Stroke Units
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2021 ◽  
pp. svn-2021-001070
Nawaf Yassi ◽  
Henry Zhao ◽  
Leonid Churilov ◽  
Bruce C V Campbell ◽  
Teddy Wu ◽  

RationaleHaematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth.Methods and designStopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework.HypothesisIn patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo.Sample size estimatesA sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients.InterventionParticipants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo.Primary efficacy measureThe primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan.DiscussionWe describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.

2021 ◽  
Vol 11 (1) ◽  
Malin C. Nylén ◽  
Hanna C. Persson ◽  
Tamar Abzhandadze ◽  
Katharina S. Sunnerhagen

AbstractThis cross-sectional, register-based study aimed to explore patterns of planned rehabilitation at discharge from stroke units in Sweden in 2011 and 2017 and identify explanatory variables for planned rehabilitation. Multivariable binary logistic regression was used to identify variables that could explain planned rehabilitation. There were 19,158 patients in 2011 and 16,508 patients in 2017 with stroke, included in the study. In 2011, 57% of patients were planned for some form of rehabilitation at discharge from stroke unit, which increased to 72% in 2017 (p < 0.001). Patients with impaired consciousness at admission had increased odds for planned rehabilitation (hemorrhage 2011 OR 1.43, 95% CI 1.13–1.81, 2017 OR 1.66, 95% CI 1.20–2.32), (IS 2011 OR 1.21, 95% CI 1.08–1.34, 2017 OR 1.49, 95% CI 1.28–1.75). Admission to a community hospital (hemorrhage 2011 OR 0.56, 95% CI 0.43–0.74, 2017 OR 0.39, 95% CI 0.27–0.56) (IS 2011 OR 0.63, 95% CI 0.58–0.69, 2017 OR 0.54, 95% CI 0.49–0.61) or to a specialized non-university hospital (hemorrhage 2017 OR 0.66, 95% CI 0.46–0.94), (IS 2011 OR 0.90, 95% CI 0.82–0.98, 2017 OR 0.76, 95% CI 0.68–0.84) was associated with decreased odds of receiving planned rehabilitation compared to admission to a university hospital. As a conclusion severe stroke was associated with increased odds for planned rehabilitation and patients discharged from non-university hospitals had consistently decreased odds for planned rehabilitation.

Leona Möller ◽  
Lars Timmermann ◽  
Anja Gerstner

ZusammenfassungDer Schlaganfall ist einer der häufigsten neurologischen Notfälle und bedarf einer schnellen Erkennung und Behandlung. Hierfür sind die Schulung des Rettungsdienstpersonals, die Optimierung von Abläufen und die enge Verzahnung zwischen prä- und intrahospitaler Phase von besonderer Bedeutung. Mobile Stroke Units und Telemedizin können die kritische Phase zusätzlich verkürzen, um ein besseres Outcome für die Patienten zu erreichen.

2021 ◽  
Vol 4 (6) ◽  
pp. 102-105
António Arsénio Duarte ◽  
Ana Paula Martin ◽  
Diana Santos ◽  
Rafael Santos ◽  
Rita Viegas

Every second a person in the world suffers from a stroke, not surprising, therefore, that stroke is the leading cause of death and morbidity in Portugal. Increasingly, acute stroke is considered a medical emergency. The evidence proves that the treatment of these patients in specialized units (stroke units) is effective in acute stroke. A stroke unit is a hospital area where professionals with specific, well-defined training work, who provide care to stroke patients who are already stabilized, but are still in an acute phase(DGS, 2001). The aim of this study is to understand the role of the occupational therapist in stroke units and to identify the perspective of the multidisciplinary team on their work, clarifying what are the advantages of this professional in the team. The study falls within the qualitative paradigm, exploratory and descriptive. Semi-structured interviews were performed to 39 health professionals. The technique used was the content analysis of interviews. Based on previously established categories, other categories emerged.

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S25-S33
Anna Ramos ◽  
Waldo R. Guerrero ◽  
Natalia Pérez de la Ossa

Purpose of the ReviewThis article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center (“drip and ship”), direct transfer of the patient to an endovascular center (“mothership”), transfer of the neurointerventional team to a local primary center (“drip and drive”), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.Recent FindingsLocal observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.SummaryPrehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S170-S177
Stacie L. Demel ◽  
Robert Stanton ◽  
Yasmin N. Aziz ◽  
Opeolu Adeoye ◽  
Pooja Khatri

More than 25 years have passed since the US Food and Drug Administration approved IV recombinant tissue plasminogen activator (alteplase) for the treatment of acute ischemic stroke. This landmark decision brought a previously untreatable disease into a new therapeutic landscape, providing inspiration for clinicians and hope to patients. Since that time, the use of alteplase in the clinical setting has become standard of care, continually improving with quality measures such as door-to-needle times and other metrics of specialized stroke unit care. The past decade has seen more widespread use of alteplase in the prehospital setting with mobile stroke units and telestroke and beyond initial time windows via the use of CT perfusion or MRI. Simultaneously, the position of alteplase is being challenged by new lytics and by the concept of its bypass altogether in the era of endovascular therapy. We provide an overview of alteplase, including its earliest trials and how they have shaped the current therapeutic landscape of ischemic stroke treatment, and touch on new frontiers for thrombolytic therapy. We highlight the critical role of thrombolytic therapy in the past, present, and future of ischemic stroke care.

2021 ◽  
Vol 12 ◽  
Aude Triquenot Bagan ◽  
Isabelle Crassard ◽  
Ludovic Drouet ◽  
Marianne Barbieux-Guillot ◽  
Raphaël Marlu ◽  

Introduction: Cerebral venous thrombosis (CVT) is a rare disease with highly variable clinical presentation and outcome. Etiological assessment may be negative. The clinical and radiological presentation and evolution can be highly variable. The mechanisms involved in this variability remain unknown.Objective: The aim of this multicenter French study registered on (NCT02013635) was therefore to prospectively recruit a cohort of patients with cerebral venous thrombosis (FPCCVT) in order to study thrombin generation and clot degradation, and to evaluate their influence on clinical radiological characteristics. The first part of the study was to compare our cohort with a reference cohort.Methods: This prospective, multicenter, French study was conducted from July 2011 to September 2016. Consecutive patients (aged &gt;15 years) referred to the stroke units of 21 French centers and who had a diagnosis of symptomatic CVT were included. All patients gave their written informed consent. The diagnosis of CVT had to be confirmed by imaging. Clinical, radiological, biological, and etiological characteristics were recorded at baseline, at acute phase, at 3 months and at last follow-up visit. Thrombophilia screening and the choice of treatment were performed by the attending physician. All data were compared with data from the International Study on CVT published by Ferro et al.Results: Two hundred thirty-one patients were included: 117 (50.6%) had isolated intracranial hypertension, 96 (41.5%) had focal syndrome. During hospitalization, 229 (99.1%) patients received anticoagulant treatment. Median length of hospital stay was 10 days. Five patients died during hospitalization (2.2%). At 3 months, 216 patients (97.0%) had follow-up with neurological data based on an outpatient visit. The mean duration of antithrombotic treatment was 9 months, and the mean time to last follow-up was 10.5 months. At the end of follow-up, eight patients had died, and 26 patients were lost to follow-up. At least one risk factor was identified in 200 patients.Conclusions: We demonstrated that the FPCCVT cohort had radiological, biological, and etiological characteristics similar to the historical ISCVT cohort. Nevertheless, the initial clinical presentation was less severe in our study probably due to an improvement in diagnostic methods between the two studies.

BMJ Open ◽  
2021 ◽  
Vol 11 (11) ◽  
pp. e049988
Sjan-Mari van Niekerk ◽  
Sureshkumar Kamalakannan ◽  
Gakeemah Inglis-Jassiem ◽  
Maria Yvonne Charumbira ◽  
Silke Fernandes ◽  

ObjectivesTo explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA).SettingSA.DesignScoping review.Search methodsWe conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results.ResultsFifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available.ConclusionThis review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.

2021 ◽  
pp. 118-121
Anjum Farooq ◽  
Narayanaswamy Venketasubramanian ◽  
Mohammad Wasay

Increasing incidence of stroke and lack of infrastructure in both urban and rural areas needs immediate attention in Pakistan. There is a high proportion of young stroke with poor stroke outcomes. Acute stroke care is scarce in Pakistan due to the small number of neurologists (1 neurologist per 1 million population), few stroke units, and limited availability of alteplase (recombinant tissue plasminogen activator) in the country.

Malin Reinholdsson ◽  
Anna Grimby-Ekman ◽  
Hanna C. Persson

Objective: To investigate associations between pre-stroke physical activity and mobility, walking ability, and self-perceived upper extremity function during stroke unit care. Design: A longitudinal, registry-based study with a consecutively collected cohort. Subjects/patients: A total of 1,092 adults with stroke admitted to 3 Swedish stroke units between 2017 and 2018. Methods: Logistic mixed effects regression models were performed to investigate associations (adjusted for age and sex). Pre-stroke physical activity was assessed with Saltin-Grimby Physical Activity Level Scale on admission. Mobility, walking ability, and self-perceived upper extremity function were assessed at admission and discharge from the stroke units and compared between pre-stroke physically active (45%) and inactive (55%) groups. Results: All groups of patients showed improvements in mobility (p  < 0.001), walking ability (p  < 0.001), and upper extremity function (p  < 0.001). The chang-es over time tended to differ between the physically inactive and active groups for mobility (p  < 0.062) and walking ability (p  < 0.056), but the differences were not significant. Conclusion: Pre-stroke physically active people show-ed a tendency to be more independent in physical functioning early after stroke. Regardless of pre-stroke physical activity, all patients showed improvements in mobility, walking ability, and self-perceived upper extremity function during inpatient care.

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