Summary Thrombolysis with alteplase administered within a narrow therapeutic window provides an effective therapy for acute ischaemic stroke. However, mainly because of prehospital delay, patients often arrive too late for treatment, and no more than 1–8% of patients with stroke obtain this treatment. We recommend that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy. Measures for improvement include continuous public awareness campaigns, education of emergency medical service personnel, the use of standardised, validated scales for recognition of stroke symptoms and for triaging to the appropriate institution, and advance notification to the receiving hospital. In the future, use of telemedicine technologies for interaction between the emergency site and hospital, and the strategy of treatment directly at the emergency site (mobile stroke unit concept), could contribute to more efficient use of resources and reduce the time taken to instigate treatment to within 60 min—the golden hour—of the onset of the symptoms of stroke.

Streamlining of prehospital stroke management: the golden hour.

Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21-23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.

https://journals.sagepub.com/doi/pdf/10.1177/2396987318808719

Action Plan for Stroke in Europe 2018-2030.

In the United States and other parts of the world, various cities, states, and regions are developing multitiered systems for the care of patients with acute stroke. These systems often involve a range of healthcare components supported by various rules and regulations. The present policy statement will put forth concepts and elements for stroke systems of care that are intended to optimize patient care and management processes and improve patient outcomes, are practical to implement, and are supported by existing clinical data or expert consensus opinion. We will also make policy recommendations for the key elements of a stroke system of care.

The public health implications of stroke care in the United States and worldwide are profound. Stroke is currently the fourth-leading cause of death in the United States and a major cause of long-term disability. Advancing age is a major risk factor for stroke, and the demographics of the US population and elsewhere reflect a continued growth of the aging population, with a resulting increase in the absolute incidence and prevalence of stroke.1 Improved stroke systems of care can ensure proper treatment of these patients and a reduction in death and disability. This is consistent with current American Heart Association and Centers for Disease Control and Prevention Healthy People 2020 public health goals and initiatives.2

There are several new care paradigms and technologies that are emerging as important elements of a stroke system of care. These include the development and proliferation of various levels of stroke centers; the expanded use of telemedicine technologies; advanced medical, endovascular, and surgical interventions; and comprehensive rehabilitation strategies and programs. Prehospital care and triage and the efficient transfer of patients between hospitals are also key components of stroke systems.

The present …

Interactions Within Stroke Systems of Care A Policy Statement From the American Heart Association/American Stroke Association

Background and Purpose—Time from symptom onset to hospital arrival is the most important factor in determining eligibility for intravenous tissue-type plasminogen activator. We used data from a large contemporary nationwide study to determine temporal trends in the proportions of patients arriving within time windows for potential acute ischemic stroke therapies. Methods—Trends in symptom onset to hospital arrival time (“onset-to-door time”) for patients with acute ischemic stroke in the Get With The Guidelines–Stroke (GWTG-Stroke) program were analyzed between 2003 and 2009. Factors associated with early onset-to-door time (≤2 hours) were also examined. Results—Between April 2003 and March 2009, 1287 hospitals submitted data on 413 147 patients with acute ischemic stroke of whom 194 352 (47.0%) had a specific onset time documented. Among all 413 147 patients, onset-to-door time was documented as ≤2 hours in 20.6%, ≤3 hours in 25.1%, ≤3.5 hours in 26.8%, and ≤8 hours in 35.8%. Early arrival within 2 hours...

Times From Symptom Onset to Hospital Arrival in the Get With The Guidelines–Stroke Program 2002 to 2009 Temporal Trends and Implications

Background
Inter-hospital teleconsultation improves stroke care. To transfer this concept into the emergency medical service (EMS), the feasibility and effects of prehospital teleconsultation were investigated.

/pdf/feasibility-of-prehospital-teleconsultation-in-acute-stroke-grfnuyzyoq.pdf

Feasibility of Prehospital Teleconsultation in Acute Stroke – A Pilot Study in Clinical Routine

Background and Purpose—Acute stroke management requires minimization of prehospital time. This study addresses the value of helicopter transport compared with other means of transportation to a stroke unit and compares their rates of thrombolysis on a nationwide basis. Methods—Prospective data collection and prespecified evaluation of data from 32 stroke units between 2003 and 2009 were used. We distinguished between patients transported either directly to a stroke unit or transferred indirectly via a peripheral hospital. Thus, there were 6 transport groups: helicopter emergency service (HEMS) direct and indirect, ambulance accompanied by an emergency physician direct and indirect, and ambulance without physician direct and indirect. Demographic and clinical factors, time delays, and rates of thrombolysis of patients transported by helicopter were compared with factors of patients transported otherwise. Results—Of 21 712 ischemic stroke patients, 905 patients (4.1%) were transported by helicopter. Of thes...

Helicopter Transport of Stroke Patients and Its Influence on Thrombolysis Rates Data From the Austrian Stroke Unit Registry

Background and purpose

Diabetes is a predictor for poor outcome after thrombolysis in stroke patients, and early post-stroke glycaemia is associated with higher rates of post-thrombolytic symptomatic intracerebral haemorrhages (SICHs). Diabetic stroke patients may nevertheless profit from thrombolysis. Here, we compared outcome data of matched thrombolysed and non-thrombolysed diabetic and non-diabetic stroke patients from a national database.



Methods

The outcomes of 1079 matched quadruples, each consisting of a thrombolysed diabetic, a non-thrombolysed diabetic, a thrombolysed non-diabetic and a non-thrombolysed non-diabetic case (a total of 4316 cases), enrolled in the Austrian Stroke Unit Registry (2004–2013), were compared. Patients were matched according to sex, age, stroke severity, pre-stroke disability and prior stroke.



Results

A regression model with improvement as depending variable found no effect of diabetes (P = 0.158) or the interaction diabetes × thrombolysis (P = 0.507), whereas the effect of thrombolysis itself was highly significant (P < 0.001). Functional outcome (modified Rankin Scale) was significantly better in thrombolysed than in non-thrombolysed diabetic patients at discharge from the stroke-unit (P < 0.001) and 3 months later (P = 0.006). No significant differences were found in the number of SICHs after thrombolytic treatment between diabetic (4.9%) and non-diabetic strokes (3.5%). Both groups had a higher risk of SICH compared with the non-thrombolysed groups (diabetics 2.6%, non-diabetics 2.5%). Due to lack of documentation, the effect of admission blood glucose on SICH was not investigated.



Conclusions

Data from this nationwide survey show that diabetic stroke patients receive a substantial benefit from thrombolysis, and therefore diabetic strokes should not be excluded from thrombolytic treatment.

Martina Reiter

Papers

Helicopter Transport of Stroke Patients and Its Influence on Thrombolysis Rates Data From the Austrian Stroke Unit Registry

Diabetes and thrombolysis for acute stroke: a clear benefit for diabetics