Helsinki Stroke Model Is Transferrable With "Real-World" Resources and Reduced Stroke Thrombolysis Delay to 34 min in Christchurch

Network analysis of stroke systems of care in Korea

Background

The landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes.

Methods

We extracted patient-level data on acute stroke care and hospital connectivity by integrating national stroke audit data with reimbursement claims data. We then used this information to transform interhospital transfers into a network framework, where hospitals were designated as nodes and transfers as edges. Using the Louvain algorithm, we grouped densely connected hospitals into distinct stroke care communities. The quality and characteristics in given stroke communities were analysed, and their distinct types were derived using network parameters. The clinical implications of this network model were also explored.

Results

Over 6 months, 19 113 patients with acute ischaemic stroke initially presented to 1009 hospitals, with 3114 (16.3%) transferred to 246 stroke care hospitals. These connected hospitals formed 93 communities, with a median of 9 hospitals treating a median of 201 patients. Derived communities demonstrated a modularity of 0.904 , indicating a strong community structure, highly centralised around one or two hubs. Three distinct types of structures were identified: single-hub (n=60), double-hub (n=22) and hubless systems (n=11). The endovascular treatment rate was highest in double-hub systems, followed by single-hub systems, and was almost zero in hubless systems. The hubless communities were characterised by lower patient volumes, fewer hospitals, no hub hospital and no stroke unit.

Conclusions

This network analysis could quantify the national stroke care system and point out areas where the organisation and functionality of acute stroke care could be improved.

Nursing and Institutional Responsibilities for In-Hospital Stroke

In-hospital stroke events occur less often than stroke outside of a health care facility; yet, the need for timely evaluation and treatment is the same regardless of geographic location. During hospitalization, nurses are generally the first to recognize possible symptoms of stroke and activate emergency protocols. Such actions in response to changes in patient condition are critical to optimal patient outcomes. A recent scientific statement from the American Heart Association notes that patients with in-hospital stroke are likely to experience delayed recognition of symptoms, less likely to receive intravenous thrombolysis therapy, and have worse outcomes compared with community-occurring stroke. The aim of this article is to expand upon that scientific statement to assist nurses and acute care hospitals in the United States and elsewhere with similar health care systems to create evidence-based, nurse-driven protocols for in-hospital stroke recognition and management.

Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis

BACKGROUND

Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT.

AIMS

This study aimed to provide precise estimates of IVT usage for AIS in Asian countries.

METHODS

A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines.

RESULTS

67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates.

CONCLUSION

The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.

Bringing door-to-needle times within the European benchmarks results in better stroke patients outcomes in a spoke hospital from the Apulian Region

INTRODUCTION

Door-to-needle time (DNT) is a key factor in acute stroke treatment success. We retrospectively analysed the effects of a new protocol aimed at reducing treatment delays in our single-centre observational series over a 1-year period (from October 1st 2021 to September 30th 2022).

METHODS

The time frame was divided into two semesters as a new protocol was started at the beginning of the second semester to ensure a rapid evaluation, imaging, and intravenous thrombolysis in all stroke patients attending our spoke-hospital serving 200,000 inhabitants. Logistics and outcome measures were obtained for each patient and compared before and after implementation of the new protocol.

RESULTS

A total of 215 patients with ischemic stroke attended our hospital within a 1-year period (109 in the first semester, 96 in the second semester). Seventeen percent and 21% of all patients underwent acute stroke thrombolysis in the first and second semesters, respectively. DNTs were strongly reduced in the second semester (from 90 to 55 min), bringing this value below the Italian and European benchmarks. This resulted in better short-term outcomes (an average of 20%) as measured by both Δ NIHSS scores at 24 h and at discharge with respect to baseline.

Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil

Background

The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed.

Methods

Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated.

Results

A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01).

Conclusion

Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.

Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion

BACKGROUND

Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for.

AIM

This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO.

METHOD

The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels.

RESULTS

This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care.

CONCLUSIONS

The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.

Use of Clinical Pathway Simulation and Machine Learning to Identify Key Levers for Maximizing the Benefit of Intravenous Thrombolysis in Acute Stroke

Expert opinion is that about 20% of emergency stroke patients should receive thrombolysis. Currently, 11% to 12% of patients in England and Wales receive thrombolysis, ranging from 2% to 24% between hospitals. The aim of this study was to assess how much variation is due to differences in local patient populations, and how much is due to differences in clinical decision-making and stroke pathway performance, while estimating a realistic target thrombolysis use.

In-hospital systems interventions in acute stroke reperfusion therapy: a meta-analysis

OBJECTIVES

The value of in-hospital systems-based interventions in streamlining treatment delays associated with reperfusion therapy delivery in acute ischaemic stroke (AIS), in the emergency department (ED), is poorly understood. This systematic review and meta-analysis aimed to assess and quantify the value of in-hospital systems-based interventions in streamlining reperfusion therapy delivery following AIS.

MATERIAL & METHODS

Articles from the following databases were retrieved: Medline, Embase and Cochrane Central Register of Controlled Trials. The primary endpoint was in-hospital time metrics between the intervention and control group. The secondary endpoint included the rate of good functional outcome at 90 days.

RESULTS

393 Systems intervention studies published after 2015 were screened, and 231 full articles were then read. In total, 35 studies with 35,815 patients were included in the final systematic review and 26 studies with 7,089 patients were used in the meta-analysis. The greatest time reductions from in-hospital system interventions were achieved in door-to-needle (DTN) time (SMD: -2.696, 95% CI: -2.976, -2.416, z = 3.03, p = 0.002). Systems interventions were also associated with a statistically significant improvement in mortality (RR: 0.25, 95% CI: 0.18, 0.38), rate of symptomatic intracerebral haemorrhage (RR: 0.07, 95% CI: 0.04, 0.1) and ≤60-minute reperfusion rates (RR: 0.63, 95% CI: 0.51, 0.79).

CONCLUSIONS

The use of in-hospital workflow optimization is imperative to expedite reperfusion therapy delivery and improving patient outcomes. To reduce the morbidity and mortality of stroke globally, in-hospital workflow guidelines should be adhered to and incorporated including the optimal elements identified in this study.

[Cerebrovascular imaging to facilitate stroke reperfusion therapy in Japan]

Imaging diagnosis is essential to perform appropriate reperfusion therapy for acute ischemic stroke. To equally perform reperfusion therapy all over in Japan, it is important to properly facilitate acute imaging evaluation for stroke suspected patients by medical staff not only in stroke-specialized hospitals but also in non-stroke-specialized hospitals. It is unique that CT and MRI are available in most of Japanese hospitals. Even in non-stroke-specialized hospitals, inpatients may suffer from in-hospital stroke. We review statements and recommendation items for a diagnostic imaging to appropriately perform reperfusion therapy based on major clinical trials, stroke guidelines and the current status of acute stroke imaging in Japan.

The Quest to Reduce Stroke Treatment Delays at A Melbourne Metropolitan Primary Stroke Centre over the Last Two Decades

BACKGROUND

Reducing door-to-needle time (DNT) for intravenous thrombolysis in acute ischaemic stroke can lead to improved patient outcomes. Long-term reports on DNT trends in Australia are lacking in the setting of extension of the thrombolysis time window, addition of mechanical thrombectomy and increasing presentations.

AIMS

To examine 17-year trends of DNT and identify factors associated with improved DNT at a high-volume, metropolitan primary stroke centre.

METHOD

Retrospective study between 2003 and 2019 of all thrombolysis cases using departmental stroke database. Since most strategies were implemented from 2012 onwards, intervention period has been defined as period 2012-2019. Factors associated with DNT reduction were examined by regression modelling.

RESULTS

15 strategies were identified including alterations to 'Code Stroke' processes. 1250 patients were thrombolysed, with 737 (58.8%) treated during the intervention period. The proportion of DNT ≤60- minutes rose from average of 22.5% during 2003-2012 to 63% during 2015-2018 and 71% in 2019. However, median DNT has only marginally improved from 58 to 51 minutes between 2015 and 2019. Faster DNT was independently associated with two modifiable workflow factors, 'Direct-to-CT' protocol (P < 0.001) and acute stroke nurse presence (P < 0.005). Over time, treated patients were older and less independent (P < 0.001), and the number of annual stroke admissions and 'Code Stroke' activations have risen by 4- and 10-fold to 748 and 1298 by 2019, respectively.

CONCLUSIONS

Targeted quality improvement initiatives are key to reducing thrombolysis treatment delays in the Australian metropolitan setting. Relative stagnation in DNT improvement is concerning and needs further investigation. This article is protected by copyright. All rights reserved.

Routine Use of Tenecteplase for Thrombolysis in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

In ischemic stroke, intravenous tenecteplase is noninferior to alteplase in selected patients and has some practical advantages. Several stroke centers in New Zealand changed to routine off-label intravenous tenecteplase due to improved early recanalization in large vessel occlusion, inconsistent access to thrombectomy within stroke networks, and for consistency in treatment protocols between patients with and without large vessel occlusion. We report the feasibility and safety outcomes in tenecteplase-treated patients.

METHODS

We performed a retrospective analysis of consecutive patients thrombolyzed with intravenous tenecteplase at 1 comprehensive and 2 regional stroke centers from July 14, 2018, to February 29, 2020. We report the baseline clinical characteristics, rates of symptomatic intracranial hemorrhage, and angioedema. These were then compared with patient outcomes with those treated with intravenous alteplase at 2 other comprehensive stroke centers. Multivariable mixed-effects logistic regression models were performed assessing the association of tenecteplase with symptomatic intracranial hemorrhage and independent outcome (modified Rankin Scale score, 0-2) at day 90.

RESULTS

There were 165 patients treated with tenecteplase and 254 with alteplase. Age (75 versus 74 years), sex (56% versus 60% male), National Institutes of Health Stroke Scale scores (8 versus 10), median door-to-needle times (47 versus 48 minutes), or onset-to-needle time (129 versus 130 minutes) were similar between the groups. Symptomatic intracranial hemorrhage occurred in 3 (1.8% [95% CI, 0.4-5.3]) tenecteplase patients compared with 7 (2.7% [95% CI, 1.1-5.7]) alteplase patients (P=0.75). There were no differences between tenecteplase and alteplase in the rates of angioedema (4 [2.4%; 95% CI, 0.7-6.2] versus 1 [0.4%; 95% CI, 0.01-2.2], P=0.08) or 90-day functional independence (100 [61%] versus 140 [57%], P=0.47), respectively. In mixed-effects logistic regression models, there was no significant association between thrombolytic choice and symptomatic intracranial hemorrhage (odds ratio tenecteplase, 0.62 [95% CI, 0.14-2.80], P=0.53) or functional independence (odds ratio tenecteplase, 1.20 [95% CI, 0.74-1.95], P=0.46).

CONCLUSIONS

Routine use of tenecteplase for stroke thrombolysis was feasible and had comparable safety profile and outcome to alteplase.

In-hospital acute stroke workflow in acute stroke - Systems-based approaches

Clinical outcomes of acute ischaemic stroke patients have significantly improved with the advent of reperfusion therapy. However, time continues to be a critical factor. Reducing treatment delays by improving workflows can improve the efficacy of acute reperfusion therapy. Systems-based approaches have improved in-hospital temporal parameters, maximizing the utility of reperfusion therapies and improving clinical benefit to patients. However, studies aimed at optimizing and hence reducing treatment delays in emergency department (ED) settings are limited. The aim of this article is to discuss existing systems-based approaches to optimize ED acute stroke workflows and its value in reducing treatment delays and identify gaps in existing workflows that need optimization. Identifying gaps in acute stroke workflow, variations in processes and challenges in implementation, in the in-hospital settings, is essential for systems-based interventions to be effective in delivering improved outcomes for patients with acute ischaemic stroke.

Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated With Atrial Fibrillation

BACKGROUND AND PURPOSE

Left atrial appendage (LAA) is the likely embolic source in atrial fibrillation (AF)-related cardioembolic strokes. We sought to determine the prevalence of LAA thrombus on hyperacute stroke imaging and its association with AF.

METHODS

We retrospectively examined the clinical and radiological features of patients assessed through the hyperacute stroke imaging pathway over a 12-month period at Christchurch Hospital. The LAA was included in the computed tomography angiogram scan-range as part of the multimodal imaging protocol. Two radiological readers blinded to clinical information independently assessed for the presence of LAA thrombus. The association between AF and LAA thrombus was determined by multivariable logistic regression analysis.

RESULTS

Of 303 patients included in the analysis, the overall prevalence of LAA thrombus was 6.6% and 14.9% in patients with known AF. Patients with LAA thrombus were older (85 versus 75 years, P<0.01), more commonly had known or newly diagnosed AF (75% versus 30%, P<0.01) and heart failure (30% versus 8%, P=0.01), and was associated with intracranial large vessel occlusion (65% versus 39%, P=0.02). In the multivariable model, AF (odds ratio, 3.71 [95% CI, 1.25-11.01] P=0.02) was independently associated with LAA thrombus after adjusting for age and congestive heart failure. Interrater reliability was moderate (kappa=0.56).

CONCLUSIONS

LAA thrombus is a potential radiological marker of AF and can be assessed as a part of hyperacute stroke imaging.

Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Background and Purpose—

Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke.

Methods—

We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome.

Results—

We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction.

Conclusions—

Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

Successful intravenous thrombolysis for ischemic stroke as a complication of coronary intervention in patients with ticagrelor pretreatment

Ticagrelor is an antiplatelet agent used for treatment of coronary artery disease via inhibition of the P2Y12 receptor. Based on limited literature the safety of intravenous thrombolysis for ischemic stroke in patients with ticagrelor pretreatment is unknown. We present two patients established on ticagrelor treated with intravenous thrombolysis for acute ischemic stroke complicating coronary intervention.

Country-Wide Analysis of Systemic Factors Associated With Acute Ischemic Stroke Door to Needle Time

Objective: Pre-hospital, in-hospital, and patient factors are associated with variation in door to needle (DTN) time in acute ischemic stroke (AIS). Publications are usually from large single centers or multicenter registries with less reporting on national results.

Materials and methods: All AIS patients treated with intravenous tissue plasminogen activator (iv-tPA) over 4 years (2013–2016) in Northern Ireland were recorded prospectively, including patient demographics, pre-hospital care, thrombolysis rate, and DTN time. Logistic regression was performed to identify factors associated with DTN time.

Results: One thousand two hundred and one patients from 10,556 stroke admissions (11.4%) were treated with iv-tPA. Median NIHSS was 10 (IQR 6-17). Median DTN time was 54 min (IQR 36-77) with 61% treated < 60 min from arrival at hospital. National thrombolysis numbers increased over time with improving DTN time (P = 0.002). Arrival method at hospital (ambulance OR 2.3 CI1.4-3.8) pre-alert from ambulance (pre-alert OR = 5.3 CI3.5-8.1) and time of day (out of hours, n = 650, OR 0.20 CI 0.22-0.38) all P < 0.001, were the independent factors in determining DTN time. Variation in DTN time between centers occurred but was unrelated to volume of stroke admissions.

Conclusion: Ambulance transport with pre-hospital notification and time of day are associated with shorter DTN time on a national level. Most thrombolysis was delivered outside of normal working hours but these patients are more likely to experience treatment delays. Re-organization of stroke services at a whole system level with emphasis on pre-hospital care and design of stroke teams are required to improve quality and equitable care in AIS nationally.

Acute Treatment of Stroke (Except Thrombectomy)

PURPOSE OF REVIEW

The management of patients with acute stroke has been revolutionized in recent years with the advent of new effective treatments. In this rapidly evolving field, we provide an update on the management of acute stroke excluding thrombectomy, looking to recent, ongoing, and future trials.

RECENT FINDINGS

Large definitive trials have provided insight into acute stroke care including broadening the therapeutic window for thrombolysis, alternatives to standard dose alteplase, the use of dual antiplatelet therapy early after minor ischemic stroke, and treating elevated blood pressure in intracerebral hemorrhage. Further ongoing and future trials are eagerly awaited in this ever-expanding area. Although definitive trials have led to improvements in acute stroke care, there remains a need for further research to improve our understanding of pathophysiological mechanisms underlying different stroke types with the potential for treatments to be tailored to the individual.