Emergency Department Arrival Times after Acute Ischemic Stroke During the 1990s

Neurophysiology tools to lower the stroke onset to treatment time during the golden hour: microwaves, bioelectrical impedance and near infrared spectroscopy

Reperfusion therapy administration timing in acute ischaemic stroke is the main determinant of patients' mortality and long-term disability. Indeed, the first hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects. Delayed ambulance transport, inappropriate triage and difficulty in accessing CT scans lead to delayed onset to treatment time (OTT) in clinical practice. To date brain CT scan is needed to rule out intracranial haemorrhage, which is a major contraindication to thrombolytic therapy. The availability, dimension and portability make CT suitable mainly for intrahospital use, determining further delays in the therapies administration. This review aims at evaluating portable neurophysiology technologies developed with the scope of speeding up the diagnostic phase of acute stroke and, therefore, the initiation of intravenous thrombolysis. Medline databases were explored for studies concerning near infrared spectroscopy (NIRS), bioelectrical impedance spectroscopy (BIS) and Microwave imaging (MWI) as methods for stroke diagnosis. A total of 1368 articles were found, and 12 of these fit with our criteria and were included in the review. For each technology, the following parameters were evaluated: diagnostic accuracy, ability to differentiate ischaemic and haemorrhagic stroke, diagnosis time from stroke onset, portability and technology readiness level (TRL). All the described methods seem to be able to identify acute stroke even though the number of studies is very limited. Low cost and portability make them potentially usable during ambulance transport, possibly leading to a reduction of stroke OTT along with the related huge benefits in terms of patients outcome and health care costs. In addition, unlike standard imaging techniques, neurophysiological techniques could allow continuous monitoring of patients for timely intrahospital stroke diagnosis.KEY MESSAGESFirst hour from the stroke onset is defined the "golden hour", in which the treatment has the highest efficacy and lowest side effects.The delay for stroke onset to brain imaging time is one of the major reasons why only a minority of patients with acute ischaemic stroke are eligible to reperfusion therapies.Neurophysiology techniques (NIRS, BIS and MWI) could have a potential high impact in reducing the time to treatment in stroke patients.

Planning a campaign to fight stroke: an educational pilot project in La Spezia, Italy

INTRODUCTION

Best medical treatments of ischemic stroke are admission to stroke unit, intravenous thrombolysis and, in selected cases, thrombectomy. Time from symptom onset to interventions is the best predictor of clinical outcome. In order to verify the effectiveness of an active education programme of awareness on the knowledge of stroke, we performed a local campaign "on the field".

SUBJECTS AND METHODS

We selected 101 subjects from the general population who took part in the "stroke awareness campaign" organised by the Italian Association for the fight against stroke (A.L.I.Ce). Mean age was 59 years (50% female; 50% male); 55% of the sample reported a high level of education (> 8 years: high school or university degree). After a short multiple-choice questionnaire, we administered a face-to-face standard educational protocol (15 min). The efficacy of that educational intervention was then verified after a period of 12 months, by telephone interview.

RESULTS

There was improvement both in the definition of stroke (66% vs. 92%, p < .001) and in recognizing symptoms and signs (19% vs. 72%, p < .001). Knowledge of the importance of stroke unit in the acute treatment of stroke did not improve, as it was already high on baseline (92% vs. 97%, p: n.s.). The improvement was evident in particular in younger and higher educated people, without difference in gender. There was no difference based on risk factor profiles of participants.

CONCLUSIONS

Our results suggest that a personalised education can improve knowledge on stroke symptoms and signs, independently of gender and personal risk factors. The results should be verified in larger and less selection population.

Machine-learning approach identifies a pattern of gene expression in peripheral blood that can accurately detect ischaemic stroke

Early and accurate diagnosis of stroke improves the probability of positive outcome. The objective of this study was to identify a pattern of gene expression in peripheral blood that could potentially be optimised to expedite the diagnosis of acute ischaemic stroke (AIS). A discovery cohort was recruited consisting of 39 AIS patients and 24 neurologically asymptomatic controls. Peripheral blood was sampled at emergency department admission, and genome-wide expression profiling was performed via microarray. A machine-learning technique known as genetic algorithm k-nearest neighbours (GA/kNN) was then used to identify a pattern of gene expression that could optimally discriminate between groups. This pattern of expression was then assessed via qRT-PCR in an independent validation cohort, where it was evaluated for its ability to discriminate between an additional 39 AIS patients and 30 neurologically asymptomatic controls, as well as 20 acute stroke mimics. GA/kNN identified 10 genes (ANTXR2, STK3, PDK4, CD163, MAL, GRAP, ID3, CTSZ, KIF1B and PLXDC2) whose coordinate pattern of expression was able to identify 98.4% of discovery cohort subjects correctly (97.4% sensitive, 100% specific). In the validation cohort, the expression levels of the same 10 genes were able to identify 95.6% of subjects correctly when comparing AIS patients to asymptomatic controls (92.3% sensitive, 100% specific), and 94.9% of subjects correctly when comparing AIS patients with stroke mimics (97.4% sensitive, 90.0% specific). The transcriptional pattern identified in this study shows strong diagnostic potential, and warrants further evaluation to determine its true clinical efficacy.

Systematic Review and Pooled Analyses of Recent Neurointerventional Randomized Controlled Trials: Setting a New Standard of Care for Acute Ischemic Stroke Treatment after 20 Years

BACKGROUND

Recent advances in the treatment of ischemic stroke have focused on revascularization and led to better clinical and functional outcomes. A systematic review and pooled analyses of 6 recent multicentered prospective randomized controlled trials (MPRCT) were performed to compare intravenous tissue plasminogen activator (IV tPA) and endovascular therapy (intervention) with IV tPA alone (control) for anterior circulation ischemic stroke (AIS) secondary to large vessel occlusion (LVO).

OBJECTIVES

Six MPRCTs (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, REVASCAT and THERAPY) incorporating image-based LVO AIS were selected for assessing the following: (1) prespecified primary clinical outcomes of AIS patients in intervention and control arms: good outcomes were defined by a modified Rankin Scale score of 0-2 at 90 days; (2) secondary clinical outcomes were: (a) revascularization rates [favorable outcomes defined as modified Thrombolysis in Cerebral Infarction scale (mTICI) score of 2b/3]; (b) symptomatic intracranial hemorrhage (sICH) rates and mortality; (c) derivation of number needed to harm (NNH), number needed to treat (NNT), and relative percent difference (RPD) between intervention and control groups, and (d) random effects model to determine overall significance (forest and funnel plots).

RESULTS

A total of 1,386 patients were included. Good outcomes at 90 days were seen in 46% of patients in the intervention (p < 0.00001) and in 27% of patients in the control groups (p < 0.00002). An mTICI score of 2b/3 was achieved in 70.2% of patients in the intervention arm. The sICH and mortality in the intervention arm compared with the control arm were 4.7 and 14.3% versus 7.9 and 17.8%, respectively. The NNT and NNH in the intervention and control groups were 5.3 and 9.1, respectively. Patients in the intervention arm had a 50.1% (RPD) better chance of achieving a good 90-day outcome as compared to controls.

CONCLUSIONS

Endovascular therapy combined with IV tPA (in appropriately selected patients) for LVO-related AIS is superior to IV tPA alone. These results support establishing an endovascular therapy in addition to IV tPA as the standard of care for AIS secondary to LVO.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Purpose—

To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.

Methods—

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

Results—

After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.

Reasons for low thrombolysis rate in a Norwegian ischemic stroke population

Only a minor proportion of patients with acute ischemic stroke receive treatment with intravenous thrombolysis. The purpose of this study was to explore reasons for not giving thrombolysis and to determine if there was a correlation between prehospital and in-hospital delay in a Norwegian ischemic stroke population. Patients with acute ischemic stroke were included during a 1-year period. Time intervals for prehospital and in-hospital delay, reasons for not treating with thrombolytic therapy in patients admitted within the time window and reasons for late arrival were recorded. In all, 290 patients were included, and 7.6 % were treated with intravenous thrombolysis. The most frequent reasons for not treating eligible patients were: minor symptoms (22.8 %), clinical improvement (17.5 %) and uncertainty about the diagnosis (12.3 %). Patients' reasons for delayed admission were: not attributing their symptoms to stroke (25.4 %), a wait-and-see attitude (25.4 %), and choosing to wait for the GP's office to open (14.3 %). Prehospital delay was strongly correlated to in-hospital delay (p < 0.001). In conclusion, a large percentage of patients with AIS are not treated with thrombolysis because of mild or rapidly improving symptoms, and because patients arrive too late to the hospital. Absolute and relative contraindications account for a minor proportion of reasons for excluding patients.

Intravenous thrombolysis in acute ischemic stroke: standard and potential future applications

Acute ischemic stroke is a medical emergency requiring urgent treatment. Randomized clinical trial and Phase IV data have provided unequivocal evidence that intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) improves early functional outcomes by restoring brain perfusion. Moreover, these studies have shed substantial light on the factors which are associated with more favorable outcome with tPA and are related to the highest benefit-to-risk ratio. Stroke physicians should consider vascular imaging techniques to aid decision making with thrombolytic therapy. The presence of intracranial occlusion is the target of treatment with early recanalization being the goal. Successful use of intravenous thrombolysis depends on a sound understanding of the decision-making process and organization of the treating team who strives for early treatment initiation and strict adherence to the protocol. Intravenous rt-PA within 4.5 h of onset should now be a standard treatment of acute disabling ischemic stroke throughout the world. This review also summarizes intravenous thrombolysis contraindications as well as the safety of novel reperfusion therapies including tenecteplase, sonothrombolysis and the combination of alteplase with direct thrombin inhibitors or glycoprotein IIb/IIIa receptor antagonists.

Thrombolysis in acute ischemic stroke: a simulation study to improve pre- and in-hospital delays in community hospitals

Background

Various studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model.

Methods

Based on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively.

Results

Combining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors.

Conclusions

Simulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study.

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

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

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

Background and Purpose—

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

Methods—

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

Results—

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

Conclusions—

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

Eligibility for Intravenous Recombinant Tissue-Type Plasminogen Activator Within a Population: The Effect of the European Cooperative Acute Stroke Study (ECASS) III Trial

BACKGROUND AND PURPOSE

The publication of the European Cooperative Acute Stroke Study (ECASS III) expanded the treatment time to thrombolysis for acute ischemic stroke from 3 to 4.5 hours from symptom onset. The impact of the expanded time window on treatment rates has not been comprehensively evaluated in a population-based study.

METHODS

All patients with an ischemic stroke presenting to an emergency department during calendar year 2005 in the 17 hospitals that compromise the large 1.3 million Greater Cincinnati/Northern Kentucky population were included in the analysis. Criteria for exclusion from thrombolytic therapy are analyzed retrospectively for both the standard and expanded timeframes with varying door-to-needle times.

RESULTS

During the study period, 1838 ischemic strokes presenting to an emergency department were identified. A small proportion of them arrived in the expanded time window (3.4%) compared with the standard time window (22%). Only 0.5% of those who arrived in this timeframe met eligibility criteria for thrombolysis compared with 5.9% using standard eligibility criteria in the standard timeframe. These results did not vary significantly by repeated analysis varying the door-to-needle time or the expanded time window's exclusion criteria.

CONCLUSIONS

In reality, the expanded time window for thrombolysis in acute ischemic stroke benefits few patients. If we are to improve recombinant tissue-type plasminogen activator administration rates, our focus should be on improving stroke awareness, transport to facilities with ability to administer thrombolysis, and familiarity of physicians with acute stroke treatment guidelines.

Thymosin beta4 improves functional neurological outcome in a rat model of embolic stroke

Thymosin beta4 (Tbeta4) is a developmentally expressed 43-amino acid peptide that inhibits organization of the actin-cytoskeleton by sequestration of G-actin monomers. Tbeta4 improves cardiac function after myocardial infarction in adult mice and promotes healing properties in both dermal and corneal wounds. We tested the hypothesis that Tbeta4 improves functional neurological outcome in a rat model of embolic stroke.

EXPERIMENTAL PROCEDURES

Male Wistar rats (n=18) were subjected to embolic middle cerebral artery occlusion (MCAo). Tbeta4 (6 mg/kg, IP) was administered 24 h after MCAo and then every 3 days for four additional doses (n=9). Rats treated with saline were used as a control (n=9). The adhesive-removal test (ART) and modified Neurological Severity Score (mNSS) were performed to measure functional outcome. Rats were sacrificed 56 days after MCAo. Immunostaining was performed with antibodies against NG-2 (chondroitin sulfate proteoglycan), CNPase (2", 3"-cyclic nucleotide 3'-phosphodiesterase) to detect immature and mature oligodendrocytes. Neurofilament-H (NF-H) antibodies were used to detect axons while myelinated axons were identified with Bielschowsky/Luxol (B/L) Blue staining. EBA (endothelial barrier antigen) was used for detection of mature vessels.

RESULTS

Ischemic rats treated with Tbeta4 demonstrated a significant overall improvement (P<0.01) in the ART and the mNSS when compared to controls. Significant improvement was observed beginning at 14 and 35 days, respectively. Lesion volumes showed no significant differences between the two groups. Treatment with Tbeta4 increased myelinated axons and increased vessel density in the ischemic boundary (P<0.05) and augmented remyelination which was associated with an increase of oligodendrocyte progenitor cells (OPCs) and myelinating oligodendrocytes (P<0.05).

CONCLUSIONS

The present study suggests that Tbeta4 improves neurological functional outcome after embolic stroke in rats. Axonal remodeling from mobilization of OPCs is proposed as contributing to Tbeta4 induced functional improvement.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Which stroke symptoms prompt a 911 call? A population-based study

INTRODUCTION

Many studies show that a major barrier to short-term treatment of stroke is patient or bystander delay in responding to stroke symptoms. Most studies have found that less than half of stroke/transient ischemic attack (TIA) events result in a 911 call. We sought to determine which symptoms prompt the public to call 911.

METHODS

A population of 1.3 million within a 5-county region was screened for TIA and all strokes in 1999 using all local hospital International Classification of Diseases, Ninth Edition, codes for stroke (430-436) during 1999. Documented stroke symptoms were abstracted from the medical record. Symptoms were grouped as weakness, numbness, speech/language, confusion/decreased level of consciousness, headache, visual changes, and dizziness/vertigo/coordination. Cases included in this analysis had their strokes at home or work and presented to an emergency department. Logistic regression assessed which symptoms predicted a 911 call, adjusting for age, race, sex, prior stroke, baseline disability, overall stroke severity, home vs work, and stroke subtype.

RESULTS

Two thousand nine hundred seventy-five stroke/TIA patients met inclusion criteria, of whom 40% used emergency medical services. After adjustment, symptoms that increased odds of a 911 call were weakness, confusion/decreased level of consciousness, speech/language, and dizziness/coordination/vertigo. Numbness was less likely to result in a 911 call as were visual changes. The presence of headache was not associated with the decision to call 911.

DISCUSSION

The public appears to respond differently based on the type of stroke symptom, independent of overall severity. Public awareness messages regarding stroke warning signs should be designed with this in mind.

A comprehensive review of prehospital and in-hospital delay times in acute stroke care

The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (P<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from emergency department arrival to emergency department evaluation (3.1%, P=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from emergency department arrival to neurology evaluation or notification (P=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from emergency department arrival to initiation of computed tomography (P=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community-based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care.