How stroke care has changed in Slovakia in the last 5 years.

Introduction: Although stroke patients in Slovakia had been treated according to European recommendations, no network of primary and comprehensive stroke centers had been officially established; the ESO recommended quality parameters had not been fulfilled. Therefore, the Slovak Stroke Society decided to change the stroke management concept and introduced mandatory evaluation of quality parameters. This article focuses on key success factors of the change in stroke management in Slovakia and presents the 5-year results and perspectives for the future. Material and methods: We processed data from the stroke register at the National Health Information Center, which is mandatory in Slovakia for all hospitals designated as primary and secondary stroke care centers. Results: Since 2016, we have started to change stroke management. New National Guideline for Stroke Care was prepared in 2017 and published in 2018 as a Recommendation of the Ministry of Health of the Slovak Republic. The recommendation included pre-hospital as well as in-hospital stroke care, a network of primary stroke centers (hospitals administering intravenous thrombolysis - 37), and secondary stroke centers (hospitals treating with intravenous thrombolysis + endovascular treatment (ET) - 6). A stroke priority was instituted, having equally high priority as myocardial infarction. More efficient in-hospital workflow and pre-hospital patient triage shortened the time to treatment. Prenotification became mandatory in all hospitals. Non-contrast CT, and CT angiography is mandatory in all hospitals. In patients with suspected proximal large-vessel occlusion the EMS stays at the CT facility in primary stroke centers until the CT angiography is finished. If LVO is confirmed, the patient is transported to an EVT secondary stroke center by the same EMS. From 2019 all secondary stroke centers offer endovascular thrombectomy in a 24/7/365 system. We consider the introduction of quality control one of the most critical steps in stroke management. The result of these activities is 25.2% of patients treated with IVT and 10.2% by endovascular treatment, and median DNT 30 min. Number of patients screened for dysphagia increased from 26.4% in 2019 to 85.9% in 2020. In the most of the hospitals the proportion of ischemic stroke patients discharged with antiplatelets and in case of AF with anticoagulants was >85%. Discussion: Our results indicate that it is possible to change stroke management at a single hospital and national level. For continuous and further improvement, regular quality monitoring is necessary; therefore, the results of stroke hospital management are presented regularly once a year at national and international level. Collaboration with the "Second for Life" patient organization is very important for the "time is brain" campaign in Slovakia. Conclusion: Due to the change in stroke management over the last 5 years, we have reduced the time for acute stroke treatment and improved the proportion of patients with acute treatment, and in this area, we have achieved and exceeded the goals of the Stroke Action Plan for Europe for 2018-2030. Nevertheless, we still have many insufficiencies in stroke rehabilitation and post-stroke nursing that need to be addressed.

Thrombolysis in Stroke With Unknown Onset Based on Non-Contrast Computerized Tomography (TRUST CT).

Background Intravenous thrombolysis (IVT) in wake-up stroke (WUS) or stroke with unknown onset (SUO) has been recently proven to be safe and effective using advanced neuroimaging (magnetic resonance imaging or computerized tomography-perfusion) for patient selection. However, in most of the thrombolyzing centers advanced neuroimaging is not instantly available. We hypothesize that pragmatic non-contrast computed tomography-based IVT in WUS/SUO may be feasible and safe. Methods and Results TRUST-CT (Thrombolysis in Stroke With Unknown Onset Based on Non-Contrast Computerized Tomography) is an international multicenter registry-based study. WUS/SUO patients undergoing non-contrast computed tomography-based IVT with National Institute of Health Stroke Scale ≥4 and initial Alberta Stroke Program Early Computerized Tomography score ≥7 were included and compared with propensity score matched non-thrombolyzed WUS/SUO controls. Primary end point was the incidence of symptomatic intracranial hemorrhage; secondary end points included 24-hour National Institute of Health Stroke Scale improvement of ≥4 and modified Rankin Scale at 90 days. One hundred and seventeen WUS/SUO patients treated with non-contrast computed tomography-based IVT were included. As compared with 112 controls, the median admission National Institute of Health Stroke Scale was 10 and the median Alberta Stroke Program Early Computerized Tomography score was 10 in both groups. Four (3.4%) IVT patients and one control patient (0.9%) suffered symptomatic intracranial hemorrhage (adjusted odds ratio 7.9, 95% CI 0.65-96, P=0.1). A decrease of ≥4 National Institute of Health Stroke Scale points was observed in 67 (57.3%) of IVT patients as compared with 25 (22.3%) in controls (adjusted odds ratio 5.8, CI 3.0-11.2, P<0.001). A months, 39 (33.3%) IVT patients reached a modified Rankin Scale score of 0 or 1 versus 23 (20.5%) controls (adjusted odds ratio 1.94, CI 1.0-3.76, P=0.05). Conclusions Non-contrast computed tomography-based thrombolysis in WUS/SUO seems feasible and safe and may be effective. Randomized prospective comparisons are warranted. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT03634748.

Risk factors associated with ischemic heart disease occurence in acute ischemic stroke patients.

AIMS: At specific time periods following ischemic stroke (IS), acute coronary syndrome as ischemic heart disease (IHD) represents a higher risk of death than IS. Not all IS patients can undergo specific examination for IHD detection. The aim of this study was to assess exclusive risk factors (RFs) associated with IHD occurrence in IS patients. Knowledge of these RFs should help in stratifying IS patients for IHD detection. MATERIALS AND METHODS: This was a hospital-based, retrospective, single centre study. The sample consisted of 192 consecutive IS patients, divided into two subgroups - Subgroup 1 (54 patients without IHD; 55.6% males; 63.1 ± 11.8 years) and Subgroup 2 (138 patients with IHD; 39.1% males; 76.3 ± 9.6 years). The following factors were identified: age; sex; presence of arterial hypertension, atrial fibrillation, diabetes mellitus; plasma levels of total cholesterol, triglycerides, low-density cholesterol, high-density cholesterol; body mass index; presence of carotid plaques. Logistic regression analysis was used for statistical evaluation. RESULTS: Of all identified risk factors only age (OR=1.109; 95% CI: 1.069 - 1.150, P=0.001) and the presence of arterial hypertension (OR=6.298; 95% CI: 2.215 - 17.905, P=0.003) were exclusively and significantly associated with the presence of IHD in IS patients. CONCLUSIONS: Age and arterial hypertension may be exclusive risk factors associated with IHD in IS patients.

Coronary artery disease is not associated with stroke recurrence.

BACKGROUND: Coronary artery disease (CAD) is a leading cause of long-term mortality in Europe and it negatively influences the outcome after stroke. However, its influence on stroke recurrence which endangers stroke patients mostly in the first months following stroke, is unclear. Previous studies have found no association between CAD and ischemic stroke recurrence. However, assessment of the relationship was not the primary endpoint of these investigations. The aim of this study was to assess the possible association between CAD and stroke recurrence. PATIENTS AND METHODS: In a hospital-based, retrospective study, the set consisted of 190 patients - 105 patients with a first ever stroke (48 males; age 37-88, mean 70.7±12.5 years) and 85 patients with stroke recurrence (36 males; age 46-94, mean 88.0±9.6 years). CAD was correlated with the following other risk factors (age, sex, occurrence of arterial hypertension, atrial fibrillation, diabetes mellitus, plasma levels of total cholesterol, triglycerides, low-density cholesterol, high-density cholesterol, body mass index, presence of carotid plaques). Logistic regression analysis was used for the statistical evaluation. RESULTS: No significant association was found between CAD and stroke recurrence. Of all of the other observed risk factors, only age showed a significant association with stroke recurrence (OR 1.04, 95% CI: 1.02-1.07). CONCLUSION: The results of the presented study indicate that CAD does not influence stroke recurrence.

Oral antiplatelet therapy in stroke prevention. Minireview.

BACKGROUND: Antiplatelet therapy plays a crucial role in the primary and secondary prevention of noncardioembolic ischemic stroke / transient ischemic attacks (IS/TIA). Several antiplatelet agents are available. This review deals with the characteristics of particular antiplatelet agents as well as choice of antiplatelet treatment in various situations, based on the evidence and international recommendations. METHODS: PubMed and Stroke Trials Registry on-line databases and the European Stroke Organisation Guidelines for Management of IS/TIA 2008 and update of the recommendations of the American Heart Association / American Stroke Association Council 2008 on Stroke were used. RESULTS: Acetylsalicylic acid (ASA) is the only antiplatelet drug used in primary prevention, mainly to reduce the risk of myocardial infarction (MI), but also in women aged 45 years or more and in some patients with non-valvular atrial fibrillation to reduce risk of IS/TIA. In the secondary prevention of noncardioembolic IS/TIA, ASA in combination with long release dipyridamole (DIP) and clopidogrel (CLOP) alone are considered first choice therapies. The choice of the particular antiplatelet agent should be individualized according to the patient risk factor profiles and treatment tolerance. ASA alone or triflusal can be used alternatively in patients who cannot be treated with either ASA+DIP or CLOP. The use of indobufen should be considered only in patients in need of temporary interruption of the antiplatelet therapy. Ticlopidine (TIC) should not be newly introduced into the treatment. Currently, insufficient data are available on the use of cilostazol in IS/TIA prevention.