Kids Identifying and Defeating Stroke (KIDS): development and implementation of a multiethnic health education intervention to increase stroke awareness among middle school students and their parents.

The Kids Identifying and Defeating Stroke (KIDS) project is a 3-year prospective, randomized, controlled, multiethnic school-based intervention study. Project goals include increasing knowledge of stroke signs and treatment and intention to immediately call 911 among Mexican American (MA) and non-Hispanic White (NHW) middle school students and their parents. This article describes the design, implementation, and interim evaluation of this theory-based intervention. Intervention students received a culturally appropriate stroke education program divided into four 50-minute classes each year during the sixth, seventh, and eighth grades. Each class session also included a homework assignment that involved the students' parents or other adult partners. Interim-test results indicate that this educational intervention was successful in improving students' stroke symptom and treatment knowledge and intent to call 911 upon witnessing a stroke compared with controls. The authors conclude that this school-based educational intervention to reduce delay time to hospital arrival for stroke shows early promise.

A randomized, controlled trial to teach middle school children to recognize stroke and call 911: the kids identifying and defeating stroke project.

BACKGROUND AND PURPOSE: Underutilization of acute stroke therapy is driven by delay to hospital arrival. We present the primary results of a pilot, randomized, controlled trial to encourage calling 911 for witnessed stroke among middle school children and their parents. METHODS: This project occurred in Corpus Christi, an urban Texas community of 325,000. Three intervention and 3 control schools were randomly selected. The intervention contained 12 hours of classroom instruction divided among sixth, seventh, and eighth grades. Parents were educated indirectly through homework assignments. Two-sample t tests were used to compare pretest and posttest responses. RESULTS: Domain 1 test questions involved stroke pathophysiology. Intervention students improved from 29% to 34% correct; control students changed from 28% to 25%. Domain 2 test questions involved stroke symptom knowledge. Intervention school students changed from 28% correct to 43%; control school students answered 25% correctly on the pretest and 29% on the posttest. Domain 3 test questions involved what to do for witnessed stroke. Intervention school students answered 36% of questions correctly on the pretest and 54% correctly on the posttest, whereas control students changed from 32% correct to 34%. A comparison of change in the mean proportion correct over time between intervention and control students was P<0.001 for each of the 3 individual domains. A poor parental response rate impaired the ability to assess parental improvement. CONCLUSIONS: A scientific, theory-based, educational intervention can potentially improve intent to call 911 for stroke among middle school children. A different mechanism is needed to effectively diffuse the curriculum to parents.

Slow progressive acceptance of intravenous thrombolysis for patients with stroke by rural primary care physicians.

BACKGROUND: In the rural United States, patients with stroke are usually first evaluated locally by a nonneurologist physician (NNP) before treatment is determined. OBJECTIVE: To determine the evolution of NNPs' familiarity and attitudes about using recombinant tissue plasminogen activator (rtPA) since this therapy has been approved. DESIGN: Cross-sectional design using 2 similar surveys mailed in 1997 and 2003 to all primary care, family, internal, and emergency medicine physicians in the state of Iowa (1582 and 1679 physicians, respectively). PARTICIPANTS: All NNPs (primary care, internal, and emergency medicine) practicing in the state of Iowa. MAIN OUTCOME MEASURES: Comparison of 1997 and 2003 aggregate responses to questions about familiarity and willingness to use rtPA to treat patients who have had an acute ischemic stroke. RESULTS: The willingness of NNPs to use rtPA to treat acute ischemic stroke increased from 18% to 32% between 1997 and 2003. The number of NNPs who were very familiar with the National Institutes of Health Stroke Scale increased from 1% to 13%. Compared with physicians in 1997, more physicians in 2003 knew that prolonged international normalized ratios (42% vs 61%) or excessively high blood pressures (61% vs 78%) were contraindications for the use of rtPA. Still, half of the respondents perceived that they were inadequately exposed to educational material about rtPA during these years. Most expressed preference for personal methods of delivery for future educational efforts. CONCLUSIONS: The familiarity and comfort among NNPs with the administration of rtPA is still relatively low in rural settings. The improvement observed between the years 1997 and 2003 is encouraging. The responses suggest that NNPs' acceptance of rtPA can be further improved with educational campaigns involving personal methods of delivery.

Kids Identifying and Defeating Stroke (KIDS): design of a school-based intervention to improve stroke awareness.

BACKGROUND: We describe the design and baseline data of an educational intervention targeting predominantly Mexican American middle school students and their parents in an effort to improve stroke awareness. Increasing awareness in this group may increase the number of patients eligible for acute stroke treatment by encouraging emergency medical services (EMS) activation. METHODS: This is a prospective, randomized study in which six middle schools were randomly assigned to receive a stroke education program or the standard health class. Primary outcome measures are the percentage of students and parents who recognize stroke symptoms and express the intent to activate EMS upon recognition of these findings. RESULTS: A total of 547 students (271 control, 276 intervention) and 484 parents (231 control, 253 intervention) have been enrolled. Pretests were administered. The intervention has been successfully carried out in the parent and student cohorts over a three-year period. Posttests and persistence test results are pending. CONCLUSION: Implementing a school-based stroke education initiative is feasible. Followup testing will demonstrate whether this educational initiative translates into a measurable and persistent improvement in stroke knowledge and behavioral intent to activate EMS upon recognition of stroke symptoms.

Argatroban tPA stroke study: study design and results in the first treated cohort.

BACKGROUND: The benefit of intravenous recombinant tissue plasminogen activator (rtPA) in acute stroke is linked to clot lysis and artery recanalization. Argatroban is a direct thrombin inhibitor that safely augments the benefit of rtPA in animal stroke models. There are no human data on this combination. DESIGN: We report the first phase of the Argatroban tPA Stroke Study, an ongoing prospective, open-label, dose-escalation, safety and activity study of argatroban and rtPA in patients with ischemic stroke. The primary outcome was incidence of intracerebral hemorrhage; secondary outcome, complete recanalization at 2 hours. After standard-dose intravenous rtPA administration, a 100-mug/kg bolus of argatroban followed by infusion of 1 mug/kg per minute for 48 hours was adjusted to a target partial thromboplastin time of 1.75 times that of the control group. RESULTS: Fifteen patients (including 10 men) were enrolled, with a mean +/- SD age of 61 +/- 13 years. All patients had middle cerebral artery occlusions. Baseline median National Institute of Health Stroke Scale score was 14 (range, 4-25). The mean +/- SD time from symptom onset to argatroban bolus administration was 172 +/- 53 minutes. Symptomatic intracerebral hemorrhage occurred in 2 patients, including 1 with parenchymal hemorrhage type 2. Asymptomatic bleeding occurred in 1 patient and there was 1 death. Recanalization was complete in 6 patients and partial in another 4, and reocclusion occurred in 3 within 2 hours of rtPA bolus administration. CONCLUSION: The safety of low-dose argatroban combined with intravenous rtPA may be within acceptable limits, and its efficacy for producing fast and complete recanalization is promising, but a larger cohort of patients is required to confirm these preliminary observations.

Use of intraoperative duplex ultrasonography for identification and patch repair of kinking stenosis after carotid endarterectomy: a single-surgeon retrospective experience.

OBJECTIVE: To provide an incidence and descriptive evaluation of kinking of the internal carotid artery (ICA) after carotid endarterectomy (CEA) in a consecutive CEA series that included the use of intraoperative duplex ultrasonography (IDUS) monitoring and to determine the effect of kink patch repair on long-term postoperative ICA restenosis. METHODS: The electronic medical records and IDUS recordings of all CEA cases performed over a 10-year period (March 2000 to October 2010) by a single neurosurgeon were retrospectively reviewed to assess cases of kinking after CEA. RESULTS: IDUS assisted in the identification of 27 of 285 cases (9.5%) of kinking after CEA. Kinked vessels with hemodynamically significant peak systolic velocities of ≥ 120 cm/second on IDUS (11 of 285 cases; 3.9%) were repaired using a synthetic patch. During follow-up, there were no neurologic symptoms, stroke, or death related to a cerebrovascular accident associated with kinking. The total incidence of postoperative stroke in this CEA series was 3 of 285 cases (1.1%). CONCLUSIONS: ICA kinking stenosis after CEA was a common finding in this CEA series. Because of their unique anatomic and hemodynamic properties, the identification and assessment of kinks after CEA required the use of IDUS monitoring. A selective patch closure method for kinked vessels with peak systolic velocities of ≥ 120 cm/second identified by IDUS was effective in resolving hemodynamically significant stenosis and minimizing long-term postoperative restenosis.

Does clinical-CT 'mismatch' predict early response to treatment with recombinant tissue plasminogen activator?

BACKGROUND: We hypothesized that patients with clinically severe strokes but less severe early ischemic changes on brain CT (i.e., clinical-CT mismatch) may respond better to intravenous recombinant tissue plasminogen activator (i.v. rt-PA) within 3 h of symptom onset. METHODS: In this secondary analysis of the CLOTBUST data, patients with middle cerebral artery occlusions on transcranial Doppler (TCD) were treated with i.v. rt-PA. Alberta Stroke Program Early CT Scores were obtained with raters blinded to the NIH Stroke Scale and TCD results. Two mismatch criteria and three criteria of response to therapy were explored. RESULTS: Of 126 patients, 67% had a mismatch type 1 and 74% had a mismatch type 2. The presence of clinical-CT mismatch by either definition did not correlate with any of the three criteria of response to rt-PA. Recanalization was a strong determinant of response, whether or not mismatch was present. CONCLUSIONS: Mismatch between severity of neurological deficit and CT findings is common but does not predict response to rt-PA therapy given within 3 h.