Rohan Grimley

Better outcomes for hospitalized patients with TIA when in stroke units An observational study

Objectives: To investigate differences in management and outcomes for patients admitted to the hospital with TIA according to care on a stroke unit (SU) or alternate ward setting up to 180 days post event. Methods: TIA admissions from 40 hospitals participating in the Australian Stroke Clinical Registry during 2010–2013 were assessed. Propensity score matching was used to assess outcomes by treatment group including Cox proportional hazards regression to compare survival differences and other appropriate multivariable regression models for outcomes including health-related quality of life and readmissions. Results: Among 3,007 patients with TIA (mean age 73 years, 54% male), 1,110 pairs could be matched. Compared to management elsewhere in hospitals, management in an SU was associated with improved cumulative survival at 180 days post event (hazard ratio 0.57, 95% confidence interval 0.35–0.94; p = 0.029), despite not being statistically significant at 90 days (hazard ratio 0.66, 95% confidence interval 0.33–1.31; p = 0.237). Overall, there were no differences for being discharged on antihypertensive medication or with a care plan, and the 90- to 180-day self-reported outcomes between these groups were similar. In subgroup analyses of 461 matched pairs treated in hospitals in one Australian state (Queensland), patients treated in an SU were more often prescribed aspirin within 48 hours (73% vs 62%, p < 0.001) and discharged on antithrombotic medications (84% vs 71%, p < 0.001) than those not treated in an SU. Conclusions: Hospitalized patients with TIA managed in SUs had better survival at 180 days than those treated in alternate wards, potentially through better management, but further research is needed.

Triage, Treatment, and Transfer Evidence-Based Clinical Practice Recommendations and Models of Nursing Care for the First 72 Hours of Admission to Hospital for Acute Stroke

Stroke is a medical emergency and care provided in the first hours is critical in shaping patients’ long-term recovery and prognosis.1 There is robust evidence demonstrating significant reductions in death and disability with early interventions in acute stroke care, including antiplatelet therapy2 stroke unit (SU) care3 and thrombolysis.4 International clinical guidelines for stroke provide key recommendations to guide clinical practice5–8; however, uptake of evidence-based care is variable and often less than optimal.9–14 For example, among patients with ischemic stroke, rates for treatment with intravenous recombinant tissue-type plasminogen activator (r-tPA) are relatively low in the USA (5%)9 and Australia (7%),10 compared with Canada (12%)11 and some European centers (14%).15 Nurses play a pivotal role in rapid identification and triage of patients with acute stroke, initial assessment, and coordinating the timely flow of patients with acute stroke through the health system. Nurses enable delivery of relevant time critical treatments, and rapid transfer to acute SUs for ongoing assessment and provision of further treatment. The purpose of this article is to highlight nursing’s essential contribution to the expedient delivery of acute stroke care by providing evidence-based recommendations for clinical practice processes of care and models of care where nurses have a pivotal role during the first 72 hours from arrival at the emergency department through to SU care. A more detailed comprehensive overview of nursing and interdisciplinary care for patients with acute ischemic stroke extending beyond the first 72 hours has been published previously.16 Where available in existing guidelines, the class and level of evidence for recommendations shown in tables have been provided using the American Heart Association taxonomy.6 As there is a dearth of evidence from high-quality stroke nursing research, not all the recommendations described …

Testing a systematic approach to identify and prioritise barriers to successful implementation of a complex healthcare intervention

BackgroundMultiple barriers may inhibit the adoption of clinical interventions and impede successful implementation. Use of standardised methods to prioritise barriers to target when selecting implementation interventions is an understudied area of implementation research. The aim of this study was to describe a method to identify and prioritise barriers to the implementation of clinical practice elements which were used to inform the development of the T3 trial implementation intervention (Triage, Treatment [thrombolysis administration; monitoring and management of temperature, blood glucose levels, and swallowing difficulties] and Transfer of stroke patients from Emergency Departments [ED]).MethodsA survey was developed based on a literature review and data from a complementary trial to identify the commonly reported barriers for the nine T3 clinical care elements. This was administered via a web-based questionnaire to a purposive sample of Australian multidisciplinary clinicians and managers in acute stroke care. The questionnaire addressed barriers to each of the nine T3 trial clinical care elements. Participants produced two ranked lists: on their perception of: firstly, how influential each barrier was in preventing clinicians from performing the clinical care element (influence attribute); and secondly how difficult the barrier was to overcome (difficulty attribute). The rankings for both influence and difficulty were combined to classify the barriers according to three categories (‘least desirable’, desirable’ or ‘most desirable’ to target) to assist interpretation.ResultsAll invited participants completed the survey; (n = 17; 35% medical, 35% nursing, 18% speech pathology, 12% bed managers). The barriers classified as most desirable to target and overcome were a ‘lack of protocols for the management of fever’ and ‘not enough blood glucose monitoring machines’.ConclusionsA structured decision-support procedure has been illustrated and successfully applied to identify and prioritise barriers to target within an implementation intervention. This approach may prove to be a useful in other studies and as an adjunct to undertaking barrier assessments within individual sites when planning implementation interventions.

The implementation of intravenous tissue plasminogen activator in acute ischaemic stroke: a scientific position statement from the National Stroke Foundation and the Stroke Society of Australasia

Intravenous tissue plasminogen activator (tPA) has been licensed in Australia for thrombolysis in selected patients with acute ischaemic stroke since 2003. The use of tPA is low but is increasing across Australia and national audits indicate efficacy and safety outcomes equivalent to international benchmarks. Implementing tPA therapy in clinical practice is, however, challenging and requires a coordinated multidisciplinary approach to acute stroke care across prehospital, emergency department and inpatient care sectors. Stroke care units are an essential ingredient underpinning safe implementation of stroke thrombolysis. Support systems such as care pathways, therapy delivery protocols, and thrombolysis‐experienced multidisciplinary care teams are also important enablers. Where delivery of stroke thrombolysis is being planned, health systems need to be re‐configured to provide these important elements. This consensus statement provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to the Australian health‐care system.

Quality of Acute Care and Long-Term Quality of Life and Survival: The Australian Stroke Clinical Registry.

Background and Purpose— Uncertainty exists over whether quality improvement strategies translate into better health-related quality of life (HRQoL) and survival after acute stroke. We aimed to determine the association of best practice recommended interventions and outcomes after stroke. Methods— Data are from the Australian Stroke Clinical Registry during 2010 to 2014. Multivariable regression was used to determine associations between 3 interventions: received acute stroke unit (ASU) care and in various combinations with prescribed antihypertensive medication at discharge, provision of a discharge care plan, and outcomes of survival and HRQoL (EuroQoL 5-dimensional questionnaire visual analogue scale) at 180 days, by stroke type. An assessment was also made of outcomes related to the number of processes patients received. Results— There were 17 585 stroke admissions (median age 77 years, 47% female; 81% managed in ASUs; 80% ischemic stroke) from 42 hospitals (77% metropolitan) assessed. Cumulative benefits on outcomes related to the number of care processes received by patients. ASU care was associated with a reduced likelihood of death (hazard ratio, 0.49; 95% confidence interval, 0.43–0.56) and better HRQoL (coefficient, 21.34; 95% confidence interval, 15.50–27.18) within 180 days. For those discharged from hospital, receiving ASU+antihypertensive medication provided greater 180-day survival (hazard ratio, 0.45; 95% confidence interval, 0.38–0.52) compared with ASU care alone (hazard ratio, 0.64; 95% confidence interval, 0.54–0.76). HRQoL gains were greatest for patients with intracerebral hemorrhage who received care bundles involving discharge processes (range of increase, 11%–19%). Conclusions— Patients with stroke who receive best practice recommended hospital care have improved long-term survival and HRQoL.

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before–after pilot study:

Objectives: To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events. Design: Controlled before–after pilot study. Setting: An acute stroke unit in a regional Australian hospital. Participants: Acute stroke patients admitted during (a) initial usual care control period, (b) an enriched environment period and (c) a sustainability period. Intervention: Usual care participants received usual one-on-one allied health intervention and nursing care. The enriched environment participants were provided stimulating resources, communal areas for eating and socializing and daily group activities. Change management strategies were used to implement an enriched environment within existing staffing levels. Main Measures: Behavioural mapping was used to estimate patient activity levels across groups. Participants were observed every 10 minutes between 7.30 am and 7.30 pm within the first 10 days after stroke. Adverse and serious adverse events were recorded using a clinical registry. Results: The enriched environment group (n = 30, mean age 76.7 ± 12.1) spent a significantly higher proportion of their day engaged in ‘any’ activity (71% vs. 58%, P = 0.005) compared to the usual care group (n = 30, mean age 76.0 ± 12.8). They were more active in physical (33% vs. 22%, P < 0.001), social (40% vs. 29%, P = 0.007) and cognitive domains (59% vs. 45%, P = 0.002) and changes were sustained six months post implementation. The enriched group experienced significantly fewer adverse events (0.4 ± 0.7 vs.1.3 ± 1.6, P = 0.001), with no differences found in serious adverse events (0.5 ± 1.6 vs.1.0 ± 2.0, P = 0.309). Conclusions: Embedding an enriched environment in an acute stroke unit increased activity in stroke patients.

STroke imAging pRevention and treatment (START): A longitudinal stroke cohort study: Clinical trials protocol

Rationale Stroke and poststroke depression are common and have a profound and ongoing impact on an individuals quality of life. However, reliable biological correlates of poststroke depression and functional outcome have not been well established in humans. Aims Our aim is to identify biological factors, molecular and imaging, associated with poststroke depression and recovery that may be used to guide more targeted interventions. Design In a longitudinal cohort study of 200 stroke survivors, the START – STroke imAging pRevention and Treatment cohort, we will examine the relationship between gene expression, regulator proteins, depression, and functional outcome. Stroke survivors will be investigated at baseline, 24 h, three-days, three-months, and 12 months poststroke for blood-based biological associates and at days 3–7, three-months, and 12 months for depression and functional outcomes. A sub-group (n = 100), the PrePARE: Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke cohort, will also be investigated for functional and structural changes in putative depression-related brain networks and for additional cognition and activity participation outcomes. Stroke severity, diet, and lifestyle factors that may influence depression will be monitored. The impact of depression on stroke outcomes and participation in previous life activities will be quantified. Study Outcomes Clinical significance lies in the identification of biological factors associated with functional outcome to guide prevention and inform personalized and targeted treatments. Evidence of associations between depression, gene expression and regulator proteins, functional and structural brain changes, lifestyle and functional outcome will provide new insights for mechanism-based models of poststroke depression.

Improving discharge from hospital after stroke: A focus on prevention medication and discharge planning

Session 1: ICH/TIA 1100–1230 Management of unruptured intracranial arteriovenous malformations in pediatric patients with stereotactic radiosurgery D Ding, Z Xu, C-P Yen, R M Starke, J P Sheehan University of Virginia, Charlottesville, Virginia, USA Background: Unruptured intracranial arteriovenous malformations (AVM) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs. Therefore, the efficacy of stereotactic radiosurgery (SRS) for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following SRS for unruptured pediatric AVMs. Methods: We evaluated a prospective, institutional AVM SRS database, from 1989 to 2013. Patients with age <18 years at the time of SRS, unruptured nidi, and at least two years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. Results: In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure (53%). The median nidus volume, radiosurgical margin dose, and radiologic follow-up were 3.2 cm, 21.5 Gy, and 45 months, respectively. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29%, 54%, and 72%, respectively. In the multivariate Cox regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55%, 16%, and 2%, respectively. The annual post-radiosurgery hemorrhage rate was 1.3%. Conclusion: Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach. 1. Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 2014; 311:1661–1669. 2. Ding D, Xu Z, Yen CP, Starke RM, Sheehan JP. Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients. Acta Neurochir (Wien) 2014. DOI: 10.1007/s00701-0142305-4. 3. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 2014; 383:614–621. Subclinical ischemic lesions in patients with intracranial haemorrhage S Singhal, J V Ly, R V Chandra, J Zhou, C Soufan, H Ma, B Clissold, V Srikanth, T G Phan Monash Health, Clayton, VIC, Australia Background and Purpose: Subclinical ischemic lesions on diffusion weighted MR imaging (MRI-DWI) have been recently described in patients with spontaneous intracerebral hemorrhage (ICH) and convexity subarachnoid hemorrhage (cSAH). Such lesions are postulated to be part of the amyloid angiopathy spectrum. We hypothesized that the frequency of these MRI-DWI lesions may differ between patients presenting with cSAH, lobar ICH and basal ganglia ICH. Methods: Retrospective study of patients presenting between 2011–2014 with cSAH and/or ICH and subsequent MRI. Patients with an aneurysm, arteriovenous malformation, or hemorrhagic infarct were excluded. ICH topography was classified as lobar or basal ganglia; MRI-DWI lesions were classified as subclinical if there were no associated symptoms; contrast enhanced scans were assessed for leptomeningeal contrast enhancement. Results: Of 115 eligible patients, 56 patients had MRI within 14 days of hemorrhage (mean age 69.4 ± 11.5 years; 48% male). Overall, 21% (n = 12/56) patients with cSAH and/or ICH had subclinical MRI-DWI lesions. MRI-DWI lesions occurred more frequently in patients with cSAH than basal ganglia ICH (n = 5/12 vs 2/30; p = 0.006) and in patients with lobar ICH than basal ganglia ICH (n = 5/18 vs 2/30; p = 0.04). There was no significant difference in MRI-DWI lesions between cSAH and lobar ICH. Patients with MRI-DWI lesions had more frequent adjacent leptomeningeal contrast enhancement (p < 0.001). Conclusion: Subclinical ischemic lesions occur more frequently in patients with cSAH and lobar ICH than basal ganglia ICH. More frequent leptomeningeal contrast enhancement in these patients may point to a common underlying amyloid-related small vessel vasculopathy. Impact of haematoma shape and density on 90-day outcome after intracerebral haemorrhage: The INTERACT2 study C Delcourt, S Zhang, H Arima, S Sato, R A-S Salman, X Wang, C Stapf, T Robinson, P Lavados, J Chalmers, E Heeley, C Anderson Neurology and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia The University of Sydney, Sydney, NSW, Australia Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia University of Edinburgh, NHS Lothian, Edinburg, United Kingdom Université Paris Diderot – Sorbonne Paris, AP-HP Hôpital Lariboisière, Paris, France Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom Departamento de Medicina, Clínica Alemana, Universidad del Desarrollo (P.M.L.), Santiago, Chile The George Institute for Global Health, Sydney, NSW, Australia Background: Irregularity of shape and heterogeneous density suggest multiple bleeding foci and different periods of bleeding, respectively, in acute intracerebral hemorrhage (ICH). These features predict hematoma expansion but with uncertain significance on patient outcome. The aim of this study was to assess the association of shape and density on outcome among participants of INTERACT2, an open-label randomized controlled trial. Method: Shape and density were measured in 2066 patients with baseline CT. The Barras scale was used to categorize the appearance of the ICH, on the largest axial slice, into ‘regular’ (1 to 2) vs ‘irregular’ (3 to 5); density variation into ‘homogeneous’ (1 to 2) vs ‘heterogeneous’ (3 to 5). Logistic regression models were used to assess hematoma parameters on the primary outcome defined as death or major disability (mRS 3–6) at 90 days. Secondary outcomes were death and major disability, separately. Results: Shape irregularity was associated with poor outcome (OR 1.64, 95%CI 1.33–2.03), and separately only on major disability (OR 1.5, 95% CI 1.24–1.83). Density heterogeneity was not associated with poor outcome (OR 1.09, 95%CI 0.87–1.36), or the separate components of death or disability. Abstracts

Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department : a systematic review using the theoretical domains framework (TDF)

BackgroundClinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED.MethodsStudies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy.ResultsFive qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of “environmental, context and resources” (such as stressful working conditions or lack of resources) and “knowledge” (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of “knowledge” (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and “skills” (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were “focus on past success” and “information about health consequences.”ConclusionsBarriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.

A case of bilateral lower cranial nerve palsies after base of skull trauma With complex management issues case report and review of the literature

Introduction: Fractures of the skull base can cause lower cranial nerve palsies because of involvement of the nerves as they traverse the skull. A variety of syndromes have been described, often involving multiple nerves. These are most commonly unilateral, and only a handful of cases of bilateral cranial nerve involvement have been reported. Case Report: We describe a 64-year-old man with occipital condylar fracture complicated by bilateral palsies of IX and X nerves associated with dramatic physiological derangement causing severe management challenges. Apart from debilitating postural hypotension, he developed dysphagia, severe gastrointestinal dysmotility, issues with airway protection as well as airway obstruction, increased oropharyngeal secretions and variable respiratory control. Conclusions: This is the first report of a patient with traumatic bilateral cranial nerve IX and X nerve palsies. This detailed report and the summary of all 6 previous case reports of traumatic bilateral lower cranial nerve palsies illustrate clinical features, treatment strategies, and outcomes of these rare events.