Acute Stroke Services Research Articles

Post stroke shoulder pain; prevalence and rates of detection on an acute stroke service

Post stroke shoulder pain; prevalence and rates of detection on an acute stroke service

Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services

BackgroundMethods for the cost-effectiveness analysis of health technologies are now well established, but such methods may also have a useful role in the context of evaluating the effects of variation in applied clinical practice. This study illustrates a general methodology for the comparative analysis of applied clinical practice at alternative institutions – risk adjusted cost-effectiveness (RAC-E) analysis – with an application that compares acute hospital services for stroke patients admitted to the main public hospitals in South Australia.MethodsUsing linked, routinely collected data on all South Australian hospital separations from July 2001 to June 2008, an analysis of the RAC-E of services provided at four metropolitan hospitals was undertaken using a decision analytic framework. Observed (plus extrapolated) and expected lifetime costs and survival were compared across patient populations, from which the relative cost-effectiveness of services provided at the different hospitals was estimated.ResultsUnadjusted results showed that at one hospital patients incurred fewer costs and gained more life years than at the other hospitals (i.e. it was the dominant hospital). After risk adjustment, the cost minimizing hospital incurred the lowest costs, but with fewer life-years gained than one other hospital. The mean incremental cost per life-year gained of services provided at the most effective hospital was under $20,000, with an associated 65% probability of being cost-effective at a $50,000 per life year monetary threshold.ConclusionsRAC-E analyses can be used to identify important variation in the costs and outcomes associated with clinical practice at alternative institutions. Such data provides an impetus for further investigation to identify specific areas of variation, which may then inform the dissemination of best practice service delivery and organisation.

Will telemedicine facilitate access to hyper acute stroke care across the UK?

Delayed and inconsistent adoption of telemedicine among many acute stroke services is undermining recent advances in acute stroke care. Widespread use of telemedicine will be required for stroke care to achieve the standards demanded by the National Stroke Strategy.

Is it beneficial to increase the provision of thrombolysis?-- a discrete-event simulation model

Although Thrombolysis has been licensed in the UK since 2003, it is still administered only to a small percentage of eligible patients. We consider the impact of investing the impact of thrombolysis on important acute stroke services, and the effect on quality of life. The concept is illustrated using data from the Northern Ireland Stroke Service. Retrospective study. We first present results of survival analysis utilizing length of stay (LOS) for discharge destinations, based on data from the Belfast City Hospital (BCH). None of these patients actually received thrombolysis but from those who would have been eligible, we created two initial groups, the first representing a scenario where they received thrombolysis and the second comprising those who do not receive thrombolysis. On the basis of the survival analysis, we created several subgroups based on discharge destination. We then developed a discrete event simulation (DES) model, where each group is a patient pathway within the simulation. Coxian phase type distributions were used to model the group LOS. Various scenarios were explored focusing on cost-effectiveness across hospital, community and social services had thrombolysis been administered to these patients, and the possible improvement in quality of life, should the proportion of patients who are administered thrombolysis be increased. Our aim in simulating various scenarios for this historical group of patients is to assess what the cost-effectiveness of thrombolysis would have been under different scenarios; from this we can infer the likely cost-effectiveness of future policies. The cost of thrombolysis is offset by reduction in hospital, community rehabilitation and institutional care costs, with a corresponding improvement in quality of life. Our model suggests that provision of thrombolysis would produce moderate overall improvement to the service assuming current levels of funding.

Abstract 2601: Neurointerventional Practice Patterns in Acute Ischemic Stroke

Background: Intra-arterial therapy (IAT) is increasingly used to treat acute ischemic stroke patients with large vessel occlusions. However, there are minimal consensus guidelines for treatment indications and performance standards. Thus we aimed to gain a better understanding of IAT practice patterns among neurointerventionalists. Methods: An internet-based survey platform ( www.iasurvey.net ) was launched to address five specific areas of IAT in acute strokes: practice setting, operator background, quality and safety, decision-making and treatment strategies. The survey was distributed electronically to members of the major worldwide neurointerventional societies. Results: Of respondents to date, 67 neurointerventionalists based in North America are included in this analysis: 58% neurologists, 27% radiologists, 15% neurosurgeons. Approximately 81% work in academic setting. Across all institutions, the average yearly volume of IA stroke cases is 52 (median 50). Each neurointerventional radiology (NIR) group consists of an average of 3 attendings, with 94% performing IAT. For 43%, activation of the NIR team is on arrival of the patient to the ED, whereas 18 of the 37 with TeleStroke capabilities are alerted after remote evaluation. IAT decisions are made jointly according to 78%, by the NIR team alone for 13% and by the acute stroke service alone for 9%. The minimum NIHSS score for consideration of IAT ranges from 4-13 (median score 8). Imaging evaluation is with CT/CTA in 85%, and with MRI in 45%. Clinical and imaging selection criteria are used in lieu of time in 40% of anterior circulation strokes and 57% of posterior circulation strokes. Despite the emphasis on imaging selection, there is pronounced variability in the specific criteria always used: noncontrast CT (NCCT) hypodensity <1/3rd MCA territory in 55%; NCCT ASPECTS in 15%; CTA source images in 40%; CT perfusion in 33%; MRI mismatch in 12%; and DWI in 22%. For infarct volume determination, 66% use visual estimation alone. Approximately half of operators (54%) prefer conscious sedation if feasible. IAT following full dose IV tPA (ie, bridging therapy) is performed by 72%. For large vessel occlusions (LVO), the Penumbra and Merci devices are the first treatments of choice among 46% and 34%, respectively; for medium sized vessels, Penumbra is preferred by 61%. Local thrombolysis is utilized as first-line therapy in LVO by only 13%, as opposed to rescue therapy for 70%. Case termination is based on time from last seen normal for 75% (range 6-11 hours for anterior circulation). Conclusions: We present a comprehensive study examining real-world practice patterns for IAT in acute ischemic stroke patients. While data collection continues, these early results illustrate the significant variation among neurointerventionalists in the use of this treatment modality. Our findings highlight the need for evidence based practice guidelines.

Abstract 2493: Enrollment In Early Brain Stimulation Arm Motor Recovery Studies Is Limited Primarily By Stimulation-unrelated Exclusions Including Ethnic And Racial Characteristics

Introduction: The high incidence of disability related to upper extremity (UE) motor impairments in stroke has led to an increasing number of clinical trials of UE motor interventions. These now include transcranial magnetic stimulation (TMS) and direct current stimulation (TDCS). Trial enrollment criteria typically depend on isolated unilateral motor impairments, a single acute stroke, with limited co-morbidities, and criteria specific to the intervention. Objectives: To determine the frequency of stimulation trial candidates in an acute stroke population, evaluate the impact of stimulation-specific exclusion criteria in trial recruitment, and examine how potential participants differ from the broader stroke population. Methods: 1701 patients evaluated at an urban academic acute stroke service over a 3 year-period were screened for a TDCS trial. Demographics, stroke characteristics were recorded prospectively. Results: This was a young (mean 58.8 +14.8 yr), predominantly male (60.6%), and racially and ethnically mixed population (non-Hispanic white 38.1%, Hispanic 21.4%, AA 32.8%, Asian 2.6%, others 5.0%). Only 29 subjects met eligibility criteria (1.7%). The five most common causes for exclusion were in descending order: 1) UE motor impairment normal or complete, 2) old strokes causing weakness, 3) stroke mimics, 4) hemorrhagic strokes, 5) severe medical conditions. African American (AA) patients trended towards less likelihood of eligibility for participation (1.09%) then the other ethnic/racial groups (p=0.2). AA patients were more likely to have had old strokes causing weakness than other patients (p < 0.001), and this was the most common cause of their exclusion. 2.88% were excluded for stimulation related reasons. 8 individuals refused participation (1 non-hispanic white, 2 females). Minority men were more likely to refuse participation than minority women and non-Hispanic white patients (p=0.008). Demographics of the 21 enrolled participants were not significantly different (age 62.0+12.0 yr, 57.1% women, non-Hispanic white 52.4%, Hispanic 23.8%, AA 14.3%, Asian 9.5%). Conclusion: In this urban multiracial sample, potential participants for brain stimulation trials are rare, and the main reasons for exclusion are suitable motor impairments and stroke lesion characteristics. Exclusions specific to the stimulation intervention were few. African Americans had old strokes causing hemiparesis limiting their eligibility. Techniques to recruit minority men to stroke recovery studies require improvement. When recruiting for highly refined study populations, racial and ethnic differences in stroke characteristics and research participation are important.

Abstract 2389: The Utility of the Modified Early Warning Score in Acute Stroke Patients

Introduction. The Modified Early Warning Score (MEWS) is a tool for estimating risk of death or poor outcome in the Emergency Department (ED). It is a 0-14 point score based on initial physiological observations including heart rate, respiratory rate, systolic blood pressure, temperature and level of consciousness. In Acute medical patients, a score > 4 has been found to be associated with increased risk of death. The score is being widely adopted for use as a risk stratification tool for patients admitted through EDs and in Acute Medical Assessment Units and has been used in stroke patients but has not been validated for acute stroke. We applied the score to a population of acute stroke patients admitted through ED to determine its utility. Methods. Records on consecutive patients admitted through ED to an acute stroke service of an inner city university teaching hospital over 8 months were identified and MEWS calculated for each. Patients dying within 6 months or with a prolonged hospital stay (>42 days) were identified. Results. 132 subjects (Mean age 71, 59% male) were admitted to the service, 122 were admitted through ED. Median MEWS was 1 (range 0-4) and 18 (17%) died within 6 months. Subjects with a MEWS>2 were significantly more likely to die (10/91 vs 10/31 p=0.006 Chi square. O.R. 3.9 (1.4-10.5)) and those who survived more likely to have a prolonged length of stay (21/81 vs 11/21 p=0.02. Chi square. O.R 3.1 (1.2-8.5)). As a tool for identifying those with acute stroke risk of dying the MEWS performed only moderately well (PPV 0.5, NPV 0.68). Conclusion. As part of a screening test for stroke patients a MEWS>2 at ED admission is associated with worse outcome however it is neither sensitive or specific enough to be used in isolation as a means of triaging stroke patients into risk categories.

Abstract 3537: Patient and Family Perceptions of the Quality of Acute Stroke Services: Findings from a Multi-Center National Study of the STROKE Perception Report

Background: The STROKE Perception Report is a valid and reliable instrument for assessment of patients’ and family members’ perceptions of the quality of acute stroke services. We examined differences in perceptions of acute stroke hospital care quality in relation to responder characteristics. Methods: As part of a psychometric analysis, data were collected from June 2010-July 2011 at 35 Stroke Centers in the continental U.S. and Hawaii. A special family instrument was used for patients with cognitive, level of consciousness, or communication issues that prevented direct patient response. Data collection occurred at the time of hospital discharge following completion of all interactions with hospital staff in a private area; surveys were sealed in de-identified envelopes once complete and submitted to independent investigators blinded to hospital sites for entry/analyses by Chi-square, Student’s t-test and logistic regression with SAS. RESULTS: A total of 1029 surveys were returned (761 [74%] patient, 268 [26%] family) with an overall complete response rate of 99.8%. Racial characteristics and ethnicity for the overall sample showed 72% white, 19% African American, 6% Asian, 2% Native Hawaiian/Pacific Islander and 1% American Indian/Alaska Native with 7% responding as Hispanic ethnicity. Education for the overall sample showed 87% of the participants graduated high school with 28% having a 4-year college degree or higher; higher educated family members were more likely to complete the survey (OR 1.178, 95% CI 1.045-1.328, p=0.0074). Length of stay (LOS) averaged 5%/-4.3 (range=1-59 days); the odds of family members acting as survey respondees was significantly associated with an increased LOS (OR 1.14, 95%CI 1.098-1.192, p<0.0001). There was no difference in the perception of care quality by race, ethnicity, or LOS. Lowest rated quality items overall were in the 'Education to Prevent and Respond to Stroke' scale, while the highest rated quality items were in the 'Caring' scale. Patients were more likely to express displeasure over the way nurses treated their family members (p<0.0001), and were more likely to state that their nurses (p=0.015) and physicians (p=0.0009) did not teach them about the warning signs for a stroke as compared to family member perceptions. Recall of educational content pertinent to stroke between patients and family members was different for facial droop (16% vs.8%; p= 0.001) and sudden onset of speech difficulty (11% vs. 5%; p= 0.016), with more patients stating these were not signs of stroke. People with a higher education were more likely to state that the nurses (p= 0.0014) and doctors (0.012) did not educate them about post-hospitalization care. Conclusions: The STROKE Perception Report provides insight into how patients and family members perceive the quality of acute stroke service, enabling ongoing performance improvement.

Abstract NS 1: S troke T reatment, R isk Factors, O utcome K nowledge and E ducation (STROKE) Perception Report: Final Results of the Prospective National Multicenter Validation Study of Instrument Validity and Reliability

Background: Measurement of patient perception of the quality of acute stroke care is an expectation for certified Stroke Centers, yet no valid and reliable instrument specific to the needs of stroke patients has been available for this purpose. We developed the STROKE Perception Report through a process consisting of 5 years of qualitative and quantitative research, culminating in a national prospective multi-center study and psychometric analysis. Methods: The final instrument was the product of 2 qualitative and 2 quantitative phases of study into the characteristics of acute stroke hospital care valued most by patients and families. The instrument consists of 39 items divided into 3 scales: Action to Diagnose and Treat Stroke; Caring; and Education to Prevent and Respond to Stroke. 35 study sites were recruited from the continental U.S. and Hawaii to participate in the study, with instrument testing commencing June 2010 and ending July 2011. Patients admitted with acute stroke completed the instrument unless disabled by cognitive, level of consciousness, or language dysfunction, whereby the family member with the most hospitalization exposure completed a family version of the instrument. Data were confidentially collected at the point of hospital discharge after all contact with hospital staff was complete, and entered and analyzed by investigators independent of participating institutions and blinded to the identity of each instrument’s originating hospital site. Analyses included Chronbach alpha internal consistency reliability, and exploratory factor analysis using principal components with varimax rotation for construct validity. Results: A total of 1029 completed instruments were received for analysis. Chronbach’s alpha scores ranged from .92 to .95 for the patient version and .92 to .94 for the family version of the instrument, demonstrating excellent reliability. Content validity was initially established by 5 panelists aware of the qualitative findings from phase 1 and 3 of the study, resulting in a content validity ratio of .99. Factor analysis testing indicated that each of the 3 scales within the instrument (Action to Diagnose and Treat Stroke; Caring; and Education to Prevent and Respond to Stroke) are capable of validly measuring their defined dimensions of patient/family perception, with factor loadings ranging from .63 to .89 for individual items overall. Individual Stroke Center reports that provide benchmark comparisons of patients’ perception of the quality of acute stroke services among participating hospitals were produced quarterly and resulted in positive feedback from program administrators and TJC PSC Reviewers during on-site certification visits. Conclusions: The STROKE Perception Report is the first and only valid and reliable instrument designed to capture both patients’ and family members’ perceptions of the quality of acute stroke services.

PO.10 The successful transformation of acute stroke services in London. A model for other major metropolitan cities?

Stroke continues to be one of the main causes of disability with substantial human and economic costs. The 2004 and 2006 National Sentinel Stroke Audits showed that the overall standard...

Acute Stroke Nursing Jane Williams , LinPerry and CarolineWatkins Acute Stroke NursingWiley-Blackwell368£32.5097814051610461405161043

ALTHOUGH AIMeD at acute stroke services, this book provides a good basis for members of the multidisciplinary team, especially all medical and neuroscience nurses. It incorporates assessment and nursing interventions, and anatomy and physiology, and addresses chronic care management and rehabilitative interventions that assist in theimplementation of a patient’s holistic needs.

Predictors of early arrival at the emergency department in acute ischaemic stroke

A requirement of an effective acute stroke service is the early arrival of patients to the hospital emergency department (ED). This will allow the possible use of thrombolytic therapy or other acute interventions within a limited time window. We investigated the predictors of early arrival in a single hospital serving a mixed urban and rural catchment area. A retrospective review of all case notes for 1 year was performed. Of 105 acute strokes, 91 were cerebral infarcts and a total of 71 cases presenting initially to the ED had timing available for analysis. 39.4% presented within 3 h, and 12.7% were potentially suitable for thrombolysis. Those living closer to the hospital were not more likely to arrive within 3 h (Z = -0.411, p = 0.68). Presenting directly to the hospital by emergency services (or private transport) was significantly associated with early arrival in a univariate comparison (p < 0.001), and in a multivariate model. The only independent predictor of early arrival to the ED is direct presentation. Improved public education of the importance of recognition of stroke symptoms and rapid contact with the emergency services will improve the early attendance following acute stroke, allowing increased use of acute stroke treatments.

Striking Rural-Urban Disparities Observed in Acute Stroke Care Capacity and Services in the Pacific Northwest

The age-adjusted stroke death rate in adults aged ≥45 years is significantly higher in the Northwest region than in the rest of the United States. Alaska, Idaho, Montana, Oregon, and Washington have substantial rural and frontier areas with unique characteristics and complexities that pose challenges to timely acute stroke care and ultimately affect the patient. A regional needs assessment was conducted to assess acute stroke care capacity and services in the Northwest region. Hospitals with an emergency department were surveyed with a standardized online tool based on the Brain Attack Coalition recommendations and developed by stroke neurologists, emergency medical services leaders, state public health professionals, and American Stroke Association members. Approximately 76% of hospitals completed the questionnaire. Striking rural-urban differences were seen with rural hospitals having a much lower capacity to adequately care for patients with stroke. Two thirds lacked the necessary personnel, one third lacked necessary neuroimaging equipment, and one fourth were functioning without written emergency department and tissue plasminogen activator stroke protocols. This survey represents the first comprehensive regional assessment of stroke care capacity and services both in the Northwest region and the whole United States. The findings have confirmed the need to focus on strengthening stroke personnel, increasing access to care, and promoting written protocols, especially in rural settings. Additionally, promoting stroke center certification, increasing the number of stroke registries throughout the region, encouraging use of inpatient stroke care protocols in rural hospitals, and conducting ongoing stroke care capacity and services surveys is highly recommended.

The palliative care needs of acute stroke patients: a prospective study of hospital admissions

despite a mortality rate of approximately 30% in acute stroke, little is known about the palliative care needs of this group of patients. prospective study of 191 acute stroke patients admitted to hospital in England. Biographical, medical and stroke-related data were collected. Participants completed the Sheffield Profile for Assessment and Referral to Care (SPARC), a screening tool for referral to specialist palliative care. over 50% reported moderate to significant fatigue-related problems. Approximately 50% reported symptom-related problems (e.g. pain) or psychological distress (e.g. anxiety). Approximately 25% had concerns about death or dying, and 66% had concerns about dependence and disability. Over 50% were worried about the impact of stroke on family members. There were significant main effects of dependence (Barthel Index) (F(1,123) = 12.640 P = 0.001) and age (F(4,123) = 3.022 P = 0.020), and a significant three-factor interaction between dependence, age and co-morbidities (F(9,123) = 2.199 P = 0.026) in predicting total SPARC scores. acute stroke patients have a high prevalence of palliative care needs. Acute stroke services should use the SPARC for needs assessment. Priority for assessment should be given to patients with a score of <15/20 on the Barthel Index, a tool already used in most stroke services.

Systematic Review of Process Indicators: Including Early Rehabilitation Interventions Used to Measure Quality of Acute Stroke Care

Stroke is a leading cause of disease burden. The quality of care provided in hospitals can affect outcome. Therefore, examining adherence to clinically important processes of care can help improve care delivery and patient outcomes. However, knowing which process indicators to measure is essential. Systematically review process indicators used to evaluate acute stroke services, including early rehabilitation interventions, and assess whether published indicators conform to clinical guidelines. Publications (1985-2006) were identified by systematically searching databases (e.g. Medline and Cochrane Library), and the internet using free text terms: 'stroke unit', 'process', 'quality', 'mobilisation', 'acute', and 'early rehabilitation'. Publications describing process indicators relating to the first 2 weeks of in-patient stroke care were included. Process indicators were categorised according to six clinical process domains covering the acute stroke admission. Commonly cited indicators (>or=6 publications) were then mapped to the 2003 Australian clinical guidelines. Sixty potential studies were found from title and abstract. Following full text review, 32 publications were retained. Of the 161 process indicators identified, 43 were commonly cited. Seventy-nine per cent of commonly cited indicators were found in the guidelines. The level of evidence underpinning each indicator ranged from low 'expert opinion' (59%), to high, 'level 1' (12%) evidence. Indicators related to rehabilitation were rare. Many acute stroke process indicators have been published. However, a quarter did not align with current clinical guidelines. Developing an 'ideal set' of process indicators to reflect the evidence base seems sensible and should include rehabilitation interventions.

Stroke Rehab Down Under: Can Rupert Murdoch, Crocodile Dundee, and an Aboriginal Elder Expect the Same Services and Care?

Australia is the world’s sixth largest country, has a relatively small population of 21.5 million, and a blended (public and private) health system. In this article, we explain the stroke rehabilitation infrastructure including consumer organisations, research networks, data collection systems, and registries. This represents a complex but fledgling set of organisations showing great promise for coordination of care and research. The article goes on to expose the inequalities in service provision by describing the paths of stroke survivors in three settings – in the city, in the country, and in remote settings. The complexities and difficulties in treating indigenous stroke survivors are described in a culturally sensitive narrative. The article then discusses the outcomes of the first Australian audit of post acute stroke services completed in December 2008, which describes the journeys of 2,119 stroke survivors at 68 rehabilitation units throughout Australia’s 6 states and 2 territories. It demonstrates an average length of stay of 26 days, with 18% of survivors requiring nursing home or other supported accommodation. The article concludes with future directions for stroke rehabilitation in Australia, which include hyperacute rehabilitation trials, studies in 7-days-a-week rehabilitation, and the potential use of robotics.

Stroke Rehab Down Under: Can Rupert Murdoch, Crocodile Dundee, and an Aboriginal Elder Expect the Same Services and Care?

Australia is the world's sixth largest country, has a relatively small population of 21.5 million, and a blended (public and private) health system. In this article, we explain the stroke rehabilitation infrastructure including consumer organisations, research networks, data collection systems, and registries. This represents a complex but fledgling set of organisations showing great promise for coordination of care and research. The article goes on to expose the inequalities in service provision by describing the paths of stroke survivors in three settings - in the city, in the country, and in remote settings. The complexities and difficulties in treating indigenous stroke survivors are described in a culturally sensitive narrative. The article then discusses the outcomes of the first Australian audit of post acute stroke services completed in December 2008, which describes the journeys of 2,119 stroke survivors at 68 rehabilitation units throughout Australia's 6 states and 2 territories. It demonstrates an average length of stay of 26 days, with 18% of survivors requiring nursing home or other supported accommodation. The article concludes with future directions for stroke rehabilitation in Australia, which include hyperacute rehabilitation trials, studies in 7-days-a-week rehabilitation, and the potential use of robotics.

Upgraded Acute Stroke Care Including Thrombolysis Is Associated with Reduced Length of Hospital Stay among Non-Stroke Patients

Background: Implementing thrombolytic therapy in a stroke unit (SU) profoundly affects the resources available to all patients admitted for suspected acute stroke. We examined the benefits of an acute stroke service to non-stroke patients in terms of length of hospitalization, and estimated the economic impact in terms of derived costs. Methods: We performed a historical follow-up study of 792 non-stroke patients admitted to our SU for suspected stroke before, during and after implementing thrombolysis as part of our service. Data on demographic and clinical characteristics, including imaging data and final diagnoses, and length of stay (LOS) were collected prospectively. Multivariate logistic regression analysis was performed to identify variables associated with LOS. Results: Median LOS for non-stroke patients in the SU decreased from 43.8 h (interquartile range, 19–96) to 23.5 h (16–44) after implementing thrombolytic therapy. Total hospital LOS for non-stroke patients decreased from 52.7 (22–147) to 28.7 (21–124) h during the same period. Initial magnetic resonance imaging was associated with shorter LOS in the SU. The derived cost reductions from shorter LOS reduced the costs of implementing recombinant tissue plasminogen activator treatment. Conclusions: Stroke care reorganization following the introduction of thrombolytic treatment was associated with a 50% reduction in LOS for non-stroke patients admitted to the SU. Reduced LOS in the SU for non-stroke patients could further add to the cost-effectiveness of thrombolytic treatment.

CT Protocol for Acute Stroke: Tips and Tricks for General Radiologists

Acute stroke services have been installed in most hospitals in the industrialized world, and dealing with hyperacute stroke has become one of the most frequently performed tasks of the on-call radiologist. Imaging plays a key role in current guidelines for thrombolysis, and knowledge of classic early ischemic signs or depiction of hemorrhage at nonenhanced computed tomography (CT) is necessary (although not sufficient) for a satisfactory imaging study. A modern CT examination must also include perfusion CT and CT angiography. Perfusion CT delineates the ischemic tissue (penumbra) by showing increased mean transit time with decreased cerebral blood flow (CBF) and normal or increased cerebral blood volume (CBV), whereas infarcted tissue manifests with markedly decreased CBF and decreased CBV. CT angiography can depict the occlusion site, help grade collateral blood flow, and help characterize carotid atherosclerotic disease. A complete CT study (nonenhanced CT, perfusion CT, and CT angiography) may be performed and analyzed rapidly and easily by general radiologists using a simple standardized protocol and may even facilitate diagnosis by less experienced radiologists in affected patients.

Setting up An Acute Stroke Service

The administration of intravenous thrombolytic therapy to appropriate patients and the provision of care in a dedicated stroke unit setting form the pillars of evidence-based acute stroke care. Yet, the availability of these interventions remains variable around the world. Many challenges exist for physicians attempting to set up an acute stroke service for the first time. Based upon their experience in three countries, the authors propose 12 key steps in setting up a successful acute stroke service: *identify the building blocks *understand local funding mechanisms *forge partnerships *engage senior managers *obtain training *be inclusive *adapt to local surroundings *maintain a clinical focus *be incremental *capitalise on the enthusiasm of others *lead from the front; and *provide feedback. The authors then examine some of the specific barriers that may be encountered and offer three historical examples of evidence-based interventions that were slow to be adopted. An acute stroke service is evidence-based and cost effective, yet the ability of patients to access such a service is variable, even in the developed world. By considering 12 common sense steps, physicians and managers can maximise their chances of setting up a sustainable and successful acute stroke service.