5è audit clínic de l'ictus: Catalunya 2018-2019

Audit clínic; Ictus; AvaluacióAudit clínico; Ictus; EvaluaciónClinical audit; Stroke; EvaluationAquest document de la cinquena edició de l'Audit Clínic de l‟ictus, realitzat l'any 2021, descriu les dades globals de Catalunya, així com una part de les dades desagregades per hospital, totes obtingudes de manera prospectiva. Igual que a la resta d‟edicions, les dades dels hospitals de cada àmbit territorial s‟han tramés a la Regió Sanitària corresponent i als professionals dels hospitals implicats, per a poder iniciar els processos de millora adients a partir de la comparació dels resultats amb la mitjana de Catalunya i amb els anteriors Audits

5È. Audit clínic de l'ictus. Catalunya 2018/19

La millora i el manteniment continu de la qualitat de l’atenció als malalts amb ictus agut requereix una avaluació periòdica de la pràctica clínica. Els Audits de l’Ictus són l’instrument avaluatiu del PDMVC. La millora dels seus resultats pretén garantir la millora dels resultats dels pacients.S’han auditat 4.008 casos ingressats per ictus agut entre 2018 i 2019. El període d’estudi s’ha ampliat a 6 mesos, en períodes de 1 mes i mig al llarg de 12 mesos, similars per a tots els centres. L’obtenció prospectiva de dades s’ha realitzat majoritàriament per infermeres de cada hospital. La mediana del temps entre l’inici dels símptomes i l’arribada a urgències va ser de 2,1 hores. El 72% dels casos van arribar a l’hospital dins les primeres quatre hores i mitja. Respecte al 4t Audit: * Augmenten els ingressos en Unitat d’ictus agut (44,2% a 61,3%), les activacions del Codi Ictus (42,9 a 61,4; realitzades pel SEM de 43,4 a 67,8%) i els tractaments de reperfusió (16% a 30% dels ictus isquèmics) * Augmenta el nombre de pacients en els que es diagnostica durant l’ingrés una fibril·lació auricular no coneguda prèviament (7% a 18,8%). * Hi ha un lleuger augment de les pneumònies(6% a 8%)ibaixa la mor talitat intrahospitalària (12% a 9%). * Sis indicadors de qualitat milloren significativament, tres 3 indicadors es mantenen i 3 indicadors empitjoren. Destaca una important millora en alguns indicadors de qualitat rellevants com són la realització del test de disfàgia, l’avaluació del perfil lipídic, l’educació sanitària als pacients i familiars, el registre de l’etiologia de l’ictus i la utilització d’escales neurològiques. Es necessiten accions de milloradels indicadors següents: pauta d’antitrombòtics abans de 48 hores, mobilització precoç i avaluació de l’estat d’ànim. L’estat d’ànim s’avalua en un baix percentatge i es fa servir una gran variabilitat d’eines de mesura.Preprin

Circadian rhythms in the efficacy of intravenous alteplase in patients with acute ischemic stroke and middle cerebral artery occlusion

Peer ReviewedPostprint (author's final draft

An Online Training Intervention on Prehospital Stroke Codes in Catalonia to Improve the Knowledge, Pre-Notification Compliance and Time Performance of Emergency Medical Services Professionals

Strokes are a time-dependent medical emergency. The training of emergency medical service (EMS) professionals is essential to ensure the activation of stroke codes with pre-notification, as well as a rapid transfer to achieve early therapy. New assessment scales for the detection of patients with suspected large vessel occlusion ensures earlier access to endovascular therapy. The aim of this study was to evaluate the impact on an online training intervention focused on the Rapid Arterial oCclusion Evaluation (RACE) scoring of EMS professionals based on the prehospital stroke code in Catalonia from 2014 to 2018 in a pre-post intervention study. All Catalonian EMS professionals and the clinical records from primary stroke patients were included. The Kirkpatrick model guided the evaluation of the intervention. Data were collected on the knowledge on stroke recognition and management, pre-notification compliance, activated stroke codes and time performance of EMS professionals. Knowledge improved significatively in most items and across all categories, reaching a global achievement of 82%. Pre-notification compliance also improved significantly and remained high in the long-term. Increasingly higher notification of RACE scores were recorded from 60% at baseline to 96.3% in 2018, and increased on-site clinical care time and global time were also observed. Therefore, the online training intervention was effective for increasing EMS professionals' knowledge and pre-notification compliance upon stroke code activation, and the wide adoption of a new prehospital scale for the assessment of stroke severity (i.e., the RACE scale) was achieved

Association of High Serum Levels of Growth Factors with Good Outcome in Ischemic Stroke : a Multicenter Study

Altres ajuts: This project was partially supported by grants from Xunta de Galicia (Consellería Educación: GRC2014/027 and IN607A2018/3), Spanish Research Network on Cerebrovascular Diseases RETICS-INVICTUS PLUS (RD16/0019), and by the European Union FEDER program.The main objective of this research work was to study the association of serum levels of growth factors (GF) and SDF-1α with the functional outcome and reduction of lesion volume in ischemic stroke patients. In this multicenter study, 552 patients with non-lacunar stroke (male, 62.1%; mean age, 68.2 ± 11.4) were included within 24 h from symptom onset. The main outcome variable was good functional outcome (modified Rankin Scale [mRS] ≤ 2) at 12 months. Secondary outcome variable was infarct volume (in mL) after 6 ± 3 months. Serum levels of VEGF, Ang-1, G-CSF, BDNF, and SDF-1α were measured by ELISA at admission, 7 ± 1 days, at 3 ± 1 months, and 12 ± 3 months. Except for BDNF, all GF and SDF-1α serum levels showed a peak value at day 7 and remained elevated during the first 3 months (all p < 0.01). High serum levels at day 7 of VEGF (OR, 19.3), Ang-1 (OR, 14.7), G-CSF (OR, 9.6), and SDF-1α (OR, 28.5) were independently associated with good outcome at 12 months (all p < 0.0001). On the other hand, serum levels of VEGF (B, − 21.4), G-CSF (B, − 14.0), Ang-1 (B, − 13.3), and SDF-1α (B, − 44.6) measured at day 7 were independently associated with lesion volume at 6 months (p < 0.01). In summary, high serum levels of VEGF, Ang-1, G-CSF, and SDF-1α at day 7 and 3 months after ischemic stroke are associated with good functional outcome and smaller residual lesion at 1 year of follow-up

Transfer to the Local Stroke Center vs Direct Transfer to Endovascular Center of Acute Stroke Patients with Suspected Large Vessel Occlusion in the Catalan Territory (RACECAT): study protocol of a cluster randomized within a cohort trial

Rationale: Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion (LVO) have not been assessed in randomized trials. Aim: To establish whether stroke subjects with RACE scale based suspicion of LVO evaluated by Emergency Medical Services in the field, have higher rates of favorable outcome when transferred directly to an Endovascular Center (EVT-SC), 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 LVO based on a pre-hospital RACE 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 hours from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with 3 strata: day/night, distance to the EVT-SC and week/week-end day. Study outcome: The primary endpoint is the modified Rankin Scale (mRS) 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 (mRS) 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.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The trial is sponsored by the nonprofit foundation Fundació Privada Ictus Malaltia Vascular, beneficiary of an unrestricted grant by Medtronic. Trial sponsor: Fundació Privada Ictus Malaltia Vascular. Elisabeth Ortínez ([email protected]). Study sponsor and funders do not participate in the study design, collection, management, analysis and interpretation of data, writing of the report or the decision to submit results for publication

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry

Background and Purpose In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors. Methods Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score 85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score 3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups' criteria). Results Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3). Conclusions Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors

Código Ictus: Medidas para mejorar la calidad y efectividad en la atención precoz del ictus

El tiempo es un factor primordial en la atención del ictus agudo, teniendo en cuenta la estrecha ventana terapéutica de las terapias de revascularización y el mayor beneficio del tratamiento en relación a la precocidad con se administre. La implementación de sistemas de Código Ictus (CI) coordinados entre los hospitales y el SEM permite reducir los tiempos de asistencia y duplicar la tasa de tratamiento trombolítico. El principal objetivo de la presente tesis doctoral es detectar los circuitos de CI que permiten una mayor efectividad del sistema. Para ello, se analizaron 1901 pacientes con activación del CI en la región del Barcelonès Nord i Maresme durante 7 años. Los resultados muestran que el origen de la activación del CI SEM con pre-aviso es la vía más efectiva: en comparación con la atención previa en un hospital comarcal, permitió reducir 80 minutos el tiempo desde el inicio de los síntomas hasta la atención especializada y 40 minutos hasta el inicio del tratamiento trombolítico, incrementó el acceso a terapias de revascularización (50% vs 21%) y aumentó la probabilidad de buen pronóstico a los tres meses en los pacientes tratados, con una OR 2.71 tras ajustar por gravedad del ictus y por otros factores pronóstico. Además, el pre-aviso al centro receptor permitió reducir 15 minutos el tiempo puerta-aguja en relación a la activación del CI desde el servicio de urgencias en los pacientes que acuden por medios propios o sin pre-aviso. En el segundo objetivo se validaron los resultados en 1326 pacientes tratados con tPAev en Catalunya durante 2 años. Los pacientes que acudieron al centro de referencia trasladados directamente por el SEM recibieron el tratamiento 40 minutos antes en comparación con los pacientes que fueron trasladados desde un hospital comarcal y 18 minutos antes en comparación con los que acudieron por medios propios. El tiempo transcurrido desde el inicio de los síntomas hasta el tPAev fue un factor independiente asociado al pronóstico clínico a los 3 meses. El tercer objetivo fue diseñar y validar una escala clínica simple que permita detectar, a nivel pre-hospitalario, los pacientes con oclusión arterial de gran vaso. La escala RACE (5 ítems) se diseñó en base a los ítems de la escala NIHSS con mayor capacidad predictiva de oclusión arterial de gran vaso en una cohorte retrospectiva de 654 pacientes con ictus isquémico de territorio anterior ingresados en nuestra unidad de ictus. Durante 18 meses, la escala RACE se cumplimentó por técnicos sanitarios del SEM en 263 pacientes trasladados vía CI. La escala RACE mostró una excelente correlación con la escala NIHSS (r=0.81) y una elevada capacidad predictiva de oclusión arterial (curva ROC: AUC 0.81). El mejor punto de corte se consideró para una escala RACE ≥ 4, con una sensibilidad de 0.86, especificidad de 0.63, valor predictivo positivo de 0.53, valor predictivo negativo de 0.90 y precisión global de 0.70 para la detección de oclusión arterial de gran vaso. La escala RACE es una herramienta clínica simple de uso pre-hospitalario que puede ser útil para detectar los pacientes con ictus agudo que deberían ser trasladados a un Centro Terciario de Ictus para valorar tratamiento endovascular. Los resultados derivados del presente trabajo de investigación refuerzan la importancia de priorizar el circuito de CI SEM, dado que permite el acceso a terapias de revascularización de forma más precoz y un mayor beneficio clínico de los pacientes con ictus agudo. Además, el traslado vía SEM ofrece la posibilidad de realizar una valoración clínica pre-hospitalaria que permita decidir el destino más adecuado de los pacientes. Teniendo en cuenta que en Catalunya actualmente sólo el 60% de los pacientes con ictus agudo alertan al SEM, o incluso un menor porcentaje en determinadas regiones rurales, estos datos pueden ser de importante ayuda para la implementación de programas formativos y sistemas de mejora a diferentes niveles de la cadena asistencial.Time is an important factor in the care of acute stroke patients, given the narrow therapeutic window of revascularization therapies. Moreover, the sooner the treatment is given, the higher the clinical benefit. Implementation of Stroke Code (SC) systems, coordinated between hospitals and EMS, reduces the time to treatment and double the rate of thrombolytic therapy. The main objective of this thesis is to detect SC circuits that allow greater effectiveness of the system. We analyzed 1901 patients in which SC was activated in the region of Barcelonès Nord i Maresme during 7 years. Results show that specialized attention at the stroke center was delayed for 80 minutes and thrombolytic therapy for 40 minutes in patients in whom the first level of care was provided at community hospitals compared with the direct transfer via EMS into the stroke center. Moreover, EMS SC activation allowed a higher rate of thrombolytic therapy (50% vs. 21%) and increased the likelihood of good outcome at three months with an OR 2.71 after adjusting for stroke severity and for other prognostic factors. In addition, pre-notification to the stroke center allowed a 15 minutes reduction on the door-to-needle time in comparison to SC activation at the emergency department of the stroke center in patients who come through their own means or without pre-notification. Accordingly with the second objective, these results were validated in 1326 patients treated with tPAev in Catalonia during 2 years. Patients who arrived to the stroke center transferred directly by EMS received tPAev 40 minutes earlier compared with patients transferred from a community hospital and 18 minutes compared with those who came by their own means. Time from symptoms onset to tPAev was independently associated with clinical outcome at 3 months. The third objective was to develop and validate in-the-field a simple pre-hospital stroke scale to detect patients with large-vessel arterial occlusion. The scale RACE (5 items) was designed based on the NIHSS scale items with a higher predictive value of large vessel occlusion on a retrospective cohort of 654 acute stroke admitted to our acute stroke unit. During 18 months, paramedics filled the RACE scale in 263 patients transferred via SC. RACE showed a strong correlation with NIHSS (r=0.81) and a high predictive value for arterial occlusion (ROC curve: AUC 0.81). The best predictive value of RACE was established as ≥ 4; this cut-off value showed sensitivity 0.86, specificity 0.63, positive predictive value 0.53, negative predictive value 0.90 and overall accuracy 0.70 for detecting large vessel occlusion. The scale RACE is a simple clinical tool to be used by paramedics at pre-hospital setting that can be useful to detect acute stroke patients who should be transferred to a Comprehensive Stroke Center for endovascular treatment. Results derived from this study reinforce the importance of prioritizing the SC activation via EMS, since it allows an earlier access to revascularization therapies and a greater clinical benefit of patients with acute stroke. Moreover, EMS transfer allows the possibility to perform a pre-hospital clinical evaluation to decide the most appropriate destination of acute stroke patients. Having into account that in Catalonia only 60% of acute stroke patients alert EMS, or even a smaller percentage in certain rural areas, these results can be useful to guide the implementation of improvement measures addressed to different levels of the healthcare chain

Código Ictus : medidas para mejorar la calidad y efectividad en la atención precoz del ictus /

El tiempo es un factor primordial en la atención del ictus agudo, teniendo en cuenta la estrecha ventana terapéutica de las terapias de revascularización y el mayor beneficio del tratamiento en relación a la precocidad con se administre. La implementación de sistemas de Código Ictus (CI) coordinados entre los hospitales y el SEM permite reducir los tiempos de asistencia y duplicar la tasa de tratamiento trombolítico. El principal objetivo de la presente tesis doctoral es detectar los circuitos de CI que permiten una mayor efectividad del sistema. Para ello, se analizaron 1901 pacientes con activación del CI en la región del Barcelonès Nord i Maresme durante 7 años. Los resultados muestran que el origen de la activación del CI SEM con pre-aviso es la vía más efectiva: en comparación con la atención previa en un hospital comarcal, permitió reducir 80 minutos el tiempo desde el inicio de los síntomas hasta la atención especializada y 40 minutos hasta el inicio del tratamiento trombolítico, incrementó el acceso a terapias de revascularización (50% vs 21%) y aumentó la probabilidad de buen pronóstico a los tres meses en los pacientes tratados, con una OR 2.71 tras ajustar por gravedad del ictus y por otros factores pronóstico. Además, el pre-aviso al centro receptor permitió reducir 15 minutos el tiempo puerta-aguja en relación a la activación del CI desde el servicio de urgencias en los pacientes que acuden por medios propios o sin pre-aviso. En el segundo objetivo se validaron los resultados en 1326 pacientes tratados con tPAev en Catalunya durante 2 años. Los pacientes que acudieron al centro de referencia trasladados directamente por el SEM recibieron el tratamiento 40 minutos antes en comparación con los pacientes que fueron trasladados desde un hospital comarcal y 18 minutos antes en comparación con los que acudieron por medios propios. El tiempo transcurrido desde el inicio de los síntomas hasta el tPAev fue un factor independiente asociado al pronóstico clínico a los 3 meses. El tercer objetivo fue diseñar y validar una escala clínica simple que permita detectar, a nivel pre-hospitalario, los pacientes con oclusión arterial de gran vaso. La escala RACE (5 ítems) se diseñó en base a los ítems de la escala NIHSS con mayor capacidad predictiva de oclusión arterial de gran vaso en una cohorte retrospectiva de 654 pacientes con ictus isquémico de territorio anterior ingresados en nuestra unidad de ictus. Durante 18 meses, la escala RACE se cumplimentó por técnicos sanitarios del SEM en 263 pacientes trasladados vía CI. La escala RACE mostró una excelente correlación con la escala NIHSS (r=0.81) y una elevada capacidad predictiva de oclusión arterial (curva ROC: AUC 0.81). El mejor punto de corte se consideró para una escala RACE ≥ 4, con una sensibilidad de 0.86, especificidad de 0.63, valor predictivo positivo de 0.53, valor predictivo negativo de 0.90 y precisión global de 0.70 para la detección de oclusión arterial de gran vaso. La escala RACE es una herramienta clínica simple de uso pre-hospitalario que puede ser útil para detectar los pacientes con ictus agudo que deberían ser trasladados a un Centro Terciario de Ictus para valorar tratamiento endovascular. Los resultados derivados del presente trabajo de investigación refuerzan la importancia de priorizar el circuito de CI SEM, dado que permite el acceso a terapias de revascularización de forma más precoz y un mayor beneficio clínico de los pacientes con ictus agudo. Además, el traslado vía SEM ofrece la posibilidad de realizar una valoración clínica pre-hospitalaria que permita decidir el destino más adecuado de los pacientes. Teniendo en cuenta que en Catalunya actualmente sólo el 60% de los pacientes con ictus agudo alertan al SEM, o incluso un menor porcentaje en determinadas regiones rurales, estos datos pueden ser de importante ayuda para la implementación de programas formativos y sistemas de mejora a diferentes niveles de la cadena asistencial.Time is an important factor in the care of acute stroke patients, given the narrow therapeutic window of revascularization therapies. Moreover, the sooner the treatment is given, the higher the clinical benefit. Implementation of Stroke Code (SC) systems, coordinated between hospitals and EMS, reduces the time to treatment and double the rate of thrombolytic therapy. The main objective of this thesis is to detect SC circuits that allow greater effectiveness of the system. We analyzed 1901 patients in which SC was activated in the region of Barcelonès Nord i Maresme during 7 years. Results show that specialized attention at the stroke center was delayed for 80 minutes and thrombolytic therapy for 40 minutes in patients in whom the first level of care was provided at community hospitals compared with the direct transfer via EMS into the stroke center. Moreover, EMS SC activation allowed a higher rate of thrombolytic therapy (50% vs. 21%) and increased the likelihood of good outcome at three months with an OR 2.71 after adjusting for stroke severity and for other prognostic factors. In addition, pre-notification to the stroke center allowed a 15 minutes reduction on the door-to-needle time in comparison to SC activation at the emergency department of the stroke center in patients who come through their own means or without pre-notification. Accordingly with the second objective, these results were validated in 1326 patients treated with tPAev in Catalonia during 2 years. Patients who arrived to the stroke center transferred directly by EMS received tPAev 40 minutes earlier compared with patients transferred from a community hospital and 18 minutes compared with those who came by their own means. Time from symptoms onset to tPAev was independently associated with clinical outcome at 3 months. The third objective was to develop and validate in-the-field a simple pre-hospital stroke scale to detect patients with large-vessel arterial occlusion. The scale RACE (5 items) was designed based on the NIHSS scale items with a higher predictive value of large vessel occlusion on a retrospective cohort of 654 acute stroke admitted to our acute stroke unit. During 18 months, paramedics filled the RACE scale in 263 patients transferred via SC. RACE showed a strong correlation with NIHSS (r=0.81) and a high predictive value for arterial occlusion (ROC curve: AUC 0.81). The best predictive value of RACE was established as ≥ 4; this cut-off value showed sensitivity 0.86, specificity 0.63, positive predictive value 0.53, negative predictive value 0.90 and overall accuracy 0.70 for detecting large vessel occlusion. The scale RACE is a simple clinical tool to be used by paramedics at pre-hospital setting that can be useful to detect acute stroke patients who should be transferred to a Comprehensive Stroke Center for endovascular treatment. Results derived from this study reinforce the importance of prioritizing the SC activation via EMS, since it allows an earlier access to revascularization therapies and a greater clinical benefit of patients with acute stroke. Moreover, EMS transfer allows the possibility to perform a pre-hospital clinical evaluation to decide the most appropriate destination of acute stroke patients. Having into account that in Catalonia only 60% of acute stroke patients alert EMS, or even a smaller percentage in certain rural areas, these results can be useful to guide the implementation of improvement measures addressed to different levels of the healthcare chain