9, p < 0.001) and less likely to be caused by recurrent intracranial hemorrhage (OR 0.7, 95% CI 0.6-0.8, p < 0.001) compared to patients without AF. CONCLUSIONS Infection is the leading cause of death in all ICH survivors. Survivors with AF were at increased risk for death from ischemic stroke. These findings will help prioritize interventions aimed to improve long-term survival and recovery in ICH survivors.
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Affiliation(s)
- Lindsey R Kuohn
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Audrey C Leasure
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Julian N Acosta
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Kevin Vanent
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Santosh B Murthy
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Charles C Matouk
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Lauren H Sansing
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Guido J Falcone
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Kevin N Sheth
- From the Divisions of Neurocritical Care and Emergency Neurology (L.R.K., A.C.L., J.N.A., K.V., G.J.F., K.N.S.) and Stroke and Vascular Neurology (L.H.S.), Department of Neurology, and Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT; and Clinical and Translational Neuroscience Unit (S.B.M., H.K.), Department of Neurology, Weill Cornell Medicine, New York, NY.
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Shoamanesh A, Patrice Lindsay M, Castellucci LA, Cayley A, Crowther M, de Wit K, English SW, Hoosein S, Huynh T, Kelly M, O'Kelly CJ, Teitelbaum J, Yip S, Dowlatshahi D, Smith EE, Foley N, Pikula A, Mountain A, Gubitz G, Gioia LC. Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020. Int J Stroke 2020; 16:321-341. [PMID: 33174815 DOI: 10.1177/1747493020968424] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
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Affiliation(s)
- Ashkan Shoamanesh
- Faculty of Medicine (Neurology), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Division of Neurology, Hamilton, Canada
| | | | - Lana A Castellucci
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, Divisions of Hematology and General Internal Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Anne Cayley
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Kerstin de Wit
- Department of Medicine (Emergency Medicine), McMaster University, Hamilton, Canada.,Hamilton Health Sciences, Divisions of Emergency Medicine and Thrombosis, Hamilton, Canada
| | - Shane W English
- Ottawa Hospital Research Institute (Clinical Epidemiology Program), Ottawa, Canada.,University of Ottawa, Department of Medicine (Critical Care) and School of Epidemiology and Public Health, Ottawa, Canada
| | - Sharon Hoosein
- Trillium Health Partners Stroke Program, Mississauga, Canada
| | - Thien Huynh
- Department of Diagnostic and Interventional Neuroradiology, Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Michael Kelly
- Department of Neurosurgery, University of Saskatchewan, Saskatoon, Canada
| | - Cian J O'Kelly
- Department of Neurological Surgery, University of Alberta, Edmonton, Canada
| | - Jeanne Teitelbaum
- Department of Neurology, Universite de Montreal, Montreal, Canada.,Department of Neurocritical Care, Montreal Neurological Institute MUHC, Montreal, Canada
| | - Samuel Yip
- Faculty of Medicine (Neurology), University of British Columbia, Vancouver, Canada
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Aleksandra Pikula
- Toronto West Regional Stroke Program, University Health Network, Toronto, Canada
| | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Canada.,Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Stroke Program, Halifax, Canada
| | - Laura C Gioia
- Department of Neurology, Universite de Montreal, Montreal, Canada.,CHUM-Centre Hospitalier de l'Université de Montréal, Stroke Program, Montréal, Canada
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38
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Clinical and radiological characteristics and outcome of wake-up intracerebral hemorrhage. Sci Rep 2020; 10:18749. [PMID: 33127937 PMCID: PMC7603492 DOI: 10.1038/s41598-020-75750-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022] Open
Abstract
There is little information on the characteristics of patients with wake-up intracerebral hemorrhage (WU-ICH). We aimed to evaluate frequency and relevant differences between WU-ICH and while-awake (WA) ICH patients. This is a retrospective study of a prospective database of consecutive patients with spontaneous ICH, who were classified as WU-ICH, WA-ICH or UO-ICH (unclear onset). We collected demographic, clinical and radiological data, prognostic and therapeutic variables, and outcome [(neurological deterioration, mortality, functional outcome (favorable when modified Rankin scale score 0-2)]. From a total of 466 patients, 98 (25.8%) were classified as UO-ICH according to the type of onset and therefore excluded. We studied 368 patients (mean age 73.9 ± 13.8, 51.4% men), and compared 95 (25.8%) WU-ICH with 273 (74.2%) WA-ICH. Patients from the WU-ICH group were significantly older than WA-ICH (76.9 ± 14.3 vs 72.8 ± 13.6, p = 0.01) but the vascular risk factors were similar. Compared to the WA-ICH group, patients from the WU-ICH group had a lower GCS score or a higher NIHSS score and a higher ICH score, and were less often admitted to a stroke unit or intensive care unit. There were no differences between groups in location, volume, rate of hematoma growth, frequency of intraventricular hemorrhage and outcome. One in five patients with spontaneous ICH are WU-ICH patients. Other than age, there are no relevant differences between WU and WA groups. Although WU-ICH is associated with worse prognostic markers vital and functional outcome is similar to WA-ICH patients.
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Specificities of acute phase stroke management in the elderly. Rev Neurol (Paris) 2020; 176:684-691. [PMID: 32980154 DOI: 10.1016/j.neurol.2020.07.006] [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: 10/25/2019] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
Abstract
Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.
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40
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Demaerschalk BM, Scharf EL, Cloft H, Barrett KM, Sands KA, Miller DA, Meschia JF. Contemporary Management of Acute Ischemic Stroke Across the Continuum: From TeleStroke to Intra-Arterial Management. Mayo Clin Proc 2020; 95:1512-1529. [PMID: 32622453 DOI: 10.1016/j.mayocp.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
Abstract
In this comprehensive contemporary review of acute ischemic stroke management, what is new and different will be highlighted beginning with prehospital stroke systems of care, emergency medical systems, and mobile stroke units, followed by hospital stroke teams, emergency evaluation, telemedicine, and brain and vascular imaging, and finishing with emergency treatments including thrombolysis and mechanical thrombectomy.
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Affiliation(s)
| | - Eugene L Scharf
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Harry Cloft
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN
| | - Kevin M Barrett
- Departments of Neurology and Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Kara A Sands
- Department of Neurology Mayo Clinic, Phoenix/Scottsdale, AZ
| | - David A Miller
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Jacksonville, FL
| | - James F Meschia
- Departments of Neurology and Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Saviluoto A, Harve-Rytsälä H, Lääperi M, Kirves H, Jäntti H, Nurmi J. A potential method of identifying stroke and other intracranial lesions in a prehospital setting. Scand J Trauma Resusc Emerg Med 2020; 28:39. [PMID: 32404134 PMCID: PMC7222442 DOI: 10.1186/s13049-020-00728-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/24/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Identifying stroke and other intracranial lesions in patients with a decreased level of consciousness may be challenging in prehospital settings. Our objective was to investigate whether the combination of systolic blood pressure, heart rate and age could be used to identify intracranial lesions. METHODS We conducted a retrospective case-control study including patients with a decreased level of consciousness who had their airway secured during prehospital care. Patients with intracranial lesions were identified based on the final diagnoses at the end of hospitalization. We investigated the ability of systolic blood pressure, heart rate and age to identify intracranial lesions and derived a decision instrument. RESULTS Of 425 patients, 127 had an intracranial lesion. Patients with a lesion were characterized by higher systolic blood pressure, lower heart rate and higher age (P < 0.0001 for all). A systolic blood pressure ≥ 140 mmHg had an odds ratio (OR) of 3.5 (95% confidence interval [CI] 1.7 to 7.0), and > 170 mmHg had an OR of 8.2 (95% CI 4.5-15.32) for an intracranial lesion (reference: < 140 mmHg). A heart rate < 100 beats/min had an OR of 3.4 (95% CI 2.0 to 6.0, reference: ≥100). Age 50-70 had an OR of 4.1 (95% CI 2.0 to 9.0), and > 70 years had an OR of 10.2 (95% CI 4.8 to 23.2), reference: < 50. Logarithms of ORs were rounded to the nearest integer to create a score with 0-2 points for age and blood pressure and 0-1 for heart rate, with an increasing risk for an intracranial lesion with higher scores. The area under the receiver operating characteristics curve for the instrument was 0.810 (95% CI 0.850-0.890). CONCLUSIONS An instrument combining systolic blood pressure, heart rate and age may help identify stroke and other intracranial lesions in patients with a decreased level of consciousness in prehospital settings. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Anssi Saviluoto
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland.
- University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.
| | - Heini Harve-Rytsälä
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00029, HUS, Finland
| | - Mitja Lääperi
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Hetti Kirves
- Prehospital Emergency Care, Hyvinkää hospital area, Hospital District of Helsinki and Uusimaa, PO Box 585, FI-05850, Hyvinkää, Finland
| | - Helena Jäntti
- University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Jouni Nurmi
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00029, HUS, Finland
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42
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Sondag L, Schreuder FHBM, Boogaarts HD, Rovers MM, Vandertop WP, Dammers R, Klijn CJM. Neurosurgical Intervention for Supratentorial Intracerebral Hemorrhage. Ann Neurol 2020; 88:239-250. [PMID: 32239722 PMCID: PMC7497162 DOI: 10.1002/ana.25732] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/11/2020] [Accepted: 03/22/2020] [Indexed: 11/30/2022]
Abstract
Objective The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage (ICH) and whether it is modified by key baseline characteristics and timing remains uncertain. Methods We performed a systematic review and meta‐analysis of randomized controlled trials of surgical treatment of supratentorial spontaneous ICH aimed at clot removal. We searched MEDLINE, Embase, and Cochrane databases up to February 21, 2019. Primary outcome was good functional outcome at follow‐up; secondary outcomes were death and serious adverse events. We analyzed all types of surgery combined and minimally invasive approaches separately. We pooled risk ratios with 95% confidence intervals and assessed the modifying effect of age, Glasgow Coma Scale, hematoma volume, and timing of surgery with meta‐regression analysis. Results We included 21 studies with 4,145 patients; 4 (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval [CI] = 1.22–1.60, I2 = 46%, 20 studies), and after minimally invasive surgery it was 1.47 (95% CI = 1.26–1.72, I2 = 47%, 12 studies). For death, the risk ratio for any type of surgery was 0.77 (95% CI = 0.68–0.85, I2 = 23%, 21 studies), and for minimally invasive surgery it was 0.68 (95% CI = 0.56–0.83, I2 = 14%, 13 studies). Serious adverse events were reported infrequently. Surgery seemed more effective when performed sooner after symptom onset (p = 0.04, 12 studies). Age, Glasgow Coma Scale, and hematoma volume did not modify the effect of surgery. Interpretation Surgical treatment of supratentorial spontaneous ICH may be beneficial, in particular with minimally invasive procedures and when performed soon after symptom onset. Further well‐designed randomized trials are needed to demonstrate whether (minimally invasive) surgery improves functional outcome after ICH and to determine the optimal time window of the treatment after symptom onset. ANN NEUROL 2020;88:239–250.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maroeska M Rovers
- Departments of Operating Rooms and Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, the Netherlands.,Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
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Capo-Lugo CE, Askew RL, Muldoon K, Maas M, Liotta E, Prabhakaran S, Naidech A. Longer Time Before Acute Rehabilitation Therapy Worsens Disability After Intracerebral Hemorrhage. Arch Phys Med Rehabil 2019; 101:870-876. [PMID: 31874157 DOI: 10.1016/j.apmr.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Assess the association of time to initiation of acute rehabilitation therapy with disability after intracerebral hemorrhage (ICH) and identify predictors of time to initiation of rehabilitation therapy. DESIGN Retrospective data analysis of prospectively collected data from an ongoing observational cohort study. SETTING Large comprehensive stroke center in a metropolitan area. PARTICIPANTS Adults with ICH consecutively admitted (n=203). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Disability was assessed with the modified Rankin Scale (mRS), with poor outcome defined as mRS 4-6 (dependence or worse). Time to initiation of acute rehabilitation therapy was defined as the number of days between hospital admission and the first consult by any rehabilitation therapy specialist (eg, physical therapy, occupational therapy, speech therapy). RESULTS The median number of days from hospital admission to initiation of acute rehabilitation therapy was 3 (range=2-7). Multivariable logistic regression models indicated that each additional day between admission and initiation of acute rehabilitation therapy was associated with increased odds of poor outcome at 30 days (adjusted odds ratio [OR]=1.151; 95% confidence interval [CI]=1.044-1.268; P=.005) and at 90 days (adjusted OR=1.107; 95% CI=1.003-1.222; P=.044) for patients with ICH. A multivariable linear regression model used to identify the predictors of time to initiation of rehabilitation therapy identified heavy drinking (>5 drinks per day), premorbid mRS<4, presence of pulmonary embolism, and longer length of stay in the intensive care unit as independent predictors of later initiation of acute rehabilitation therapy. CONCLUSIONS Longer time to initiation of acute rehabilitation therapy after ICH may have persistent effects on poststroke disability. Delays in acute rehabilitation therapy consults should be minimized and may improve outcomes after ICH.
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Affiliation(s)
- Carmen E Capo-Lugo
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Robert L Askew
- Department of Psychology, Stetson University, DeLand, Florida
| | - Kathryn Muldoon
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston
| | - Matthew Maas
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston
| | - Eric Liotta
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston
| | - Shyam Prabhakaran
- Department of Neurology, The University of Chicago, Chicago, Illinois
| | - Andrew Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Evanston
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Toyoda K, Koga M, Iguchi Y, Itabashi R, Inoue M, Okada Y, Ogasawara K, Tsujino A, Hasegawa Y, Hatano T, Yamagami H, Iwama T, Shiokawa Y, Terayama Y, Minematsu K. Guidelines for Intravenous Thrombolysis (Recombinant Tissue-type Plasminogen Activator), the Third Edition, March 2019: A Guideline from the Japan Stroke Society. Neurol Med Chir (Tokyo) 2019; 59:449-491. [PMID: 31801934 PMCID: PMC6923159 DOI: 10.2176/nmc.st.2019-0177] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
| | | | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | | | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
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Zachrison KS, Aaronson E, Mahmood S, Rosand J, Viswanathan A, Schwamm LH, Goldstein JN. Resource utilisation among patients transferred for intracerebral haemorrhage. Stroke Vasc Neurol 2019; 4:223-226. [PMID: 32030206 PMCID: PMC6979870 DOI: 10.1136/svn-2019-000255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/23/2019] [Accepted: 09/12/2019] [Indexed: 11/21/2022] Open
Abstract
Background Patients with intracerebral haemorrhage (ICH) are frequently transferred between hospitals for higher level of care. We aimed to identify factors associated with resource utilisation among patients with ICH admitted to a single academic hospital. Methods We used a prospectively collected registry of consecutive patients with primary ICH at an urban academic hospital between 1 January 2005 and 31 December 2015. The primary outcome was use of either intensive care unit (ICU) admission or surgical intervention. Logistic regression examined factors associated with the outcome, controlling for age, sex, Glasgow coma score (GCS) and ICH score. Results Of the 2008 patients included, 887 (44.2%) received ICU stay or surgical intervention. These patients were younger (71 vs 74 years, p<0.001), less often white (83.9% vs 89.3%, p<0.001), had lower baseline GCS (12 vs 14, p<0.001) and more frequently had intraventricular haemorrhage (58.6% vs 43.4%, p<0.001). Factors independently associated with ICU stay or surgical intervention were age >65 years (OR 0.38, 95% CI 0.21 to 0.69), GCS <15 (1.23, 95% CI 1.01 to 1.52) and ICH score >0 (OR 2.23, 95% CI 1.70 to 2.91). Conclusion Among this cohort of primary patients with ICH, GCS of 15 and ICH score of 0 were associated with less frequent use of ICU or intervention. These results should be validated in a larger sample but may be valuable for hospitals considering which patients with ICH could safely remain at the referring facility.
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Affiliation(s)
- Kori Sauser Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Schellen C, Posekany A, Ferrari J, Krebs S, Lang W, Brainin M, Staykov D, Sykora M. Temporal trends in intracerebral hemorrhage: Evidence from the Austrian Stroke Unit Registry. PLoS One 2019; 14:e0225378. [PMID: 31747428 PMCID: PMC6867701 DOI: 10.1371/journal.pone.0225378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 11/04/2019] [Indexed: 12/21/2022] Open
Abstract
Background To assess changes in frequency, severity, complications, therapy and outcome of intracerebral hemorrhage in patients treated in stroke units in Austria, we evaluated data from the Austrian Stroke Unit Registry between 2008 and 2016. Methods and findings Data of 6707 cases of ICH covering a time span of 9 years and including information on age, risk factors, pre-stroke modified Rankin Score (mRS), baseline stroke severity (NIHSS), complications, therapy, functional outcome, and mortality were extracted from the Austrian Stroke Unit Registry. A multivariate regularized logistic regression model and linear models for temporal dependence were computed for analyzing statistical inference and time trends. Bonferroni correction was applied to correct for multiple testing. Between 2008 and 2016, the proportion of ICH admissions to stroke units in Austria declined, with a shift among patients towards older age (>70 years, p = 0.04) and lower admission NIHSS scores. While no significant time trends in risk factors, pre-stroke mRS and medical complications were observed, therapeutic interventions declined significantly (p<0.001). Three-month mortality increased over the years independently (p = 0.003). Conclusions Despite declining incidence and clinical severity of ICH we observed a clear increase in three-month mortality. This effect seems to be independent of predictors including age, admission NIHSS, pre-morbid MRS, or medical complications. The observations from this large retrospective database cohort study underline an urgent call for action in the therapy of ICH.
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Affiliation(s)
- Christoph Schellen
- Department of Radiology, Rudolf Foundation Hospital ("Krankenanstalt Rudolfstiftung"), Vienna, Austria
| | - Alexandra Posekany
- Department for Clinical Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Julia Ferrari
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Michael Brainin
- Department for Clinical Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Dimitre Staykov
- Department of Neurology, St. John's Hospital, Eisenstadt, Austria
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
- I. Department of Neurology, Comenius University, Bratislava, Slovakia
- * E-mail:
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Seiffge DJ, Goeldlin MB, Tatlisumak T, Lyrer P, Fischer U, Engelter ST, Werring DJ. Meta-analysis of haematoma volume, haematoma expansion and mortality in intracerebral haemorrhage associated with oral anticoagulant use. J Neurol 2019; 266:3126-3135. [PMID: 31541341 PMCID: PMC6851029 DOI: 10.1007/s00415-019-09536-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/05/2019] [Accepted: 09/10/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To obtain precise estimates of age, haematoma volume, secondary haematoma expansion (HE) and mortality for patients with intracerebral haemorrhage (ICH) taking oral anticoagulants [Vitamin K antagonists (VKA-ICH) or non-Vitamin K antagonist oral anticoagulants (NOAC-ICH)] and those not taking oral anticoagulants (non-OAC ICH) at ICH symptom onset. METHODS We conducted a systematic review and meta-analysis of studies comparing VKA-ICH or NOAC-ICH or both with non-OAC ICH. Primary outcomes were haematoma volume (in ml), HE, and mortality (in-hospital and 3-month). We calculated odds ratios (ORs) using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95%CI) and determined the mean ICH volume difference. RESULTS We identified 19 studies including data from 16,546 patients with VKA-ICH and 128,561 patients with non-OAC ICH. Only 2 studies reported data on 4943 patients with NOAC-ICH. Patients with VKA-ICH were significantly older than patients with non-OAC ICH (mean age difference: 5.55 years, 95%CI 4.03-7.07, p < 0.0001, I2 = 92%, p < 0.001). Haematoma volume was significantly larger in VKA-ICH with a mean difference of 9.66 ml (95%CI 6.24-13.07 ml, p < 0.00001; I2 = 42%, p = 0.05). HE occurred significantly more often in VKA-ICH (OR 2.96, 95%CI 1.74-4.97, p < 0.00001; I2 = 65%). VKA-ICH was associated with significantly higher in-hospital mortality (VKA-ICH: 32.8% vs. non-OAC ICH: 22.4%; OR 1.83, 95%CI 1.61-2.07, p < 0.00001, I2 = 20%, p = 0.27) and 3-month mortality (VKA-ICH: 47.1% vs. non-OAC ICH: 25.5%; OR 2.24, 95%CI 1.52-3.31, p < 0.00001, I2 = 71%, p = 0.001). We did not find sufficient data for a meta-analysis comparing NOAC-ICH and non-OAC-ICH. CONCLUSION This meta-analysis confirms, refines and expands findings from prior studies. We provide precise estimates of key prognostic factors and outcomes for VKA-ICH, which has larger haematoma volume, increased rate of HE and higher mortality compared to non-OAC ICH. There are insufficient data on NOACs.
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Affiliation(s)
- David J Seiffge
- Stroke Research Centre, Institute of Neurology, University College London, Russell Square House, 10 Russell Square, London, UK. .,Stroke Center and Neurology, Department of Clinical Research, University Hospital and University, Basel, Switzerland. .,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Martina B Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Philippe Lyrer
- Stroke Center and Neurology, Department of Clinical Research, University Hospital and University, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan T Engelter
- Stroke Center and Neurology, Department of Clinical Research, University Hospital and University, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, Institute of Neurology, University College London, Russell Square House, 10 Russell Square, London, UK.
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48
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Hostettler IC, Seiffge DJ, Werring DJ. Intracerebral hemorrhage: an update on diagnosis and treatment. Expert Rev Neurother 2019; 19:679-694. [PMID: 31188036 DOI: 10.1080/14737175.2019.1623671] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Spontaneous non-traumatic intracerebral hemorrhage (ICH) is most often caused by small vessel diseases: deep perforator arteriopathy (hypertensive arteriopathy) or cerebral amyloid angiopathy (CAA). Although ICH accounts for only 10-15% of all strokes it causes a high proportion of stroke mortality and morbidity, with few proven effective acute or preventive treatments. Areas covered: We conducted a literature search on etiology, diagnosis, treatment, management and current clinical trials in ICH. In this review, We describe the causes, diagnosis (including new brain imaging biomarkers), classification, pathophysiological understanding, treatment (medical and surgical), and secondary prevention of ICH. Expert opinion: In recent years, significant advances have been made in deciphering causes, understanding pathophysiology, and improving acute treatment and prevention of ICH. However, the clinical outcome remains poor and many challenges remain. Acute interventions delivered rapidly (including medical therapies - targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, anticoagulant reversal - and minimally invasive surgery) are likely to improve acute outcomes. Improved classification of the underlying arteriopathies (from neuroimaging and genetic studies) and prognosis should allow tailored prevention strategies (including sustained blood pressure control and optimized antithrombotic therapy) to further improve longer-term outcome in this devastating disease.
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Affiliation(s)
- Isabel C Hostettler
- a UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation , UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery , London , UK
| | - David J Seiffge
- a UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation , UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery , London , UK.,b Stroke Center, Department of Neurology and Department of Clinical Research , University of Basel and University Hospital Basel , Basel , Switzerland
| | - David J Werring
- a UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation , UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery , London , UK
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49
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[Atypical intracerebral hemorrhage-etiology and acute management]. DER NERVENARZT 2019; 90:423-441. [PMID: 30915485 DOI: 10.1007/s00115-019-0695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Acute management as well as establishing the etiology of an intracerebral hemorrhage is still a challenge for clinicians. The location of the intracerebral hemorrhage alone should not be used to determine the cause because atypically located hemorrhages can be caused by long-standing arterial hypertension and typically located hemorrhages can occur due to non-hypertensive causes. Besides discussing the classification of intracerebral hemorrhages, this article focuses on a diagnostic algorithm as well as the presentation of potential (rarer) causes of non-traumatic intracerebral hemorrhages. Furthermore, the acute treatment of intracerebral hemorrhage with respect to recent data on blood pressure management as well as the management of bleeding under oral anticoagulant treatment are described.
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50
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Al-Shahi Salman R, Klijn CJM, Selim M. Minimally invasive surgery plus alteplase for intracerebral haemorrhage. Lancet 2019; 393:965-967. [PMID: 30739746 DOI: 10.1016/s0140-6736(19)30309-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 01/31/2019] [Indexed: 01/12/2023]
Affiliation(s)
| | - Catharina J M Klijn
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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