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Background Major system reform is complex but can yield improved outcomes at multiple levels. We aimed to evaluate the impact of implementing a hub and spoke model of stroke care across metropolitan Adelaide (population 1.2 million), South Australia on mortality, morbidity, service and quality stroke indicators. Methods Analysis of 24 months of prospectively collected, patient-level data covering all metropolitan stroke admissions during the contiguous pre-, during- and post-implementation time periods, linked to mortality data from the National Death Index. The three metropolitan tertiary hospital-based stroke units undertook the implementation of a centralised ‘hub and spoke’ model: one central comprehensive stroke centre offering 24 h stroke reperfusion therapies, and two primary stroke centres providing 12 h thrombolysis. The main outcome measures were mortality (any cause) up to 180 days post-admission; reperfusion treatment proportions and timings; stroke care quality composite metric; length of stay. Results There were 3917 confirmed stroke admissions over the 24-month period (3325 (84.9%) ischaemic) and 650 deaths (19.6%) within 180 days. Compared to the baseline period, post-intervention mortality and discharge disability did not differ, although a possible temporary increase in ischaemic stroke mortality during implementation was seen. Rates of endovascular thrombectomy (EVT) (5.7% vs. 12.5%, adjusted Rate Ratio (aRR) = 1.94, 95%CI 1.21,3.10) and timeliness of EVT (median 126 min (IQR 83, 154) vs. 95 min (53, 132), p  < 0.001) improved as did the composite stroke quality metric indicator (0.60, 95% CI 0.50, 0.70 vs. 0.64, 95% CI 0.50, 0.75; adjusted difference 0.041, 95% CI 0.015, 0.066). Length of stay decreased for ischaemic stroke (8.2 (SD 12.4) vs. 7.9 (SD 8.9) days, adjusted geometric mean ratio = 0.83, 95% CI 0.73. 0.94) but not for intracerebral haemorrhage. Conclusion The major implementation of a metropolitan centralised ‘hub and spoke’ model of acute stroke care was associated with overall significant improvements in process indicators but a possible temporary increase in ischaemic stroke mortality during implementation.

BackgroundTo assess whether stroke patients admitted to stroke units (SU) have a better short-term outcome than those treated in conventional wards (CW).MethodsA total of 20 hospitals from 16 provinces in China were initially selected in this study. Finally, 24,090 consecutive admissions in 2013–2015 treated in CW and 21,332 consecutive entries in 2017–2019 treated in SU were included. The primary endpoint of this study was the all-cause death or dependency condition three months after admission.ResultsPatients in the SU group were more likely receiving thrombolytic therapy (3.9 vs 2.1%) and intravascular treatment (1.2 and 0.7%). In-hospital death were lower in the SU group than the CW group (SU vs CW: 2.93 vs 4.58% [absolute difference, − 2.28% {95% CI, − 3.32% to − 0.93%}, odd ratio {OR}, 0.72{95% CI, 0.61 to 0.82}]. Death after discharge was also lower in the SU group than the CW (SU vs CW: 5.07 vs 6.72% [absolute difference, − 2.33% {95% CI, − 3.39% to − 0.90%}, odd ratio {OR}, 0.75{95% CI, 0.68 to 0.84}]. In addition, patients who received SU care were less likely to be dead or disabled than those patients who received CW care after adjusting for other variability (SU vs CW: 36.20 vs 44.33% [absolute difference, − 11.33% {95% CI, − 15.32% to − 7.14%}, odd ratio {OR}, 0.78{95% CI, 0.80 to 0.85}].ConclusionsAmong patients with stroke, admission to a designated SU was associated with modestly lower mortality at discharge, reduced probability of death, or being disabled at the end of follow-up.

Stroke Unit Care (SUC), intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are evidence-based treatment options for acute ischemic stroke (AIS). Using nationwide comprehensive administrative data from Germany, we recently reported nationwide development of AIS admissions, SUC rates, IVT rates and MT rates in Germany between 2010 and 2016. In this update paper, we analyze data on the further development of these data to 2019 after publication of time window extensions for recanalization therapies. We considered all hospitalized cases with the main diagnosis of the ICD-10-GM code I63 (AIS) for the year 2019. We identified stroke therapies by using the corresponding Operating and Procedure Keys for IVT, MT and SUC out of the DRG statistics. Regional analyses are based on data from the 412 German administrative districts and cities. We compared the results with those from 2016. Number of hospitalized AIS patients showed a mild decrease in 2019 (n = 225,531) compared with 2016 (n = 227,687), with significant more AIS patients treated on a stroke unit in 2019 (n = 167,799; 74.4% vs. n = 164,270; 72.1%, p < 0.001). The rate of IVT further increased from 14.9% (n = 33,916) in 2016 to 16.3% (n = 36,745) in 2019 (p < 0.001). Similarly, the MT rate increased from 4.3% (n = 9795) in 2016 to 7.2% (n = 16,135) in 2019 (p < 0.001). There was still a high regional variability for MT (1.4 to 15.2%) according to the place of residence of the AIS patients. In Germany, the rates of recanalization therapies in patients with AIS continued to increase from 2016 to 2019. Compared to IVT-rates and numbers, the respective data for MT procedures showed an even more pronounced increase.

Background/objective Few reports have directly compared the outcomes of patients with acute ischemic stroke (AIS) who are managed in a stroke care unit (SCU) with those who are managed in an intensive care units (ICU). This large database study in Japan aimed to compare in-hospital mortality between patients with AIS admitted into SCU and those admitted into ICU. Methods Patients with AIS who were admitted between April 1, 2014, and March 31, 2019, were selected from the administrative database and divided into the SCU and ICU groups. We calculated the propensity score to match groups for which the admission unit assignment was independent of confounding factors, including the modified Rankin scale (mRS) score. The primary outcome was in-hospital mortality, and secondary outcomes were the mRS score at discharge, length of stay (LOS), and total hospitalization cost. Results Overall, 8,683 patients were included, and 960 pairs were matched. After matching, the in-hospital mortality rates of the SCU and ICU groups were not significantly different (5.9% vs. 7.9%, P  = 0.106). LOS was significantly shorter (SCU = 20.9 vs. ICU = 26.2 days, P  < 0.001) and expenses were significantly lower in the SCU group than in the ICU group (SCU = 1,686,588 vs. ICU = 1,998,260 yen, P  < 0.001). mRS scores (score of 1–3 or 4–6) at discharge were not significantly different after matching. Stratified analysis showed that the in-hospital mortality rate was lower in the ICU group than in the SCU group among patients who underwent thrombectomy. Conclusions In-hospital mortality was not significantly different between the ICU and SCU groups, with significantly lower costs and shorter LOS in the SCU group than in the ICU group.

IntroductionDoor-to-needle time (DNT) is a key factor in acute stroke treatment success. We retrospectively analysed the effects of a new protocol aimed at reducing treatment delays in our single-centre observational series over a 1-year period (from October 1st 2021 to September 30th 2022).MethodsThe time frame was divided into two semesters as a new protocol was started at the beginning of the second semester to ensure a rapid evaluation, imaging, and intravenous thrombolysis in all stroke patients attending our spoke-hospital serving 200,000 inhabitants. Logistics and outcome measures were obtained for each patient and compared before and after implementation of the new protocol.ResultsA total of 215 patients with ischemic stroke attended our hospital within a 1-year period (109 in the first semester, 96 in the second semester). Seventeen percent and 21% of all patients underwent acute stroke thrombolysis in the first and second semesters, respectively. DNTs were strongly reduced in the second semester (from 90 to 55 min), bringing this value below the Italian and European benchmarks. This resulted in better short-term outcomes (an average of 20%) as measured by both Δ NIHSS scores at 24 h and at discharge with respect to baseline.

Background Factors influencing access to stroke unit (SU) care and data on quality of SU care in Germany are scarce. We investigated characteristics of patients directly admitted to a SU as well as patient-related and structural factors influencing adherence to predefined indicators of quality of acute stroke care across hospitals providing SU care. Methods Data were derived from the German Stroke Registers Study Group (ADSR), a voluntary network of 9 regional registers for monitoring quality of acute stroke care in Germany. Multivariable logistic regression analyses were performed to investigate characteristics influencing direct admission to SU. Generalized Linear Mixed Models (GLMM) were used to estimate the influence of structural hospital characteristics (percentage of patients admitted to SU, year of SU-certification, and number of stroke and TIA patients treated per year) on adherence to predefined quality indicators. Results In 2012 180,887 patients were treated in 255 hospitals providing certified SU care participating within the ADSR were included in the analysis; of those 82.4% were directly admitted to a SU. Ischemic stroke patients without disturbances of consciousness ( p <  .0001), an interval onset to admission time ≤3 h ( p <  .0001), and weekend admission ( p <  .0001) were more likely to be directly admitted to a SU. A higher proportion of quality indicators within predefined target ranges were achieved in hospitals with a higher proportion of SU admission ( p =  0.0002). Quality of stroke care could be maintained even if certification was several years ago. Conclusions Differences in demographical and clinical characteristics regarding the probability of SU admission were observed. The influence of structural characteristics on adherence to evidence-based quality indicators was low.

Background: Pusher behavior after stroke is an important sequela that interferes with rehabilitation and independence in activities of daily living. As represented by visual or vestibular feedback, conventional methods require substantial assistance and time commitments, but have limited effectiveness. A recent case series suggests that prone posture may alleviate pusher behavior in patients with acute stroke. This study was conducted to retrospectively investigate the effects of prone posture maneuvers. Methods: This retrospective cross-sectional observational study was conducted in a stroke care unit at a university hospital. In total, 37 acute stroke cases presenting with pusher behavior were included from 787 eligible patients. Individuals with pusher behavior were conditioned with prone posturing for 10 min for 2 consecutive days, in addition to regular daily rehabilitation training. The Scale for Contraversive Pushing (SCP) values, Stroke Impairment Assessment Set (SIAS), and functional activities were assessed before, immediately after, and three days after the intervention. Results: The SCP value and the ability to roll over and sit balanced significantly improved compared with the baseline (p < 0.05) and persisted for 3 days after the intervention. Multiple regression analysis identified the SIAS motor score as a determinant of SCP changes. Conclusions: The prone posture maneuver promptly and consistently suppressed pusher behavior, particularly in patients with mild paresis, as indicated by SCP values in acute stroke cases. The uncontrolled, single-site, and retrospective features of the current study require further investigation.

We aimed to assess how evidence-based stroke care changed over the two waves of the COVID-19 pandemic. We analyzed acute stroke patients admitted to a tertiary care hospital in Germany during the first (2 March 2020–9 June 2020) and second (23 September 2020–31 December 2020, 100 days each) infection waves. Stroke care performance indicators were compared among waves. A 25.2% decline of acute stroke admissions was noted during the second (n = 249) compared with the first (n = 333) wave of the pandemic. Patients were more frequently tested SARS-CoV-2 positive during the second than the first wave (11 (4.4%) vs. 0; p < 0.001). There were no differences in rates of reperfusion therapies (37% vs. 36.5%; p = 1.0) or treatment process times (p > 0.05). However, stroke unit access was more frequently delayed (17 (6.8%) vs. 5 (1.5%); p = 0.001), and hospitalization until inpatient rehabilitation was longer (20 (1, 27) vs. 12 (8, 17) days; p < 0.0001) during the second compared with the first pandemic wave. Clinical severity, stroke etiology, appropriate secondary prevention medication, and discharge disposition were comparable among both waves. Infection control measures may adversely affect access to stroke unit care and extend hospitalization, while performance indicators of hyperacute stroke care seem to be untainted.

Cerebrovascular complications are being frequently recognized in the pediatric intensive care unit in the recent few years. The epidemiology and risk factors for pediatric stroke are different from that of the adults. The incidence of ischemic stroke is almost slightly more than that of hemorrhagic stroke. The list of diagnostic causes is increasing with the availability of newer imaging modalities and laboratory tests. The diagnostic work up depends on the age of the child and the rapidity of presentation. Magnetic resonance imaging, computerized tomography and arteriography and venography are the mainstay of diagnosis and to differentiate between ischemic and hemorrhagic events. Very sophisticated molecular diagnostic tests are required in a very few patients. There are very few pediatric studies on the management of stroke. General supportive management is as important as the specific treatment. Most of the treatment guidelines and suggestions are extrapolated from the adult studies. Few guidelines are available for the use of anticoagulants and thrombolytic agents in pediatric patients. So, our objective was to review the available literature on the childhood stroke and to provide an insight into the subject for the pediatricians and critical care providers.

Stroke patients with development of delirium have unfavorable outcomes, higher mortality, longer hospitalizations, and a greater degree of dependence after discharge. Studies suggest that delirium is associated with abnormal immunological responses and a resultant increase in inflammatory markers. Our aim was to determine whether there is an entity relationship between delirium, inflammation and acute ischemic stroke (AIS). Sixty AIS patients admitted to the hospital were consecutively recruited. Delirium was diagnosed with the clinical assessment according to the Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Enzyme-linked immunosorbent assay (ELISA) was used to measure serum levels of Interleukin-1 beta (IL-1 beta), Interleukin 18 (IL-18), Tumor Necrosis Factor-alpha (TNF-alpha), Brain-Derived Neurotrophic Factor (BDNF), and Neuron Specific Enolase (NSE) at admission. Eleven (18.3%) of 60 patients were diagnosed with delirium, and the majority (n=8, 72.7%) was the hypoactive type. Delirious and non-delirious patients had similar demographic and clinical features. Delirious patients had significantly higher lengths of hospital stay, National Institutes of Health Stroke Scale (NIHSS) at admission and discharge compared to non-delirious patients. In addition, there was no significant statistical difference between delirious and non-delirious patients with AIS in respect of levels of TNF-alpha, IL-1 beta, IL-18, BDNF and NSE. This study suggests that delirium is not scarce in patients with AIS admitted to the non-intensive stroke unit, and that delirium developing after AIS seems not to be associated with serum TNF-alpha, IL-1 beta, IL-18, BDNF and NSE but is associated with length of hospital stay and stroke severity.