Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center

Background

Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.

Methods

This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.

Results

One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).

Conclusions

Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.

Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression

Introduction

The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions.

Methods

We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria.

Results

A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4–15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1–10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window.

Conclusions

The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.

The impact of a comprehensive national policy on improving acute stroke patient care in Lithuania

Introduction:

Reperfusion therapy (RT) is a mainstay treatment for acute ischemic stroke (AIS). We aimed to evaluate the impact of a comprehensive national policy (CNP) to improve access to RT for AIS patients across Lithuania.

Patients and methods:

Aggregated anonymized data on AIS cases treated in Lithuanian hospitals between 2006 and 2019 were retrospectively obtained from the Institute of Hygiene and the Stroke Integrated Care Management Committee. Through an interrupted time series analysis, we examined the trends in AIS hospital admissions, RT, and in-hospital case fatality rates prior to the enactment of CNP in 2014, changes immediately after the intervention, and differences in trends between the pre- and post-intervention periods. Mean yearly door-to-needle times were calculated post-intervention.

Results:

114,436 cases were treated for AIS in Lithuanian hospitals before, and 65,084 after the government intervention. We observed a significant decreasing post-intervention trend change in AIS hospital admission rate per 100,000 population (regression coefficient ± standard error: β = –16.47 ± 3.95, p = 0.002) and an increasing trend change in the proportion of AIS patients who received reperfusion treatment: intravenous thrombolysis (β = 1.42 ± 0.96, p < 0.001) and endovascular therapy (β = 0.85 ± 0.05, p < 0.001). The proportion of patients treated in stroke centers increased immediately after the intervention (β = 4.95 ± 1.14, p = 0.001), but the long-term post-intervention trend did not change. In addition, there was a significant decreasing trend in all cause in-hospital case fatality rate within primary and comprehensive stroke centers after the intervention (β = –0.60 ± 0.18, p = 0.008) despite its prompt initial immediate increase (β = 1.68 ± 0.73, p = 0.043). The mean countrywide door-to-needle time decreased from 68 min in 2014 to 43 min in 2019.

Conclusion:

The comprehensive national stroke patient care policy could be associated with an immediate increase in stroke center treatment rate, increased access to RT, and improved stroke care performance measures.

Pharmacological Modulation and (Patho)Physiological Roles of TRPM4 Channel-Part 2: TRPM4 in Health and Disease

Transient receptor potential melastatin 4 (TRPM4) is a unique member of the TRPM protein family and, similarly to TRPM5, is Ca²⁺ sensitive and permeable for monovalent but not divalent cations. It is widely expressed in many organs and is involved in several functions; it regulates membrane potential and Ca²⁺ homeostasis in both excitable and non-excitable cells. This part of the review discusses the currently available knowledge about the physiological and pathophysiological roles of TRPM4 in various tissues. These include the physiological functions of TRPM4 in the cells of the Langerhans islets of the pancreas, in various immune functions, in the regulation of vascular tone, in respiratory and other neuronal activities, in chemosensation, and in renal and cardiac physiology. TRPM4 contributes to pathological conditions such as overactive bladder, endothelial dysfunction, various types of malignant diseases and central nervous system conditions including stroke and injuries as well as in cardiac conditions such as arrhythmias, hypertrophy, and ischemia-reperfusion injuries. TRPM4 claims more and more attention and is likely to be the topic of research in the future.

"Hesitating and Puzzling": The Experiences and Decision Process of Acute Ischemic Stroke Patients with Prehospital Delay after the Onset of Symptoms

Despite campaigns to increase public awareness of stroke symptoms by advocating FAST (Face-Arms-Speech-Time), some stroke patients still show delays in the recognition of and response to stroke symptoms and miss the golden first 4.5 h to receive rt-PA (recombinant tissue plasminogen activator) treatment. The aim of this study was to explore how acute ischemic stroke patients with prehospital delay seek help and undergo the decision process before arriving at the hospital. A qualitative approach using a grounded theory was applied. There were 24 ischemic stroke patients recruited by purposive sampling. Our main findings were: “Hesitating and puzzling” was the core category to describe and guide the process of acute ischemic stroke patients with prehospital delay. During the process, “Awareness the sudden change of physical sensation and/or function” was the antecedent category. In the prehospital delay experience, the following five interaction categories were identified: (1) “Self-judgment and interpretation according to previous experience,” (2) “Puzzling and doubting—it may only be a minor problem,” (3) “Self-treatment or seeking medical attention nearby,” (4) “Unexpected symptoms getting worse” needing immediate advanced medical help and (5) “Rushing to ER with different transportation—self-alerting that serious disease is coming.” Eventually, the patients “Regret to delay seeking treatment and become a disable person.” The process of prehospital delay provides some hidden cues for patients to increase their knowledge about strokes. The study emphasizes the importance of educating community residents about identifying stroke symptoms, breaking the myth of folk therapy, and seeking medical attention immediately. These results will assist healthcare providers by offering references for designing patient-centric educational strategies for preventing stroke prehospital delay to improve the quality of stroke medical care.

Trends of r-tPA (Recombinant Tissue-Type Plasminogen Activator) Treatment and Treatment-Influencing Factors in Acute Ischemic Stroke

Background and Purpose- Frequencies of treatment with r-tPA (recombinant tissue-type plasminogen activator) are increasing over the past 15 years. However, published data on the influence of various demographic and clinical factors on r-tPA treatment as well as estimates of future trajectories are limited. We evaluated time trends and future trajectories of r-tPA treatment in patients with acute stroke and the influence of various factors on r-tPA treatment by analyzing data of 103 970 patients enrolled in the Austrian Stroke Unit Registry from 2006 to 2018, of which 18 953 were treated with r-tPA. Methods- Time trends of r-tPA-treatment were investigated in predefined subgroups (minor/major stroke, age, anterior/posterior circulation stroke); limited exponential time series models were calculated to estimate future trends of r-tPA-treatment. Logistic regression models were calculated to estimate the influence of clinical variables on r-tPA-treatment. Results- Overall, r-tPA treatment frequencies increased from 9.9% in 2006 to 21.8% in 2018. We observed a particular increase in patients >80 years, patients presenting with a National Institutes of Health Stroke Scale Score of 2 to 3, patients with posterior circulation stroke, patients with wake-up stroke, and patients without atrial fibrillation. Forecast of overall r-tPA frequencies predicted a further but flattened increase up to 24% by 2025. Logistic regression of time-dependent associations of clinical variables with r-tPA-treatment revealed increasing odds of r-tPA-treatment in patients with a posterior circulation stroke and decreasing odds of r-tPA-treatment in patients with atrial fibrillation. Conclusions- We observed a positive development of r-tPA-treatment frequencies mirroring increasing confidence with intravenous thrombolysis in clinical practice; however, decreasing odds of r-tPA-treatment over time in patients with atrial fibrillation deserve particular attention.

Factors Associated with Shortening of Prehospital Delay among Patients with Acute Ischemic Stroke

BACKGROUND

Despite recent advances in acute stroke care, only 1-8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD).

OBJECTIVE

This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital.

METHODS

A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital (Burgos, Spain). Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses.

RESULTS

The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms (OR 10.36; 95% confidence interval (CI) 4.47-23.99), onset of stroke during the daytime (OR 7.73; 95% CI 3.09-19.34) and the weekend (OR 2.64; 95% CI 1.19-5.85), occurrence of stroke outside the home (OR 7.09; 95% CI 1.97-25.55), using a prenotification system (OR 6.46; 95% CI 1.71-8.39), patient's perception of being unable to control symptoms without assistance (OR 5.14; 95% CI 2.60-10.16), previous knowledge of stroke as a medical emergency (OR 3.20; 95% CI 1.38-7.40), call to emergency medical services as the first medical contact (OR 2.77; 95% CI 1.32-5.88), speech/language difficulties experienced by the patient (OR 2.21; 95% CI 1.16-4.36), and the identification of stroke symptoms by the patient (OR 1.98; 95% CI 1.03-3.82).

CONCLUSIONS

The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns.

Stroke Factors Associated with Thrombolysis Use in Hospitals in Singapore and US: A Cross-Registry Comparative Study

BACKGROUND AND OBJECTIVES

This paper aims to describe and compare the characteristics of 2 stroke populations in Singapore and in St. Louis, USA, and to document thrombolysis rates and contrast factors associated with its uptake in both populations.

METHODS

The stroke populations described were from the Singapore Stroke Registry (SSR) in -Singapore and the Cognitive Rehabilitation Research Group Stroke Registry (CRRGSR) in St. Louis, MO, USA. The registries were compared in terms of demographics and stroke risk factor history. Logistic regression was used to determine factors associated with thrombolysis uptake.

RESULTS

A total of 39,323 and 8,106 episodes were recorded in SSR and CRRGSR, respectively, from 2005 to 2012. Compared to CRRGSR, patients in SSR were older, male, and from the ethnic majority. Thrombolysis rates in SSR and CRRGSR were 2.5 and 8.2%, respectively, for the study period. History of ischemic heart disease or atrial fibrillation was associated with increased uptake in both populations, while history of stroke was associated with lower uptake. For SSR, younger age and males were associated with increased uptake, while having a history of smoking or diabetes was associated with decreased uptake. For CRRGSR, ethnic minority status was associated with decreased uptake.

CONCLUSIONS

The comparison of stroke populations in Singapore and St Louis revealed distinct differences in clinicodemographics of the 2 groups. Thrombolysis uptake was driven by nonethnicity demographics in Singapore. Ethnicity was the only demographic driver of uptake in the CRRGSR population, highlighting the need to target ethnic minorities in increasing access to thrombolysis.

Saving the brain initiative - Developing an effective hub-and-spoke model to improve the acute stroke management pathways in urban India

OBJECTIVES

We aimed to develop and evaluate a hub-and-spoke model in the East Delhi by assessing knowledge and creating awareness through sensitization programs in target communities and among general physicians (GPs) along with implementation of a standard stroke management protocol (SMP) at our institute in order to extend the benefit of thrombolytic therapy.

METHODS

We carried out a prospective interventional study using sensitization program comprising 1046 community participants and 101 GPs under "Saving the Brain Initiative" project. Network included one hub and six nearby spoke hospitals. The pre-awareness and post-awareness data along with clinical outcome of thrombolysis collected over 2012-2017 was analyzed.

RESULTS

We observed lack of awareness in communities and among GPs regarding stroke symptomatology and treatment options. There was 17.3% increase in patients with stroke post-awareness programs. Door-to-door time improved as 49.3% of patients reached hospital within <2 h of onset as compared to 32.2% in pre-awareness period. 89.4% patients had good outcome and were discharged with improved NIHSS. In the post-awareness period, the rate of thrombolysis increased by 4.0%.

CONCLUSIONS

Sensitization of primary physicians, paramedical and medical staff along with community dwellers and implementation of SMP through hub-and-stroke model is instrumental in improving the rate of thrombolysis and its outcome.

Profile of intravenous glyburide for the prevention of cerebral edema following large hemispheric infarction: evidence to date

Glyburide (also known as glibenclamide) is a second-generation sulfonylurea drug that inhibits sulfonylurea receptor 1 (Sur1) at nanomolar concentrations. Long used to target K_ATP (Sur1–Kir6.2) channels for the treatment of diabetes mellitus type 2, glyburide was recently repurposed to target Sur1–transient receptor potential melastatin 4 (Trpm4) channels in acute central nervous system injury. Discovered nearly two decades ago, SUR1–TRPM4 has emerged as a critical target in stroke, specifically in large hemispheric infarction, which is characterized by edema formation and life-threatening brain swelling. Following ischemia, SUR1–TRPM4 channels are transcriptionally upregulated in all cells of the neurovascular unit, including neurons, astrocytes, microglia, oligodendrocytes and microvascular endothelial cells. Work by several independent laboratories has linked SUR1–TRPM4 to edema formation, with blockade by glyburide reducing brain swelling and death in preclinical models. Recent work showed that, following ischemia, SUR1–TRPM4 co-assembles with aquaporin-4 to mediate cellular swelling of astrocytes, which contributes to brain swelling. Additionally, recent work linked SUR1–TRPM4 to secretion of matrix metalloproteinase-9 (MMP-9) induced by recombinant tissue plasminogen activator in activated brain endothelial cells, with blockade of SUR1–TRPM4 by glyburide reducing MMP-9 and hemorrhagic transformation in preclinical models with recombinant tissue plasminogen activator. The recently completed GAMES (Glyburide Advantage in Malignant Edema and Stroke) clinical trials on patients with large hemispheric infarctions treated with intravenous glyburide (RP-1127) revealed promising findings with regard to brain swelling (midline shift), MMP-9, functional outcomes and mortality. Here, we review key elements of the basic science, preclinical experiments and clinical studies, both retrospective and prospective, on glyburide in focal cerebral ischemia and stroke.

Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia

Background

Tissue plasminogen activator within 4.5 h of onset is effective for acute ischemic stroke. However, only small proportion of patients is treated due to delayed presentation. We aimed to examine the factors associated with delays of stroke patients in Riyadh, Saudi Arabia.

Methods

A cross-sectional survey was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during a 6-month period. An interviewer administered structured questionnaire addressed to the acute stroke patients or their relatives was used to explore the factors associated with delayed arrival.

Results

A total of 227 patients attending the emergency department were interviewed. The mean age was 60.4 ± 15.6 years. Approximately 56.4% presented after 4.5 h of stroke onset. Factors associated with late arrival were being alone during the onset of stroke, not being transported in an ambulance, not knowing that they were experiencing a stroke, and residing outside the city of Riyadh.

Conclusion

More than half of patients missed the golden hours for thrombolysis due to delayed presentation. Reasons include lack of knowledge, underuse of ambulance and difficult access to care. Urgent community-based interventions are needed to address these factors.

Improving Access to Thrombolysis and Inhospital Management Times in Ischemic Stroke: A Stepped-Wedge Randomized Trial

BACKGROUND AND PURPOSE

A suboptimal number of ischemic stroke patients eligible for thrombolysis actually receive it, partly because of extended inhospital delays. We developed a comprehensive program designed for emergency unit staff and evaluated its effectiveness for reducing intrahospital times and improving access to thrombolysis.

METHODS

We conducted a randomized stepped-wedge controlled trial in 18 emergency unit. The sequentially implemented training intervention, targeting emergency physicians and nurses, was based on specifically designed videos and interactive simulation workshops on intrahospital management optimization. The effectiveness was assessed on intrahospital times and thrombolysis proportion. During the study period, all consecutive patients with confirmed ischemic stroke and no contraindications to thrombolysis were included.

RESULTS

A total of 328 patients were enrolled in the control group and 363 in the intervention group. Mean age was 73.6 years. Overall thrombolysis proportion was 34.2% in the intervention group versus 25.6% in the control group (adjusted odds ratio, 1.42; 95% confidence interval, 1.01-2.01), thrombolysis proportion within 4 hours 30 minutes almost doubled (adjusted odds ratio, 1.9; 95% confidence interval, 1.32-2.73). Although imaging-to-stroke unit time was significantly decreased in the intervention group (39 versus 53 minutes; P=0.03), median door-to-imaging and door-to-needle times were not different between groups (P=0.70 and P=0.40, respectively).

CONCLUSIONS

An interactive and multifaceted training program targeting emergency professionals was significantly associated with an increased access to thrombolysis, especially within 4 hours and 30 minutes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02814760.

Thrombolysis Alert in Hassan II University Teaching Hospital of Fez (Morocco): A Prospective Study of 2 Years

BACKGROUND

Thrombolysis alert (TA) is a procedure triggered every time a patient consults for sudden focal neurological deficit within 4.5 hours.

OBJECTIVE

We aimed to determine firstly the etiological profile of TA and secondly to evaluate the delays in the management not only of thrombolyzed patients but also of nonthrombolyzed patients to determine the intrahospital delays to optimize.

METHODS

Patients aged over 18 years who consulted for sudden focal neurological deficit within 4.5 hours for whom a TA has been triggered were included. Patients admitted within 4.5 hours for which a TA has not been triggered were not included. Patients with sudden focal neurological deficit who consulted more than 4.5 hours, but for whom TA has been triggered, were also included.

RESULTS

We included 313 patients. The average onset-to-door time was 125.59 ± 62.78 minutes with an average National Institutes of Health Stroke Scale scores of 11.29 ± 5.98. The average door-to-imaging time was 28.36 ± 20.62 minutes. Ischemic stroke (IS) was the most common cause (70.3%), followed by hemorrhagic stroke (11.8%). Other nonstroke causes (stroke mimics) represented 17.9% of cases. They were seizures (46.4%), conversion disorders (26.8%), hypoglycemia (10.7%), brain tumors (10.7%), chronic subdural hematoma (1.8%), carbon monoxide intoxication (1.8%), and cavernoma (1.8%). Forty-six patients had been thrombolyzed. The average door-to-needle time was 90.89 ± 34.48 minutes. After 3 months, 52.1% of thrombolyzed patients were autonomous (modified Rankin scale between 0 and 2). Two patients had died (4.3%), all in the first week after the IS.

CONCLUSION

Our study shows that efforts need to be made at the extra-hospital and intra-hospital level to improve delays to increase the proportion of the thrombolyzed patients.

Factors related to immediate response to symptoms in patients with stroke or transient ischaemic attack

INTRODUCTION

Despite recent advances in the management of acute stroke, fewer than 10% of patients receive reperfusion therapy. One of the main reasons for such a low rate of administration is the delay on the part of patients and their families in seeking medical attention. This study aimed to analyse this delay.

METHODS

A prospective observational study was conducted on consecutive stroke or transient ischaemic attack. Data on sociodemographic and clinical parameters, decision delay, pre-hospital delay, and first medical contact were collected. Descriptive, bivariate, and multivariate logistic regression analyses were performed to determine factors associated with seeking medical attention within the first 15minutes of stroke or TIA occurrence.

RESULTS

A total of 382 patients were included, 24.9% of whom had a decision delay of 15minutes or less. Stroke severity (OR 1.08; 95% CI, 1.04-1.13; P<.001), patient's son/daughter witnessing the event (OR 3.44; 95% CI, 1.88-6.27; P<.001), and insulin treatment (OR 2.89; 95% CI, 1.35-6.20; P=.006) were related to an immediate reaction. Lacunar infarcts (OR 0.41; 95% CI, 0.17-0.97; P=.042), partial anterior circulation infarcts (OR 0.43; 95% CI, 0.22-0.85; P=.015), and monosymptomatic events not involving limb paresis or aphasia (OR 0.15; 95% CI, 0.033-0.724; P=.018) favoured delays longer than 15minutes.

CONCLUSIONS

Severity of the event and presence of a son/daughter are the factors most frequently associated with an immediate response to stroke. Future interventions should emphasise the need for an immediate response irrespective of severity and include a wider spectrum of symptoms.

Response to Symptoms and Prehospital Delay in Stroke Patients. Is It Time to Reconsider Stroke Awareness Campaigns?

BACKGROUND

Despite recent advances in acute stroke care, reperfusion therapies are given to only 1%-8% of patients. Previous studies have focused on prehospital or decision delay. We aim to give a more comprehensive view by addressing different time delays and decisions.

METHODS

A total of 382 patients with either acute stroke or transient ischemic attack were prospectively included. Sociodemographic and clinical parameters and data on decision delay, prehospital delay, and first medical contact were recorded. Multivariate logistic regression analyses were conducted to identify factors related to decision delay of 15 minutes or shorter, calling the Extrahospital Emergency Services, and prehospital delay of 60 minutes or shorter and 180 minutes or shorter.

RESULTS

Prehospital delay was 60 minutes or shorter in 11.3% of our patients and 180 minutes or shorter in 48.7%. Major vascular risk factors were present in 89.8% of patients. Severity was associated with decision delay of 15 minutes or shorter (odds ratio [OR] 1.08; confidence interval [CI] 1.04-1.13), calling the Extrahospital Emergency Services (OR 1.17; CI 1.12-1.23), and prehospital delay of 180 minutes or shorter (OR 1.08; CI 1.01-1.15). Adult children as witnesses favored a decision delay of 15 minutes or shorter (OR 3.44; CI 95% 1.88-6.27; P < .001) and calling the Extrahospital Emergency Services (OR 2.24; IC 95% 1.20-4.22; P = .012). Calling the Extrahospital Emergency Services favored prehospital delay of 60 minutes or shorter (OR 5.69; CI 95% 2.41-13.45; P < .001) and prehospital delay of 180 minutes or shorter (OR 3.86; CI 95% 1.47-10.11; P = .006).

CONCLUSIONS

Severity and the bystander play a critical role in the response to stroke. Calling the Extrahospital Emergency Services promotes shorter delays. Future interventions should encourage immediately calling the Extrahospital Emergency Services, but the target should be redirected to those with known risk factors and their caregivers.

Quality Indicators of Intravenous Thrombolysis from North India

Background:

Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit.

Methods:

All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0–1 good outcome).

Results:

Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19–95) years. Median NIHSS at admission was 12 (interquartile range 2–24). Average onset-to-door (O-D) time was 76.8 (5–219) min, door-to-examination (D-E) time was 17.8 (5–105) min, door-to-CT (D-CT) time was 48 (1–205) min, and door-to-needle (D-N) time was 90 (20–285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0–1).

Conclusion:

Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.

Complications in the first week after stroke: a 10-year comparison

Background

Complications after stroke have been associated with poor outcome. Modern stroke treatment might reduce the occurrence of complications. The aim of this study was to investigate whether the frequency and type of complications during the first week after stroke has changed in patients treated in a stroke unit in 2013 compared to 2003.

Methods

In total 489 patients in 2003 and 185 patients in 2013 with acute stroke were included and followed prospectively for 1 week, examining the frequency of 12 predefined complications adjusted for severity of stroke. Informed consent was given by all patients or their next of kin.

Results

Mean (SD) age was 77.2 (10.2) and 76.9 (8.5) in 2003 and 2013 respectively, P = 0.455. Severity of stroke, measured by the Scandinavian Stroke Scale, was 39.5 (16.8) versus 37.0 (16.4), P = 0.011. After adjustment for stroke severity the results showed an odds ratio of 0.64 for experiencing one or more complications in the 2013 cohort versus the 2003 cohort, P = 0.035. The subgroup analysis showed that the reduction was only significant in the group with moderate stroke, with 74 % experiencing one or more complications in 2003 compared to 45 % in 2013, P < 0.001. Progressing stroke and myocardial infarction occurred significantly less frequent in 2013 than in 2003; the frequency of other complications remained unchanged.

Conclusions

The risk of experiencing one or more complications has decreased from 2003 to 2013. The reduction was most pronounced in patents with moderate stroke with a significant reduction in progressing stroke and myocardial infarction.

Increase in national intravenous thrombolysis rates for ischaemic stroke between 2005 and 2012: is bigger better?

BACKGROUND

Intravenous thrombolytic therapy after ischaemic stroke significantly reduces mortality and morbidity. Actual thrombolysis rates are disappointingly low in many western countries. It has been suggested that higher patient volume is related to shorter door-to-needle-time (DNT) and increased thrombolysis rates. We address a twofold research question: a) What are trends in national thrombolysis rates and door-to-needle times in the Netherlands between 2005-2012? and b) Is there a relationship between stroke patient volume per hospital, thrombolysis rates and DNT?

METHODS

We used data from the Stroke Knowledge Network Netherlands dataset. Information on volume, intravenous thrombolysis rates, and admission characteristics per hospital is acquired through yearly surveys, in up to 65 hospitals between January 2005 and December 2012. We used linear regression to determine a possible relationship between hospital stroke admission volume, hospital thrombolysis rates and mean hospital DNT, adjusted for patient characteristics.

RESULTS

Information on 121.887 stroke admissions was available, ranging from 7.393 admissions in 2005 to 24.067 admissions in 2012. Mean national thrombolysis rate increased from 6.4% in 2005 to 14.6% in 2012. Patient characteristics (mean age, gender, type of stroke) remained stable. Mean DNT decreased from 72.7 min in 2005 to 41.4 min in 2012. Volume of stroke admissions was not an independent predictor for mean thrombolysis rate nor for mean DNT.

CONCLUSION

Intravenous thrombolysis rates in the Netherlands more than doubled between 2005 and 2012, in parallel with a large decline in mean DNT. We found no convincing evidence for a relationship between stroke patient volume per hospital and thrombolysis rate or DNT.

Sur1-Trpm4 Cation Channel Expression in Human Cerebral Infarcts

The nonselective monovalent cation channel transient receptor potential melastatin 4 (Trpm4) is transcriptionally upregulated in neural and vascular cells in animal models of brain infarction. It associates with sulfonylurea receptor 1 (Sur1) to form Sur1-Trpm4 channels, which have critical roles in cytotoxic edema, cell death, blood-brain barrier breakdown, and vasogenic edema. We examined Trpm4 expression in postmortem brain specimens from 15 patients who died within the first 31 days of the onset of focal cerebral ischemia. We found increased Trpm4 protein expression in all cases using immunohistochemistry; transcriptional upregulation was confirmed using in situ hybridization of Trpm4 messenger RNA. Transient receptor potential melastatin 4 colocalized and coassociated with Sur1 within ischemic endothelial cells and neurons. Coexpression of Sur1 and Trpm4 in necrotic endothelial cells was also associated with vasogenic edema indicated by upregulated perivascular tumor necrosis factor, extravasation of serum immunoglobulin G, and associated inflammation. Upregulated Trpm4 protein was present up to 1 month after the onset of cerebral ischemia. In a rat model of middle cerebral artery occlusion stroke, pharmacologic channel blockade by glibenclamide, a selective inhibitor of sulfonylurea receptor, mitigated perivascular tumor necrosis factor labeling. Thus, upregulated Sur1-Trpm4 channels and associated blood-brain barrier disruption and cerebral edema suggest that pharmacologic targeting of this channel may represent a promising therapeutic strategy for the clinical management of patients with cerebral ischemia.

Glibenclamide for the treatment of ischemic and hemorrhagic stroke

Ischemic and hemorrhagic strokes are associated with severe functional disability and high mortality. Except for recombinant tissue plasminogen activator, therapies targeting the underlying pathophysiology of central nervous system (CNS) ischemia and hemorrhage are strikingly lacking. Sur1-regulated channels play essential roles in necrotic cell death and cerebral edema following ischemic insults, and in neuroinflammation after hemorrhagic injuries. Inhibiting endothelial, neuronal, astrocytic and oligodendroglial sulfonylurea receptor 1-transient receptor potential melastatin 4 (Sur1-Trpm4) channels and, in some cases, microglial KATP (Sur1-Kir6.2) channels, with glibenclamide is protective in a variety of contexts. Robust preclinical studies have shown that glibenclamide and other sulfonylurea agents reduce infarct volumes, edema and hemorrhagic conversion, and improve outcomes in rodent models of ischemic stroke. Retrospective studies suggest that diabetic patients on sulfonylurea drugs at stroke presentation fare better if they continue on drug. Additional laboratory investigations have implicated Sur1 in the pathophysiology of hemorrhagic CNS insults. In clinically relevant models of subarachnoid hemorrhage, glibenclamide reduces adverse neuroinflammatory and behavioral outcomes. Here, we provide an overview of the preclinical studies of glibenclamide therapy for CNS ischemia and hemorrhage, discuss the available data from clinical investigations, and conclude with promising preclinical results that suggest glibenclamide may be an effective therapeutic option for ischemic and hemorrhagic stroke.

Glibenclamide in cerebral ischemia and stroke

The sulfonylurea receptor 1 (Sur1)-transient receptor potential 4 (Trpm4) channel is an important molecular element in focal cerebral ischemia. The channel is upregulated in all cells of the neurovascular unit following ischemia, and is linked to microvascular dysfunction that manifests as edema formation and secondary hemorrhage, which cause brain swelling. Activation of the channel is a major molecular mechanism of cytotoxic edema and "accidental necrotic cell death." Blockade of Sur1 using glibenclamide has been studied in different types of rat models of stroke: (i) in conventional non-lethal models (thromboembolic, 1-2 h temporary, or permanent middle cerebral artery occlusion), glibenclamide reduces brain swelling and infarct volume and improves neurological function; (ii) in lethal models of malignant cerebral edema, glibenclamide reduces edema, brain swelling, and mortality; (iii) in models with rtPA, glibenclamide reduces swelling, hemorrhagic transformation, and death. Retrospective studies of diabetic patients who present with stroke have shown that those whose diabetes is managed with a sulfonylurea drug and who are maintained on the sulfonylurea drug during hospitalization for stroke have better outcomes at discharge and are less likely to suffer hemorrhagic transformation. Here, we provide a comprehensive review of the basic science, preclinical experiments, and retrospective clinical studies on glibenclamide in focal cerebral ischemia and stroke. We also compare the preclinical work in stroke models to the updated recommendations of the Stroke Therapy Academic Industry Roundtable (STAIR). The findings reviewed here provide a strong foundation for a translational research program to study glibenclamide in patients with ischemic stroke.

Predicting intracerebral hemorrhage by baseline magnetic resonance imaging in stroke patients undergoing systemic thrombolysis

Objectives

Intracerebral hemorrhage (ICH) remains a serious complication in ischemic stroke patients undergoing systemic thrombolysis. Here, we examined whether the risk of treatment-associated hemorrhage can be predicted from magnetic resonance imaging (MRI) using fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) within 3 h after symptom onset.

Methods

In this single-center observational study involving 122 ischemic stroke patients between January 2005 and December 2008, the incidence of FLAIR-positive lesions within diffusion-restricted areas was determined on baseline MRI, which was carried out prior to treatment with tissue plasminogen activator (Actilyse®) within 3 h from symptom onset. The rate of ICH was assessed by computed tomography performed within 24 h after treatment. Relationships between FLAIR-positive lesions, DWI lesion size, proportion of FLAIR/DWI-positive lesions, and occurrence of bleeding were explored.

Results

Data from 97 patients were evaluated. FLAIR-positive lesions were present in 25 patients (25.8%) and ICH occurred in 32 patients (33.0%). FLAIR-positive lesions were associated with a bleeding rate of 80.0% compared with 16.7% in FLAIR-negative patients (P < 0.001; odds ratio 20.0, positive predictive value 0.8). DWI lesion size was significantly correlated with the rate of ICH (P = 0.001). In contrast, FLAIR/DWI proportion was not associated with ICH (P = 0.788).

Conclusions

In ischemic stroke patients within 3 h from symptom onset, the existence of FLAIR-positive lesions on pretreatment MRI is significantly associated with an increased bleeding risk due to systemic thrombolysis. Therefore, considering FLAIR-positive lesions on baseline MRI might guide treatment decisions in ischemic stroke.

Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time

BACKGROUND

In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator 'door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT.

METHODS

We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression.

RESULTS

Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT.

CONCLUSION AND IMPLICATIONS

The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.

Trends in stroke treatment and outcome between 1995 and 2010: observations from Riks-Stroke, the Swedish stroke register

BACKGROUND

Continuous changes in stroke treatment and care, as well as changes in stroke characteristics, may alter stroke outcome over time. The aim of this paper is to describe time trends for treatment and outcome data, and to discuss if any such changes could be attributed to quality changes in stroke care.

METHODS

Data from Riks-Stroke, the Swedish stroke register, were analyzed for the time period of 1995 through 2010. The total number of patients included was 320,181. The following parameters were included: use of computed tomography (CT), stroke unit care, thrombolysis, medication before and after the stroke, length of stay in hospital, and discharge destination. Three months after stroke, data regarding walking, toileting and dressing ability, as well social situation, were gathered. Survival status after 7, 27 and 90 days was registered.

RESULTS

In 1995, 53.9% of stroke patients were treated in stroke units. In 2010 this proportion had increased to 87.5%. Fewer patients were discharged to geriatric or rehabilitation departments in later years (23.6% in 2001 compared with 13.4% in 2010), but more were discharged directly home (44.2 vs. 52.4%) or home with home rehabilitation (0 vs. 10.7%). The need for home help service increased from 18.2% in 1995 to 22.1% in 2010. Regarding prevention, more patients were on warfarin, antihypertensives and statins both before and after the stroke. The functional outcome measures after 3 months did improve from 2001 to 2010. In 2001, 83.8% of patients were walking independently, while 85.6% were independent in 2010. For toileting, independence increased from 81.2 to 84.1%, and for dressing from 78.0 to 80.4%. Case fatality (CF) rates after 3 months increased from 18.7% (2001) to 20.0% (2010). This trend is driven by patients with severe strokes.

CONCLUSIONS

Stroke outcomes may change over a relatively short time period. In some ways, the quality of care has improved. More stroke patients have CT, more patients are treated in stroke units and more have secondary prevention. Patients with milder strokes may have benefited more from these measures than patients with severe strokes. Increased CF rates for patients with severe stroke may be caused by shorter hospital stays, shorter in-hospital rehabilitation periods and lack of suitable care after discharge from hospital.

[Management of acute stroke - guidelines from the Expert Group of the Section of Cerebrovascular Diseases of the Polish Neurological Society. Update 2013: thrombolysis]

Thrombolysis is the most effective therapy for ischaemic stroke. The current guidelines and approvals have limited its use to patients available for treatment within 4.5 hours of onset and those aged 80 or less. There are also a number of other limitations derived from clinical trial protocols, i.e. minor and major strokes. The available evidence has indicated its possible efficacy in patients treated within 6 hours of onset and not fulfilling other limitations. Last year, the results of the IST-3 (Third International Stroke Trial: Thrombolysis) and a meta-analysis of all available trials including IST-3 were published. They point out the possible benefit of thrombolysis in patients not meeting the current criteria, which has been acknowledged in the Polish guidelines for management of stroke.

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.

Sulfonylurea receptor 1 expression in human cerebral infarcts

Supplemental Digital Content is available in the article.

In animal models of stroke, sulfonylurea receptor 1 (Sur1), a member of the adenosine triphosphate binding cassette transporter gene family, is transcriptionally upregulated in neural and vascular cells in which it plays a leading role in edema formation and necrotic cell death. To date, expression of Sur1 in the brains of humans with cerebral infarcts has not been systematically evaluated. We examined Sur1 expression in postmortem specimens obtained from 13 patients within the first 31 days after focal infarcts, 5 patients with lacunar infarcts, and 6 normal control brains using immunohistochemistry. Elevated immunoreactivity for Sur1 was detected in all cases of focal infarcts, with 3 distinct temporal patterns of expression: 1) neurons and endothelium showed the greatest elevation during the first week, after which levels declined; 2) astrocytes and microglia/macrophages showed progressive increases during the first 31 days; and 3) neutrophils near the infarct showed prominent immunoreactivity that did not change over time. Upregulation of Sur1 was corroborated using in situ hybridization for Abcc8 mRNA. Sulfonylurea receptor 1 immunoreactivity in lacunar infarcts was less prominent and more sporadic than in nonlacunar infarcts. In conjunction with previous studies, these data suggest that Sur1 may be a promising treatment target in patients with acute cerebral infarction.

Trends in stroke survival incidence rates in older Australians in the new millennium and forecasts into the future

AIMS

The objective of this study is (i) to evaluate trends in the incidence rates of stroke survivors aged 60 years and older over a 11-year period in the Australian Capital Territory (ACT) and (ii) to forecast future trends in Australia until 2051.

METHODS

Analysis of age- and sex-specific standardized incidence rates of older first-ever stroke survivors in ACT from 1999-2000 to 2009-2010 and projections of number of stroke survivors (NSS) in 2021 and 2051 using 2 models based only on (i) demographic changes and (ii) assuming changing of both incidence rates and demography.

RESULTS

In the ACT in the first decade of the 21st century, the absolute numbers and age-adjusted standardized incidence rates of stroke survivors (measured as a function of age and period) increased among both men and women aged 60 years or older. The trend toward increased survival rates in both sexes was driven mainly by population aging, whereas the effect of stroke year was more pronounced in men compared with women. The absolute NSS (and the financial burden to the society) in Australia is predicted to increase by 35.5%-59.3% in 2021 compared with 2011 and by 1.6- to 4.6-fold in 2051 if current only demographic (first number) or both demographic and incidence trends (second number) continue.

CONCLUSIONS

Our study demonstrates favorable trends in stroke survivor rates in Australia in the first decade of the new millennium and projects in the foreseeable future significant increases in the absolute numbers of older stroke survivors, especially among those aged 70 years or older and men.

Factors associated with the administration of tissue plasminogen activator for acute ischemic stroke

BACKGROUND

The use of intravenous tissue plasminogen activator (t-PA) can be an effective treatment for acute ischemic stroke if administered promptly. Despite its clinical effectiveness, overall use in Japan remains low, and regional variations have been reported. Factors such as ambulance utilization and geographical distance from patients' residences to hospitals may influence t-PA administration rates. The aim of this study is to identify factors associated with the administration of t-PA for acute ischemic stroke while adjusting for casemix using a large-scale administrative database in Japan.

METHODS

We analyzed acute ischemic stroke patients admitted to acute care hospitals between July 2010 and March 2011 using a nationwide database. A logistic regression model was used to analyze the factors influencing t-PA administration. Candidate factors included patient gender, age, stroke severity, direct distance between each patient's residence and admitting hospital, and ambulance utilization.

RESULTS

Of the 10,615 ischemic stroke patients from 89 hospitals analyzed, 557 (5.2%) received t-PA treatment. Patients aged 75 years and older were found to be associated with decreased t-PA administration. In contrast, severe stroke and ambulance utilization were associated with increased t-PA administration. Distance was not significantly associated with the use of t-PA.

CONCLUSIONS

Our findings suggest that ambulance utilization is an important factor for improving the likelihood of t-PA administration in patients with stroke and may underline a need for educational programs to the general public that promote the use of ambulances for suspected stroke patients.

Safety of off-label stroke treatment with tissue plasminogen activator

BACKGROUND

Many patients with acute ischaemic stroke do not receive intravenous thrombolysis due to contraindications. We aimed to assess safety, short-term clinical development, short-term outcome and mortality in patients treated off-label with tissue plasminogen activator (tPA).

METHODS

Stroke patients treated with tPA within 4.5 h after symptom onset during 2006-2011 were prospectively included. Patients with contraindications to tPA according to national guidelines were compared to patients without any of these contraindications. Separate analyses were performed on patients who had compatible contraindications and did not receive tPA. Primary outcome was rate of symptomatic intracerebral haemorrhage (SICH). Secondary outcomes were short-term clinical development, short-term outcome and 30-day mortality.

RESULTS

Of the 265 patients who received tPA, 135 patients (50.9%) had formal contraindications and 130 patients (49.1%) had no such contraindications. Rates of SICH were similar for patients with or without contraindications (P = 0.305). Patients with contraindications to tPA had a similar rate of clinical improvement (P = 0.504), a trend of less favourable outcome (P = 0.052) and higher mortality (P = 0.005) than patients without contraindications. Logistic regression analysis showed no association between presence of contraindications to tPA and short-term outcome or mortality when adjusted for age, sex and admission National Institute of Health Stroke Scale score. Short-term outcome and mortality were similar in patients with contraindications who received tPA and patients with contraindications who did not receive tPA (n = 134).

CONCLUSIONS

Intravenous thrombolysis with tPA may be safe and efficient in stroke patients with a number of formal contraindications to tPA. Prospective randomized trials are imperative to clarify the need for a re-evaluation of the current contraindications to tPA.

Variation in clinical practice of intravenous thrombolysis in stroke in the Netherlands

In the Netherlands in 2010, 11% of patients with ischemic stroke received intravenous thrombolysis (IVT), varying from 4 to 26% between hospitals. The aim of this study was to investigate variation in clinical practice and organization of IVT in relationship to performance and outcome. In all 84 Dutch hospitals performing IVT, a stroke neurologist was approached using a web-based survey. The response rate was 82%. The study showed considerable variation. For example, door-to-needle time ranged from 25 to 80 min. High blood pressure was actively lowered before performing IVT by 57% of neurologists, while 35% chose to wait. 28% started IVT without knowledge of laboratory results. Better follow-up data are needed to see whether this variation results in differences in outcome.

Treating the elderly stroke patient: complications, controversies, and best care metrics

Acute stroke is a devastating disease that affects almost 800,000 Americans annually. Worldwide, the incidence of stroke is rapidly increasing. Although stroke can affect all age groups, patients over age 80 are at much higher risk for ischemic stroke. Despite this, there are disparities in thrombolytic treatment rates, and as well as outcomes, between elderly stroke patients and their younger counterparts. This article discusses what is currently known about the elderly stroke patient for a greater understanding of the disease burden, research limitations and potential treatment options.