Knowledge about stroke in patients admitted in a French Stroke Unit

Admission delay remains the main cause for stroke patient exclusion from urgent therapeutic protocols. Public lack of knowledge about stroke symptoms may result in delay in seeking medical care and late presentation at hospital. Lack of knowledge of risk factors for stroke may also hamper compliance with stroke prevention practices. The aim of this prospective study using a standardized questionnaire was to evaluate the stroke awareness of acute stroke patients in France. From July 2, 1998 to July 2, 1999, 166 consecutive stroke patients were admitted at our stroke unit. Among the 91 patients who were able to answer the questionnaire during the first 48 hours, only 19 patients (21 p.cent) thought they were having a stroke before their arrival at the hospital, 38 patients (42 p.cent) did not know a single sign of stroke and 33 patients (36 p.cent) did not know a single risk factor of stroke. The most common risk factors named by the patients were smoking and hypercholesterolemia (named by 31 patients (34 p.cent) and 19 patients (21 p.cent), respectively). The most common warning signs named by the patients were paralysis of one side of body or one limb and speech disturbance (named by 40 patients (44 p.cent) and 15 patients (16 p.cent), respectively). Female sex and "knowing somebody who had a stroke" were significantly associated with awareness of signs of stroke in multivariate analysis. Educational public programs regarding stroke awareness are needed in France. Educational campaigns must stress the risk factors and symptoms of stroke and the appropriate response in the hopes of reducing admission delay and improving stroke prevention.     

Epidemiology and management of stroke patients in emergency departments of the Centre region of France

INTRODUCTION: Stroke is a leading cause of death and disability. Patients with suspected stroke are usually managed in emergency departments (ED). Stroke units must be created in our country, but only few French epidemiological data are available to define needs in stroke care. OBJECTIVE: A prospective study was planned to evaluate epidemiology and stroke care for patients with suspected stroke admitted in the 22 ED of our region in the center of France during a two-month period. METHODS: Patients with suspected stroke seen at the 22 ED were prospectively followed until discharge or one month after admission. Data on demographic characteristics, mode of transport, delay of arrival and imaging, clinical findings at arrival, department of admission, diagnosis, Rankin scale at day 7, in-hospital mortality, and outcome at a month were collected. A global statistical analysis and a comparison between rural and urban ED were performed. RESULTS: Five hundred and ninety-eight patients were included. Mean age was 75 years. Median admission delay was 4 hours and 52 minutes. Predominant mode of transport was a private ambulance. A CT scan was obtained in 91 p.cent of cases with a median delay of 2 hours and 30 minutes. Only a third of the patients were admitted in departments of Neurology. Final diagnosis was: ischemic stroke (61 p.cent), transient ischemic attack (16 p.cent), hemorrhagic stroke (10 p.cent), other vascular disease (3 p.cent), non vascular disease (10 p.cent). In-hospital mortality was 20 p.cent, factors significantly associated with death rate were elevated age and a Glasgow coma scale<10 at admission. Mean length of stay was 12 days for stroke patients. At one month, 63 percent of patients were discharged to their home, 28 percent were transferred to an institution or in a rehabilitation unit, and 15 percent were still hospitalized. Significant differences in stroke care were found between rural and urban ED. CONCLUSION: This prospective study provides epidemiological data for our region. Creation of stroke units and definition of acute stroke networks are necessary to improve stroke care.     

Results of carotid endarterectomy with prospective neurologist follow-up

BACKGROUND: Previous studies have shown that neurologic complications following carotid endarterectomy (CE) are underestimated if patients are not examined by neurologists after surgery. OBJECTIVE: To review the morbidity and mortality in a cohort of patients examined before and after CE in a neurology and stroke clinic. METHODS: This was a prospective case series from an academic medical center; 44 patients were referred for CE during the period June 1995 to April 1999. Mean age was 64.3 years; 70.5% were referred for symptomatic stenosis and 29.5% were asymptomatic. Three neurosurgeons and two vascular surgeons operated on the patients. RESULTS: The 30-day mortality rate was 4.5% and the 30-day stroke or death rate was 11.4%. One patient had a TIA due to thrombus formation at the operative site and a second patient had an asymptomatic intimal flap. CONCLUSIONS: With prospective follow-up by neurologists, the CE complication rate in an academic medical center was significantly higher than the rates reported in controlled clinical trials. The generalizability of data from CE clinical trials is limited and local audits are necessary to better establish the risk/benefit ratio for individual hospitals and surgeons.     

Intravenous rt-PA for acute ischemic stroke: 69 consecutive patients managed in an emergency stroke centre

INTRODUCTION: After the 2002 European agreement on the use of rt-PA for fibrinolysis within less than 3 hours after ischemic stroke, we designed a specific patient management scheme for patients referred to our center. METHODS: We report the activity of the "stroke emergency" pathway in the Purpan Hospital (Toulouse) for 4 years. We wanted to evaluate our daily practice and to confirm that the results obtained in the randomized clinical trials with rt-PA can be reproduced in routine practice. RESULTS: Among all stroke patients treated in the Neurology Department, 10.2 per cent were managed via this new pathway, in order to receive a fibrinolytic treatment. Amongst these, 25.6 per cent were treated with rt-PA (2.6 per cent of all ischemic and hemorrhagic strokes, with an average NIHSS score of 15.8 at admission [5; 25]. In 90 per cent of the cases, potential patients for thrombolysis were selected by CT-scan. Time from onset to treatment averaged 2 h 25 min, whilst door-to-treatment time averaged 40 minutes. Two patients (3 percent) showed a symptomatic intra-cerebral hemorrhage. Death rate was 18.8 per cent. After 3 months, 53.5 per cent of patients were regarded as functionally "independent" (Rankin scale<3). CONCLUSION: These results in our unit confirm the feasibility, reproducibility, efficacy and safety of the rt-PA fibrinolytic treatment for ischemic stroke of less than 3 hours. A "Stroke emergency" pathway appears to be a helpful option to treat as many patients as possible with the shortest possible lead times.     

Treatment with intravenous rt-PA in a general hospital context: A review of the Saint-Jean Hospital experience from Perpignan, France

INTRODUCTION: Intravenous recombinant tissue plasminogen activator (rt-PA) has approval for use despite of its authorization for treatment of ischemic stroke within the 3-hour time window in 2003, is rarely used in community hospital (CH). It therefore remains questionable if the positive results of the key studies conducted in specialized centers may be extended to community hospitals less specialized in the management of stroke. METHODS: We report the results of an observational cohort study including 39 patients treated with intravenous rt-Pa (according to the NINDS rt-PA stroke trail treatment protocol) at St Jean Hospital (Perpignan, France) between March 1, 2002 and August 31, 2005. Results are compared to those of the treated arm of the NINDS study. RESULTS: 1.2p.cent of ischemic stroke were treated with intravenous rt-Pa. Results are similar to those of the NINDS study: The outcome was favorable (modified Rankin score (mRS) with 0 or 1) for 44p.cent of the patients (as compared to 39p.cent in the NINDS study (X2 = 0.34; p = 0.5)) and there was no significant difference in term of death or outcome as assessed by mRS at 3 months (X2 = 0.09; p = 0.75 and X2 = 0.77; p = 0.75, respectively). No symptomatic hemmorrhagic transformation related to the use of rt-Pa was observed. CONCLUSION: Our results indicate that rt-PA therapy for ischemic stroke may be as safe and effective in the setting of a community hospital as it is in specialized centers.     

Evaluation of care given by nurses during the acute stage of stroke

INTRODUCTION: We report the results of a one-day survey of nursing care load in University Hospitals (UH), General Hospitals (GH) and Stroke Units (SU) regarding the acute stage of stroke. METHODS: The type of care and the time devoted to care were compared by type of stroke (transient ischemic attack, ischemic stroke, hemorrhagic stroke, cerebral thrombophlebitis, sub-arachnoid hemorrhage), and degree of handicap (Barthel score). RESULTS: Twenty-two hospitals (13 UH and 9 GH) participated in the study and provided care for 328 stroke victims (30 transient ischemic attacks, 247 ischemic strokes, 36 hemorrhagic strokes, 3 cerebral thrombophlebitis events and 11 strokes of unknown mechanism). Care was given in UHs for 63 percent of the patients and in GHs for 37 percent; in SUs for 40 percent (132 patients) and general neurology units for 60 percent (196 patients). Care involved physiotherapy for 70 percent, speech therapy for 42 percent, and care for cognitive decline for 36 percent. Mean time spent by nurses and nursing assistants peaked in the morning with a significant time not devoted to care. More than 3 hours of nurse care per day of care was significantly more frequent in SUs (p<0.001) and in GHs (p=0.02) for patients with Barthel score<40 or hemorrhagic stroke, irrespective of age. Patients older than 80 years, with a Barthel score<40, with hemorrhagic stroke, and who were admitted more than 15 days before the survey required more than two hours per day of nursing assistant care significantly more often. The probability of more than three hours per day of nurse care for stroke increased 2.8-fold for hemorrhagic stroke, 6.0-fold for Barthel Score<40, and 2.0-fold for care in a GH. The probability of more than two hours per day of nurse assistant care for stroke increased 3.0-fold for hemorrhagic stroke, 6.1-fold for Barthel score<40, 2.0-fold for patients older than 70 years, and 1.5-fold for stroke onset more than 14 days before the survey. CONCLUSION: This survey enabled calculating the number of care givers required for 10 patients: 6 nurses and 5 nursing assistants, a level in line with recommended practices. These results emphasize the important role of nursing care for stroke victims, and points out that the type of hospital, the type of stroke, and the patient's age and degree of handicap have an effect on nursing load. This one-day survey enabled calculation of the number of nurses and nursing assistants needed for a 10-patient unit.     

Less is more - The Finnish Prehospital Stroke Scale prospective validation

ObjectivesThe current bifurcation of the acute stroke care pathway requires prehospital separation of strokes caused by large vessel occlusion. The first four binary items of the Finnish Prehospital Stroke Scale (FPSS) identify stroke in general, while the fifth binary item alone identifies stroke due to large vessel occlusion. The straightforward design is both easy for paramedics and statistically beneficial. We implemented FPSS based Western Finland Stroke Triage Plan, including medical districts of a comprehensive stroke center and four primary stroke centers.Patients and MethodsThe prospective study population was consecutive recanalization candidates transported to the comprehensive stroke center within the first six months of implementing the stroke triage plan. Cohort 1 consisted of n=302 thrombolysis- or endovascular treatment candidates transported from the comprehensive stroke center hospital district. Cohort 2 comprised ten endovascular treatment candidates transferred directly to the comprehensive stroke center from the medical districts of four primary stroke centers.ResultsIn Cohort 1, FPSS sensitivity for large vessel occlusion was 0.66, specificity 0.94, positive predictive value 0.70, and negative predictive value 0.93. Of the ten Cohort 2 patients, nine had large vessel occlusion, and one had an intracerebral hemorrhage.ConclusionsFPSS is straightforward enough to be implemented in primary care services to identify candidates for endovascular treatment and thrombolysis. When used by paramedics, it predicted two-thirds of large vessel occlusions with the highest specificity and positive predictive value reported to date.     

CEA治疗伴对侧颈内动脉闭塞的颈动脉重度狭窄的疗效

目的评价颈动脉内膜剥脱术治疗一侧颈内动脉重度狭窄伴对侧颈内动脉闭塞的疗效。方法回顾性分析11例患者的临床资料,包括围手术期并发症及近远期疗效;并比较术前及术后3个月颈部及大脑中动脉血管血流峰值。结果即刻成功率为100%,术后患者脑缺血症状均得到改善,围手术期无病例死亡或缺血性脑卒中等严重并发症发生,仅有1例出现皮下血肿、1例出现短暂声音嘶哑,经积极治疗后均好转。随访率100%,随访时间6~61(32.5±17.2)个月。患者均无术侧颈动脉再狭窄,其中1例再发对侧缺血性脑卒中。术后患者颈动脉血流峰值及大脑中动脉收缩期血流峰值与术前比较差异有统计学意义(均P0.05)。结论对于一侧颈内动脉重度狭窄伴对侧颈动脉闭塞的高危患者,颈动脉内膜剥脱术具有满意的围手术期结果和较好的远期脑卒中预防疗效。     

Experience with t-PA treatment in a large south American City.

Background and purpose: Early thrombolysis with intravenous recombinant tissue plasminogen activator (t-PA) reduces disability following ischemic stroke. However, only a small fraction of the potential candidates receive therapy. We studied the proportion of eligible patients who did not receive t-PA and the reasons therapy was withheld from patients admitted to a Brazilian university hospital. Methods: From July 1996 to June 1997, each suspected case of hyperacute ischemic stroke led to the immediate evaluation by a research physician. Patients first seen in primary care centers near the research hospital were to be rapidly transferred. Reasons for patient exclusion were detailed. Results: Fifty-six patients were evaluated; only 5 received t-PA therapy. The main reason for not receiving t-PA (34 cases) was late hospital arrival. This was caused by lack of recognition of the early stroke signs (n=13); delayed personal or family response (n=7); wrong medical orientation (n=4); and late patient transportation (n=10). A computed tomographic (CT) scand could not be done fast enough to allow therapy in 8 patients. Nine of 14 patients in whom neurological evaluation and CT scan were done within the 3-hour period were also excluded. The main reason was refusal of informed consent (n=5). Only a few patients were excluded because of medical contraindications (n=3) or the presence of early mass effect (n=1). Conclusions: The main factor limiting access of patients with ischemic stroke to t-PA therapy in Rio de Janeiro is a low public awareness of early stroke symptoms and of the need for urgent hospital evaluation. Public education, an efficient transport system for suspected stroke patients, and optimization of the use of available CT scanners could have a significant impact on the number of treated patients.     

Identification of factors influencing hospital admission delay after ischemic cerebrovascular stroke. Study of a rural population

We studied the time of arrival of 235 consecutive patients admitted to the emergency department of a University Hospital located in a rural area after the first symptoms of ischemic stroke or TIA. Among the following factors, we determined those that might be involved in delayed admission: place of symptom onset, time and place of onset of the first symptoms, contact with a general practitioner before admission time, mode of transportation, clinical score, impairment of consciousness, presence of seizures, heart complaints or headache, age and past medical history of cerebrovascular, cardiovascular and hypertension diseases. Half of the patients arrived within 4 h 10 of symptom discovery and 55 p. cent arrived within 6 hours. The percentage of patients arriving within 3 h (p = 0.001) and 6 h (p = 0.001) was higher for those who had a stroke during the day (8 a.m.-8 p.m.) than during the evening and night. The other characteristics associated with a shorter delay included a low neurological score on the Mathew's Stroke Scale (p < 0.001 at 3 h and p = 0.001 at 6 h) and younger age (p = 0.015 at 3 h). Presence of headache delayed admission (p = 0.010). Forty-five percent of patients arrive at the hospital 6 hours after the discovery of symptoms, too late to receive optimal stroke therapy. Widespread public education on stroke is necessary to reduce the delay of admission, particularly for old patients and in case of mild to moderate deficits.     

The last days of dying stroke patients referred to a palliative care consult team in an acute hospital

Background and purpose:  Needs of patients dying from stroke are poorly investigated. We aim to assess symptoms of these patients referred to a palliative care consult team, and to review their treatment strategies.
Methods:  All charts of patients dying from stroke in a tertiary hospital, and referred consecutively to a palliative care consultant team from 2000 to 2005, were reviewed retrospectively. Symptoms, ability to communicate, treatments, circumstances and causes of death were collected.
Results:  Forty-two patients were identified. Median NIH Stroke Scale on admission was 21. The most prevalent symptoms were dyspnoea (81%), and pain (69%). Difficulties or inability to communicate because of aphasia or altered level of consciousness were present in 93% of patients. Pharmacological respiratory treatments consisted of anti-muscarinic drugs (52%), and opioids (33%). Pain was mainly treated by opioids (69%). During the last 48 h of life, 81% of patients were free of pain and 48% of respiratory distress. The main causes of death were neurological complications in 38% of patients, multiple medical complications in 36%, and specific medical causes in 26%.
Conclusions:  Patients dying from stroke and referred to a palliative care consult team have multiple symptoms, mainly dyspnoea and pain. Studies are warranted to develop specific symptoms assessment tools in non-verbal stroke patients, to accurately assess patients' needs, and to measure effectiveness of palliative treatments.     

Optimizing the deep brain stimulation care pathway in patients with Parkinson’s disease

Management of Parkinson’s disease (PD) using deep brain stimulation (DBS) requires complex care in specialized, multidisciplinary centers. A well-organized, efficient patient flow is crucial to ensure that eligible patients can quickly access DBS. Delays or inefficiencies in patient care may impact a center’s ability to meet demand, creating a capacity bottleneck. Analysis of the current practices within a center may help identify areas for improvement. After external audit of the DBS workflow of the Lyon Neurological Hospital and comparison with other European centers, manageable steps were suggested to restructure the care pathway. Propositions of the audit comprised, for example: (1) directly admitting referred patients to hospital, without a prior neurological outpatient visit and (2) including the preoperative anesthesia consultation in the hospital stay 1 month before surgery, not separately. This reorganization (between 2013 and 2016) was performed without increases in hospital medical resources or costs. The time from patients’ first referral to surgery was reduced (from 22 to 16 months; p = 0.033), as was the number of pre- and postoperative patient visits (11–5; p = 0.025) and the total cumulative length of in-hospital stay (20.5–17.5 nights; p = 0.02). Ultimately, the total number of PD consultations increased (346–498 per year), as did the number of DBS implants per year (32–45 patients). In this single center experience, restructuring the DBS care pathway allowed a higher number of PD patients to benefit from DBS therapy, with a shorter waiting time and without decreasing the quality of care.     

Comparison of stroke ward care versus mobile stroke teams in the Hungarian stroke database project

Although previous studies have proved that both stroke wards and mobile stroke teams are considerably better than non-specialized stroke care, an unresolved debate in vascular neurology is whether or not stroke wards provide better outcomes in some specific cases to stroke victims. Our prospective, multicenter, cohort study compared dedicated stroke wards versus specialist stroke team care at general hospital wards in 11 centers nationwide for 8743 consecutive stroke events during 18 months. Twenty-eight-day case-fatality rate was 12.6% at stroke wards versus 15.2% at stroke teams for all patients ( P  = 0.002), and stroke ward care also predicted better outcome when analyzed with multivariate logistic regression model (odds ratio 1.701; confidence interval: 1.025–2.822). Case-fatality rates were not significantly different in patients with modified Rankin score ≥2 (case-fatality rate: 17.8% vs. 20.3%; P  = 0.163), and over 60 (case-fatality rate: 14.8% vs. 15.9%; P  = 0.250), however these patients were more probably at home after 4 weeks when treated at stroke wards (56.1% vs. 50.6%; P  = 0.03, and 69.5% vs. 64.5%; P  = 0.004). In our study, stroke ward admission provided lower case-fatality rate below 60 and for those independent prior to their strokes, and lower institutionalization over 60 and amongst previously dependent patients, when compared with stroke teams.     

Stroke unit care--who benefits? Comparisons with general medical care in relation to prognostic indicators on admission

The clinical outcome in 110 patients admitted to a non-intensive stroke unit was compared to that in 183 patients treated for acute stroke in general medical wards. At entry, the two groups of patients were closely similar in all prognostic indicators. Subsets of patients were analyzed in an attempt to identify groups that benefit more than others from stroke unit care. The stroke unit regime had little effect on short-term and long-term mortality rates in the entire stroke population as well as in subgroups. But after the care in the stroke unit, the need for long-term hospitalization in survivors was reduced (p = 0.0001). This difference in favour of the stroke unit was independent of the patients' age, the extent of neurological deficit on admission and previous history. In subgroups where the general prognosis is fair or good (minor neurological deficits and less than 75 yrs), SU care accelerated the process of rehabilitation, but the need for institutional care very late after the stroke was influenced only little. In groups with a poor general prognosis (major deficits and greater than or equal to 75 yrs), the ultimate proportion of patients able to return home was enhanced by SU care. It is concluded that care in a stroke unit benefits the great majority of stroke patients and that such a unit should be designed to admit all acute stroke patients without selection.     

Feasibility of acute thrombolytic therapy for stroke

BACKGROUND: Thrombolysis is an expensive medical intervention for ischemic stroke and hence there is a need to study the feasibility of thrombolysis in rural India. Aims: To asses the feasibility and limitations of providing thrombolytic therapy to acute ischemic stroke patients in a rural Indian set-up. MATERIAL AND METHODS: The first 64 consecutive patients registered under the Acute Stroke Registry in a university referral hospital with a rural catchment area were studied as per a detailed protocol and questionnaire. RESULTS: Of the 64 patients 44 were ischemic strokes, and 20 were hemorrhagic. Thirteen (29.55%) patients with ischemic stroke reached a center with CT scan facility within 3 hours, of whom only 7 (15.91%) were eligible to receive thrombolytic therapy as per the existing clinical and radiological criteria, but none received the therapy. Of the remaining 31 (70.45%) who arrived late, 11 (25%) had no clinical and radiological contraindications for thrombolysis, except the time factor. All the patients belonged to a low socioeconomic status and a rural background. CONCLUSION: Though a large proportion of ischemic stroke patients were eligible to receive thrombolytic therapy, the majority could not reach a center with adequate facilities within the recommended time window. More alarmingly, even for those patients who reached within the time window, no significant attempt was made to initiate thrombolysis. These data call not only for attention to improve existing patient transport facilities, but also for improving the awareness of efficacy and therapeutic window of thrombolysis in stroke, among the public as well as primary care doctors.     

Utilization and outcome in an overnight psychiatric observation program at a Veterans Affairs Medical Center

OBJECTIVE: The effectiveness of an overnight psychiatric observation program was evaluated. The program was designed to avoid unnecessary hospitalization of patients experiencing acute psychiatric crises. METHODS: Of 110 patients admitted to the observation unit at a Veterans Affairs medical center over a six-month period in 1996, the charts of 92 patients were retrospectively reviewed. Characteristics of patients referred to the program were documented, inpatient hospitalization rates and suicide rates in the six-month periods before and after admission to the observation unit were examined, and variables related to the need for hospitalization immediately after observation were explored. RESULTS: Most of the 92 patients (98 percent) were referred from the medical center's emergency room. At the time of observation, 80 percent of the patients were unemployed, 55 percent expressed suicidal or homicidal ideation, 49 percent were intoxicated or at risk for alcohol withdrawal, and 41 percent were homeless. The most frequent psychiatric diagnosis was substance abuse or dependence (77 percent). The large majority of patients (88 percent) were referred the next day to other outpatient programs for follow-up and treatment, which avoided costly inpatient treatment. In the six months before admission to the observation program, the mean number of inpatient psychiatric bed days was 9.8, compared with 2.7 days in the six-month period after discharge from the observation program. No increase in suicide gestures or attempts was noted among the patients. No variables significantly predicted admission to inpatient care after the observation period. CONCLUSIONS: Overnight observation programs may provide a cost-effective alternative to traditional inpatient treatment for some individuals with psychiatric disorders.     

Do transient ischemic attacks have a neuroprotective effect?

OBJECTIVE: To determine whether TIAs have a neuroprotective effect. BACKGROUND: Ischemic tolerance or preconditioning, which protects the brain against stroke, has been demonstrated in animal models of cerebral ischemia. Because TIA may represent a clinical model of ischemic tolerance, patients with TIA before cerebral infarction (CI) may therefore have a better outcome than patients without TIA before CI. METHODS: A total of 2,490 patients admitted consecutively to a primary care center for first-ever CI in the anterior circulation were divided into two groups on the basis of the presence or absence of prior ipsilateral TIAs. Duration of TIA was classified into three groups (<10 minutes, 10 to 20 minutes, and >20 minutes). The severity of the neurologic picture on admission and functional disability after stroke were compared between patients with and without TIAs. RESULTS: A total of 293 (12%) of the 2,490 patients had prior ipsilateral TIAs before CI. Risk factors did not differ between patients with or without TIAs, whereas the topography and etiology of ischemic stroke did differ (p < 0.001). Patients without prior TIAs had a more severe clinical picture on admission, with a greater reduction of consciousness (p = 0.009). Patients with previous TIAs had a more favorable outcome than those without TIAs (67% versus 58%, p = 0.004). After adjustment for confounding variables, TIAs lasting 10 to 20 minutes were still associated with a favorable outcome (odds ratio, 1.98; 95% confidence interval, 1.27 to 3.08; p = 0.002). The interval between TIA and CI influenced the outcome (p = 0.007). CONCLUSIONS: This study suggests that ischemic tolerance may play a role in patients with ipsilateral TIAs before CI, allowing better recovery from a subsequent ischemic stroke.     

Delay between stroke onset and emergency department evaluation

BACKGROUND: Public educational programs have been developed to reduce delays between the onset of ischemic stroke symptoms and emergency department evaluation. An increase in the proportion of patients presenting soon after stroke would reflect the effectiveness of these efforts. METHODS: All patients (n = 506) with ischemic stroke admitted to an academic medical center located within the 'Stroke Belt' of the USA were prospectively identified over 2 years (1998-1999). Demographics, stroke characteristics and time from symptom onset to arrival in the emergency department were recorded. RESULTS: A higher proportion of ischemic stroke patients presented within 3 h of symptoms in 1998 than in 1999 (18% of 234 vs. 8% of 272, p = 0.0001). Those with less severe strokes (Canadian Neurological Scale score; Spearman r = 0.18, p < 0.0001) and younger patients (r = -0.09, p = 0.04) had greater delays. There was no difference in time to presentation based on race (13% of whites and blacks presented within 3 h, p = 0.70) or sex (16% of women vs. 9% of men, p = 0.10). Logistic regression showed that time to presentation was independently related to both stroke severity and year. CONCLUSIONS: These data show that, after accounting for other variables, the proportion of stroke patients presenting within 3 h of symptom onset to one academic medical center decreased by 10% between 1998 and 1999. Revision of public stroke-related educational programs may need to be considered.     

Early supported discharge for stroke patients improves clinical outcome. Does it also reduce use of health services and costs? One-year follow-up of a randomized controlled trial

BACKGROUND: An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up. METHODS: Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG. RESULTS: There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke. CONCLUSION: Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.     

Subacute stereotactic aspiration of haematomas within the basal ganglia reduces occurrence of complications in the course of haemorrhagic stroke in non-comatose patients

BACKGROUND AND PURPOSE: Medical complications occurring after stroke of both ischaemic and haemorrhagic origin are frequent and constitute an important problem. The strongest factor predicting the occurrence of complications is known to be the initial neurological impairment level. The aim of this study was to examine whether subacute stereotactic aspiration of haematomas within the basal ganglia is suitable to reduce the occurrence of complications in the course of haemorrhagic stroke in non-comatose patients. METHODS: Following rigorous selection criteria, 56 consecutive non-comatose patients were treated by subacute stereotactic evacuation of the haematomas. Glasgow Coma Scale (GCS) scores after initiation of treatment, medical complications, mortality and length of in-patient stay before discharge for further rehabilitative treatment were recorded for each patient and were compared with the results obtained in a comparable group of 39 patients treated purely medically in another hospital. RESULTS: The level of consciousness improved markedly after stereotactic surgery, and GCS scores were significantly higher than those after pure medical treatment (p < 0.0001). In comparison with medical patients, complications were considerably fewer in the surgical group, and thus peri-ictal morbidity and mortality were significantly lower. Length of necessary treatment in the intensive care unit as well as total in-patient stay in the acute care facility were significantly reduced. CONCLUSIONS: Improving alertness, subacute stereotactic aspiration of deep-seated haematomas decreases occurrence of medical complications in the course of haemorrhagic stroke. Recovery can be accelerated, and patients are earlier suitable for further rehabilitative treatment.