XVII. European Stroke Conference
Nice, France

Poster Session: Regional stroke aspects
 

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Stroke incidence and short-term mortality in Batumi, Georgia
J. Makaradze    A. Tsiskaridze    T. Vashadze     R. Shakarishvili                                            
 
Tbilisi State University, Tbilisi, Georgia

GEORGIA

Background: Although stroke is one of the major causes of death and disability worldwide, the relevant epidemiological studies from different parts of the world, especially developing countries, are lacking. We established prospective population-based registry of stroke in a city of Batumi located at the Black Sea cost of Georgia, a country in transition in the South Caucasian region. Methods: All first-ever strokes occurred from September 1998 to January 2002 in overall population of Batumi with 121,806 residents (162,407 person-years) were registered and analyzed by using overlapping sources of information and standard diagnostic criteria. Results: The crude average annual incidence rate for all strokes was estimated to be 144 per 100,000 residents. Regarding stroke subtypes, incidence rate was 84 per 100,000 residents for ischemic stroke (IS), 23 per 100,000 for intracerebral hemorrhage (ICH), 8 per 100,000 for subarachnoidal hemorrhage (SAH), and 29 per 100,000 for unspecified stroke (US). One-month case-fatality rates were 26%, 46%, 53%, and 81% for IS, ICH, SAH and US, respectively. Conclusion: Stroke incidence rates in Batumi, Georgia are significantly lower than in developing countries of Eastern Europe and former Soviet Union, while short-term mortality is among the highest ever reported. Geographical, lifestyle and public health system variations may serve as a cause of such difference between this part of Georgia and other countries with similar to Georgia socio-economic status.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Hospital Care and Stroke: the Irish National Audit of Stroke Care (INASC)
N.F.Horgan    A.  Hickey    H. McGee     S. Murphy     D. O'Neill                                    
On behalf of the INASC Team
Royal College of Surgeons in Ireland

IRELAND

A national evidence base is essential in planning and evaluating health service delivery. The Irish National Audit of Stroke Care conducted a national audit of hospital and community stroke services in the Republic of Ireland in 2006-2007. We report on the first such audit of organisational aspects of stroke care in acute hospitals. All 37 public hospitals providing acute services to stroke patients participated. A group of senior staff in each (typically the chief executive a senior physician, nursing and paramedical staff) was interviewed as a team. The interview was based on the Organisational Audit Proforma of the UK National Sentinel Stroke Audit 2004. Hospital stroke services in Ireland were notable by the complete absence, with one exception, of the recommended standard for optimal care of patients following stroke. Only one hospital, representing 3% of relevant hospitals, had a stroke unit. This compares with 91% of hospitals in the United Kingdom (Intercollegiate Working Party for Stroke Sentinel Audit UK 2006). Five hospitals (14%) had evolving stroke services short of a full stroke unit. 30% of hospitals did not have access to routine CT scanning within 48 hours of stroke, and access to emergency MR scanning was only 41%. Carotid Doppler scanning was not available in 14% of hospitals. Routine thrombolysis services for stroke patients were not available in Ireland. Access to rehabilitation was very variable, with low or absent representation of some professional groups (i.e., clinical psychology). The majority of hospitals (66%) have submitted requests to the health authorities for stroke unit funding. This audit provides comprehensive information for the first time on the inadequate availability of hospital services of proven efficacy for those with stroke in Ireland. There was also considerable variation in access to services. Commitment and resources now need to be galvanised in a National Stroke Strategy with designated funding and an urgent timeframe for development of stroke services, with repeat audits to measure implementation.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
ORGANISATION OF A POPULATION-BASED ACUTE STROKE CARE MODEL IN CATALONIA
M. GALLOFRE    S. ABILLEIRA    J. ALVAREZ-SABIN     A. CHAMORRO     A. DAVALOS    J. MARTI-FABREGAS     J. ROQUER     J. SERENA             
 
STROKE PROGRAMME - HEALTH DEPARTMENT

SPAIN

BACKGROUND AND OBJECTIVE: A Stroke Programme, launched in Catalonia in 2004, has implemented a territory-based model of acute stroke care organisation that covers all the Catalan territory (7 million people). Candidates to receive dedicated acute stroke care –Stroke Code (SC) patients- are referred to 13 Primary Stroke Centers (PSC) previously certified. The aim of this retrospective hospital-based popu-lation monitored study was to evaluate the number of SC activations, IV tPA treatments, and door-to-needle times in PSC during the first year, following the implementation of a model of acute stroke care. METHODS: Criteria for SC activation were patients < 81 years-old, with an acute stroke of <6 hours from symptoms onset, and neither prior dependency nor serious co-morbidities. PSC hospitals were designated across the territory, with a territorial reference area that included community hospitals and primary care centers, forming a network that covers the country as a hole. 7 out of 13 PSC had semi-intensive stroke units. The Emergency Medical System (EMS) was alerted by the SC activation when patients fulfilled the aforementioned criteria. RESULTS: From 11.303 stroke patients hospitalised in 2006, 1835 were admitted through a correct SC activation. In other 521 patients SC activation was not correct, either because of stroke mimics (27%) or criteria deviations (such as more than 6 hours from onset in 34%). Thirty-four percent of patients arrived on their own way to PSC, 26% were primarily transferred by the EMS and 18% from community hospitals. IV tPA was given to 460 patients. The main reason for tPA exclusion was >3 h from onset (21%), minor deficit (19%) and ICH (19%). Median door-to-needle time was 63 min CONCLUSIONS: A territory-based model of acute stroke care organisation facilitates a uniform approach to stroke patients. Monitoring allows evaluating present and future trends in access to dedicated stroke care and quality standards.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Pre-hospital care in acute ischemic stroke in urban and rural areas – report from PRUM registry.
G. Kozera    K. Chwojnicki    D. Gasecki     M. Wiśniewska     S. Szczyrba    M. Szczypek     W.M.Nyka                     
 
Medical University of Gdansk, Department of Neurology for Adults *on behalf of PRUM members

POLAND

The negative influence of the patients accommodation on the acute stroke treatment still stays an important challenge for European community. The aim of our study was to assess the impact of patients location on pre-hospital acute stroke care, especially for cerebral thrombolysis implementation. Materials and methods: The data of 946 patients recorded in Pomerania Stroke Registry from 01.06.2006 - 31.05.2007 were evaluated: 524 hospitalized in 3 stroke units located in big urban areas (cities over 50 thousand inhabitants) and 421 treated 5 in stroke units located rural areas (towns below 50 thousand inhabitants). Results: In rural location higher percentage of patients has to wait for qualified medical aid over 45 minutes (57,9 % vs. 40,9% in urban areas, p<0,001) and were transported to hospital by emergency specialist team (75,1 % vs. 67 % in urban areas, p<0,001). More patients were admitted from outside the hospital location in rural than in urban areas (73,5 % vs. 18,1; p<0,001). In urban location more patients reached hospital by it’s own transportation (23,7 % vs. 17,9 %, p<0,05) and without any previous medical aid (10,6 % vs. 2,1 % in rural areas). Both in urban and rural location a high percentage of patients delayed calling the medical service over 1 hour (64,7 % and 62,8 % respectively). In rural areas 22,6 % of patients were admitted to stroke unit during 3 hours from stroke onset vs. 15,3 % in urban areas (p<0,05). In spite of that only 1,9 % of strokes were treated with rt-PA in rural vs. 6,5 % in urban stroke units. Conclusions: Our data indicate that better efficacy of pre-hospital care is not supported by implementation of modern standards of acute stroke treatment in rural areas.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
How is stroke dealt with in hospitals of Umbria region, central Italy? An epidemiological survey
S. Ricci    I. Vescarelli    M.G.Celani     E. Righetti     T. Mazzoli                                    
 
UOCD Neurologia e Ictus, USL 2 dell' Umbria

ITALY

Several international guidelines depict the ideal diagnostic and therapeutic workup for patients admitted with acute stroke; however, application of these recommendations is far from complete, particularly in peripheral hospitals. We sought to verify how patients with acute stroke are dealt with in Umbria, central Italy, with 830000 residents. In 2006, 2383 discharge forms (SDO) classified as DRG 14 (stroke) were retrieved. We randomly selected a 10% sample, stratified by hospital of admission, obtained the hospital notes and verified the following items: diagnosis, length of stay in hospital, time from onset of symptoms to admission, time to CT scan, use of ASA if indicated, start of rehabilitation, indications for secondary prevention at discharge. We describe here results related to the first 150 forms. We could confirm a diagnosis of stroke in 139 cases (93%); there were 66 women, and mean age was 76 (range 30 to 97). There were 23 haemorrhages (16.5%). Mean length of stay was 11 days (range 0 to 69); 27 patients (19.4%) were admitted after 24 hours from stroke onset. In 89% of cases CT scan was obtained within 24 hours; 85% of patients with ischaemic strokes were treated with ASA during the admission period; only 39 patients (28%) received some sort of early rehabilitation; finally, in just 28 cases (20%) we were able to find some indication on secondary prevention written in the hospital notes. While we are still registering data to reach the predetermined sample size, and we are adding information on nursing procedures (dysphagia detection, use of catheters, etc), our preliminary conclusions are: A) there is still a number of wrong coding (in our sample 7%) which makes epidemiological studies based on DRG not reliable. B) lenght of stay is extremely variable, and does not reflect the presence of a stroke unit (just 3 in Umbria); there are still too many patients who are admitted too late, scanned too late and not treated appropriately. C) rehabilitaion in hospital is very poorly applied.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Managing STROKE in pre-hospital settings
N. Catorze    P. Lavinha    R. Glied     I. Santos     N. Pereira                                    
 
Instituto Nacional de Emergência Médica - INEM

PORTUGAL

STROKE is a frequent pathology in all Emergency Departments associated with an increased morbidity. The creation of Stroke Units have been the main reason for the mortality and morbidity reduction, increasing the patients quality of life, with no, or minor sequelae. Our institution is responsible for the evaluation of all pre-hospital patients, including those with neurological signs, determining which hospital they should go. The authors present 2 yrs of retrospective data from pre-hospital stroke patients in an urban area, where 3 new stroke units were implemented. All data were collected from the 112 database, regarding Lisbon, with 1 million estimated resident populations. Our data reveals 846 patients (510 males vs. 336 females) with acute neurological signs less than 3h of onset. The median age was 63.94yrs (80-23yrs) and 95% of them presented hemi paresis and disarthria. The clinical presentations of the rest of the patients were convulsions and coma. Hypertension, diabetes and dyslipidemia were the most common associated morbidity (> 45%). Each patient was evaluated for a reperfusion protocol validated by case by case by the medical staff from each Stroke Unit. The acute symptoms should have less than 3h and also should be in hospital during that interval. The median time for transportation form scene to hospital was 40,3 min (30-60 min) during which Oxygen was delivered, blood pressure controlled and neurological monitoring maintained. The outcomes of these patients are being evaluated, after the hospital discharge, being the preliminary report very enthusiastic. This small retrospective study, involving pre-hospital stroke managing, contribute to decrease the morbidity overall, facilitating the patient access to Stroke Units.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Integrating research into clinical practice: Impact of the Stroke Research Network on a thrombolysis service
O. Browne    E. Klaasen    J. Godwin     N. Harding     D. Werring    M.M.Brown                             
 
University College London Hospitals NHS Trust

UNITED KINGDOM

BACKGROUND: The UK Stroke Research Network (SRN) was established by the Department of Health to provide infrastructure to facilitate stroke research and improve the integration of research into clinical practice. One of the trials supported by the SRN is the International Stroke Trial-3 (IST-3) which is testing the benefit of thrombolysis for ischaemic stroke outside licence indications e.g. 3-6 hours after onset. We report the results of SRN involvement in establishing a hyperacute stroke service at our hospital designed to integrate licensed and research indications for thrombolysis. METHODS: The hyperacute stroke service was set up to provide a 24/7 service for North Central London as a joint venture between Emergency Room (ER) staff, neurology and SRN staff at our hospital in collaboration with local hospitals not able to offer a 24 hour thrombolysis service, and the London Ambulance Service (LAS). The LAS brings FAST (Face, Arm, Speech, Test) positive patients to the ER within 6 hours of symptom onset. All patients are assessed by a neurology registrar using a single combined proforma which combines both licensed and IST-3 research eligibility criteria for thrombolysis up to six hours after onset. The SRN staff are involved in training the clinical staff in licence and research indications for thrombolysis. RESULTS The service was established in August 2007. 157 suspected stroke patients were assessed during the first 17 weeks of the service (mean 1.3 patients/day). Of these, 56 (36%) were diagnosed as stroke mimics and 13 (8%) TIA. Of the 88 patients with stroke, 7 (8.0%) were thrombolysed within licence, 7 (8.0%) were randomised within IST-3, and 3 (3.4%) refused randomisation. DISCUSSION The service has successfully achieved the aim of the SRN to integrate research into routine clinical practice. Research based education of staff has facilitated improvement in the care of stroke patients. If IST-3 confirms benefit, as many as 20% of acute stroke patients will be eligible for thrombolysis.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Love's Labour's Won - Making change happen across all the hospitals in a country.
A. Hoffman    A. Rudd    D. Lowe     R. Grant     F. Wurie                                    
 
Clinical Standards Department, Royal College of Physicians, London

UNITED KINGDOM

Background The UK has had a national stroke programme consisting of guideline production, national clinical audit and government strategies for at least 8 years. This has proved successful in identifying how research sets evidence based standards for clinicians and managers, clinical audits every two years to measure progress against these standards nationally and regionally and both aspects providing information to government to develop policy. The involvement of patient and carer groups and provision of named hospital results has been fundamental to the process. Results see table Conclusion In this way we have seen improvements in stroke care at a structural and clinical level in most hospitals in the UK. In some parts of the UK (i.e.Wales) where this has not been followed comprehensively, the rate of change has been slower.

http://www.eurostroke.org/ni_graphics/g_aid3018.htm
 

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
The State of Emergency Stroke Resources and Care in Rural Arizona
M.L.Miley    N.L.Olmstead    B.J.Bobrow     B.M.Demaerschalk                                            
 
Mayo Clinic Arizona

USA

Background and goals: 10,000 Arizonians suffer stroke annually. 1/3 reside outside a metropolitan community and do not have access to emergency stroke expertise. Our purpose was to evaluate the emergency stroke resources available at and care provided by 35 remote Arizona hospitals. Methods: We excluded the 70 hospitals in Phoenix and Tucson. The research project was introduced to the remaining hospitals by telephone. Consenting managers or directors of emergency and quality departments at the 35 hospitals were mailed a formal survey on behalf of the Arizona Department of Health Services. Results: 24/35 (69%) hospitals completed the survey. 24% hospitals reported >100 annual acute strokes, 19% reported 50-100, and 57% reported fewer than 50. Of the 24 hospitals, 57% had both CT and MRI, 33% had CT only, and 10% had neither CT nor MRI. Radiological interpretation was available on-site 24/7 at 33% of hospitals, occasionally on site at 43%, 24/7 teleradiology was used at 24%. Only 1 hospital had neurologists on call 24/7. 2 of the 24 hospitals served as stroke telemedicine spoke centers with an urban PSC. 90% of the remaining hospitals were interested in participating in a state-wide stroke telemedicine initiative. Cumulatively, hospitals administered tPA to 2-4% of all stroke patients. Conclusion: Remote communities of Arizona are under serviced with regard to the availability of neurologists and the delivery of emergency stroke care. The majority of the remote Arizona Eds are both interested in and capable of participating as spoke sites in a state-wide stroke telemedicine initiative.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Stroke Telemedicine for Arizona Rural Residents (STARR)
M.L.Miley    B.J.Bobrow    B.M.Demaerschalk                                                    
 
Mayo Clinic Arizona

USA

Background and goals: A deficit of emergency stroke care in Arizona's remote communities calls for a state-wide acute stroke care plan centered on stroke telemedicine. Our purpose was to formulate a 5-year stroke telemedicine plan for Arizona rural residents. Methods: We derived data from our previously designed 1-hub, 2-spoke research trial to estimate the resources (neurologists, equipment, management personnel, information technology, and administration). We examined the counties’ epidemiology from a government census. We determined that Phoenix would serve the northern and Tucson the southern portions of the state. To determine the boundary between portions, we used a combination of county borders, highways, and proximity to metropolitan areas. We devised a prioritization scheme for staged spoke site participation in the opening year. Results: The STARR plan divides Arizona into two regions: 85,123 mi2 in the north and 28,511 mi2 in the south. The population is 4,778,415 in the north and 1,387,905 in the south. 8 Phoenix primary stroke centers (PSC) would service 26 remote EDs and 3 Tucson PSCs would service 9 EDs. Each hub will have 2-4 stroke neurologists sharing call duties, 1 director at 0.20 full-time equivalent (FTE) and 1 coordinator (0.20 FTE). A manager will oversee the entire STARR program (1.0 FTE). The budget for the first year is US $5,712,843 and the 5-year budget is US $25,137,015. Conclusion: The 5-year plan for STARR has been formulated and initiated. Telemedicine may be an effective method to provide expert care to stroke patients located in rural areas.