Antje Sundseth

Outcome After Mobilization Within 24 Hours of Acute Stroke A Randomized Controlled Trial

Background and Purpose— Very early mobilization (VEM) is considered to contribute to the beneficial effects of stroke units, but there are uncertainties regarding the optimal time to start mobilization. We hypothesized that VEM within 24 hours after admittance to the hospital would reduce poor outcome 3 months poststroke compared with mobilization between 24 and 48 hours. Methods— We conducted a prospective, randomized, controlled trial with blinded assessment at follow-up. Patients admitted to the stroke unit within 24 hours after stroke were assigned to either VEM within 24 hours of admittance or mobilization between 24 and 48 hours (control group). Primary outcome was the proportion of poor outcome (modified Rankin scale score, 3–6), whereas secondary outcomes were death rate, change in neurological impairment (National Institutes of Health Stroke Scale score), and dependency (Barthel Index 0–17). Results— Fifty-six patients were included (mean age±SD, 76.9±9.4 years), 27 were in the VEM group and 29 were in the control group. VEM patients had nonsignificant higher odds (adjusted for age and National Institutes of Health Stroke Scale score on admission) of poor outcome (OR, 2.70; 95% CI, 0.78–9.34; P=0.12), death (OR, 5.26; 95% CI, 0.84–32.88; P=0.08), and dependency (OR, 1.25; 95% CI, 0.36–4.34; P=0.73). The control group, having milder strokes (National Institutes of Health Stroke Scale score±SD: control group, 7.5±4.2; VEM, 9.2±6.5; P=0.26), had better neurological improvement (P=0.02). Conclusions— We identified a trend toward increased poor outcome, death rate, and dependency among patients mobilized within 24 hours after hospitalization, and an improvement in neurological functioning in favor of patients mobilized between 24 and 48 hours. Very early or delayed mobilization after acute stroke is still undergoing debate, and results from ongoing larger trials are required.

Prehospital delay in acute stroke and TIA

Background Early management improves outcome in acute stroke. This study was designed to assess the prehospital path from symptom onset to arrival in hospital and to identify factors associated with prehospital delay. Methods A prospective study was conducted including patients with acute ischaemic stroke, intracerebral haemorrhage and transient ischaemic attack admitted to hospital. Time intervals for prehospital delay, background data, severity, type of first medical contact and mode of transport were recorded. Univariate and multivariate analyses were performed to identify factors influencing prehospital delay. Results A total of 440 patients were included, with a mean age of 71.4±13.0 years (44.3% female subjects), consisting of 65.9% patients with ischaemic stroke, 11.4% with intracerebral haemorrhage and 22.7% with transient ischaemic attack. The median time from symptom onset to admission was 3.0 h (179 min; IQR 77–542). The median decision delay was 1.5 h (92 min, IQR 25–405) and accounted for 55.1% (median value) of the prehospital delay. 310 (70.5%) patients arrived by ambulance. In the multivariate linear regression analysis, high National Institute of Health Stroke Scale score (p<0.001), transport by ambulance (p<0.001) and lower age (p=0.048) were significantly associated with early admission. Conclusions Severe strokes, use of ambulance and lower age are associated with reduced prehospital delay. The present study shows that more than half of the delay is caused by the hesitation to contact medical services. Public information campaigns should focus on fast symptom recognition and the importance of immediately contacting the Emergency Medical Services upon symptom onset.

Factors Related to Decision Delay in Acute Stroke

BACKGROUND The time from symptom onset to seeking medical assistance (decision delay) accounts for a proportion of prehospital delay in acute stroke. The aims of this study were to identify factors related to decision delay and calling the emergency medical services (EMS) as the first medical contact. METHODS Data were prospectively collected from 350 patients with acute stroke or transient ischemic attack. Data on decision delay, prehospital delay, types of first medical contact, and previous stroke knowledge were recorded. Multivariable logistic regression analyses were conducted to identify factors related to decision delay of 1 hour or less and calling the EMS as the first medical contact. RESULTS The median decision delay was 2.0 hours. Decision delay accounted for 62.3% of prehospital delay (median value). Moderate (National Institutes of Health Stroke Scale [NIHSS] score 8-16; odds ratio [OR] 4.16 [95% confidence interval 1.86-9.30]) or severe symptoms (NIHSS score ≥ 17; OR 10.38 [2.70-39.90]) and living together (OR 1.84 [1.02-3.43]) were associated with decision delay of 1 hour or less. Moderate (OR 6.31 [2.79-14.29]) or severe symptoms (OR 8.44 [2.64-26.98]) were associated with calling the EMS as the first medical contact. Previous stroke knowledge did not affect an early decision or EMS use. CONCLUSIONS The decision to seek medical assistance in acute stroke accounts for more than half of the prehospital delay. Severity of symptoms and living together are related to an early decision (≤1 hour). Previous stroke knowledge does not affect decision delay or EMS use.

Early Mobilization after Acute Stroke

BACKGROUND Treatment in stroke units reduces mortality and disability compared with treatment in general medical wards. Early mobilization is considered one element of stroke unit care contributing to this benefit. There are uncertainties regarding the effect of this approach on different groups of acute stroke patients. In this study, we compared the proportions of patients having a modified Rankin Scale score ≤2 assessed 3 months poststroke in patients mobilized within 24 hours versus between 24 to 48 hours of hospitalization, and explored whether other factors were associated with good outcome. METHODS Patients hospitalized within 24 hours of stroke onset were enrolled in this prospective, randomized, controlled trial with blinded outcome assessment. They were assigned to 2 groups; 1 that was mobilized within 24 hours of admittance and 1 that was mobilized 24 to 48 hours after admittance. Binary logistic regression was performed to analyze predictors of good outcome, with stepwise elimination of nonsignificant variables in the multivariate model. Candidate variables were mobilization within 24 hours of admittance, age, sex, stroke risk factors, and National Institutes of Health Stroke Scale score on admittance. RESULTS Twenty-seven patients were mobilized within 24 hours of hospitalization and 25 between 24 and 48 hours. The median times to first mobilization were 7.5 hours (interquartile range 2.5-16.3) and 30.0 hours (interquartile range 25.5-38.0), respectively. Fifty-five percent of patients had a good outcome. None of the candidate variables had a significant association with good outcome. CONCLUSIONS Neither time to mobilization nor any other candidate variable was associated with good outcome 3 months poststroke.

Hand hygiene among neurologists attending a congress

Hand hygiene is effective in preventing health care-associated infections, but hand hygiene compliance is low among health care workers in different hospital settings. Less is known about hand hygiene among physicians in a nonhospital setting. We evaluated handwashing behavior among 200 neurologists (100 males and 100 females) attending a world congress. Overall, 74.0% performed proper hand hygiene using soap and water, and there were significant differences between sex and handwashing behavior.

Prehospitalt forløp ved akutt hjerneslag

BACKGROUND Too few patients with acute stroke receive thrombolytic therapy owing to the limited time window for treatment and prehospital delay. The purpose of this study is to describe the prehospital path for patients with acute stroke and, in particular, what distinguishes patients who contact the Emergency Medical Communication Centre (EMCC) from those who contact their general practitioner (GP) or Out-of-hours (OOH) services. MATERIAL AND METHOD Patients with acute cerebral infarction and intracerebral haemorrhage admitted to the Stroke Unit, Department of Neurology, Akershus University Hospital, were included. Data on the prehospital path (prehospital delay, medical contacts) were collected over the period 15 April 2009 – 1 April 2010. RESULTS A total of 299 patients were included in the study. The median age was 75 years and 48.5 % were women. In all, 63.9 % of patients with acute stroke called the EMCC, and 93.7 % of these were taken directly to hospital by ambulance. Of those who called the GP’s office or OOH services, 60.7 % were asked to go to the GP’s office or OOH services in person. Patients who called and attended the GP’s office or OOH services had milder neurological deficits (p < 0.001) and longer patient delay (p = 0.018) than those who called the EMCC. INTERPRETATION Six out of ten patients who contacted the primary health care services were asked to go to the GP’s office/OOH services in person, which resulted in unnecessary delay. The findings from this study may indicate a need for specific training of this group of health care professionals in the prompt handling of patients with possible stroke.

Patient knowledge on stroke risk factors, symptoms and treatment options

Background Public campaigns focus primarily on stroke symptom and risk factor knowledge, but patients who correctly recognize stroke symptoms do not necessarily know the reason for urgent hospitalization. The aim of this study was to explore knowledge on stroke risk factors, symptoms and treatment options among acute stroke and transient ischemic attack patients. Methods This prospective study included patients admitted to the stroke unit at the Department of Neurology, Akershus University Hospital, Norway. Patients with previous cerebrovascular disease, patients receiving thrombolytic treatment and patients who were not able to answer the questions in the questionnaire were excluded. Patients were asked two closed-ended questions: “Do you believe that stroke is a serious disorder?” and “Do you believe that time is of importance for stroke treatment?”. In addition, patients were asked three open-ended questions where they were asked to list as many stroke risk factors, stroke symptoms and stroke treatment options as they could. Results A total of 173 patients were included, of whom 158 (91.3%) confirmed that they regarded stroke as a serious disorder and 148 patients (85.5%) considered time being of importance. In all, 102 patients (59.0%) could not name any treatment option. Forty-one patients (23.7%) named one or more adequate treatment options, and they were younger (p<0.001) and had higher educational level (p<0.001), but had a nonsignificant shorter prehospital delay time (p=0.292). Conclusion The level of stroke treatment knowledge in stroke patients seems to be poor. Public campaigns should probably also focus on information on treatment options, which may contribute to reduce prehospital delay and onset-to-treatment-time.

Predictors of early in-hospital death after decompressive craniectomy in swollen middle cerebral artery infarction

BackgroundSwollen middle cerebral artery infarction is a life-threatening disease and decompressive craniectomy is improving survival significantly. Despite decompressive surgery, however, many patients are not discharged from the hospital alive. We therefore wanted to search for predictors of early in-hospital death after craniectomy in swollen middle cerebral artery infarction.MethodsAll patients operated with decompressive craniectomy due to swollen middle cerebral artery infarction at the Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway, between May 1998 and October 2010, were included. Binary logistic regression analyses were performed and candidate variables were age, sex, time from stroke onset to decompressive craniectomy, NIHSS on admission, infarction territory, pineal gland displacement, reduction of pineal gland displacement after surgery, and craniectomy size.ResultsFourteen out of 45 patients (31%) died during the primary hospitalization (range, 3–44 days). In the multivariate logistic regression model, middle cerebral artery infarction with additional anterior and/or posterior cerebral artery territory involvement was found as the only significant predictor of early in-hospital death (OR, 12.7; 95% CI, 0.01–0.77; p = 0.029).ConclusionsThe present study identified additional territory infarction as a significant predictor of early in-hospital death. The relatively small sample size precludes firm conclusions.