Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

<p>Abstract</p> <p>Background</p> <p>Mass media interventions have been implemented to improve emergency response to stroke given the emergence of effective acute treatments, but their impact is unclear.</p> <p>Methods</p> <p>Systematic review of mass media interventions aimed at improving emergency response to stroke, with narrative synthesis and review of intervention development.</p> <p>Results</p> <p>Ten studies were included (six targeted the public, four both public and professionals) published between 1992 and 2010. Only three were controlled before and after studies, and only one had reported how the intervention was developed. Campaigns aimed only at the public reported significant increase in awareness of symptoms/signs, but little impact on awareness of need for emergency response. Of the two controlled before and after studies, one reported no impact on those over 65 years, the age group at increased risk of stroke and most likely to witness a stroke, and the other found a significant increase in awareness of two or more warning signs of stroke in the same group post-intervention. One campaign targeted at public and professionals did not reduce time to presentation at hospital to within two hours, but increased and sustained thrombolysis rates. This suggests the campaign had a primary impact on professionals and improved the way that services for stroke were organised.</p> <p>Conclusions</p> <p>Campaigns aimed at the public may raise awareness of symptoms/signs of stroke, but have limited impact on behaviour. Campaigns aimed at both public and professionals may have more impact on professionals than the public. New campaigns should follow the principles of good design and be robustly evaluated.</p

Timing of Recanalization After Tissue Plasminogen Activator Therapy Determined by Transcranial Doppler Correlates With Clinical Recovery From Ischemic Stroke

Background—The duration of cerebral blood flow impairment correlates with irreversibility of brain damage in animal models of cerebral ischemia. Our aim was to correlate clinical recovery from stroke with the timing of arterial recanalization after therapy with intravenous tissue plasminogen activator (tPA). Methods—Patients with symptoms of cerebral ischemia were treated with 0.9 mg/kg tPA IV within 3 hours after stroke onset (standard protocol) or with 0.6 mg/kg at 3 to 6 hours (an experimental institutional review board–approved protocol). National Institutes of Health Stroke Scale (NIHSS) scores were obtained before treatment, at the end of tPA infusion, and at 24 hours; Rankin Scores were obtained at long-term follow-up. Transcranial Doppler (TCD) was used to locate arterial occlusion before tPA and to monitor recanalization (Marc head frame, Spencer Technologies; Multigon 500M, DWL MultiDop-T). Recanalization on TCD was determined according to previously developed criteria. Results—Forty patients were studied (age 70±16 years, baseline NIHSS score 18.6±6.2). A tPA bolus was administered at 132±54 minutes from symptom onset. Recanalization on TCD was found at the mean time of 251±171 minutes after stroke onset: complete recanalization occurred in 12 (30%) patients and partial recanalization occurred in 16 (40%) patients (maximum observation time 360 minutes). Recanalization occurred within 60 minutes of tPA bolus in 75% of patients who recanalized. The timing of recanalization inversely correlated with early improvement in the NIHSS scores within the next hour (polynomial curve, third order r2=0.429, P300 minutes. Conclusions—The timing of arterial recanalization after tPA therapy as determined with TCD correlates with clinical recovery from stroke and demonstrates a 300-minute window to achieve early complete recovery. These data parallel findings in animal models of cerebral ischemia and confirm the relevance of these models in the prediction of response to reperfusion therapy

Deterioration Following Spontaneous Improvement

Background and Purpose—Some stroke patients will deteriorate following improvement (DFI), but the cause of such fluctuation is often unclear. While resolution of neurological deficits is usually related to spontaneous recanalization or restoration of collateral flow, vascular imaging in patients with DFI has not been well characterized. Methods—We prospectively studied patients who presented with a focal neurological deficit that resolved spontaneously within 6 hours of symptom onset. Patients were evaluated with bedside transcranial Doppler (TCD). Digital subtraction angiography (DSA), computed tomographic angiography (CTA), or magnetic resonance angiography (MRA) were performed when feasible. DFI was defined as subsequent worsening of the neurological deficit by ≥4 National Institutes of Health Stroke Scale points within 24 hours of the initial symptom onset. Results—We studied 50 consecutive patients presenting at 165±96 minutes from symptom onset. Mean age was 61±14 years; 50% were females. All patients had TCD at the time of presentation, and 68% had subsequent angiographic examinations (DSA 10%, CTA 4%, and MRA 44%). Overall, large-vessel occlusion on TCD was found in 16% of patients (n=8); stenosis was found in 18% (n=9); 54% (n=27) had normal studies; and 6 patients (12%) had no temporal windows. DFI occurred in 16% (n=8) of the 50 patients: in 62% of patients with TCD and angiographic evidence of occlusion, in 22% with stenosis, and in 4% with normal vascular studies (P Conclusions—DFI is strongly associated with the presence of large-vessel occlusion or stenosis of either atherosclerotic or embolic origin. Normal vascular studies and lacunar events were associated with stable spontaneous resolution without subsequent fluctuation. Urgent vascular evaluation may help identify patients with resolving deficits and vascular lesions who may be candidates for new therapies to prevent subsequent deterioration

High Rate of Complete Recanalization and Dramatic Clinical Recovery During tPA Infusion When Continuously Monitored With 2-MHz Transcranial Doppler Monitoring

Background and Purpose—Clot dissolution with tissue plasminogen activator (tPA) can lead to early clinical recovery after stroke. Transcranial Doppler (TCD) with low MHz frequency can determine arterial occlusion and monitor recanalization and may potentiate thrombolysis. Methods—Stroke patients receiving intravenous tPA were monitored during infusion with portable TCD (Multigon 500M; DWL MultiDop-T) and headframe (Marc series; Spencer Technologies). Residual flow signals were obtained from the clot location identified by TCD. National Institutes of Health Stroke Scale (NIHSS) scores were obtained before and after tPA infusion. Results—Forty patients were studied (mean age 70±16 years, baseline NIHSS score 18.6±6.2, tPA bolus at 132±54 minutes from symptom onset). TCD monitoring started at 125±52 minutes and continued for the duration of tPA infusion. The middle cerebral artery was occluded in 30 patients, the internal carotid artery was occluded in 11 patients, the basilar artery was occluded in 3 patients, and occlusions were multiple in 7 patients; 4 patients had no windows; and 1 patient had a normal TCD. Recanalization on TCD was found at 45±20 minutes after tPA bolus: recanalization was complete in 12 (30%) and partial in 16 (40%) patients. Dramatic recovery during tPA infusion (total NIHSS score Conclusions—Dramatic recovery during tPA therapy occurred in 20% of all patients when infusion was continuously monitored with TCD. Recovery was associated with recanalization on TCD, whereas no early improvement indicated persistent occlusion or reocclusion. At 24 hours, 40% of all patients improved by ≥10 NIHSS points or recovered completely. Ultrasonic energy transmission by TCD monitoring may expose more clot surface to tPA and facilitate thrombolysis and deserves a controlled trial as a way to potentiate the effect of tPA therapy

Measurement of Patients' Perceptions of the Quality of Acute Stroke Services: Development and Validation of the STROKE Perception Report

INTRODUCTION: Patients' perceptions of healthcare quality have become an important part of quality measurement. We explored patients' and family's lived experiences during acute stroke hospitalization to develop a quantitative instrument. METHODS: Focus groups were conducted using open-ended scripted questions. Interview data were coded and analyzed using an inductive approach to thematic analysis. Symmetric patient and family instruments were developed based on qualitative domains and serially refined to a set of 30 survey items, 12 stroke knowledge test items, and 5 subject demographic fields. Scales were evaluated for internal consistency reliability using Cronbach alpha; construct validity with exploratory factor analysis using principal components with varimax rotation was performed to determine the extent to which items in a scale measure the same underlying factor. Feasibility of an electronic cloud-based survey was also tested. RESULTS: Three main themes emerged: fast action to diagnose and treat stroke, genuine caring, and education to prevent and respond to stroke. A total of 1029 subjects completed the final instrument with no differences in perception found by race, ethnicity, or length of stay. Scales showed satisfactory internal consistency reliability (Cronbach alpha scores, .89-.94); factor loadings across each scale ranged from 0.55 to 0.87. Data entry by electronic pad was perceived by 77% to be more confidential than paper surveys; median score for difficulty was 4 ("easy to use"). CONCLUSION: The STROKE Perception Report enables understanding of patients' and family's beliefs about the quality of acute stroke care in essential new domains never explored before.Open access articleThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

The role of stroke nurses in thrombolysis administration in Australia and the United Kingdom: A cross-sectional survey of current practice

Background: The role of stroke nurses in patient selection and administration of recombinant tissue plasminogen activator (rt-PA) for acute ischaemic stroke is evolving. Objectives: Compare differences in stroke nurses’ practices related to rt-PA administration in Australia and the United Kingdom (UK) and to examine whether these differences influence rt-PA treatment rates. Methods: Cross- sectional, self-administered questionnaire administered to a lead stroke clinician from hospitals known to provide rt-PA for acute ischaemic stroke. Chi-square tests were used to analyse between-country differences in ten pre-specified rt-PA practices. Non-parametric equality of medians test was used to assess within-country differences for likelihood of undertaking practices and association with rt-PA treatment rates. Reporting followed STROBE checklist. Results: Response rate 68%; [Australia: 74% (n=63/85); UK: 65% (n=93/144)]. There were significant differences between countries for 7/10 practices. UK nurses were more likely to: request CT scan; screen patient for rt-PA suitability; gain informed consent; use telemedicine to assess, diagnose or treat; assist in the decision for rt-PA with Emergency Department physician or neurologist; and undergo training in rt-PA administration. Reported median hospital rt-PA treatment rates were 12% in the UK and 7.8% in Australia: (7.8%). In Australia, there was an association between higher treatment rates and nurses involvement in 5/10 practices; read and interpret CT scans; screen patient for rt-PA suitability; gain informed consent; assess suitability for rt-PA with neurologist/stroke physician; undergo training in rt-PA administration. There was no relationship between UK treatment rates and likelihood of a stroke nurse to undertake any of the ten rt-PA practices. Conclusion: Stroke nurses’ active role in rt-PA administration can improve rt-PA treatment rates. Models of care that broaden stroke nurses’ scope of practice to maximise rt-PA treatment rates for ischaemic stroke patients are needed