RESUMO
BACKGROUND AND PURPOSE: Interhospital transfer is a critical component in the treatment of acute anterior circulation large vessel occlusive stroke transferred for mechanical thrombectomy. Real-world data for benchmarking and theoretical modeling are limited. We sought to characterize transfer workflow from primary stroke center (PSC) to comprehensive stroke center after the publication of positive thrombectomy trials. METHODS: Consecutive patients transferred from 3 high-volume PSCs to a single comprehensive stroke center between January 2015 and August 2016 were included in a retrospective study. Factors associated with key time metrics were analyzed with emphasis on PSC intrahospital workflow. RESULTS: Sixty-seven patients were identified. Median age was 74 years (interquartile range [IQR], 63.5-78) and National Institutes of Health Stroke Scale 17 (IQR, 12-21). Median transfer time measured by PSC-door-to-comprehensive stroke center-door was 128 minutes (IQR, 107-164), of which 82.8% was spent at PSCs (door-in-door-out [DIDO]; 106 minutes; IQR, 86-143). The lengthiest component of DIDO was computed-tomography-to-retrieval-request (median 59.5 minutes; IQR, 44-83). The 37.3% had DIDO exceeding 120 minutes. DIDO times differed significantly between PSCs (P=0.01). In multivariate analyses, rerecruiting the initial ambulance crew for transfer (P<0.01) and presentation during working hours (P=0.04) were associated with shorter DIDO times. CONCLUSIONS: In a metropolitan hub-and-spoke network, PSC-door-to-comprehensive stroke center-door and DIDO times are long even in high-volume PSCs. Improving PSC workflow represents a major opportunity to expedite mechanical thrombectomy and improve patient outcomes.
Assuntos
Hospitais Especializados/estatística & dados numéricos , Trombólise Mecânica/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Trombectomia/estatística & dados numéricos , Fluxo de Trabalho , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de TempoRESUMO
OBJECTIVES: Hospital data used to assess regional variability in disease management and outcomes, including mortality, lack information on disease severity. We describe variance between hospitals in 30-day risk-adjusted mortality rates (RAMRs) for stroke, comparing models that include or exclude stroke severity as a covariate. DESIGN: Cohort design linking Australian Stroke Clinical Registry data with national death registrations. Multivariable models using recommended statistical methods for calculating 30-day RAMRs for hospitals, adjusted for demographic factors, ability to walk on admission, stroke type, and stroke recurrence. SETTING: Australian hospitals providing at least 200 episodes of acute stroke care, 2009-2014. MAIN OUTCOME MEASURES: Hospital RAMRs estimated by different models. Changes in hospital rank order and funnel plots were used to explore variation in hospital-specific 30-day RAMRs; that is, RAMRs more than three standard deviations from the mean. RESULTS: In the 28 hospitals reporting at least 200 episodes of care, there were 16 218 episodes (15 951 patients; median age, 77 years; women, 46%; ischaemic strokes, 79%). RAMRs from models not including stroke severity as a variable ranged between 8% and 20%; RAMRs from models with the best fit, which included ability to walk and stroke recurrence as variables, ranged between 9% and 21%. The rank order of hospitals changed according to the covariates included in the models, particularly for those hospitals with the highest RAMRs. Funnel plots identified significant deviation from the mean overall RAMR for two hospitals, including one with borderline excess mortality. CONCLUSIONS: Hospital stroke mortality rates and hospital performance ranking may vary widely according to the covariates included in the statistical analysis.
Assuntos
Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Acidente Vascular Cerebral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Sistema de Registros , Risco AjustadoRESUMO
BACKGROUND: In 2010, rapid access to stroke thrombolysis centres was limited in some regional areas in the Australian state of Victoria. These results, and planning for endovascular clot retrieval (ECR), have led to the implementation of strategies by the Victorian Stroke Clinical Network, the Victorian Stroke Telemedicine Program and local health services to improve state-wide access. AIMS: To examine whether access to stroke reperfusion services (thrombolysis and ECR) in regional Victoria have subsequently improved. METHODS: The locations of suspected stroke patients attended by ambulance in 2015 were mapped, and drive times to the nearest reperfusion services were calculated. We then calculated the proportion of cases with transport times within: (i) 60 min to thrombolysis centres; and (ii) 180 min to two ECR centres designated to receive regional patients. Statistical comparisons to existing 2010 data were made. RESULTS: In 2015, Ambulance Victoria attended 16 418 cases of suspected stroke (2.9% of all emergency calls), of whom 4597 (28%) were located in regional Victoria. Compared to 2010, a greater proportion of regional suspected stroke patients in 2015 were located within 60 min of a thrombolysis centre by road (77-95%, P < 0.001). A 3-h road travel time to the two ECR centres is currently possible for 88% of regional patients. CONCLUSION: A strategic and region-specific approach has resulted in improved access by road transport to reperfusion therapies for stroke patients across Victoria.
Assuntos
Ambulâncias/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde , Reperfusão/estatística & dados numéricos , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Humanos , População Rural , Acidente Vascular Cerebral/epidemiologia , Telemedicina , Fatores de Tempo , Vitória/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVE: CT perfusion (CTP) is rapid and accessible for emergency ischaemic stroke diagnosis. The feasibility of introducing CTP and diagnostic accuracy versus non-contrast CT (NCCT) in a tertiary hospital were assessed. METHODS: All patients presenting <9 h from stroke onset or with wake-up stroke were eligible for CTP (Siemens 16-slice scanner, 2×24 mm slabs) unless they had estimated glomerular filtration rate (eGFR)<50 ml/min or diabetes with unknown eGFR. NCCT was assessed by a radiologist and stroke neurologist for early ischaemic change and hyperdense arteries. CTP was assessed for prolonged time to peak and reduced cerebral blood flow. Technical adequacy was defined as 2 CTP slabs of sufficient quality to diagnose stroke. RESULTS: Between January 2009 and September 2011, 1152 ischaemic stroke patients were admitted, 475 (41%) were <9 h/wake-up onset. Of these, 276 (58%) had CTP. Reasons for not performing CTP were diabetes with unknown eGFR (48 (10%)), known kidney disease (36 (8%)), established infarct on NCCT (27 (6%)), posterior circulation syndrome (25 (5%)) and patient motion/instability (16 (3%)). Clinician discretion excluded a further 47 (10%). CTP was more frequently diagnostic than NCCT (80% vs 50%, p<0.001). Non-diagnostic CTP was due to lacunar infarction (28 (10%)), infarct outside slab coverage (21 (8%)), technical failure (4 (1%)) and reperfusion (2 (0.7%)). Normal CTP in 86/87 patients with stroke mimics supported withholding tissue plasminogen activator. CTP technical adequacy improved from 56% to 86% (p<0.001) after the first 6 months. Median time for NCCT/CTP/arch-vertex CT angiogram (including processing and interpretation) was 12 min. No clinically significant contrast nephropathy occurred. CONCLUSIONS: CTP in suspected stroke is widely applicable, rapid and increases diagnostic confidence.
Assuntos
Isquemia Encefálica/diagnóstico por imagem , Angiografia Cerebral , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Idoso , Isquemia Encefálica/diagnóstico , Angiografia Cerebral/métodos , Feminino , Humanos , Masculino , Estudos Prospectivos , Sensibilidade e Especificidade , Acidente Vascular Cerebral/diagnóstico , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Stroke is one of the most disabling neurological conditions. Clinical research is vital for expanding knowledge of treatment effectiveness among stroke patients. However, evidence begins to accumulate that stroke patients who take part in research represent only a small proportion of all stroke patients. Research participants may also differ from the broader patient population in ways that could potentially distort treatment effects reported in therapeutic trials. The aims of this study were to estimate the proportion of stroke patients who take part in clinical research studies and to compare demographic and clinical profiles of research participants and non-participants. METHODS: 5,235 consecutive patients admitted to the Stroke Care Unit of the Royal Melbourne Hospital, Melbourne, Australia, for stroke or transient ischaemic attack between January 2004 and December 2011 were studied. The study used cross-sectional design. Information was collected on patients' demographic and socio-economic characteristics, risk factors, and comorbidities. Associations between research participation and patient characteristics were initially assessed using χ(2) or Mann-Whitney tests, followed by a multivariable logistic regression analysis. The logistic regression analysis was carried out using generalised estimating equations approach, to account for patient readmissions during the study period. RESULTS: 558 Stroke Care Unit patients (10.7%) took part in at least one of the 33 clinical research studies during the study period. Transfer from another hospital (OR = 0.35, 95% CI 0.22-0.55), worse premorbid function (OR = 0.61, 95% CI 0.54-0.70), being single (OR = 0.61, 95% CI 0.44-0.84) or widowed (OR = 0.77, 95% CI 0.60-0.99), non-English language (OR = 0.67, 95% CI 0.53-0.85), high socio-economic status (OR = 0.74, 95% CI 0.59-0.93), residence outside Melbourne (OR = 0.75, 95% CI 0.60-0.95), weekend admission (OR = 0.78, 95% CI 0.64-0.94), and a history of atrial fibrillation (OR = 0.79, 95% CI 0.63-0.99) were associated with lower odds of research participation. A history of hypertension (OR = 1.50, 95% CI 1.08-2.07) and current smoking (OR = 1.23, 95% CI 1.01-1.50) on the other hand were associated with higher odds of research participation. CONCLUSIONS: The results of this study indicate that stroke patients who take part in clinical research do not represent 'typical' patient admitted to a stroke unit. The imbalance of prognostic factors between stroke participants and non-participants has serious implications for interpretation of research findings reported in stroke literature. This study provides insights into clinical, demographic, and socio-economic characteristics of stroke patients that could potentially be targeted to enhance generalizability of stroke research studies. Given the imbalance of prognostic factors between research participants and non-participants, future studies need to examine differences in stroke outcomes of these groups of patients.
Assuntos
Ensaios Clínicos como Assunto/métodos , Recusa de Participação , Sujeitos da Pesquisa , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Ensaios Clínicos como Assunto/estatística & dados numéricos , Comorbidade , Estudos Transversais , Diabetes Mellitus/epidemiologia , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Voluntários Saudáveis/estatística & dados numéricos , Humanos , Hipertensão/epidemiologia , Renda , Ataque Isquêmico Transitório/economia , Ataque Isquêmico Transitório/epidemiologia , Idioma , Masculino , Estado Civil , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Seleção de Pacientes , Transferência de Pacientes/estatística & dados numéricos , Prognóstico , Recidiva , Reprodutibilidade dos Testes , Sujeitos da Pesquisa/economia , Características de Residência , Fatores de Risco , População Rural/estatística & dados numéricos , Fumar/epidemiologia , Fatores Socioeconômicos , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/epidemiologia , População Urbana/estatística & dados numéricos , Vitória/epidemiologiaRESUMO
BACKGROUND AND PURPOSE: Small vessel disease plays a role in cerebral events. We aimed to investigate the prevalence and patterns of retinal microvascular signs (surrogates for cerebral small vessel disease) among patients with transient ischemic attack (TIA) or acute stroke and population control subjects. METHODS: Patients with TIA or acute stroke aged ≥49 years admitted to hospitals in Melbourne and Sydney, Australia, were recruited to the Multi-Centre Retina and Stroke Study (n=693, 2005 to 2007). Control subjects were Blue Mountains Eye Study participants aged ≥49 years without TIAs or stroke (n=3384, 1992 to 1994, west of Sydney). TIA, ischemic stroke, or primary intracerebral hemorrhage was classified using standardized neurological assessments, including neuroimaging. Retinal microvascular signs (retinopathy, focal arteriolar narrowing, arteriovenous nicking, enhanced arteriolar light reflex) were assessed from retinal photographs masked to clinical information. RESULTS: Patients with TIA or acute stroke were older than control subjects and more likely to have stroke risk factors. After adjustment for study site and known risk factors, all retinal microvascular signs were more common in patients with TIA or acute stroke than in control subjects (OR, 1.9 to 8.7; P<0.001). Patients with TIA and those with ischemic stroke had similar prevalences of nondiabetic retinopathy (26.9% versus 29.5%; OR, 0.8; 95% CI, 0.5 to 1.6), diabetic retinopathy (55.5% versus 50.0%; OR, 1.3; 95% CI, 0.4 to 3.6), focal arteriolar narrowing (15.6% versus 18.4%; OR, 0.8; 95% CI, 0.4 to 1.5), and arteriovenous nicking (23.0% versus 17.8%; OR, 1.4; 95% CI, 0.7 to 2.7). CONCLUSIONS: Patients with TIA and acute stroke may share similar risk factors or pathogenic mechanisms.
Assuntos
Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/patologia , Doenças Retinianas/etiologia , Doenças Retinianas/patologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/patologia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Microcirculação/fisiologia , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND AND PURPOSE: The relationship of cortical and subcortical cerebral atrophy to cerebral microvascular disease is unclear. We aimed to assess the associations of retinal vascular signs with cortical and subcortical atrophy in patients with acute stroke. METHODS: In the Multi-Centre Retinal Stroke Study, 1360 patients with acute stroke admitted to 2 Australian and 1 Singaporean tertiary hospital during 2005 to 2007 underwent neuroimaging and retinal photography. Cortical and subcortical cerebral atrophy were graded based on standard CT scans. A masked assessment of retinal photographs identified focal retinal vascular signs, including retinopathy and retinal arteriolar wall signs (ie, focal arteriolar narrowing, arteriovenous nicking, arteriolar wall light reflex) and measured quantitative signs (retinal arteriolar and venular caliber). RESULTS: After adjusting for age, gender, study site, hypertension, hypercholesterolemia, diabetes, and smoking status, none of the retinal vascular signs assessed were associated with cortical atrophy, whereas retinopathy (OR, 1.9; CI, 1.2 to 3.0) and enhanced arteriolar light reflex (OR, 2.0; CI, 1.2 to 3.2) were significantly associated with subcortical atrophy. CONCLUSIONS: Our finding that certain retinal vascular signs are associated with subcortical but not cortical atrophy, suggests a differential pathophysiology between these 2 cerebral atrophy subtypes and a potential role for small vessel disease underlying subcortical cerebral atrophy.
Assuntos
Córtex Cerebral/patologia , Retina/patologia , Vasos Retinianos/patologia , Acidente Vascular Cerebral/patologia , Idoso , Idoso de 80 Anos ou mais , Atrofia/diagnóstico por imagem , Atrofia/patologia , Atrofia/fisiopatologia , Austrália , Córtex Cerebral/diagnóstico por imagem , Córtex Cerebral/fisiopatologia , Feminino , Humanos , Modelos Logísticos , Imageamento por Ressonância Magnética , Masculino , Radiografia , Retina/fisiopatologia , Vasos Retinianos/fisiopatologia , Fatores de Risco , Singapura , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologiaRESUMO
BACKGROUND AND PURPOSE: Deep intracerebral hemorrhage (ICH) and lacunar infarcts are the result of small vessel disease, whereas nonlacunar infarcts are often caused by large artery atherosclerosis or cardiac embolism. We hypothesized that patients with deep ICH and lacunar infarcts have similar retinal microvascular signs and that these differ from those seen in patients with nonlacunar infarcts. METHODS: We studied patients with acute stroke and classified their stroke as deep ICH, lacunar infarction, or nonlacunar infarction. In a masked fashion we assessed retinal photographs for quantitative and qualitative evidence of microvascular damage. RESULTS: We recruited 630 patients (51 had deep ICH, 93 had lacunar infarction, and 486 had nonlacunar infarction). Patients with deep ICH were more likely than those with nonlacunar infarcts to have severe focal narrowing of the retinal arterioles (OR, 3.7), severe arteriovenous nicking (OR, 2.6), and quantitatively narrower retinal arterioles and wider retinal venules. Retinal microvascular signs were similar in patients with deep ICH and lacunar infarction. CONCLUSIONS: Patients with deep ICH and lacunar infarcts are more likely than patients with nonlacunar infarcts to have signs indicating hypertensive damage in the retinal arteriolar wall.
Assuntos
Infarto Encefálico , Microvasos/patologia , Vasos Retinianos/patologia , Acidente Vascular Cerebral , Doenças Vasculares/complicações , Doenças Vasculares/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Infarto Encefálico/etiologia , Infarto Encefálico/patologia , Humanos , Hipertensão/complicações , Hipertensão/patologia , Masculino , Microvasos/fisiopatologia , Pessoa de Meia-Idade , Vasos Retinianos/fisiopatologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/patologia , Doenças Vasculares/classificação , Doenças Vasculares/diagnósticoRESUMO
BACKGROUND AND PURPOSE: Previous studies show that both retinal vascular caliber and carotid disease predict incident stroke in the general population, but the exact relationship between these 2 microvascular and macrovascular structural risk factors is unclear. We studied the relationship between retinal vascular caliber and carotid disease in patients presenting with acute ischemic stroke. METHODS: We conducted a cross-sectional study of patients with acute ischemic stroke recruited from 3 centers (Melbourne, Sydney, Singapore). The caliber of retinal arterioles and venules was measured from digital retinal photographs. Severe extracranial carotid disease was defined as stenosis >or=75% or occlusion determined by carotid Doppler using North American Symptomatic Carotid Endarterectomy Trial-based criteria. RESULTS: Among the 1029 patients with acute stroke studied, 7% of the population had severe extracranial carotid disease. Retinal venular caliber was associated with ipsilateral severe carotid disease (P<0.001 in multivariate models). Patients with wider retinal venular caliber were more likely to have severe ipsilateral carotid disease (multivariable-adjusted OR, 3.81; 95% CI, 1.80 to 8.07, comparing the largest and smallest venular caliber quartiles). The retinal venular caliber-carotid disease association remained significant in patients with large artery stroke. CONCLUSIONS: In patients with acute stroke, retinal venular widening was strongly associated with ipsilateral severe extracranial carotid disease. Our findings suggest concomitant retinal and cerebral microvascular disease may be present in patients with carotid stenosis or occlusion disease. The pathogenesis of stroke due to carotid disease may thus be partially mediated by microvascular disease.
Assuntos
Isquemia Encefálica/epidemiologia , Estenose das Carótidas/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Arteríolas/patologia , Arteríolas/fisiopatologia , Austrália/epidemiologia , Isquemia Encefálica/fisiopatologia , Artérias Carótidas/patologia , Artérias Carótidas/fisiopatologia , Estenose das Carótidas/diagnóstico por imagem , Causalidade , Estudos de Coortes , Comorbidade , Estudos Transversais , Técnicas de Diagnóstico Oftalmológico , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Artéria Retiniana/patologia , Artéria Retiniana/fisiopatologia , Oclusão da Artéria Retiniana/fisiopatologia , Veia Retiniana/patologia , Veia Retiniana/fisiopatologia , Fatores de Risco , Acidente Vascular Cerebral/fisiopatologia , Ultrassonografia Doppler , Vênulas/patologia , Vênulas/fisiopatologiaRESUMO
BACKGROUND AND PURPOSE: The retinal and cerebral vasculature share similar anatomic, physiological, and embryological characteristics. We reviewed the literature, focusing particularly on recent population-based studies, to examine the relationship between retinal signs and stroke. Summary of Review- Hypertensive retinopathy signs (eg, focal retinal arteriolar narrowing, arterio-venous nicking) were associated with prevalent stroke, incident stroke, and stroke mortality, independent of blood pressure and other cerebrovascular risk factors. Diabetic retinopathy signs (eg, microaneurysms, hard exudates) were similarly associated with incident stroke and stroke mortality. Retinal arteriolar emboli were associated with stroke mortality but not incident stroke. There were fewer studies on the association of other retinal signs such as retinal vein occlusion and age-related macular degeneration with stroke, and the results were less consistent. CONCLUSIONS: Many retinal conditions are associated with stroke, reflecting possible concomitant pathophysiological processes affecting both the eye and the brain. However, the incremental value of a retinal examination for prediction of future stroke risk remains to be determined.
Assuntos
Doenças Retinianas/diagnóstico , Doenças Retinianas/fisiopatologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Humanos , Doenças Retinianas/epidemiologia , Fatores de Risco , Acidente Vascular Cerebral/epidemiologiaRESUMO
BACKGROUND: Whether intravenous tissue plasminogen activator (alteplase) is effective beyond 3 h after onset of acute ischaemic stroke is unclear. We aimed to test whether alteplase given 3-6 h after stroke onset promotes reperfusion and attenuates infarct growth in patients who have a mismatch in perfusion-weighted MRI (PWI) and diffusion-weighted MRI (DWI). METHODS: We prospectively and randomly assigned 101 patients to receive alteplase or placebo 3-6 h after onset of ischaemic stroke. PWI and DWI were done before and 3-5 days after therapy, with T2-weighted MRI at around day 90. The primary endpoint was infarct growth between baseline DWI and the day 90 T2 lesion in mismatch patients. Major secondary endpoints were reperfusion, good neurological outcome, and good functional outcome. Patients, caregivers, and investigators were unaware of treatment allocations. Primary analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00238537. FINDINGS: We randomly assigned 52 patients to alteplase and 49 patients to placebo. Mean age was 71.6 years, and median score on the National Institutes of Health stroke scale was 13. 85 of 99 (86%) patients had mismatch of PWI and DWI. The geometric mean infarct growth (exponential of the mean log of relative growth) was 1.24 with alteplase and 1.78 with placebo (ratio 0.69, 95% CI 0.38-1.28; Student's t test p=0.239); the median relative infarct growth was 1.18 with alteplase and 1.79 with placebo (ratio 0.66, 0.36-0.92; Wilcoxon's test p=0.054). Reperfusion was more common with alteplase than with placebo and was associated with less infarct growth (p=0.001), better neurological outcome (p<0.0001), and better functional outcome (p=0.010) than was no reperfusion. INTERPRETATION: Alteplase was non-significantly associated with lower infarct growth and significantly associated with increased reperfusion in patients who had mismatch. Because reperfusion was associated with improved clinical outcomes, phase III trials beyond 3 h after treatment are warranted.
Assuntos
Imagem Ecoplanar/métodos , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/patologia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Avaliação de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placebos , Estudos Prospectivos , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
This paper is a case report of Terson's Syndrome (TS) in spontaneous spinal subarachnoid haemorrhage (SAH). A 66-year-old woman with acute onset of severe back pain was transferred to our institution for management of her sciatica. The presence of an intraretinal haemorrhage alerted us to consider intracranial SAH, but investigations showed no intracranial source. Eventually, the patient was diagnosed with a thoracic spinal SAH. The patient's symptoms gradually improved with conservative management but within 1 month she had a recurrence. A spinal and CT angiogram did not elicit the aetiology. The diagnosis of spontaneous spinal SAH can be difficult. The recognition of TS has important prognostic implications, often heralding subarachnoid rebleeding. Fundoscopic examination appears mandatory as a tool for diagnosis and regular non-invasive monitoring of patients with SAH.
Assuntos
Hemorragia Retiniana/etiologia , Hemorragia Subaracnóidea/complicações , Hemorragia Vítrea/etiologia , Idoso , Feminino , Humanos , Imageamento por Ressonância Magnética , Hemorragia Retiniana/patologia , Hemorragia Subaracnóidea/patologia , Síndrome , Tomografia Computadorizada por Raios X , Hemorragia Vítrea/patologiaRESUMO
BACKGROUND: In acute ischemic stroke, magnetic resonance diffusion-weighted imaging (DWI) is increasingly used to select patients for inclusion or as a surrogate outcome marker in clinical trials, or in routine practice. Little is known of what factors might affect DWI lesion size measurement. We examined morphologic factors that might affect DWI lesion measurement. METHODS: On DWI obtained less than 24 hours after stroke, we categorized lesions according to DWI appearance (solitary or multifocal; well-defined or ill-defined edges), lesion size (>5 cm(3)), and time to imaging (<6, 6-12, and 12-24 hours). Two observers (senior neuroradiologist; less-experienced imaging neuroscientist) measured all lesions. In 4 representative cases we assessed DWI lesion volume using two apparent diffusion coefficient thresholds (0.55 and 0.65 x 10(-3) mm(2)/s). RESULTS: Among 63 patients (33% imaged < 6 hours after stroke), the neuroradiologist measured larger lesion volumes than the imaging neuroscientist (median 4.29 v 3.50 cm(3), respectively, P < .01). Differences between observers were greatest in patients scanned within 6 hours of stroke, in multifocal ill-defined or large lesions (all P < .01). Both apparent diffusion coefficient thresholds underestimated lesion extent and included remote normal tissue, particularly in multifocal ill-defined large lesions. CONCLUSION: DWI lesion characteristics influence lesion volume measurement. Large, multifocal, ill-defined DWI lesions obtained in less than 6 hours have the greatest variability. Trials using DWI should account for this in their study design.
Assuntos
Isquemia Encefálica/patologia , Encéfalo/patologia , Ensaios Clínicos como Assunto/métodos , Imagem de Difusão por Ressonância Magnética , Variações Dependentes do Observador , Projetos de Pesquisa , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Viés , Biomarcadores , Competência Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurorradiografia , Neurociências , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de TempoRESUMO
Scaling of projects from inception to establishment within the healthcare system is rarely formally reported. The Victorian Stroke Telemedicine (VST) programme provided a very useful opportunity to describe how rural hospitals in Victoria were able to access a network of Melbourne-based neurologists via telemedicine. The VST programme was initially piloted at one site in 2010 and has gradually expanded as a state-wide regional service operating with 16 hospitals in 2017. The aim of this paper is to summarise the factors that facilitated the state-wide transition of the VST programme. A naturalistic case-study was used and data were obtained from programme documents, e.g. minutes of governance committees, including the steering committee, the management committee and six working groups; operational and evaluation documentation, interviews and research field-notes taken by project staff. Thematic analysis was undertaken, with results presented in narrative form to provide a summary of the lived experience of developing and scaling the VST programme. The main success factors were attaining funding from various sources, identifying a clinical need and evidence-based solution, engaging stakeholders and facilitating co-design, including embedding the programme within policy, iterative evaluation including performing financial sustainability modelling, and conducting dissemination activities of the interim results, including promotion of early successes.
Assuntos
Acidente Vascular Cerebral/terapia , Telemedicina/organização & administração , Prática Clínica Baseada em Evidências , Humanos , Liderança , Avaliação das Necessidades , Estudos de Casos Organizacionais , Projetos Piloto , Telemedicina/economia , VitóriaRESUMO
BACKGROUND AND PURPOSE: The bedside clinical assessment of the patient with suspected stroke has not been well studied. Improving clinical skills may accelerate patient progress through the emergency department. We aimed to determine the frequency and nature of stroke mimics and to identify the key clinical features that distinguish between stroke and mimic at the bedside. METHODS: Consecutive presentations to an urban teaching hospital with suspected stroke were recruited. A standard bedside clinical assessment was performed. The final diagnosis was determined by an expert panel, which had access to clinical features, brain imaging, and other tests. Univariate and multivariate analyses determined the bedside features that distinguished stroke from mimic. RESULTS: There were 350 presentations by 336 patients. The final diagnosis was stroke in 241 of 350 (69%) and mimic in 109 (31%). The mimics included 44 events labeled "possible stroke or TIA." Eight items independently predicted the diagnosis in patients presenting with brain attack: cognitive impairment and abnormal signs in other systems suggested a mimic, an exact time of onset, definite focal symptoms, abnormal vascular findings, presence of neurological signs, being able to lateralize the signs to the left or right side of the brain, and being able to determine a clinical stroke subclassification suggested a stroke. CONCLUSIONS: The bedside clinical assessment can be streamlined substantially. This has important implications for teaching less experienced clinicians how to assess the patient with suspected stroke.
Assuntos
Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/patologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Encéfalo/patologia , Artérias Carótidas/patologia , Diagnóstico Diferencial , Ecocardiografia/métodos , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Análise Multivariada , Razão de Chances , Análise de Regressão , Reprodutibilidade dos Testes , Fatores de Risco , Fatores de Tempo , UltrassonografiaRESUMO
BACKGROUND AND PURPOSE: Stroke remains primarily a clinical diagnosis, with information obtained from history and examination determining further management. We aimed to measure inter-rater reliability for the clinical assessment of stroke, with emphasis on items of history, timing of symptom onset, and diagnosis of stroke or mimic. We explored reasons for poor reliability. METHODS: The study was based in an urban hospital with an acute stroke unit. Pairs of observers independently assessed suspected stroke patients. Findings from history, neurological examination, and the diagnosis of stroke or mimic, were recorded on a standard form. Reliability was measured by the kappa statistic. We assessed the impact of observer experience and confidence, time of assessment, and patient-related factors of age, confusion, and aphasia on inter-rater reliability. RESULTS: Ninety-eight patients were recruited. Most items of the history and the diagnosis of stroke were found to have moderate to good inter-rater reliability. There was agreement for the hour and minute of symptom onset in only 45% of cases. Observer experience and confidence improved reliability; patient-related factors of confusion and aphasia made the assessment more difficult. There was a trend for worse inter-rater reliability among patients assessed very early and very late after symptom onset. CONCLUSIONS: Clinicians should be aware that inter-rater reliability of the clinical assessment is affected by a variety of factors and is improved by experience and confidence. Our findings have implications for training of doctors who assess patients with suspected stroke and identifies the more reliable components of the clinical assessment.
Assuntos
Neurologia/métodos , Acidente Vascular Cerebral/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Transtornos Cerebrovasculares/diagnóstico , Humanos , Modelos Estatísticos , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Fatores de Risco , Acidente Vascular Cerebral/classificação , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Some infarcts have persistently hyperintense areas on diffusion-weighted MRI (DWI) even at 1 month after stroke, whereas others have become isointense to normal brain. We hypothesized that late DWI hyperintensity reflected different infarct evolution compared with areas that were isointense by 1 month. METHODS: We recruited patients prospectively with ischemic stroke, performed DWI and perfusion-weighted MRI (PWI) on admission, at 5 days, 14 days, and 1 month after stroke, and assessed functional outcome at 3 months (Rankin Scale). Patient characteristics and DWI/PWI values were compared for patients with or without "still hyperintense" infarct areas on 1-month DWI. RESULTS: Among 42 patients, 27 (64%) had "still hyperintense" infarct regions at 1 month, mostly in white matter. Patients with "still hyperintense" regions at 1 month had lower baseline apparent diffusion coefficient ratio (ADCr; mean+/-SD 0.76+/-0.12 versus 0.85+/-0.12; hyperintense versus isointense; P<0.05), prolonged reduction of ADCr (repeated-measures ANOVA; P<0.01), no difference in baseline perfusion but delayed normalization of mean transit time (P<0.05) and cerebral blood flow ratios (repeated measures ANOVA; P<0.05), initially more severe stroke, and worse 3-month outcome than patients whose lesions were isointense by 1 month. CONCLUSIONS: The late DWI lesion hyperintensity emphasizes the heterogeneity in temporal evolution of stroke injury and suggests ongoing "ischemia." Lower baseline ADCr precedes delayed perfusion normalization, suggesting that worse cell swelling impedes reperfusion. Further study is required to determine underlying mechanisms and any potential for subacute intervention to improve recovery.
Assuntos
Encéfalo/patologia , Infarto Cerebral/diagnóstico , Imageamento por Ressonância Magnética/métodos , Acidente Vascular Cerebral/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Encéfalo/fisiopatologia , Circulação Cerebrovascular , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/fisiopatologia , Fatores de TempoRESUMO
We undertook a qualitative analysis to identify the broader benefits of a state-wide acute stroke telemedicine service beyond the patient-clinician consultation. Since 2010, the Victorian Stroke Telemedicine (VST) programme has provided a clinical service for regional hospitals in Victoria, Australia. The benefits of the Victorian Stroke Telemedicine programme were identified through document analysis of governance activities, including communications logs and reports from hospital co-ordinators of the programme. Discussions with the Victorian Stroke Telemedicine management were undertaken and field notes were also reviewed. Several benefits of telemedicine were identified within and across participating hospitals, as well as for the state government and community. For hospitals, standardisation of clinical processes was reported, including improved stroke care co-ordination. Capacity building occurred through professional development and educational workshops. Enhanced networking, and resource sharing across hospitals was achieved between hospitals and organisations. Governments leveraged the Victorian Stroke Telemedicine programme infrastructure to provide immediate access to new treatments for acute stroke care in regional areas. Standardised data collection allowed routine quality of care monitoring. Community awareness of stroke symptoms occurred with media reports on the novel technology and improved patient outcomes. The value of telemedicine services extends beyond those involved in the clinical consultation to healthcare funders and the community.