Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients.A cross-sectional hospital-based registry study.

Abstract Background Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines morbidity and mortality; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients. Methods The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. Results We investigated 152 patients. The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Pharyngeal-phase dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6-17] vs. 7 [4-12], p=.013; median mRS 5 [IQR 4-5] vs. 4 [IQR 3-5], p=.012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p=.107). FEES examinations revealed that only 30.9% of the patients had an adequate oral diet. A change of oral diet was associated with a better outcome at discharge (mRS; p=.006), less need of mechanical ventilation (p=.028), shorter period of hospitalisation (p=.044), and lower rates of pneumonia (p=.007) and mortality (p=.011). Conclusion Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adequately adjust the oral diet for the vast majority of stroke patients (69.1%), potentially avoiding severe complications. Trial registration The study was not registered

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Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients.A cross-sectional hospital-based registry study.

10.21203/rs.2.9300/v2 ◽

2019 ◽

Author(s):

Tobias Braun ◽

Martin Juenemann ◽

Maxime Viard ◽

Marco Meyer ◽

Iris Reuter ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Stroke ◽

Standard Procedure ◽

University Hospital ◽

Stroke Severity ◽

Stroke Patients ◽

Silent Aspiration ◽

Cross Sectional ◽

The Impact ◽

Oral Diet

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Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients.A cross-sectional hospital-based registry study.

10.21203/rs.2.9300/v1 ◽

2019 ◽

Author(s):

Tobias Braun ◽

Martin Juenemann ◽

Maxime Viard ◽

Marco Meyer ◽

Iris Reuter ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Stroke ◽

Standard Procedure ◽

University Hospital ◽

Stroke Severity ◽

Stroke Patients ◽

Silent Aspiration ◽

Cross Sectional ◽

The Impact ◽

Oral Diet

Abstract Background Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines the outcome; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients. Methods The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. Results We investigated 152 patients (173 FEES). The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6-17] vs. 7 [4-12], p=.013; median mRS 5 [IQR 4-5] vs. 4 [IQR 3-5], p=.012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p=.107). FEES examinations revealed that only 30.9% of the patients had an adequate oral diet. A change of oral diet was associated with a better outcome at discharge (mRS; p=.006), less need of mechanical ventilation (p=.028), shorter period of hospitalisation (p=.044), and lower rates of pneumonia (p=.007) and mortality (p=.011). Discussion Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adequately adjust the oral diet for the vast majority of stroke patients (69.1%), potentially avoiding severe complications.

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Adjustment of oral diet based on flexible endoscopic evaluation of swallowing (FEES) in acute stroke patients: a cross-sectional hospital-based registry study

BMC Neurology ◽

10.1186/s12883-019-1499-8 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Tobias Braun ◽

Martin Juenemann ◽

Maxime Viard ◽

Marco Meyer ◽

Iris Reuter ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Stroke ◽

Standard Procedure ◽

Oropharyngeal Dysphagia ◽

University Hospital ◽

Stroke Severity ◽

Stroke Patients ◽

Cross Sectional ◽

The Impact ◽

Oral Diet

Abstract Background Diagnosing dysphagia in acute stroke patients is crucial, as this comorbidity determines morbidity and mortality; we therefore investigated the impact of flexible nasolaryngeal endoscopy (FEES) in acute stroke patients. Methods The FEES investigation as performed in acute stroke patients treated at a large university hospital, allocated as a standard procedure for all patients suspected of dysphagia. We correlated our findings with baseline data, disability status, pneumonia, duration of hospitalisation, necessity for mechanical ventilation and treatment on the intensive care unit. The study was designed as a cross-sectional hospital-based registry. Results We investigated 152 patients. The median age was 73; 94 were male. Ischemic stroke was diagnosed in 125 patients (82.2%); 27 (17.8%) suffered intracerebral haemorrhage. Oropharyngeal dysphagia was diagnosed in 72.4% of the patients, and was associated with higher stroke severity on admission (median NIHSS 11 [IQR 6–17] vs. 7 [4–12], p = .013; median mRS 5 [IQR 4–5] vs. 4 [IQR 3–5], p = .012). Short-term mortality was higher among patients diagnosed with dysphagia (7.2% vs. 0%, p = .107). FEES examinations revealed that only 30.9% of the patients had an oral diet appropriate for their swallowing abilities. A change of oral diet was associated with a better outcome at discharge (mRS; p = .006), less need of mechanical ventilation (p = .028), shorter period of hospitalisation (p = .044), and lower rates of pneumonia (p = .007) and mortality (p = .011). Conclusion Due to the inability of clinical assessments to detect silent aspiration, FEES might be better suited to identify stroke patients at risk and may contribute to a better functional outcome and lower rates of pneumonia and mortality. Our findings also point to a low awareness of dysphagia, even in a specialised stroke centre. FEES in acute stroke patients helps to adjust the oral diet for the vast majority of stroke patients (69.1%) based on their swallowing abilities, potentially avoiding severe complications.

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The frequency and impact of admission hyperglycemia on short term outcome of acute stroke patients admitted to Tikur Anbessa Specialized hospital, Addis Ababa, Ethiopia: a cross-sectional study

BMC Neurology ◽

10.1186/s12883-019-1578-x ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Yared Zenebe Zewde ◽

Abenet Tafesse Mengesha ◽

Yeweynhareg Feleke Gebreyes ◽

Halvor Naess

Keyword(s):

Acute Stroke ◽

Cross Sectional Study ◽

Stroke Severity ◽

Sectional Study ◽

Stroke Management ◽

Stroke Patients ◽

Short Term ◽

Cross Sectional ◽

Specialized Hospital ◽

Tikur Anbessa Specialized Hospital

Abstract Background Admission hyperglycemia (HG) has been associated with worse outcomes among acute stroke patients. A better understanding and awareness of the potentially adverse influence of hyperglycemia on the clinical outcome of acute stroke patients would help to provide guidance for acute stroke management and prevention of its adverse outcomes. We aimed to assess the frequency of admission hyperglycemia and its impact on short term (30-days) morbidity and mortality outcomes of stroke in adult Ethiopian patients in an urban setting. Methods A prospective, cross-sectional study was conducted among acute stroke patients admitted to Tikur Anbessa Specialized Hospital (TASH), within 72 h of symptom onset, from July to December 2016. Socio-demographic data, neuroimaging findings and capillary blood glucose values were obtained on admission. Hyperglycemia was defined as > 140 mg/dl. National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to assess the baseline stroke severity and the 30-days post-stroke outcome, respectively. Results A total of 103 first-ever acute stroke patients were included (mean age = 55.5 + 15.3 years, 64.1% male and 65% under the age of 65 years) and 51 (49.5%) were hyperglycemic at time of admission. The median admission NIHSS score was worse in the hyperglycemic patients 14 (IQR 10–19) compared to normoglycemic patients 11 (IQR 8–15). Among stroke survivors, patients with hyperglycemia were 3.83 times (95% CI, 1.99–6.19) more likely to be functionally impaired (mRS = 3–5) at 30-days compared to normoglycemic patients (P = 0.041).Older age (≥ 65 years) (P = 0.017) and stroke severity (NIHSS > 14) (P = 0.006) at admission were both significantly associated with poor functional recovery at 30-day. Among patients who died at 30-day, two-third (66.7%) were hyperglycemic but they failed to show any significant association. Conclusions Hyperglycemia is prevalent among Ethiopian stroke patients at the time of presentation and it is associated with significantly poor functional recovery at 30th-day of follow up. This finding provides a rationale for achieving normal blood glucose in the course of acute stroke management which could have a favorable impact on the neurological outcome and quality of life for patients.

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What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study

BMJ Open ◽

10.1136/bmjopen-2017-019016 ◽

2018 ◽

Vol 8 (3) ◽

pp. e019016 ◽

Cited By ~ 4

Author(s):

Tobias Braun ◽

Martin Juenemann ◽

Maxime Viard ◽

Marco Meyer ◽

Sven Fuest ◽

...

Keyword(s):

Clinical Investigation ◽

Brain Lesions ◽

University Hospital ◽

Secondary Outcome ◽

Endoscopic Evaluation ◽

Cross Sectional ◽

Neurological Patients ◽

The Impact ◽

Oral Diet ◽

Structural Brain

ObjectivesFibre-endoscopic evaluation of swallowing (FEES) to detect dysphagia is gaining more and more importance as a diagnostic tool. Therefore, we have investigated the impact of FEES in neurological patients in a clinical setting.DesignCross-sectional hospital-based registry.SettingPrimary acute care in a neurological department of a German university hospital.Participants241patients with various neurological diseases who underwent FEES procedure.Primary and secondary outcome measuresDysphagia and related comorbidities.Results267 FEES were performed in 241 patients with various neurological diagnoses. Dysphagia was diagnosed in 68.9% of the patients. In only 33.1% of the patients, appropriate oral diet was chosen prior to FEES. A relevant dysphagia occurred more often in patients with structural brain lesions (83.1% vs 65.3%, P=0.001), patients with dysphagia had a longer hospitalisation (median 18 (IQR 12–30) vs 15 days (IQR 9.75–22.75), P=0.005) and had a higher mortality (8.4% vs 1.3%, P=0.041). When the oral diet was changed, we observed a lower pneumonia rate (36% vs 50%, P=0.051) and a lower mortality (3.7% vs 11.3%, P=0.043) in comparison to no change of oral diet. A restriction of oral diet was identified more often in older patients (median 75 years (IQR 66.3–82 years) vs median 72 years (IQR 60–79 years), P=0.01) and in patients with structural brain lesions (86.8% vs 73.1%, P=0.05).ConclusionOn clinical investigation, dysphagia was misjudged for the majority of the patients. FEES might help to compensate this drawback, revising the diet regime in nearly 70% of the patients.

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The frequency and impact of admission hyperglycemia on short term outcome of acute stroke patients admitted to Tikur Anbessa Teaching Hospital, Addis Ababa, Ethiopia: a cross-sectional study

10.21203/rs.2.13261/v2 ◽

2019 ◽

Author(s):

Yared Zenebe Zewde ◽

Abenet Tafesse Mengesha ◽

Yeweyenhareg Feleke Gebreyes ◽

Halvor Naess

Keyword(s):

Blood Glucose ◽

Acute Stroke ◽

Functional Recovery ◽

Cross Sectional Study ◽

Stroke Severity ◽

Sectional Study ◽

Stroke Management ◽

Stroke Patients ◽

Short Term ◽

Cross Sectional

Abstract Background: Admission hyperglycemia (HG) has been associated with worse outcomes among acute stroke patients. A better understanding and awareness of the potentially adverse influence of hyperglycemia on the clinical outcome of acute stroke patients would help to provide guidance for acute stroke management and prevention of its adverse outcomes. We aimed to assess the frequency of admission hyperglycemia and its impact on short term (30-days) morbidity and mortality outcomes of stroke in adult Ethiopian patients in an urban setting.Methods: A prospective, cross-sectional study was conducted among acute stroke patients admitted to Tikur Anbessa Specialized Hospital (TASH), within 72 hours of symptom onset, from July to December 2016. Socio-demographic data, neuroimaging findings and capillary blood glucose values were obtained on admission. Hyperglycemia was defined as >140mg/dl. National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to assess the baseline stroke severity and the 30-days post-stroke outcome, respectively.Results: A total of 103 first-ever acute stroke patients were included (mean age = 55.5+15.3 years, 64.1% male and 65% under the age of 65 years) and 51 (49.5%) were hyperglycemic at time of admission. The median admission NIHSS score was worse in the hyperglycemic patients 14 (IQR 10-19) compared to normoglycemic patients 11 (IQR 8-15). Among stroke survivors, patients with hyperglycemia were 3.83 times (95% CI, 1.99-6.19) more likely to be functionally impaired (mRS = 3-5) at 30-days compared to normoglycemic patients (p = 0.041).Older age (≥ 65 years) (p = 0.017) and stroke severity (NIHSS >14) (p = 0.006) at admission were both significantly associated with poor functional recovery at 30-day. Among the patients who died at 30-day, two-third (66.7%) were hyperglycemic but they failed to show any significant association.Conclusions: Hyperglycemia is prevalent among Ethiopian stroke patients at the time of presentation and it is associated with significantly poor functional recovery at 30th-days of follow up. This finding provides a rationale for achieving normal blood glucose in the course of acute stroke management which could have a favorable impact on the neurological outcome and quality of life for patients.

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EFFECT OF STROKE SEVERITY INDEX WITH FUNCTIONAL INDEPENDENCE ON CAREGIVERS BURDEN IN ACUTE STROKE PATIENTS.

10.36106/ijar/5910458 ◽

2021 ◽

pp. 13-16

Author(s):

Dhruvina Jaykumar Suru ◽

Shivani Milind Pandirkar ◽

Shailaja Sandeep Jaywant

Keyword(s):

Acute Stroke ◽

Caregiver Burden ◽

Negative Correlation ◽

Barthel Index ◽

Tertiary Care ◽

Functional Independence ◽

Stroke Severity ◽

Care Hospital ◽

Stroke Patients ◽

The Impact

Greater number of stroke survivors suffer from disability and extended years of care is required to be undertaken by family members which adds burden to caregivers daily life. Thus burden on caregivers needs attention to study the impact of stroke .Till now, scarce literature is found to study the correlation of severity of stroke and burden on caregivers. This study was done to nd the correlation of severity of stroke with functional independence and also intends to nd the correlation of Functional dependency with the caregivers burden& severity of stroke with caregivers burden in acute stroke patients Patients admitted in the tertiary care hospital of metropolitan city in Maharashtra with the Acute stroke within 48 hours of onset were included in study , on 3rd day after stroke/admission to hospital. National Institutes Of Health Stroke Scale ( NIHSS), Barthel Index (BI), Burden Scale For Family Caregivers (BSFC), were used to gather information from 100 stroke patients admitted in hospital wards. Study showed strong negative correlation of -0.705 between NIHSS and BI, Barthel index correlation with caregiver burden score shows moderate negative correlation of – 0.482, NIH scale score correlation with caregiver burden score shows moderate positive correlation of 0.59. Thus stroke severity affects negatively on functional independence. caregivers have reported moderate burden due to dependance of patient. stroke severity has positive impact on caregivers burden. Further research in various stages of Stroke recovery on caregivers burden and functional independence level is recommended

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Bottlenecks in the Acute Stroke Care System during the COVID-19 Pandemic in Catalonia

Cerebrovascular Diseases ◽

10.1159/000516309 ◽

2021 ◽

pp. 1-9

Author(s):

Anna Ramos-Pachón ◽

Álvaro García-Tornel ◽

Mònica Millán ◽

Marc Ribó ◽

Sergi Amaro ◽

...

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Stroke Care ◽

Care Quality ◽

Point Of View ◽

Stroke Severity ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

Prehospital Delays ◽

The Impact

Introduction: The COVID-19 pandemic resulted in significant healthcare reorganizations, potentially striking standard medical care. We investigated the impact of the COVID-19 pandemic on acute stroke care quality and clinical outcomes to detect healthcare system’s bottlenecks from a territorial point of view. Methods: Crossed-data analysis between a prospective nation-based mandatory registry of acute stroke, Emergency Medical System (EMS) records, and daily incidence of COVID-19 in Catalonia (Spain). We included all stroke code activations during the pandemic (March 15–May 2, 2020) and an immediate prepandemic period (January 26–March 14, 2020). Primary outcomes were stroke code activations and reperfusion therapies in both periods. Secondary outcomes included clinical characteristics, workflow metrics, differences across types of stroke centers, correlation analysis between weekly EMS alerts, COVID-19 cases, and workflow metrics, and impact on mortality and clinical outcome at 90 days. Results: Stroke code activations decreased by 22% and reperfusion therapies dropped by 29% during the pandemic period, with no differences in age, stroke severity, or large vessel occlusion. Calls to EMS were handled 42 min later, and time from onset to hospital arrival increased by 53 min, with significant correlations between weekly COVID-19 cases and more EMS calls (rho = 0.81), less stroke code activations (rho = −0.37), and longer prehospital delays (rho = 0.25). Telestroke centers were afflicted with higher reductions in stroke code activations, reperfusion treatments, referrals to endovascular centers, and increased delays to thrombolytics. The independent odds of death increased (OR 1.6 [1.05–2.4], p 0.03) and good functional outcome decreased (mRS ≤2 at 90 days: OR 0.6 [0.4–0.9], p 0.015) during the pandemic period. Conclusion: During the COVID-19 pandemic, Catalonia’s stroke system’s weakest points were the delay to EMS alert and a decline of stroke code activations, reperfusion treatments, and interhospital transfers, mostly at local centers. Patients suffering an acute stroke during the pandemic period had higher odds of poor functional outcome and death. The complete stroke care system’s analysis is crucial to allocate resources appropriately.

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Effect of early sleep apnoea treatment with adaptive servo-ventilation in acute stroke patients on cerebral lesion evolution and neurological outcomes: study protocol for a multicentre, randomized controlled, rater-blinded, clinical trial (eSATIS: early Sleep Apnoea Treatment in Stroke)

Trials ◽

10.1186/s13063-020-04977-w ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Simone B. Duss ◽

Anne-Kathrin Brill ◽

Sébastien Baillieul ◽

Thomas Horvath ◽

Frédéric Zubler ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Acute Stroke ◽

Acute Ischaemic Stroke ◽

Sleep Apnoea ◽

Resonance Imaging ◽

Stroke Patients ◽

Adaptive Servo Ventilation ◽

Randomized Controlled ◽

The Impact

Abstract Background Sleep-disordered breathing (SDB) is highly prevalent in acute ischaemic stroke and is associated with worse functional outcome and increased risk of recurrence. Recent meta-analyses suggest the possibility of beneficial effects of nocturnal ventilatory treatments (continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV)) in stroke patients with SDB. The evidence for a favourable effect of early SDB treatment in acute stroke patients remains, however, uncertain. Methods eSATIS is an open-label, multicentre (6 centres in 4 countries), interventional, randomized controlled trial in patients with acute ischaemic stroke and significant SDB. Primary outcome of the study is the impact of immediate SDB treatment with non-invasive ASV on infarct progression measured with magnetic resonance imaging in the first 3 months after stroke. Secondary outcomes are the effects of immediate SDB treatment vs non-treatment on clinical outcome (independence in daily functioning, new cardio-/cerebrovascular events including death, cognition) and physiological parameters (blood pressure, endothelial functioning/arterial stiffness). After respiratory polygraphy in the first night after stroke, patients are classified as having significant SDB (apnoea-hypopnoea index (AHI) > 20/h) or no SDB (AHI < 5/h). Patients with significant SDB are randomized to treatment (ASV+ group) or no treatment (ASV− group) from the second night after stroke. In all patients, clinical, physiological and magnetic resonance imaging studies are performed between day 1 (visit 1) and days 4–7 (visit 4) and repeated at day 90 ± 7 (visit 6) after stroke. Discussion The trial will give information on the feasibility and efficacy of ASV treatment in patients with acute stroke and SDB and allows assessing the impact of SDB on stroke outcome. Diagnosing and treating SDB during the acute phase of stroke is not yet current medical practice. Evidence in favour of ASV treatment from a randomized multicentre trial may lead to a change in stroke care and to improved outcomes. Trial registration ClinicalTrials.gov NCT02554487, retrospectively registered on 16 September 2015 (actual study start date, 13 August 2015), and www.kofam.ch (SNCTP000001521).

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Abstract P850: Four C’s Are Vital in Improving Door to Thrombolytic Administration

Stroke ◽

10.1161/str.52.suppl_1.p850 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Betty A McGee ◽

Melissa Stephenson

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Median Time ◽

Survival Data ◽

Stroke Patients ◽

Eligibility Criteria ◽

Before And After ◽

Administration Time ◽

System Data ◽

The Impact

Background and Purpose: Thrombolytic therapy is a key link in the stroke chain of survival. Data suggests that four components are vital in decreasing door to thrombolytic administration in acute stroke patients eligible for treatment. Analysis of system data, pre and post implementation of a Door to Needle Project, afforded the opportunity to assess. Hypothesis: We assessed the hypothesis that commitment, collaboration, communication, and consistency (referred to as Four C’s) are vital in improving door to thrombolytic administration time in ischemic stroke patients. Methods: In this quantitative study, we utilized case data collected by a quality improvement team serving five emergency departments within a healthcare system. We retrospectively reviewed times of thrombolytic administration from admission to the emergency department in acute ischemic stroke patients. Cases were included based on eligibility criteria from American Heart Association’s Get With the Guidelines. Times from 2019 were compared with times through April 2020, before and after implementation of the project, which had multidisciplinary process interventions that reinforced the Four C’s. Results: The data revealed a 13.5 % reduction in median administration time. Cases assessed from 2019 had a median time of 52 minutes from door to thrombolytic administration, 95% CI [47.0, 59.0], n = 52. Cases assessed through April 2020 had a median time of 45 minutes from door to thrombolytic administration, 95% CI [39.0, 57.5], n = 18. Comparing cases through April 2020 to those of 2019, there were improvements of 38.1% fewer cases for administration in greater than 60 minutes and 27.8% fewer cases for administration in greater than 45 minutes. Conclusion: The hypothesis that Four C’s are vital in improving door to thrombolytic administration was validated by a decrease in median administration time as well as a reduction in cases exceeding targeted administration times. The impact to clinical outcomes is significant as improving administration time directly impacts the amount of tissue saved. Ongoing initiatives encompassing the Four C’s, within a Cerebrovascular System of Care, are essential in optimizing outcomes in acute stroke patients.

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