Clinical and radiological differences between patients diagnosed with acute ischemic stroke and chameleons at the emergency room: insights from a single center observational study.

BACKGROUND: Scarce data exist about clinical/radiological differences between acute ischemic strokes diagnosed in the emergency room (AISER) and stroke chameleons (SC). We aimed at describing the differences observed in a comprehensive stroke center in Chile. METHODS: Prospective observational study of patients with ischemic stroke syndromes admitted to the ER of Clínica Alemana between December 2014 and October 2023. RESULTS: 1197 patients were included; of these 63 (5.2%, 95%CI 4.1-6.6) were SC; these were younger (p<0.001), less frequently hypertensive (p=0.03) and they also had lower systolic (SBP) (p<0.001), diastolic blood pressures (DBP) (p=0.011), and NIHSS (p<0.001). Clinically they presented less frequently gaze (p=0.008) and campimetry alterations (p=0.03), facial (p<0.001) and limb weakness (left arm (p=0.004), right arm (p=0,041), left leg (p=0.001), right leg P=0.0029), sensory abnormalities (p<0.001), and dysarthria (p<0.001). Neuro-radiological evaluations included less frequently large vessel occlusions (p=0.01), and stroke locations (p=0.005); they also differed in their etiologies (p<0.001). Brainstem strokes (p<0.001) and extinction/inattention symptoms (p<0.001) were only seen in AISER. In multivariate analysis, younger age (OR: 0.945; 95% CI 0.93 - 0.96), DBP (OR: 0.97; 95% CI, 0.95-0.99), facial weakness (OR: 0.39; CI 95% 0.19-0.78), sensory abnormities (OR: 0.16.18; 95% CI, 0.05-0.4), infratentorial location (OR: 0.36; 95% CI, 0.15-0.78), posterior circulation involvement (OR: 3.02; 95% CI, 1.45-6.3), cardioembolic (OR: 3.5; 95% CI, 1.56-7.99) and undetermined (OR: 2.42; 95% CI, 1.22-4.7; 95%) etiologies, remained statistically significant. A stepwise analysis including only clinical elements present on the patient's arrival to the ER, demonstrates that age (OR: 0.95; 95% CI 0.94 - 0.97), DBP (OR: 0.97; 95% CI, 0.95-0.99), the presence of atrial fibrillation (OR: 2.22; 95% CI, 1.04-4.75, NIHSS (OR: 0.88; 95% CI, 0.71-0.89) and the presence in NIHSS of 1.a Level of consciousness (OR: 5.66; CI 95% 1.8-16.9), 1.b Level of consciousness questions (OR: 3.023; 95% CI, 1.35-6.8), facial weakness (OR: 0.3; CI 95% 0.17-0.8) and sensitive abnormalities (OR: 0.27; 95% CI, 0.1-0.72) remained statistically significant. CONCLUSIONS: SC had clinical and radiological differences compared to AISER. An additional relevant finding is that any neurological symptom in a patient with atrial fibrillation, even in the presence of a negative DWI should be considered an episode of stroke until this is satisfactorily ruled out.

A Chilean Experience of Telestroke in a COVID-19 Pandemic Year.

BACKGROUND AND PURPOSE: Telemedicine for stroke patients' care (telestroke [TS]) has grown notably in recent decades and may offer advantages during health crisis. Hospital admissions related to stroke have decreased globally during the COVID-19 pandemic, but scarce information is available regarding the effect of COVID-19 in TS. Using a population-based TS registry, we investigated the impact of the first year of the COVID-19 pandemic throughout our TS network in Santiago, Chile. METHODS: Stroke codes evaluated after the onset of COVID-19 restrictions in Chile (defined as March 15, 2020) were compared with those evaluated in 2019. We analyzed differences between number of stroke codes, thrombolysis rate, stroke severity, and time from the stroke onset to hospital admission. RESULTS: We observed that the number of stroke codes and the number of patients undergoing reperfusion therapy did not change significantly (p = 0.669 and 0.415, respectively). No differences were found with respect to the median time from the stroke onset to admission (p = 0.581) or in National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.055). The decision-making-to-needle time was significantly shorter in the COVID-19 period (median 5 min [IQR 3-8], p < 0.016), but no significant changes were found at the other times. CONCLUSIONS: This study demonstrates the potential of adapting TS to extreme situations such as the COVID-19 pandemic, as well as the importance of establishing networks that facilitate patient access to quality treatments.

Risk Factors and Diet Components Determining Adherence to the Mediterranean Diet in Acute Ischemic Stroke Patients: A Cross-Sectional Analysis of a Prospective Hospital Register Study.

OBJECTIVES: Low adherence to a Mediterranean diet (MeDi) is associated with increased incidence, mortality, and severity of acute ischemic strokes (AIS). Nevertheless, the explanatory factors associated with such results are unclear. Our aim was to investigate stroke risk factors associated with adherence to a MeDi in a prospective cohort of AIS patients. MATERIALS AND METHODS: Patients admitted from February 2017 to February 2020 were included in this study. Adherence was measured using the 14-point Mediterranean Diet Adherence Screener (MEDAS). Demographic and clinical characteristics were compared with adherence with a univariate analysis. A binomial regression was used to investigate the independent association of premorbid factors and MeDi components with adherence. RESULTS: There were 413 patients. Mean age was 68.6 (17.4), 176 (42.6%) women. Median MEDAS score was 6 (IQR 4-7) points. 253 patients (61.2%) had a low adherence (MEDAS ≤ 6). In the univariate analysis, a low MEDAS was associated with lower education, diabetes, sedentary lifestyle, greater body mass index (BMI), lower alcohol consumption, and higher LDLc. In the regression analysis, younger age, lower education, functional disability, hypertension, sedentary lifestyle, and higher BMI were associated with lower MEDAS scores. Six MeDi components had particularly low patient adherence: seafood, legumes, olive oil, nuts, wine, and fruit. DISCUSSION: These data indicate low adherence to MeDi in younger patients who are less educated and have existing cardiovascular risk factors, in particular hypertension, sedentary lifestyle, and higher BMI. Some components of the diet had a particularly low adherence. CONCLUSIONS: Tailoring diet prevention interventions to these specific populations, focusing on components with known less adherence, could improve adherence to a MeDi and the opportunity for secondary stroke prevention.

Stroke symptoms, risk factors awareness and personal decision making in Chile. A national survey.

BACKGROUND: Knowledge about stroke symptoms, correct decision in front of a stroke case and recognition of stroke risk factors are crucial to fight against stroke burden. We aimed to assess the stroke awareness among a sample of the Chilean population. METHODS: A closed-ended questions structured survey was applied in November 2019 using a computer-assisted telephone interviewing system. Probabilistic sample, random selection and stratification for region was used. Multivariate logistic regression model was used to estimate the association between participants' characteristics and responses. RESULTS: Of 706 participants, only 74.4% (95% CI 70.9-77.5) recognized at least one typical stroke symptom. Most (586, 82.4% 95% CI 75.2-89.7) chose to contact the emergency ambulance or directly go to the emergency department in case of a stroke symptom and recognized at least one risk factor (692, 97.9% CI 96.7-98.8). In multivariable analysis, sociodemographic characteristics associated to a worse recognition of at least one stroke symptom were being men (OR 0.67, 95% CI 0.47-0.96), being 55 years old or older (OR 0.59 95% CI 0.37-0.93) and from the lowest socioeconomic level (SES) (OR 0.33 95% CI 0.16-0.67). Female sex was associated with lower stroke risk factor knowledge (OR 0.64 95% IC 0.47-0.87). Participants who recognized at least one typical stroke symptom and would promptly seek care at an emergency department differed significantly between SES (p=0.001) and age groups (p=0.035). CONCLUSIONS: We found insufficient knowledge about stroke symptoms and best decisions making in the Chilean population. We describe gaps that can be targeted in future stroke awareness campaigns. There is a need to strengthen tailored stroke education particularly for underserved populations.

Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis.

BACKGROUND: Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. METHODS: We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. RESULTS: Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. CONCLUSIONS: Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

Pre-stroke adherence to a Mediterranean diet pattern is associated with lower acute ischemic stroke severity: a cross-sectional analysis of a prospective hospital-register study.

BACKGROUND: High adherence to a Mediterranean Diet is associated with reduced incidence and mortality of acute ischemic stroke (AIS) but may also be associated with severity. Our purpose was to investigate the association of adherence to a Mediterranean diet and severity in a prospective hospital register of AIS patients. METHODS: We included AIS patients admitted from February 2017 to July 2019. All were assessed by a neurologist with a standard stroke protocol, including NIHSS. Adherence to Mediterranean diet was prospectively measured by the 14-point Mediterranean Diet Adherence Screener (MEDAS) and defined as low (0-6 points) or high (7-14 points). Demographic and clinical characteristics were compared by group with univariate analysis. A Generalized Linear Model (GLM) was used to investigate the association of admission NIHSS as a continuous ordinal variable and an ordinal logistic regression (OLR) analysis to determine the independent association of the NIHSS quartiles with adherence to Mediterranean diet. RESULTS: Three hundred sixty-eight patients were included, mean age 68.3 (17.7), 158 (42.9%) females. The median NIHSS score was 3 (IQR 1-9) and the median MEDAS score was 6 (IQR 4.5-8). Patients with high MEDAS scores had significantly lower; admission NIHSS scores, sedentary lifestyle, body mass index, total and LDL cholesterol levels, but higher alcohol consumption. After adjustments, high adherence to Mediterranean diet remained independently associated with lower stroke severity both in the GLM (ß coefficient = - 0.19, p = 0.01) and in the OLR model (OR for lower NIHSS quartiles 0.6 (95% CI 0.37-0.98, p = 0.04). CONCLUSIONS: Higher pre-stroke adherence to a Mediterranean diet is independently associated with lower AIS severity.

[Determinants of door to needle time for intravenous thrombolysis in acute ischemic stroke]. / Determinantes del tiempo puerta-aguja en trombolisis endovenosa en el infarto cerebral, experiencia de un centro.

BACKGROUND: Intravenous thrombolysis (IT) in acute ischemic stroke (AIS) is time dependent. The time elapsed from hospital admission to the thrombolytic bolus is named door to needle time (DNT) and is recommend to be of less than 60 min. AIM: To describe the DNT in our center and determine those factors associated with a DNT longer than 60 min. MATERIAL AND METHODS: Prospective analysis of patients treated with IT at a private hospital between June 2016 and June 2019. The percentage of patients with DNT exceeding 60 min, and the causes for this delay were evaluated. RESULTS: IT was used in 205 patients. DNT was 43.6 ± 23.8 min. Forty patients (19.5% (95% CI, 14.4-25.7), had a DNT longer than 60 min. Uni-varied analysis demonstrated that AIS with infratentorial symptomatology (ITS), was significantly associated with DNTs exceeding 60 min. A history of hypertension, a higher NIH Stroke Scale score, the presence of an hyperdense sign in brain tomography (p = 0.001) and the need for endovascular therapy (p = 0.019), were associated with DNT shorter than 60 min. Multivariate analysis ratified the relationship between ITS and DNT longer than 60 min (Odds ratio: 3.19, 95% confidence intervals 1.26-8). CONCLUSIONS: The individual elements that correlated with a DNT longer than 60 min were the failure to detect the AIS during triage and doubts about its diagnosis.

Yield of Echocardiography in the Evaluation of Cerebral Ischemic Events: A Single Center Cohort Study.

BACKGROUND: Echocardiography (ECO) is frequently used as a screening test in patients with acute ischemic brain disease. We aimed to evaluate the additional information and therapeutic impact resulting from ECO in these patients. METHODS: We conducted a prospective study performing ECO on consecutive patients with ischemic stroke or transient ischemic attacks, admitted to our centre between February 2013 and May 2017. RESULTS: A total of 696 patients were included (female, 57.3%; mean age, 70 ± 15.3 years). Seven hundred thirty two echocardiographic examinations were performed (696 transthoracic and 36 transesophageal). Echocardiography yielded findings judged of clinical importance in 142 patients (20.4%, 95% CI 17.5-23.5). The most frequent of these were left atrial volume enlargement or a normal evaluation. Echocardiography findings resulted in changes in the management of 76 patients (10.7% 95% CI 8.8-13.4); initiation of anticoagulation therapy, administration of IV antibiotic therapy, cardiac surgeries, or other pharmacological therapies occurring in 42 cases (6%). The presence of coronary heart disease (OR: 2.64 95% CI 1.34-5.25), atrial fibrillation (OR: 0.24; 95% CI, 0.2-0.69), and admission NIHSS (OR: 1.04; 95% CI, 1.01-1.09), were the variables associated with changes in management. CONCLUSIONS: In unselected patients with acute ischemic stroke ECO had a low yield of additional information, and it changed management in a small percentage of patients.

Diffusion-weighted imaging determinants for acute ischemic stroke diagnosis in the emergency room.

PURPOSE: The aim of this study was to investigate the clinical-radiological determinants of diffusion-weighted image (DWI) abnormalities in patients with suspected acute ischemic stroke (AIS) seen at the emergency room (ER). METHODS: During the study period, 882 consecutive patients were screened at Clínica Alemana de Santiago, Chile; 786 had AIS and 711 (90.4%) were included. RESULTS: DWI demonstrated 87.3% sensitivity and 99.0% specificity, with a positive likelihood ratio of 79 and a negative likelihood ratio of 0.13 for the detection of AIS. In the univariate analysis, a positive DWI in AIS was associated with admission National Institute of Health Stroke Scale (NIHSS) score (OR 1.09, 95% CI 1.04-1.1%), time from symptom onset to DWI (OR 1.03, 95% CI 1.01-1.05), presence of a relevant intracranial artery occlusion (OR 3.18, 95% CI 1.75-5.76), posterior circulation ischemia (OR 0.44, 95% CI 0.28-0.7), brainstem location of the AIS (OR 0.16, 95% CI 0.093-0.27), infratentorial location of AIS (OR 0.44, 95% CI 0.28-0.70), and lacunar (OR 0.27, 95% CI 0.11-0.68) or undetermined stroke etiology (OR 0.12, 95% CI 0.3-0.31). In multivariate analysis, only admission NIHSS score (OR 1.07, 95% CI 1.01-1.13), time from symptom onset to DWI (OR 1.04, 95% CI 1.01-1.13), brainstem location (OR 0.13, 95% CI 0.051-0.37), and lacunar (OR: 0.4, 95% CI 0.21-0.78) or undetermined etiology (OR: 0.4, 95% CI 0.22-0.78) remained independently associated. CONCLUSION: DWI detects AIS accurately; the positivity of these evaluations in the ER is associated only with NIHSS on admission, time to DWI, brainstem location, and AIS etiology.

Reliability of Hand-Held Transcranial Doppler with M-mode Ultrasound in Middle Cerebral Artery Measurement.

PURPOSE: To determine the intra- and interrater agreement of mean flow velocity (MFV) and pulsatility index (PI) measurement in middle cerebral arteries, assessed by transcranial Doppler (TCD) with M-mode. METHODS: Masked experienced neurosonologists performed TCD with M-mode using handheld probe in healthy adult volunteers. The Bland-Altman method for concordance and intraclass correlation coefficient were used. RESULTS: Seventy-seven healthy volunteers and seven raters participated (3 on regular TCD shift and 4 off-shift). The intrarater absolute mean difference between measurements was 5.5 cm/s [95% confidence interval (CI), 4.7-6.3] for MVF and 0.073 (95% CI, 0.063-0.083) for PI. The difference between MFV measurements was significantly higher in off-shift raters (p = 0.015). The interrater absolute mean difference between measurements was 6.5 cm/s (95% CI, 5.5-7.5) for MVF and 0.065 (95% CI, 0.059-0.071) for PI. No influence was found for the middle cerebral artery side, volunteer's sex, or age, and there was no significant difference between raters. The intraclass correlation coefficient was 82.2% (95% CI 77.8-85.6) and 72.9% (95% CI 67.4-77.6) for MFV and PI, respectively. CONCLUSIONS: There exists good intra- and interrater agreement in MFV and PI measurements using M-mode TCD. These results support the use of this noninvasive tool and are important for clinical and investigational purposes.

[Thrombolysis in stroke mimics: Experience in 10 cases]. / Trombolisis intravenosa en cuadros imitadores de isquemia cerebral: experiencia de un centro.

BACKGROUND: The effectiveness of intravenous thrombolysis (IVT) in cerebral ischemia is time dependent. Stroke mimics (SM) are frequent in emergency rooms. The effort to reduce door to needle time, can lead to administer thrombolytics to SM. AIM: To describe the frequency and prognosis of SM treated with IVT. MATERIAL AND METHODS: Prospective analysis of all patients evaluated in a Chilean private clinic between December 2004 and July 2015 with a suspected acute ischemic stroke (AIS). We calculated the number of SM that were treated with IVT. In these patients, we analyzed the presence of symptomatic cerebral hemorrhage defined as the presence of a neurological deterioration of four points or more on the National Institute of Health Stroke Scale, the presence of extracranial bleeding according to Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries criteria and the patient's functional status at three months by modified Rankin scale (MRS). RESULTS: We evaluated 1,417 patients with suspected AIS, of which 240 (16.9%) were finally diagnosed as SM. A total of 197 patients were treated with IVT, of these 10 (5%) corresponded to SM. All SM patients treated with thrombolytic drugs were functionally independent at 3 months and showed no bleeding complications. CONCLUSIONS: Occasionally SM patients were treated with IVT. This treatment was not associated with bleeding complications and the prognosis of these patients at three months was favorable.

Head position and cerebral blood flow velocity in acute ischemic stroke: a systematic review and meta-analysis.

BACKGROUND: Patients with acute ischemic stroke (AIS) have impaired vasomotor reactivity, especially in the affected cerebral hemisphere, such that they may depend directly on systemic blood pressure to maintain perfusion to vulnerable 'at risk' penumbral tissue. As the sitting up position may affect cerebral perfusion by decreasing cerebral blood flow (CBF) in salvageable tissue, positioning AIS patients with their head in a lying flat position could increase CBF through collateral circulation or gravitational force. We wished to quantify the effect of different head positions on mean flow velocity (MFV) by transcranial Doppler ultrasonography (TCD) in AIS patients to assess the potential for benefit (or harm) of head positioning in a clinical trial. METHODS: We performed a systematic review and meta-analysis of observational studies with TCD to evaluate differences in cerebral MFV between the lying flat and sitting up head positions in AIS. For each study and each comparison, we obtained the mean value of changes in MFV and its variance. RESULTS: A total of 303 studies were identified, but 298 were excluded for varying reasons; 4 papers met the inclusion criteria and 57 patients were included in the meta-analysis for calculation of the overall mean difference in MFV. We found a significant increase in MFV from a bed angle of 30 to 15° (4.6 cm/s, 95% confidence interval, CI, 2.9-6.2, p < 0.001) and from 30 to 0° (8.3 cm/s, 95% CI 5.3-11.3, p < 0.001) in the affected hemisphere but not on the normal side in AIS patients. CONCLUSIONS: In AIS patients, MFV increased significantly in the side affected by the stroke but not in the unaffected side when they were positioned in a lying flat head position at 0 or 15° compared to an upright head position at 30°. The clinical significance of these findings is now undergoing further randomized evaluation in the international multicenter Head Position in Acute Stroke Trial (HeadPoST).

Intravenous Thrombolysis in Patients 90 Years or Older with Moderate to Severe Acute Ischemic Stroke Increases Ambulation at Discharge and Is Safe: A Prospective Cohort Study from a Single Center in Santiago, Chile.

INTRODUCTION: The World Health Organization predicts that the global population aged 60 years and older will double by 2050, leading to a significant rise in the public health impact of acute ischemic stroke (AIS). Existing stroke guidelines do not specify an upper age limit for the administration of intravenous thrombolysis (IVT), although some suggest a relative exclusion criterion in patients aged ≥80 in the 3-4.5-h window. Many physicians avoid treating these patients with IVT, argumenting high risk and little benefit. Our aim was to investigate the efficacy and safety of IVT treatment in patients with non-minor AIS aged ≥90, admitted to our institution. The primary efficacy endpoint was the ability to walk at discharge (mRS 0-3), and the primary safety endpoints were death and symptomatic intracranial hemorrhagic transformation (sIHT) at discharge. METHODS: Patients with AIS aged ≥90 admitted to our center from January 2003 to December 2022 were included. They were selected if had an NIHSS ≥5, were previously ambulatory (prestroke mRS score 3 or less), and arrived within 6 h from symptom onset. Those treated or not with IVT were compared with univariate analysis. RESULTS: The mean age was 93.2 (2.4) years, and 51 (73.9%) were female. The admission mRS and NIHSS were 1 (IQR 0-2) and 14 (IQR 7-22), respectively. Thrombolyzed patients had a shorter time from symptom onset to door and lower glycemia on admission. IVT was associated with a higher proportion of patients achieving mRS 0-3 at discharge (p = 0.03) and at 90 days (p = 0.04). There were no differences between groups in the risk of death (p = 0.55) or sIHT (p = 0.38). CONCLUSION: In this small sample, ambulatory patients aged ≥90 with moderate or severe AIS treated with IVT had increased odds of being able to walk independently at discharge than those not treated, without safety concerns.

Accuracy of diffusion-weighted imaging in the diagnosis of stroke in patients with suspected cerebral infarct.

BACKGROUND AND PURPOSE: The accuracy of diffusion-weighted imaging (DWI) for the diagnosis of acute cerebral ischemia among patients with suspected ischemic stroke arriving to an emergency room has not been studied in depth. METHODS: DWI was performed in 712 patients with acute or subacute focal symptoms that suggested an acute ischemic stroke (AIS), 609 of them with AIS. RESULTS: DWI demonstrated a sensitivity of 90% and specificity of 97%, a positive likelihood ratio of 31 and a negative likelihood ratio of 0.1 for detecting AIS. The overall accuracy was 95%. Of those patients who demonstrated abnormal DWI studies, 99.5% were AIS patients, and of those patients with normal DWI studies 63% were stroke mimics. CONCLUSIONS: DWI is accurate in detecting AIS in unselected patients with suspected AIS; a negative study should alert for nonischemic conditions.

Exclusion criteria for intravenous thrombolysis in stroke mimics: an observational study.

BACKGROUND: Stroke mimics (SMs) are frequent in emergency departments (EDs), but are treated infrequently with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. We aimed at identifying the factors that lead to the exclusion of SMs from thrombolytic therapy. METHODS: Consecutive patients presenting to the ED between December 2004 and March 2011 with symptoms that suggested acute ischemic stroke were included. RESULTS: Eight hundred forty-two patients were included in this study; 113 (13.4%) were considered SMs; these patients were younger (P = .01), more frequently diabetic (P = .001), arrived later to the ED (P = .03), had lower National Institutes of Health Stroke Scale scores (P < .001), and higher frequencies of negative diffusion-weighted imaging studies (P = .002). The most common causes of cases of SM were toxic metabolic disorders (n = 34 [30.1%]) and seizures (n = 22 [19.5%]). The most frequent cause of consultation was aphasia (n = 43 [37.6%]). SM patients had a total of 152 contraindications for rt-PA, with 34 (30%) patients having >1 contraindication. The most frequent of these were being beyond the therapeutic window for thrombolysis (n = 96) and having deficits not measurable by the National Institutes of Health Stroke Scale or very mild symptoms before the start of rt-PA (n = 37). Twenty-four (21.2%) patients had both contraindications simultaneously. Two patients (1.76%) in the SM group were candidates for rt-PA but did not receive this treatment because they or their family rejected it. Of 729 stroke patients, 87 (11.9%) did receive rt-PA. CONCLUSIONS: SM patients frequently had exclusion criteria for systemic thrombolysis, the most frequent being presenting beyond the established thrombolytic window.

Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience.

BACKGROUND: The efficacy of intravenous thrombolysis (IVT) is time-dependent. OBJECTIVE: To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. METHODS: Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. RESULTS: A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant. CONCLUSION: Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.

ANTECEDENTES: La respuesta a la trombólisis intravenosa (TIV) es dependiente del tiempo. OBJECTIVO: Comparar los tiempo puerta-aguja (TPAs) de neurólogos vasculares (NVs) contra los de neurólogos no vasculares (NNVs) y médicos emergencistas (MEs), y determinar los elementos asociados a un PTA ≤ 20 minutos. MéTODOS: Análisis observacional prospectivo de pacientes con TIV tratados en Clínica Alemana entre junio de 2016 y septiembre de 2021. RESULTADOS: En total, 301 pacientes con TIV fueron tratados. El TPA promedio fue de 43,3 ± 23,6 minutos. Un total de 173 (57,4%) pacientes fueron evaluados por NVs, 122 (40,5%), por NNVs, y 6 (2,1%), por MEs; los TPAs promedios fueron de 40,8 ± 23; 46 ± 24,7 y 58 ± 22,5 minutos, respectivamente. Los TPAs ≤ 20 minutos fueron más frecuentes en pacientes tratados por NVs versus NNVs y MEs: 15%, 4% y 0%, respectivamente (odds ratio [OR]: 4,3; intervalo de confianza del 95% [IC95%]: 1,66­11,5; p = 0,004). El análisis univariado demostró que TPA ≤ 20 minutos se asoció con: tratamiento por NVs (p = 0,002), periodo de la pandemia de enfermedad por coronavirus 2019 (COVID-19; p = 0,21), tiempo a urgencia (p = 0,21), diabetes (p = 0,142), hipercolesterolemia (p = 0,007), fibrilación auricular (p < 0,09), puntaje en la National Institutes of Health Stroke Scale [NIHSS] (p = 0,001), presión arterial sistólica (p = 0,143) y diastólica menores (p = 0,21), Alberta Stroke Program Early CT Score (ASPECTS ; p = 0,09), oclusión de vasos cerebrales (p =0,05), uso de tecneteplase (p = 0,18), trombectomía (p = 0,13) y años de experiencia del médico (p < 0,001). El análisis multivariado demostró que ser tratado por NVs (OR: 3,95; IC95%: 1,44­10,8; p = 0,007), el puntaje en la NIHSS (OR: 1,07; IC95%: 1,02­1,12; p < 0,002) y la presión arterial sistólica (OR: 0,98; IC95%: 0,96­0,99; p < 0,003) se asociaron a TPA ≤ 20 minutos. CONCLUSIóN: El tratamiento por NVs resultó en un TPA menor y en una mayor probabilidad de tratamiento ≤ 20 minutos.

Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression.

Introduction: The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions. Methods: We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria. Results: A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4-15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1-10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window. Conclusions: The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.

Incidence, risk factors, prognosis, and health-related quality of life after stroke in a low-resource community in Chile (ÑANDU): a prospective population-based study.

BACKGROUND: Stroke is a leading cause of disability and death worldwide. The best estimates of local, national, and global burden of stroke are derived from prospective population-based studies. We aimed to investigate the incidence, risk factors, long-term prognosis, care, and quality of life after stroke in the Ñuble region of Chile. METHODS: We did a prospective community-based study with use of multiple overlapping sources of hospitalised, ambulatory, and deceased cases. Standardised diagnostic criteria were used to identify and follow up all cases occurring in the resident population of the Ñuble region, Chile (in a low-income rural-urban population including predominantly people of Indigenous-European heritage), for 1 year. Participants were included if they had a clinical diagnosis of stroke confirmed according to the study criteria. All cases were adjudicated by vascular neurologists. Incidence rates of first-ever stroke were calculated from the population of Ñuble according to the 2017 national census. FINDINGS: From April 1, 2015, to March 31, 2016, we ascertained 1103 stroke cases, of which 890 (80·7%) were first-ever incident cases. The mean age of patients with first-ever stroke was 70·3 years (SD 14·1) and 443 (49·8%) were women. A CT scan was obtained in 801 (90%) of 890 patients (mean time from symptom onset to scan of 13·4 h (SD 29·8). The incidence of first-ever stroke age-adjusted to the world population was 121·7 (95% CI 113·7-130·1) per 100 000. The age-adjusted incidence rates, per 100 000 inhabitants, by main pathological subtypes were as follows: ischaemic stroke (101·5 [95% CI 90·9-113·0]); intracerebral haemorrhage (17·9 [13·5-23·4]), and subarachnoid haemorrhage (4·2 [2·1-7·3]). The 30-day case-fatality rate was 24·6% (21·9-27·6). At 6 months after the stroke, 55·9% (432 of 773) of cases had died or were disabled, which increased to 61·0% (456 of 747) at 12 months. Health-related quality of life in survivors was low at 6 months, improving slightly at 12 months after the stroke. INTERPRETATION: The incidence of stroke in this low-resource population was higher than our previous finding in northern Chile and within the mid-range of most population-based stroke studies. This result was due mainly to a higher incidence of ischaemic stroke, probably associated with increasing age and a high prevalence of cardiometabolic risk factors in the population studied. Our findings suggest that more should be done for the prevention and care of stroke in communities like the Ñuble population. FUNDING: The National Agency for Research and Development and the Technology-Health Research Fund, Clínica Alemana de Santiago, Boehringer Ingelheim, Bristol Meyers Squibb, The Herminda Martin Clinical Hospital of Chillán, Universidad Mayor, and Universidad de Concepción.