Validation of a Smartphone Application in the Evaluation and Treatment of Acute Stroke in a Comprehensive Stroke Center.
Martins Sheila C O,Weiss Gustavo,Almeida Andrea G,Brondani Rosane,Carbonera Leonardo A,de Souza Ana Claudia,Martins Magda Carla O,Nasi Guilherme,Nasi Luiz A,Batista Carlos,Sousa Fabrício B,Rockenbach Márcio A B C,Gonçalves Felipe M,Vedolin Leonardo M,Nogueira Raul G
Stroke
Background and Purpose- The increasing demand and shortage of experts to evaluate and treat acute stroke patients has led to the development of remote communication tools to aid stroke management. We aimed to evaluate the JOIN App smartphone system-a low-cost tool for rapid clinical and neuroimaging data sharing to expedite decision-making in stroke. Methods- Consecutive acute ischemic stroke patients treated at a University Hospital in Brazil from December 2014 to December 2015 were evaluated. The analysis included all patients presenting with acute ischemic stroke who underwent initial evaluation by neurology residents followed by JOIN teleconsultation with a stroke neurologist on call for management decisions. An expert panel of stroke neurologists and neuroradiologists revised all cases using a standard Picture Archiving and Communication System imaging workstation within 24 hours and analyzed the decision made with remote assistance during the emergency setting. Results- A total of 720 stroke codes were evaluated with 442 acute ischemic stroke qualifying. Seventy-eight (18%) patients were treated with intravenous thrombolysis. The main reasons for tPA (tissue-type plasminogen activator) exclusion were symptom onset >4.5 hours (n=295; 67%) and hypodense middle cerebral artery territory area >1/3 (n=31; 7%). The agreement rates between Picture Archiving and Communication System versus JOIN-based thrombolysis decisions were 100% for the stroke (unblinded) and 99.3% for the neuroradiologist (blinded) experts. The use of the application resulted in a significant reduction in the door-to-needle times across the pre- versus postimplementation periods (median, 90 [interquartile range, 75-106] versus 63 [interquartile range, 61-117] minutes; =0.03). The rates of 90-day excellent outcomes (modified Rankin Scale, 0-1) were 51.3%; 90-day mortality, 2.6%; and symptomatic intracranial hemorrhage, 3.8%. Conclusions- The JOIN smartphone system allows rapid sharing of clinical and imaging data to facilitate decisions for stroke treatment. The remote application-based decisions seem to be as accurate as the physical presence of stroke experts and might lead to faster times to treatment. This system represents an easily implementable low-cost telemedicine solution for centers that cannot afford the full-time presence of stroke specialists.
10.1161/STROKEAHA.119.026727
[Preliminary study on outcome assessment system of treatment of stroke].
Lai Shi-long,Guo Xin-feng,Liang Wei-xiong
Zhongguo Zhong xi yi jie he za zhi Zhongguo Zhongxiyi jiehe zazhi = Chinese journal of integrated traditional and Western medicine
OBJECTIVE:In order to scientifically reflect the real efficacy of TCM treatment and to preliminarily establish a definitely valid and reliable assessment system of stroke treatment, with multi-dimensional outcome assessment indexes, including efficacy evaluation system of conventional western medicine, syndrome evaluation criteria in TCM and quality of life assessment system. METHODS:An integrative approach of cross-sectional survey and prospective follow-up was adopted. Two hundred and forty-five case-episodes of stroke patients were assessed by determining such parameters as nerve functional deficit scale, grading of total status of living ability, activity of daily living (ADL), TCM stroke criteria of diagnosing-treatment, TCM syndrome related symptoms/signs, Health Survey Questionnaire (Short form 36, SF-36), and index of quality of life (QOL), and their construction and relation were analyzed by such methods as multivariate relation, partial relation, linear regression, factor analysis, Cronbach's alpha coefficients, and the responsiveness estimation. RESULTS:The multi-dimensional assessment system of stroke treatment, containing 57 indexes with clarified constructions and classification, was created, and its validity and reliability confirmed after assessement. Various degrees of relationship were found between different TCM Syndromes and different domains of QOL. CONCLUSION:The assessment system of stroke treatment preliminarily created has satisfied reliability and validity. It could be expected to reflect the real efficacy of TCM treatment more inclusive and accurate. TCM Syndrome indexes are considered to be the factor related to both domains of mental and physical health, particularly with the former, therefore, to improve the TCM Syndrome would imply improvement of the mental health, physical health and QOL of the patients.
[Mission (im)possible : Setting up a neurological center 12,000 km away with telemedicine].
Meyding-Lamadé U,Craemer E M,Lamadé E K,Bassa B,Enk K,Ilsen H,Jacobi C,Jost V,Lorenz M W,Mohs C,Schwark C,Zimmerlein B,Gottschalk T,Hacke W,Kress B
Der Nervenarzt
BACKGROUND:Specialized neurological treatment decreases the mortality and morbidity of stroke patients. In many regions of the world an extensive coverage is not available. The cooperation between the Krankenhaus Nordwest (KHNW, Frankfurt, Germany) and the Government of Brunei Darussalam describes the set-up process of a specialized neurological center, including stroke unit, science and rehabilitation center. AIM:The aim of this project called to teach to treat - to treat to teach was to set up a center of excellence in neurology in Brunei Darussalam over a distance of 12,000 km. Treatment options were elucidated by teaching and taught by case examples. MATERIAL AND METHODS:The construction of the Brunei Neuroscience Stroke and Rehabilitation Center (BNSRC) began in July 2010. To overcome the large distance between the department of neurology and neuroradiology at the KHNW and the BNSRC, a telemedical network was established. We provided daily teleteaching for all professions involved in patient care as well as 24/7 availability of teleneurological services from Germany to support the local team on site. RESULTS:In the BNSRC unit over 1000 patients with ischemic and hemorrhagic stroke and all the various acute neurological conditions were treated from July 2010 until July 2016 as inpatients and over 5000 were treated as outpatients. Since 2010, a total of 52 patients with stroke were treated by thrombolysis within the thrombolytic window and 81 hemicraniectomies were performed. CONCLUSION:The project has shown that it is possible to convey specialized neurological knowledge over large distances to provide significant benefits for patients and caregivers.
10.1007/s00115-016-0267-x
Construction of Simulation Platform for Chinese Stroke Economic Burden Based on the National Screening Data.
Li Xuemeng,Bian Di,Li Mei,Zhao Dongsheng
Studies in health technology and informatics
With the characteristics of high incidence, high prevalence and high mortality, stroke has a serious impact on residents' health and imposes a heavy ecomomic burden on China. In order to simulate the economic burden of stroke in the next 20 years, we construct a simulation platform for Chinese stroke economic burden based on the national stroke screening data. We use the Leslie model for population prediction and the equilibrium model to simulate the stroke economic burden in the platform. The platform constructed in this study can dynamically simulate the stroke economic burden during 2020-2040 by computing the incidence, prevelance and mortality rates from the national stroke screening data or as customized by the user. Based on this platform, we can further develop a warning mechanism at the national level, and provide a guide for the planning and allocation of national health resources.
10.3233/SHTI190370
Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study.
Tuinman M P,van Golde E G A,Portier R P,Knottnerus I L H,van der Palen J,den Hertog H M,Brouwers P J A M
Journal of neurology
INTRODUCTION:We aimed to disprove an in-hospital off-hour effect in stroke patients by adjusting for disease severity and poor prognostic findings on imaging. PATIENTS AND METHODS:Our study included 5378 patients from a single center prospective stroke registry of a large teaching hospital in the Netherlands, admitted between January 2003 and June 2015. Patients were categorized by admission time, off-hours (OH) or working hours (WH). The in-hospital mortality, 7-day mortality, unfavorable functional outcome (modified Rankin scale > 2) and discharge to home were analyzed. Results were adjusted for age, sex, stroke severity (NIHSS score) and unfavorable findings on imaging of the brain (midline shift and dense vessel sign). RESULTS:Overall, 2796 patients (52%) were admitted during OH, which had a higher NIHSS score [3 (IQR 2-8) vs. 3 (IQR 2-6): p < 0.01] and had more often a dense vessel sign at admission (7.9% vs. 5.4%: p < 0.01). There was no difference in mortality between the OH-group and WH-group (6.2% vs. 6.0%; p = 0.87). The adjusted hazard ratio of in-hospital mortality during OH was 0.87 (95% CI: 0.70-1.08). Analysis of 7-day mortality showed similar results. Unadjusted, the OH-group had an unfavorable outcome [OR: 1.14 (95% CI: 1.02-1.27)] and could less frequently be discharged to home [OR: 1.16 (95% CI: 1.04-1.29)], which was no longer present after adjustment. DISCUSSION AND CONCLUSIONS:The overall outcome of stroke patients admitted to a large Dutch teaching hospital is not influenced by time of admission. When studying OH effects, adjustment for disease severity and poor prognostic findings on imaging is crucial before drawing conclusions on staffing and material.
10.1007/s00415-018-9079-1
Vitamin D Status and Risk of Stroke: The Rotterdam Study.
Berghout Brian P,Fani Lana,Heshmatollah Alis,Koudstaal Peter J,Ikram M Arfan,Zillikens M Carola,Ikram M Kamran
Stroke
Background and Purpose- Recent findings suggest that vitamin D, a neuroprotective prohormone, is involved in the pathogenesis of cardiovascular disease. However, previous studies investigating the association between vitamin D and stroke have shown inconsistent findings. In view of these discrepancies, we determined the association of vitamin D status with stroke using data from a population-based study. Methods- Within the RS (Rotterdam Study), an ongoing prospective population-based study, we measured serum 25-hydroxyvitamin D concentrations between 1997 and 2008 in 9680 participants (56.8% women) aged ≥45 years. We assessed a history of stroke at baseline and subsequently followed for incident stroke until January 1, 2016. Regression models were used to investigate the association of serum 25-hydroxyvitamin D with prevalent and incident stroke separately, adjusted for age, sex, study cohort, season of blood sampling, and other cardiovascular risk factors. Results- Of 9680 participants, 339 had a history of stroke at baseline. Serum 25-hydroxyvitamin D concentration was associated with prevalent stroke, adjusted odds ratio per SD decrease, 1.31; 95% CI, 1.14-1.51. After excluding participants with prevalent stroke, we followed 9338 participants for a total of 98 529 person-years. During follow-up, 735 participants developed a stroke. Lower serum 25-hydroxyvitamin D concentration was not associated with a higher stroke risk, adjusted hazard ratio per SD decrease, 1.06; 95% CI, 0.97-1.16. However, severe vitamin D deficiency did show a significant association: hazard ratio, 1.25; 95% CI, 1.05-1.50. Conclusions- In this population-based cohort, we found an association between vitamin D and prevalent stroke. Only severe vitamin D deficiency was associated with incident stroke. This suggests that lower vitamin D levels do not lead to a higher stroke risk but are instead a consequence of stroke.
10.1161/STROKEAHA.119.025449
Estimated Impact of Emergency Medical Service Triage of Stroke Patients on Comprehensive Stroke Centers: An Urban Population-Based Study.
Katz Brian S,Adeoye Opeolu,Sucharew Heidi,Broderick Joseph P,McMullan Jason,Khatri Pooja,Widener Michael,Alwell Kathleen S,Moomaw Charles J,Kissela Brett M,Flaherty Matthew L,Woo Daniel,Ferioli Simona,Mackey Jason,Martini Sharyl,De Los Rios la Rosa Felipe,Kleindorfer Dawn O
Stroke
BACKGROUND AND PURPOSE:The American Stroke Association recommends that Emergency Medical Service bypass acute stroke-ready hospital (ASRH)/primary stroke center (PSC) for comprehensive stroke centers (CSCs) when transporting appropriate stroke patients, if the additional travel time is ≤15 minutes. However, data on additional transport time and the effect on hospital census remain unknown. METHODS:Stroke patients ≥20 years old who were transported from home to an ASRH/PSC or CSC via Emergency Medical Service in 2010 were identified in the Greater Cincinnati area population of 1.3 million. Addresses of all patients' residences and hospitals were geocoded, and estimated travel times were calculated. We estimated the mean differences between the travel time for patients taken to an ASRH/PSC and the theoretical time had they been transported directly to the region's CSC. RESULTS:Of 929 patients with geocoded addresses, 806 were transported via Emergency Medical Service directly to an ASRH/PSC. Mean additional travel time of direct transport to the CSC, compared with transport to an ASRH/PSC, was 7.9±6.8 minutes; 85% would have ≤15 minutes added transport time. Triage of all stroke patients to the CSC would have added 727 patients to the CSC's census in 2010. Limiting triage to the CSC to patients with National Institutes of Health Stroke Scale score of ≥10 within 6 hours of onset would have added 116 patients (2.2 per week) to the CSC's annual census. CONCLUSIONS:Emergency Medical Service triage to CSCs based on stroke severity and symptom duration may be feasible. The impact on stroke systems of care and patient outcomes remains to be determined and requires prospective evaluation.
10.1161/STROKEAHA.116.015971
NfL (Neurofilament Light Chain) Levels as a Predictive Marker for Long-Term Outcome After Ischemic Stroke.
Uphaus Timo,Bittner Stefan,Gröschel Sonja,Steffen Falk,Muthuraman Muthuraman,Wasser Katrin,Weber-Krüger Mark,Zipp Frauke,Wachter Rolf,Gröschel Klaus
Stroke
Background and Purpose- Ischemic stroke causes major disability as a consequence of neuronal loss and recurrent ischemic events. Biomarkers predicting tissue damage or stroke recurrence might be useful to guide an individualized stroke therapy. NfL (neurofilament light chain) is a promising biomarker that might be used for this purpose. Methods- We used individual data of patients with an acute ischemic stroke and clinical long term follow-up. Serum NfL (sNfL) was quantified within 24 hours after admission and after 1 year and compared with other biomarkers (GDF15 [growth differentiation factor 15], S100, NT-proBNP [N-terminal pro-B-type natriuretic peptide], ANP [atrial natriuretic peptide], and FABP [fatty acid-binding protein]). The primary end point was functional outcome after 90 days and cerebrovascular events and death (combined cardiovascular end point) within 36 months of follow-up. Results- Two hundred eleven patients (mean age, 68.7 years; SD, ±12.6; 41.2% women) with median clinical severity on the National Institutes of Health Stroke Scale (NIHSS) score of 3 (interquartile range, 1-5) and long-term follow-up with a median of 41.8 months (interquartile range, 40.0-44.5) were prospectively included. We observed a significant correlation between sNfL and NIHSS at hospital admission (r=0.234; <0.001). sNfL levels increased with the grade of age-related white matter changes (<0.001) and were able to predict unfavorable clinical outcome (modified Rankin Scale score, ≥2) 90 days after stroke (odds ratio [OR], 1.562; 95% CI, 1.003-2.433; =0.048) together with NIHSS (OR, 1.303; 95% CI, 1.164-1.458; <0.001) and age-related white matter change rating (severe; OR, 3.326; 95% CI, 1.186-9.326; =0.022). Similarly, sNfL was valuable for the prediction of the combined cardiovascular end point (OR, 2.002; 95% CI, 1.213-3.302; =0.007), besides NIHSS (OR, 1.110; 95% CI, 1.000-1.232; =0.049), diabetes mellitus (OR, 2.942; 95% CI, 1.306-6.630; =0.005), and age-related white matter change rating (severe; OR, 4.816; 95% CI, 1.206-19.229; =0.026) after multivariate regression analysis. Kaplan-Meier analysis revealed significantly more combined cardiovascular end points (18 [14.1%] versus 38 [45.8%], log-rank test <0.001) during long-term follow-up in patients with elevated sNfL levels. Conclusions- sNFL is a valuable biomarker for functional independence 90 days after ischemic stroke and predicts cardiovascular long-term outcome. Clinical Trial Registration- URL: http://www.isrctn.com. Unique identifier: ISRCTN 46104198.
10.1161/STROKEAHA.119.026410
Workflow Optimization for Ischemic Stroke in a Community-Based Stroke Center.
Aghaebrahim Amin,Granja Manuel F,Agnoletto Guilherme J,Aguilar-Salinas Pedro,Cortez Gustavo M,Santos Roberta,Monteiro Andre,Camp Wendy,Day Jason,Dellorso Scott,Naval Neeraj,Chmayssani Mohamad,Stromberg Richard,Rill Matthew C,Sauvageau Eric,Hanel Ricardo
World neurosurgery
BACKGROUND:We analyzed the effect of specific optimization steps to reduce treatment delays in a nonacademic stroke hospital setting. METHODS:The data from patients with ischemic stroke who had been treated with intravenous tissue plasminogen activator or endovascular therapy, or both, were analyzed. The metrics were divided into 2 periods: preoptimization period (October 1, 2015 to September 30, 2016) and postoptimization period (October 1, 2016 to September 30, 2017). The key interventions were 1) notification by the emergency medical service to the emergency department and stroke team; 2) division of the stroke alert between level 1 (intravenous/intra-arterial candidate) and level 2; 3) direct transportation of level 1 patients to brain computed tomography; 4) limitation of nonessential interventions; 5) stroke orientation; 6) 24-hour, 7-day code stroke response by a vascular neurologist; 7) earlier notification of the interventional radiology team; 8) direct transportation from computed tomography to angiography suite for large vessel occlusion; and 9) multidisciplinary monthly meetings to discuss delayed cases. RESULTS:A total of 279 patients were identified. No significant differences in any of the baseline characteristics were documented. Almost all metrics favored the postoptimization period, with remarkable improvement in the door-to-puncture time (median, 64 minutes; interquartile range, 36-86; vs. 47 minutes; interquartile range, 20-62; P = 0.001). We observed an increased percentage of good clinical outcomes in the postoptimization group (60.1% vs. 54.8%; P = 0.500). We found an 8.4% increase in patients with good clinical outcomes in the postoptimization group compared with our previously reported work. CONCLUSIONS:For acute reperfusion therapies, significant reductions in workflow intervals can be achieved after simple optimization methods in a nonacademic community-based hospital.
10.1016/j.wneu.2019.05.127
Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study.
Fekadu Ginenus,Chelkeba Legese,Kebede Ayantu
BMC neurology
BACKGROUND:Stroke is the second-leading global cause of death behind heart disease in 2013 and is a major cause of permanent disability. The burden of stroke in terms of mortality, morbidity and disability is increasing across the world. It is currently observed to be one of the commonest reasons of admission in many health care setups and becoming an alarming serious public health problem in our country Ethiopia. Despite the high burden of strokes globally, there is insufficient information on the current clinical profile of stroke in low and middle income countries (LMICs) including Ethiopia. So, this study was aimed to assess risk factors, clinical presentations and predictors of stroke subtypes among adult patients admitted to stroke unit of Jimma university medical center (JUMC). METHODS:Prospective observational study design was carried out at stroke unit (SU) of JUMC for 4 consecutive months from March 10-July 10, 2017. A standardized data extraction checklist and patient interview was used to collect data. Data was entered into Epi data version 3.1 and analyzed using SPSS version 20. Multivariable logistic regression was used to identify the predictors of stroke subtypes. RESULT:A total of 116 eligible stroke patients were recruited during the study period. The mean age of the patients was 55.1 ± 14.0 years and males comprised 62.9%. According to world health organization (WHO) criteria of stroke diagnosis, 51.7% of patients had ischemic while 48.3% had hemorrhagic stroke. The most common risk factor identified was hypertension (75.9%) followed by family history (33.6%), alcohol intake (22.4%), smoking (17.2%) and heart failure (17.2%). The most common clinical presentation was headache complained by 75.0% of the patients followed by aphasia 60.3% and hemiparesis 53.4%. Atrial fibrillation was the independent predictor of hemorrhagic stroke (AOR: 0.08, 95% CI: 0.01-0.68). CONCLUSION:The clinical characteristics of stroke in this set up were similar to other low- and middle-resource countries. As stroke is a high priority chronic disease, large-scale public health campaign should be launched focusing on public education regarding stroke risk factors and necessary interventions.
10.1186/s12883-019-1409-0
Multicenter, Prospective, Controlled, Before-and-After, Quality Improvement Study (Stroke123) of Acute Stroke Care.
Cadilhac Dominique A,Grimley Rohan,Kilkenny Monique F,Andrew Nadine E,Lannin Natasha A,Hill Kelvin,Grabsch Brenda,Levi Christopher R,Thrift Amanda G,Faux Steven G,Wakefield John,Cadigan Greg,Donnan Geoffrey A,Middleton Sandy,Anderson Craig S
Stroke
Background and Purpose- Hospital uptake of evidence-based stroke care is variable. We aimed to determine the impact of a multicomponent program involving financial incentives and quality improvement interventions, on stroke care processes. Methods- A prospective study of interventions to improve clinical care quality indicators at 19 hospitals in Queensland, Australia, during 2010 to 2015, compared with historical controls and 23 other Australian hospitals. After baseline routine audit and feedback (control phase, 30 months), interventions involving financial incentives (21 months) and then addition of externally facilitated quality improvement workshops with action plan development (9 months) were implemented. Postintervention phase was 13 months. Data were obtained for the analysis from a previous continuous audit in Queensland and subsequently the Australian Stroke Clinical Registry. Primary outcome: change in median composite score for adherence to ≤8 indicators. Secondary outcomes: change in adherence to self-selected indicators addressed in action plans and 4 national indicators compared with other Australian hospitals. Multivariable analyses with adjustment for clustered data. Results- There were 17 502 patients from the intervention sites (median age, 74 years; 46% women) and 20 484 patients from other Australian hospitals. Patient characteristics were similar between groups. There was an 18% improvement in the primary outcome across the study periods (95% CI, 12%-24%). The largest improvement was following introduction of financial incentives (14%; 95% CI, 8%-20%), while indicators addressed in action plans provided an 8% improvement (95% CI, 1%-17%). The national score (4 indicators) improved by 17% (95% CI, 13%-20%) versus 0% change in other Australian hospitals (95% CI, -0.03 to 0.03). Access to stroke units improved more in Queensland than in other Australian hospitals ( P<0.001). Conclusions- The quality improvement interventions significantly improved clinical practice. The findings were primarily driven by financial incentives, but were also contributed to by the externally facilitated, quality improvement workshops. Assessment in other regions is warranted.
10.1161/STROKEAHA.118.023075
Public Awareness of Stroke and the Appropriate Responses in China: A Cross-Sectional Community-Based Study (FAST-RIGHT)
Li Shengde,Cui Li-Ying,Anderson Craig,Zhu Suiqiang,Xu Ping,Wei Tiemin,Luo Yun,Chen Shengli,Jiang Nan,Hong Yuehui,Liu Weidong,Li Jian,Gao Chunpeng,Yu Chengdong,Shan Guangliang,Wang Longde,Peng Bin,
Stroke
Background and Purpose—Early presentation is critical for receiving effective reperfusion therapy for acute ischemicstroke, therefore, we undertook a national survey of awareness and responses to acute stroke symptoms in China.Methods—We undertook a cross-sectional community-based study of 187 723 adults (age ≥40 years) presenting to 69administrative areas across China between January 2017 and May 2017 to determine the national stroke recognition rateand the correct action rate. Multivariable logistic regression models were used to identify factors associated with strokerecognition and intention-to-avail emergency medical services.Results—Estimates of stroke recognition rate and correct action rate were 81.9% (153 675/187723) and 60.9%(114 380/187723), respectively, but these rates varied widely by sociodemographic status, region, and stroke risk.Approximately one-third of participants who recognized a stroke failed to call emergency medical service. Low likelihoodof emergency medical service use was associated with younger age (40–59 years), being male, rural location, (regions ofeast, south, and northwest China), high body mass index (≥24), low education (primary school or below), low personalincome (<US $731 per annum), living with immediate family, having multiple children (≥2), having a friend with stroke,exposure to less avenues to learn about stroke, nonsmoking, regular exercise, unknown family history, and no history ofcardiovascular disease. Intention of calling emergency medical service was strongly related to awareness of stroke (oddsratio 2.05; 95% CI, 2.00–2.10; P<0.001).Conclusions—Substantial discrepancies exist between stroke recognition and correct action and not all stroke patientsknow the appropriate responses. Further, national stroke educational programs with specific plans targeting differentgroups are needed, which do not solely focus on stroke recognition, but also on the appropriate responses at the time of astroke.
10.1161/STROKEAHA.118.023317
Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System.
Nguyen-Huynh Mai N,Klingman Jeffrey G,Avins Andrew L,Rao Vivek A,Eaton Abigail,Bhopale Sunil,Kim Anne C,Morehouse John W,Flint Alexander C,
Stroke
BACKGROUND AND PURPOSE:Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California's Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. METHODS:The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. RESULTS:This study included 310 patients treated with alteplase in the pre-EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; =0.29). CONCLUSIONS:Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.
10.1161/STROKEAHA.117.018413
Serum 25-Hydroxyvitamin D Concentrations and Ischemic Stroke and Its Subtypes.
Larsson Susanna C,Traylor Matthew,Mishra Aniket,Howson Joanna M M,Michaëlsson Karl,Markus Hugh S,
Stroke
Background and Purpose- Observational studies have reported increased risk of ischemic stroke among individuals with low serum 25-hydroxyvitamin D (S-25OHD) concentrations but uncertainty remains about the causality of this association. We sought to determine whether S-25OHD concentrations are causally associated with ischemic stroke and its subtypes using Mendelian randomization. Methods- We used summary-level data for ischemic stroke (34 217 cases and 404 630 noncases) from the MEGASTROKE consortium. As instruments, we used 6 single nucleotide polymorphisms, explaining 7.5% of the variance in S-25OHD, previously identified to be associated with S-25OHD concentrations in the Study of Underlying Genetic Determinants of Vitamin D and Highly Related Traits consortium (n=79 366). The analyses were conducted using the inverse-variance-weighted method and complemented with the weighted median, heterogeneity-penalized, and Mendelian randomization-Egger approaches. Results- Genetically higher S-25OHD concentration was not associated with ischemic stroke. The odds ratios (95% CI) per genetically predicted 1-SD (≈18 nmol/L) increase in S-25OHD concentrations, based on all 6 single nucleotide polymorphisms, were 1.01 (0.94-1.08; P=0.84) for all ischemic stroke, 0.94 (0.80-1.11; P=0.49) for large artery stroke, 0.95 (0.82-1.11; P=0.55) for small vessel stroke, and 1.02 (0.90-1.16; P=0.74) for cardioembolic stroke. The results were similar in sensitivity analyses. Conclusions- These findings provide no support that higher S-25OHD concentrations are causally associated with any ischemic stroke subtype. Thus, vitamin D supplementation will unlikely reduce the risk of ischemic stroke in the general population.
10.1161/STROKEAHA.118.022242
Brief Educational Intervention Improves Emergency Medical Services Stroke Recognition.
Stroke
Background and Purpose- Recognition of stroke symptoms and hospital prenotification by emergency medical services (EMS) facilitate rapid stroke treatment; however, one-third of patients with stroke are unrecognized by EMS. To promote stroke recognition and quality measure compliant prehospital stroke care, we deployed a 30-minute online EMS educational module coupled with a performance feedback system in a single Michigan county. Methods- During a 24-month study period, a registry of consecutive EMS-transported suspected or unrecognized stroke cases was utilized to perform an interrupted time series analysis of the impact of the EMS education and feedback intervention. For each agency, we compared EMS stroke recognition and quality measure compliance rates, as well as emergency department performance and hospital outcomes during 12 preintervention months with performance in the remaining study months. Results- A total of 1805 EMS-transported cases met inclusion criteria; 1235 (68.4%) of these had ischemic or hemorrhagic strokes or transient ischemic attacks. There were no trends toward improvement in any outcome before the intervention. After the intervention, the EMS stroke recognition rate increased from 63.8% to 69.5% ( P=0.037). Prenotification increased from 60.9% to 77.3% ( P<0.001). Among patients with ischemic stroke/transient ischemic attack, there was a trend toward higher rates of tPA (tissue-type plasminogen activator) delivery (13.9%-17.7%; P=0.096) and a significant increase in tPA delivery within 45 minutes (5.7%-8.9%; P=0.042) after intervention. However, improvements in EMS recognition were limited to the first 3 months following intervention. Conclusions- A brief educational intervention was associated with improved EMS stroke recognition, hospital prenotification, and faster tPA delivery. Gains were primarily observed immediately following education and were not sustained through provision of performance feedback to paramedics.
10.1161/STROKEAHA.118.023885
Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update.
Adeoye Opeolu,Nyström Karin V,Yavagal Dileep R,Luciano Jean,Nogueira Raul G,Zorowitz Richard D,Khalessi Alexander A,Bushnell Cheryl,Barsan William G,Panagos Peter,Alberts Mark J,Tiner A Colby,Schwamm Lee H,Jauch Edward C
Stroke
In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.
10.1161/STR.0000000000000173
Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency.
Nolte Christian H,Ebinger Martin,Scheitz Jan F,Kunz Alexander,Erdur Hebun,Geisler Frederik,Braemswig Tim Bastian,Rozanski Michal,Weber Joachim E,Wendt Matthias,Zieschang Katja,Fiebach Jochen B,Villringer Kersten,Grittner Ulrike,Kaczmarek Sabina,Endres Matthias,Audebert Heinrich J
Stroke
BACKGROUND AND PURPOSE:Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily -independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency. METHODS:This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression. RESULTS:Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69-159; STEMO) and 135 (interquartile range, 98-184; CC; <0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%; =0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive (=0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02-3.87; =0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95-3.16; =0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%; =0.167). CONCLUSIONS:The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT02358772.
10.1161/STROKEAHA.117.019060
Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research.
Stroke
BACKGROUND AND PURPOSE:Emergency medical services routing of patients with acute stroke to designated centers may increase the proportion of patients receiving care at facilities meeting national standards and augment recruitment for prehospital stroke research. METHODS:We analyzed consecutive patients enrolled within 2 hours of symptom onset in a prehospital stroke trial, before and after regional Los Angeles County Emergency Medical Services implementation of preferentially routing patients with acute stroke to approved stroke centers (ASCs). From January 2005 to mid-November 2009, patients were transported to the nearest emergency department, whereas from mid-November 2009 to December 2012, patients were preferentially transported to first 9, and eventually 29, ASCs. RESULTS:There were 863 subjects enrolled before and 764 after emergency medical service preferential routing, with implementation leading to an increase in the proportion cared for at an ASC from 10% to 91% (P<0.0001), with a slight decrease in paramedic on-scene to emergency department arrival time (34.5 [SD, 9.1] minutes versus 33.5 [SD, 10.3] minutes; P=0.045). The effects of routing were immediate and included an increase in proportion of receiving ASC care (from 17% to 88%; P<0.001) and a greater number of enrollments (18.6% increase) when comparing 12 months before and after regional stroke system implementation. CONCLUSIONS:The establishment of a regionalized emergency medical services system of acute stroke care dramatically increased the proportion of patients with acute stroke cared for at ASCs, from 1 in 10 to >9 in 10, with no clinically significant increase in prehospital care times and enhanced recruitment of patients into a prehospital treatment trial. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
10.1161/STROKEAHA.115.010264
Use of Emergency Medical Services and Timely Treatment Among Ischemic Stroke.
Gu Hong-Qiu,Rao Zhen-Zhen,Yang Xin,Wang Chun-Juan,Zhao Xing-Quan,Wang Yi-Long,Liu Li-Ping,Wang Cai-Yun,Liu Chelsea,Li Hao,Li Zi-Xiao,Xiao Rui-Ping,Wang Yong-Jun,
Stroke
Background and Purpose- Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods- We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates' balance assessments. We used multivariable logistic models with the generalized estimating equations to account for intrahospital clustering in identifying demographic and clinical factors associated with EMS use as well as in evaluating the association of EMS use with timely treatment. Results- Of the 560 447 patients with ischemic stroke analyzed, only 69 841 (12.5%) were transported by EMS. Multivariable-adjusted results indicated that those with younger age, lower levels of education, less insurance coverage, lower income, lower stroke severity, hypertension, diabetes mellitus, and peripheral vascular disease were less likely to use EMS. However, a history of cardiovascular diseases was associated with increased EMS usage. Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95-2.20] for onset-to-door time ≤2 hours, 2.32 [2.18-2.47] for onset-to-door time ≤3.5 hours), and more rapid treatment (2.96 [2.88-3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62-1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ≤2 hours, and 1.76 [1.70-1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ≤3.5 hours). Conclusions- Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.
10.1161/STROKEAHA.118.024232
Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization.
Man Shumei,Cox Margueritte,Patel Puja,Smith Eric E,Reeves Mathew J,Saver Jeffrey L,Bhatt Deepak L,Xian Ying,Schwamm Lee H,Fonarow Gregg C
Stroke
BACKGROUND AND PURPOSE:Primary stroke center (PSC) certification was established to identify hospitals providing evidence-based care for stroke patients. The numbers of PSCs certified by Joint Commission (JC), Healthcare Facilities Accreditation Program, Det Norske Veritas, and State-based agencies have significantly increased in the past decade. This study aimed to evaluate whether PSCs certified by different organizations have similar quality of care and in-hospital outcomes. METHODS:The study population consisted of acute ischemic stroke patients who were admitted to PSCs participating in Get With The Guidelines-Stroke between January 1, 2010, and December 31, 2012. Measures of care quality and outcomes were compared among the 4 different PSC certifications. RESULTS:A total of 477 297 acute ischemic stroke admissions were identified from 977 certified PSCs (73.8% JC, 3.7% Det Norske Veritas, 1.2% Healthcare Facilities Accreditation Program, and 21.3% State-based). Composite care quality was generally similar among the 4 groups of hospitals, although State-based PSCs underperformed JC PSCs in a few key measures, including intravenous tissue-type plasminogen activator use. The rates of tissue-type plasminogen activator use were higher in JC and Det Norske Veritas (9.0% and 9.8%) and lower in State and Healthcare Facilities Accreditation Program certified hospitals (7.1% and 5.9%) (P<0.0001). Door-to-needle times were significantly longer in Healthcare Facilities Accreditation Program hospitals. State PSCs had higher in-hospital risk-adjusted mortality (odds ratio 1.23, 95% confidence intervals 1.07-1.41) compared with JC PSCs. CONCLUSIONS:Among Get With The Guidelines-Stroke hospitals with PSC certification, acute ischemic stroke quality of care and outcomes may differ according to which organization provided certification. These findings may have important implications for further improving systems of care.
10.1161/STROKEAHA.116.014426
Impact of Stroke Center Certification on Mortality After Ischemic Stroke: The Medicare Cohort From 2009 to 2013.
Man Shumei,Schold Jesse D,Uchino Ken
Stroke
BACKGROUND AND PURPOSE:An increasing number of hospitals have been certified as primary stroke centers (PSCs). It remains unknown whether the action toward PSC certification has improved the outcome of stroke care. This study aimed to understand whether PSC certification reduced stroke mortality. METHODS:We examined Medicare fee-for-service beneficiaries aged ≥65 years who were hospitalized between 2009 and 2013 for ischemic stroke. Hospitals were classified into 3 groups: new PSCs, the hospitals that received initial PSC certification between 2009 and 2013 (n=634); existing PSCs, the PSCs certified before 2009 (n=785); and non-SCs, the hospitals that have never been certified as PSCs (n=2640). Multivariate logistic regression and Cox proportional hazards model was used to compare the mortality among the 3 groups. RESULTS:Existing PSCs were significantly larger than new PSCs as reflected by total number of beds and annual stroke admission (<0.0001). Compared with existing PSCs, new PSCs had lower in-hospital (odds ratio, 0.862; 95% confidence interval [CI], 0.817-0.910) and 30-day mortality (hazard ratio [HR], 0.981; 95% CI, 0.968-0.993), after adjusting for patient demographics and comorbidities. Compared with non-SCs, new PSCs had lower adjusted in-hospital (odds ratio, 0.894; 95% CI, 0.848-0.943), 30-day (HR, 0.904; 95% CI, 0.892-0.917), and 1-year mortality (HR, 0.907; 95% CI, 0.898-0.915). Existing PSCs had lower adjusted 30-day (HR, 0.922; 95% CI, 0.911-0.933) and 1-year mortality (HR, 0.900; 95% CI, 0.892-0.907) than non-SCs. CONCLUSIONS:Obtaining stroke certification may reduce stroke mortality and overcome the disadvantage of being smaller hospitals. Further study of other outcome measures will be useful to improve stroke system of care.
10.1161/STROKEAHA.116.016473
Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies.
Mullen Michael T,Pajerowski William,Messé Steven R,Mechem C Crawford,Jia Judy,Abboud Michael,David Guy,Carr Brendan G,Band Roger
Stroke
BACKGROUND AND PURPOSE:We evaluated the impact of a primary stroke center (PSC) destination policy in a major metropolitan city and used geographic modeling to evaluate expected changes for a comprehensive stroke center policy. METHODS:We identified suspected stroke emergency medical services encounters from 1/1/2004 to 12/31/2013 in Philadelphia, PA. Transport times were compared before and after initiation of a PSC destination policy on 10/3/2011. Geographic modeling estimated the impact of bypassing the closest hospital for the closest PSC and for the closest comprehensive stroke center. RESULTS:There were 2 326 943 emergency medical services runs during the study period, of which 15 099 had a provider diagnosis of stroke. Bypassing the closest hospital for a PSC was common before the official policy and increased steadily over time. Geographic modeling suggested that bypassing the closest hospital in favor of the closest PSC adds a median of 3.1 minutes to transport time. Bypassing to the closest comprehensive stroke center would add a median of 8.3 minutes. CONCLUSIONS:Within a large metropolitan area, the time cost of routing patients preferentially to PSCs and comprehensive stroke centers is low.
10.1161/STROKEAHA.118.020691