Public awareness of stroke in Korea: a population-based national survey

Current Status of Information and Communication Technologies Utilization, Education Needs, Mobile Health Literacy, and Self-Care Education Needs of a Population of Stroke Patients

BACKGROUND/OBJECTIVES

With the rising prevalence of chronic diseases and an aging population, the incidence of stroke is continuously increasing, which leads to higher medical costs. Stroke carries a high risk of recurrence, necessitating ongoing self-care and lifestyle changes, for which education is crucial. The aim of this study is to identify the ICT utilization education needs, mobile health literacy, and self-care education needs of stroke patients and confirm the differences in mobile health literacy and self-care education needs according to ICT utilization to establish a basis for self-care intervention.

METHODS

The study included 100 stroke patients diagnosed at three general hospitals or higher in City C, hospitalized or visiting neurology and neurosurgery outpatient clinics. A survey was conducted from 7 July 2023 to 30 May 2024. The survey cites computers, the Internet, live broadcasting technology, recorded broadcasting technology, and telephony as examples of ICTs. The gathered data were analyzed using descriptive statistics, independent t-tests, one-way ANOVA, and the Pearson correlation coefficient.

RESULTS

The final analysis included 100 people, with 64 participants being men and an average age of 57.75 ± 12.30 years. Self-care education needs showed no significant differences based on general or disease-related characteristics. Many patients could use smart devices but experienced difficulties in searching for information. The main reasons for using smart devices included acquiring disease-related information and accessing resources without time limitations. The use of ICT services that provide disease-related information was low, 70% of participants were willing to use them in the future. Additionally, they preferred doctor-led education sessions once a month, lasting no longer than 30 min each. Mobile health literacy was significantly higher among those willing to use ICT services.

CONCLUSIONS

Mobile health literacy was significantly higher in the group willing to use ICT services than in the group unwilling. Self-care education needs were both highly important and necessary in the group willing to utilize ICT, but no statistically significant difference was found.

Temporal Trends in Public Stroke Awareness in Korea, 2009 to 2023

BACKGROUND

No large-scale survey on public stroke awareness has been conducted in Korea since 2009. This study assessed temporal trends in awareness of stroke warning signs (WSs) and risk factors (RFs) from 2009 to 2023. We hypothesized that stroke awareness remains inadequate and that changes in information sources have influenced the depth of knowledge.

METHODS

Surveys were conducted nationwide in 2009 (n=1000) and 2023 (n=1012) assessing participants' knowledge of WSs, RFs, stroke treatment, response to stroke symptoms, and information sources. Multivariable logistic regression was used to analyze trends in RF knowledge and factors associated with adequate stroke response, which is contacting emergency medical services immediately.

RESULTS

Between 2009 and 2023, the percentage of participants unable to identify any WS or RF significantly decreased (WSs: 38.5% to 22.6%, RFs: 43.9% to 37.2%; P<0.01). However, recognition of multiple RFs declined significantly (51.4% to 40.2%, P<0.01), with a more pronounced decrease among those without vascular RFs (adjusted odds ratio, 0.33 [95% CI, 0.21-0.51]; P=0.03 for the interaction term). In contrast, the decline was less pronounced among individuals with vascular RFs (adjusted odds ratio, 0.56 [95% CI, 0.42-0.74]). Intravenous thrombolysis awareness increased (30.4% to 55.6%, P<0.01), and adequate stroke response improved (32.5% to 48.9%, P < 0.01). Information sources shifted, with an increase in the use of digital platforms. Adequate stroke response was significantly associated with intravenous thrombolysis knowledge (adjusted odds ratio, 1.54 [95% CI, 1.09-2.18]; P=0.02) and recognition of ≥2 WSs (adjusted odds ratio, 1.43 [95% CI, 1.09-1.86]; P=0.01).

CONCLUSIONS

Although stroke awareness has seen some improvements, it remains insufficient, highlighting the need for targeted educational strategies.

Assessment of knowledge and awareness of stroke among Arabic speaking adults: unveiling the current landscape in seven countries through the first international representative study

Introduction

While several studies have examined stroke public knowledge and awareness in individual countries within the Middle East and North Africa (MENA) region, none have provided a comprehensive cross-country assessment.

Purpose

To assess public stroke knowledge and awareness among Arabic-speaking adults in seven MENA countries and identify associated factors.

Materials and methods

An online cross-sectional survey was self-administered by the public population in Iraq, Lebanon, Sudan, Jordan, United Arab Emirates, Syria, and Saudi Arabia (April 2021-2023). Associations of stroke risk factors, early symptoms, and consequences with socio-demographics and medical history were analyzed using logistic regression models.

Results

Of 4,090 participants (58.3% females), 42.9% identified four out of five correct answers related to general stroke knowledge. Only 25.2% identified all stroke risk factors, 24.7% recognized all symptoms, and 37.5% knew all possible consequences. Results show consistent pattern of high identification for at least one risk factor and consequences across all countries (96.3 to 99.8% and 86.2 to 100%, respectively), with varying levels of early symptom identification (56.8 to 97.9%). Females were more likely to identify a stroke risk factor, symptom, and consequence compared to males (OR = 2.525, 2.474, and 2.302, respectively, p < 0.001). Employed, urban residents, and those with higher education demonstrated better stroke awareness.

Conclusion

The sample showed variable levels of stroke knowledge among the public, underscoring the pressing need for targeted community initiatives, media campaigns, and educational interventions. These efforts are paramount for improving awareness, early detection, and timely response, especially in countries with lower levels of community stroke awareness.

Assessing the efficacy of an educational video on stroke knowledge in Lebanon: a single-arm interventional study

OBJECTIVE

This study aimed to assess the public's knowledge of stroke before and after viewing an educational video about stroke risk factors, preventive measures, and alarming signs.

METHODS

A single-arm interventional study was conducted in Lebanon using a 3-minute video-based education about stroke. A pre- and post-structured questionnaire compared the level of knowledge about stroke.

RESULTS

The study included 685 participants. Knowledge of stroke, risk factors, warning signs, treatment, and preventive measures significantly increased post-educational video sessions. A higher baseline knowledge score was associated with a family history of stroke (Beta = 1.76) and being a healthcare professional (Beta = 3.35). Participants between 25 and 34 years (Beta=-1.39) and those with a high risk of stroke (Beta=-1.03) were significantly associated with a lower knowledge score.

CONCLUSION

This study demonstrated the effectiveness of a video-based educational tool to raise awareness about stroke. Short, targeted audio-visual resources using lay language can convey health education messages and influence behavioral changes. The community can benefit from a large-scale educational campaign that targets different socio-economic statuses to enhance knowledge of stroke and save lives.

Al Meslamani A. Assessment of Knowledge and attitude towards Stroke among the UAE population during the COVID-19 pandemic: A cross-sectional study

Background: Despite significant advancements in healthcare, the burden of stroke continues to rise in the developed world, especially during the COVID-19 pandemic. Association between COVID-19 infection and stroke is well established. Factors identified for the delay in presentation and management include a lack of awareness regarding stroke. We aimed to assess the general public knowledge and attitudes on stroke and stroke risk factors in the United Arab Emirates during the COVID-19 pandemic. Methods: A cross-sectional study was conducted between September 2021 and January 2022 among adults≥ 18 years old. Participants completed a self-administered questionnaire on sociodemographic characteristics and stroke knowledge and attitudes. Knowledge and attitude scores were calculated based on the number of correct responses. Linear regression analysis was performed to determine the factors related to knowledge and attitude towards stroke. Results: Of the 500 respondents, 69.4% were females, 53.4% were aged between 18 and 25, and nearly half were students (48.4%). The mean knowledge score was 13.66 (range 2-24). Hypertension (69%), smoking (63.2%), stress (56.4%) obesity/overweight (54.4%), and heart disease (53.6%) were identified as risk factors. Overall, the knowledge of signs/symptoms was suboptimal. The mean attitude score was 4.41 (range, 1-6); 70.2% would call an ambulance if someone were having a stroke. A monthly income of 11,000-50,000 AED and being a student were associated with positive knowledge. Being a non-health worker and lacking access to electronic media sources were associated with worse attitudes. Conclusion: Overall, we identified poor knowledge and suboptimal attitudes toward stroke. These findings reflect the need for effective public health approaches to improve stroke awareness, knowledge, and attitudes for effective prevention in the community. Presently, this is of utmost necessity, given the increased occurrence of stroke and its severity among COVID-19 patients.

Sex Differences in Attitudes Toward Marriage and Childbearing Based on the Assumption of Being BRCA1/2 Mutation Carriers Among Young People

Purpose

This study investigated changes in attitudes toward marriage and childbearing assuming a BRCA1/2 mutation carrier status among healthy, unmarried individuals in Korea.

Methods

A nationally representative sample of healthy, unmarried individuals aged 20–39 years was surveyed. A questionnaire on marriage and childbearing intentions was administered to the participants before and after providing them with information on BRCA1/2 mutation carriers’ breast and ovarian cancer risks and their autosomal dominant inheritance pattern. The participants were asked about their attitudes toward childbearing through preimplantation genetic diagnosis (PGD).

Results

Of the participants who initially wanted to marry, the assumption that they or their partners had BRCA1/2 mutation caused 25.3% to no longer want to get married and 36.2% to change their attitude from wanting to bear children to no longer wanting them. Females were more likely than males to change their attitudes toward marriage and childbearing. The participants who had negative attitudes toward genetic testing were more likely to change their attitudes regarding marriage and childbearing than those who were favorable toward both disclosure and testing. More than 50% of the participants who did not want children were willing to bear children through PGD when it was assumed that they were BRCA mutation carriers.

Conclusion

On the assumption of being carriers, general, young, and healthy females were more likely than males to negatively change their attitudes toward marriage and childbearing. Public education on the implications of living with mutation carriers and reproductive options may be required.

Effect of Community Education Program on Stroke Symptoms and Treatment on School and College Students from South India: A Longitudinal Observational Study

Community awareness regarding stroke signs, risk factors, and actions that help reduce the risk and complications of stroke is poorly addressed, as it is thought to be the best approach to control and prevent stroke. Aim: To establish the awareness of stroke and its management among high school and college students using an educational intervention. A questionnaire was administered to students from five high schools and four colleges with different areas of focus, (arts, science and commerce), types (public, semi-public and private), and economic locations before and after an educational lecture on stroke. The lecture covered the following elements: stroke definition, signs, risk factors, actions, time window for thrombolytic therapy, and types of rehabilitation interventions. This study included 1036 participants, of whom 36.3% were male and 56.4% were high school students, and the mean age was 17.15 ± 1.29 (15-22) years. Before the lecture, 147 participants were unaware of a single sign of stroke, and 124 did not know the risk factors. After the intervention, 439 participants knew four signs of stroke, and 196 knew 12 risk factors. Female students had better knowledge about stroke signs (odds ratio (OR), 3.08; 95% confidence interval (95% CI), 2.15-4.43). Hypertension (52.7%) and weakness (59.85%) were the most known signs and risk factors. The proportion of students who selected traditional medicine as the mode of treatment decreased from 34.75% to 8.59% after the lecture. Other rehabilitation methods (e.g., physical therapy, occupational therapy, speech therapy and counseling) were chosen by more than 80% of the students. The results of the current study showed that the awareness on stroke risk factors and management among the school and college students can be significantly improved with regular educational interventions, and therefore stroke can be prevented to some extent.

Variation in Knowledge of Stroke Warning Signs by Age and Presence of Conventional Risk Factors: A Community Health Survey in Korea

BACKGROUND

It is important to recognize stroke in the general public.

OBJECTIVES

The purpose of this study was to investigate factors affecting knowledge of stroke warning signs (SWSs) according to age group in the Korean population.

METHODS

This study is a cross-sectional study. Using data from the Korean Community Health Survey conducted in Korea in 2017, 198 403 subjects were analyzed. Knowledge about SWSs was assessed by face-to-face interviews using structured close-ended questionnaires with 5 items about stroke symptoms (sudden unilateral weakness of face, arm or leg; sudden difficulty in speaking, or trouble understanding speech; sudden visual impairment in 1 eye, or double vision; sudden dizziness or loss of balance; and sudden severe headache).

RESULTS

The overall percentage of subjects with good knowledge of SWSs (>4 correct answers to the SWS questionnaire) was 66.5%. It was highest in the middle-aged subjects (72.6%), followed by the young subjects (63.5%) and the older subjects (61.5%). The youngest of the young subjects and the oldest of the older subjects had the least knowledge. Subjects with conventional risk factors generally had more knowledge about SWSs, except for those with diabetes mellitus. However, in the young subjects, knowledge about SWSs was not increased by the presence of conventional risk factors such as hypertension and dyslipidemia.

CONCLUSION

Stoke risk factors are increasing among young people; they still have poor knowledge about SWSs. More education is needed to increase appropriate treatment, especially in young people with stroke-related risk factors.

Increased recurrent risk did not improve cerebrovascular disease survivors' response to stroke in China: a cross-sectional, community-based study

Background

Cerebrovascular disease (CVD) survivors are at a high risk of recurrent stroke. Although it is thought that survivors with higher risk of stroke respond better to stroke onset, to date, no study has been able to demonstrate that. Thus, we investigated whether the intent to call emergency medical services (EMS) increased with recurrent stroke risk among CVD survivors.

Methods

A cross-sectional community-based survey was conducted from January 2017 to May 2017, including 187,723 adults (age ≥ 40 years) across 69 administrative areas in China. A CVD survivor population of 6290 was analyzed. According to the stroke risk score based on Essen Stroke Risk Score, CVD survivors were divided into three subgroups: low (0), middle (1–3) and high (4–7) recurrent risk groups. Multivariable logistic regression models were used to identify the association between the stroke risk and stroke recognition, as well as stroke risk and EMS calling.

Results

The estimated stroke recognition rate in CVD survivors with low, middle, and high risk was 89.0% (503/565), 85.2% (3841/4509), and 82.5% (1001/1213), respectively, while the rate of calling EMS was 66.7% (377/565), 64.3% (2897/4509), and 69.3% (840/1213), respectively. The CVD survivors’ knowledge of recognizing stroke and intent to call EMS did not improve with recurrent stroke risk, even after adjustment for multiple socio-demographic factors.

Conclusions

Despite being at a higher risk of recurrent stroke, Chinese CVD survivors showed poor knowledge of stroke, and their intent to call EMS did not increase with recurrent stroke risk. Enhanced and stroke risk-orientated education on stroke recognition and proper response is needed for all CVD survivors.

Knowledge of Stroke, Its Warning Symptoms, Risk Factors and Treatment among the General Public and General Practitioners in a South Asian Population

BACKGROUND

An adequate stroke literacy among the general public and first-contact physicians is an essential prerequisite to ensure timely treatment and prevention of stroke. Knowledge on stroke pathophysiology, warning symptoms, risk factors and treatment, and its determinants was assessed among general public and general practitioners (GPs) in a South Asian population.

METHODS

A cross-sectional study was conducted among relatives of nonstroke patients admitted to the apex tertiary-care hospital in Sri Lanka. Trained doctors administered pretested, structured, open- and close-ended questionnaires. A postal survey using self-administered questionnaires was conducted among all registered GPs in Sri Lanka.

RESULTS

The sample of general public (51.7% males; mean age = 40.7 years) from 21 of 25 districts of Sri Lanka was 840 (response-rate = 97.4%) while the sample of GPs (77.6% males; mean age = 59.63 years) was 98 (response-rate = 30%). Of the general public, 83.2% were aware of a vascular aetiology of stroke, but only 46.8% were aware that the affected organ was the brain while 67.5% believed that either the heart or limb muscles die as sequalae of stroke. Over 50% correctly identified stroke warning symptoms while 84.7% would seek immediate Western medical treatment. Approximately, 32%-46% were not aware of the major stroke risk factors. Lower education (adj. OR = 1.7; 95% CI = 1.3-2.3), absence of stroke risk factors (2.6; 1.9-3.7) and nonutility of information sources (1.5; 1.0-2.0) determined poor knowledge on risk factors. Only about 1 in 8 GPs accurately defined stroke and TIA while only 43.9% correctly classified stroke subtypes. Only 1 in 10 GPs were aware of the recommended therapeutic window for thrombolysis. Older age (P = 0.01) and longer service (P = 0.04) of GPs were associated with not requesting brain imaging in stroke.

CONCLUSIONS

Strategies to educate both the public and first-contact physicians to improve stroke literacy need to be an integral part of programmes that aim to reduce the burden of stroke in any population.

Remote Management of Poststroke Patients With a Smartphone-Based Management System Integrated in Clinical Care: Prospective, Nonrandomized, Interventional Study

Background

Advances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases.

Objective

We developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients.

Methods

With a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3.

Results

The study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0], P<.001; 12 weeks: 74.7 [SD 14.0], P<.001) and BDI score (baseline: 12.7 [SD 10.1]; 4 weeks: 11.2 [SD 10.2], P=.01; 12 weeks: 10.7 [SD 10.2], P<.001) showed gradual improvement; however, no significant differences were found in the mean EQ-5D score (baseline: 0.66 [SD 0.33]; 4 weeks: 0.69 [SD 0.34], P=.01; 12 weeks: 0.69 [SD 0.34], P<.001). Twenty-six patients who had uncontrolled BP at baseline had −13.92 mmHg (P=.001) and −6.19 mmHg (P<.001) reductions on average in systolic and diastolic BP, respectively, without any antihypertensive medication change. Medication compliance was better at visit 2-3 (60.9% [SD 37.2%]) than at visit 1-2 (47.8% [SD 38.7%], P<.001).

Conclusions

Awareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost.

Knowledge and Poor Understanding Factors of Stroke and Heart Attack Symptoms

OBJECTIVES

Adequate awareness of cardiovascular disease (CVD) may help in its prevention and control. Therefore, we evaluated knowledge among the general population of stroke and heart attack symptoms and determined the factors associated with poor understanding of CVD.

METHODS

This cross-sectional study included 228,240 adults (102,408 males, 125,832 females) who participated in the 2017 Korean Community Health Survey. Data on sociodemographic characteristics and cognizance of the warning signs of CVD events (stroke and heart attack) were examined. Logistic regression analysis was used to investigate factors associated with poor understanding of CVD.

RESULTS

The stroke and heart attack warning signs that were identified least often by respondents were "sudden poor vision in one or both eyes" (66.1%) and "pain or discomfort in the arm or shoulder" (53.8%). Of the subjects, 19.0% had low CVD knowledge scores (less than 4 out of 10) with males having lower scores than females. In the multivariate analysis, poor understanding of CVD warning signs was significantly associated with older age, male gender, lower education level, lack of regular exercise, unmarried status, unemployment, poor economic status, poor health behaviors (high salt diet, no health screening), poor psychological status (high stress, self-perceived poor health status), and the presence of hypertension or dyslipidemia.

CONCLUSIONS

Specialized interventions, including those based on public education, should focus on groups with less knowledge of CVD.

Knowledge, attitude, and practice of stroke among high school students in Nepal

Background:

Baseline stroke knowledge in a targeted population is indispensable to promote the effective stroke education. We report the baseline knowledge, attitude, and practice (KAP) of high school students with respect to stroke from Nepal.

Materials and Methods:

A self-structured questionnaire survey regarding KAP about stroke was conducted in high school students of 33 schools of Bharatpur, Nepal. Descriptive statistics including Chi-square test was used, and the significant variables were subjected to binary logistic regression.

Results:

Among 1360 participants, 71.1% had heard or read about stroke; 30.2% knew someone with stroke. 39.3% identified brain as the organ affected. Sudden onset limb/s weakness/numbness (72%) and hypertension (74%) were common warning symptom and risk factor identified. 88.9% would take stroke patients to a hospital. Almost half participants (55.5%) felt ayurvedic treatment be effective. 44.8% felt stroke as a hindrance to a happy life and 86.3% believed that family care was helpful for early recovery. Students who identified at least one risk factor were 3.924 times (P < 0.001, confidence interval [CI] = 1.867–8.247) or those who identified at least one warning symptom were 2.833 times (P ≤ 0.023, CI = 1.156–6.944) more likely to take stroke patients to a hospital.

Conclusion:

KAP of high school Nepalese students regarding stroke was satisfactory, and the students having knowledge about the risk factors and warning symptoms were more likely to take stroke patients to a hospital. However, a few misconceptions persisted.

Age-Group and Gender Differences in Stroke Knowledge in an Israeli Jewish Adult Population

BACKGROUND

Stroke is a leading cause of long-term disability and the fifth leading cause of death in Israel. Knowledge of stroke warning signs has been linked to early seeking of medical help. Little is known about knowledge of stroke warning signs in Israeli Jewish adults.

METHODS

Stroke knowledge was examined among Jewish Israeli adults. Using a structured questionnaire, registered nurses interviewed a convenience sample of the respondents, 18 years or older, with no stroke history. Stroke knowledge and demographics were examined by 3 age groups (<45, 45-64, and >64 years) in men and women.

RESULTS

In total, 1137 Jewish Israelis were interviewed, 457 (40.2%) men and 680 women (59.8%); 493 (43.4%) were younger than 45 years, 541 (47.6%) were aged 45 to 64 years, and 102 (9%) were older than 64 years; 1 (0.1%) did not report age. On average, each interview lasted for 25 to 30 minutes. Participants younger than 45 years showed the lowest knowledge of stroke cause. Women younger than 45 years were less likely to identify at least 2 stroke warning signs. Participants younger than 45 years were less likely to identify at least 2 risk factors, compared with participants aged 45 to 64 years and older than 64 years. Women younger than 45 years were less likely to identify at least 2 stroke prevention strategies.

CONCLUSION

Participants younger than 45 years showed the lowest levels of stroke knowledge. The highest stroke knowledge was found in the 45 to 64 years age group. Stroke knowledge among different age groups was similar in both genders. Educational campaigns aimed at increasing knowledge of stroke among the general population and targeting the younger population are recommended.

Stroke awareness in Korean high school students

Public awareness is essential for the early diagnosis, treatment, and prevention of stroke. In particular, young adults represent an important avenue for increasing awareness and precluding the adoption of unhealthy, risk-increasing behaviors. This study was the first to investigate the basic knowledge of Korean adolescents about stroke and evaluate the improvement of this knowledge after an educational lecture. In total, 1269 high school students were instructed on the risk factors, symptoms, diagnosis, and management of stroke. Knowledge was evaluated before education (Pre-E), immediately after the lecture (Post-E1), and during a 2-week follow-up (Post-E2), using a questionnaire. Overall, we found that students' knowledge increased after the educational session. On the questionnaire section pertaining to stroke risk factors, out of nine possible points, the mean scores were 3.97, 5.28, and 5.10, on the Pre-E, Post-E1, and Post-E2 tests, respectively, indicating a significant improvement (p < 0.001). Additionally, students who reported that they paid attention during the lecture performed better, and scored 4.29, 6.32, and 6.40, on the Pre-E, Post-E1, and Post-E2 tests, respectively, again indicating a significant improvement (p < 0.001). Our findings indicate that incorporating a stroke education program into school curriculums will enhance the knowledge of Korean adolescents. Implementing this type of program is critical as it may reduce behavior associated with increased stroke risk, and more effort is needed to develop educational methods for engaging students and increasing their concentration during these programs.

Where Does the Time Go? The Effect of Protocols for Stroke Last Known Well Documentation on Intravenous Recombinant Tissue Plasminogen Activator Delivery in the Northeast

BACKGROUND

Despite significant efforts to improve thrombolytic use in the United States, only a small number of patients with ischemic stroke are currently treated. Although there are a number of contraindications to tissue plasminogen activator use, many patients are excluded because of the narrow therapeutic time window, which is determined by the "last known well" (LKW) time. However, it is unclear how the LKW is obtained and documented in the acute hospital setting.

METHODS

We surveyed hospitals throughout the Northeast region to determine if they had established protocols for documenting LKW times. Treatment rates as reported to Get with The Guidelines Stroke were then compared in hospitals with and without established protocols for documenting LKW times.

RESULTS

The majority of hospitals (73%) lacked established protocols for LKW documentation. Those without established protocols more often missed this variable when reporting to Get With The Guidelines-Stroke. Treatment rates were low overall (7%), although rates in patients who presented within 2 hours of symptom onset were high in hospitals whether they had an established protocol (86%) or not (87%). However, the lack of documentation of LKW is common and could influence the treatment rates if patients are erroneously excluded from treatment.

CONCLUSIONS

Improved documentation of LKW times should be attempted. The addition of this variable to existing protocols could more accurately track the number of patients ineligible for treatment based on delayed presentation.

Public Awareness of Stroke and Its Predicting Factors in Korea: a National Public Telephone Survey, 2012 and 2014

The aim of this study was to investigate time trends in the public awareness of stroke and its predicting factors. The target population was 9,600 community-dwelling adults, aged 19-79 years, in 16 metropolitan cities and provinces in Korea. The survey samples in 2012 and 2014 were selected separately (entirely different sets of subjects) using a proportionate quota sampling method. Information concerning knowledge of stroke and demographics was collected by trained telephone interviewers using random digit dialing. After excluding subjects with a non-response or refusal to answer any question, the analyses included 8,191 subjects in 2012 and 8,127 subjects in 2014. Respondents' awareness of stroke warning signs (numbness or weakness, difficulty speaking or understanding speech, dizziness, visual impairment, and severe headache) was highest for difficulty speaking or understanding speech (80.9% in 2012 and 86.4% in 2014). There were significant increases in the proportion of respondents understanding the appropriate action (i.e., calling an ambulance) at the time of stroke occurrence (59.6% to 67.1%), and in the proportion aware of the general need for prompt treatment (86.7% to 89.8%). In multivariable logistic regression analysis, older age, higher education level, higher household income, current non-smoking, exposure to stroke-related public relations materials, and experience of stroke education were significantly associated with both high knowledge of stroke warning signs and awareness of the need for prompt treatment. Between 2012 and 2014, the public's awareness of stroke increased significantly. More specialized interventions, including public relations materials and education, should focus on subgroups who have lower stroke knowledge.

Impact of Prehospital Intervention on Delay Time to Thrombolytic Therapy in a Stroke Center with a Systemized Stroke Code Program

BACKGROUND

The use of emergency medical services (EMS) and notification to hospitals by paramedics for patients with suspected stroke are crucial determinants in reducing delay time to acute stroke treatment. The aim of this study is to investigate whether EMS use and prehospital notification (PN) can shorten the time to thrombolytic therapy in a stroke center with a systemized stroke code program.

METHODS

Beginning in January 2012, stroke experts in our stroke center received direct calls via mobile phone from paramedics prenotifying the transport of patients with suspected stroke. We compared baseline characteristics and prehospital/in-hospital delay time in stroke patients treated with intravenous recombinant tissue plasminogen activator for 44 months with and without EMS use and/or PN.

RESULTS

Intravenous thrombolytic therapy was performed on 274 patients. Of those patients, 215 (78.5%) were transported to the hospital via EMS and 59 (21.5%) were admitted via private modes of transportation. The patients who used EMS had shorter median onset-to-arrival times (62 minutes versus 116 minutes, P < .001). There was no difference in in-hospital delay time between the 2 groups. In 28 cases (13%) of EMS transport, EMS personnel called the clinical staff to notify the incoming patient. Prenotification by EMS was associated with shorter median door-to-imaging time (9 minutes versus 12 minutes, P = .045) and door-to-needle time (20 minutes versus 29 minutes, P = .011).

CONCLUSIONS

We found that EMS use reduces prehospital delay time. However, EMS use without prenotification does not shorten in-hospital processing time in a stroke center with a systemized stroke code program.

The Effect of Emergency Medical Service Use and Inter-hospital Transfer on Prehospital Delay among Ischemic Stroke Patients: A Multicenter Observational Study

The time between symptom onset and arrival at an emergency department (ED) (S2D) is a crucial time for optimal intravenous reperfusion care for ischemic stroke. We aimed to analyze the effect of emergency medical services (EMS) utilization and inter-hospital transfer on S2D in Korea. Ischemic stroke patients were prospectively enrolled from November 2007 to December 2012 in 23 tertiary and teaching hospital EDs in Korea. Of 31,443 adult ischemic stroke patients, 20,780 were categorized into 4 groups based on modes of EMS utilization and inter-hospital transfer: direct transport to destination ED by EMS (EMS direct; n=6,257, 30.1%), transfer after transport to another ED by EMS (EMS indirect; n=754, 3.6%), direct transport to the ED without using EMS (non-EMS direct; n=8,928, 43.0%), and transfer after visiting another hospital without using EMS (non-EMS indirect; n=4,841, 23.3%). Our primary outcome variable was of S2D within 2 hr (S2D ≤ 2 hr) and found that 30.8% of all patients and 52.3%, 16.4%, 25.9%, and 13.9% of EMS direct, EMS indirect, non-EMS direct, and non-EMS indirect, respectively, achieved S2D ≤ 2 hr. Adjusted odds ratio for S2D ≤ 2 hr were 6.56 (95% confidence interval [CI], 5.94-7.24), 2.27 (95% CI, 2.06-2.50), and 1.07 (95% CI, 0.87-1.33) for EMS direct, non-EMS direct, and EMS indirect, respectively. Patients directly transported to destination hospitals by the EMS show the highest proportion of therapeutic time window for optimal care in ischemic stroke.

Identifying Target Risk Factors Using Population Attributable Risks of Ischemic Stroke by Age and Sex

Background and Purpose

Estimating age- and sex-specific population attributable risks (PARs) of major risk factors for stroke may be a useful strategy to identify risk factors for targeting preventive strategies.

Methods

For this case-control matched study, consecutive patients aged 18-90 years and admitted to nine nationwide hospitals with acute ischemic stroke between December 2008 and June 2010, were enrolled as cases. Controls, individually matched by age and sex, were chosen from the 4th Korean National Health & Nutrition Examination Survey (2008-2010). Based on odds ratios and prevalence, standardized according to the age and sex structure of the Korean population, PARs of major risk factors were estimated according to age (young, ≤ 45; middle-aged, 46-65; and elderly, ≥ 66 years) and sex subgroups.

Results

In 4,743 matched case-control sets, smoking (PAR, 45.1%) was the greatest contributing risk factor in young men, followed by hypertension (28.5%). In middle-aged men, the greatest contributing factors were smoking (37.4%), hypertension (22.7%), and diabetes (14.6%), whereas in women the greatest factors were hypertension (22.7%) and stroke history (10.6%). In the elderly, hypertension was the leading factor in men (23.7%) and women (23.4%). Other noticeable factors were stroke history (men, 19.7%; women, 17.3%) and diabetes (men, 12.5%; women, 15.1%). In young women, risk factors with a PAR greater than 10% were not found.

Conclusions

Smoking cessation in young people and hypertension and diabetes control in older people may be effective in reducing the burden of stroke on the population. In the elderly, secondary prevention could also be emphasized.

Factors Associated with Early Hospital Arrival in Patients with Acute Ischemic Stroke

Background and Purpose

Factors associated with early arrival may vary according to the characteristics of the hospital. We investigated the factors associated with early hospital arrival in two different stroke centers located in Korea and Japan.

Methods

Consecutive patients with ischemic stroke arrived hospital within 48 hours of onset between January 2011 and December 2012 were identified and the clinical and time variables were retrieved from the prospective stroke registries of Severance Hospital of Yonsei University Health System (YUHS; Seoul, Korea) and National Cerebral and Cardiovascular Center (NCVC; Osaka, Japan). Subjects were dichotomized into early (time from onset to arrival ≤4.5 hours) and late (>4.5 hours) arrival groups. Univariate and multivariate analyses were performed to evaluate factors associated with early hospital arrival.

Results

A total of 1,966 subjects (992 from YUHS; 974 from NCVC) were included in this study. The median time from onset to arrival was 6.1 hours [interquartile range, 1.7-17.8 hours]. In multivariate analysis, the factors associated with early arrival were atrial fibrillation (Odds ratio [OR], 1.505; 95% confidence interval [CI], [1.168-1.939]), higher initial National Institute of Health Stroke Scale scores (OR, 1.037; 95% CI [1.023-1.051]), onset during daytime (OR, 2.799; 95% CI [2.173-3.605]), and transport by an emergency medical service (OR, 2.127; 95% CI [1.700-2.661]). These factors were consistently associated with early arrival in both hospitals.

Conclusions

Despite differences between the hospitals, there were common factors related to early arrival. Efforts to identify and modify these factors may promote early hospital arrival and improve stroke outcome.

Stroke awareness and knowledge in an urban New Zealand population

BACKGROUND

Stroke is the third most common cause of death and a major cause of chronic disability in New Zealand. Linked to risk factors that develop across the life-course, stroke is considered to be largely preventable. This study assessed the awareness of stroke risk, symptoms, detection, and prevention behaviors in an urban New Zealand population.

METHODS

Demographics, stroke risk factors awareness, symptoms, responsiveness, and prevention behaviors were evaluated using a structured oral questionnaire. Binomial logistic regression analyses were used to identify predictors of stroke literacy.

RESULTS

Although personal experience of stroke increased awareness of symptoms and their likeliness to indicate the need for urgent medical attention, only 42.7% of the respondents (n = 850) identified stroke as involving both blood and the brain. Educational attainment at or above a trade certificate, apprenticeship, or diploma increased the awareness of stroke symptoms compared with those with no formal educational attainment. Pacific Island respondents were less likely than New Zealand Europeans to identify a number of stroke risk factors. Māori, Pacific Island, and Asian respondents were less likely to identify symptoms of stroke and indicate the need for urgent medical attention.

CONCLUSIONS

The variability in stroke awareness and knowledge may suggest the need to enhance stroke-related health literacy that facilitates understanding of risk and of factors that reduce morbidity and mortality after stroke in people of Māori and Pacific Island descent and in those with lower educational attainment or socioeconomic status. It is therefore important that stroke awareness campaigns include tailored components for target audiences.

Magnetic resonance imaging in acute ischemic stroke treatment

Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.

[Identification of subgroups with lower level of stroke knowledge using decision-tree analysis]

PURPOSE

This study was performed to explore levels of stroke knowledge and identify subgroups with lower levels of stroke knowledge among adults in Korea.

METHODS

A cross-sectional survey was used and data were collected in 2012. A national sample of 990 Koreans aged 20 to 74 years participated in this study. Knowledge of risk factors, warning signs, and first action for stroke were surveyed using face-to-face interviews. Descriptive statistics and decision tree analysis were performed using SPSS WIN 20.0 and Answer Tree 3.1.

RESULTS

Mean score for stroke risk factor knowledge was 7.7 out of 10. The least recognized risk factor was diabetes and four subgroups with lower levels of knowledge were identified. Score for knowledge of stroke warning signs was 3.6 out of 6. The least recognized warning sign was sudden severe headache and six subgroups with lower levels of knowledge were identified. The first action for stroke was recognized by 65.7 percent of participants and four subgroups with lower levels of knowledge were identified.

CONCLUSION

Multi-faceted education should be designed to improve stroke knowledge among Korean adults, particularly focusing on subgroups with lower levels of knowledge and less recognition of items in this study.

Factors related to knowledge of stroke symptoms and risk factors in a norwegian stroke population

BACKGROUND

Previous studies have identified insufficient knowledge of stroke symptoms and risk factors both among survivors of stroke and in the general population. The purpose of this study was to investigate knowledge of stroke symptoms and risk factors in a Norwegian stroke population and to identify factors associated with good knowledge.

METHODS

This prospective study included patients with acute transient ischemic attack, ischemic stroke, and intracerebral hemorrhage. Knowledge of stroke symptoms and risk factors was explored by asking open-ended questions. Bivariate and multivariate regression analyses were performed to identify factors related to good knowledge.

RESULTS

In total, 287 patients (mean age ± standard deviation, 70.0 ± 12.9 years) answered the open-ended questionnaire of which 71% knew at least 1 symptom of stroke whereas 43% knew at least 1 risk factor. Knowledge of both numbness/weakness and speech difficulties as symptoms of stroke (43% of the patients) was associated with lower age (odds ratio [OR], .96; 95% confidence interval [CI], .94-.99), higher education (OR, 2.25; 95% CI, 1.17-4.30), and having previously received information regarding stroke (OR, 7.74; 95% CI, 3.82-15.67). Knowing at least 2 of the 3 risk factors of stroke "smoking", "hypertension", and "diabetes" (14% of the patients) was associated with lower age (OR, .94; 95% CI, .92-.97).

CONCLUSIONS

Knowledge of stroke symptoms and risk factors in patients with acute cerebrovascular disease seems to be insufficient. Further educational efforts are needed, as better knowledge may improve prevention of stroke and increase the number of patients who can receive thrombolysis.

Stroke units in Italy: engaging the public in optimizing existing resources

BACKGROUND AND PURPOSE

The lack of a wide implementation of stroke units (SU)s in Italy appears to accompany the underuse of the operating units. Community awareness of acute stroke care options may affect stroke resource use. Our aim was to determine the level of knowledge about SUs and tissue-plasminogen activator (t-PA) treatment amongst Italian adults and investigate its relationship to local stroke services implementation.

METHODS

A nation-based telephone survey was carried out in a sample of 1000 residents aged >18 years in May-June 2010. The questionnaire included close-ended questions regarding knowledge of SUs and t-PA treatment. Number and location of both SUs and t-PA treatments were provided by a concurrent national hospital-based survey. The prevalence and distribution of acute stroke care awareness in the community was examined and multivariate analyses were generated.

RESULTS

Amongst the 1000 participants (474 men, mean age 48.8 ± 17.2), only 26.2% reported knowing about the availability of t-PA treatment and only 15% were aware of the existence of SUs. Awareness of both SUs and t-PA was significantly associated only with education. These associations remained significant in the multivariate analyses. The degree of stroke services implementation (in terms of SUs/inhabitant rates and number of t-PA treatments) was not associated with SU and t-PA awareness.

CONCLUSIONS

This is the first European study that explored public knowledge about t-PA treatment and SUs. Italian adults proved insufficiently educated about SUs and t-PA; there is no higher awareness in areas with a greater supply of stroke services. This might partially explain the underuse of Italian SUs.

Stroke Statistics in Korea: Part II Stroke Awareness and Acute Stroke Care, A Report from the Korean Stroke Society and Clinical Research Center For Stroke

The aim of the current Part II of Stroke Statistics in Korea is to summarize nationally representative data on public awareness, pre-hospital delay, thrombolysis, and quality of acute stroke care in a single document. The public's knowledge of stroke definition, risk factors, warning signs, and act on stroke generally remains low. According to studies using open-ended questions, the correct definition of stroke was recognized in less than 50%, hypertension as a stroke risk factor in less than 50%, and other well-defined risk factors in less than 20%. Among stroke warning signs, sudden paresis or numbness was best appreciated, with recognition rates ranging in 36.9-73.7%, but other warning signs including speech disturbance were underappreciated. In addition, less than one third of subjects in a representative population survey were aware of thrombolysis and had knowledge of the appropriate act on stroke, calling emergency medical services (EMS). Despite EMS being an essential element in the stroke chain of survival and outcome improvement, EMS protocols for field stroke diagnosis and prehospital notification for potential stroke patients are not well established. According to the Assessment for Quality of Acute Stroke Care, the median onset-to-door time for patients arriving at the emergency room was 4 hours (mean, 17.3 hours) in 2010, which was not reduced compared to 2005. In contrast, the median door-to-needle time for intravenous tissue plasminogen activator (IV-TPA) treatment was 55.5 minutes (mean, 79.5 minutes) in 2010, shorter than the median time of 60.0 minutes (mean, 102.8 minutes) in 2008. Of patients with acute ischemic stroke, 7.9% were treated with IV-TPA in 2010, an increase from the 4.6% in 2005. Particularly, IV-TPA use for eligible patients substantially increased, from 21.7% in 2005 to 74.0% in 2010. The proportion of hospitals equipped with a stroke unit has increased from 1.1% in 2005 to 19.4% in 2010. Performance, as measured by quality indicators, has steadily improved since 2005, and the performance rates for most indicators were greater than 90% in 2010 except for early rehabilitation consideration (89.4%) and IV-TPA use for eligible patients (74.0%). In summary, the current report indicates a substantial improvement in in-hospital acute stroke care, but also emphasizes the need for enhancing public awareness and integrating the prehospital EMS system into acute stroke management. This report would be a valuable resource for understanding the current status and implementing initiatives to further improve public awareness of stroke and acute stroke care in Korea.

Functional recovery at 3 months in stroke patients not receiving thrombolytic therapy: the comparison between patients arriving earlier and later than 4.5 hours

BACKGROUND

We aim to study the recovery of functional abilities of stroke patients who did not receive recombinant tissue plasminogen activator (rtPA) after treatment for 3 months comparing patients who arrived at a hospital within 4.5 hours and those who arrived after 4.5 hours of symptom onset. Also, we investigated the predictors of the functional recovery and the quality of life (QOL) at 3 months after stroke.

MATERIAL AND METHOD

Data were collected by interviewing the stroke patients and caregivers twice on Day 1 and at 3 months after the stroke onset. We collected the demographic data, Modified Rankin Scale (mRS), Barthel Index, National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), and World Health Organization Quality of Life-Bref-Thai (WHOQOL-Bref-Thai).

RESULTS

Eighty-eight and 85 patients arrived at a hospital within 4.5 and after 4.5 hours respectively. At 3 months after treatment, the recovery of stroke patients as assessed by mRS, Barthel Index, and the QOL in both groups did not differ significantly (P > .05). Approximately 80% in both groups had good QOL. Both groups of patients had a similar low stroke awareness and knowledge in terms of risk factors (P = .825) and care of stroke patients (P = .562). Four variables that significantly predicted the improvement of the mRS score at 3 months after treatment were age 60 years and younger, premorbid self-care ability, the NIHSS score of 14 or less and Day 1 mRS score.

CONCLUSION

Stroke patients arriving at the hospital within and after 4.5 hours of the onset who did not receive the rtPA did not have significant differences in the functional outcomes and quality of life at 3 months. However, the eligibility for rtPA is not known before arriving at the hospital so that the necessity of seeking medical treatment as quickly as possible is still warranted. Increasing effective public awareness regarding stroke risk factors and care should be implemented.

Fantasies about stem cell therapy in chronic ischemic stroke patients

Stem cell therapy (SCT) has been proposed for the treatment of neurological disorders. Although there is insufficient clinical evidence to support its efficacy, unproven SCTs are being performed worldwide. In this study, we investigated the perspectives and expectations of chronic ischemic stroke patients and physicians about SCTs. A total of 250 chronic ischemic stroke patients were interviewed at 4 hospitals. Structured open and closed questions about SCT for chronic stroke were asked by trained interviewers using the conventional in-person method. In addition, 250 stroke-related physicians were randomly interviewed via an e-mail questionnaire. Of the 250 patients (mean 63 years, 70% male), 121 (46%) responded that they wanted to receive SCT in spite of its unknown side effects. Around 60% of the patients anticipated physical, emotional, and psychological improvement after SCT, and 158 (63%) believed that SCT might prevent strokes. However, physicians had much lower expectations about the effectiveness of SCTs, which was not in line with patient expectations. Multivariate analysis revealed that the male gender [odds ratio (OR): 2.00, 95% confidence interval (CI): 1.10-3.64], longer disease duration (OR: 1.01, 95% CI: 1.00-1.02), higher modified Rankin Scale score (OR: 1.30, 95% CI: 1.06-1.60), and familiarity with stem cells (OR: 1.86, 95% CI: 1.10-3.15) were independently associated with wanting SCT. The major source of information about SCT was television (68%), and the most reliable source was physicians (49%). Patients have unfounded expectations that SCT will improve their functioning. Considering our finding that the major source of information on stem cells is media channels, but not the physician, to decrease patients' inappropriate exposure, doctors should make more effort to educate patients using mass media with accurate information.