The stroke mothership model survived during COVID-19 era: an observational single-center study in Emilia-Romagna, Italy

Abstract Introduction A reduction of the hospitalization and reperfusion treatments was reported during COVID-19 pandemic. However, high variability in results emerged, potentially due to logistic paradigms adopted. Here, we analyze stroke code admissions, hospitalizations, and stroke belt performance for ischemic stroke patients in the metropolitan Bologna region, comparing temporal trends between 2019 and 2020 to define the impact of COVID-19 on the stroke network. Methods This retrospective observational study included all people admitted at the Bologna Metropolitan Stroke Center in timeframes 1 March 2019–30 April 2019 (cohort-2019) and 1 March 2020–30 April 2020 (cohort-2020). Diagnosis, treatment strategy, and timing were compared between the two cohorts to define temporal trends. Results Overall, 283 patients were admitted to the Stroke Center, with no differences in demographic factors between cohort-2019 and cohort-2020. In cohort-2020, transient ischemic attack (TIA) was significantly less prevalent than 2019 (6.9% vs 14.4%, p = .04). Among 216 ischemic stroke patients, moderate-to-severe stroke was more represented in cohort-2020 (17.8% vs 6.2%, p = .027). Similar proportions of patients underwent reperfusion (45.9% in 2019 vs 53.4% in 2020), although a slight increase in combined treatment was detected (14.4% vs 25.4%, p = .05). Door-to-scan timing was significantly prolonged in 2020 compared with 2019 (28.4 ± 12.6 vs 36.7 ± 14.6, p = .03), although overall timing from stroke to treatment was preserved. Conclusion During COVID-19 pandemic, TIA and minor stroke consistently reduced compared to the same timeframe in 2019. Longer stroke-to-call and door-to-scan times, attributable to change in citizen behavior and screening at hospital arrival, did not impact on stroke-to-treatment time. Mothership model might have minimized the effects of the pandemic on the stroke care organization.

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Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Neuroepidemiology ◽

10.1159/000514077 ◽

2021 ◽

pp. 1-6

Author(s):

Silvia Pastor ◽

Elena de Celis ◽

Itsaso Losantos García ◽

María Alonso de Leciñana ◽

Blanca Fuentes ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Organization ◽

Stroke Units ◽

Health Region ◽

Number Of Patients ◽

The Impact

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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Abstract TP383: Ischemic Stroke Patients With Diabetes Looking for Practices in Need of Improvement

Stroke ◽

10.1161/str.51.suppl_1.tp383 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Cynthia Bautista ◽

Sally Gerard

Keyword(s):

Ischemic Stroke ◽

Cause Of Death ◽

Demographic Data ◽

Stroke Care ◽

The United States ◽

Stroke Patients ◽

Co Morbidity ◽

Patients With Diabetes ◽

Care Outcomes ◽

Stroke Center

Background/Purpose: Stroke is the fifth leading cause of death and Diabetes is the seventh leading cause of death in the United States. Diabetes is an independent risk factor for stroke. Diabetes is a common co-morbidity in stroke patients and is associated with poor outcomes after stroke. Get with the Guidelines - Stroke (GWTG-S) Registry database provides a rich opportunity to look at disease-specific data and find opportunities for improving care. The purpose of this study was to examine specific elements of acute ischemic stroke care in patients with diabetes using the GWTG-S at Comprehensive and Primary Stroke Centers in Northeast of America. Methods: A retrospective, descriptive study at both a Comprehensive and Primary Stroke Center. The analysis focused on patients with ischemic stroke and diabetes entered in the GWTG-S from January 1, 2015, to December 31, 2017. Data were analyzed looking at measures specific to stroke and the presence of diabetes. General demographic data were examined to compare populations and quality outcome measures. Results: The sample of patients with ischemic stroke and diabetes was over 1,000 patient’s at the two sites (Comprehensive site N = 804, Primary site N = 203) Incidence of ischemic stroke with diabetes at the two sites were 32% and 26%, respectively. Demographic data were similar in most categories including age, race, and gender. Significant differences were found in regard to the type of insurance. Stroke care outcomes indicated thrombolytic administration rates were the same at 8%. Diabetes care outcomes indicated patients discharged on insulin occurred in 18% to 26% of the sample. Conclusion/Implications for Practice: Ischemic stroke patients with diabetes were shown to receive similar care at both a comprehensive and primary care stroke center. There were no differences between centers in thrombolysis treatment for ischemic stroke patients with diabetes. Several opportunities for improvement in diabetes-related care need to be addressed.

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Management of acute ischemic stroke

BMJ ◽

10.1136/bmj.l6983 ◽

2020 ◽

pp. l6983 ◽

Cited By ~ 15

Author(s):

Michael S Phipps ◽

Carolyn A Cronin

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Treatment Time ◽

Recurrent Stroke ◽

Time Windows ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Developed Countries ◽

Future Research ◽

The Impact

ABSTRACT Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

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Mandatory Neuroendovascular Evolution: Meeting the New Demands

Interventional Neurology ◽

10.1159/000495075 ◽

2018 ◽

Vol 8 (1) ◽

pp. 69-82

Author(s):

Mohammad El-Ghanem ◽

Francisco E. Gomez ◽

Prateeka Koul ◽

Rolla Nuoman ◽

Justin G. Santarelli ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Endovascular Intervention ◽

Stroke Patients ◽

Hub And Spoke ◽

Comprehensive Stroke Center ◽

Stroke Center

Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.

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Collateral Circulation Predicts the Size of the Infarct Core and the Proportion of Salvageable Penumbra in Hyperacute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Cerebrovascular Diseases ◽

10.1159/000439064 ◽

2015 ◽

Vol 40 (3-4) ◽

pp. 182-190 ◽

Cited By ~ 18

Author(s):

Harri Rusanen ◽

Jukka T. Saarinen ◽

Niko Sillanpää

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Collateral Circulation ◽

Cerebral Blood Volume ◽

Treatment Time ◽

Ct Perfusion ◽

Mean Transit Time ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

The Impact

Background: We studied the impact of collateral circulation on CT perfusion (CTP) parametric maps and the amount of salvaged brain tissue, the imaging and clinical outcome at 24 h and at 3 months in a retrospective acute (<3 h) stroke cohort (105 patients) with anterior circulation thrombus treated with intravenous thrombolysis. Methods: Baseline clinical and imaging information were collected and groups with different collateral scores (CS) were compared. Binary logistic regression analyses using good CS (CS ≥2) as the dependent variable were calculated. Results: CTP Alberta Stroke Program Early CT Score (ASPECTS) was successfully assessed in 58 cases. Thirty patients displayed good CS. Poor CS were associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (15 vs. 7, p = 0.005) and at 24 h (10 vs. 3, p = 0.003) after intravenous thrombolysis. Good CS were associated with a longer mean onset-to-treatment time (141 vs. 121 min, p = 0.009) and time to CTP (102 vs. 87 min, p = 0.047), better cerebral blood volume (CBV) ASPECTS (9 vs. 6, p < 0.001), better mean transit time (MTT) ASPECTS (6 vs. 3, p < 0.001), better noncontrast CT (NCCT) ASPECTS (10 vs. 8, p < 0.001) at arrival and with favorable clinical outcome at 3 months (modified Rankin Scale ≤2, p = 0.002). The fraction of penumbra that was salvageable at arrival and salvaged at 24 h was higher with better CS (p < 0.001 and p = 0.035, respectively). In multivariate analysis, time from the onset of symptoms to imaging (p = 0.037, OR 1.04 per minute, 95% CI 1.00-1.08) and CBV ASPECTS (p = 0.001, OR 2.11 per ASPECTS point, 95% CI 1.33-3.34) predicted good CS. In similar multivariable models, MTT ASPECTS (p = 0.04, OR 1.46 per ASPECTS point, 95% CI 1.02-2.10) and NCCT ASPECTS predicted good CS (p = 0.003, OR 4.38 per CT ASPECTS point, 95% CI 1.66-11.55) along with longer time from the onset of symptoms to imaging (p = 0.045, OR 1.03 per minute, 95% CI 1.00-1.06 and p = 0.02, OR 1.05 per minute, 95% CI 1.00-1.09, respectively). CBV ASPECTS had a larger area under the receiver operating characteristic curve for good CS (0.837) than NCCT ASPECTS (0.802) or MTT ASPECTS (0.752) at arrival. Conclusions: Favorable CBV ASPECTS, NCCT ASPECTS and MTT ASPECTS are associated with good CS along with more salvageable tissue and longer time from the onset of symptoms to imaging in ischemic stroke patients treated with intravenous thrombolysis.

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Trends in the seeking of emergency service for ischemic stroke and its risk factors during the COVID-19 pandemic, a study from Taiwan

Neurology Asia ◽

10.54029/2021axy ◽

2021 ◽

Vol 26 (3) ◽

pp. 441-447

Author(s):

Yi Te Tsai ◽

Yachung Jeng ◽

Hsiu-Hsi Chen ◽

Kai-Chieh Chang

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Emergency Services ◽

Stroke Care ◽

University Hospital ◽

Minor Stroke ◽

Stroke Severity ◽

Health Seeking ◽

Stroke Patients ◽

Ich Score

Background & Objectives: COVID-19 may influence the health seeking behavior of acute ischemic stroke patients. This study aimed to determine the characteristics of the patients who visited the emergency room in a centre designated for stroke care in Taiwan. Methods: This was a retrospective database-based study comparing the severity of ischemic stroke, intracerebral hemorrhage (ICH), and risk factors of patients seen between 2019 and 2020 in the National Taiwan University Hospital Yunlin Branch. Patients with or without thrombolysis therapy were analysed. Results: The median NIHSS of ischemic stroke patients were lower in 2019 than in 2020 (p = 0.015). The difference was seen in non-thrombolysis patients (2019: 3[1-6] vs. 4 [2-7.5], p = 0.012) but not in thrombolysis patients. The frequency of minor stroke was higher in 2019 (45.1%) than in 2020 (37.9%, p = 0.038). The discharge mRS was lower overall (p = 0.004) and in non-thrombolysis patients (0.003), but not in thrombolysis patients in 2019. As for the ICH patients, the severity of ICH score (p = 0.021) and discharge mRS (p = 0.001) were also lower in 2019. The frequencies of risk factors of stroke were higher in 2019 than in 2020, including smoking (24% vs. 18.2%, p = 0.046), alcohol (11.9% vs. 7.5%, p = 0.039), hypertension (72.9% vs. 66.2%, p = 0.039), history of stroke (16.5% vs. 11.6%, p = 0.047), and atrial fibrillation (11.9% vs. 7.5%, p = 0.039). Conclusions: This study in Taiwan revealed a decline in the willingness to seek emergency services under the influence of COVID-19 among patients with lower stroke severity, especially those with more risk factors.

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Abstract WP289: The Impact of Infection on Neurological Deterioration and Outcome in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.44.suppl_1.awp289 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Amelia K Boehme ◽

Andre D Kumar ◽

Adrianne M Dorsey ◽

James E Siegler ◽

Michael J Lyerly ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Symptom Onset ◽

Neurological Deterioration ◽

Stroke Patients ◽

Poor Functional Outcome ◽

Acute Hospitalization ◽

Stroke Center ◽

The Impact

Introduction: To date, few studies have assessed the influence of infection on neurological deterioration (ND) and other outcome measures in acute ischemic stroke. Methods: Patients admitted to our stroke center (07/08-12/10) were retrospectively assessed. Patients were excluded if they had an in-hospital stroke, unknown time of symptom onset, or delay from symptom onset to hospital arrival >48 hours. Positive blood or urine culture, or chest x-ray consistent with pneumonia were classified as infection and stratified according to whether the infection was diagnosed within the first 24 hours of admission or after 24 hours. ND was defined as an increase ≥2 points on the NIHSS score within a 24hr period. Poor functional outcome was defined as a mRS score of 3-6 on discharge. Results: Of the 334 patients included in this study, 78 had an infection (19 on admission). The majority of infections were found in the urinary tract (64%), while pneumonia (37%) and bacteremia (24%) were also common. Infection on admission was predictive of ND (Table 1; OR=2.79, 95% CI 1.18-6.64, p=0.0211) and poor functional outcome (OR=3.0, 95% CI 1.1-7.9, p=0.0182). Developing an infection during acute hospitalization was an even stronger predictor of ND (OR=11.9, 95% CI 5.8-24.5, p<0.0001) and poor functional outcome (OR=56.4, 95% CI 7.7-414, p<0.0001). After adjusting for age, NIHSS at baseline and glucose on admission, the development of an infection during acute hospitalization remained a significant predictor of ND (OR=8.9, 95% CI 4.2-18.6, p<0.0001) and poor functional outcome (OR=41.7, 95% CI 5.2-337.9, p=0.005) while an infection on admission was no longer predictive of ND (OR=1.5, 95%CI 0.59-3.99, p=0.3738) or poor functional outcome (OR=1.09, 95%CI 0.3-3.9, p=0.8984). Conclusion: Our data suggest that ischemic stroke patients who develop an infection during their acute hospitalization are at increased odds of experiencing ND and of being discharged with significant disability.

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National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010–2016

International Journal of Stroke ◽

10.1177/1747493019884526 ◽

2019 ◽

pp. 174749301988452 ◽

Cited By ~ 1

Author(s):

Akiko Kada ◽

Kuniaki Ogasawara ◽

Takanari Kitazono ◽

Kunihiro Nishimura ◽

Nobuyuki Sakai ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Temporal Trends ◽

Stroke Severity ◽

Stroke Patients ◽

Poor Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. Aims To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. Methods This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1–25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3–6) at discharge were examined using hierarchical logistic regression models. Results Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010–2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95–0.99), 0.97 (0.95–0.998), 1.07 (1.04–1.10), and 1.21 (1.14–1.28), respectively). Conclusions This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

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A national economic and clinical model for ischemic stroke care development in Saudi Arabia: A call for change

International Journal of Stroke ◽

10.1177/1747493019851284 ◽

2019 ◽

Vol 14 (8) ◽

pp. 835-842

Author(s):

Fahmi Al-Senani ◽

Mohammed Al-Johani ◽

Mohammad Salawati ◽

Souda ElSheikh ◽

Maha AlQahtani ◽

...

Keyword(s):

Saudi Arabia ◽

Ischemic Stroke ◽

Development Program ◽

Stroke Care ◽

Care Organization ◽

Health Economic Analysis ◽

Clinical Model ◽

The Impact ◽

Care Development ◽

Effective Treatments

Background Stroke is a significant burden in Saudi Arabia and the Saudi Ministry of Health's stroke committee has identified an urgent need to improve care. Aim The purpose of this study was to undertake a health-economic analysis to quantify the impact of developing stroke care in the country. Methods An economic model was developed to assess the costs and clinical outcomes associated with an ischemic stroke care development program compared with current stroke care. Based on Saudi epidemiological data, cohorts of ischemic stroke patients enter the model each year for the first 10 years based on increasing incidence. Four treatment options were modeled including reperfusion and non-reperfusion treatments. The development scenario estimates the impact of gradually increasing uptake of more effective treatments over 10 years. Changes in the stroke care organization are considered along with resources required to increase capacity, allowing more patients to be admitted to stroke hospitals and access effective treatments. Results The stroke care development program is associated with an increase in functionally independent patients and a decrease in disabling strokes compared with current stroke care. Additionally, the development program is associated with estimated cost savings of $602 million over 15 years ($255 million direct costs, $348 million indirect costs). Conclusions The model predicts that the stroke care development program is associated with improved patient outcomes and lower overall costs compared with the current stroke care program.

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The impact of tele-neurologists on acute stroke care at an advanced primary stroke centre

Journal of Telemedicine and Telecare ◽

10.1177/1357633x20921039 ◽

2020 ◽

pp. 1357633X2092103

Author(s):

Scott Gutovitz ◽

Jonathan Leggett ◽

Leslie Hart ◽

Samuel M Leaman ◽

Heather James ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Final Diagnosis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Care Guidelines ◽

Stroke Center ◽

The Impact ◽

Stroke Centre

Introduction We evaluated the impact of tele-neurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. Methods This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016–28 February, 2017; tele-neurology: 1 April, 2017–31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. Results Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 tele-neurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups ( p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the tele-neurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among tele-neurology (64 min (51.5–83.5)) than bedside neurology patients (45 min (34–69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and tele-neurology (90.4 ± 33.4 min; p = 0.67). Discussion At this facility, our tele-neurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

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