Stroke thrombolysis in England, Wales and Northern Ireland: how much do we do and how much do we need?

Rudd, Anthony; Hoffman, Alex; Grant, Robert R.; Campbell, James T.; Lowe, Derek

doi:10.1136/jnnp.2009.203174

Cited by 55 publications

(57 citation statements)

References 24 publications

(16 reference statements)

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“…[5][6][7][8] We found that about one-quarter of the patients who did not receive thrombolysis were noted to have neurological deficits that were too mild for treatment, which is similar to data from a 2001 study by Barber and colleagues. 18 However, about one-third of these patients will have an outcome of death or disability, 18,19 which suggests that some of these patients could have undergone treatment.…”

Section: Cmaj Opensupporting

confidence: 77%

The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit

et al. 2014

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Section: Cmaj Opensupporting

confidence: 77%

The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit

et al. 2014

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“…5 Despite this, audits in many countries have shown that a minority of eligible patients receive tissue-type plasminogen activator 6,7 (eg, a National Audit in England showed low thrombolysis rates with only 1.4% of patients receiving alteplase in 2008). 8 Thrombolysis rates are increasing in some but not in all countries. 6,9 A major challenge is how to make 24-hour specialized stroke care available to the whole population.…”

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confidence: 99%

User Experience of a Centralized Hyperacute Stroke Service

Moynihan

Paul

Markus

2013

Stroke

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Background and Purpose-Centralizing hyperacute stroke unit (HASU) care services allows improved access to thrombolysis but could be associated with worse patient experience, particularly when early repatriation to a local stroke recovery unit occurs as this may result in discontinuity of care. A centralized model of care was introduced in London, United Kingdom, with 8 HASUs providing acute care for the whole 8.3 million population, with repatriation on day 3 to a local stroke recovery unit. The patient and carer experience of this model of care has not been previously reported. Methods-We undertook a prospective observational study of the new model of care in the South West London sector.Patient and carer experiences were evaluated using a modified Picker Questionnaire. Separate questionnaires were used for patients discharged directly home from the HASU, those repatriated to local stroke recovery units, and for carers of patients admitted to the HASU. Results-Despite moving from a selected to nonselected admission pattern, thrombolysis rates increased from 6% to 9%.High satisfaction rates were reported among both patients and carers. Patients discharged directly home had higher satisfaction levels than those requiring repatriation to their local stroke unit, who were older and had more severe stroke. A total of 47% of carers expressed anxiety over the repatriation from the HASU back to the local stroke recovery unit, but few patients and carers reported an impact of this move on patient recovery. Conclusion-Centralized HASU care is associated with good levels of patient and carer satisfaction.

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“…As a consequence, it is not surprising that, despite the commendable efforts of many stroke clinicians, the number of treated patients was very small, with figures around 2-3 % of all strokes [2].On 23 May 2012, during the European Stroke Conference in Lisbon, results of international stroke trial 3 (IST 3) were presented. The IST 3 is the largest randomised study on thrombolysis in acute ischaemic stroke ever done.…”

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confidence: 99%

mentioning

confidence: 99%

Ischaemic stroke and thrombolysis: ask the onset time, not the age!

2012

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As of May 2012, indications for thrombolysis in acute ischaemic stroke were particularly limited [1]: patients had to be treated within 4.5 h from the onset, should be younger than 80 years old, should present with a moderate neurological deficit, and should not present important early ischaemic changes on admission head CT scan, and should not have any of the traditional contraindications for rt-PA therapy. As a consequence, it is not surprising that, despite the commendable efforts of many stroke clinicians, the number of treated patients was very small, with figures around 2-3 % of all strokes [2].On 23 May 2012, during the European Stroke Conference in Lisbon, results of international stroke trial 3 (IST 3) were presented. The IST 3 is the largest randomised study on thrombolysis in acute ischaemic stroke ever done. The trial, whose complete results were subsequently published in Lancet on the 23 June 2012 [3], included 3,035 patients, without age or severity limits, randomised and treated within 6 h from symptoms onset. IST 3 is a non-profit trial, driven by researchers, with financial support from public agencies, randomized, with open treatment but blind assessment (PROBE design); it lasted 12 years (from 2000 to 2012). It is obvious that during this time many aspects changed in analysing and interpreting stroke trials results, and therefore some adjustments had been necessary during the trial conduct, to adequately study new information, particularly in the field of outcome evaluation. In fact, at the trial start a traditional cut off in Rankin scale (0-2 vs. 3-6) was chosen to evaluate the outcome, and from this cut off a sample size of 3,100 patients was calculated, to show an absolute benefit of 4 %. In the following years, however, two facts prompted the steering committee to add further prognostic evaluations: the first one was ECASS 3 results publication [4], which were not conventionally significant for 2/3 Rankin cut-off, but were statistically significant when using a different cut off (0-1 vs. 2-6); these results caused a wide variation in clinical practice, moving the time limit of treatment from 3 to 4.5 h. The second one was the re-evaluation of trials results by means of ordinal shift analysis [5], a statistical tool which uses all the information from the data, considering all the shifts from one to another grade in Rankin scale, and therefore is more powerful and sensitive for outcome evaluation in acute stroke. Therefore, the steering committee decided, much in advance of the database opening, to introduce these two new endpoints (Rankin cut-off 1/2 and OSA), and to publish the whole statistical analysis plan [6], a procedure not very frequent in stroke trials; in this way, anyone could know the plans for data analysis and interpretation, with the researchers still blind to the actual results.Further to the whole analysis of data, with the three aforementioned endpoints, a few hypotheses, based on clinical impressions and beliefs, had to be verified by IST 3 results: the earlier the trea...

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Stroke thrombolysis in England, Wales and Northern Ireland: how much do we do and how much do we need?

Cited by 55 publications

References 24 publications

The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit

The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit

User Experience of a Centralized Hyperacute Stroke Service

Ischaemic stroke and thrombolysis: ask the onset time, not the age!

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