Management Of Acute Stroke Patients Research Articles

Acute stroke management in Turkey: Current situation and future projection.

In Turkey, the incidence of acute stroke is increasing, obviously with the contribution of the aging population. With the publication of "Directive on Health Services to be Provided to Patients with Acute Stroke" on July 18, 2019 and its entry into force in March 2021, an important period of catching up and updating has begun in the management of acute stroke patients in our country. During this period, 57 comprehensive stroke centers and 51 primary stroke centers were certified. These units have covered approximately 85% of the country's population. In addition, around 50 interventional neurologists were trained and became the directors of many of these centers. In the following 2 years, the "inme.org.tr campaign" was launched. This campaign, aimed at increasing the public's knowledge and awareness about stroke, continued unabated during the pandemic period. Now is the time to continue the efforts to ensure homogeneous quality metrics and to develop and continuously improve the established system.

Abstract WP87: Statewide Availability Of Acute Stroke Treatment And Services In North Carolina Hospitals

Introduction: With recent advancements in acute stroke treatments, evidence-based care capabilities among hospitals are believed to vary widely; however, current data are limited. Therefore, we conducted a statewide assessment of hospital-based stroke care capabilities in North Carolina (NC). Methods: An online survey was emailed to each licensed hospital in NC. Based on prior surveys and current stroke care guidelines, questions asked about diagnostic testing, acute stroke treatments and protocols, and post-acute management. All 112 hospitals responded (100% response rate) between October 2020 and April 2021. Descriptive statistics were computed from responses for 109 hospitals that reported providing acute stroke care. Results: Among 109 hospitals, 10 (9%) were Comprehensive Stroke Centers, 2 (2%) were Thrombectomy-Capable Stroke Centers, 35 (32%) were Primary Stroke Centers, 16 (15%) were Acute Stroke Ready Hospitals, and 46 (42%) had no stroke certification. Ninety-eight (90%) had an acute stroke clinical care pathway, and 92 (84%) had pre-written stroke care orders. All 109 (100%) reported non-contrast CT imaging capability. Further, hospitals reported the following: CT angiography (104, 95%), CT perfusion (55, 50%), and diffusion-weighted MRI (63, 58%) . Almost all (108, 99%) administered intravenous alteplase for stroke, whereas only 16 (15%) had capabilities to provide endovascular thrombectomy for stroke. Ninety-five (87%) hospitals reported transferring stroke patients treated with alteplase or transferring those in need of endovascular treatment. Eighty-nine (82%) used telestroke services for the treatment and management of acute stroke patients, of which 78 (72%) relied on telestroke exclusively 24/7; and 80 (73%) used telestroke to decide when and where to transfer stroke patients. Conclusions: Among NC hospitals, basic capabilities, such as CT imaging and acute stroke care protocols, were widely available. However, advanced imaging and endovascular capabilities were less common. Most hospitals used telestroke services for treatment as well as transfer decisions. This statewide assessment is an important first step in improving access to evidence-based stroke care and developing stroke systems of care.

Using Multiple Logistic Regression to Determine Factors Affecting Delaying Hospital Arrival of Patients with Acute Ischemic Stroke.

Early treatment of ischemic stroke patients who arrive at the hospital ≤4.5 hours after the onset of symptoms with recombinant tissue plasminogen activator is more beneficial and very important. This study is aimed to investigate the factors delaying the hospital arrival of patients with acute ischemic stroke by using multiple logistic regression analysis. This descriptive cross-sectional study was done on patients diagnosed with acute ischemic stroke who were referred to Ardabil city Training and Research hospital at 2018. All patients and/or patient relatives were interviewed and data were collected through a checklist including demographic and clinical data of patients to explore the involved factors delaying hospital arrival of patients and then analyzed using multiple logistic regression analysis. Of all included patients, only 25.3% arrived at the hospital in ≤ 4.5 hours. By using multivariate logistic regression analysis, living in cities (P = 0.007), cigarette consumption (P = 0.032), having valvular heart disease (P = 0.008), and gender (P = 0.049) were factors associated with an early arrival to the hospital. Results showed that most of the patients had a considerable delay in arriving at the hospital in ≤ 4.5 hours. Thus, providing health promotion strategies to improve society awareness of early symptoms of stroke, training of local physicians about the importance of early arrival of stroke patients, and more extended ambulance services in all cities and rural areas are necessary for better management of acute stroke patients in this area.

How to Improve the Management of Acute Ischemic Stroke by Modern Technologies, Artificial Intelligence, and New Treatment Methods.

Stroke remains one of the leading causes of death and disability in Europe. The European Stroke Action Plan (ESAP) defines four main targets for the years 2018 to 2030. The COVID-19 pandemic forced the use of innovative technologies and created pressure to improve internet networks. Moreover, 5G internet network will be helpful for the transfer and collecting of extremely big databases. Nowadays, the speed of internet connection is a limiting factor for robotic systems, which can be controlled and commanded potentially from various places in the world. Innovative technologies can be implemented for acute stroke patient management soon. Artificial intelligence (AI) and robotics are used increasingly often without the exception of medicine. Their implementation can be achieved in every level of stroke care. In this article, all steps of stroke health care processes are discussed in terms of how to improve them (including prehospital diagnosis, consultation, transfer of the patient, diagnosis, techniques of the treatment as well as rehabilitation and usage of AI). New ethical problems have also been discovered. Everything must be aligned to the concept of “time is brain”.

Indian College of Radiology and Imaging (ICRI) Consensus Guidelines for the Early Management of Patients with Acute Ischemic Stroke: Imaging and Intervention.

The medical science has witnessed significant change in the management of acute stroke patients as a result of recent advances in the field of stroke imaging and endovascular mechanical thrombectomy in addition to intravenous thrombolysis and optimization of stroke services in balance with available resources. Despite initial negative trials, we witnessed the publication of five multicenter randomized clinical trials showing superiority of the endovascular approach over standard medical management in patients with large vessel occlusion. The aim of this study is to provide comprehensive set of evidence-based recommendations regarding imaging and endovascular interventions in acute ischemic stroke patients.

The Effect of Implementing Initial Emergency Care Bundle on Early Outcomes among Acute Ischemic Stroke Patients

Implementing an initial emergency care bundle for acute stroke patients bridges the gap between evidence-based and clinical practice to improve patients outcomes. Aim: To evaluate the effect of implementing the initial emergency care bundle on early outcomes among acute stroke patients. Setting: This study was conducted at the emergency department and neurocritical care unit at Mansoura University Hospital, Egypt. Method: An experimental research design was utilized in this study. A random sample of 120 adults patient with acute stroke was selected and divided into two equal groups of 60 patients in each group. Two tools were utilized to collect data: Tool (I): Tool I: Stroke patient assessment. Tool II: Stroke patients' outcomes assessment. Results: It was noticed that nearly one-third (30.0%) of patients of the control group were died compared to only 11.7% of the study group during 7 days post-admission to the intensive care unit. Also, there were highly statistically significant improvements among patients of both control and study groups regarding patient outcomes which include physiological parameters, pre feeding assessment, hydration status, and activity level on admission, 3 days, and 7 days following implementation of stroke care bundle. Conclusions: Acute stroke patients who received the initial emergency care bundle had a statistically significant reduction in mortality rate, higher independency, and normal pre-feeding assessment compared to those who receive routine care on admission, 3 days, and 7 days post-admission Recommendations: The recent evidence-based practice should be integrated into the management of acute stroke patients to improve the patients' outcomes.

Abstract P272: Management of Acute Stroke Patients in the Extended Window in a Large Community Cohort

Background: Published data suggest that treating qualified acute strokes within the extended window (EW) or 6-24 hours of last seen normal with endovascular therapy (EST) is associated with better 90-day outcome. In a real-world multi-ethnic practice setting, we assessed our experience in triaging and treating patients in the EW. Methods: In 2016, our system of care launched a telestroke program for 19 primary and 2 comprehensive stroke centers to include immediate video evaluation by a stroke neurologist. In 2018, screening in the EW began. If the patient met clinical criteria (baseline independence and initial NIHSS ≥ 6), neuroimaging was performed to assess for a large vessel occlusion (LVO). Referral for EST was made for patients with an LVO and appropriate CT perfusion criteria. Our study included all health plan members presenting within the EW in 2019. Assessment included demographics, NIHSS, neuroimaging data, LVO, discharge outcomes, 90-day mRS and mortality with 95% confidence interval. Results: In 2019, there were 5349 suspected strokes (1255 EW) evaluated by teleneurologists; 2130 (39.8%) patients were appropriate for acute stroke imaging workup. Of 2130, final study cohort included 388 (18.2%) EW patients who met clinical criteria and underwent neuroimaging workup, and 117 of these patients (30.2%) had an LVO. There were 57 (14.7%) meeting CT perfusion criteria and referred for EST. Compared to 331 who were not referred for EST, the 57 patients were older and more likely to have atrial fibrillation, higher NIHSS, and to be discharged to a short-term facility than home. The 51 patients who went for EST within our system had 90-day good (mRS 0-2), bad (mRS 5-6), and mortality rates comparable to those from DAWN and DEFUSE-3 trials [Table]. Conclusions: In our system, only a small proportion of suspected strokes met criteria for EST during the EW. It was possible in a community setting to achieve 90-day outcomes that were comparable to those from clinical trials.

A new telestroke network system in northern area of Okayama prefecture

AbstractBackgroundTelestroke network can provide rapid access to specialized treatment and improves on‐site management of acute stroke patients through the “hub‐and‐spoke” model. In the northern part of Okayama Prefecture, there has been a regional gap of stroke care due to the shortage of stroke specialists and facilities. In addition, due to the novel coronavirus disease 2019 (COVID‐19), it is required to reduce the unnecessary contact with stroke patients from other hospitals.AimWe organized a novel cost‐free telestroke network with an image and video sharing for neurological diseases in the northern part of Okayama Prefecture to improve the stroke management in the area.MethodWe prepared the tablet device on which Skype® application was installed for each hospital and recruited the patients who visited or hospitalized in the spoke hospitals and were suspected to have some neurological diseases from April 2019 to May 2020. The patient's clinical data were recorded and analyzed.ResultsDuring the study period, 5 patients were recruited including the cases with the initial diagnosis of stroke or brain tumor. Among them, 2 cases were transferred to the hub hospital, 2 cases were transferred to other hospitals, and 1 case was treated on site under specialist's advice.ConclusionThe new telestroke network system may be beneficial for acute stroke management and reducing the unnecessary patient's transfer in the rural area, especially under coexistence with COVID‐19.

Results of an International Questionnaire Investigating Changes in Acute Stroke Management between Before and During the COVID-19 Pandemic.

The present study investigated changes in the management of acute stroke patients between before and during the coronavirus disease 2019 (COVID-19) pandemic in several countries using a questionnaire. A questionnaire survey was conducted at 23 stroke centers in 20 countries to examine how stroke management systems have changed from 2019 (before the COVID-19 pandemic) to 2020 (during the COVID-19 pandemic). Questionnaire responses were obtained from 14 stroke centers (61%) in 14 countries. Among the surveyed stroke centers, 36% utilized full personal protective equipment (PPE) including N95 masks in all cases. After the proper application of infection precautions and screening for COVID-19, the initial imaging modality and indications for endovascular thrombectomy (ET) for ischemic stroke remained unchanged in more than 85% of the surveyed stroke centers. The transmission of COVID-19 from stroke patients to doctors or nurses was confirmed in 29% of the surveyed stroke centers, and hospital-acquired infection from patients to other patients occurred in 25%. The number of cases undergoing ET decreased by 10-70% in 50% of stroke centers during the COVID-19 pandemic. Despite successful recanalization, 50% of patients who underwent ET died, and death was mainly attributed to COVID-19-related systemic complications. No significant differences were observed in stroke management or treatment strategies between before and during the COVID-19 pandemic in most stroke centers, except for COVID-19 precautions. However, the higher proportion of hospital-acquired infections and increased morbidity rate among patients despite successful recanalization due to COVID-19-related systemic complications are important findings.

Refined Ischemic Penumbra Imaging with Tissue pH and Diffusion Kurtosis Magnetic Resonance Imaging.

Imaging has played a vital role in our mechanistic understanding of acute ischemia and the management of acute stroke patients. The most recent DAWN and DEFUSE-3 trials showed that endovascular therapy could be extended to a selected group of late-presenting stroke patients with the aid of imaging. Although perfusion and diffusion MRI have been commonly used in stroke imaging, the approximation of their mismatch as the penumbra is oversimplified, particularly in the era of endovascular therapy. Briefly, the hypoperfusion lesion includes the benign oligemia that does not proceed to infarction. Also, with prompt and effective reperfusion therapy, a portion of the diffusion lesion is potentially reversible. Therefore, advanced imaging that provides improved ischemic tissue characterization may enable new experimental stroke therapeutics and eventually further individualize stroke treatment upon translation to the clinical setting. Specifically, pH imaging captures tissue of altered metabolic state that demarcates the hypoperfused lesion into ischemic penumbra and benign oligemia, which remains promising to define the ischemic penumbra's outer boundary. On the other hand, diffusion kurtosis imaging (DKI) differentiates the most severely damaged and irreversibly injured diffusion lesion from the portion of diffusion lesion that is potentially reversible, refining the inner boundary of the penumbra. Altogether, the development of advanced imaging has the potential to not only transform the experimental stroke research but also aid clinical translation and patient management.

Evaluating the utility of fasting lipid panel in addition to random lipid panel in determining lipid-lowering therapy in acute ischemic stroke or TIA patients

BackgroundHyperlipidemia is one of the major risk factors for cerebrovascular disease and it is common practice to obtain fasting lipid profile prior to starting lipid lowering therapy (LLT). Recent AHA Guidelines published in 2018 allow for a non-fasting value to be used. ObjectiveTo determine if obtaining fasting lipid levels in addition to random lipid levels prompts changes in hyperlipidemia management of acute stroke patients. Methods206 patients met the study criteria which included a diagnosis of acute ischemic stroke or transient ischemic attack on admission and availability of both random and fasting LDL levels collected within 72 h of each other. Patients were divided into three groups based on random LDL at admission: Group A: LDL < 70, Group B: LDL 70−99, and Group C: LDL ≥ 100 mg/dL. The dataset was analyzed to conform to the 2018 AHA/ACC guidelines using an LDL cutoff of 70 mg/dL. ResultsIn 206 patients, statin management would change based on the fasting LDL level in 12 patients, 11 of whom were in Group B. Our data suggests that lipid management is more likely to change if the initial random LDL falls between 70−99 mg/dL as compared to a value outside of this range (P < 0.001). We present a decision algorithm to guide lipid management in acute stroke patients. ConclusionsForegoing a fasting lipid panel to guide LLT in patients with ischemic stroke is appropriate in most cases but for select patients with random LDL levels between 70 and 99, fasting lipid profile should be obtained prior to deciding upon LLT.

Acute stroke care algorithm in a private tertiary hospital in the Philippines during the COVID-19 pandemic: A third world country experience

Background and purposeSince the declaration of the Novel Coronavirus Disease (COVID-19) pandemic, ensuring the safety of our medical team while delivering timely management has been a challenge. Acute stroke patients continue to present to the emergency department and they may not have the usual symptoms of COVID-19 infection. Stroke team response and management must be done within the shortest possible time to minimize worsening of the functional outcome without compromising safety of the medical team. MethodsInfection control recommendations, emergency department protocols and stroke response pathways utilized prior to the COVID 19 pandemic within our institution were evaluated by our stroke team in collaboration with the multidisciplinary healthcare services. Challenges during the COVID-19 scenario were identified, from which a revised acute stroke care algorithm was formulated to adapt to this pandemic. ResultsWe formulated an algorithm that incorporates practices from internationally devised protocols while tailoring certain aspects to suit the available resources in our system locally. We highlighted the significance of the following: team role designation, coordination among different subspecialties and departments, proper use of personal protective equipment and resources, and telemedicine use during this pandemic. ConclusionsThis pandemic has shaped the stroke team's approach in the management of acute stroke patients. Our algorithm ensures proper resource management while optimizing acute stroke care during the COVID-19 pandemic in our local setting. This algorithm may be utilized and adapted for local practice and other third world countries who face similar constraints.

Management of Acute Stroke Patients Amid the Coronavirus Disease 2019 Pandemic: Scientific Statement of the Korean Stroke Society.

Management of Acute Stroke Patients Amid the Coronavirus Disease 2019 Pandemic: Scientific Statement of the Korean Stroke Society.

Abstract 173: Effect of a Regional Telestroke Program on Door-to-Needle Time and Clinical Outcomes

Background: Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. Telestroke allows community hospitals to access stroke expertise in the management of acute stroke patients. In a real-world practice setting, we assessed the influence of a regional standardized telestroke program among community hospitals on door-to-needle (DTN) time and clinical outcomes. Methods: In January 2016, a new standardized acute telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, an expedited IV alteplase treatment program, rapid CT angiographic investigation, and expedited transfer and treatment for patients with large vessel occlusion. We compared patient characteristics, DTN times, length of stay (LOS), discharge outcomes, and 90-day mortality between those treated with IV alteplase pre- (July 2013 to June 2015) to post-telestroke program (January 2016 to December 2017). Results: Post-implementation of the telestroke program, more patients were treated with alteplase (Table). Median DTN time and LOS were shorter. A greater percentage of patients were discharged home (57.3% in post-telestroke vs. 12.1% in pre, p&lt;0.001). In-hospital mortality was higher in post-telestroke compared to pre. However, symptomatic hemorrhage rates were not significantly different, at 4.5% in 2014 pre-EXPRESS, 4.3% in 2016 and 3.2% in 2017 post-EXPRESS. In addition, 90-day mortality was not different between pre- and post-telestroke (Table). Conclusions: Implementation of a regional standardized telestroke program in a community setting increased utilization of alteplase, improved DTN time, decreased length of stay and significantly increased the chances of patients going home. Further analyses are needed to understand the significant contributing factors to the success of this program.

Pre-hospital management of acute stroke patients eligible for thrombolysis \u2013 an evaluation of ambulance on-scene time

BackgroundStroke is a leading cause of death and disability with effective treatment, including thrombolysis or thrombectomy, being time-critical for favourable outcomes. While door-to-needle time in hospital has been optimized for many years, little is known about the ambulance on-scene time (OST). OST has been reported to account for 44% of total alarm-to-door time, thereby being a major time component. We aimed to analyse ambulance OST in stroke patients eligible for thrombolysis and identify potential areas of time optimization.MethodsA study-specific registration form was developed to record detailed information about OST consumption in cases where the Emergency Medical Services (EMS) suspected a stroke from July 2014–May 2015. Registration forms were completed by ambulance personnel and included details on estimated time spent: 1) localising patient, 2) clinical examination, 3) consulting with the on-call neurologist, 4) mobilising patient to the ambulance, 5) treatment in ambulance before departure. Additionally, estimated total OST was noted. For patients found eligible for further evaluation at a stroke centre, time points were analysed using multivariate Poisson regressions.ResultsA total of 520 cases were included. The median OST was 21 min (Interquartile Range (IQR) 16–27). Time consumption was significantly lower (17 vs 21 min, p = 0.0015) when electrocardiography (ECG) was obtained in-hospital instead of on-scene, when intravenous (IV) access was established during transportation instead of before transportation (17 vs 21 min, p < 0.0001), and when the quality of communication with the stroke centres was rated as “good” as opposed to “acceptable/poor” (21 vs 23 min, p = 0.014). Neither the presence of relatives nor ambulance trainees had a significant effect on OST.ConclusionsIn-hospital ECG recording and IV cannulation during transport were found to reduce OST, while “acceptable/poor” communication was found to prolong OST relative to “good” communication. These components of pre-hospital stroke management represent potential opportunities for lowering OST with relatively simple changes, which could ultimately lead to earlier treatment and better patient outcome.Trial registrationUnique identifier: NCT02191514.

Radiology Nursing in the Management of the Acute Stroke Patient: Beyond Emergency Revascularization

Endovascular therapy is now the first-line treatment for acute ischemic stroke secondary to large vessel occlusions. As an important part of the neurovascular triad (radiology, neurology, and neurosurgery), nurses within the specialty of radiology play in important role in emergency revascularization. However, the role of nursing in acute stroke extends beyond timely recanalization, well into the convalescent phase. The purpose of our study was to explore the other important aspects of clinical care performed by diagnostic and interventional radiology nurses in acute stroke. After Institutional Review Board approval, imaging and clinical records of 100 consecutive patients presenting to a tertiary-care center with acute stroke and a large vessel occlusion were reviewed. Hospitalization records were examined for the type and number of interventional radiology-related non-neurovascular procedures performed in this patient population. Non-neurovascular interventional radiology-related procedures were performed in over 40% of patients, most commonly gastrostomy tube placement, IVC filter placement, and peripherally inserted central catheter placement. 28 gastrostomy tubes, 10 IVC filters, and 10 peripherally inserted central catheter lines were placed. The average age of IVC filter placement was 60 years, with a range of 45 to 81 years. Radiology nurses have an important role to play in the management of acute stroke patients, even after patients have undergone revascularization. Educating clinical colleagues and patients about radiology nursing-related services in acute stroke can advance the field of radiology nursing and other advanced practitioners while improving the care of the large number of patients afflicted by acute stroke.

Abstract 117: One Stop Management of Acute Stroke Patients: Minimizing Door to Groin Times and Improving Functional Outcome

Introduction: Intrahospital time delays significantly affect neurological outcome of stroke patients with large vessel occlusion. Conventional imaging prior to thrombectomy leads to time delays. We report the 100 first consecutive (mothership and transfer) patients triaged in our department with a one stop management, based on flat detector CT (FDCT) and FDCTA. Methods: In this observational study, we transported stroke patients with an NIHSS ≥ 7 directly to the angio suite, bypassing multidetector CT. Multimodal imaging consisted of noncontrast FDCT and biphasic FDCTA. Patients with large vessel occlusion remained on the angio table and were treated with intravenous rtPA, if no exclusion criteria were present, and thrombectomy; peripheral occlusions were treated with intravenous rtPA; intracranial hemorrhage and stroke mimics were treated as per guidelines. Intrahospital times as well as outcomes were recorded and compared to past patients with a case-control analysis, matched for age, admission NIHSS, ASPECTS and symptom-to-door time. Results: One-hundred consecutive patients were transferred directly to our angio suite. Mean age was 77 (IQR 69-83). Symptom onset to admission time was 137 min (IQR 70-187). Ischemic stroke was diagnosed in 79 patients, intracranial hemorrhage was present in 11 and Todd`s paresis in 10 patients. We recorded a median door-to-groin time of 25 min (IQR 19-29) and door-to-reperfusion time of 68 min (IQR 53-89). Compared to patients triaged with multidetector CT, we observed a highly significant reduction of door-to-groin times (60 min (95% CI 54-65) to 25 min (95% CI 21-26); P&lt;0.001). Median mRS at 90 days was lower in the FDCT group (MDCT group 4 (95% CI 3-5) to FDCT group 2 (95% CI 2-4); P=0.168). Mortality (21 vs. 23%), sICH (7 vs. 5%) and any hemorrhage (25% vs. 17%) rates were comparable. Conclusions: One stop management is feasible for stroke triage and results in reduction of intrahospital times and improved functional outcomes.

Public stroke knowledge, awareness, and response to acute stroke: Multi-center study from 4 Egyptian governorates

Background and purposeAcute stroke treatment has significantly improved over the years in Egypt. However, there is often notable delay in pre-hospital and in-hospital management of acute stroke patients. The delay may be largely attributed to poor stroke knowledge and awareness of the general public and this study was aimed at the evaluation of the abovementioned factors. MethodsDescriptive cross-sectional study involving 1154 participants from 4 governorates using a questionnaire in Arabic, collecting sociodemographic data, participants' risk factors, and knowledge and stroke awareness (risk factors, symptoms, prevention, treatment and prognosis, action in response to acute stroke). Data were collected during the World stroke day October 29, 2015. ResultsStudy participants were found to have a low level of awareness of stroke with median percent score of 35.7% and interquartile range (IQR) of 17.86. Higher income, level of education, having risk factors and knowing someone with stroke were significant predictors of a higher level of stroke awareness. ConclusionIn general, low public stroke awareness has been detected among Egyptians, and this is a call for healthcare authorities to invest in public education programmes among the Egyptian population.

Trends for Optimal Management of Acute Stroke Patients in 2017

Trends for Optimal Management of Acute Stroke Patients in 2017

Post-thrombectomy management of the ELVO patient: Guidelines from the Society of NeuroInterventional Surgery

Recent trials have proven the benefits of endovascular treatment for patients with stroke from emergent large vessel occlusions (ELVOs).1–5 Optimal management of these patients involves attention to pre-procedural, intra-procedural, and...