Welcome to the ESOC 2021 Virtual Conference Calendar

Group Name

on behalf of the PRESTO investigators.

Background And Aims

Prehospital stroke scales are suggested to estimate the likelihood of proximal intracranial large vessel occlusion (LVO) in patients with suspected stroke symptoms. We aimed to compare the prehospital assessment by paramedics to the in-hospital NIHSS.

Methods

We analyzed data from the PRESTO study, a prospective multicenter observational cohort study of suspected stroke patients transferred by ambulance. Paramedics scored nine prehospital stroke scale items in the field. We calculated Spearman’s correlation between the prehospital assessment and in-hospital NIHSS assessed at the emergency department, stratified by diagnosis. Secondary analyses were the sensitivity and specificity for each prehospital item against the corresponding NIHSS item (a score of 0 vs. ≥1).

Results

We included 1036 patients; 120 (12%) patients had an ischemic stroke due to LVO. Correlation between the prehospital assessment and NIHSS was 0.72 (95% CI: 0.69–0.75). Correlations subdivided per diagnosis were 0.81 (95% CI: 0.71–0.88) for patients with intracranial hemorrhage, 0.72 (95% CI: 0.63–0.80) for patients with LVO, 0.68 (95% CI: 0.62–0.73) for patients with non-LVO ischemic stroke, 0.64 (95% CI: 0.56–0.70) for patients with stroke mimic and 0.27 (95% CI: 0.13–0.40) for patients with TIA. The prehospital items “Arm” and “Leg” had the highest sensitivity (97%, 94%) with the lowest specificity (63%, 62%) (Table). “Neglect” had the lowest sensitivity (34%) with the highest specificity (93%).

Conclusions

Prehospital assessments by paramedics are strongly correlated with in-hospital assessments, but not in patients with TIA. Only neglect is missed frequently by paramedics. Our results indicate that paramedics can adequately assess neurological deficits in the field.

Trial Registration Number

Not applicable

Background And Aims

Assessing the severity of posterior circulation strokes, due to the variety of symptoms, is a significant clinical problem. Current clinimetric scales show lower accuracy in the measurement of posterior stroke severity, compared with that of anterior strokes. The aim of the study was to design a validated tool, termed Adam’s Scale of Posterior Stroke (ASPOS), for better assessment and prediction of posterior stroke

Methods

This prospective, observational study involved 126 posterior circulation ischemic stroke subjects. Four researchers, previously trained
in ASPOS, randomized the stroke severity using a novel tool and other appropriate stroke scales (The National Institute of Health Stroke Scale—NIHSS, modified Rankin Scale—mRS, Glasgow Coma Scale, Barthel Index, or Israeli Vertebrobasilar Stroke Scale—IVBSS) to assess the psychometric properties, reliability, and validity of ASPOS and investigate its predictive value

Results

ASPOS reached a Cronbach’s alpha coefficient of 0.7449. The Bland–Altman analysis showed a good coefficient of repeatability (CR) of 0.46 and excellent intraclass correlation coefficients or weighted kappa values (>0.90), reflecting high reliability. Significant correlations with other scales confirmed the construct and predictive validity of ASPOS. A total ASPOS score of three points indicated a significantly increased probability of severe stroke based on the NIHSS, compared to a total ASPOS of 1–2 points (odds ratio (OR) 141; 95% CI: 6.72–2977.66; p = 0.0014).

Conclusions

We developed a valid and reliable tool to assess posterior circulation strokes. This can contribute to a more comprehensive estimation of posterior stroke and due to its predictive properties, it can be used to more accurately select candidates for specific treatments.

Group Name

on behalf of the MR CLEAN Registry Investigators

Background And Aims

Delay in start of endovascular treatment (EVT) for acute ischemic stroke results in worse functional outcome. However, the magnitude of this effect in patients with posterior circulation ischemic stroke (PCS) is not well known. We aim to assess the association of time to EVT with outcome in patients with PCS.

Methods

We included patients from the MR CLEAN registry who underwent EVT for PCS between March 2014 and December 2018, within 6 hours of stroke onset. We assessed the association between time from estimated stroke onset to start of EVT and functional outcome (90-day mRS score) and functional independence (mRS 0-2) with univariable and multivariable ordinal and binary logistic regression, and calculated absolute probabilities of functional independence and death per hour delay.

Results

Of 264 patients who underwent EVT for PCS, 183 (69%) received EVT within 6 hours of stroke onset. In these patients, increased time to EVT was associated with worse outcomes; acOR per one hour delay to EVT was 0.86 (95% CI, 0.67-1.08) for the full mRS, and 0.74 (95% CI, 0.55-1.00) for functional independence (Figure). Per hour delay to EVT, the probability for functional independence decreased with 6.4%, and the probability for death increased with 2.3%.

Conclusions

In patients undergoing EVT for PCS within 6 hours from stroke onset, increased time to EVT is associated with worse outcomes. The detrimental effect of this delay is similar to the effect observed in strokes in the anterior circulation.

Background And Aims

Prolonged time to diagnosis of intracerebral haemorrhage (ICH) can result in delays in obtaining appropriate blood pressure control, reversal of coagulopathy or surgical intervention in select cases. We sought to characterise the time to diagnosis in a cohort of patients with ICH and identify factors associated with delayed diagnosis.

Methods

The stroke database of our hospital was retrospectively reviewed to identify patients presenting to our hospitals emergency department with ICH from January 2017 until December 2018. Data collected included demographics (age and sex), comorbidities, anticoagulation status, clinical (NIHSS, GCS, ICH score), imaging (anatomical site, haematoma size). Time of symptom onset imaging diagnosis was recorded. Factors associated with diagnosis >24 hours post ictus were assessed using t-tests and chi squared tests.

Results

235 patients were identified with 125 males (53%) and a median age of 76 (range 40-98). Mean NIHSS score at presentation was 14.3 ± 10.4, and mean ICH score was 1.9 (± 1.4). In 148 (63%) cases hypertension was the aetiology. The site of haemorrhage was lobar in 96 (41%), deep cerebral in 106 (45%), cerebellar in 23 (10%) and brainstem in 10 (4%). 134 (57%) were diagnosed within ≤6 hours of ictus, 77 (33%) at 6-24 hours and 24 (10%) were diagnosed >24 hours post ictus. Factors associated with delayed diagnosis included lower NIHSS (p=0.01), absence of hemiplegia (p=0.01) and a code stroke not being called (p=0.01).

Conclusions

The majority of patients with ICH present within 6 hours of ictus. Cases of delayed diagnosis involved patients with less prominent clinical deficits.

Background And Aims

An estimated 9% of all stroke patients are initially misdiagnosed in the emergency department (ED). Efforts to improve diagnosis should be informed by an assessment of the knowledge, attitudes, and beliefs of ED physicians about neurologic diagnosis.

Methods

We conducted semi-structured interviews of ED physicians practicing at 4 different urban sites in the USA. Conventional content analysis was used to identify themes. Interview transcripts were entered into NVivo qualitative data management. Each transcript was independently coded by two researchers via an iteratively derived code book with consensus used to resolved coding differences. Interviews continued until thematic saturation was reached.

Results

Sixteen physicians were interviewed. We identified two broad themes: (1) challenges unique to neurological complaints and (2) those related more broadly to diagnostic decision making. Subthemes relevant to neurology included: (1) knowledge gaps and uncertainty about aspects of neurological evaluations, (2) patient related barriers to diagnosis (e.g. atypical presentations, low health literacy), and (3) perceived lack of ground truth in clinical neurology. Subthemes relevant to diagnostic decision making included: (1) cognitive biases, (2) comfort with diagnostic uncertainty, (3) diagnostic error identification, (4) comfort with non-neurological diseases, and (5) ED system/environmental issues (e.g. pace of care, communication between providers). Physicians reported relying on patients’ medical co-morbidities and clinical gestalt to guide diagnostic decision making, particularly when index neurological complaint was subjective or transient.

Conclusions

Physicians identified a number of diagnostic challenges unique to neurological disease, many of which must be accounted for when designing interventions to improve stroke diagnostic accuracy in the ED.

Background And Aims

Nighttime is associated with worse outcome and higher mortality in stroke care, especially in Primary Stroke Centers (PSC). However, studies treating this subject have been inconsistent. Our aim was to investigate whether this negative off-hour-effect also exists for patients being transferred from a PSC to a Comprehensive Stroke Center (CSC) for endovascular treatment (EVT).

Methods

From 01/02/2018 to 30/11/2019 consecutive patients who were transferred for EVT within the telestroke network TEMPiS were included and categorized by time of admission in the PSC. Nighttime-hours were defined as from 10pm to 8am. Primary outcome was distribution of modified Rankin Scale (mRS) after 90 days. Secondary outcomes were treatment delays and safety.

Results

Of 266 patients, 84 were admitted during nighttime. The baseline characteristics did not differ significantly between night- and daytime, except for onset-to-door (208 vs. 85min, p=0.0067) and treatment with systemic thrombolysis (37% vs. 52%, p=0.034). There was no difference between groups regarding clinical outcome after 90 days (adjusted common odds for higher mRS during nighttime 0.98, 95%CI 0.58–1.79). Time delays from first door to groin puncture were on average 18 minutes shorter during nighttime (205 vs. 223min, p=0.044). Neither any intracranial hemorrhage (35% vs. 23%, p=0.072) nor mortality after 90 days (31% vs. 31%, p=0.85) differed significantly between groups.

Conclusions

Nighttime admission was not associated with worse clinical outcome or reduced safety in patients being transferred for EVT from a PSC to a CSC. These results support the hypothesis, that quality managed telestroke networks with 24/7 service may prevent a negative off-hour-effect.

Trial Registration Number

not applicable

Background And Aims

Background: Ensuring oral care provision to patients admitted with a disabling stroke can have far-reaching implications, including reduced incidence of complications such as aspiration pneumonia.

Aims: To meet the standards of nursing care in the delivery of oral hygiene in stroke patients and to observe the impact of administering regular supervised oral care on the length of patient stay.

Methods

We included 100 patients admitted to the Acute Stroke Unit at our hospital with either Dysphagia on admission, kept Nil by mouth or on Nasogastric feed between April and August 2020. Patients received full oral care once and twice daily in the first and second PDSA cycles, respectively.

Results

The incidence of chest infection in stroke patients reduced from 30% to 18% with increased oral care frequency. The percentage of patients requiring antibiotic therapy was lower at 26% in those receiving twice-daily oral care compared to 38% in those receiving once-daily oral care. The total number of antibiotic courses was fewer in patients with twice-daily oral care (16 vs 23). Patients with increased oral care frequency stayed longer in hospital (8.35 vs 6.29 days), had lower inpatient mortality (12% vs 16%) and better outcome (discharge NIHSS 2.5 vs 2).

Conclusions

The incidence of chest infection and mortality in stroke patients can be reduced with enhanced oral care. Checking the patient's oral health should be done by all team members to enable early identification of care deficiencies. The education and training of all members of the team are essential to ensuring good oral hygiene.

Trial Registration Number

Not applicable

Background And Aims

Long-term support for stroke patients living at home is often delivered by family caregivers (FC). We assessed demographic and clinical characteristics of stroke patients cared by FC, positive and negative experiences of FC and determinants of caregiving experiences by FC at 3-months (3M) after stroke.

Methods

Data were collected within TRANSIT-Stroke, a regional telemedical stroke-network comprising 12 hospitals. Patients with stroke/TIA providing informed consent were followed up 3M after the index event. Patients receiving care were asked to pass on the Caregiver Reaction Assessment (CRA) and a self-rated burden-scale (SRB) in addition. Multivariable logistic and linear regression analyses were performed to identify determinants to receive FC and characteristics associated with CRA-subscales and SRB.

Results

Between 01/2016 and 06/2019, 3,654 patients provided baseline and 3M-follow-up-data and 1,044 FC completed the standardized CRA-questionnaire. Half of all FC were older than 55 years, 70% were women and 68% were spouses. Old age, lower Barthel Index at hospital discharge and diabetes were associated with a higher probability to receive care by a FC at 3M (p<.0001). Caring was important for most FC (81.4%) and 69.6% felt privileged to care for their relative. 18% of FC reported financial shortcomings associated with caregiving. Old age of stroke patients resulted in lower caregiver burden, whereas higher caregiver age led to less burden determined by SRB. FC-women had a poorer outcome regarding their health (CRA-health-subscale; p=0.0163).

Conclusions

Most caregivers want to care for their relative after stroke, but are at risk of burden and health disadvantages at the same time.

Trial Registration Number

DRKS No. 11696