Certified Stroke Unit Research Articles

Predictors of spontaneous intracerebral hemorrhage mortality: a community-based study in Brno, Czech Republic.

Intracerebral hemorrhage (ICH) is a serious medical condition with high mortality. However, factors leading to long-term mortality after ICH are largely unclear. The aim of this community-based study is to assess predictors of long-term mortality after spontaneous ICH. We identified all patients admitted with spontaneous ICH to hospitals with a certified stroke unit in Brno, the second largest city in the Czech Republic (CR), in 2011, the year of the Czech Population and Housing Census. We reviewed their medical records for risk factors, radiographic parameters, and measures of post-stroke neurological deficit [National Institutes of Health Stroke Scale (NIHSS)]. Using the dates of death from the Czech National Mortality Register, we calculated mortality at 30days, six months, one year, and three years after the ICH. Multivariate analysis with forward stepwise logistic regression was performed to determine independent predictors of mortality (p < 0.05). In 2011, 1086 patients with stroke were admitted to the four stroke-certified hospitals in Brno, CR. Of these, 134 had spontaneous ICH, with complete data available in 93 of them entering the final analysis. The mortality at 30days, 6months, 1year, and 3years post-ICH was 34%, 47%, 51%, and 63%, respectively. The mortality was highest in the first few days post-event, with 50% of patients dying in 255days and average survival being 884 ± 90days. Both NIHSS and modified ICH (MICH) score showed to be strong and reliable predictors of short- as well as long-term mortality; the risk of death post-ICH increased with older age and size of ICH. Other risk factors contributing to higher, primarily shorter-term mortality included history of cardiac failure, myocardial infarction, or atrial fibrillation. In our community-based study, we found that severity of neurological deficit at admission (NIHSS), combined with age and size of ICH, well predicted short- as well as long-term mortality after spontaneous ICH. A history of cardiac failure, myocardial infarction, or atrial fibrillation at presentation were also predictors of mortality, underscoring the need for optimal cardiac management in patients with ICH.

Association of Centre Quality Certification with Characteristics of Patients, Management, and Outcomes Following Carotid Endarterectomy or Carotid Artery Stenting.

Background: The aim of this study was to analyze the association between center quality certifications and patients' characteristics, clinical management, and outcomes after carotid revascularization. Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the Bavarian subset of the nationwide German statutory quality assurance carotid database. Hospitals were classified as to whether a certified vascular center (cVC) or a certified stroke unit (cSU) was present on-site or not. The primary outcome event was any stroke or death until discharge from the hospital. Results: In total, 31,793 cases were included between 2012 and 2018. The primary outcome rate in asymptomatic patients treated by CEA ranged from 0.7% to 1.5%, with the highest rate in hospitals with cVC but without cSU. The multivariable regression analysis revealed a significantly lower primary outcome rate in centers with cSU in asymptomatic patients (aOR 0.69; 95% CI 0.56-0.86; p < 0.001). In symptomatic patients needing emergency treatment, the on-site availability of a cSU was associated with a significantly lower primary outcome rate (aOR 0.56; 95% CI 0.40-0.80; p < 0.001), whereas the presence of a cVC was associated with higher risk (aOR 3.07; 95% CI 1.65-5.72). Conclusions: This study provides evidence of statistically significant better results in some sub-cohorts in certified centers. In centers with cSU, the risk of any stroke or death was significantly lower in asymptomatic patients receiving CEA or symptomatic patients treated by emergency CEA.

Echocardiography in acute stroke patients: a nationwide analysis in departments with certified stroke units in Germany

BackgroundEchocardiography is highly relevant in patients with ischemic stroke or TIA. Utilization of routine echocardiographic examinations [transthoracic (TTE) or transesophageal (TEE)] on stroke units remains however unknown. To representatively examine echocardiographic rates on stroke units in Germany and to evaluate structural factors that may influence the decision to conduct echocardiography.MethodsA nationwide analysis was performed by using certification audit data of all primary and comprehensive stroke centers (pSC and cSC) in Germany.ResultsStructural and organizational requirements of 310 departments (cSCs: 42.6%) were extracted. Median TTE rate was 63.3% (IQR 39.3–80.8), median TEE rate 21.3% (IQR 16.4–29.5). A cardiological department on site was present in 74.2%, and they were associated with higher TEE rates. TTE rates decreased with increasing numbers of patients (p = 0.026). Likewise, TEE rates decreased with increasing numbers of patients (p = 0.006), mediated by departments with cSCs (p = 0.008 for cSCs vs p = 0.230 for pSCs). TTE rates were far more inhomogeneously distributed than TEE rates and higher in pSCs (p = 0.011). Overall, 12.9% of centers did not perform any echocardiographic examination in at least 50% of all stroke patients.ConclusionMore detailed recommendations regarding echocardiography should be included in future guidelines. Moreover, evaluating the impact of echocardiographic examinations on long-term prognosis in stroke patients should be focus of further evaluations.

Implementability of collecting patient-reported outcome data in stroke unit care \u2013 a qualitative study

BackgroundPatient-reported outcome measures (PROMs) assess patient-relevant effects of medical treatments. We aimed to evaluate the implementation of the International Consortium for Health Outcomes Measurement Standard Set for Stroke (ICHOM-SSS) into routine inpatient care of a stroke unit.MethodsThe ICHOM-SSS was administered in a certified stroke unit during and after inpatient care. Semi-structured interviews with medical staff (n = 5) and patients or their proxies (n = 19) about their experience were audio-recorded and analysed using thematic analyses. Implementation outcomes were chosen in advance and adhered to current standards of implementation science.ResultsPatients perceived the ICHOM-SSS to be relevant and feasible. They reported limited understanding of why the assessment was introduced. The overall acceptance of using PROMs was high. While medical staff, too, perceived the assessment to be appropriate and relevant, their appraisal of feasibility, sustainability, and their acceptance of the implementation were low.ConclusionsFor a sustainable implementation of PROMs in clinical practice, IT resources need to be adapted, medical care needs to be reorganized, and additional clinical resources are required. Future research should investigate benefits of the ICHOM-SSS and a simpler, automated implementation in stroke care.Trial registrationClinicalTrials.gov Identifier: NCT03795948, retrospectively registered on 8 January 2019.

Predictors of Short- and Long-Term Mortality in Ischemic Stroke: A Community-Based Study in Brno, Czech Republic

Background and Objective: Short- and long-term mortality following ischemic stroke (IS) and their predictors have not been defined in the Czech population, and studies on long-term mortality are largely missing for the populations of Central Europe. Methods: Using the National Register of Hospitalized Patients and the Czech National Mortality Registry, we analyzed data on 1-month, 1-year, and 3-year all-cause mortality for patients admitted with IS to any of the 4 hospitals with a certified stroke unit in Brno, Czech Republic, in 2011. We reviewed discharge summaries and recorded potential factors impacting mortality after the index stroke event. Using univariate and multivariable analyses, we identified predictors of mortality at all 3 time points. Results: In our multivariable model, statin use (odds ratio [OR] 0.095, p < 0.0001), age at stroke (OR 1.03, p = 0.0445), and admission National Institutes of Health Stroke Scale (NIHSS) score (OR 1.16, p < 0.0001) predicted 1-month mortality, while statin use (OR 0.43, p = 0.0004), history of cardiac failure (OR 2.17, p = 0.0137), age at stroke (OR 1.07, p < 0.0001), and admission NIHSS score (OR 1.14, p < 0.0001) predicted 1-year mortality. Statin use (OR 0.54, p = 0.0051), history of cardiac failure (OR 2.13, p = 0.0206), age at stroke (OR 1.07, p < 0.0001), and admission NIHSS score (OR 1.11, p < 0.0001) also predicted 3-year mortality. Conclusions: Our study is the first to report data on short- and long-term mortality rates and their predictors in patients hospitalized with IS in the Czech population. Our results indicate that mortality rates and predictors of mortality are consistent with those reported in studies from other populations throughout the world.

Multicenter Prospective Analysis of Hypertrophic Olivary Degeneration Following Infratentorial Stroke (HOD-IS): Evaluation of Disease Epidemiology, Clinical Presentation, and MR-Imaging Aspects

Introduction: Ischemic and hemorrhagic strokes in the brainstem and cerebellum with injury to the functional loop of the Guillain-Mollaret triangle (GMT) can trigger a series of events that result in secondary trans-synaptic neurodegeneration of the inferior olivary nucleus. In an unknown percentage of patients, this leads to a condition called hypertrophic olivary degeneration (HOD). Characteristic clinical symptoms of HOD progress slowly over months and consist of a rhythmic palatal tremor, vertical pendular nystagmus, and Holmes tremor of the upper limbs. Diffusion Tensor Imaging (DTI) with tractography is a promising method to identify functional pathway lesions along the cerebello-thalamo-cortical connectivity and to generate a deeper understanding of the HOD pathophysiology. The incidence of HOD development following stroke and the timeline of clinical symptoms have not yet been determined in prospective studies—a prerequisite for the surveillance of patients at risk.Methods and Analysis: Patients with ischemic and hemorrhagic strokes in the brainstem and cerebellum with a topo-anatomical relation to the GMT are recruited within certified stroke units of the Interdisciplinary Neurovascular Network of the Rhine-Main. Matching lesions are identified using a predefined MRI template. Eligible patients are prospectively followed up and present at 4 and 8 months after the index event. During study visits, a clinical neurological examination and brain MRI, including high-resolution T2-, proton-density-weighted imaging, and DTI tractography, are performed. Fiberoptic endoscopic evaluation of swallowing is optional if palatal tremor is encountered.Study Outcomes: The primary endpoint of this prospective clinical multicenter study is to determine the frequency of radiological HOD development in patients with a posterior fossa stroke affecting the GMT at 8 months after the index event. Secondary endpoints are identification of (1) the timeline and relevance of clinical symptoms, (2) lesion localizations more prone to HOD occurrence, and (3) the best MR-imaging regimen for HOD identification. Additionally, (4) DTI tractography data are used to analyze individual pathway lesions. The aim is to contribute to the epidemiological and pathophysiological understanding of HOD and hereby facilitate future research on therapeutic and prophylactic measures.Clinical Trial Registration: HOD-IS is a registered trial at https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020549.

Interdisciplinary networking for optimal treatment decision-making : Fast decision-making in acute ischemic stroke management

Every year, about 270,000 strokes occur in Germany. In the entire DACH region (Germany, Austria, Switzerland), more than 310,000cases are reported each year. Two thirds of the surviving patients are dependent on external assistance after the stroke. Increasingly, imaging data are becoming the focus of treatment decisions. These data provide critical information about the location and extent of vessel occlusion, infarct size, volume of salvageable brain tissue, and degree of collateralization. Certified stroke units and stroke networks already specialize in state-of-the-art therapeutic options, but they need additional information technology tools to deliver the right therapy to the right patient population as quickly as possible. For multidisciplinary, seamless support in stroke care, both prehospital and in-hospital processes need to be optimized. This article presents aconcept for supraregional stroke care by means of networking all involved actors in the prehospital as well as in the in-hospital area. Further needs analyses should ensure the implementation as well as the generalizability to different regions.

Systematic monitoring for detection of atrial fibrillation in patients with acute ischaemic stroke (MonDAFIS): a randomised, open-label, multicentre study

Systematic electrocardiogram (ECG) monitoring improves detection of covert atrial fibrillation in stroke survivors but the effect on secondary prevention is unknown. We aimed to assess the effect of systematic ECG monitoring of patients in hospital on the rate of oral anticoagulant use after 12 months. In this investigator-initiated, randomised, open-label, parallel-group multicentre study with masked endpoint adjudication, we recruited patients aged at least 18 years with acute ischaemic stroke or transient ischaemic attack without known atrial fibrillation in 38 certified stroke units in Germany. Patients were randomly assigned (1:1) to usual diagnostic procedures for atrial fibrillation detection (control group) or additional Holter-ECG recording for up to 7 days in hospital (intervention group). Patients were stratified by centre using a random permuted block design. The primary outcome was the proportion of patients on oral anticoagulants at 12 months after the index event in the intention-to-treat population. Secondary outcomes included the number of patients with newly diagnosed atrial fibrillation in hospital and the composite of recurrent stroke, major bleeding, myocardial infarction, or death after 6 months, 12 months, and 24 months. This trial was registered with ClinicalTrials.gov, NCT02204267, and is completed and closed for participants. Between Dec 9, 2014, and Sept 11, 2017, 3465 patients were randomly assigned, 1735 (50·1%) to the intervention group and 1730 (49·9%) to the control group. Oral anticoagulation status was available in 2920 (84·3%) patients at 12 months (1484 [50·8%] in the intervention group and 1436 [49·2%] in the control group). For the primary outcome, at 12 months, 203 (13·7%) of 1484 patients in the intervention group versus 169 (11·8%) of 1436 in the control group were on oral anticoagulants (odds ratio [OR] 1·2 [95% CI 0·9-1·5]; p=0·13). Atrial fibrillation was newly detected in patients in hospital in 97 (5·8%) of 1714 in the intervention group versus 68 (4·0%) of 1717 in the control group (hazard ratio [HR] 1·4 [95% CI 1·0-2·0]; p=0·024). The composite of cardiovascular outcomes and death did not differ between patients randomly assigned to the intervention group versus the control group at 24 months (232 [13·5%] of 1714 vs 249 [14·5%] of 1717; HR 0·9 [0·8-1·1]; p=0·43). Skin reactions due to study ECG electrodes were reported in 56 (3·3%) patients in the intervention group. All-cause death occured in 73 (4·3%) patients in the intervention group and in 103 (6·0%) patients in the control group (OR 0·7 [0·5-0·9]). Systematic core centrally reviewed ECG monitoring is feasible and increases the detection rate of atrial fibrillation in unselected patients hospitalised with acute ischaemic stroke or transient ischaemic attack, if added to usual diagnostic care in certified German stroke units. However, we found no effect of systematic ECG monitoring on the rate of oral anticoagulant use after 12 months and further efforts are needed to improve secondary stroke prevention. Bayer Vital. For the German translation of the abstract see Supplementary Materials section.

Swiss guidelines for the prehospital phase in suspected acute stroke

Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.

Interdisziplinäre neurovaskuläre Netzwerke: eine Standortbestimmung

In order to treat the complete spectrum of neurovascular diseases at a high level of quality, which goes beyond the purely acute treatment of stroke, the German Stroke Society (DSG) together with the German Societies for Neurosurgery and Neuroradiology developed a certification procedure for neurovascular networks (NVN). Structurally, a NVN consists of acoordinating center with at least three neurovascular network partners with a certified stroke unit. From 2018 to 2020 a total of 15 NVN have so far been audited and certified according to this new standard. How efficient are the NVN? Are high standards maintained? The reports of the audits were analyzed. The data were taken from the period 2017-2019. The 15 NVN treated a total of 86,510 stroke patients in the years examined and were networked with a total of 107 partner clinics, which were situated an average of 25 km from the coordinating center and transferred a total of 2726 patients. The coordinating centers performed 2463 thrombectomies and treated 2383 patients with nontraumatic intracerebral bleeding. In 712 patients with acute aneurysmatic subarachnoid hemorrhages endovascular treatment was carried out and clipping in 401. The audit was successful in the majority of the NVN. The certification process of NVN has been successfully established and the audits proved to be auseful instrument for quality control and improvement. The 15 NVN are highly efficient and treat more than one quarter of stroke patients in German stroke units.

Two years\u2019 experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke)

BackgroundTelemedicine improves the quality of acute stroke care in rural regions with limited access to specialized stroke care. We report the first 2 years’ experience of implementing a comprehensive telemedical stroke network comprising all levels of stroke care in a defined region.MethodsThe TRANSIT-Stroke network covers a mainly rural region in north-western Bavaria (Germany). All hospitals providing acute stroke care in this region participate in TRANSIT-Stroke, including four hospitals with a supra-regional certified stroke unit (SU) care (level III), three of those providing teleconsultation to two hospitals with a regional certified SU (level II) and five hospitals without specialized SU care (level I). For a two-year-period (01/2015 to 12/2016), data of eight of these hospitals were available; 13 evidence-based quality indicators (QIs) related to processes during hospitalisation were evaluated quarterly and compared according to predefined target values between level-I- and level-II/III-hospitals.ResultsOverall, 7881 patients were included (mean age 74.6 years ±12.8; 48.4% female). In level-II/III-hospitals adherence of all QIs to predefined targets was high ab initio. In level-I-hospitals, three patterns of QI-development were observed: a) high adherence ab initio (31%), mainly in secondary stroke prevention; b) improvement over time (44%), predominantly related to stroke specific diagnosis and in-hospital organization; c) no clear time trends (25%). Overall, 10 out of 13 QIs reached predefined target values of quality of care at the end of the observation period.ConclusionThe implementation of the comprehensive TRANSIT-Stroke network resulted in an improvement of quality of care in level-I-hospitals.

Stroke prevention in patients with acute ischemic stroke and atrial fibrillation in Germany - a cross sectional survey

BackgroundAtrial fibrillation (AF) is present in 15–20% of patients with acute ischemic stroke. Oral anticoagulation reduces the risk of AF-related recurrent stroke but clinical guideline recommendations are rather vague regarding its use in the acute phase of stroke. We aimed to assess the current clinical practice of medical stroke prevention in AF patients during the acute phase of ischemic stroke.MethodsIn April 2017, a standardized anonymous questionnaire was sent to clinical leads of all 298 certified stroke units in Germany.ResultsOverall, 154 stroke unit leads participated (response rate 52%). Anticoagulation in the acute phase of stroke is considered feasible in more than 90% of AF patients with ischemic stroke. Clinicians assume that about two thirds of all AF patients (range 20–100%) are discharged on oral anticoagulation. According to local preferences, acetylsalicylic acid is given orally in the majority of patients with delayed initiation of oral anticoagulation. A non-vitamin K-dependent oral anticoagulant (NOAC) is more often prescribed than a vitamin K-dependent oral anticoagulant (VKA). VKA is more often chosen in patients with previous VKA intake than in VKA naive patients. In the minority of patients, stroke unit leads discuss the prescription of a specific oral anticoagulant with the treating general practitioner. Adherence to medical stroke prevention after hospital discharge is not assessed on a regular basis in any patient by the majority of participating stroke centers.ConclusionsEarly secondary stroke prevention in AF patients in German stroke units is based on OAC use but prescription modalities vary in clinical practice.

Abstract WP355: Quality of Stroke Care Between 2008 and 2014 in Korea: Analysis of the Nationwide Acute Stroke Quality Assessment Program

Introduction: Higher quality of stroke care based on guideline recommendations is associated with better clinical outcomes. However, there is limited information about contemporary status of quality of stroke care and its association with improvements in clinical outcomes in Korea. Methods: This retrospective observational study was performed by analyzing the data of the patients admitted to 258 acute stroke care hospitals covering an entire country from the Acute Stroke Quality Assessment Program, which was carried out by the Health Insurance Review and Assessment Service from 2008 to 2014. Six GWTG-Stroke performance measures (except prophylaxis for venous thromboembolism) were applied to evaluate quality of stroke care in Korea. The primary outcome variable was defect-free care, which is defined as the proportion of patients who received all of the performance measure interventions for which they were eligible. Multivariable analysis was performed to evaluate the association between defect-free care and clinical outcomes. Temporal trends and hospital variations of performance measures were evaluated. Results: Among 43 793 patients (mean age, 67±14 years; male, 55%) with acute stroke during the study period, 31 915 (72.9%) patients were hospitalized due to ischemic stroke or transient ischemic attack. The proportion of defect-free care for stroke steadily increased throughout the study period: from 80.2% in 2008 to 92.1% in 2014. Defect-free care was given more frequently in patients admitted to hospitals with a higher volume of stroke cases or intravenous thrombolysis administration, and stroke units. Patients who received defect-free care were associated with discharge to home (adjusted odds ratio 1.96; 95% CI 1.78-2.16) and 1-year survival (adjusted odds ratio 0.41; 95% CI 0.37-0.46). Only 60% of stroke patients were managed in hospitals with a certified stroke unit, and the distribution of certified stroke units showed an urban-to-rural gradient. Conclusions: The quality of stroke care in Korea has improved over time, and defect-free care was associated with discharge to home and 1-year mortality. There are still opportunities to improve the quality of stroke care in Korea by development of stroke networks in Korea.

Stroke units, certification, and outcomes in German hospitals: a longitudinal study of patient-based 30-day mortality for 2006\u20132014

BackgroundTreatment of stroke patients in stroke units has increased and studies have shown improved outcomes. However, a large share of patients in Germany is still treated in hospitals without stroke unit. The effects of stroke unit service line, and total hospital quality certification on outcomes remain unclear.MethodsWe employ annual hospital panel data for 1100–1300 German hospitals from 2006 to 2014, which includes structural data and 30-day standardized mortality. We estimate hospital- and time-fixed effects regressions with three main independent variables: (1) stroke unit care, (2) stroke unit certification, and (3) total hospital quality certification.ResultsOur results confirm the trend of decreasing stroke mortality ratios, although to a much lesser degree than previous studies. Descriptive analysis illustrates better stroke outcomes for non-certified and certified stroke units and hospitals with total hospital quality certification. In a fixed effects model, having a stroke unit has a significant quality-enhancing effect, lowering stroke mortality by 5.6%, while there is no significant improvement effect for stroke unit certification or total hospital quality certification.ConclusionsPatients and health systems may benefit substantially from stroke unit treatment expansion as installing a stroke unit appears more meaningful than getting it certified or obtaining a total hospital quality certification. Health systems should thus prioritize investment in stroke unit infrastructure and centralize stroke care in stroke units. They should also prioritize patient-based 30-day mortality data as it allows a more realistic representation of mortality than admission-based data.

Clinical Relevance of Patent Foramen Ovale and Atrial Septum Aneurysm in Stroke: Findings of a Single-Center Cross-Sectional Study

Background: A significant proportion of ischemic strokes are cryptogenic. In this context, the clinical pertinence of patent foramen ovale (PFO) with and without atrial septum aneurysm (ASA) remains controversial. The aim of this study was to identify how PFO +/–ASA and cryptogenic stroke are associated in a representative sample of stroke patients. Methods: We enrolled all patients (n = 909) with ischemic stroke or transient ischemic attack admitted to the certified stroke unit or neurological intensive care unit of our university medical center who underwent transesophageal echocardiography (TEE) between 2012 and 2014. The baseline characteristics, cardio-/neurovascular risk factors, clinical parameters and TEE findings were analyzed. Results: PFO was present in 26.2%, and PFO was combined with an ASA in 9.9%. In cryptogenic stroke, the prevalence of PFO was higher compared to other etiologies (30.9 vs. 21.9%; p < 0.002). Patients with PFO had lower National Institute of Health Stroke Score (NIHSS) values at admission than those without (2 [0–5] vs. 3 [1–7]; p = 0.001; 95% CI [0.62–0.88]). No difference was found in NIHSS values of PFO patients with or without ASA (2 [0–5] vs. 2 [0–5]; p = 0.683; 95% CI 0.94 [0.68–1.28]). Conclusions: Our study indicates that a detected PFO +/–ASA could exhibit a stroke-relevant finding, if classical risk factors for the stroke were lacking.

Guideline conform diagnostics for dysphagia : Arepresentative survey of speech therapists at certified stroke units in Germany

Almost 260,000 people in Germany suffer from astroke each year. As aconsequence, for more than 60% this leads to dysphagia. In order to prevent secondary diseases, such as pneumonia, malnutrition and dehydration, adifferentiated diagnosis by amultiprofessional team in astroke unit is required. The guidelines in 2015 for diagnosing neurologic dysphagia by the German Society of Neurology recommend adetailed anamnesis, astandardized screening, aclinical swallowing examination and additional instrumental diagnostics. This study examined whether dysphagia is diagnosed by speech therapists at certified stroke units according to the recommended guidelines. An online questionnaire was compiled and sent to 1 speech therapist at each of the 195 certified stoke units and 112 participants responded to the questionnaire. The questionnaire consisted of questions about anamnesis, clinical swallowing diagnostics and the instrumental diagnostics. Of the speech therapists working on a stroke unit 57% participated in this study. The results show that 50% of the participants elaborated adetailed and differentiated anamnesis, 64% used astandardized screening (Daniels test) and 66% implemented aguideline conform swallowing test. As technical instruments, 35% of the respondents used video fluoroscopy and 71% of the respondents afiber endoscopy. The implementation of adetailed and differentiated anamnesis, standardized screening, and aclinical swallowing examination with testing of different food consistencies suggests ahigh quality of the dysphagia diagnostics at stroke units in Germany. The increasing availability of technical instruments, especially fiber endoscopy, substantiates this view.

Abstract TP215: Atrial Fibrillation and Flutter as a Cause of Stroke in an Unspecific Stroke Population. Stroke Subtypes in the Findaf Randomised Study

Introduction: The intensity of AF detection modalities in stroke patients has been modulated by the stroke subtype. Hence, most studies have been performed in so called cryptogenic stroke. However, it has never been proven that AF is more prevalent in cryptogenic stroke as compared to non-cryptogenic stroke. The Find-AF randomised trial (ISRCTN 46104198) is a randomised trial comparing prolonged Holter ECG monitoring (3x 10 day monitoring) and usual care in 400 patients with ischemic stroke. The primary results of Find-AF randomised will be submitted for presentation as a late breaking clinical trial to ISC 2016. In contrast to previous randomised trials (e. g. EMBRACE and CRYSTAL-AF), this trial will include all ischemic stroke patients, not only cryptogenic strokes. Hypothesis: We hypothesized that the AF detection rate is independent from the stroke subtype according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST), but is associated with clinical variables (e. g. age, NIHSS, prevalence of coronary artery disease). Methods: 402 patients with ischemic stroke were recruited on certified stroke units within seven days after the index event. Stroke was classified by the Trial of Org 10172 in Acute Stroke Treatment (TOAST), dividing the patient collective into five subgroups according to the most likely stroke etiology. Results: The following table presents a preliminary assessment of relevant baseline characteristics of 392 participants (full data set will be available upon abstract presentation. In addition, all index strokes will be independently assessed by an adjudication committee, consisting of three neurologists. We will present AF detection rates in different stroke subtypes. Conclusion: If our hypothesis is correct, future studies on AF detection in stroke patients should not be confined to stroke subtypes (e. g. cryptogenic or embolic stroke of unknown source), but rather include clinical parameters to increase the probability of finding AF.

Prehospital Thrombolysis: A Manual from Berlin

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis at the emergency site would be preferable. However, apart from neurological expertise and laboratory investigations a computed tomography (CT) scan is necessary to exclude hemorrhagic stroke prior to thrombolysis. Therefore, a specialized ambulance equipped with a CT scanner and point-of-care laboratory was designed and constructed. Further, a new stroke identifying interview algorithm was developed and implemented in the Berlin emergency medical services. Since February 2011 the identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of this ambulance, a stroke emergency mobile (STEMO). On arrival, a neurologist, experienced in stroke care and with additional training in emergency medicine, takes a neurological examination. If stroke is suspected a CT scan excludes intracranial hemorrhage. The CT-scans are telemetrically transmitted to the neuroradiologist on-call. If coagulation status of the patient is normal and patient's medical history reveals no contraindication, prehospital thrombolysis is applied according to current guidelines (intravenous recombinant tissue plasminogen activator, iv rtPA, alteplase, Actilyse).Thereafter patients are transported to the nearest hospital with a certified stroke unit for further treatment and assessment of strokeaetiology. After a pilot-phase, weeks were randomized into blocks either with or without STEMO care. Primary end-point of this study is time from alarm to the initiation of thrombolysis. We hypothesized that alarm-to-treatment time can be reduced by at least 20 min compared to regular care.

Prehospital Thrombolysis: A Manual from Berlin

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis at the emergency site would be preferable. However, apart from neurological expertise and laboratory investigations a computed tomography (CT) scan is necessary to exclude hemorrhagic stroke prior to thrombolysis. Therefore, a specialized ambulance equipped with a CT scanner and point-of-care laboratory was designed and constructed. Further, a new stroke identifying interview algorithm was developed and implemented in the Berlin emergency medical services. Since February 2011 the identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of this ambulance, a stroke emergency mobile (STEMO). On arrival, a neurologist, experienced in stroke care and with additional training in emergency medicine, takes a neurological examination. If stroke is suspected a CT scan excludes intracranial hemorrhage. The CT-scans are telemetrically transmitted to the neuroradiologist on-call. If coagulation status of the patient is normal and patient's medical history reveals no contraindication, prehospital thrombolysis is applied according to current guidelines (intravenous recombinant tissue plasminogen activator, iv rtPA, alteplase, Actilyse). Thereafter patients are transported to the nearest hospital with a certified stroke unit for further treatment and assessment of strokeaetiology. After a pilot-phase, weeks were randomized into blocks either with or without STEMO care. Primary end-point of this study is time from alarm to the initiation of thrombolysis. We hypothesized that alarm-to-treatment time can be reduced by at least 20 min compared to regular care.

Abstract TP403: Presence Of Severe Aphasia Reduces Benefit From Thrombolytic Therapy

Background: Patients with severe aphasia are underrepresented in randomized clinical trials because of difficulties getting an informed consent. We wanted to know, if the presence of a severe aphasia influences benefit or risk from thrombolytic therapy. Methods: Retrospective analysis of a prospectively collected dataset of patients treated with thrombolytic therapy. For this analysis we included every patient with a supratentorial infarction treated with rtPA or thrombectomy between 1998 and 2011. Aphasia was graded at admission following item 9 of the NIHSS by an experienced speech-and-language-pathologist. All patients were treated following institutional SOP at an ICU or a certified stroke unit. Outcome was assessed using the modified Rankin scale (mRS) three months after treatment; good clinical outcome was defined as mRS 0-2. Symptomatic intracranial hemorrhage (sICH) was defined as in ECASS2. Univariate (Fisher’s exact or Mann-Whitney U tests) and multivariate (logistic regression) analyses were applied using outcome parameters as dependent and those variables having a p-value of &lt;0.1 in univariate tests as independent variables. The NIHSS was corrected for this analysis by subtracting the aphasia-score. Results: Overall 1.345 patients were analyzed: 645 had no, 76 mild, 190 moderate and 433 a severe aphasia. After adjustment for sex, side of infarction, type of treatment, hypertension, diabetes, CAD, atrial fibrillation, age, NIHSSc presence of severe aphasia was negative predictive for a good clinical outcome (OR 0.46; 95%CI 0.33-0.65; p&lt;0.0001). In addition severe aphasia was associated with increased mortality after adjustment for sex, type of treatment, hypertension, diabetes, smoking, previous stroke, CAD, PAD, atrial fibrillation, age and NIHSS (OR 1.85; 95%CI 1.32-2.61; p=0.0004). There was no clear association with the risk of suffering from a sICH (p=0.096). Conclusion: In this analysis we discovered that patients with severe aphasia had a lower chance of being clinically independent after thrombolytic therapy and had a higher mortality compared to patients with no or mild aphasia. This is probably due to the involvement of larger brain areas - especially cortical territories - in patients with severe aphasia.