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Nimjee SM, Hill MD. Stroke Thrombolysis: Can You Feel the Need for Speed? Neurology 2024; 102:e209253. [PMID: 38502898 DOI: 10.1212/wnl.0000000000209253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/08/2024] [Indexed: 03/21/2024] Open
Affiliation(s)
- Shahid M Nimjee
- From the Department of Neurosurgery (S.M.N.), Wexner Medical Center, Ohio State University, Columbus; and Department of Clinical Neurosciences (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael D Hill
- From the Department of Neurosurgery (S.M.N.), Wexner Medical Center, Ohio State University, Columbus; and Department of Clinical Neurosciences (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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2
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Simpson JR, VanCoevering RJ, Jeppson K, Case D, Seinfeld J, Roark C, Poisson SN. Clinical Decision Support for Patients Presenting With Large Vessel Occlusion. Neurohospitalist 2024; 14:182-185. [PMID: 38666277 PMCID: PMC11040614 DOI: 10.1177/19418744231220699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
A single center had a collaborative, multidisciplinary review to determine how to best implement new acute ischemic stroke trials involving large vessel occlusions. A flow diagram process map was created for clinical decision support. Patients were divided into four groups based upon size of infarct and timing of presentation. The process map, available in the electronic health record (EHR) for clinicians to reference, guides the selection of patients for endovascular therapy with neuroimaging. In addition, the process map offers guidance for discussions with families and patients experiencing large vessel occlusions with both small and large core infarcts. This manuscript describes the process of creating the process map through a multidisciplinary review and discussion, with points of controversy and how these were addressed.
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Affiliation(s)
- Jennifer R. Simpson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - David Case
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher Roark
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sharon N. Poisson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
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Hamed Y, Seddeek MI, Ahmed AM, Dawa TA, Hashem H, Othman AM, Fayed AGI, Elbazzar N, Metwally RA, El Sayed MESAE, Yousry A, Shokry AE. Factors predicting functional outcome after rtPA for patients with acute ischemic stroke. Egypt J Neurol Psychiatry Neurosurg 2024; 60:17. [DOI: https:/doi.org/10.1186/s41983-024-00790-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024] Open
Abstract
Abstract
Background
Accurate outcome prediction for patients with acute ischemic stroke after intravenous recombinant tissue plasminogen activator (rtPA) treatment is essential for optimizing patients’ management. We aimed to identify factors associated with unfavorable outcomes following intravenous rtPA treatment. This study was carried out on 162 patients who presented with acute ischemic stroke within 4.5 h from onset of neurological symptoms and were eligible for intravenous rtPA. After exclusion of 48 patients, 114 patients were finally eligible for follow-up. After complete medical and neurological history, complete medical and neurological examination and brain image (CT and or MRI brain) were collected from the patients. patients eligible were included in the study. NIHS scale was assessed for all patients at time of admission, after 24 h, and follow-up for 3 months.
Results
After a 90-day follow-up period for 114 patients with acute ischemic stroke after rtPA, 35.8% had good outcome (MRS; 0–2), 18.5% had partial outcome (MRS; 3–4) and 12.5% had poor outcome (MRS; 5–6). Atrial fibrillation (AF), PH of stroke, stroke severity, and severity of symptom (NIHSS) score were significantly (P: 0.004, 0.001, 0.007 and 0.001) correlated with poor outcome after rtPA. Similarly, old age, high blood pressure at time of presentation, hypertension, and dyslipidemia were showed to carry poor outcome.
Conclusions
AF, high NIHSS score, PH of stroke, previous stroke, hypertension, dyslipidemia, and high blood pressure on presentation were significantly correlated with poor functional outcome.
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Wong Zhang DE, Zhang SR, Kim HA, Sobey CG, De Silva TM. The Photothrombotic Model of Ischemic Stroke. Methods Mol Biol 2024; 2746:225-235. [PMID: 38070093 DOI: 10.1007/978-1-0716-3585-8_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Stroke is a major cause of morbidity worldwide; yet, there is a lack of treatment options to address post-stroke cognitive and motor impairment, thus there is an urgency for developing neuroprotective and restorative therapies. Much of our fundamental understanding of stroke pathology has been derived from animal models. The photothrombotic model of ischemic stroke is commonly used to study cellular and molecular mechanisms of neurodegeneration, test functional/cognitive outcomes, identify important biomarkers, and assess the effectiveness of novel therapies. It allows for the precise targeting of an infarct to a specific region of the brain, has a low mortality rate, low seizure rate, and is relatively easy to perform. This chapter outlines materials and methods for the photothrombotic model of ischemic stroke in mice, its limitations, and some considerations needed when using this model.
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Affiliation(s)
- David E Wong Zhang
- Centre for Cardiovascular Biology and Disease Research, Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University, Bundoora, VIC, Australia
| | - Shenpeng R Zhang
- Centre for Cardiovascular Biology and Disease Research, Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University, Bundoora, VIC, Australia
| | - Hyun Ah Kim
- Centre for Cardiovascular Biology and Disease Research, Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University, Bundoora, VIC, Australia
| | - Christopher G Sobey
- Centre for Cardiovascular Biology and Disease Research, Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University, Bundoora, VIC, Australia
| | - T Michael De Silva
- Centre for Cardiovascular Biology and Disease Research, Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University, Bundoora, VIC, Australia.
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5
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Klu M, de Souza AC, Carbonera LA, Secchi TL, Pille A, Rodrigues M, Brondani R, de Almeida AG, Dal Pizzol A, Camelo DMF, Mantovani GP, Oldoni C, Tessari MS, Nasi LA, Martins SCO. Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil. Front Neurol 2023; 14:1155931. [PMID: 37492852 PMCID: PMC10365273 DOI: 10.3389/fneur.2023.1155931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/13/2023] [Indexed: 07/27/2023] Open
Abstract
Background The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.
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Affiliation(s)
- Marcelo Klu
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Claudia de Souza
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leonardo Augusto Carbonera
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Thais Leite Secchi
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Arthur Pille
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Marcio Rodrigues
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rosane Brondani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Garcia de Almeida
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Angélica Dal Pizzol
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Daniel Monte Freire Camelo
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Gabriel Paulo Mantovani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carolina Oldoni
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marcelo Somma Tessari
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luiz Antonio Nasi
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sheila Cristina Ouriques Martins
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
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Cutforth M, Watson H, Brown C, Wang C, Thomson S, Fell D, Dilys V, Scrimgeour M, Schrempf P, Lesh J, Muir K, Weir A, O’Neil AQ. Acute stroke CDS: automatic retrieval of thrombolysis contraindications from unstructured clinical letters. Front Digit Health 2023; 5:1186516. [PMID: 37388253 PMCID: PMC10305776 DOI: 10.3389/fdgth.2023.1186516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
Introduction Thrombolysis treatment for acute ischaemic stroke can lead to better outcomes if administered early enough. However, contraindications exist which put the patient at greater risk of a bleed (e.g. recent major surgery, anticoagulant medication). Therefore, clinicians must check a patient's past medical history before proceeding with treatment. In this work we present a machine learning approach for accurate automatic detection of this information in unstructured text documents such as discharge letters or referral letters, to support the clinician in making a decision about whether to administer thrombolysis. Methods We consulted local and national guidelines for thrombolysis eligibility, identifying 86 entities which are relevant to the thrombolysis decision. A total of 8,067 documents from 2,912 patients were manually annotated with these entities by medical students and clinicians. Using this data, we trained and validated several transformer-based named entity recognition (NER) models, focusing on transformer models which have been pre-trained on a biomedical corpus as these have shown most promise in the biomedical NER literature. Results Our best model was a PubMedBERT-based approach, which obtained a lenient micro/macro F1 score of 0.829/0.723. Ensembling 5 variants of this model gave a significant boost to precision, obtaining micro/macro F1 of 0.846/0.734 which approaches the human annotator performance of 0.847/0.839. We further propose numeric definitions for the concepts of name regularity (similarity of all spans which refer to an entity) and context regularity (similarity of all context surrounding mentions of an entity), using these to analyse the types of errors made by the system and finding that the name regularity of an entity is a stronger predictor of model performance than raw training set frequency. Discussion Overall, this work shows the potential of machine learning to provide clinical decision support (CDS) for the time-critical decision of thrombolysis administration in ischaemic stroke by quickly surfacing relevant information, leading to prompt treatment and hence to better patient outcomes.
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Affiliation(s)
| | - Hannah Watson
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Cameron Brown
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Chaoyang Wang
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Stuart Thomson
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Dickon Fell
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | | | | | | | - James Lesh
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Keith Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, United Kingdom
| | - Alexander Weir
- Canon Medical Research Europe, Edinburgh, United Kingdom
| | - Alison Q O’Neil
- Canon Medical Research Europe, Edinburgh, United Kingdom
- School of Engineering, University of Edinburgh, Edinburgh, United Kingdom
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7
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Li L, Yang JH, Li C, Zhou HF, Yu L, Wu XL, Lu YH, He Y, Wan HT. Danhong injection improves neurological function in rats with ischemic stroke by enhancing neurogenesis and activating BDNF/AKT/CREB signaling pathway. Biomed Pharmacother 2023; 163:114887. [PMID: 37207429 DOI: 10.1016/j.biopha.2023.114887] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/21/2023] Open
Abstract
Danhong injection (DHI) is a traditional Chinese medicine injection that promotes blood circulation and removes blood stasis and has been widely used in the treatment of stroke. Many studies have focused on the mechanism of DHI in acute ischemic stroke (IS); however, few studies have thoroughly explored its role during recovery. In this study, we aimed to determine the effect of DHI on long-term neurological function recovery after cerebral ischemia and explored the related mechanisms. Middle cerebral artery occlusion (MCAO) was used to establish an IS model in rats. The efficacy of DHI was assessed using neurological severity scores, behaviors, cerebral infarction volume and histopathology. Immunofluorescence staining was performed to assess hippocampal neurogenesis. An in vitro oxygen-glucose deprivation/reoxygenation (OGD/R) cell model was constructed and western-blot analyses were performed to verify the underlying mechanisms. Our results showed that DHI treatment greatly reduced the infarct volume, promoted neurological recovery and reversed brain pathological changes. Furthermore, DHI promoted neurogenesis by increasing the migration and proliferation of neural stem cells, and enhancing synaptic plasticity. Moreover, we found that the pro-neurogenic effects of DHI were related to an increase in brain-derived neurotrophic factor (BDNF) expression and the activation of AKT/CREB, which were attenuated by ANA-12 and LY294002, the inhibitors of the BDNF receptor and PI3K. These results suggest that DHI improves neurological function by enhancing neurogenesis and activating the BDNF/AKT/CREB signaling pathways.
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Affiliation(s)
- Lan Li
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Jie-Hong Yang
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Chang Li
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Hui-Fen Zhou
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Li Yu
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Xiao-Long Wu
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Yi-Hang Lu
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China
| | - Yu He
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China.
| | - Hai-Tong Wan
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang province, China.
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Helboe KS, Eddelien HS, Kruuse C. Visual symptoms in acute stroke - A systematic review of observational studies. Clin Neurol Neurosurg 2023; 229:107749. [PMID: 37163931 DOI: 10.1016/j.clineuro.2023.107749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Atypical symptoms of stroke, such as non-specific visual symptoms, are a challenging aspect of acute stroke diagnostics. Among patients evaluated for stroke in the Emergency Department, 2-28% present with stroke chameleons, and 30-43% with stroke mimics. We aimed to identify the type of visual symptoms present in typical strokes, stroke mimics, and stroke chameleons. PATIENTS AND METHODS By use of Preferred Reporting Items for Systematic Reviews and Meta-Analysis we searched PubMed and Embase for studies with reports of acute visual symptoms in typical strokes vs mimics or chameleons (PROSPERO protocol, ID CRD42022364749). Risk of bias was assessed by The Critical Appraisal Skills Program. RESULTS Thirteen papers were included, comprising data from 9248 patients evaluated for stroke. Compared to mimics, visual symptoms in stroke presented more frequently as hemianopia (28.2% vs 4.8%, 7,4% vs 2.3%, 22% vs 0%), visual loss (11.6% vs 1.8%), visual field defect (11.6% vs 4%, 24% vs 2%, 19% vs 1.7%), eye movement disorder (19.4% vs 6.4%), eye deviation (9.6% vs 0.9%), gaze palsy (32.1% vs 8.6%), oculomotor disturbance (37% vs 0%), and visual inattention (17.5% vs 4%). Compared to strokes, mimics more often presented "non-systematized visual trouble" (10% vs 3%) and blurred vision (22% vs 5%), whereas "visual disturbance" was reported more often in stroke chameleons than in typical strokes (10% vs 3%). CONCLUSION Detailed reports of visual symptoms were lacking in most studies, however blurred vision and "non-systematized visual trouble" were more frequent in mimics, "visual disturbance" in stroke chameleons, and negative visual symptoms such as visual field defects in typical strokes. A more systematic and detailed approach to visual symptoms may facilitate acute stroke recognition in patients with visual symptoms.
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Affiliation(s)
- Katrine Sofie Helboe
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark & Dept of Clinical Medicine, University of Copenhagen, Denmark
| | - Heidi Shil Eddelien
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark & Dept of Clinical Medicine, University of Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark & Dept of Clinical Medicine, University of Copenhagen, Denmark.
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9
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Nguyen CP, Maas WJ, van der Zee DJ, Uyttenboogaart M, Buskens E, Lahr MMH. Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review. BMC Health Serv Res 2023; 23:315. [PMID: 36998011 PMCID: PMC10064746 DOI: 10.1186/s12913-023-09310-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT. METHODS A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality. RESULTS Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%). CONCLUSIONS A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands.
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
- Department of Pharmaceutical Administration and Economics, Hanoi University of Pharmacy, Hanoi, Vietnam.
| | - Willemijn J Maas
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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10
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García-Tornel Á, Flores A, Terceño M, Cardona P, Amaro S, Gomis M, Zaragoza J, Krupinski J, Gómez-Choco M, Mas N, Cocho D, Catena E, Purroy F, Deck M, Rubiera M, Pagola J, Rodriguez-Luna D, Juega J, Rodríguez-Villatoro N, Molina CA, Soro C, Jimenez X, Salvat-Plana M, Dávalos A, Jovin TG, Abilleira S, Pérez de la Ossa N, Ribó M. Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia. Stroke 2023; 54:770-780. [PMID: 36848432 DOI: 10.1161/strokeaha.122.041013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. METHODS We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am-8:59 pm) and nighttime (9:00 pm-7:59 am). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. RESULTS We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020-2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680-1.163]; P
interaction=0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548-1.072]; nighttime, acOR, 1.785 [95% CI, 1.024-3.112] ; P
interaction<0.01); no heterogeneity was observed for other stroke subtypes (P
interaction>0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. CONCLUSIONS Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02795962.
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Alan Flores
- Department of Neurology, Hospital Universitari Joan XXIII, Tarragona, Spain (A.F.)
| | - Mikel Terceño
- Stroke Unit, Hospital Universitari Josep Trueta, Girona, Spain (M.T.)
| | - Pedro Cardona
- Stroke Unit, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Spain (P.C.)
| | - Sergi Amaro
- Stroke Unit, Hospital Clínic, Barcelona, Spain (S.A.)
| | - Meritxell Gomis
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Josep Zaragoza
- Department of Neurology, Hospital Verge de la Cinta, Tortosa, Spain (J.Z.)
| | - Jerzy Krupinski
- Department of Neurology, Hospital Mútua Terrassa, Spain (J.K.)
| | - Manuel Gómez-Choco
- Department of Neurology, Hospital Moisés Broggi, Sant Joan Despí, Spain (M.G.-C.)
| | - Natalia Mas
- Department of Neurology, Hospital Sant Joan de Déu - Fundació Althaia, Manresa, Spain (N.M.)
| | - Dolores Cocho
- Department of Neurology, Hospital General Granollers, Spain (D.C.)
| | - Esther Catena
- Department of Neurology, Consorci Sanitari Alt Penedès-Garraf, Spain (E.C.)
| | - Francesc Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Spain (F.P.)
| | - Matias Deck
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
| | - Cristina Soro
- Sistema d'Emergències Mèdiques, Barcelona, Spain (C.S., X.J.)
| | - Xavier Jimenez
- Sistema d'Emergències Mèdiques, Barcelona, Spain (C.S., X.J.)
| | - Mercè Salvat-Plana
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (M.S.-P., S.A.)
| | - Antoni Dávalos
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Tudor G Jovin
- Neurological Institute, Cooper University Hospital, Camden, NJ (T.G.J.)
| | - Sonia Abilleira
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (M.S.-P., S.A.)
| | - Natalia Pérez de la Ossa
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (M.G., A.D., N.P.d.l.O.)
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (A.G.-T., M.D., M. Rubiera., J.P., D.R.L., J.J., N.R.V., C.A.M., M. Ribó)
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11
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Yogendrakumar V, Beharry J, Churilov L, Alidin K, Ugalde M, Pesavento L, Weir L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Dewey HM, Wijeratne T, Yan B, Desmond PM, Sharma G, Parsons MW, Donnan GA, Davis SM, Campbell BCV, Bush S, Scroop R, Simpson M, Brooks M, Asadi H, Ang T, Miteff F, Levi C, Rodrigues E, Zhao H, Alemseged F, Ng F, Salvaris P, Garcia‐Esperon C, Bailey P, Rice H, de Villiers L, Choi P, Brown H, Redmond K, Leggett D, Fink J, Collecutt W, Kraemer T, Cordato D, Muller C, Coulthard A, Mitchell K, Clouston J, Mahady K, Field D, O’Brien B, Clissold B, Clissold A, Cloud G, Bolitho L, Bonavia L, Bhattacharya A, Wright A, Mamun A, O’Rourke F, Worthington J, Wong A, Ma H, Phan T, Chong W, Chandra R, Slater L, Krause M, Harrington T, Faulder K, Steinfort B, Bladin C. Tenecteplase Improves Reperfusion across Time in Large Vessel Stroke. Ann Neurol 2023; 93:489-499. [PMID: 36394101 DOI: 10.1002/ana.26547] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/17/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tenecteplase improves reperfusion compared to alteplase in patients with large vessel occlusions. To determine whether this improvement varies across the spectrum of thrombolytic agent to reperfusion assessment times, we performed a comparative analysis of tenecteplase and alteplase reperfusion rates. METHODS Patients with large vessel occlusion and treatment with thrombolysis were pooled from the Melbourne Stroke Registry, and the EXTEND-IA and EXTEND-IA TNK trials. The primary outcome, thrombolytic-induced reperfusion, was defined as the absence of retrievable thrombus or >50% reperfusion at imaging reassessment. We compared the treatment effect of tenecteplase and alteplase, accounting for thrombolytic to assessment exposure times, via Poisson modeling. We compared 90-day outcomes of patients who achieved reperfusion with a thrombolytic to patients who achieved reperfusion via endovascular therapy using ordinal logistic regression. RESULTS Among 893 patients included in the primary analysis, thrombolytic-induced reperfusion was observed in 184 (21%) patients. Tenecteplase was associated with higher rates of reperfusion (adjusted incidence rate ratio [aIRR] = 1.50, 95% confidence interval [CI] = 1.09-2.07, p = 0.01). Findings were consistent in patient subgroups with first segment (aIRR = 1.41, 95% CI = 0.93-2.14) and second segment (aIRR = 2.07, 95% CI = 0.98-4.37) middle cerebral artery occlusions. Increased thrombolytic to reperfusion assessment times were associated with reperfusion (tenecteplase: adjusted risk ratio [aRR] = 1.08 per 15 minutes, 95% CI = 1.04-1.13 vs alteplase: aRR = 1.06 per 15 minutes, 95% CI = 1.00-1.13). No significant treatment-by-time interaction was observed (p = 0.87). Reperfusion via thrombolysis was associated with improved 90-day modified Rankin Scale scores (adjusted common odds ratio = 2.15, 95% CI = 1.54-3.01) compared to patients who achieved reperfusion following endovascular therapy. INTERPRETATION Tenecteplase, compared to alteplase, increases prethrombectomy reperfusion, regardless of the time from administration to reperfusion assessment. Prethrombectomy reperfusion is associated with better clinical outcomes. ANN NEUROL 2023;93:489-499.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Khairunnisa Alidin
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Melissa Ugalde
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Lauren Pesavento
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Weir
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, University of Melbourne and Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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12
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Pengtong W, Aimyong N, Nilanont Y. Intracranial Hemorrhage after Recombinant Tissue Plasminogen Activator: The competing risks survival analysis. Interdisciplinary Neurosurgery 2023. [DOI: 10.1016/j.inat.2023.101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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13
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Al-Qahtani S, Jalal Z, Paudyal V, Mahmood S, Mason J. The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10112315. [PMID: 36421639 PMCID: PMC9691113 DOI: 10.3390/healthcare10112315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/05/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022] Open
Abstract
Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.
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Affiliation(s)
- Saeed Al-Qahtani
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
- School of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia
- Correspondence: ; Tel.: +966-560742224
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sajid Mahmood
- Department of Pharmacy, Quaid-i-Azam University, Islamabad 45320, Pakistan
| | - Julie Mason
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK
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14
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Yuan G, Xia H, Xu J, Long C, Liu L, Huang F, Zeng J, Yuan L. Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department. Front Neurol 2022; 13:931193. [PMID: 36226088 PMCID: PMC9548581 DOI: 10.3389/fneur.2022.931193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
Objective This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS). Materials and methods We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group. Results The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min. Conclusions Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.
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Affiliation(s)
- Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Hong Xia
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jun Xu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Lei Liu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Feng Huang
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- *Correspondence: Jianping Zeng
| | - Lingqing Yuan
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Lingqing Yuan
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15
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Esbjörnsson M, Ullberg T. Safety and usability of wearable accelerometers for stroke detection the STROKE ALARM PRO 1 study. J Stroke Cerebrovasc Dis 2022; 31:106762. [PMID: 36115106 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/16/2022] [Accepted: 09/04/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The introduction of time-dependent reperfusion therapies in acute ischemic stroke has increased the need for early identification. We explore the safety and feasibility of STROKE ALARM which detects sudden arm paresis, the most frequent symptom in stroke. MATERIALS AND METHODS Consecutive patients admitted with a stroke or TIA at Skåne University Hospital were screened according to inclusion and exclusion criteria, and included in the STROKE ALARM PRO 1 Study aiming to explore the feasibility of prolonged use (30 days) of the system in the community. STROKE ALARM consists of paired arm bracelets with accelerometers, coupled with a stroke test in a smartphone application. In case of an imbalance in arm movements, the user is prompted to perform an app-based stroke test. Failure to respond or to complete the stroke test correctly, triggers notification by SMS to predefined emergency contacts. Patients were followed up by telephone after completion. RESULTS Thirty patients were included and 28 completed follow-up. Median age was 68 years and 36.7% were female. No stroke events were recorded during follow-up. False indications occurred in all but one patient, and 22 (78.6%) experienced alarms to their emergency contacts. Despite a high level of false alarms, general user experience was rated in a positive or neutral manner by almost 90%. Very frequent alarms were probably due to mild arm paresis not detected in routine clinical assessment. CONCLUSIONS Use of STROKE ALARM for 30 days after stroke/TIA was well tolerated warranting further study for early automated detection of stroke recurrence.
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Affiliation(s)
- Magnus Esbjörnsson
- Institution of Clinical Sciences Lund, Neurology, Lund University, Department of Internal Medicine, Hässleholm Hospital, S-28125 Hässleholm, Sweden.
| | - Teresa Ullberg
- Institution of Clinical Sciences Lund, Neurology, Lund University, Department of neurology, Skåne University Hospital Lund, S-20502 Malmö, Sweden
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16
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García‐Tornel Á, Seró L, Urra X, Cardona P, Zaragoza J, Krupinski J, Gómez‐Choco M, Mas Sala N, Catena E, Palomeras E, Serena J, Hernandez‐Perez M, Boned S, Olivé‐Gadea M, Requena M, Muchada M, Tomasello A, Molina CA, Salvat‐Plana M, Escudero M, Jimenez X, Davalos A, Jovin TG, Purroy F, Abilleira S, Ribó M, Perez de la Ossa N, Jacobi MR, Sanjuan E, Santana K, Molina C, Rubiera M, Rodríguez N, Pagola J, Rodriguez‐Luna D, Maisterra O, Santamarina E, Muchada M, Juega J, Boned S, Franco AP, García‐Tornel Á, Gadea MO, Deck M, Requena M, Sala V, de la Ossa NP, Muñoz L, Millán M, Gomis M, López‐Cancio E, Dorado L, Hernández‐Pérez M, Ciurans J, Samaniego D, Canento T, Martin L, Planas A, Broto J, Sorrentino A, Paré M, Zhu N, Garrido A, Grau L, Crespo AM, Presas S, Almendrote M, Ramos A, Lucente G, Ispierto L, Lozano M, Becerra JL, Jiménez M, Rolán DV, Guanyabens N, Sanchez‐Ojanguren J, Martínez‐Piñeiro A, Forcén S, Gea M, Álvarez M, Ramos A, Lizarbe MD, Sara, Guerra R, Bragado I, Arbex A, Rodríguez L, Bustamante A, Portela PC, García HQ, Rodríguez BL, Cayuela N, Miró J, Marzal C, Paipa A, Campoy S, Núñez A, Arroyo P, Besora S, Adell V, Campdelacreu J, Martí MA, González B, Vila LB, Crespo MF, Berbel A, Urbaneja CV, Guillen N, Vidal N, Santamaria PVV, Navarro DH, Simó M, Falip M, Matas E, Ochoa NM, Gifreu A, Muñoz A, Romero L, Portell E, Perez GH, Esteve FR, Teixidor S, Talavera AS, Gómez R, Nuin XU, Vargas M, Chamorro Á, Amaro S, Llull L, Renú A, Rudilosso S, del Valle RS, Ariño H, Solà N, la Puma D, Gil F, Gómez JB, Matos N, Falgàs N, Borrego S, Sánchez A, Balasa M, Montejo C, Guasp M, Reyes D, Cervilla PS, Contador JM, Monge VAV, Ramos O, Manzanera LSR, Rodríguez A, Campello AR, Ballester GR, Trujillano ML, Steinhauer EG, Godia EC, Santiago AJO, Conde JJ, Fábregas JM, Guisado D, Prats L, Camps P, Delgado R, Domeño AM, Marín R, Cànovas D, Estela J, Ros M, Aranceta S, Espinosa J, Rubio M, Lafuente C, Barrachina O, Anguita A, Reverter A, García C, Sansa G, Hervas M, Crosas M, Delgado T, Krupinski J, Folch DSH, Gamito GM, Alvarez JT, Subirana T, Molina J, Besora S, Romero LC, Valls GG, Jover M, Sotova JJ, Sánchez SMG, Valenzuela S, Gómez‐Choco M, Mengual JJ, Font MÀ, Ruiz MIG, Zubizarreta I, González SF, Gubieras L, Cobos CE, Romo LM, Caballol N, Cano L, Leal JS, Blas YS, Izarra MT, Trigo IB, Viturro SB, Albiñana LP, Garrido MR, Cazcarra CM, Uscamaita KE, Márquez F, Coll C, Villlas MIL, Vila BS, Perna BA, Domínguezl DL, de Lera M, Foraster AC, Monge VAV, Bojaryn U, García FP, Benabdelhak I, Capdevila GM, Montesinos JS, Vázquez D, Hervás JV, González C, Quílez A, Pascual MV, Ruiz M, Riba Y, Villar MPG, García C, Roig XU, Mora MB, Guinjoan AP, Borras J, Martínez AM, Marés R, Viñas i Gaya J, Seró L, Flores A, Rodríguez DP, Castilho G, Ortega AM, Reverté S, Zaragoza J, Baiges JJ, Zaragoza J, Ozaeta GM, Escalante S, Belloch PE, Payo I, Salvado JS, Sala NM, Soler Insa JM, Vilamala ET, Navarro JA, Tabuenca HC, Sánchez TC, Ros M, Matos N, Roldán E, Rubiol EP, Franquet E, Fuentes L, Donaire J, Martí E, Giménez L, Vázquez JG, Ambrós ENCG, Rodríguez P, Oletta JF, Mellado PP, Catena, Gómez B, Raileau V, Ruíz EC, Pardina O, Mercadal J, López‐Diéguez M, Pérez P, Gabarró L, Orriols M, Molina JC, Canet JJ, Roca M, Álvaro M, Boneu F, Giménez G, Albà J, Gibert F, Garcia J, Barragan P, Jurado G, Pascual V, Ortega JS, Solano JAM, Fernández V, Torres M, Alvaredo ABM, Parejo LR, Aragonés JM, Bullón A, Loste C, González P, Bejarano N, Sanchez F, Lucchetti G, Pla X, Gimeno J, Reynaga E, Barcons M, Celedón G, Ortiz J, Anastasovski G, Mascaró O, de los Ríos JD, Feliu M, Ribera A, Ruiz C, Corominas G, Nunes DD, Roca C, Latorre N, Yataco L, Cruz M, Blanco N, Castejón S, Calderón DC, Sunyer CP, Garcia JE, Martin RP, de Luis Sanchez A, Vivas DE, Molina JV, Palome GP, Chaume LT, Vilella AV, Bustamante M, Boltes A, Rodríguez F, Arrieta I, Molist JC, Andreu B, Soler EP, Buscà NG, López MD, Farreres JB, Ruiz VC, Batiste DM, Cartagena MPS, de Vega EC, Real JB, Roman HP, Socolich C, Camp JMA, Orgaz ATC, Felip MPF, Morón N, Bacca S, Molina M, Casarramona F, Elias L, Bukaei MZ, Gutierrez JAM, Escuin JL, Olaizola C, Vargas YL, Oyonarte JJ, Soultana R, Golpe ES, Salvador E, Vila G, Serrano M, Claverol MNL, Lamolla M, Amate M, Rodriguez A, Romero R, del Carpio M, Hernandez AI, Martín J, Rosas MC, Nogueroles A, Encarnación S, Robles A, Herrera JA, Gavilán R, Mameghani T, Araujo G, Morales MAG, Segui ERA, Climent EF, Pujol FP, Seira MJG, Pía LG, Nuñez FS, Peñalver CA, Lopes CV, Tasa ER, Vilchez CR, Zambrana MS, Ribas BS, Panés IV, Planavila MV, Lorenzo AV, Guixes MS, Medina J, Sambrano D, Zamarreño J, Pirela C, Vélez P, Cajamarca L, Pérez H, Martínez Y, Gonçalves JA, Regordosa C, Mormeneo C, Griu L, Colina MF, Farik E, Duch DC, Badenas C, Bernal O, Agramunt N, Morales S, Reynoso V, Guerrero M, Cid PR, Folqué M, Pedroza C, Hachem A, Martínez ÍS, García XV, Amorós ML, Subirós XC, Benet MC, Eendenburg CV, Osuna T, Santos DG, Pallisera DM, Oliva LG, Sanchez DG, Basurto X, Vivoda L, Van der Kleyn R, Robles DL, Barranco AC, Almendros MC, Oliveras MP, Álvarez AF, Rybyeva M, Viñas A, Barcons M, Tavera JDA, Burbano P, López C, Cruz D, Bisbe P, Fernández N, Palacio JC, Fraiz E, Aguiló O, Amorodjo R, Velázquez J, Sánchez E, Español J, de Celis JP, Coll A, Díaz G, Vergés i Sala M, Capdevila MÁC, Ferrini YY, Gorriz A, Navarro DC, Velásquez D, Soler JP, González J, Higuera JD, Cuellar L, Miniello LM, Pujol L, Cracan S, Angela MVM, Anabel LL, Molist MG, Anna D, Muñoz SS, Yolanda F, Pujalte C, Marín ET, Casas YF, Luque SH, Sendra JM, Valero FM, Olga CE, Carles GDL, Enric LD, Paramio C, Xavier, Xavier CE, Jaime EM, Jordi CM, Antonio CA, Elena CNM, Lluis CRP, Anna DF, Pere FSJ, Ana FG, Antoni FBJ, Carlos GHJ, Sergio HP, Zulma IT, Rafael MR, Albert OG, Marta OC, Soledad QGM, RodriguezJavier R, Joaquin RS, Ramon RMJ, Pere SV, Jose SAM, Angeles SGM, Francisco TE, José TGP, Isabel VCM, Jose VLJ, Angeles LCM, Isaac LG, Arnulfo MAJ, Olga MF, Teresa SGM, Miquel TM, Mercedes VLM, Manuel PRJ, Marta RF, Dominica RT, Jose SG, Meritxell SG, Sheila AR, Falip AG, Vanessa AO, Stella BP, Miriam CM, Monica CF, Estefani CM, Nuria DM, Laura DM, Margarita FP, Sylvia FC, Georgina GT, del Mar GGA, de Jesus LAD, Pilar LS, Monica LV, Jordi MC, de la Cruz Raquel M, Arantxa MB, Marcos OO, Núria PS, Sergi PM, Carlos RGJ, Virginia RP, Anna SP, Mireia SV, Rossana SL, Judit TR, Anna TC, Maria VA, Teresa AGM, Silvia BV, Maria CGR, Antonio ECJ, Agusti EM, Helena GF, Sar HL, Sonia JD, Angel MGM, Pau OS, Noemi PF, Jesus SF, Carlos SAA, Giovanna TL, Sandra VH, Marta TG, Ada AV, Sonia AA, Laura AN, Mar AB, Cristina AM, Angels AO, Jeannette AC, Miriam AP, Vanessa ACM, Remedios AGE, Silvia AS, Izaskun AS, Nuria BG, Sergio BB, Teresa BT, Roser BP, Ariadna BP, Isabel BG, Nuria BS, Laia BA, Salvador CC, Arnau CC, Iren CM, Nuria CB, Daniel CF, Marc CS, Teresa CM, Cristina CB, Sandra CC, Borrego AJLC, Orri AC, Vilanova GC, Sole AC, Torres MC, Estepa NC, de Sostoa Graell M, del Rio Lopez L, Sandra BDC, Carmen DB, Lucia DMA, Carme DPM, Javier DCP, Laura DM, Khadija EA, Pau EM, David EC, Daniel FP, Sergi FQ, Sergio FE, Anna FA, del Valle Africa F, del Valle Mª Luisa F, Maria FQS, Teresa FRM, Rut GF, Alicia GG, Laura GC, Marina GR, Gemma C, Manuela GA, Xavier GG, Beatriz GF, Marta GG, Ricardo GG, Flor GL, Maria GO, Marta GB, Susana GR, Albert GE, Gemma HS, Dolça HC, Lluis HA, Marta HR, Paula IB, Alessandro I, Marta IC, Etxetxikia JU, Jordi JG, Rajaa KA, Gustavo LG, Anna LM, de Jesus LAD, Lourdes LMM, Aida LC, Monica LB, Laura LM, Cristian LR, Pedro LR, Tania LM, Ruth LM, Jessica LC, Alexia LN, Antonio MDJ, Morales MTP, Albert MC, Natanael MCD, David MG, Paula MG, Quesada M, Marzà Fusté Mireia CM, Marta ML, Jordi MM, Pastalle MP, Silvia MV, Emma MM, Christian MP, Olga MF, Helena MC, Mireia MV, Guillem MS, Aldara MQ, Natalia NR, Asuncion NIM, Pilar NMM, Judith OM, Roger PR, Xenia PT, Ivana PB, Anna PG, Mireia PO, Alejandra PRM, Raquel PY, Anna PM, Sergi PM, Alba PC, Lourdes QB, Cristina RB, Helena RF, del Carmen RGM, Joaquim RP, Inma RF, Amalia RF, Mariola RF, Raquel RM, Yolanda RN, Alicia RI, Albert RG, Silvia RB, de Eugenio Ramon R, Priscila RBARL, Julia SL, Carolina SJA, Daniel SS, Jordi SS, Marta SS, Enriqueta SP, Maria SB, Ruth SD, Ignacio TM, Cristina TV, Ines TSE, Soledad TT, Lluis TF, Marina TR, Anna TG, Nuria TE, Florenc U, Garazi VB, De la Paz Angel V, Fernando VG, Ingrit VG, Natalia VM, Eva VC, Jose VJM, Angela VF, Carla VG, Elisabeth VV, Jose CJF, Agusti GV, Albert GG, Laura JM, Jose MC, Felix MO, Jose MBM, Manuel ML, Jesus MRM, Carles MG, Ricardo MH, Eva MO, Ramon PP, Camilo PC, Antonio PAJ, Pol QM, Jordi RM, Sonia AA, Celia AA, Lorena AF, Joan BP, Laia BA, Francisco CV, Jaume CH, Gloria CGM, Gonzalo CM, Xavier CE, Enric CG, Montserrat CS, Carlos DS, Javier ER, del Mar ECM, Joaquin FA, Carlos FG, Patricia FP, Laura FE, Cristina FG, Marta GP, Ainhoa GG, Rafael HS, Dolça HC, Marta HR, Sonia JA, Pedro JR, Angeles LCM, Alejandro LL, Aleix LO, Rosa MRM, Daniel MM, Marta MM, Noelia ME, Olga MF, Sandra MJ, Matilde MR, Jessica NR, Maria NIR, Raquel NV, Alba PTM, Montserrat PVC, Alba PC, Angels RM, Alejandro RT, Merce RO, Mariola RF, Baltasar SG, Paola SP, Enriqueta SP, Cristina SB, Angeles SGM, Meritxell TF, Gemma TB, Jose TA, Agusti EM, Purificacion FM, Luis HP, Laura JM, Pedro LF, Alfonso LG, Felix MO, Jose MBM, Carles MG, Eva MO, Ricardo PL, Ramon PP, Joan QA, Miguel VL, Consuelo AD, Jeannette AC, Miguel AM, Anna AC, Raquel BG, Antonio BC, Del Mar CGM, Montserrat CO, Daniel CF, Marc CS, Isabel CMC, Alexander CB, Gloria CGM, Gonzalo CM, Sergio CC, Alexandre CO, Lidia CP, Rita CO, Carles DE, Javier DCP, del Mar ECM, Raquel FM, Luis GLP, Marta GP, Vallve GA, Manuela GA, Xavier GG, Carlos GM, Elena HV, Dolça HC, Cristina HG, Rafael MR, Marta MM, Daniel MM, Sergi MB, Xavier MP, Isabel MD, Maria MC, Pastalle MP, de la Cruz Raquel M, Olga MF, Javier MSF, Roger PR, Alba PTM, Feliciano PB, Monica PA, Cristina RB, Obed RP, Javier RPF, Mar RT, Sandra RP, Laura SS, Yolanda SM, Sheila SM, Eduardo SC, Soledad TT, Lluis TF, José TGP, Ricard TT, Narcis VD, Olga VE, Nuria VP, Andres BG, Marc BP, Cristina BS, Victor BA, Gemma BB, Estel BC, Alejandro CG, Esther CC, Sanchez CF, Toledo EJF, Roger ER, Xavier ERF, Mireia FS, Jordi GL, Daniel GL, Jorge HL, Alicia JLS, Joel LO, Samuel LY, Marta LV, Soto LS, Nicolas MC, Jesus MCD, Arich MP, Susana MS, Raul MM, Isabel MHM, Jose OFM, Bàrbara PB, Pedro PS, Judith RC, Marc RL, Verònica RL, Silvina RL, Gerard SC, Marc SL, Manel SR, Meritxell SG, Albert SC, Noemí SD, Gabriel SMG, Miquel TM, Maria VPA, Silvia VM, Salvat‐Plana M, Roig J, Hidalgo V, Vivanco‐Hidalgo RM, Gallofré M, Cobo E. Workflow times and outcomes in patients triaged for a suspected severe stroke. Ann Neurol 2022; 92:931-942. [DOI: 10.1002/ana.26489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/21/2022] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Álvaro García‐Tornel
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Laia Seró
- Department of Neurology Hospital Universitari Joan XXIII Tarragona Spain
| | | | - Pere Cardona
- Stroke Unit Hospital Universitari Bellvitge, L'Hospitalet de Llobregat Spain
| | - Josep Zaragoza
- Department of Neurology Hospital Verge de la Cinta Tortosa Spain
| | | | - Manuel Gómez‐Choco
- Department of Neurology Complex Hospitalari Hospital Moisés Broggi Sant Joan Despí Spain
| | - Natalia Mas Sala
- Department of Neurology Hospital Sant Joan de Déu ‐ Fundació Althaia Manresa Spain
| | - Esther Catena
- Department of Neurology Consorci Sanitari Alt Penedès‐Garraf Spain
| | | | - Joaquin Serena
- Stroke Unit Hospital Universitari Josep Trueta Girona Spain
| | | | - Sandra Boned
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Olivé‐Gadea
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Manuel Requena
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
- Department of Interventional Neurorradiology. Hospital Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Marian Muchada
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Alejandro Tomasello
- Department of Interventional Neurorradiology. Hospital Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Carlos A. Molina
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Mercè Salvat‐Plana
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS) CIBER Epidemiología y Salud Pública (CIBERESP) Barcelona Spain
| | | | | | - Antoni Davalos
- Stroke Unit Hospital Germans Trias i Pujol Badalona Barcelona Spain
| | - Tudor G Jovin
- Neurological Institute Cooper University Hospital Camden New Jersey
| | - Francesc Purroy
- Stroke Unit. Department of Neurology Hospital Universitari Arnau de Vilanova de Lleida Lleida Spain
| | - Sonia Abilleira
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS) CIBER Epidemiología y Salud Pública (CIBERESP) Barcelona Spain
| | - Marc Ribó
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
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Anderson CS, Song L, Liu J. Therapeutic Strategies for Intracranial Atherosclerosis. JAMA 2022; 328:529-531. [PMID: 35943482 DOI: 10.1001/jama.2022.11525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- The George Institute for Global Health, China, Beijing, China
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- The George Institute for Global Health, China, Beijing, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Navy Medical University, Shanghai, China
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Quan X, Han Y, Lu P, Ding Y, Wang Q, Li Y, Wei J, Huang Q, Wang R, Zhao Y. Annexin V-Modified Platelet-Biomimetic Nanomedicine for Targeted Therapy of Acute Ischemic Stroke. Adv Healthc Mater 2022; 11:e2200416. [PMID: 35708176 DOI: 10.1002/adhm.202200416] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/18/2022] [Indexed: 01/24/2023]
Abstract
Thromboembolic stroke is typically characterized by the activation of platelets, resulting in thrombus in the cerebral vascular system, leading to high morbidity and mortality globally. Intravenous thrombolysis by tissue plasminogen activator (tPA) administration within 4.5 h from the onset of symptoms is providing a standard therapeutic strategy for ischemic stroke, but this reagent simultaneously shows potential serious adverse effects, e.g., hemorrhagic transformation. Herein, a novel delivery platform based on Annexin V and platelet membrane is developed for tPA (APLT-PA) to enhance targeting efficiency, therapeutic effects, and reduce the risk of intracerebral hemorrhage in acute ischemic stroke. After preparation by extrusion of platelet membrane and subsequent insertion of Annexin V to liposomes, APLT-PA exhibits a high targeting efficiency to activated platelet in vitro and thrombosis site in vivo, due to the binding to phosphatidylserine (PS) and activated platelet membrane proteins. One dose of APLT-PA leads to obvious thrombolysis and significant improvement of neurological function within 7 days in mice with photochemically induced acute ischemic stroke. This study provides a novel, safe platelet-biomimetic nanomedicine for precise thrombolytic treatment of acute ischemic stroke, and offers new theories for the design and exploitation of cell-mimetic nanomedicine for diverse biomedical applications.
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Affiliation(s)
- Xingping Quan
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Yan Han
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Pengde Lu
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Yuanfu Ding
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Qingfu Wang
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Yiyang Li
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Jianwen Wei
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Qiaoxian Huang
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Ruibing Wang
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China.,Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Macau, Taipa, Macau SAR, 999078, P. R. China
| | - Yonghua Zhao
- Institute of Chinese Medical Sciences, State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Taipa, Macau SAR, 999078, P. R. China.,Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Macau, Taipa, Macau SAR, 999078, P. R. China
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Maas WJ, Lahr MMH, Uyttenboogaart M, Buskens E, van der Zee DJ. Expediting workflow in the acute stroke pathway for endovascular thrombectomy in the northern Netherlands: a simulation model. BMJ Open 2022; 12:e056415. [PMID: 35387821 PMCID: PMC8987797 DOI: 10.1136/bmjopen-2021-056415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The objective of this study is to identify barriers for the timely delivery of endovascular thrombectomy (EVT) and to investigate the effects of potential workflow improvements in the acute stroke pathway. DESIGN Hospital data prospectively collected in the MR CLEAN Registry were linked to emergency medical services data for each EVT patient and used to build two Monte Carlo simulation models. The 'mothership (MS) model', reflecting patients who arrived directly at the comprehensive stroke centre (CSC); and the 'drip and ship' (DS) model, reflecting patients who were transferred to the CSC from primary stroke centres (PSCs). SETTING Northern region of the Netherlands. One CSC provides EVT, and its catchment area includes eight PSCs. PARTICIPANTS 248 patients who were treated with EVT between July 2014 and November 2017. OUTCOME MEASURES The main outcome measures were total delay from stroke onset until groin puncture, functional independence at 90 days (modified Rankin Scale 0-2) and mortality. RESULTS Barriers identified included fast-track emergency department routing, prealert for transfer to the CSC, reduced handover time between PSC and ambulance, direct transfer from CSC arrival to angiography suite entry, and reducing time to groin puncture. Taken together, all workflow improvements could potentially reduce the time from onset to groin puncture by 59 min for the MS model and 61 min for the DS model. These improvements could thus result in more patients-3.7% MS and 7.4% DS-regaining functional independence after 90 days, in addition to decreasing mortality by 3.0% and 5.0%, respectively. CONCLUSIONS In our region, the proposed workflow improvements might reduce time to treatment by about 1 hour and increase the number of patients regaining functional independence by 6%. Simulation modelling is useful for assessing the potential effects of interventions aimed at reducing time from onset to EVT.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten M H Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Centre, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
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Eddelien HS, Butt JH, Christensen T, Danielsen AK, Kruuse C. Sex and Age Differences in Patient-Reported Acute Stroke Symptoms. Front Neurol 2022; 13:846690. [PMID: 35386418 PMCID: PMC8978710 DOI: 10.3389/fneur.2022.846690] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/11/2022] [Indexed: 11/20/2022] Open
Abstract
Background Identification of sex- and age-related differences in the presentation of atypical symptoms at stroke onset may reduce prehospital delay and improve stroke treatment if acknowledged at first contact. Aim To explore sex- and age-related differences in patient-reported typical and atypical symptoms of a stroke. Methods We used data from a cross-sectional survey at two non-comprehensive stroke units in the Capital Region of Denmark. Patient-reported symptoms, stroke knowledge, and behavioral response were analyzed by the Chi-square test or a Fisher's exact test separated by sex. Multivariable logistic regression adjusted for covariates were used to explore sex- and age-related differences according to each patient-reported typical or atypical symptoms. Results In total, 479 patients with acute stroke were included (median age 74 years [25th to 75th percentile: 64–80], and 40.1% were women). Female sex was associated with higher odds of presenting with atypical symptoms, such as loss of consciousness (OR 2.12 [95% CI 1.08–4.18]) and nausea/vomiting (OR 2.33 [95% CI 1.24–4.37]), and lower odds of presenting with lower extremity paresis (OR 0.59 [95% CI 0.39–0.89). With each year of age, the odds decreased of presenting with sensory changes (OR 0.95 [95% CI 0.94–0.97]) and upper extremity paresis (OR 0.98 [95% CI 0.96–0.99]), whereas odds of presenting with dysphagia (OR 1.06 [95% CI 1.02–1.11]) increased. Conclusions Patients of female sex and younger age reported on admission more frequently atypical stroke symptoms. Attention should be drawn to this possible atypical first presentation to facilitate correct identification and early stroke revascularization treatment to improve the outcome for both sexes.
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Affiliation(s)
- Heidi S. Eddelien
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Heidi S. Eddelien
| | - Jawad H. Butt
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Thomas Christensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Nordsjællands Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne K. Danielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gastroenterology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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21
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Satumanatpan N, Tonpho W, Thiraratananukulchai N, Chaichanamongkol P, Lekcharoen P, Thiankhaw K. Factors Associated with Unfavorable Functional Outcomes After Intravenous Thrombolysis in Patients with Acute Ischemic Stroke. Int J Gen Med 2022; 15:3363-3373. [PMID: 35368796 PMCID: PMC8964447 DOI: 10.2147/ijgm.s362116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose Intravenous thrombolysis (IVT) has become a standard treatment for eligible ischemic stroke patients. However, functional outcomes after receiving IVT varied widely. Hence the primary goal of this study is to identify characteristics related to poor outcomes. Patients and Methods The study enrolled acute ischemic stroke patients aged 18 or older who received IVT within 4.5 hours after onset between January 2018 and December 2020. The data were retrospectively collected from medical records. The patients were classified as having an excellent (0–2) or poor (3–6) outcomes based on the 90-day modified Rankin Scale (mRS). Univariable and multivariable logistic regression analyses were used to evaluate the results. The predictive model was determined and developed the score using regression coefficients. The prediction power was validated using the area under the receiver operating characteristic curve analysis. Results The study included 138 eligible participants. Forty-eight patients had unfavorable functional outcomes. With multivariable logistic regression analysis, factors significantly associated with poor outcomes were age (adjusted odds ratio (AOR), 1.03; 95% confidence interval (CI), 0.99–1.07; P = 0.05), diabetes (3.96; 1.61–9.37; P = 0.003), admission National Institute of Health Stroke Scale (NIHSS) (1.08; 1.01–1.15; P = 0.02) and initial Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (0.56; 0.37–0.86; P = 0.009). The predictive model developed from the findings demonstrated good discrimination power (AuROC 0.803, 95% CI 0.728–0.877). Conclusion The current study found that older age, diabetes, atrial fibrillation, higher admission NIHSS, and lower ASPECTS on the initial NCCT brain were related to unfavorable functional outcomes following IVT and served as good predictors of patient functional outcomes.
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Affiliation(s)
- Nat Satumanatpan
- Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Warinyupa Tonpho
- Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | | | | | | | - Kitti Thiankhaw
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- The Northern Neuroscience Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Correspondence: Kitti Thiankhaw, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Inthawaroros Road, Sriphum, Chiang Mai, 50200, Thailand, Tel +66 5393 5899, Fax +66 5393 5481, Email ;
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22
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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23
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Bulmer T, Volders D, Blake J, Kamal N. Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals. Front Neurol 2021; 12:746404. [PMID: 34777215 PMCID: PMC8586711 DOI: 10.3389/fneur.2021.746404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements. Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site. Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively. Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional and Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - John Blake
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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24
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Baskar PS, Chowdhury SZ, Bhaskar SMM. In-hospital systems interventions in acute stroke reperfusion therapy: a meta-analysis. Acta Neurol Scand 2021; 144:418-432. [PMID: 34101170 DOI: 10.1111/ane.13476] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The value of in-hospital systems-based interventions in streamlining treatment delays associated with reperfusion therapy delivery in acute ischaemic stroke (AIS), in the emergency department (ED), is poorly understood. This systematic review and meta-analysis aimed to assess and quantify the value of in-hospital systems-based interventions in streamlining reperfusion therapy delivery following AIS. MATERIAL & METHODS Articles from the following databases were retrieved: Medline, Embase and Cochrane Central Register of Controlled Trials. The primary endpoint was in-hospital time metrics between the intervention and control group. The secondary endpoint included the rate of good functional outcome at 90 days. RESULTS 393 Systems intervention studies published after 2015 were screened, and 231 full articles were then read. In total, 35 studies with 35,815 patients were included in the final systematic review and 26 studies with 7,089 patients were used in the meta-analysis. The greatest time reductions from in-hospital system interventions were achieved in door-to-needle (DTN) time (SMD: -2.696, 95% CI: -2.976, -2.416, z = 3.03, p = 0.002). Systems interventions were also associated with a statistically significant improvement in mortality (RR: 0.25, 95% CI: 0.18, 0.38), rate of symptomatic intracerebral haemorrhage (RR: 0.07, 95% CI: 0.04, 0.1) and ≤60-minute reperfusion rates (RR: 0.63, 95% CI: 0.51, 0.79). CONCLUSIONS The use of in-hospital workflow optimization is imperative to expedite reperfusion therapy delivery and improving patient outcomes. To reduce the morbidity and mortality of stroke globally, in-hospital workflow guidelines should be adhered to and incorporated including the optimal elements identified in this study.
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Affiliation(s)
- Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- Liverpool Hospital & South West Sydney Local Health District (SWSLHD) Department of Neurology & Neurophysiology Sydney NSW Australia
- Ingham Institute for Applied Medical Research Stroke & Neurology Research Group Sydney NSW Australia
- NSW Brain Clot Bank NSW Health Statewide Biobank and NSW Health Pathology Sydney NSW Australia
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25
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Goit RK, Ng TC, Tam KC, Tsang JKW, Taylor AW, Lo ACY. Neuropeptide α-Melanocyte-Stimulating Hormone Promotes Neurological Recovery and Repairs Cerebral Ischemia/Reperfusion Injury in Type 1 Diabetes. Neurochem Res 2021. [PMID: 34586586 DOI: 10.1007/s11064-021-03453-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022]
Abstract
Persons with type 1 diabetes have an increased risk of stroke compared with the general population. α-Melanocyte-stimulating hormone (α-MSH) is a neuropeptide that has protective effects against ischemia/reperfusion (I/R) induced organ damages. In this study, we aimed to investigate the neuroprotective role of this peptide on I/R induced brain damage after experimental stroke associated with hyperglycemia using C57BL/6J Ins2Akita/+ mice. Experimental stroke was induced by blocking the right middle cerebral artery for 2 h with reperfusion for 2 and 22 h, respectively using the intraluminal method. Animals were treated intraperitoneally with or without α-MSH at 1 h after ischemia and 1 h after reperfusion. Significantly higher survival rate and lower neurological scores were recorded in animals injected with α-MSH. Similarly, neuron death, glial cells activation as well as oxidative and nitrosative stress were significantly decreased in α-MSH treated group. Relative intensities of matrix metallopeptidases 9, cyclooxygenase 2 and nuclear factor-κB were significantly decreased while intensities of Akt, heme oxygenase (HO) 1, HO-2 and B-cell lymphoma 2 were significantly increased after α-MSH treatment. In addition, gene expressions of monocarboxylate transporter (MCT) 1, MCT-2 and activity-regulated cytoskeleton-associated protein were significantly higher in brain samples treated with α-MSH, suggesting this peptide may have role in neuron survival by an involvement of lactate metabolism. In conclusion, α-MSH is neuroprotective under hyperglycemic condition against I/R induced brain damage by its anti-inflammatory, anti-oxidative and anti-apoptotic properties. The use of α-MSH analogues may be potential therapeutic agents for diabetic stroke.
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26
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van Meenen LCC, den Hartog SJ, Groot AE, Emmer BJ, Smeekes MD, Siegers A, Kommer GJ, Majoie CBLM, Roos YBWEM, van Es ACGM, Dippel DW, van der Worp HB, Lingsma HF, Roozenbeek B, Coutinho JM. Relationship between primary stroke center volume and time to endovascular thrombectomy in acute ischemic stroke. Eur J Neurol 2021; 28:4031-4038. [PMID: 34528335 PMCID: PMC9292965 DOI: 10.1111/ene.15107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
Background and purpose We investigated whether the annual volume of patients with acute ischemic stroke referred from a primary stroke center (PSC) for endovascular treatment (EVT) is associated with treatment times and functional outcome. Methods We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) registry (2014–2017). We included patients with acute ischemic stroke of the anterior circulation who were transferred from a PSC to a comprehensive stroke center (CSC) for EVT. We examined the association between EVT referral volume of PSCs and treatment times and functional outcome using multivariable regression modeling. The main outcomes were time from arrival at the PSC to groin puncture (PSC‐door‐to‐groin time), adjusted for estimated ambulance travel times, time from arrival at the CSC to groin puncture (CSC‐door‐to‐groin time), and modified Rankin Scale (mRS) score at 90 days after stroke. Results Of the 3637 patients in the registry, 1541 patients (42%) from 65 PSCs were included. Mean age was 71 years (SD ± 13.3), median National Institutes of Health Stroke Scale score was 16 (interquartile range [IQR]: 12–19), and median time from stroke onset to arrival at the PSC was 53 min (IQR: 38–90). Eighty‐three percent had received intravenous thrombolysis. EVT referral volume was not associated with PSC‐door‐to‐groin time (adjusted coefficient: −0.49 min/annual referral, 95% confidence interval [CI]: −1.27 to 0.29), CSC‐door‐to‐groin time (adjusted coefficient: −0.34 min/annual referral, 95% CI: −0.69 to 0.01) or 90‐day mRS score (adjusted common odds ratio: 0.99, 95% CI: 0.96–1.01). Conclusions In patients transferred from a PSC for EVT, higher PSC volumes do not seem to translate into better workflow metrics or patient outcome.
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Affiliation(s)
- Laura C C van Meenen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Sanne J den Hartog
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands.,Department of Radiology & Nuclear Medicine, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - Adrien E Groot
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Martin D Smeekes
- Emergency Medical Services North-Holland North, Alkmaar, the Netherlands
| | | | - Geert Jan Kommer
- Center for Nutrition, Prevention, and Health Services, National Institute of Public Health and the Environment, Bilthoven, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederik W Dippel
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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27
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Butt JH, Kragholm K, Kruuse C, Christensen H, Iversen HK, Johnsen SP, Rørth R, Vinding NE, Yafasova A, Christiansen CB, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Workforce Attachment after Ischemic Stroke - The Importance of Time to Thrombolytic Therapy. J Stroke Cerebrovasc Dis 2021; 30:106031. [PMID: 34450481 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/23/2021] [Accepted: 08/01/2021] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVES The ability to remain in employment addresses an important consequence of stroke beyond the usual clinical parameters. However, data on the association between time to intravenous thrombolysis and workforce attachment in patients with acute ischemic stroke are sparse. MATERIALS AND METHODS In this nationwide cohort study, stroke patients of working age (18-60 years) treated with thrombolysis (2011-2016) who were part of the workforce prior to admission and alive at discharge were identified using the Danish Stroke Registry. The association between time to thrombolysis and workforce attachment one year later was examined with multivariable logistic regression. RESULTS The study population comprised 1,329 patients (median age 51 years [25th-75th percentile 45-56], 67.3% men). The median National Institutes of Health Stroke Scale score at presentation was 4 (25th-75th percentile 2-8), and the median time from symptom-onset to initiation of thrombolysis was 140min (25th-75th percentile 104-196min). The proportion of patients who were part of the workforce at one-year follow-up was 64.6%, 64.3%, 64.9%, and 60.0% in patients receiving thrombolysis within 90min, between 91-180min, between 181-270min, and after 270min, respectively. In adjusted analysis, time to thrombolysis between 91-180min, 181-270min, and >270min was not significantly associated with workforce attachment compared with thrombolysis received ≤90min of symptom-onset (ORs 0.89 [95%CI 0.60-1.31], 0.93 [0.66-1.31], and 0.80 [0.43-1.52], respectively). CONCLUSIONS In patients of working age admitted with stroke and treated with thrombolysis, two out of three were part of the workforce one year after discharge. There was no graded relationship between time to thrombolysis and the likelihood of workforce attachment.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark.
| | | | - Christina Kruuse
- Department of Neurology, Herlev-Gentofte University Hospital, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Denmark
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark
| | - Rasmus Rørth
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Naja Emborg Vinding
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Adelina Yafasova
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | | | - Gunnar H Gislason
- Department of Cardiology, Herlev-Gentofte University Hospital, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
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28
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Li S, Campbell BCV, Schwamm LH, Fisher M, Parsons M, Li H, Pan Y, Wang Y. Tenecteplase Reperfusion therapy in Acute ischaemic Cerebrovascular Events-II (TRACE II): rationale and design. Stroke Vasc Neurol 2021; 7:71-76. [PMID: 34446531 PMCID: PMC8899655 DOI: 10.1136/svn-2021-001074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/02/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND PURPOSE Tenecteplase (TNK) is a promising agent for treatment of acute ischaemic stroke (AIS). We hypothesised that recombinant human TNK tissue-type plasminogen activator (rhTNK-tPA) is non-inferior to rt-PA in achieving excellent functional outcome at 90 days, when administered within 4.5 hours of ischaemic stroke onset. METHODS AND DESIGN Tenecteplase Reperfusion therapy in Acute ischemic Cerebrovascular Events (TRACE) is a phase III, multicentre, prospective, randomised, open-label, blinded-end point non-inferiority study. Patients eligible for intravenous thrombolysis therapy are randomised to rhTNK-tPA 0.25 mg/kg (single bolus) to a maximum of 25 mg or rt-PA 0.9 mg/kg (10% bolus+90% infusion/1 hour) to a maximum of 90 mg. Medications considered necessary for the patient's health may be given at the discretion of the investigator during 90-day follow-up. STUDY OUTCOMES The primary study outcome is excellent functional outcome defined as modified Rankin Scale (mRS) 0-1 at 90 days. Secondary efficacy outcomes include favourable functional outcome defined as mRS ≤2 at 90 days, ordinal distribution of mRS and major neurological improvement on the National Institutes of Health Stroke Scale. Safety outcomes are symptomatic intracranial haemorrhage within 36 hours and death from any cause. DISCUSSION There is no completed registration study of TNK in AIS worldwide. TRACE II strives to provide evidence for a new drug application for rhTNK-tPA in AIS within 4.5 hours through a well-designed and rigorously executed randomised trial in China. TRIAL REGISTRATION NUMBER NCT04797013.
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Affiliation(s)
- Shuya Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C V Campbell
- Department of Medicine and Neurology, University of Melbourne, Melbourne, Victoria, Australia
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc Fisher
- Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mark Parsons
- Department of Neurology, Liverpool Hospital, South Western Sydney Clinical School, Sydney, New South Wales, Australia
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Karakus A, Girerd N, Sanchez JC, Sabben C, Wietrich A, Lavandier K, Marchal S, Aubertin A, Humbertjean L, Mione G, Bouali S, Duarte K, Reymond S, Gory B, Richard S. Identifying patients with cerebral infarction within the time window compatible with reperfusion therapy, diagnostic performance of glutathione S-transferase-π (GST-π) and peroxiredoxin 1 (PRDX1): exploratory prospective multicentre study FLAG-1 protocol. BMJ Open 2021; 11:e046167. [PMID: 34417212 PMCID: PMC8381327 DOI: 10.1136/bmjopen-2020-046167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Plasma biomarkers may be useful in diagnosing acute cerebral infarction requiring urgent reperfusion, but their performance remains to be confirmed. If confirmed, these molecules could be used to develop rapid and reliable decentralised measurement methods, making it possible to initiate reperfusion therapy before hospital admission. The FLAG-1 large prospective study will constitute a plasma bank to assess the diagnostic performance of two biomarkers: glutathione S-transferase-π and peroxiredoxin 1. These molecules are involved in the oxidative stress response and could identify cerebral infarction within a therapeutic window of less than 4.5 hours following the onset of symptoms. Secondary objectives include assessing performance of these biomarkers within 3-hour and 6-hour windows; identifying additional biomarkers diagnosing cerebral infarction and significant criteria guiding therapeutic decisions: ischaemic features of stroke, presence of diffusion/fluid-attenuated inversion recovery mismatch, volume of cerebral infarction and penumbra on cerebral MRI. METHODS AND ANALYSIS The exploratory, prospective, multicentre FLAG-1 Study will include 945 patients with acute stroke symptoms (onset ≤12 hours, National Institute of Health Stroke Scale score ≥3). Each patient's 25 mL blood sample will be associated with cerebral MRI data. Two patient groups will be defined based on the time of blood collection (before and after 4.5 hours following onset). Receiver operating characteristic analysis will determine the diagnostic performance of each biomarker, alone or in combination, for the identification of cerebral infarction <4.5 hours. ETHICS AND DISSEMINATION The protocol has been approved by an independent ethics committee. Biological samples are retained in line with best practices and procedures, in accordance with French legislation. Anonymised data and cerebral imaging records are stored using electronic case report forms and a secure server, respectively, registered with the French Data Protection Authority (Commission Nationale de l'Informatique et des Libertés (CNIL)). Results will be disseminated through scientific meetings and publication in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03364296).
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Affiliation(s)
- Arif Karakus
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
- University of Lorraine, Nancy, France
| | - Nicolas Girerd
- University of Lorraine, Nancy, France
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Jean-Charles Sanchez
- Department of Human Protein Sciences, University of Geneva Medical Centre, 1206 Geneva, Switzerland
| | | | - Anthony Wietrich
- Stroke Unit, Bar-le-Duc Hospital Centre, 55000 Bar-le-Duc, France
| | - Karine Lavandier
- Stroke Unit, Bar-le-Duc Hospital Centre, 55000 Bar-le-Duc, France
| | - Sophie Marchal
- Stroke Unit, Verdun Hospital Centre, 55100 Verdun, France
| | - Anne Aubertin
- Stroke Unit, Hospital Centre Troyes, CS 20718, 10003 Troyes, France
| | - Lisa Humbertjean
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
| | - Gioia Mione
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
| | - Sanae Bouali
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Kevin Duarte
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Sandrine Reymond
- Department of Human Protein Sciences, University of Geneva Medical Centre, 1206 Geneva, Switzerland
| | - Benjamin Gory
- University of Lorraine, Nancy, France
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, IADI, University Hospital Centre Nancy, 54035 Nancy, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
- University of Lorraine, Nancy, France
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
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30
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Holodinsky JK, Onaemo VN, Whelan R, Hunter G, Graham BR, Hamilton J, Schwartz L, Latta L, Peeling L, Kelly ME. Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan. BMJ Open Qual 2021; 10:bmjoq-2020-001214. [PMID: 34385186 PMCID: PMC8362703 DOI: 10.1136/bmjoq-2020-001214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/27/2021] [Indexed: 11/04/2022] Open
Abstract
Background For ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place. Methods A quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts. Results The number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre. Conclusions The implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.
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Affiliation(s)
- Jessalyn K Holodinsky
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vivian N Onaemo
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Ruth Whelan
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jessica Hamilton
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Schwartz
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Latta
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael E Kelly
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Eddelien HS, Butt JH, Amtoft AC, Nielsen NSK, Jensen ES, Danielsen IMK, Christensen T, Danielsen AK, Hornnes N, Kruuse C. Patient-reported factors associated with early arrival for stroke treatment. Brain Behav 2021; 11:e2225. [PMID: 34087953 PMCID: PMC8413799 DOI: 10.1002/brb3.2225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/29/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Timely evaluation and initiation of treatment is the key for improving stroke outcomes, although minimizing the time from symptom onset to the first contact with healthcare professionals remains a challenge. We aimed to identify patient-related factors associated with early hospital arrival. MATERIALS AND METHODS In this cross-sectional survey, we included patients with stroke or transient ischemic attack admitted directly to one of two noncomprehensive stroke units or transferred to the units from comprehensive stroke centers in the Capital Region of Denmark. Patient-reported factors associated with early hospital arrival were analyzed using multivariable logistic regression analysis adjusted for age, sex, education, living arrangement, brain location of the stroke, stroke severity, patient-perceived symptom severity, history of prior stroke, stroke risk factors, and knowledge of stroke symptoms. RESULTS In total, 479 patients with acute stroke were included (median age 74 (25th-75th percentile, 64-80), 40% women), of whom 46.4% arrived within 180 min of symptom onset. Factors associated with early hospital arrival were patients or bystanders choosing emergency medical service (EMS) for the first contact with a medical professional (adjusted odds ratio (OR), 3.41; 95% confidence interval, CI [1.57, 7.35]) or the patient's perceived symptom severity above the median score of 25 on a 100-point verbal scale (adjusted OR, 2.44; 95% CI [1.57, 3.82]). Living alone reduced the likelihood of early arrival (adjusted OR, 0.53; 95% CI [0.33, 0.86]). CONCLUSIONS Only when patients perceived symptoms as severe or when EMS was selected as the first contact, early arrival for stroke treatment was ensured.
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Affiliation(s)
- Heidi S Eddelien
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jawad H Butt
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - André C Amtoft
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nicholine S K Nielsen
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Emilie S Jensen
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ida M K Danielsen
- Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Christensen
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anne K Danielsen
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Gastroenterology, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nete Hornnes
- Department of Neurology, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Kruuse
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Yaghi S, Mistry E, de Havenon A, Leon Guerrero CR, Nouh A, Liberman AL, Giles J, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, Fakhri H, Brown Espaillat K, Asad SD, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Scher E, Trivedi T, Wu T, Khan M, Keyrouz S, Furie K, Henninger N. Effect of Alteplase Use on Outcomes in Patients With Atrial Fibrillation: Analysis of the Initiation of Anticoagulation After Cardioembolic Stroke Study. J Am Heart Assoc 2021; 10:e020945. [PMID: 34323120 PMCID: PMC8475683 DOI: 10.1161/jaha.121.020945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology Brown University Providence RI
| | - Eva Mistry
- Department of Neurology Vanderbilt University Nashville TN
| | - Adam de Havenon
- Department of Neurology University of Utah Salt Lake City UT
| | | | - Amre Nouh
- Department of Neurology Hartford Hospital Hartford CT
| | - Ava L Liberman
- Department of Neurology Montefiore Medical Center New York NY
| | - James Giles
- Department of Neurology Washington University Saint Louis MO
| | - Angela Liu
- Department of Neurology Washington University Saint Louis MO
| | - Muhammad Nagy
- Department of Neurology Hackensack Medical Center Hackensack NJ
| | | | - Idrees Azher
- Department of Neurology Brown University Providence RI
| | | | - Hiba Fakhri
- Department of Neurology Vanderbilt University Nashville TN
| | | | | | | | - Heather Martin
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Jose Tan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | | | - Charles Esenwa
- Department of Neurology Montefiore Medical Center New York NY
| | - Natalie Cheng
- Department of Neurology Montefiore Medical Center New York NY
| | | | | | - Mithilesh Siddu
- Department of Neurology George Washington University Washington DC
| | - Erica Scher
- Department of Neurology New York University New York NY
| | | | - Teddy Wu
- Department of Neurology Christchurch Hospital Christchurch New Zealand
| | - Muhib Khan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Salah Keyrouz
- Department of Neurology Washington University Saint Louis MO
| | - Karen Furie
- Department of Neurology Brown University Providence RI
| | - Nils Henninger
- Department of Neurology University of Massachusetts Worcester MA.,Department of Psychiatry University of Massachusetts Worcester MA
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Bandini F, Vestito L, Filippi L. Prehospital scales in acute ischaemic stroke management. Lancet Neurol 2021; 20:504. [PMID: 34146502 DOI: 10.1016/S1474-4422(21)00167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
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34
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Butt JH, Kruuse C, Kragholm K, Johnsen SP, Kristensen SL, Havers-Borgersen E, Yafasova A, Østergaard L, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Nursing Home Admission and Initiation of Domiciliary Care After Ischemic Stroke - The Importance of Time to Thrombolysis. J Stroke Cerebrovasc Dis 2021; 30:105916. [PMID: 34144336 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES There is a paucity of data on the risk of nursing home admission or domiciliary care initiation according to time to intravenous thrombolysis for ischemic stroke. We investigated the association between time to intravenous thrombolysis and the composite of nursing home admission or domiciliary care initiation in patients with acute ischemic stroke. MATERIALS AND METHODS In this nationwide cohort study, all stroke patients treated with intravenous thrombolysis (2011-2015) and alive at discharge were identified from the Danish Stroke Registry and other nationwide registries. The composite of nursing home admission or domiciliary care initiation one year post-discharge according to time to thrombolysis was examined with multivariable Cox regression. RESULTS The study population comprised 4,349 patients (median age 67 years [25th-75th percentile 57-75], 65.2% men). The median National Institutes of Health Stroke Scale score at presentation was 5, and the median time from symptom-onset to initiation of thrombolysis was 143 min. The absolute 1-year risk of the composite endpoint was 14.0% (95%CI, 11.5-16.8%) in the ≤90 min group, 16.6% (15.1-18.1%) in the 91-180min group, and 16.0% (14.0-18.2%) in the 181-270 min group. Compared with thrombolysis ≤90 min, time to thrombolysis between 91-180 min and 181-270 min was associated with a significantly higher risk of the composite endpoint (hazard ratio 1.31 [1.04-1.65] and 1.47 [1.14-1.91], respectively). CONCLUSIONS In patients admitted with ischemic stroke, increasing time to thrombolysis was associated with a greater risk of the composite of nursing home admission or domiciliary care initiation. Continued efforts to shorten the time delay from symptom-onset to initiation of thrombolysis are warranted.
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Almekhlafi MA, Goyal M, Dippel DWJ, Majoie CBLM, Campbell BCV, Muir KW, Demchuk AM, Bracard S, Guillemin F, Jovin TG, Mitchell P, White P, Hill MD, Brown S, Saver JL. Healthy Life-Year Costs of Treatment Speed From Arrival to Endovascular Thrombectomy in Patients With Ischemic Stroke: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials. JAMA Neurol 2021; 78:709-717. [PMID: 33938914 DOI: 10.1001/jamaneurol.2021.1055] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance The benefits of endovascular thrombectomy (EVT) are time dependent. Prior studies may have underestimated the time-benefit association because time of onset is imprecisely known. Objective To assess the lifetime outcomes associated with speed of endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion (LVO). Data Sources PubMed was searched for randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time, and for which a peer-reviewed, complete primary results article was published by August 1, 2020. Study Selection All randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time were included. Data Extraction/Synthesis Patient-level data regarding presenting clinical and imaging features and functional outcomes were pooled from the 7 retrieved randomized clinical trials of stent retriever thrombectomy devices (entirely or predominantly) vs medical therapy. All 7 identified trials published in a peer-reviewed journal (by August 1, 2020) contributed data. Detailed time metrics were collected including last known well-to-door (LKWTD) time; last known well/onset-to-puncture (LKWTP) time; last known well-to-reperfusion (LKWR) time; door-to-puncture (DTP) time; and door-to-reperfusion (DTR) time. Main Outcomes and Measures Change in healthy life-years measured as disability-adjusted life-years (DALYs). DALYs were calculated as the sum of years of life lost (YLL) owing to premature mortality and years of healthy life lost because of disability (YLD). Disability weights were assigned using the utility-weighted modified Rankin Scale. Age-specific life expectancies without stroke were calculated from 2017 US National Vital Statistics. Results Among the 781 EVT-treated patients, 406 (52.0%) were early-treated (LKWTP ≤4 hours) and 375 (48.0%) were late-treated (LKWTP >4-12 hours). In early-treated patients, LKWTD was 188 minutes (interquartile range, 151.3-214.8 minutes) and DTP 105 minutes (interquartile range, 76-135 minutes). Among the 298 of 380 (78.4%) patients with substantial reperfusion, median DTR time was 145.0 minutes (interquartile range, 111.5-185.5 minutes). Care process delays were associated with worse clinical outcomes in LKW-to-intervention intervals in early-treated patients and in door-to-intervention intervals in early-treated and late-treated patients, and not associated with LKWTD intervals, eg, in early-treated patients, for each 10-minute delay, healthy life-years lost were DTP 1.8 months vs LKWTD 0.0 months; P < .001. Considering granular time increments, the amount of healthy life-time lost associated with each 1 second of delay was DTP 2.2 hours and DTR 2.4 hours. Conclusions and Relevance In this study, care delays were associated with loss of healthy life-years in patients with acute ischemic stroke treated with EVT, particularly in the postarrival time period. The finding that every 1 second of delay was associated with loss of 2.2 hours of healthy life may encourage continuous quality improvement in door-to-treatment times.
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Affiliation(s)
- Mohammed A Almekhlafi
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Diederik W J Dippel
- Erasmus MC University Medical Center Depts of Neurology, Rotterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Université de Lorraine, Inserm, IADI, CHRU Nancy, Nancy, France
| | - Francis Guillemin
- CHRU-Nancy, INSERM, Université de Lorraine, CIC Clinical Epidemiology, Nancy, France
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden, New Jersey
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael D Hill
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Scott Brown
- Altair Biostatistics, St Louis Park, Minnesota
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
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Bulmer T, Volders D, Kamal N. Analysis of Thrombolysis Process for Acute Ischemic Stroke in Urban and Rural Hospitals in Nova Scotia Canada. Front Neurol 2021; 12:645228. [PMID: 33790851 PMCID: PMC8005571 DOI: 10.3389/fneur.2021.645228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/12/2021] [Indexed: 11/27/2022] Open
Abstract
Background: Stroke is a devastating disease, but it is treatable with alteplase or tissue plasminogen activator (tPA). The effectiveness of tPA is highly time-dependent, meaning rapid treatment is critical. Fast treatment with tPA has been reported in many urban hospitals, but hospitals in rural locations struggle to reduce treatment times. This qualitative study examines current thrombolysis processes in one urban and two rural hospitals in Nova Scotia, Canada, by mapping and comparing the treatment process in these settings for acute ischemic stroke (AIS) patients, and by analyzing the healthcare professionals views on various treatment topics. Methods: Structured interviews were conducted with healthcare professionals involved in stroke treatment across the three sites. The interviews focused on the various activities in the thrombolysis treatment at each site. Additionally, participants were asked about the following 10 topics: comfort treating acute ischemic stroke patients; perceptions about tPA; appropriate tPA treatment window; stroke patient priority; tPA availability; patient consent; urban-rural treatment differences; efficiency of their treatment process; treatment delays; and suggested process improvements. Results were analyzed using the Framework Method, as well as through the development of process maps. Results: Twenty three healthcare professionals were interviewed at 2 rural hospitals and 1 urban hospital. Acute ischemic stroke patients are triaged as the highest or urgent priority at each included site. Physicians are more hesitant to treat with tPA in rural settings. A total of 11 urban-rural treatment differences were noted by the rural sites. Additionally, 11 patient-related and 29 system treatment delays were described. A process map was developed for each site, representing the arrival by ambulance and by private vehicle pathways. Conclusions: Guidelines and clear protocols are critical in reducing treatment times and ensuring consistent access to treatment. The majority of treatment delays encountered are system delays, which can be appropriately planned for to reduce delays within the care pathway. There is a general consensus that there is an urban-rural treatment gap for acute ischemic stroke patients in Nova Scotia, and that continuing education is key in rural hospitals to improve Emergency Department (ED) physician comfort with treating patients with tPA.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional & Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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Yafasova A, Fosbøl EL, Johnsen SP, Kruuse C, Petersen JK, Alhakak A, Vinding NE, Torp-Pedersen C, Gislason GH, Køber L, Butt JH. Time to Thrombolysis and Long-Term Outcomes in Patients With Acute Ischemic Stroke: A Nationwide Study. Stroke 2021; 52:1724-1732. [PMID: 33657854 DOI: 10.1161/strokeaha.120.032837] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Adelina Yafasova
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark (S.P.J.)
| | - Christina Kruuse
- Department of Neurology, Herlev and Gentofte University Hospital, Denmark (C.K.).,University of Copenhagen, Institute of Clinical Medicine, Denmark (C.K.)
| | - Jeppe Kofoed Petersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Amna Alhakak
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Naja Emborg Vinding
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark (C.T.-P.).,Department of Cardiology, Aalborg University Hospital, Denmark (C.T.-P.)
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark (G.H.G.).,The Danish Heart Foundation, Copenhagen, Denmark (G.H.G.).,The National Institute of Public Health, University of Southern Denmark, Odense, Denmark (G.H.G.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
| | - Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.Y., E.L.F., J.K.P., A.A., N.E.V., L.K., J.H.B.)
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Yu AYX, Hill MD. Designing Health Systems to Optimize Endovascular Thrombectomy in the Population. Stroke 2021; 52:1030-1032. [PMID: 33535777 DOI: 10.1161/strokeaha.120.033601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amy Y X Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, ON, Canada (A.Y.X.Y.)
| | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine and Radiology; Hotchkiss Brain Institute, University of Calgary and Foothills Medical Centre, AB, Canada (M.D.H.)
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Zhu F, Gauberti M, Marnat G, Bourcier R, Kyheng M, Labreuche J, Sibon I, Dargazanli C, Arquizan C, Anxionnat R, Audibert G, Mazighi M, Blanc R, Lapergue B, Consoli A, Richard S, Gory B. Time from I.V. Thrombolysis to Thrombectomy and Outcome in Acute Ischemic Stroke. Ann Neurol 2020; 89:511-519. [PMID: 33274475 DOI: 10.1002/ana.25978] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Whether the time from intravenous thrombolysis (IVT) to endovascular treatment (EVT) in patients with acute ischemic stroke has an effect on the functional outcome is unknown. METHODS The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, multicenter, observational study that perform EVT in France. Data were analyzed from patients treated by IVT and EVT between October 2013 and December 2018 in 6 comprehensive stroke centers. In the primary analysis, we assessed the association of time from IVT administration to start of EVT with functional outcome (measured with the modified Rankin Scale [mRS]), by means of ordinal logistic regression. Secondary end points included angiographic and safety outcomes. RESULTS We analyzed 1,986 patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent IVT and EVT. An increased IVT to start of EVT time was associated with a worse functional outcome at 90 days (mRS = 0-2, adjusted odds ratio [OR] per 30 minutes increase in time = 0.91, 95% confidence interval [CI] = 0.86-0.96; mRS = 0-1, adjusted OR per 30 minutes increase in time = 0.89, 95% CI = 0.84-0.94), a lower chance of modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b to 3 reperfusion (adjusted OR per 30 minutes increase in time = 0.93, 95% CI = 0.87-0.98), and an increased probability of symptomatic intracerebral hemorrhage (adjusted OR per 30 minutes increase in time = 1.09, 95% CI = 0.99-1.18). INTERPRETATION These findings provide a basis for further studies to determine if the functional outcome of patients with stroke can be greatly improved by optimizing IVT to EVT times. ANN NEUROL 2021;89:511-519.
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Affiliation(s)
- François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, Nancy, France
| | - Maxime Gauberti
- Unité Mixte de Recherche-S U1237, "Physiopathology and Imaging for Neurological Disorders," Institut National de la Santé et de la Recherche Médicale, Université de Caen Normandie, Caen, France.,Department of Diagnostic Imaging and Interventional Radiology, CHU Caen Côte de Nacre, Caen, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Maéva Kyheng
- CHU Lille, EA 2694, Santé Publique: épidémiologie et Qualité des Soins, University Lille, Lille, France
| | - Julien Labreuche
- CHU Lille, EA 2694, Santé Publique: épidémiologie et Qualité des Soins, University Lille, Lille, France
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Stroke Unit, CHRU Gui de Chauliac, Montpellier, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, Nancy, France
| | - Gérard Audibert
- Department of Anesthesiology and Surgical Intensive Care, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, Stroke Unit, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, Université de Lorraine, Nancy, France.,INSERM U1116, CHRU-Nancy, CIC-P 1433, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, Nancy, France
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Wang Y, Wu X, Zhu C, Mossa-Basha M, Malhotra A. Bridging Thrombolysis Achieved Better Outcomes Than Direct Thrombectomy After Large Vessel Occlusion: An Updated Meta-Analysis. Stroke 2020; 52:356-365. [PMID: 33302795 DOI: 10.1161/strokeaha.120.031477] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The utility and necessity of pretreatment with intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains an issue of strong debate. This study aims to compare the outcomes of bridging thrombolysis (BT, IVT+MT) with direct MT (d-MT) after large vessel ischemic stroke based on the most up-to-date evidence. MEDLINE, EMBASE, Scopus, and the Cochrane Library from January 2017 to June 2020 were searched for studies that directly compared the outcomes of the 2 strategies. Methodological quality was assessed using the Quality in Prognostic Studies tool. Combined estimates of odds ratios (ORs) of BT versus d-MT were derived. Multiple subgroup analyses were performed, especially for IVT-eligible patients. Thirty studies involving 7191 patients in the BT group and 4891 patients in the d-MT group were included. Methodological quality was generally high. Compared with patients in the d-MT group, patients in the BT group showed significantly better functional independence (modified Rankin Scale score 0-2) at 90 days (OR=1.43 [95% CI, 1.28-1.61]), had lower mortality at 90 days (OR=0.67 [95% CI, 0.60-0.75]), and achieved higher successful recanalization (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate (OR=1.23 [95% CI, 1.07-1.42]). No significant difference was detected in the occurrence of symptomatic intracranial hemorrhage between 2 groups (OR=1.01 [95% CI, 0.86-1.19]). Subgroup analysis showed that functional independence frequency remained significantly higher in BT group regardless of IVT eligibility or study design. Compared with d-MT, bridging with IVT led to better clinical outcomes, lower mortality at 90 days, and higher successful recanalization rates, without increasing the risk of near-term hemorrhagic complications. The benefits of BT based on this most recent literature evidence support the current guidelines of using BT.
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Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu (Y.W.)
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California, San Francisco (X.W.)
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine and Yale University, New Haven, CT (A.M.)
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Tork MA, Aref HM, El-khawas HM, Khalil MF, Elsadek A. Outcome predictors of intravenous thrombolytic therapy in acute ischemic stroke patients: an Egyptian center experiences. Egypt J Neurol Psychiatry Neurosurg 2020; 56. [DOI: 10.1186/s41983-020-00229-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intravenous thrombolytic therapy remains the guideline-recommended treatment to improve outcomes after acute ischemic stroke. However, the functional outcome among patients with acute ischemic stroke after receiving intravenous thrombolytic therapy is influenced by huge variety of factors, and this was the aim of our study to evaluate the outcome predictors of intravenous thrombolytic therapy in a sample of Egyptian patients with acute ischemic stroke.
Methods
We enrolled 183 acute ischemic stroke patients who were treated with intravenous recombinant tissue plasminogen activator (IV rtPA) according to the last updated guidelines of American Heart Association and American Stroke Association (AHA/ASA) from February 2018 to February 2020; however, only 150 patients of them completed our study plan till the end. Data of study variables were collected, analyzed statistically and correlated with the functional outcome 3 months after receiving IV rtPA using the modified Rankin Scale (mRS).
Results
Good functional outcome was seen in 98 (65.3%) patients and poor functional outcome was seen in 52 (34.7%) patients. Multivariate analysis of the study variables was done to detect the significant independent predictors of the functional outcome. Atrial fibrillation (AF) (P value < 0.001*OR 6.28* (95% C.I)), hypertension (P value 0.001*OR 3.65*(95% C.I)), diabetes mellitus (DM) (P value 0.009*OR 2.805*(95% C.I)), increased National Institute of Health Stroke Scale (NIHSS) score 24 h after receiving IV rtPA (P value 0.003* OR 8.039* (95% C.I)), increased pulsatility index (PI) value in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of poor functional outcome. On the other hand decreased NIHSS score 24 h after receiving IV rtPA (P value 0.003* OR 0.124*(95% C.I)), Normal value of PI in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of good functional outcome.
Conclusion
Intravenous thrombolytic therapy improves the functional outcome of acute ischemic stroke patients. Also, AF, hypertension, DM, NIHSS 24 h after receiving IV rtPA and PI could be used as independent predictors of the functional outcome.
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42
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Ospel JM, Singh N, Almekhlafi MA, Menon BK, Butt A, Poppe AY, Jadhav A, Silver FL, Shah R, Dowlatshahi D, O'Hare AM, Demchuk AM, Goyal M, Hill MD. Early Recanalization With Alteplase in Stroke Because of Large Vessel Occlusion in the ESCAPE Trial. Stroke 2020; 52:304-307. [PMID: 33213288 DOI: 10.1161/strokeaha.120.031591] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Quantitating the effect of intravenous alteplase on the technical outcome of early recanalization of large vessel occlusions aids understanding. We report the prevalence of early recanalization in patients with stroke because of large vessel occlusion treated with and without intravenous alteplase and endovascular thrombectomy, and its association with clinical outcome. METHODS Patients with acute ischemic stroke with large vessel occlusion from the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times Trial) were included in this post hoc analysis. Outcomes of interest were the prevalence of early recanalization (1) and good outcome (2), defined as modified Rankin Scale score of 0 to 2 at 90 days. RESULTS Among 147 patients who did not receive endovascular thrombectomy, early recanalization occurred in 4/30 (13.3%) patients without and 48/117 (41.0%) patients with intravenous alteplase (adjusted risk ratios, 3.2 [95% CI, 1.2-8.1]). Good outcome was achieved by 34/116 (29.3%) of patients who received intravenous alteplase versus 10/29 (34.5%) who did not receive alteplase (adjusted risk ratios, 1.0 [95% CI, 0.6-1.5) and by 20/52 (38.5%) patients with versus 24/93 (25.8%) without early recanalization (adjusted risk ratios, 1.9 [95% CI, 1.2-2.9]). CONCLUSIONS Early recanalization was confirmed as a strong predictor of good outcome in patients who did not undergo endovascular thrombectomy and was improved with intravenous alteplase, yet a majority of patients (59.0%) did not achieve early reperfusion. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01778335.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
| | - Nishita Singh
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Asif Butt
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada (A.B.)
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Centre Hospitalier de l'Université de Montréal, Montréal, Canada (A.Y.P.)
| | - Ashutov Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.J.)
| | - Frank L Silver
- Department of Medicine (Neurology), Toronto Western Hospital, University Health Network, Canada (F.L.S.)
| | - Ruchir Shah
- Erlanger Medical Centre (Neurosciences), Chattanooga, TN (R.S.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa, Canada (D.D.)
| | - Alan M O'Hare
- Department of Radiology (Neuroradiology), Beaumont Hospital, Dublin, Ireland (A.M.O.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Department of Medicine (M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
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Maas WJ, Lahr MMH, Buskens E, van der Zee DJ, Uyttenboogaart M. Pathway Design for Acute Stroke Care in the Era of Endovascular Thrombectomy: A Critical Overview of Optimization Efforts. Stroke 2020; 51:3452-3460. [PMID: 33070713 DOI: 10.1161/strokeaha.120.030392] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The efficacy of intravenous thrombolysis and endovascular thrombectomy (EVT) for acute ischemic stroke is highly time dependent. Optimal organization of acute stroke care is therefore important to reduce treatment delays but has become more complex after the introduction of EVT as regular treatment for large vessel occlusions. There is no singular optimal organizational model that can be generalized to different geographic regions worldwide. Current dominant organizational models for EVT include the drip-and-ship- and mothership model. Guidelines recommend routing of suspected patients with stroke to the nearest intravenous thrombolysis capable facility; however, the choice of routing to a certain model should depend on regional stroke service organization and individual patient characteristics. In general, design approaches for organizing stroke care are required, in which 2 key strategies could be considered. The first entails the identification of interventions within existing organizational models for optimizing timely delivery of intravenous thrombolysis and/or EVT. This includes adaptive patient routing toward a comprehensive stroke center, which focuses particularly on prehospital triage tools; bringing intravenous thrombolysis or EVT to the location of the patient; and expediting services and processes along the stroke pathway. The second strategy is to develop analytical or simulation model-based approaches enabling the design and evaluation of organizational models before their implementation. Organizational models for acute stroke care need to take regional and patient characteristics into account and can most efficiently be assessed and optimized through the application of model-based approaches.
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Affiliation(s)
- Willemijn J Maas
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, Health Technology Assessment unit (W.J.M., M.M.H.L., E.B.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, the Netherlands (E.B., D.-J.v.d.Z.)
| | - Maarten Uyttenboogaart
- Department of Neurology (W.J.M., M.U.), University of Groningen, University Medical Center Groningen, the Netherlands.,Department of Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands
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Affiliation(s)
- Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Greece (G.T.)
- Department of Neurology, University of Tennessee HealthCare Center, Memphis (G.T.)
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45
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Heck D. Patients Transferred for Endovascular Stroke Therapy Do Worse: What Do We Do About It? JACC Cardiovasc Interv 2020; 13:2167-9. [PMID: 32861628 DOI: 10.1016/j.jcin.2020.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 11/20/2022]
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46
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Siegler JE, Jovin TG. Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tsivgoulis G, Goyal N, Katsanos AH, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Magoufis G, Psychogios K, Lioutas VA, Van Nostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Mitsias PD, Inoa V, Hoit D, Elijovich L, Arthur AS, Alexandrov AV. Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity. Eur J Neurol 2020; 27:1039-1047. [PMID: 32149450 DOI: 10.1111/ene.14199] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.
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Affiliation(s)
- G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - K Malhotra
- Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA
| | - M F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA
| | - A M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - V Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - M Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - P D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - M Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - D Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - M Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neurology, Hamad General Hospital, Doha, Qatar
| | - P Garcia-Bermejo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - K Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - V A Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Van Nostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - V K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, National University Hospital, Singapore, Singapore
| | - M Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - A Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - C Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - P D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece
| | - V Inoa
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - D Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - L Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Sharobeam A, Jones B, Walton-Sonda D, Lueck CJ. Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2021; 268:2723-34. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
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Feil K, Reidler P, Kunz WG, Küpper C, Heinrich J, Laub C, Müller K, Vöglein J, Liebig T, Dieterich M, Kellert L. Addressing a real-life problem: treatment with intravenous thrombolysis and mechanical thrombectomy in acute stroke patients with an extended time window beyond 4.5 h based on computed tomography perfusion imaging. Eur J Neurol 2019; 27:168-174. [PMID: 31349393 DOI: 10.1111/ene.14051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/22/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke treatment with intravenous thrombolysis (IVT) is restricted to a time window of 4.5 h after known or presumed onset. Recently, magnetic resonance imaging-guided treatment decision-making in wake-up stroke (WUS) was shown to be effective. The aim of this study was to determine the safety and outcome of IVT in patients with a time window beyond 4.5 h selected by computed tomography perfusion (CTP) imaging. METHODS We analyzed all consecutive patients last seen well beyond 4.5 h after stroke onset treated with IVT based on CTP between January 2015 and October 2018. CTP was visually assessed to estimate the mismatch between cerebral blood flow and cerebral blood volume maps. Early infarct signs were documented according to Alberta Stroke Program Early CT Score (ASPECTS). Safety data were obtained for mortality and symptomatic intracerebral hemorrhage (sICH). Follow-up was assessed with the modified Rankin Scale (mRS). RESULTS A total of 70 patients fulfilled the inclusion criteria (mean age ± SD 77.6 ± 11.5 years, 50.0% female). Median National Institutes of Health Stroke Scale score on admission was 8.0 [interquartile range (IQR), 4-14]. The most frequent reasons for an extended time window were WUS (60.0%) and delayed hospital admission (27.1%). Median time from last seen well to IVT was 11.4 h. Median ASPECTS was 10 (IQR, 9-10) and CTP mismatch 90% (IQR, 80%-100%). A total of 24 patients (34.3%) underwent additional mechanical thrombectomy. sICH occurred in four patients (5.7%). At follow-up, 49.3% had an mRS score of 0-2 and 22.4% had an mRS score of 0-1. CONCLUSIONS In patients presenting in an extended time window beyond 4.5 h, IVT treatment with decision-making based on CTP might be a safe procedure. Further evaluation in clinical trials is needed.
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Affiliation(s)
- K Feil
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - P Reidler
- Department of Radiology, Ludwig Maximilian University, Munich, Germany
| | - W G Kunz
- Department of Radiology, Ludwig Maximilian University, Munich, Germany
| | - C Küpper
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - J Heinrich
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - C Laub
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - K Müller
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - J Vöglein
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Neurodegenerative Diseases, Munich, Germany
| | - T Liebig
- Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany
| | - M Dieterich
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - L Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
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