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1.
Eur Stroke J ; 4(1): 13-28, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31165091

RESUMO

Introduction: Acute stroke unit care, intravenous thrombolysis and endovascular treatment significantly improve the outcome for patients with ischaemic stroke, but data on access and delivery throughout Europe are lacking. We assessed best available data on access and delivery of acute stroke unit care, intravenous thrombolysis and endovascular treatment throughout Europe. Methods: A survey, drafted by stroke professionals (ESO, ESMINT, EAN) and a patient organisation (SAFE), was sent to national stroke societies and experts in 51 European countries (World Health Organization definition) requesting experts to provide national data on stroke unit, intravenous thrombolysis and endovascular treatment rates. We compared both pooled and individual national data per one million inhabitants and per 1000 annual incident ischaemic strokes with highest country rates. Population estimates were based on United Nations data, stroke incidences on the Global Burden of Disease Report. Results: We obtained data from 44 European countries. The estimated mean number of stroke units was 2.9 per million inhabitants (95% CI 2.3-3.6) and 1.5 per 1000 annual incident strokes (95% CI 1.1-1.9), highest country rates were 9.2 and 5.8. Intravenous thrombolysis was provided in 42/44 countries. The estimated mean annual number of intravenous thrombolysis was 142.0 per million inhabitants (95% CI 107.4-176.7) and 72.7 per 1000 annual incident strokes (95% CI 54.2-91.2), highest country rates were 412.2 and 205.5. Endovascular treatment was provided in 40/44 countries. The estimated mean annual number of endovascular treatments was 37.1 per million inhabitants (95% CI 26.7-47.5) and 19.3 per 1000 annual incident strokes (95% CI 13.5-25.1), highest country rates were 111.5 and 55.9. Overall, 7.3% of incident ischaemic stroke patients received intravenous thrombolysis (95% CI 5.4-9.1) and 1.9% received endovascular treatment (95% CI 1.3-2.5), highest country rates were 20.6% and 5.6%. Conclusion: We observed major inequalities in acute stroke treatment between and within 44 European countries. Our data will assist decision makers implementing tailored stroke care programmes for reducing stroke-related morbidity and mortality in Europe.

2.
Int J Stroke ; 14(7): 734-744, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31142219

RESUMO

RATIONALE: Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion have not been assessed in randomized trials. AIM: To establish whether stroke subjects with rapid arterial occlusion evaluation scale based suspicion of large vessel occlusion evaluated by emergency medical services in the field have higher rates of favorable outcome when transferred directly to an endovascular center (endovascular treatment stroke center), as compared to the standard transfer to the closest local stroke center (local-SC). DESIGN: Multicenter, superiority, cluster randomized within a cohort trial with blinded endpoint assessment. PROCEDURE: Eligible patients must be 18 or older, have acute stroke symptoms and not have an immediate life threatening condition requiring emergent medical intervention. They must be suspected to have intracranial large vessel occlusion based on a pre-hospital rapid arterial occlusion evaluation scale of ≥5, be located in geographical areas where the default health authority assigned referral stroke center is a non-thrombectomy capable hospital, and estimated arrival at a thrombectomy capable stroke hospital in less than 7 h from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with three strata: day/night, distance to the endovascular treatment stroke center, and week/week-end day. STUDY OUTCOME: The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is mortality at 90 days. ANALYSIS: The primary endpoint based on the modified intention-to-treat population is the distribution of modified Rankin Scale scores at 90 days analyzed under a sequential triangular design. The maximum sample size is 1754 patients, with two planned interim analyses when 701 (40%) and 1227 patients have completed follow-up. Hypothesized common odds ratio is 1.35.

4.
Front Neurol ; 9: 427, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29928257

RESUMO

Stroke, and mainly ischemic stroke, is the second cause of death and disability. To confront the huge burden of this disease, innovative stroke systems of care are mandatory. This requires the development of national stroke plans to offer the best treatment to all patients eligible for reperfusion therapies. Key elements for success include a high level of organization, close cooperation with emergency medical services for prehospital assessment, an understanding of stroke singularity, the development of preassessment tools, a high level of commitment of all stroke teams at Stroke Centres, the availability of a disease-specific registry, and local government involvement to establish stroke care as a priority. In this mini review, we discuss recent evidence concerning different aspects of stroke systems of care and describe the success of the Catalan Stroke Programme as an example of innovation. In Catalonia, reperfusion treatment rates have increased in recent years and currently are among the highest in Europe (17.3% overall, 14.3% for IVT, and 6% for EVT in 2016).

5.
J Am Med Dir Assoc ; 18(9): 780-784, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28578883

RESUMO

OBJECTIVE: To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. DESIGN: Quasi-experimental longitudinal study. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. PARTICIPANTS: In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. INTERVENTION: Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. MEASUREMENTS: We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. RESULTS: No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. CONCLUSION: The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs.


Assuntos
Artroplastia/reabilitação , Prestação Integrada de Cuidados de Saúde/economia , Fraturas Ósseas/reabilitação , Serviços Hospitalares de Assistência Domiciliar/economia , Idoso , Idoso de 80 Anos ou mais , Custos e Análise de Custo , Feminino , Hospitalização/economia , Humanos , Estudos Longitudinais , Masculino , Recuperação de Função Fisiológica/fisiologia
6.
J Am Geriatr Soc ; 65(9): E117-E122, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28574595

RESUMO

OBJECTIVES: The aim of the study was to confirm the safety and effectiveness of using intravenous thrombolysis (IVT) with individuals aged 80 and older in routine practice in different hospital settings. DESIGN: Observasional registry. SETTING: Prospective multicenter population-based registry of acute stroke patients treated with reperfusion therapies in Catalonia, Spain (Sistema Online d'Informació de l'Ictus Agut). PARTICIPANTS: Individuals treated only with IVT (N = 3,231; 1,189 (36.8%) aged ≥80). MEASUREMENTS: Symptomatic intracranial hemorrhage, mortality, and favorable outcome (modified Rankin Scale (mRS) score = 0-2) at 3 months were evaluated according to hospital characteristics. Treating hospitals were classified in three categories: comprehensive stroke centers (CSCs), primary stroke centers (PSCs), and community hospitals operating a telestroke system (TS). First individuals aged 80 and older were compared with those younger than 80, and then participants aged 80 and older were focused on. RESULTS: Participants aged 80 and older had significantly higher baseline National Institute of Health Stroke Scale (NIHSS) scores, longer onset to treatment times, and worse outcomes than younger participants. For participants aged 80 and older, 90-day mortality was 23.2%, with 38.7% having favorable outcomes at 3 months. Symptomatic intracranial hemorrhage (SICH; Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy definition) was observed in 4.7% of subjects. None of the risk factors differed significantly between participants treated in different types of hospitals. Basal stroke severity measured according to NIHSS score was not significantly different either. The three different types of hospitals achieved similar outcomes, although the TS and PSC hospitals had significantly higher proportions of SICH (6.3% and 6.3%, respectively) than the CSC (3.2%). CONCLUSION: Older adults with acute stroke treated with IVT had similar outcomes regardless of hospital characteristics.


Assuntos
Hospitais , Infusões Intravenosas/métodos , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Masculino , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Espanha , Acidente Vascular Cerebral/mortalidade , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento
7.
Stroke ; 48(2): 375-378, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28062859

RESUMO

BACKGROUND AND PURPOSE: Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients. METHODS: Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel-Haenszel test statistic. RESULTS: We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74-1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74-1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25-1.27). CONCLUSIONS: This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.


Assuntos
Procedimentos Endovasculares/tendências , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Trombectomia/tendências , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Acidente Vascular Cerebral/mortalidade , Trombectomia/mortalidade , Terapia Trombolítica/mortalidade , Terapia Trombolítica/tendências , Resultado do Tratamento
8.
Eur Stroke J ; 2(2): 163-170, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31008311

RESUMO

Introduction: Endovascular thrombectomy was recently established as a new standard of care in acute ischemic stroke patients with large artery occlusions. Using small area health statistics, we sought to assess dissemination of endovascular thrombectomy in Catalonia throughout the period 2011-2015. Patients and methods: We used registry data to identify all endovascular thrombectomies for acute ischemic stroke performed in Catalonia within the study period. The SONIIA registry is a government-mandated, population-based and externally audited data base that includes all reperfusion therapies for acute ischemic stroke. We linked endovascular thrombectomy cases identified in the registry with the Central Registry of the Catalan Public Health Insurance to obtain the primary care service area of residence for each treated patient, age and sex. We calculated age-sex standardized endovascular thrombectomy rates over time according to different territorial segmentation patterns (metropolitan/provincial rings and primary care service areas). Results: Region-wide age-sex standardized endovascular thrombectomy rates increased significantly from 3.9 × 100,000 (95% confidence interval: 3.4-4.4) in 2011 to 6.8 × 100,000 (95% confidence interval: 6.2-7.6) in 2015. Such increase occurred in inner and outer metropolitan rings as well as provinces although highest endovascular thrombectomy rates were persistently seen in the inner metropolitan area. Changes in endovascular thrombectomy access across primary care service areas over time were more subtle, but there was a rather generalized increase of standardized endovascular thrombectomy rates. Discussion: This study demonstrates temporal and territorial dissemination of access to endovascular thrombectomy in Catalonia over a 5-year period although variation remains at the completion of the study. Conclusion: Mapping of endovascular thrombectomy is essential to assess equity and propose actions for access dissemination.

9.
PLoS One ; 11(11): e0166304, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27829011

RESUMO

BACKGROUND: Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. METHODS: We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). RESULTS: Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles. CONCLUSION: Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.


Assuntos
Instituições para Cuidados Intermediários/estatística & dados numéricos , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Atividades Cotidianas , Idoso , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Índice de Gravidade de Doença , Acidente Vascular Cerebral/complicações
10.
Stroke ; 47(5): 1381-4, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-27032445

RESUMO

BACKGROUND AND PURPOSE: Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model. METHODS: We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups. RESULTS: Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245-435]) and 120 minutes longer in group C (350 minutes [284-408]) compared with group A (230 minutes [160-407]; P<0.001). CONCLUSIONS: Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.


Assuntos
Assistência à Saúde/estatística & dados numéricos , Procedimentos Endovasculares/estatística & dados numéricos , Hospitais Especializados/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Reperfusão/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Espanha
11.
Maturitas ; 88: 65-9, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27105701

RESUMO

OBJECTIVE: Older citizens with orthopaedic conditions need specialised care for the facilitation of early community reintegration and restitution of physical function. We introduced a new community care programme as an alternative to usual hospital rehabilitation for orthopaedic patients. STUDY DESIGN: This was an observational study of a cohort of older orthopaedic patients attending a hospital-at-home integrated care programme (HHU), compared with a contemporary cohort of users of a geriatric rehabilitation unit (GRU) in the urban area of Badalona, Catalonia, Spain. MAIN OUTCOMES MEASURES: Functional gain at discharge was measured using the Barthel Index (BI). Other outcomes were: length of intervention (days), rehabilitation efficiency and discharge destination. RESULTS: Over the 2 years of the study we assessed 270 patients (69 at HHU; 201 at GRU). We found no significant differences in baseline characteristics between HHU and GRU groups-mean (IQR) or % age 83 (79-87) vs. 84 (79-88), cognitive impairment 27.5% vs. 24.9%, functional decline 40 (31-48) vs. 43 (32-58). Overall, we found no statistically significant differences between HHU and GRU groups on functional gain: 35 (22-45) vs. 32 (18-46), and discharge home 85.5% vs. 86.1%. Length of intervention was shorter in the HHU group, 43 (32-56) vs. 57 (44-81); p<0.01, for hip fracture patients. In a multivariate analysis, the adjusted mean difference in rehabilitation efficiency between HHU and GRU groups in the hip fracture subgroup was 0.27 (0.09 to 0.46); p=0.004. CONCLUSIONS: This hospital-at-home service obtained similar clinical results to the usual hospital-based rehabilitation care, and for hip fracture patients attending that service, rehabilitation efficiency was better.


Assuntos
Transtornos Cognitivos , Prestação Integrada de Cuidados de Saúde , Fraturas do Quadril/reabilitação , Hospitais , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Ortopedia , Espanha
12.
Stroke ; 46(12): 3437-42, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26508752

RESUMO

BACKGROUND AND PURPOSE: Recent trials have shown the superiority of endovascular thrombectomy (EVT) over medical therapy alone in certain stroke patients with proximal arterial occlusion. Using data from the Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke due to Anterior Circulation Large Vessel Occlusion Presenting Within 8-Hours of Symptom Onset (REVASCAT) and a parallel reperfusion treatment registry, we sought to assess the utilization of EVT in a defined patient population, comparing the outcomes of patients treated in and outside the REVASCAT trial. METHODS: SONIIA [Sistema Online d'Informació de l'Ictus Agut], a population-based, government-mandated, prospective registry of reperfusion therapies for stroke encompassing the entire population of Catalonia, was used as data source. The registry documents 5 key inclusion criteria of the REVASCAT trial: age, stroke severity, time to treatment, baseline functional status, and occlusion site. We compared procedural, safety, and functional outcomes in patients treated inside and outside the trial. RESULTS: From November 2012 to December 2014, out of 17596 ischemic stroke patients in Catalonia (population 7.5 million), 2576 patients received reperfusion therapies (17/100000 inhabitants-year), mainly intravenous thrombolysis only (2036). From the remaining 540 treated with EVT, 103 patients (out of 206 randomized) were treated within REVASCAT and 437 outside the trial. Of these, 399 did not fulfill some of the study criteria, and 38 were trial candidates (8 treated at REVASCAT centers and 30 at 2 non-REVASCAT centers). The majority of procedural, safety, and functional outcomes were similar in patients treated with EVT within and outside REVASCAT. CONCLUSIONS: REVASCAT enrolled nearly all eligible patients representing one third of all patients treated with EVT. Patients treated with EVT within and outside REVASCAT had similar outcomes, reinforcing the therapeutic value of EVT. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01692379.


Assuntos
Trombólise Mecânica/métodos , Vigilância da População , Sistema de Registros , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Estudos Prospectivos , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Trombectomia/métodos
13.
Neurol Sci ; 36(10): 1875-80, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26050232

RESUMO

Recovery after a stroke is determined by a broad range of neurological, functional and psychosocial factors. Evidence regarding these factors is not well established, in particular influence of cognition changes during rehabilitation. We aimed to investigate whether selective characteristics, including cognitive performance and its change over time, modulate functional recovery with home discharge in stroke survivors admitted to post-acute rehabilitation units. We undertook a multicenter cohort study, including all patients discharged from acute wards to any geriatric rehabilitation unit in Catalonia-Spain during 2008. Patients were assessed for demographics, clinical and functional variables using Conjunt Mínim Bàsic de Dades dels Recursos Sociosanitaris (CMBD-RSS), which adapts the Minimum Data Set tool used in America's nursing homes. Baseline-to-discharge change in cognition was calculated on repeated assessments using the Cognitive Performance Scale (CPS, range 0-6, best-worst cognition). The multivariable effect of these factors was analyzed in relation to the outcome. 879 post-stroke patients were included (mean age 77.48 ± 10.18 years, 52.6% women). A worse initial CPS [OR (95% CI) = 0.851 (0.774-0.935)] and prevalent fecal incontinence [OR (95% CI) = 0.560 (0.454-0.691)] reduced the likelihood of returning home with functional improvement; whereas improvement of CPS, baseline to discharge, [OR (95% CI) = 1.348 (1.144-1.588)], more rehabilitation days within the first 2 weeks [OR (95% CI) = 1.011 (1.006-1.015)] and a longer hospital stay [OR (95% CI) = 1.011 (1.006-1.015)] were associated with the outcome. In our sample, different clinical characteristics, including cognitive function and its improvement over time, are associated with functional improvement in stroke patients undergoing rehabilitation. Our results might provide information to further studies aimed at exploring the influence of cognition changes during rehabilitation.


Assuntos
Cognição , Recuperação de Função Fisiológica , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/psicologia , Idoso , Estudos de Coortes , Feminino , Serviços de Saúde para Idosos , Humanos , Masculino , Centros de Reabilitação , Espanha , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
14.
N Engl J Med ; 372(24): 2296-306, 2015 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-25882510

RESUMO

BACKGROUND: We aimed to assess the safety and efficacy of thrombectomy for the treatment of stroke in a trial embedded within a population-based stroke reperfusion registry. METHODS: During a 2-year period at four centers in Catalonia, Spain, we randomly assigned 206 patients who could be treated within 8 hours after the onset of symptoms of acute ischemic stroke to receive either medical therapy (including intravenous alteplase when eligible) and endovascular therapy with the Solitaire stent retriever (thrombectomy group) or medical therapy alone (control group). All patients had confirmed proximal anterior circulation occlusion and the absence of a large infarct on neuroimaging. In all study patients, the use of alteplase either did not achieve revascularization or was contraindicated. The primary outcome was the severity of global disability at 90 days, as measured on the modified Rankin scale (ranging from 0 [no symptoms] to 6 [death]). Although the maximum planned sample size was 690, enrollment was halted early because of loss of equipoise after positive results for thrombectomy were reported from other similar trials. RESULTS: Thrombectomy reduced the severity of disability over the range of the modified Rankin scale (adjusted odds ratio for improvement of 1 point, 1.7; 95% confidence interval [CI], 1.05 to 2.8) and led to higher rates of functional independence (a score of 0 to 2) at 90 days (43.7% vs. 28.2%; adjusted odds ratio, 2.1; 95% CI, 1.1 to 4.0). At 90 days, the rates of symptomatic intracranial hemorrhage were 1.9% in both the thrombectomy group and the control group (P=1.00), and rates of death were 18.4% and 15.5%, respectively (P=0.60). Registry data indicated that only eight patients who met the eligibility criteria were treated outside the trial at participating hospitals. CONCLUSIONS: Among patients with anterior circulation stroke who could be treated within 8 hours after symptom onset, stent retriever thrombectomy reduced the severity of post-stroke disability and increased the rate of functional independence. (Funded by Fundació Ictus Malaltia Vascular through an unrestricted grant from Covidien and others; REVASCAT ClinicalTrials.gov number, NCT01692379.).


Assuntos
Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/terapia , Trombectomia , Ativador de Plasminogênio Tecidual/uso terapêutico , Doença Aguda , Administração Intravenosa , Idoso , Isquemia Encefálica/terapia , Terapia Combinada , Contraindicações , Procedimentos Endovasculares , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Stents , Acidente Vascular Cerebral/tratamento farmacológico , Trombectomia/efeitos adversos , Trombectomia/instrumentação , Trombectomia/métodos , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/efeitos adversos
15.
Cerebrovasc Dis ; 38(5): 328-36, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25428822

RESUMO

BACKGROUND: Among the acute ischemic stroke patients with large vessel occlusions and contraindications for the use of IV thrombolysis, mainly on oral anticoagulation or presenting too late, primary endovascular therapy is often performed as an alternative to the standard therapy even though evidence supporting the use of endovascular reperfusion therapies is not yet established. Using different statistical approaches, we compared the functional independence rates at 3 months among patients undergoing primary endovascular therapy and patients treated only with IV thrombolysis. METHODS: We used data from a prospective, government-mandated and externally audited registry of reperfusion therapies for ischemic stroke (January 2011 to November 2012). Patients were selected if treated with either IV thrombolysis alone (n = 1,582) or primary endovascular thrombectomy (n = 250). A series of exclusions were made to homogenize the clinical characteristics among the two groups. We then carried out multivariate logistic regression and propensity score matching analyses on the final study sample (n = 1,179) to compare functional independence at 3 months, as measured by the modified Rankin scale scores 0-2, between the two groups. RESULTS: The unadjusted likelihood of good outcome was poorer among the endovascular group (OR: 0.69; 95% CI: 0.47-1.0). After adjustment, no differences by treatment modality were seen (OR: 1.51; 95% CI: 0.93-2.43 for primary endovascular therapy). Patients undergoing endovascular thrombectomy within 180-270 min (OR: 2.89; 95% CI: 1.17-7.15) and patients with severe strokes (OR: 1.84; 95% CI: 1.02-3.35) did better than their intravenous thrombolysis counterparts. The propensity score-matched analyses with and without adjustment by additional covariates showed that endovascular thrombectomy was as effective as intravenous thrombolysis alone in achieving functional independence (OR for unadjusted propensity score matched: 1.35; 95% CI: 0.9-2.02, OR for adjusted propensity score matched: 1.45; 95% CI: 0.91-2.32). CONCLUSION: This comparative effectiveness study shows that in ischemic stroke patients with contraindications for IV thrombolysis, primary endovascular treatment might be an alternative therapy at least as effective as IV thrombolysis alone. Randomized controlled trials are urgently needed.


Assuntos
Procedimentos Endovasculares , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
16.
Stroke ; 45(4): 1046-52, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24595590

RESUMO

BACKGROUND AND PURPOSE: We sought to assess outcomes after endovascular treatment/therapy of acute ischemic stroke, overall and by subgroups, and looked for predictors of outcome. METHODS: We used data from a mandatory, population-based registry that includes external monitoring of completeness, which assesses reperfusion therapies for consecutive patients with acute ischemic stroke since 2011. We described outcomes overall and by subgroups (age ≤ or >80 years; onset-to-groin puncture ≤ or >6 hours; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization), and determined independent predictors of good outcome (modified Rankin Scale score ≤2) and mortality at 3 months by multivariate modeling. RESULTS: We analyzed 536 patients, of whom 285 received previous IV recombinant tissue-type plasminogen activator. Overall, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%, 5.6% developed symptomatic intracerebral hemorrhages, 43.3% achieved good functional outcome, and 22.2% were dead at 90 days. Adjusted comparisons by subgroups systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome). Multivariate analyses confirmed the independent protective effect of revascularization. Additionally, age >80 years, stroke severity, hypertension (deleterious), atrial fibrillation, and onset-to-groin puncture ≤6 hours (protective) also predicted good outcome, whereas lack of previous disability and anterior circulation strokes (protective) as well as and hypertension (deleterious) independently predicted mortality. CONCLUSIONS: This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Revascularização Cerebral , Procedimentos Endovasculares , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Adulto , Idoso , Isquemia Encefálica/mortalidade , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Sistema de Registros/estatística & dados numéricos , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
17.
Stroke ; 43(4): 1094-100, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22403051

RESUMO

BACKGROUND AND PURPOSE: To investigate the 30-day and 12-month mortality risks among hospitalized stroke patients according to compliance with guideline-based process indicators. METHODS: We used data from the Second Stroke Audit and the Mortality Register of Catalonia (Spain). The audit retrospectively explored quality of stroke care based on compliance with indicators among patients discharged from all public hospitals in Catalonia in 2007; they were identified and selected through a pre-established sampling method. The magnitude of the independent association of each indicator with 30-day and 12-month mortality was assessed using logistic regression with generalized estimating equations to account for clustering of patients within hospitals. Generalized estimating equations modeling was initially restricted to patients alive >72 hours poststroke to control for confounding by severity. Analyses were also run in 3 other samples (all patients, patients alive >7 days, and patients alive >14 days). RESULTS: Of 1767 stroke admissions in the Second Stroke Audit, 1697 patients survived >72 hours poststroke. Within this sample, the adjusted 30-day mortality risk was negatively associated with nonadherence to different indicators, of which only antithrombotics at discharge (OR, 4.3; 95% CI, 1.72-10.78) remained significant in all data sets. At 12 months, the adjusted mortality risk was negatively associated with management of hypertension (OR, 1.87; 95% CI, 1.22-2.86) and antithrombotics at discharge (OR, 2.79; 95% CI, 1.41-5.54). Both remained unchanged across different samples. CONCLUSIONS: Assessing the impact of quality of stroke care on mortality is complex and is hampered by residual confounding, particularly in the short-term. Nevertheless, this study suggests that at least a few indicators should be used to monitor quality of stroke services.


Assuntos
Fidelidade a Diretrizes , Hospitais Públicos , Qualidade da Assistência à Saúde , Sistema de Registros , Acidente Vascular Cerebral/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Acidente Vascular Cerebral/terapia , Fatores de Tempo
18.
Int J Stroke ; 7(1): 19-24, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21967542

RESUMO

BACKGROUND: Periodic audits allow monitoring of healthcare quality by comparing performances at different time points. Aims To assess quality of in-hospital stroke care in Catalonia in 2007 and compare it with 2005 (post-/preguidelines delivery, respectively). METHODS: Data on 13 evidence-based performance measures were collected by a retrospective review of medical records of consecutive stroke admissions (January-December 2007) to 47 acute hospitals in Catalonia. Adherence was calculated according to the ratio (patients with documented performance measures' compliance) (valid cases for that measure). Sampling weights were applied to produce estimates of compliance. The proportions of compliance with performance measures in both audits were compared using random-effects logistic regressions, with each performance measure as the dependent variable and audit edition as the explanatory variable to determine whether changes in stroke care quality occurred along time. RESULTS: We analyzed 1767 events distributed among 47 hospitals. In 2007, there was an increase in tissue plasminogen activator administrations (2·8% vs. 5·9%) and stroke unit admissions (16·6% vs. 22·6%) and a reduction in seven-day mortality (9·5% vs. 6·8%). Logistic regression models provided evidence of improved adherences to seven performance measures (screening of dysphagia, management of hyperthermia, baseline computed tomography scan, baseline glycemia, rehabilitation needs, early mobilization, and anticoagulants for atrial fibrillation), but worsening of management of hypertension, dyslipidemia, and antithrombotics at discharge. The remaining three performance measures showed no changes. CONCLUSIONS: The Second Stroke Audit showed improvements in most dimensions of care, although unexpectedly a few but relevant performance measures became worse. Therefore, periodic stroke audits are needed to check changes in quality of care over time.


Assuntos
Fidelidade a Diretrizes , Neurologia/normas , Garantia da Qualidade dos Cuidados de Saúde , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Espanha , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia
19.
Stroke ; 42(7): 2001-6, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21566237

RESUMO

BACKGROUND AND PURPOSE: From 2006, the Stroke Code system operates throughout Catalonia with full coverage. The objective of this study was to determine safety and effectiveness of intravenous thrombolysis in routine practice through a monitored study (Catalan Stroke Code and Thrombolysis [Cat-SCT]) and to assess outcomes according to hospitals' previous experience. METHODS: We conducted a prospective, multicenter, observational, monitored study of recombinant tissue plasminogen activator-treated patients declared to the Cat-SCT by all treating hospitals in Catalonia (n=13, of which 6 were newly designated) over a 12-month period. Consecutive recruitment and quality of data were assured through comprehensive quality control. We estimated rates of outcome measures for the potential final sample (after inclusion of undeclared cases) and compared them with those reported for the actual sample. Symptomatic intracranial hemorrhage, mortality, and favorable outcome (modified Rankin Scale score 0 to 1) at 3 months were also evaluated according to hospitals' previous experience using multilevel logistic regression. RESULTS: We analyzed 488 patients with a median age of 72 years (interquartile range: 63, 77), 57.2% males, with a baseline National Institutes of Health Stroke Scale score of 13 (interquartile range: 8, 19), and stroke to treatment time of 150 minutes (interquartile range: 120, 180 minutes). Symptomatic intracranial hemorrhage (Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy definition) was observed in 3.3% patients. Ninety-day mortality was 16.6% and 38.5% showed a favorable outcome at 3 months. External monitoring set inclusion losses at <5%. A sensitivity analysis including undeclared cases did not show significant changes in main outcomes. Inexperienced hospitals achieved similar outcomes, except for a higher rate of favorable outcome at 3 months. CONCLUSIONS: Health planning applied to acute stroke care and based on dissemination of the Stroke Code system and designation of new referral hospitals showed intravenous thrombolysis safe and effective in routine practice, even among inexperienced hospitals.


Assuntos
Infusões Intravenosas/métodos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Idoso , Cardiologia/normas , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Controle de Qualidade , Análise de Regressão , Espanha , Resultado do Tratamento
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