National Institutes of Health Stroke Scale: comparison of original and modified versions for Singapore culture

INTRODUCTION@#The National Institutes of Health Stroke Scale (NIHSS), originally designed in the United States of America, contains items on dysphasia and dysarthria that are deemed culturally unsuitable for the Singapore context. We compared the error rates of dysphasia objects, dysphasia phrases and dysarthria words between the original and alternative items in a cohort of Singaporean subjects without dysphasia or dysarthria.@*METHODS@#In this prospective study, 140 English-speaking Singaporean subjects without impairments of dysphasia or dysarthria had an assessment of NIHSS items 9 and 10 using the original and alternative items. Paired analyses were conducted for comparison of error rates.@*RESULTS@#The error rates were high for four original dysphasia objects (Hammock: 62.9%, Cactus: 38.6%, Feather: 23.6%, Glove: 20.7%) and significantly lower for alternative items (Snail: 5%, Horse: 1.4%, Hanger: 1.4%, Car: 0%) (P < 0.001). For dysphasia phrases and dysarthria words, the error rates were low and there were no differences in error rates between the original and alternative items.@*CONCLUSION@#There are cultural issues with several dysphasia objects in the original NIHSS as evidenced by the high error rates, which were lowered with more culturally suitable alternatives. This study formed a basis to derive a more suitable version of the NIHSS for English-speaking subjects in Singapore.

Intracranial dural arteriovenous fistula mimicking ischemic stroke and treated with intravenous thrombolysis

@#Stroke patients are evaluated with a non-contrasted brain computed tomography (CT) scan for decision-making for intravenous thrombolysis. We report a case of a patient who presented with receptive aphasia, and was administered IV alteplase after the non-contrasted brain CT showed no contraindication. However, a dural arteriovenous fistula (dAVF) was detected on the subsequent CT angiography performed in the consideration for endovascular therapy. The patient developed fatal symptomatic intra-cerebral hemorrhage, despite subsequent cessation and reversal of thrombolysis. This case highlights how early CT angiography can be useful in hyper-acute stroke patients beyond the detection of large vessel occlusions, with its ability in revealing stroke mimics such as dural arteriovenous fistula and other contraindications to thrombolysis, which may be missed on the noncontrasted brain CT.

Surveys of Stroke Patients and Their Next of Kin on Their Opinions towards Decision-Making and Consent for Stroke Thrombolysis

<p><b>INTRODUCTION</b>Early initiation of stroke thrombolysis is associated with improved outcomes. Procurement of consent is a key factor in prolonging the door-to-needle duration. This study aimed to determine the attitudes and preferences of stroke patients and their next of kin (NOK) towards decision-making for stroke thrombolysis in Singapore.</p><p><b>MATERIALS AND METHODS</b>We surveyed acute ischaemic stroke patients (n = 171) who presented beyond the 4.5-hour therapeutic window and their NOK (n = 140) using a questionnaire with scenarios on obtaining consent for intravenous thrombolysis.</p><p><b>RESULTS</b>In the patient survey, 83% were agreeable for their NOK to decide on their behalf if mentally incapacitated and 74% were agreeable for the doctor to decide if the NOK was absent. In the NOK survey, the majority (81%) wanted to be consulted before mentally capacitated patients made their decision; 72% and 74%, meanwhile, were willing to decide on behalf of a mentally capacitated and mentally incapacitated patient, respectively. In the scenario where a doctor recommended a mentally incapacitated stroke patient to undergo thrombolysis but the family declined, there was a near equal split in preference to follow the family's or doctor's decision in both the patient and NOK surveys.</p><p><b>CONCLUSION</b>The survey found that in the decision-making process for stroke thrombolysis, there was no clear consensus on the preference for the decision maker of the mentally incapacitated patient. In Singapore, there is a strong influence of the NOK in decision-making for thrombolysis.</p>

Wake-up Stroke and Onset-to-door Duration Delays: Potential Future Indications for Reperfusion Therapy

<p><b>INTRODUCTION</b>There is limited utilisation of acute stroke reperfusion treatments which have narrow therapeutic windows, with delayed hospital presentation being a major limiting factor in Singapore. Most patients who wake up with symptoms are ineligible for reperfusion treatments as duration from onset time is not known. We studied the profile of wake-up strokes, onset-to-door duration and their associated factors among ischaemic stroke patients in the context of potential new treatments.</p><p><b>MATERIALS AND METHODS</b>This is an observational study of consecutive ischaemic stroke patients presenting within 2 weeks of symptom onset to the Singapore General Hospital in 2012.</p><p><b>RESULTS</b>Of the 642 ischaemic stroke patients studied, 33% of the cases were wake-up strokes [median age 64 years, 88%<80 years; median NIHSS score 4, 98%<20]. The median onset-to-door duration was 14.3 hours (Interquartile range, 4.8 to 38.2 hours), 20% of them arrived <3.5 hours (considering eligibility for intravenous alteplase in the proven 4.5 hours window accounting for a one hour door-to-needle duration), 14%: ≥3.5 to <8 hours, 11%: ≥8 to <12 hours, and 56%: ≥12 hours. Most patients with known stroke risk factors including atrial fibrillation (66%), hypertension (78%) and prior stroke (81%) presented beyond 3.5 hours.</p><p><b>CONCLUSION</b>The one- third proportion of wake-up stroke in this cohort and low prevalence of relative contraindications suggest this is a promising group for emerging thrombolysis indications. With the majority of patients presenting after 8 hours, widening of the therapeutic window with new potential reperfusion treatments would not appreciably increase treatment utilisation. This study reaffirms the urgent need for public education to improve stroke awareness in Singapore.</p>

Stroke literacy in Singapore: data from a survey of public housing estate residents

<p><b>INTRODUCTION</b>Knowledge of stroke symptoms is associated with seeking medical attention early, and knowledge of risk factors is an essential factor in stroke prevention. In this study, we evaluated the level of stroke literacy in Singapore.</p><p><b>MATERIALS AND METHODS</b>A cross-sectional study of Singapore citizens and permanent residents aged 21 years and above was conducted in a public housing estate. Participants were randomly sampled using multi-stage stratified sampling. Assessment of awareness of stroke symptoms and risk factors was performed using open-ended questions. In total, 687 respondents were recruited, with a response rate of 69.7%.</p><p><b>RESULTS</b>Overall, 52.4% of respondents identified the brain as the source of pathology, and 47.6% could cite at least 1 of the 3 FAST symptoms (facial droop, arm weakness and speech difficulty), while 40% could name 2 or more of 7 established risk factors for stroke (high blood pressure, high cholesterol, cigarette smoking, diabetes mellitus, older age, previous heart attacks and stroke). Respondents at higher risk of stroke (older individuals and those with stroke risk factors) did not have greater awareness of stroke symptoms and risk factors. The majority of respondents reported they would seek immediate medical care if they experienced stroke symptoms. Only 59.4% knew the emergency ambulance service telephone number.</p><p><b>CONCLUSION</b>In a sample of Singaporean adults residing in a public housing estate, we found evidence of poor stroke literacy, highlighting the need for comprehensive population-based education efforts. There is a role for opportunistic education among those at higher risk of stroke.</p>

Attitudes and Practices on the Consent Process and Decision-making for Intravenous Stroke Thrombolysis: Physicians' Perspective

<p><b>INTRODUCTION</b>Earlier treatment with intravenous stroke thrombolysis improves outcomes and lowers risk of bleeding complications. The decision-making and consent process is one of the rate-limiting steps in the duration between hospital arrival and treatment initiation. We aim to describe the attitudes and practices of neurologists in Singapore on the consent and decision-making processes for stroke thrombolysis.</p><p><b>MATERIALS AND METHODS</b>A survey of neurologists and neurologists-in-training in 2 large tertiary public hospitals in Singapore was conducted.</p><p><b>RESULTS</b>Among 46 respondents, 94% of them considered stroke thrombolysis an emergency treatment and 67% of them indicated there is a need for written informed consent. The majority (87%) knew that from a legal perspective, the doctor should be the decision-maker in an emergency treatment for a mentally incapacitated patient. However, 63% of respondents reported that it is the next-of-kin who usually makes the decision in actual practice. If confronted with a mentally incapacitated stroke patient, 57% of them were willing to be the proxy decision-maker and 13% of them were not. In 3 commonly encountered vignettes when a mentally incapacitated patient was being considered for stroke thrombolysis, there was no clear consensus on the respondents' practices.</p><p><b>CONCLUSION</b>The next-of-kin is usually the decision-maker for stroke thrombolysis in practice for a mentally incapacitated patient despite most doctors considering thrombolysis an emergency treatment. This, together with the lack of consensus and variance in decision-making and consent practice amongst neurologists for stroke thrombolysis, demonstrates the need to develop best practice guidelines to standardise healthcare practices for greater consistency in health service delivery.</p>

Timing of arrival to a tertiary hospital after acute ischaemic stroke - A follow-up survey 5 years later

<p><b>INTRODUCTION</b>Intravenous tissue plasminogen activator (tPA) within 3 hours of stroke onset is a licensed proven therapy for ischaemic stroke, with recent trial data showing benefit up to 4.5 hours. We previously published in this journal data of a survey conducted in 2004 showing only 9% of ischaemic stroke patients presenting to the Singapore General Hospital (SGH) arrived within 2 hours of onset. We aimed to determine whether the problem of delayed hospital arrival persists in 2009 and to establish the impact of widening the time window for intravenous tPA to 4.5 hours.</p><p><b>MATERIALS AND METHODS</b>We prospectively surveyed consecutive ischaemic stroke patients admitted to the SGH from 9th March to 30th April 2009. Patients and/or relatives were interviewed with a standardised form similar to the 2004 survey.</p><p><b>RESULTS</b>Among the 146 ischaemic stroke patients surveyed (median age 67 years, 59% male, median NIHSS score 2), 6% presented to SGH within 2 hours and 15% within 3.5 hours of onset. Median time from stroke onset to hospital arrival was 1245 minutes (20.75 hours). Pre-hospital consultation was significantly associated with hospital arrival after 2 hours from onset. Main reasons cited for delay were not realising the gravity of symptoms (31%) and not recognising them as stroke (27%).</p><p><b>CONCLUSION</b>Delayed arrival to SGH following acute ischaemic stroke remains a problem in 2009. This confirms the lack of stroke awareness in Singapore and highlights the need for public stroke education. Furthermore, these data confirm that widening the time window for intravenous tPA treatment to 4.5 hours at SGH will increase its utilisation.</p>

Concomitant coronary artery disease among Asian ischaemic stroke patients

<p><b>INTRODUCTION</b>Coronary artery disease (CAD) is the leading cause of death following ischaemic stroke. We aimed to study the prevalence and associations of concomitant CAD among ischaemic stroke patients in Singapore.</p><p><b>MATERIALS AND METHODS</b>We prospectively studied 2686 consecutive Asian ischaemic stroke patients.</p><p><b>RESULTS</b>CAD was prevalent among 24% of the study patients. Older age, hypertension, diabetes, hyperlipidaemia, atrial fibrillation, large stroke and South Asian ethnicity were independently associated with CAD.</p><p><b>CONCLUSIONS</b>The variables found to be associated with CAD are known atherosclerotic risk factors (older age, hypertension, diabetes, hyperlipidaemia) or associations of cardioembolic stroke (atrial fibrillation, large stroke). The over-representation of South Asians with concomitant CAD is consistent with the high burden of CAD in this ethnic group.</p>

Timing of hospital presentation after acute cerebral infarction and patients' acceptance of intravenous thrombolysis

<p><b>INTRODUCTION</b>Intravenous thrombolysis has been shown to improve outcome after acute cerebral infarction if given within 3 hours of symptom onset. There are no data in Singapore on the timing of hospital presentation after acute cerebral infarction as well as factors and reasons for delayed presentation.</p><p><b>MATERIALS AND METHODS</b>As intravenous thrombolysis has recently been licensed for use in acute cerebral infarction in Singapore, we studied 100 consecutive acute cerebral infarction admitted to the Singapore General Hospital for timing of hospital presentation, reasons associated with delay in presentation and hypothetical acceptance of intravenous thrombolysis.</p><p><b>RESULTS</b>Only 9% of patients presented to hospital within 2 hours of symptom onset. Factors associated with hospital presentation within 2 hours were a large stroke and lack of pre-hospital consultation. Failure to recognise the severity of symptoms and inability to seek medical attention unaided were the 2 most common reasons for delayed presentation. One-third of patients or their relatives hypothetically would accept intravenous thrombolysis, suggesting that a thrombolysis service is feasible at the Singapore General Hospital. However, it would be hindered by the low proportion of patients who present early to hospital after symptom onset.</p><p><b>CONCLUSION</b>Our results support the need for a public education programme to highlight the identification of stroke symptoms and the need to present to hospital as soon as possible after the onset of stroke symptoms.</p>