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Anees A, Panicker P, Iype T, Sreelekha KR. Assessment of onset-to-door time in acute ischemic stroke and factors associated with delay at a tertiary care center in South India. J Neurosci Rural Pract 2024; 15:86-94. [PMID: 38476422 PMCID: PMC10927050 DOI: 10.25259/jnrp_325_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/26/2023] [Indexed: 03/14/2024] Open
Abstract
Objectives Intravenous thrombolysis is an effective treatment of acute ischemic stroke but has a narrow therapeutic time window of 3-4.5 h. Pre-hospital delay is a major barrier to patients becoming eligible for thrombolysis. This single-center study assessed the factors causing longer onset-to-door (OTD) time to identify measures that will help decrease the delay. Materials and Methods Patients with acute ischemic stroke presenting to the emergency department from August to October 2022 were included in the study. The data were collected using a structured questionnaire and was completed by interviewing the patient or the caregivers. Patients were classified as early and late arrivers with the cutoff being 3.5 h. We then analyzed the relationship between early arrival and demographic factors, clinical factors, patient response factors, and logistic factors. Results Our study consisted of 153 patients. The average OTD time was 674.33 ± 812.713 min (median: 300; interquartile range: 151-885). The pre-hospital delay was present in 66% of patients. 16.9% of patients came beyond 24 h. In the multivariate analysis, the odds of early arrival were higher among patients who perceived their symptoms as serious (odds ratio [OR]: 18.801; confidence interval [CI]: 3.728-94.803) and lower among patients who experienced a delay in reaching due to traffic (OR: 0.085; CI: 0.008-0.873). Lack of knowledge about stroke centers among both patients and health professionals also contributed to longer OTD times. Out of 52 early arrivers, 24 received thrombolytic therapy after excluding wake-up strokes and contraindications. Conclusion Pre-hospital delay continues to stand in the way of patients receiving thrombolysis. Comprehensive stroke education, increasing awareness regarding stroke centers, and promoting ambulance services are some of the interventions which could help tackle the issue.
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Affiliation(s)
- Ashika Anees
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - Praveen Panicker
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - Thomas Iype
- Department of Neurology, Government Medical College Thiruvananthapuram, Kerala, India
| | - K. R. Sreelekha
- Department of Community Medicine, Government Medical College Thiruvananthapuram, Kerala, India
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Ardila Jurado E, Sturm V, Brugger F, Nedeltchev K, Arnold M, Bonati LH, Carrera E, Michel P, Cereda CW, Bolognese M, Albert S, Medlin F, Berger C, Schelosky L, Renaud S, Niederhauser J, Bonvin C, Mono ML, Rodic B, Tarnutzer AA, Schwegler G, Salmen S, Luft AR, Peters N, Vehoff J, Kägi G. Central Retinal Artery Occlusion: Current Practice, Awareness and Prehospital Delays in Switzerland. Front Neurol 2022; 13:888456. [PMID: 35677327 PMCID: PMC9167925 DOI: 10.3389/fneur.2022.888456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Central retinal artery occlusion (CRAO) often leads to permanent monocular blindness. Hence, early recognition and rapid re-perfusion is of paramount importance. This study aims to describe prehospital pathways in CRAO compared to stroke and study the knowledge about CRAO. Methods (1) Description of baseline characteristics, prehospital pathways/delays, and acute treatment (thrombolysis/thrombectomy vs. standard of care) of patients with CRAO and ischemic stroke registered in the Swiss Stroke Registry. (2) Online survey about CRAO knowledge amongst population, general practitioners (GPs) and ophthalmologists in Eastern Switzerland. Results Three hundred and ninety seven CRAO and 32,816 ischemic stroke cases were registered from 2014 until 2019 in 20 Stroke Centers/Units in Switzerland. In CRAO, 25.6% arrived at the hospital within 4 h of symptom onset and had a lower rate of emergency referrals. Hence, the symptom-to-door time was significantly longer in CRAO compared to stroke (852 min. vs. 300 min). The thrombolysis/thrombectomy rate was 13.2% in CRAO and 30.9% in stroke. 28.6% of the surveyed population recognized CRAO-symptoms, 55.4% of which would present directly to the emergency department in contrast to 90.0% with stroke symptoms. Almost 100% of the ophthalmologist and general practitioners recognized CRAO as a medical emergency and 1/3 of them considered IV thrombolysis a potentially beneficial therapy. Conclusions CRAO awareness of the general population and physician awareness about the treatment options as well as the non-standardized prehospital organization, seems to be the main reason for the prehospital delays and impedes treating CRAO patients. Educational efforts should be undertaken to improve awareness about CRAO.
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Affiliation(s)
- Elena Ardila Jurado
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Veit Sturm
- Department of Ophthalmology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Florian Brugger
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Leo H. Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlo W. Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | | | | | | | | | - Ludwig Schelosky
- Division of Neurology, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Susanne Renaud
- Division of Neurology, Cantonal Hospital Neuchatel, Neuchâtel, Switzerland
| | | | | | | | - Biljana Rodic
- Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Guido Schwegler
- Division of Neurology, Hospital Limmattal, Schlieren, Switzerland
| | | | - Andreas R. Luft
- Department of Neurology and Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitaiton, Vitznau, Switzerland
| | - Nils Peters
- Department of Neurology, Hirslanden Clinic, Zurich, Switzerland
| | - Jochen Vehoff
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Georg Kägi
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- *Correspondence: Georg Kägi
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Chang T, Ibrahim S, Ranasinghe HM, Mihirini AHTM, Weerasinghe D, Vithanage TDP, Banagala C, Arambepola C. Knowledge of Stroke, Its Warning Symptoms, Risk Factors and Treatment among the General Public and General Practitioners in a South Asian Population. J Stroke Cerebrovasc Dis 2020; 29:104760. [PMID: 32173224 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104760] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND An adequate stroke literacy among the general public and first-contact physicians is an essential prerequisite to ensure timely treatment and prevention of stroke. Knowledge on stroke pathophysiology, warning symptoms, risk factors and treatment, and its determinants was assessed among general public and general practitioners (GPs) in a South Asian population. METHODS A cross-sectional study was conducted among relatives of nonstroke patients admitted to the apex tertiary-care hospital in Sri Lanka. Trained doctors administered pretested, structured, open- and close-ended questionnaires. A postal survey using self-administered questionnaires was conducted among all registered GPs in Sri Lanka. RESULTS The sample of general public (51.7% males; mean age = 40.7 years) from 21 of 25 districts of Sri Lanka was 840 (response-rate = 97.4%) while the sample of GPs (77.6% males; mean age = 59.63 years) was 98 (response-rate = 30%). Of the general public, 83.2% were aware of a vascular aetiology of stroke, but only 46.8% were aware that the affected organ was the brain while 67.5% believed that either the heart or limb muscles die as sequalae of stroke. Over 50% correctly identified stroke warning symptoms while 84.7% would seek immediate Western medical treatment. Approximately, 32%-46% were not aware of the major stroke risk factors. Lower education (adj. OR = 1.7; 95% CI = 1.3-2.3), absence of stroke risk factors (2.6; 1.9-3.7) and nonutility of information sources (1.5; 1.0-2.0) determined poor knowledge on risk factors. Only about 1 in 8 GPs accurately defined stroke and TIA while only 43.9% correctly classified stroke subtypes. Only 1 in 10 GPs were aware of the recommended therapeutic window for thrombolysis. Older age (P = 0.01) and longer service (P = 0.04) of GPs were associated with not requesting brain imaging in stroke. CONCLUSIONS Strategies to educate both the public and first-contact physicians to improve stroke literacy need to be an integral part of programmes that aim to reduce the burden of stroke in any population.
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Affiliation(s)
- Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - Shiyana Ibrahim
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Hasanthika M Ranasinghe
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - A H T M Mihirini
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Dinushi Weerasinghe
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - T D P Vithanage
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Chinthaka Banagala
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Scott PA, Meurer WJ, Frederiksen SM, Kalbfleisch JD, Xu Z, Haan MN, Silbergleit R, Morgenstern LB. A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial. Lancet Neurol 2012; 12:139-48. [PMID: 23260188 DOI: 10.1016/s1474-4422(12)70311-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of alteplase improves outcome in some patients with stroke. Several types of barrier frequently prevent its use. We assessed whether a standardised, barrier-assessment, multicomponent intervention could increase alteplase use in community hospitals in Michigan, USA. METHODS In a cluster-randomised controlled trial, we selected adult, non-specialty, acute-care community hospitals in the Lower Peninsula of Michigan, USA. Eligible hospitals discharged at least 100 patients who had had a stroke per year, had less than 100 000 visits to the emergency department per year, and were not academic comprehensive stroke centres. Using a computer-generated randomisation sequence, we selected 12 matched pairs of eligible hospitals. Within pairs, the hospitals were allocated to intervention or control groups with restricted randomisation in January, 2007. Between January, 2007, and December, 2007, intervention hospitals implemented a multicomponent intervention that included qualitative and quantitative assessment of barriers to alteplase use and ways to address the findings, and provided additional support. The primary outcome was change in alteplase use in patients with stroke in emergency departments between the pre-intervention period (January, 2005, to December, 2006) and the post-intervention period (January, 2008, to January, 2010). Physicians in participating hospitals and the coordinating centre could not be masked to group assignment, but were masked to progress made in paired control hospitals. External medical reviewers who were masked to group assignment assessed outcomes. We did intention-to-treat (ITT) and target-population (without one pair that was excluded after randomisation) analyses. This trial is registered at ClinicalTrials.gov, number NCT00349479. FINDINGS All 24 hospitals completed the study. Overall, 745 of 40 823 patients with stroke received intravenous alteplase treatment. In the ITT analysis, the proportion of patients with stroke who were admitted and treated with alteplase increased between the pre-intervention and post-intervention periods in intervention hospitals (89 [1·25%] of 7119 patients to 235 [2·79%] of 8419) to a greater extent than in control hospitals (99 [1·25%] of 7946 to 194 [2·10%] of 9222), but the difference between groups was not significant (relative risk [RR] 1·37, 95% CI 0·96-1·93; p=0·08). In the target-population analysis, the increase in alteplase use in intervention hospitals (59 [1·00%] of 5882 to 191 [2·62%] of 7288) was significantly greater than in control hospitals (65 [1·09%] of 5957 to 120 [1·72%] of 6989; RR 1·68, 95% CI 1·09-2·57; p=0·02), but was still clinically modest. INTERPRETATION The intervention did not significantly increase alteplase use in patients with ischaemic stroke. The increase in use of alteplase in the target population was significant, but smaller than the effect to which the study was powered. Additional strategies to increase acute stroke treatment are needed. FUNDING National Institutes of Health National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Phillip A Scott
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
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