Sex-based differences in emergency department treatment times for acute ischaemic stroke: evidence from a large Italian cohort

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke.

In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States.

Introduction: Disparities in acute ischemic stroke (IS) care due to patients’ pre-stroke disabilities remain understudied. Using the Greater Cincinnati Northern Kentucky (GCNK) Stroke Study, we aimed to understand the differences in acute stroke presentation and care according to patients’ pre-stroke functional status. Methods: We ascertained all hospitalized IS patients ≥18 years old presenting to emergency departments in the GCNK region in 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46; all cases were physician-reviewed. Trained nurses ascertained pre-stroke functional status from the medical record. Acute IS presentation, time metrics, and treatment were compared between patients with pre-stroke mRS 0-1 vs ≥2 using Wilcoxon rank-sum or chi-square tests. Logistic regression was used to evaluate the association between pre-stroke mRS and intravenous thrombolysis (IVT) and endovascular treatment adjusting for age, presenting NIHSS, time to presentation, and baseline anticoagulation use. Results: Of 2191 patients with IS, 1134 had a pre-stroke mRS ≥2. Patients in the latter group were older, more likely be female, had higher rates of medical comorbidities, had higher presenting NIHSS (3[1-8] vs 2[1-5], p&lt;0.01, Table). They were less likely to receive IVT (aOR 0.43[0.28-0.68], p&lt;0.01, for patients presenting within 0-4 hours) and EVT (aOR 0.32[0.13-0.78], p=0.01, for patients presenting within 0-23.5 hours). They had a higher rate of presentation via EMS, but the time from stroke onset to ED presentation was longer. Conclusions: Acute IS patients with pre-stroke disability presented later, with more severe strokes, and were less likely to receive reperfusion treatments. Further research into factors driving acute stroke medical decision-making for patients with a pre-stroke disability is needed to ensure optimal acute neurovascular care for all IS patients across the nation and worldwide.

Clinical trials on acute ischemic stroke have demonstrated the clinical effectiveness of revascularization treatments within an appropriate time window after stroke onset: intravenous thrombolysis (NINDS and ECASS-III) through the administration of tissue plasminogen activator within a 4.5-hour time window, endovascular thrombectomy (ESCAPE, REVASCAT, SWIFT-PRIME, MR CLEAN, EXTEND-IA) within a 6-hour time window, and extending the treatment time window up to 24 hours for endovascular thrombectomy (DAWN and DEFUSE 3). However, a substantial number of patients in these trials were ineligible for revascularization treatment, and treatments of some patients were considerably futile or sometimes dangerous in the clinical trials. Guidelines for the early management of patients with acute ischemic stroke have evolved to accept revascularization treatment as standard and include eligibility criteria for the treatment. Imaging has been crucial in selecting eligible patients for revascularization treatment in guidelines and clinical trials. Stroke specialists should know imaging criteria for revascularization treatment. Stroke imaging studies have demonstrated imaging roles in acute ischemic stroke management as follows: 1) exclusion of hemorrhage and stroke mimic disease, 2) assessment of salvageable brain, 3) localization of the site of vascular occlusion and thrombus, 4) estimation of collateral circulation, and 5) prediction of acute ischemic stroke expecting hemorrhagic transformation. Here, we review imaging methods and criteria to select eligible patients for revascularization treatment in acute anterior circulation stroke, focus on 2019 guidelines from the American Heart Association/American Stroke Association, and discuss the future direction of imaging-based patient selection to improve treatment effects.

Introduction: The COVID-19 pandemic has wreaked havoc on the presentation, care and outcomes of patients with acute cerebrovascular and cardiovascular conditions. We sought to measure the national impact of COVID-19 on the care for acute ischemic stroke (AIS) and acute myocardial infarction (AMI). Methods: In this retrospective, observational study, we used the Premier Healthcare Database to evaluate the changes in the volume of care and hospital outcomes for AIS and AMI in relation to the pandemic. The pandemic months were defined from March 1, 2020- April 30, 2020 and compared to the same period in the year prior. Outcome measures were volumes of hospitalization and reperfusion treatment for AIS and AMI (including intravenous thrombolysis [IVT] and/or mechanical thrombectomy [MT] for AIS and percutaneous coronary interventions [PCI] for AMI) as well as in-hospital mortality, hospital length of stay (LOS) and hospitalization costs were compared across a 2-month period at the height of the pandemic versus the corresponding period in the prior year. Results: There were 95,453 AIS patients across 145 hospitals and 19,744 AMI patients across 126 hospitals. There was a significant nation-wide decline in the absolute number of hospitalizations for AIS (-38.94%;95%CI,-34.75% to -40.71%) and AMI (-38.90%;95%CI,-37.03% to -40.81%) as well as IVT (-30.32%;95%CI,-27.02% to -33.83%), MT (-23.54%;95%CI,-19.84% to -27.70%), and PCI (-35.05%;95%CI,-33.04% to -37.12%) during the first two months of the pandemic. This occurred across low-, mid-, and high-volume centers and in all geographic regions. Higher in-hospital mortality was observed in AIS patients (5.7% vs.4.2%, p=0.0037;OR 1.41,95%CI 1.1-1.8) but not AMI patients. A shift towards an increase in the proportion of admitted AIS and AMI patients receiving reperfusion therapies suggests a greater clinical severity among patients that were hospitalized for these conditions during the pandemic. A shorter length of stay (AIS: -17%, AMI: -20%), and decreased hospitalization costs (AIS: -12%, AMI: -19%) were observed. Conclusions: Our findings shed light on the combined health outcomes and economic impact the COVID-19 pandemic has had on acute stroke and cardiac emergency care.

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Role of Abciximab in the Management of Acute Ischemic Stroke

Time Metrics in Acute Ischemic Stroke Care During the Second and First Wave of COVID 19 Pandemic: A Tertiary Care Center Experience from South India

Outcomes From a Nursing-Driven Acute Stroke Care Protocol for Telehealth Encounters

Background: Acute ischemic stroke (AIS) is a leading cause of mortality and long-term disability worldwide, with upper-middle-income countries (UMICs) facing a disproportionate burden due to systemic inefficiencies in healthcare delivery. Kazakhstan reports the highest global age-standardized mortality rate from ischemic stroke, underscoring the need to evaluate current stroke care practices and identify areas for improvement. Objective: This study aimed to assess the current state of acute ischemic stroke care in Kazakhstan by examining key time metrics, protocol adherence, and the utilization of advanced technologies such as artificial intelligence (AI) and telemedicine. Additionally, this study sought to identify regional disparities in care and propose actionable recommendations to improve patient outcomes. Methods: A multi-center cross-sectional survey was conducted across 79 stroke centers in Kazakhstan. Data were collected from 145 healthcare professionals, including neurologists, neurosurgeons, and interventional radiologists, through a validated 23-question online questionnaire. Statistical analysis was performed to identify significant associations between variables. Results: Significant regional disparities were observed in stroke care timelines and technology adoption. Remote and rural areas experienced prolonged prehospital delays, with transport times ranging from 120 to 180 min, contributing to door-to-needle times exceeding the recommended benchmark. Urban centers with higher adoption of AI and telemedicine demonstrated faster treatment initiation and better protocol compliance. Staff training was significantly associated with improved treatment outcomes, with trained centers more likely to implement direct-to-angiography suite protocols, reducing in-hospital delays. Conclusions: Addressing acute ischemic stroke care disparities in Kazakhstan requires a multifaceted approach, including expanding AI and telemedicine, implementing targeted staff training programs, and establishing standardized national stroke protocols. These strategies can help reduce treatment delays, bridge the urban-rural healthcare divide, and improve patient outcomes. The findings have implications for other UMICs facing similar challenges in delivering equitable stroke care.

Background Acute Ischemic Stroke (AIS) remains a critical global health challenge that requires continuous improvement in diagnostic strategies. Timely and accurate diagnosis is essential for effective reperfusion therapies such as intravenous thrombolysis and mechanical thrombectomy, whose clinical benefits rapidly diminish with treatment delays. Artificial Intelligence (AI) offers promising potential to enhance diagnostic accuracy and clinical decision-making in AIS. However, data fragmentation and strict privacy regulations limit the development of robust AI systems. Objectives: We aim to provide a perspective-style review that explores how collaborative AI can reshape AIS diagnostics by overcoming data access barriers, fostering cross-institutional model development, and improving diagnostic equity. Methods We analysed current challenges in developing AIS-related AI tools, particularly the limitations caused by restricted data sharing across healthcare institutions. The study highlights collaborative AI approaches, such as federated learning and privacy-preserving computation, which enable decentralised model training while maintaining patient confidentiality. Relevant literature and recent developments in clinical AI collaboration were reviewed. Results Collaborative AI enables multiple institutions to contribute to model training without exposing raw patient data. This approach improves data diversity, model generalizability, and fairness across healthcare settings. Evidence from multi-centre studies suggests that collaborative AI frameworks can produce more accurate and ethically compliant diagnostic models compared to isolated development efforts. Conclusions Collaborative AI presents a transformative pathway for AIS management by balancing data utility and privacy protection. It supports the creation of trustworthy, scalable, and inclusive diagnostic systems. As healthcare systems increasingly adopt digital solutions, collaborative AI provides a foundation for equitable and privacy-conscious innovation in stroke care.

Marc Fisher MD Kennedy Lees MD Section Editors: On September 26, 2008, the New England Journal of Medicine published the results of the European Cooperative Stroke Study (ECASS) III,1 the first randomized, placebo-controlled trial to demonstrate safe and effective use of intravenous recombinant tissue plasminogen activator (rtPA) to treat patients with acute ischemic stroke (AIS) beyond 3 hours from stroke onset. The ECASS investigators studied the safety and efficacy of administering intravenous rtPA to patients with AIS 3 to 4.5 hours after AIS onset. Using the modified Rankin Scale score at 90 days after stroke occurrence as the primary end point of the study, the investigators demonstrated a modest, statistically significant increase in the likelihood of having normal or near normal recovery (modified Rankin Scale=0 or 1) in favor of rtPA treatment compared with placebo (unadjusted OR, 1.34; 95% CI, 1.02 to 1.76; P =0.04). So, what impact will the results of the study have on acute stroke management and stroke research in the United States and elsewhere? With regard to the first part of the question, the answer is complex. First, the ECASS III results will hopefully help to increase the number of thrombolysis eligible patients with AIS who receive rtPA. Twelve years after the US Food and Drug Administration approved the management of AIS within 3 hours of symptom onset as an indication for the use of intravenous rtPA, less than 5% of patients with AIS are being treated worldwide with rtPA within 3 hours of stroke onset. One of the major factors contributing to this parlous state of affairs has been disagreement among healthcare professionals about the validity of the results of the National Institutes of Neurological Disorders and Stroke (NINDS) trial of rtPA for acute stroke.2 In the late 1990s, the stroke community unexpectedly …

Objective: To assess the impact of the Jilin Province Stroke Emergency Map (JSEM) initiative on the efficiency of emergency care for acute ischemic stroke. Methods: This study utilized data from the Jilin Stroke Center Construction Management Information System to describe the contruction of the regional stroke emergency network in Jilin Province since the JSEM initiative launched. Comparisons were made regarding the number and proportion of acute ischemic stroke patients receiving intravenous thrombolysis (IVT) and mechanical thrombectomy (MT), as well as the Emergency Medical Services (EMS) response times, during the following periods: the 1-year pre-JSEM period (August 2016-July 2017), and the 1-year periods following the release of JSEM Version 1 (August 2017-July 2018), Version 2 (August 2018-July 2019), Version 4 (December 2021-November 2022), and Version 5 (August 2023-July 2024). Results: As JSEM evolved from Version 1 (August 2017) to Version 6 (September 2024), the number of hospitals in Jilin Province with IVT capability increased from 19 to 71, and those with MT capability increased from 10 to 30. With the increase in IVT-capable hospitals within the JSEM network, the number of acute ischemic stroke patients receiving IVT in Jilin Province has increased continuously, from 2 585 cases in the year pre-Version 1 to 9 464 cases within the year following Version 5 release. The IVT rate among the patients entering the"green channel"of stroke also increased from 3.3% (2 585/78 063)to 5.5%(9 464/172 951). The median door-to-needle time decreased from 62 (54, 71) minutes pre-Version 1 to 51 (43, 60) minutes post-Version 5. Meanwhile, the number of patients receiving emergency MT in Jilin Province rose from 457 cases pre-Version 1 to 1 337 cases post-Version 5; the MT rate among patients entering the"green channel"of stroke increased from 0.6% (457/78 063) to 0.8% (1 337/172 951). Treatment timeliness for MT also improved: the door-to-puncture time shortened from 136 (104, 157) minutes pre-Version 1 to 112 (94, 143) minutes post-Version 5. Conclusions: The launch and promotion of JSEM effectively reduces stroke-induced death and disability rates by optimizing the provincial stroke emergency network, reducing pre-and post admission delays, and enhancing treatment efficiency, which contributes to achieving the goals of the national"One Million Disability Reduction Project".

Background and Purpose: Guideline adherence for acute ischemic stroke (AIS) management is often suboptimal, particularly in thrombolytic therapy and anticoagulants for atrial fibrillation. We sought to achieve quality improvement of AIS patients via a collaborative learning model, the Breakthrough Series (BTS)-Stroke, in a nationwide, multi-center activity in Taiwan. Methods: A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance AIS care quality. There were 24 teaching and community hospitals participating in and submitting data for this stroke quality improvement campaign from August 2010 to June 2011. The Get With The Guideline (GWTG)-Stroke measures were adopted to evaluate the performance and outcome of the AIS patients. The results of this study were compared to those of the previous Taiwan Stroke Registry (TSR, 22642 AIS patients from 39 hospitals, 2006-08). Results: Data from 24 hospitals with 13181 AIS patients during a 1-year period were analyzed. The BTS-Stroke (2010-11) had better performance as compared to the TSR (2006-08): intravenous thrombolysis frequency for all AIS patients (4.1% vs 1.5%), symptomatic hemorrhage after intravenous thrombolysis (6.0% vs 8.2%), early antithrombotics (96.6% vs 94.1%), anticoagulation for atrial fibrillation (57.1% vs 28.3%), lipid lowering drugs for low-density lipoprotein &gt;100 mg/dL (63.4% vs 38.7%), antithrombotics at discharge (94.0% vs 85.5%), and one-month mortality (3.5% vs 4.0%). Temporal improvement was noted in 7 of 14 performance measures when the fourth BTS-Stroke quarter compared with the first quarter: intravenous thrombolysis frequency for all AIS patients (4.1% vs 3.7%), symptomatic hemorrhage after intravenous thrombolysis (3.4% vs 5.5%), lipid lowering drugs for low-density lipoprotein &gt;100 mg/dL (67.3% vs 60.5%), antithrombotics at discharge (95.5% vs 91.4%), dysphagia screening (81.9% vs 63.4%), early rehabilitation (71.7% vs 63.6%), stroke education before discharge (95.6% vs 83.4%). Conclusions: A BTS collaborative learning and campaign model can improve the guideline adherence of stroke. The GWTG-Stroke can be successfully applied to other countries outside the United States.