الفهرس 
Epidemiology of cerebrovascular diseases:Only 14 pages are availabe for public view
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Abstract
Identifying causes of delayed presentation to ER for acute ischemic stroke patients and dealing with them through appropriate institutional and national programs might increase the percentage of patients who might benefit from stroke acute intervention.
Age, sex, marital status, address and educational level seem not to affect time to presentation to ER. However, monthly income (as a determinant of social class) did affect time of presentation, were a higher percentage of lower social class arrived to the hospital in window period. This though can be explained by the fact that our hospital is near areas with dominant low and middle social class residences rather than high social class. Also the fact that the total percentage of high social class admitted is low compared to others.
Education should have affected the time of presentation since a higher education level means better awareness, yet formal awareness about stroke in particular and acute intervention is not supplied to the general public.
Although how far away from the hospital should have been a determining factor for early arrival, yet it didn’t affect time to arrival except for places more than 2 hours of reach to the hospital.
These results do agree with most of the literature in this topic where sociodemographic variables had little effect on delayed presentation as Moser et al, 2006, Derex et al, 2002 and Lacy et al, 2001, with the exception of Derex et al finding that female sex is associated with early arrival.
Type of stroke whether ischemic, TIA or hemorrhagic didn’t have significance over time to presentation, though this disagree with some literature as Addo et al, 2005, Derex et al 2002 which found out that hemorrhagic stroke or intracerebral hemorrhage is associated with earlier presentation than ischemic stroke. This may be explained by the fact that symptoms of hemorrhagic stroke are usually very sudden, associated with significant headache and are usually worsening. The findings of this study may have shown non-significance because of the small number of hemorrhagic strokes included in the study.
Mode of onset, being sudden, course of symptoms being worsening and stroke site being in anterior circulation were favorable factors for early presentation. Posterior circulation strokes were associated with a greater percentage of delayed presentation, especially if the predominant deficit was ataxia. This may be associated with the fact that those posterior circulation stroke symptoms are less commonly regarded as those of stroke and often prescribed nonspecific treatment.
In many cases interviewed, presenting with ataxia and vertigo, they were usually prescribed anti0emetics, analgesics or anti-vertigo measures and were mostly discharged home by their first physician or referred to other specialties as ENT. Another explanation for these results may be that posterior circulation strokes are less severe and of more step-wise course than anterior circulation strokes.
These results mean that one of the awareness messages that should be given to doctors are those of identifying the “Unusual” stroke signs since many non-neurologists fails to identify them.
Increasing severity of stroke as judged by NIH score is associated with earlier presentation than patients with NIH score below 7. Also weakness and dysphasia as the predominant deficit were associated with earlier presentation than ataxia, dysarthria and sensory deficit.
This may be explained by that most strokes with mild severity are regarded by patients as non-important and they usually tend to wait for the symptoms to go away rather than contact physicians. This was observed particularly with patients interviewed whom strokes occurred during fasting, they usually wait to end their fasting thinking that it may be the cause and only seeks advice when the symptoms do not resolve.
This agree with Derex et al, 2002 , Lacy et al, 2001 and Moser et al, 2006 that mode of stroke onset being sudden and stroke severity being more severe are associated with earlier ER presentation
Although increased awareness might have been thought to influence earlier presentation yet results show that knowledge of stroke symptoms and even identifying patient symptoms as that of stroke had no effect on time of presentation. The only factor affecting time to presentation was knowledge of acute intervention that favored earlier presentation.
These findings agree with Moser et al, 2006 and Addo et al, 2012. This may be related to the public perception of stroke as untreatable. This is supported by the fact that knowledge of acute intervention did favor early presentation rather than the actual identification of stroke.
This was also observed during the interviews held to many internists who were the first doctors to examine the patients arriving at the ER. Some of them thought that all that is to be given to a stroke patient-after excluding hemorrhage- would be statins and antiplatelet regardless of the time of presentation, severity of symptoms or course of the deficit. Also they tend to discharge patients with mild symptoms or strokes more than 48 hours of onset.
These findings though were not the target of the study and, therefore, were not pursued. Further research regarding the quality of information available to non-neurologists should be further investigated.
Most of the patients used private cars or public transportation rather than an ambulance for transportation to the hospital. Although using these means sometimes may reduce time of arrival yet it affects the pre-hospital management that may be required to the patient and could help to fasten the logistics when reaching the hospital. Supposed pre-hospital management should include taking history to determine exact time of occurrence of symptoms, establish an IV access and even take necessary vital data and blood samples to be ready upon hospital arrival.
Percentage of insured patients who will be capable of “affording” such a treatment is very low. So either number of insured population should be increased or rTPA should be available, free of charge, in university hospitals at least.
Previous stroke and previous ISHD and family history of either had no significance regarding time of presentation to ER, yet routine medical care seems to favor early presentation. This means that no medical education or awareness programs are offered to patients with ischemic events regarding the fact of the presence of acute intervention. It also means that patients unless educated will fail to identify symptoms of stroke if it recurred in other forms or later in their lives or to a relative..
These agree with Derex et al, 2002 and Moser et al 2006
These results signify the lack of comprehensive programs administered to the patients during their stay in the hospital. As history of previous stroke specifically had no influence on time to arrival, which means that proper information was not given to the patient during his first admission.
Though routine medical care favored earlier presentation, yet without substantial increase compared to other factors which means that even this needs improvement. Routine medical care given to some of the subjects of the study was directed towards the improvement of their symptoms and control of vital data as blood pressure and random blood sugar without any concern towards medical awareness.
Other risk factors as smoking, hypertension, DM and dyslipidemia had no effect on time of presentation.
Routine Laboratory results seem to be faster in the university hospital (el Demerdash) in comparison for the same results in ASUSH were specific measure should be undertaken to ensure fast result. In ASUSH, though, time for imaging is significantly shorter.
The lack for the need of insurance approval in the university hospital may help in shortening the time window for rTPA. One of the cases who received rTPA in the study was in ASUSH. Patient arrived after 1 hour of symptoms, yet received rTPA at 5.5 hours due to waiting of insurance approval and other beurocratic details. These are absent in El-Demerdash making the door to needle time about 3 hours.
71 patients (26.4%) of the study subjects did arrive in the window period to a hospital, whether ours or another hospital. Only 7 of them received acute intervention (6 received thrombolysis and 1 underwent thrombectomy). The lack of administration of acute intervention to the remaining group was either due to the presence of a contraindication to rTPA, absence of the acute intervention in the hospital at time of presentation, faulty diagnosis and management or delay of in-hospital logistics.
Main cause for in-hospital delay in ElDemerdash is imaging time which is about 2 hours. where the main cause in ASUSH is paper work, insurance approval and laboratory results are the cause of delay in some cases.
The 2 main causes of delay were lack of physician awareness and patient’s awareness. Many first contacted physicians didn’t advice referral to hospital, some prescribed nonspecific treatments while others failed to diagnose stroke and others discharged the patient home.
This may be related to what is mentioned earlier that for non-neurology specialties, only 6 hours of formal education about stroke is given during the whole study years. So not only physicians fail to diagnose stroke, but also they tend not to refer to a hospital and does not regard it as potentially treatable.
Formal views and knowledge of physicians were not the scope of this study and so this needs to be investigated in coming studies.
The fact that awareness of patients with stroke itself didn’t affect the time to arrival but rather the presence of acute intervention point out that awareness campaigns should focus on acute intervention more as it seems to be an earlier and stronger motivator for early presentation. This agrees with Moser et al, 2006 that reached the same results from pooled analysis of similar studies.
Time from arrival to CT scan interpretation should be about 45 minutes in AHA recommendations. Yet mean time to a CT scan in the university hospital is about 2 hours causing significant delay for patients.
Also absence of rTPA and governmental coverage of such treatment hinders its use. This also applies for endovascular treatment which is available only in private hospitals.
It was found out that 63 patients (23.4%) were eligible for rTPA, which means that 63 patient might have benefited from acute intervention using rTPA if they have arrived earlier or if facilities were available. In comparison to only 6 patients who received rTPA and one patient who received endovascular treatment. This means that arriving early will increase rates of acute intervention (thrombolysis or thrombectomy) from 2.06% to 23.4%. this number may even increase if some of the Exclusion criteria stated in the guide lines are neglected. Some exclusion criteria as seizures at onset, decreased severity of symptoms, improving symptoms or the time window itself are being reviewed with some studies showing that some of these criteria could be changed or neglected with no effect on side effects and can improve outcome. This is particularly true for strokes with NIH < 7 and improving symptoms.
One other factor which may improve rates is the perfusion imaging. Some stroke could be treated with thrombolysis out of the window if perfusion studies provided clues that patient may benefit from such an approach. Yet till now availability of such modalities is limited and not currently available in both of the university hospitals.
This agrees with the CASPER study which predicted an increase from 4.3% to 28.6% if the patient arrived earlier to the hospital, if they were educated to do so.
The aim of the study was to identify main causes of delayed presentation of stroke patients. This was identified and demonstrated in the results section. The following are some recommendations suggested by the author to improve the medical service given to stroke patients. These recommendations are influenced by the current practice and logistics in Ain Shams University hospitals and should only act as a modifiable guide to other centers where circumstances might differ.
Formal teaching course to physicians of stroke should be conducted especially to emergency department physicians. This should focus on identification of stroke, best practice when presented and presence of acute intervention.
Although public awareness campaigns are needed, yet if not feasible at the time being, at least in-hospital awareness programs should be implemented and can be used as Herd awareness. Recommendations for a public awareness campaign are provided in appendix 3.
Setting an ER code for stroke in window, e.g. “Code Blue”, where laboratory technician, radiologists and nurses are instructed to prioritize these patients to lessen the time for in-hospital logistics. Recommendations for a suggested management of acute stroke patient in Ain Shams university hospitals are provided later in this chapter.
Role play training of junior neurologists and ER staff on “Code Blue” of stroke should be done regularly, each for his designated task. This should include training on both NIHSS and ASPECTS score, training for rapid history and examination and patient preparation to receive rTPA.
rTPA should be available in 24 hours basis with no delay for beurocratic logistics or waiting insurance approval as the cost of a disabling stroke is higher ,as demonstrated in earlier chapters.
Conclusion:
198 (73.6%) patients arrived beyond the window period for acute intervention. Main causes of delay were lack of awareness among patients and physicians. Improvement of awareness should raise the rTPA rates of administration from 2.06% to 23.4% solely by improving the awareness of both patients and physicians.
Further research required:
After the implementation of an awareness program, the study should be repeated to test its effectiveness and change in trends of presentation.
Studying exact times of in-hospital logistics in a more precise manner can improve the quality of programs aiming at improving speed of service required to complete emergency labs and imaging and providing treatment. This should include every single point the patient passes through, including registration, payment, lab results, imaging, delivery to intermediate care…etc.
As the study is limited to Ain Shams University, a wider, multi-center study should be done to produce nationally valid results.
Studying the physician’s knowledge of stroke symptoms, diagnosis and recent treatments might help improve teaching syllabus to improve their awareness and overall service regarding stroke patients.
Study limitations and criticism:
Since the study was carried in Ain shams university hospitals only, which is considered a tertiary care center, not all primary care centers have been covered and most data about them came retrograde from patients themselves
Ain Shams University is considered as a tertiary referral center so the demographic distribution and severity of symptoms might be affected by this fact.
Number of the patients was limited due to the number of investigators and time period of the study.
Also some part of the study time was carried when one of the stroke units was under maintenance which might also affects some of the results. The university hospital stroke unit was under maintenance during 3 months of the study period which has affected rates of presence of intermediate care bed and rates of rTPA administration.
Patient selection was done from in patients, who are readily admitted, yet doing the same study for ER patients might provide additional insights.
Suggested protocol for management of stroke patient presenting in Emergency department:
Flow chart for the approach of a patient presenting with acute focal neurological deficit is shown in figure 23 A and B.
Figure 22 A: flow chart of approach to patient with focal neurological deficit.
Indications and exclusion criteria for rTPA and Endovascular treatments are mentioned in chapters 3 and 4.
Emergency labs required are: CBC with platelet count, RBS, PT, PTT, and INR, Full chemistry including electrolytes and BUN and creatinine and pregnancy test for selected patients.
Imaging required is non-contrast enhanced CT brain for patients being considered for rTPA. CT angiography or MRA –whichever feasible- should be done for patients being considered for thrombectomy.
Time to needle time is about 2 hours currently, but measures should be undertaken to lessen this time to 60 minutes as recommended, mainly by decreasing time necessary for imaging.
Time to groin puncture was 7 hours in the only case done in the study but should be decreased to 5-6 hours that are implemented in other international centers. Doing so mainly requires organization of thrombectomy team availability and decreasing imaging times. Also emergency CT angiography should be available with experienced technician.
Figure 22 B: flow chart of approach to patient with focal neurological deficit.
English summary
Cerebro vascular stroke is a leading cause of death and disability worldwide. It is the third cause of death after cancer and heart disease. It causes significant disability with high DALYs.
There are number of acute interventions available to the management of stroke patients. To date, these include thrombolysis and endovascular thrombectomy with a stent retriever. Yet the use of such interventions is done in very low rates due to many reasons. One of these reasons is delayed presentation of patients to the hospital at a proper time.
For a stroke patient to receive acute intervention, it results in significant improvements regarding remaining disability and mortality rates. So every effort is to be done to increase rates of administration of such interventions.
This study was conducted to investigate the causes of delayed presentation of stroke patients to our university and asses the current status of acute intervention in our university hospitals. This was done by a structured interview and questionnaire (supplied in appendix 4) to cover various areas regarding patients’ socioeconomic and demographic characteristics, stroke factors and risk factors. It also covered areas as pre-hospital and in-hospital logistics and lastly awareness of both patients and physicians of different approaches to the right conduct during stroke.
It was found that main causes of delay are lack of awareness of patients and doctors alike of the presence of acute intervention. Other causes of delay were attributed to both pre and in-hospital logistics.
Of all study subjects only 7 received acute intervention. They signify less than 3% of the study population. Increasing this number can be done via properly equipping our hospitals and do some system amendments to hasten the process of acute intervention, the second thing is by raising the patients’ awareness by proper awareness programs. This alone can raise the rates of administration of acute intervention to about 25%.