Strategies to reduce delays in delivering mechanical thrombectomy for acute ischaemic stroke - an umbrella review.

Background: Mechanical thrombectomy is a time-sensitive treatment, with rapid initiation and reduced delays being associated with better patient outcomes. Several systematic reviews reported on various interventions to address delays. Hence, we performed an umbrella review of systematic reviews to summarise the current evidence. Methods: Medline, Embase, Cochrane Library and JBI were searched for published systematic reviews. Systematic Reviews that detailed outcomes related to time-to-thrombectomy or functional independence were included. Methodological quality was assessed using the JBI critical appraisal tool by two independent reviewers. Results: A total of 17 systematic reviews were included in the review. These were all assessed as high-quality reviews. A total of 13 reviews reported on functional outcomes, and 12 reviews reported on time-to-thrombectomy outcomes. Various interventions were identified as beneficial. The most frequently reported beneficial interventions that improved functional and time-related outcomes included: direct-to-angio-suite and using a mothership model (compared to drip-and-ship). Only a few studies investigated other strategies including other pre-hospital and teamwork strategies. Conclusion: Overall, there were various strategies that can be used to reduce delays in the delivery of mechanical thrombectomy with different effectiveness. The mothership model appears to be superior to the drip-and-ship model in reducing delays and improving functional outcomes. Additionally, the direct-to-angiosuite approach appears to be beneficial, but further research is required for broader implementation of this approach and to determine which groups of patients would benefit the most.

Case of syndrome of headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) with focal slowing on electroencephalogram.

We describe a case of headache and neurological deficits with cerebrospinal fluid (CSF) lymphocytosis in a patient presenting with a 3-week history of recurrent severe headaches associated with negative sensory symptoms and dysphasia. The patient had no cardiovascular risk factors and no family history of migraines. Neurological examination was unremarkable. Cerebral magnetic resonance imaging was unremarkable. CSF analysis revealed lymphocytosis (leucocytes 84 × 10(6)/L, 100% lymphocytes). Extensive laboratory investigations of CSF and serum did not reveal an infectious, autoimmune or metabolic cause. Visual evoked potentials were normal. Awake electroencephalogram revealed intermittent 3-5 Hz generalised slowing and frontal intermittent rhythmic delta activity, without epileptiform discharges. Repeat CSF analysis showed marked reduction of the total leucocyte count and remained negative for infectious aetiology. Propranolol was commenced, and no recurrence of headache or neurological symptoms was observed at follow-up. An extensive literature review on the topic is discussed.

Very early mobilisation and complications in the first 3 months after stroke: further results from phase II of A Very Early Rehabilitation Trial (AVERT).

BACKGROUND: Interventions that may reduce the number and severity of potentially harmful post-stroke complications are desirable. This study explored whether very early and frequent mobilisation (VEM) affected complication type (immobility/stroke related), number and severity. METHODS: Secondary analysis from phase II, randomised controlled trial. Patients admitted within 24 h of stroke, whose physiological parameters fell within set limits, were randomised to either VEM, commencing <24 h, or standard care. Complications to 3 months were recorded by a blinded assessor and classified by a neurologist. Analysis was intention to treat. RESULTS: Seventy-one patients were recruited (standard care 33; VEM 38).There were no significant group differences in the number, type or severity of complications by 3 months, and most patients (81.6%) experienced one or more complications. Falls were common, while depression was absent. The multivariate analysis showed older age (OR 1.10, 95% CI: 1.02-1.18, p = 0.009) and longer length of stay (OR 1.18, 95% CI: 1.06-1.32, p = 0.002) were associated with experiencing an immobility-related complication. CONCLUSION: Interventions that promote recovery and reduce complications may consequently reduce length of stay. The larger phase III trial currently underway may shed light on whether increasing mobilisation reduces complications after stroke.

Introduction of an acute stroke team: an effective approach to hasten assessment and management of stroke in the emergency department.

Recombinant tissue plasminogen activator (rtPA) reduces the combined endpoint of death and disability if given within three hours of onset of ischaemic stroke. However few patients receive rtPA, with delays in in-hospital evaluation and treatment being key barriers to therapy. The Austin Hospital Acute Stroke Team (AST) was introduced with the aim of improving the speed of assessment and management of acute stroke patients presenting to the emergency department. We sought to assess the effect of the AST on number of eligible patients receiving rtPA and assessment times within our already active stroke service. Data were obtained prospectively for all AST calls during the period from 17 January 2005--31 December 2005. Information recorded included: demographics, time of call, clinical features, diagnosis and any treatment with rtPA. Information prospectively acquired from patients receiving stroke thrombolysis the previous year was also analysed. There were 663 stroke unit admissions and 224 AST calls during the study period. 53% of calls occurred within working hours and 68% had a final diagnosis of stroke. Twenty-seven patients received treatment with rtPA (12% of calls), whereas only ten patients received rtPA in 2004. The most common reason for not treating was mild or rapidly resolving deficit. Onset-needle time and door-needle times significantly improved following introduction of the AST. Thus, we conclude that the introduction of the AST emergency call system has increased the number of eligible patients receiving rtPA. Improved onset-needle and door-needle times are achievable by this team approach.

Impact of acute stroke team emergency calls on in-hospital delays in acute stroke care.

INTRODUCTION: Acute stroke is a medical emergency. Therefore, early recognition and rapid activation of the medical system are important prerequisites for successful management. We sought to investigate the impact of our new Acute Stroke Team emergency call system (AST) on admission delays from the emergency department (ED) to the stroke care unit (SCU) and on the subsequent length of stay (LOS) and in-hospital mortality. METHODS: We retrospectively analysed data obtained from the Austin Hospital stroke unit database and the electronic medical record/patient tracking system for the 5 months before (August to December 2004) and after (January to May 2005) the introduction of the AST. RESULTS: Data for 352 patients were extracted. Of these, there were 260 (73.9%) patients with ischaemic stroke, 38 (10.8%) with intracerebral haemorrhage and 54 (15.3%) with transient ischaemic attack (TIA). One hundred and seventy-two patients were admitted before and 180 after AST introduction. There were 70 AST calls from January to May 2005. Baseline characteristics of both groups were similar. Between the two groups, the median (Q1,Q3) time from door to CT scan was significantly reduced from 104 (60,149) to 82 (40,132) minutes. The LOS was significantly reduced from 6 (3,9) to 3 (2,7) days. There was no significant impact on mortality. CONCLUSION: The introduction of AST has reduced the time from door to brain CT scan. This is an important finding as the window period for thrombolysis is short and early diagnosis is crucial.

Stroke incidence on the east coast of Australia: the North East Melbourne Stroke Incidence Study (NEMESIS).

BACKGROUND AND PURPOSE: Community-based stroke incidence studies are the most accurate way of explaining mortality trends and developing public health policy. The purpose of this study was to determine the incidence of stroke in a geographically defined region of Melbourne, Australia. METHODS: All suspected strokes occurring in a population of 133 816 residents in suburbs north and east of Melbourne, Australia, during a 12-month period of 1996 and 1997 were found and assessed. Multiple overlapping sources were used to ascertain cases, and standard definitions and criteria for stroke and case fatality were used. RESULTS: A total of 381 strokes occurred among 353 people during the study period, 276 (72%) of which were first-ever-in-a-lifetime strokes. The crude annual incidence rate (first-ever strokes) was 206 (95% CI, 182 to 231) per 100 000 per year overall, 195 (95% CI, 161 to 229) for males, and 217 (95% CI, 182 to 252) for females. The corresponding rates adjusted to the "world" population were 100 (95% CI, 80 to 119) overall, 113 (95% CI, 92 to 134) for males, and 89 (95% CI, 70 to 107) for females. The 28-day case fatality rate for first-ever strokes was 20% (95% CI, 16% to 25%). CONCLUSIONS: The incidence rate of stroke in our population-based study is similar to that of many European studies but is significantly higher than that observed on the west coast of Australia.

Incidence of the major stroke subtypes: initial findings from the North East Melbourne stroke incidence study (NEMESIS).

BACKGROUND AND PURPOSE: Population-based stroke incidence studies are the only accurate way to determine the number of strokes that occur in a given society. Because the major stroke subtypes have different patterns of incidence and outcome, information on the natural history of stroke subtypes is essential. The purpose of the present study was to determine the incidence and case-fatality rate of the major stroke subtypes in a geographically defined region of Melbourne, Australia. METHODS: All suspected strokes that occurred among 133 816 residents of suburbs north and east of Melbourne, Australia, during a 12-month period of 1996 and 1997 were identified and assessed. Multiple overlapping sources were used to ascertain cases, and standard criteria for stroke and case-fatality were used. Stroke subtypes were defined by CT, MRI, and autopsy. RESULTS: Three hundred eighty-one strokes occurred among 353 persons during the study period, with 276 (72%) being first-ever-in-a-lifetime strokes. Of these, 72.5% (95% CI 67.2% to 77.7%) were cerebral infarction, 14.5% (95% CI 10.3% to 18.6%) were intracerebral hemorrhage, 4.3% (95% CI 1.9% to 6.8%) were subarachnoid hemorrhage, and 8.7% (95% CI 5.4% to 12.0%) were stroke of undetermined type. The 28-day case-fatality rate was 12% (95% CI 7% to 16%) for cerebral infarction, 45% (95% CI 30% to 60%) for intracerebral hemorrhage, 50% (95% CI 22% to 78%) for subarachnoid hemorrhage, and 38% (95% CI 18% to 57%) for stroke of undetermined type. CONCLUSIONS: The overall distribution of stroke subtypes and 28-day case-fatality rates are not significantly different from those of most European countries or the United States. There may, however, be some differences in the incidence of subtypes within Australia.

Informal care for stroke survivors: results from the North East Melbourne Stroke Incidence Study (NEMESIS).

BACKGROUND AND PURPOSE: Informal caregivers play an important role in the lives of stroke patients, but the cost of providing this care has not been estimated. The purpose of this study was to determine the nature and amount of informal care provided to stroke patients and to estimate the economic cost of that care. METHODS: The primary caregivers of stroke patients registered in the North East Melbourne Stroke Incidence Study (NEMESIS) were interviewed at 3, 6, and 12 months after stroke, and the nature and amount of informal care provided were documented. The opportunity and replacement costs of informal care for all first-ever-in-a-lifetime strokes (excluding subarachnoid hemorrhages) that occurred in 1997 in Australia were estimated. RESULTS: Among 3-month stroke survivors, 74% required assistance with activities of daily living and received informal care from family or friends. Two thirds of primary caregivers were women, and most primary caregivers (>90%) provided care during family or leisure time. Total first-year caregiver time costs for all first-ever-in-a-lifetime strokes were estimated to be A$21.7 million (opportunity cost approach) or A$42.5 million (replacement cost approach), and the present values of lifetime caregiver time costs were estimated to be A$171.4 million (opportunity cost approach) or A$331.8 million (replacement cost approach). CONCLUSIONS: Informal care for stroke survivors represents a significant hidden cost to Australian society. Because our community is rapidly aging, this informal care burden may increase significantly in the future.

Cost of stroke in Australia from a societal perspective: results from the North East Melbourne Stroke Incidence Study (NEMESIS).

BACKGROUND AND PURPOSE: Accurate information about resource use and costs of stroke is necessary for informed health service planning. The purpose of this study was to determine the patterns of resource use among stroke patients and to estimate the total costs (direct service use and indirect production losses) of stroke (excluding SAH) in Australia for 1997. METHODS: An incidence-based cost-of-illness model was developed, incorporating data obtained from the North East Melbourne Stroke Incidence Study (NEMESIS). The costs of stroke during the first year after stroke and the present value of total lifetime costs of stroke were estimated. RESULTS: The total first-year costs of all first-ever-in-a lifetime strokes (SAH excluded) that occurred in Australia during 1997 were estimated to be A$555 million (US$420 million), and the present value of lifetime costs was estimated to be A$1.3 billion (US$985 million). The average cost per case during the first 12 months and over a lifetime was A$18 956 (US$14 361) and A$44 428 (US$33 658), respectively. The most important categories of cost during the first year were acute hospitalization (A$154 million), inpatient rehabilitation (A$150 million), and nursing home care (A$63 million). The present value of lifetime indirect costs was estimated to be A$34 million. CONCLUSIONS: Similar to other studies, hospital and nursing home costs contributed most to the total cost of stroke (excluding SAH) in Australia. Inpatient rehabilitation accounts for approximately 27% of total first-year costs. Given the magnitude of these costs, investigation of the cost-effectiveness of rehabilitation services should become a priority in this community.

Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit.

Acute vestibular syndrome may be due to vestibular neuritis (VN) or posterior circulation strokes. Bedside ocular motor testing performed by experts is superior to early MRI in excluding strokes. We sought to demonstrate that differentiation of strokes from VN in our stroke unit is reliable. During a prospective study at a tertiary hospital over 1 year, patients with AVS were evaluated in the emergency department (ED) and underwent admission with targeted examination: gait, gaze-holding, horizontal head impulse test (hHIT), testing for skew deviation (SD) and vertical smooth pursuit (vSP). Neuroimaging included CT, transcranial Doppler (TCD) and MRI with MR angiogram (MRA). VN was diagnosed with normal diffusion-weighted images (DWI) and absence of neurological deficits on follow-up. Acute strokes were confirmed with DWI. A total of 24 patients with AVS were enrolled and divided in two groups. In the pure vestibular group (n = 20), all VN (n = 10/10) had positive hHIT and unidirectional nystagmus, but 1 patient had SD and abnormal vertical smooth pursuit (SP). In all the strokes (n = 10/10), one of the following signs suggestive of central lesion was present: negative hHIT, central-type nystagmus, SD or abnormal vSP. Finding one of these was 100% sensitive and 90% specific for stroke. In the cochleovestibular group (n = 4) all had normal DWI, but 3 patients had central ocular motor signs (abnormal vertical SP and SD). Whilst the study is small, classification of AVS in our stroke unit is reliable. The sensitivity and specificity of bedside ocular motor testing are comparable to those previously reported by expert neuro-otologists. Acute cochleovestibular loss and normal DWI may signify a labyrinthine infarct but differentiating between different causes of inner ear dysfunction is not possible with bedside testing.

Sex differences in presentation, severity, and management of stroke in a population-based study.

OBJECTIVES: Women may have poorer outcomes after stroke than men because of differences in their acute management. We examined sex differences in presentation, severity, in-hospital treatment, and early mortality in a cohort of first-ever-in-a-lifetime stroke patients. METHODS: Data were collected from May 1, 1996, to April 30, 1999, in the North East Melbourne Stroke Incidence Study. Stroke symptoms, prestroke medical history, in-hospital investigations, admission and discharge medications, initial stroke severity, and 28-day mortality were recorded. Multivariable regression was used to estimate sex differences in treatment, investigations, and 28-day mortality. RESULTS: A total of 1,316 patients were included. Women were older (mean age 76 +/- 0.6 vs 72 +/- 0.6, p < 0.01), had more severe strokes (median NIH Stroke Scale score 6 vs 5, p < 0.01), and more likely to experience loss of consciousness (31% vs 23%, p = 0.003) and incontinence (22% vs 11%, p = 0.01) than men. Women were less often on lipid-lowering therapy on admission. Echocardiography and carotid investigations were less frequently performed in women due to greater age and stroke severity. Women had greater 28-day mortality (32% vs 21%, p < 0.001) and stroke severity (44% vs 36%, p = 0.01) than men, but adjustment for age, comorbidities, and stroke severity (for mortality only) completely attenuated these associations. CONCLUSION: Sex differences seen in this study were mostly explained by women's older age, greater comorbidity, and stroke severity. The reasons for differences according to age may need further examination.

Hypertension and TIA.

Transient ischemic attack is a medical emergency because early stroke risk after transient ischemic attack is high. Hypertension is the most important modifiable risk factor for stroke and transient ischemic attack. The aims of this review are to provide a summary of the current knowledge concerning the relationship between blood pressure and transient ischemic attack, as well as outline issues regarding diurnal variation and the potential of chronotherapy (timing medications to accord with diurnal patterns of blood pressure). There is a strong relationship between hypertension and the incidence of transient ischemic attack and the subsequent short-term risk for stroke. Ambulatory blood pressure monitoring is a reliable diagnostic and monitoring tool for hypertension and provides additional information about diurnal variation in blood pressure. Different diurnal blood pressure patterns may confer variable stroke risk. Patients with stroke commonly have abnormal diurnal blood pressure patterns and this may relate, in part, to autonomic nervous system dysfunction. However, blood pressure patterns have not been systematically studied in patients with transient ischemic attack. Blood pressure remains poorly controlled in a large proportion of patients after transient ischemic attack and under-treatment and poor adherence are important factors. Chronotherapy for blood pressure may result in more effective blood pressure control. More research is needed in this area. Hypertension is strongly associated with transient ischemic attack. Diurnal blood pressure patterns may influence subsequent stroke risk after transient ischemic attack and more evidence is needed to inform clinical practice to improve blood pressure management for transient ischemic attack patients.

Is prestroke use of angiotensin-converting enzyme inhibitors associated with better outcome?

BACKGROUND: There is evidence that angiotensin-converting enzyme inhibitors (ACEIs) reduce the risk of stroke. However, it is unclear whether ACEI use before stroke provides a vasoprotective effect resulting in less severe stroke. METHODS: We ascertained all strokes occurring in a defined population in Melbourne, Australia. Prestroke use of ACEIs and concomitant medications was obtained from medical records. Initial neurologic deficit was dichotomized according to a NIH Stroke Scale (NIHSS) score < 8 (less severe deficit) or > or = 8 (severe deficit). Logistic regression was used to assess the association between prestroke use of ACEIs and stroke severity (measured by severity of neurologic deficits and death at 28 days). RESULTS: Seven hundred sixteen first-ever ischemic stroke patients were included. Previous use of ACEIs was independently associated with a reduced risk of severe neurologic deficits (odds ratio [OR] 0.56; 95% CI 0.35 to 0.91) and death within 28 days (OR 0.46; 95% CI 0.24 to 0.87). Diuretics were associated with an increased risk of severe neurologic deficits (OR 1.81; 95% CI 1.13 to 2.90). Factors associated with a greater NIHSS score were older age, atrial fibrillation, heart failure, and use of diuretics. These factors and claudication were associated with an increased risk of 28-day mortality, whereas use of anticoagulants was associated with a reduced risk of severe neurologic deficits and death. CONCLUSION: Within this large community-based cohort, prestroke use of angiotensin-converting enzyme inhibitors was associated with a reduced risk of severe stroke.

Neurological disability and neurological rehabilitation.

Evidence is increasing that neurorehabilitation lessens patient disability and improves quality of life in both acute and chronic neurological conditions. A focused, multidisciplinary team approach is the key to a successful rehabilitation outcome. The general practitioner will be more closely involved in the rehabilitation process in the future. Patients will be discharged home earlier to complete the acute rehabilitation program. GPs will supervise function over the long term and activate community rehabilitation resources when necessary to maintain patient function. Ideally, rehabilitation services should be available for most patients with neurological disorders, as it is difficult to predict which individual patients will not benefit.

Interrater reliability of the National Institutes of Health Stroke Scale: rating by neurologists and nurses in a community-based stroke incidence study.

The reliability of the National Institutes of Health Stroke Scale (NIHSS) for use by trained neurologists in clinical trials of acute stroke has been established in several hospital-based studies. However, it also has the potential for application in community-based settings and to be used by nonneurologists: issues which have not been explored before. Hence, we aimed to determine the reliability of the NIHSS when administered by research nurses within the existing North Eastern Melbourne Stroke Incidence Study. Using the NIHSS, thirty-one consecutively registered stroke patients were assessed by 2 neurologists and 1 of 2 trained research nurses. The interrater reliability of observations was compared using weighted and unweighted kappa statistics and intraclass correlation coefficients (ICC). There was a high level of agreement for total scores between the 2 neurologists (ICC = 0.95) and between each neurologist and research nurse (ICC = 0.92 and 0.96). While there was moderate to excellent agreement among neurologists and research nurse (weighted kappa > 0.4) for the majority of the NIHSS items, there was poor agreement for the component 'limb ataxia'. Overall, agreement between nurse and neurologist for individual items was not significantly different from agreement between neurologists. It appears that in both hospital and community settings, trained research nurses can administer the NIHSS with a reliability similar to stroke-trained neurologists. This ability could be used to advantage in large community-based trials and epidemiological studies.

Progressive dementia after first-ever stroke: a community-based follow-up study.

OBJECTIVES: To examine the risk and determinants of a progressive dementia syndrome and cognitive impairment not dementia (CIND) in community-based nonaphasic first-ever stroke cases 1 year after stroke, relative to a matched community-based stroke-free group. METHODS: Matched cohort design, with cognitive tests given on two occasions 9 months apart to 99 mild-to-moderate first-ever stroke patients and 99 age- and sex-matched people without stroke. At follow-up, progressive dementia or CIND were diagnosed, with judges blinded to stroke/nonstroke status. RESULTS: Progressive dementia was diagnosed in 12.5% of stroke patients and 15.4% of those without strokes (RR 1.1, 95% CI 0.5 to 2.2, p = 0.85). CIND was diagnosed in 37.5% of stroke patients and 17.6% of participants without strokes (RR 2.1, 95% CI 1.2 to 3.4, p = 0.003). In multivariable regression, age (p = 0.04) and baseline cognition (p < 0.001) were independently associated with dementia whereas stroke (p = 0.002), age (p = 0.05), baseline cognition (p = 0.001), and baseline mood (p = 0.03) were independently associated with CIND at follow-up. CONCLUSIONS: In this community-based nonaphasic sample, mild-to moderate first-ever stroke was not associated with the presence of progressive dementia 1 year later, but was clearly associated with a greater risk of cognitive impairment not dementia (CIND). Baseline mood impairment remained independently associated with CIND at 1 year after taking into account stroke, age, and baseline cognitive ability.