Telestroke networks for area-wide access to endovascular stroke treatment.

BACKGROUND: Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. MAIN BODY: Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. CONCLUSION: The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.

[Telemedicine in stroke-pertinent to stroke care in Germany]. / Telemedizin in der Schlaganfallversorgung ­ versorgungsrelevant für Deutschland.

BACKGROUND AND OBJECTIVE: Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution. METHODS: The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks. RESULTS: Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states. CONCLUSION: Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

Patient-centredness in acute stroke care - a qualitative study from the perspectives of patients, relatives and staff.

BACKGROUND AND PURPOSE: Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff. METHODS: A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned. RESULTS: Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures. CONCLUSIONS: In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: There is no clear consensus among current guidelines on the preferred admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for patients with intracerebral hemorrhage. Based on expert opinion, the American Heart Association and European Stroke Organization recommend treatment in neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke Organization guideline states that there are no studies available directly comparing outcomes between ICUs and SUs. METHODS: We performed an observational study comparing outcomes of 10 811 consecutive non-comatose patients with intracerebral hemorrhage according to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes were the modified Rankin Scale score at discharge and intrahospital mortality. An additional analysis compared NICUs with SUs. RESULTS: Treatment outside an SU was associated with higher odds for an unfavorable outcome [ICU vs. SU: odds ratio (OR), 1.27; 95% confidence interval (CI), 1.09-1.46; NW vs. SU: OR, 1.28; 95% CI, 1.08-1.52] and higher odds for intrahospital mortality (ICU vs. SU: OR, 2.11; 95% CI, 1.75-2.55; NW vs. SU: OR, 1.52; 95% CI, 1.23-1.89). A subgroup analysis of severely affected patients treated in dedicated NICUs (vs. SUs) showed that they had a lower risk of a poor outcome (OR, 0.45; 95% CI, 0.26-0.79). CONCLUSIONS: Treatment in SUs was associated with better functional outcome and reduced mortality compared with ICUs and NWs. Our findings support the current guideline recommendations to treat patients with intracerebral hemorrhage in SUs or NICUs and suggest that some patients may further benefit from NICU treatment.

Risk factors associated with progressive lacunar strokes and benefit from dual antiplatelet therapy.

BACKGROUND AND PURPOSE: Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. METHODS: Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to in-house standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. RESULTS: Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. CONCLUSIONS: Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.

Intravenous thrombolysis for acute ischaemic stroke in the elderly: data from the Baden-Wuerttemberg stroke registry.

BACKGROUND AND PURPOSE: In Europe intravenous thrombolysis (IVT) for ischaemic stroke is still not approved for patients aged >80 years. However, elderly patients are frequently treated based on individual decision making. In a retrospective observational study a consecutive and prospective stroke registry in southwest Germany was analysed. METHODS: The data registry collected 101,349 patients with ischaemic stroke hospitalized from January 2008 to December 2012. Of these, 38,575 (38%) were aged 80 years and older and 10 286 (10.1%) underwent IVT. Favourable outcome at discharge was defined as modified Rankin Scale (mRS) ≤1 or not worse than prior to stroke. Multiple logistic regression models stratified by 10-year age groups were used to assess the relationship between IVT and mRS at discharge, adjusted for patient characteristics, admitting facility and length of hospital stay. RESULTS: The highest IVT rate was 15% in patients aged <50 years, with a continuous decline down to 8% in patients aged ≥90 years. Adjusted odds ratios and 95% confidence intervals for patients 80-89 years of age were 2.20 (1.95-2.47) (P < 0.0001) and 1.25 (0.88-1.78) (P = 0.21) for patients >90 years of age, compared to patients of the same age decade not treated with IVT. CONCLUSIONS: The evidence from routine hospital care in southwest Germany indicates that IVT is an effective treatment also for aged patients with ischaemic stroke in an age range between 80 and 89 years. Although no clear evidence for the effectiveness of IVT beyond 90 years was found, treatment should also be carefully considered in these patients. High age should not discourage from treatment.

Prevalence of atrial fibrillation in intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Oral anticoagulation (OAC) is an effective preventive therapy for ischemic stroke in atrial fibrillation (AF). The management of anticoagulation in AF patients with previous intracerebral hemorrhage (ICH) is challenging. The aim of this study was to determine the prevalence of AF after acute ICH in a consecutive monocenter cohort, and to document the subsequent management with respect to OAC. METHODS: Consecutive patients with spontaneous ICH were prospectively included within 19 months. Diagnosis of AF was based on medical history, 12-lead electrocardiogram (ECG), 24-h and continuous ECG monitoring. CHADS2 scores and patient medication were recorded at admission and after 3 months. Additionally, after 3 months mortality, the management of anticoagulation and a newly detected AF were assessed. RESULTS: In total, 206 ICH patients were eligible for data analysis. After 3 months, AF had been diagnosed in 64/206 ICH patients (31.1%). Mortality after 3 months was higher in patients with AF in univariate analysis (45.3% vs. 31.0%). After adjusting for comorbidities and OAC use, AF did not remain an independent predictor for mortality. In total, 35 patients with AF survived 3 months. Of these, CHADS2 score was 2 (2/3, median, interquartile range (IQR)) and 27/35 patients had an indication for OAC with respect to the CHADS2 score, but only 25.7% had been (re-)started on OAC. No consistent factors for deciding whether to initiate OAC treatment could be identified. CONCLUSIONS: Atrial fibrillation is a frequent comorbidity in patients suffering an ICH. Our findings underline the prevailing uncertainty regarding the anticoagulation management of AF after ICH.

A consecutive and prospective stroke database covers the state of Baden-Wuerttemberg with 10.8 million inhabitants in Germany.

BACKGROUND: In 1998 Baden-Wuerttemberg (BW), a federal state in southwest Germany with 10.8 million inhabitants, implemented a structured medical concept for the treatment of acute stroke. METHODS: Since 2004 participation in the BW stroke database is mandatory for all hospitals in BW involved in acute stroke care. The stroke database includes all inpatients ≥18 years of age who have suffered an ischemic or hemorrhagic stroke within 7 days before hospitalization. This article presents methodological aspects and first results of the BW stroke database in the time period from 2007 to 2011. RESULTS: Annual inclusion numbers increased continuously (29,422 vs. 35,724, p < 0.001). Median age of stroke onset was stable over time. The proportion of stroke patients ≥80 years increased from 36.9 to 38.8% (p < 0.001). Rates of patients treated in neurology departments rose from 50.7 to 60.9% (p < 0.001) and numbers of patients treated in stroke units rose from 59.1 to 68.4% (p < 0.001). Admission via emergency medical systems increased from 42.8 to 49.7% (p < 0.001) and arrival within 3 h increased from 29.8 to 34.4% (p < 0.001). CONCLUSION: We present results from a large, prospective and consecutive stroke patient database. This first analysis demonstrates a continuous increase of absolute and relative numbers of stroke patients who arrive within 3 h after onset, are hospitalized in neurology departments and treated in stroke units, and are aged ≥80 years.

Microalbuminuria: a potential prognostic marker for acute stroke.

INTRODUCTION: Stroke is potentially preventable through risk factor reduction. Over the past decade, the role of microalbuminuria (MA) as a risk factor for chronic diseases has become apparent. The aim of this study was to determine the prognostic value of MA in acute stroke patients. MATERIALS AND METHODS: Patients with acute ischemic stroke admitted to our stroke unit were included in this study. Clinical history and vascular risk factors were recorded. Severity of stroke and outcome were assessed by NIHSS and modified Rankin scale (mRS) upon admission and discharge. Urinary albumin excretion was measured in 24-h urine samples. Multivariate analysis was performed to investigate predictors of poor outcome. RESULTS: MA was found in 43% of 138 patients and was associated with elevated levels of C-reactive protein (CRP), glucose at baseline, and HbA1c; higher rates of diabetes mellitus and atrial fibrillation; higher systolic blood pressure; greater age; and higher premorbid mRS, NIHSS upon admission/discharge, and mRS upon discharge. In a multivariate analysis, MA (OR 5.07, 95%CI 2.18-11.77; p = 0.004), premorbid mRS (OR 2.030, 95%CI 1.369-3.011; p = 0.0001), and NIHSS upon admission (OR 1.116, 95%CI 1.044-1.193; p = 0.001) were independent predictors of poor outcome upon discharge. CONCLUSION: MA was frequently found in acute ischemic stroke patients. It was associated with severe neurological deficit upon admission and severe functional impairment upon discharge. MA in the acute phase was shown to be an independent predictor of poor outcome. The association between MA and CRP levels points to potential linkage of MA to the inflammatory response in acute stroke.

Continuous monitoring versus HOLTER ECG for detection of atrial fibrillation in patients with stroke.

BACKGROUND AND PURPOSE: Detection of atrial fibrillation is of vital importance because oral anticoagulation decreases the risk of a stroke by 64%. Current standards for stroke unit treatment require continuous electrocardiogram (ECG) monitoring for at least 24 h. Additionally, a 24-h HOLTER ECG (HOLTER) should be performed in selected patients. It remains unclear whether continuous monitoring at the bedside is equivalent to HOLTER for the detection of atrial fibrillation. Furthermore, we investigate how many additional patients with paroxysmal atrial fibrillation can be identified as a result of a longer duration of continuous monitoring. METHODS: In this study, we prospectively compared the detection rates of HOLTER and 24-h monitoring at the Stroke Unit at the University of Heidelberg over a period of 9 months. Continuous monitoring was analyzed by trained nurses, HOLTER by cardiologists. RESULTS: We included 370 patients with ischemic stroke or transient ischemic attack (TIA) in our study. Of these, 192 patients underwent HOLTER. Previously unknown atrial fibrillation was detected in 44 patients, 13 patients had no atrial fibrillation in baseline ECG, but atrial fibrillation was detected by continuous monitoring. In two patients, the HOLTER showed atrial fibrillation; both patients had also been detected by continuous monitoring. Median time to detection of the atrial fibrillation during continuous monitoring was 43 h after hospitalization. CONCLUSION: In this study, use of HOLTER does not give any additional benefit in comparison with continuous monitoring with intermittent analysis by trained staff alone. The median detection time of 43 h emphasizes the importance of longer continuous monitoring.