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Early Ischemic Stroke Presentation in Pakistan

Published online by Cambridge University Press:  02 December 2014

Ayeesha Kamran Kamal ,
Bhojo Asumal Khealani ,
Sajjad Ahmed Ansari ,
Maria Afridi  and
Nadir Ali Syed
Ayeesha Kamran Kamal*
Affiliation:
Neurology Section, Department of Medicine, Aga Khan University, Karachi, Pakistan
Bhojo Asumal Khealani
Affiliation:
Neurology Section, Department of Medicine, Aga Khan University, Karachi, Pakistan
Sajjad Ahmed Ansari
Affiliation:
Neurology Section, Department of Medicine, Aga Khan University, Karachi, Pakistan
Maria Afridi
Affiliation:
Neurology Section, Department of Medicine, Aga Khan University, Karachi, Pakistan
Nadir Ali Syed
Affiliation:
Neurology Section, Department of Medicine, Aga Khan University, Karachi, Pakistan
*
Department of Medicine, 1st Floor, Aga Khan University, Stadium Road, Karachi ' 74800, Pakistan
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Abstract

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Introduction:

There are no studies from Pakistan that describe stroke presentation rates or factors associated with early or delayed presentation. This is important to know because current clinical protocols limit the use of recombinant tissue plasminogen activator (rtPA), the only available therapy for acute ischemic stroke, to a three-hour window from symptom onset.

Methods:

All patients aged 14 years or above with acute ischemic stroke of ≤ 48 hours duration were prospectively identified from the Aga Khan University Stroke Data Bank over a 22-month period ending May 2001.

Results:

269 ischemic stroke patients presented within 48 hours of stroke onset. 55 out of 269 (21%) presented within first three hours and 110 out of 269 (41%) within first six hours. Unawareness of treatment options (p <0.001) and inappropriate diagnosis and field triage (p=0.005) were associated with delayed presentation. Small vessel occlusion or lacunar stroke in the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) ischemic stroke subtype was associated with delayed presentation (p=0.047) and cardioembolic stroke was associated with earlier presentation (p=0.048). Stroke severity assessed with the National Institutes of Health Stroke Scale at a cut off score of ≥ 15 was not associated with earlier time to presentation at three hours (p=0.114) but there was some tendency at six hours (p=0.097).

Conclusions:

The rate of early stroke presentation in a Pakistani tertiary care facility is comparable to certain developed countries. To increase the proportion of patients who can benefit from thrombolytic therapy, programs need to be instituted to increase public awareness of treatment options for stroke and expedited referral by the primary care provider.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 36 , Issue 2 , March 2009 , pp. 181 - 186
Copyright
Copyright © The Canadian Journal of Neurological 2009

References

1.Wardlaw, J, Berge, E, del Zoppo, G, Yamaguchi, T.Thrombolysis for acute ischemic stroke. Stroke. 2004;35:2914–5.Google Scholar
2.Hacke, W, Donnan, G, Fieschi, C, Kaste, M, von Kummer, R, Broderick, JP, et al.ATLANTIS Trials Investigators, ECASS Trials Investigators, NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–74.Google Scholar
3.Kwiatkowski, T, Libman, R, Tilley, BC, Lewandowski, C, Grotta, JC, Lyden, P, et al.National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. The impact of imbalances in baseline stroke severity on outcome in the National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study. Ann Emerg Med. 2005;45:377–84.CrossRefGoogle Scholar
4.Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333:1581–7.Google Scholar
5.Rossnagel, K, Jungehülsing, GJ, Nolte, CH, Müller-Nordhorn, J, Roll, S, Wegscheider, K, et al.Out-of-hospital delays in patients with acute stroke. Ann Emerg Med. 2004 Nov;44(5):476–83.Google Scholar
6.Harraf, F, Sharma, AK, Brown, MM, Lees, KR, Vass, RI, Kalra, L.A multicentre observational study of presentation and early assessment of acute stroke. BMJ. 2002;325:17–21.Google Scholar
7.Barber, PA, Zhang, J, Demchuk, AM, Hill, MD, Buchan, AM.Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology. 2001 Apr 24;56(8):1015–20.Google Scholar
8.Morris, DL, Rosamond, W, Madden, K, Schultz, C, Hamilton, S.Prehospital and emergency department delays after acute stroke: The Genentech Stroke presentation survey. Stroke. 2000;31: 2585–90.Google Scholar
9.Chang, K, Tseng, M, Tan, T.Prehospital delay after acute stroke in Kaohsiung, Taiwan. Stroke. 2004;35:700–4.Google Scholar
10.Casetta, I, Granieri, E, Gilli, G, Lauria, G, Tola, MR, Paolino, E.Temporal trend and factors associated with delayed hospital admission of stroke patients. Neuroepidemiology. 1999;18(5): 255–64.Google Scholar
11.Vemmos, KN, Takis, CE, Georgilis, K, Zakopoulos, NA, Lekakis, JP, Papamichael, , et al.The Athens stroke registry: results of a five-year hospital-based study. Cerebrovasc Dis. 2000 Mar-Apr;10 (2):133–41.Google Scholar
12.Derex, L, Adeleine, P, Nighoghossian, N, Honnorat, J, Trouillas, P.Factors influencing early admission in a French stroke unit. Stroke. 2002;33:153–9.Google Scholar
13.Streifler, JY, Davidovitch, S, Sendovski, U.Factors associated with the time of presentation of acute stroke patients in an Israeli community hospital. Neuroepidemiology. 1998;17(3):161–6.Google Scholar
14.Leopoldino, JF, Fukujima, MM, Silva, GS, do Prado, GF.Time of presentation of stroke patients in Sao Paulo Hospital. Arq Neuropsiquiatr. 2003 Jun;61(2A):186–7.Google Scholar
15.Srivastava, AK, Prasad, K.A study of factors delaying hospital arrival of patients with acute stroke. Neurol India. 2001;49: 272–6.Google Scholar
16.Hatano, S.Experience from a multicentric stroke register - a preliminary report. Bulletin WHO. 1976;54:541–53.Google Scholar
17.Adams, HP Jr, Bendixen, BH, Kappelle, LJ.Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41.Google Scholar
18.World Health Organization: Global burden of stroke. World Health Organization; 2002. [cited 2008 May 5] Available from: http://www.who.intGoogle Scholar
19.Syed NA, KB, Ali, S, Hasan, A, Akhtar, N, Brohi, H, Mozaffar, T, et al.Ischemic stroke subtypes in Pakistan: The Aga Khan University stroke data bank. J Pak Med Assoc. 2003;53:584–8.Google Scholar
20.Jafar, TH.Blood pressure, diabetes and increased dietary salt associated with stroke- results from a community-based study in Pakistan. J Hum Hypertens. 2006;20:83–5.Google Scholar
21.Williams, LS, Bruno, A, Rouch, D, Marriott, DJ.Stroke patients’ knowledge of stroke: influence on time to presentation. Stroke. 1997;28:912–5.Google Scholar
22.Kothari, R, Sauerbeck, L, Jauch, E, Broderick, J, Brott, T, Khoury, J, et al.Patients’ awareness of stroke signs, symptoms, and risk factors. Stroke. 1997;28:1871–5.Google Scholar
23.Lin, CS, Tsai, J, Woo, P, Chang, H.Prehospital delay and emergency department management of ischemic stroke patients in Taiwan, R.O.C. Prehosp Emerg Care. 1999;3:194–200.Google Scholar
24.Carleton, RA, Bazzarre, T, Drake, J, Dunn, A, Fisher, EB Jr, Grundy, SM, et al.Report of the expert panel on awareness and behavior change to the Board of Directors, American Heart Association. Circulation. 1996;93:1768–72.Google Scholar
25.Moser, DK, Kimble, LP, Alberts, MJ, Alonzo, A, Croft, JB, Dracup, K, et al.Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: A scientific statement from the American Heart Association Council on Cardio-Vascular Nursing and Stroke Council. Circulation. 114:168–82.Google Scholar
26.Wester, P, Radberg, J, Lundgren, B, Peltonen, M.Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Seek-Medical-Attention-in-Time Study Group. Stroke. 1999;30:40–8.Google Scholar
27.Lannehoa, Y, Bouget, J, Pinel, JF, Garnier, N, Leblanc, JP, Branger, B.Analysis of time management in stroke patients in three French emergency departments: from stroke onset to computed tomography scan. Eur J Emerg Med. 1999;6:95–103.Google Scholar
28.Jorgensen, HS, Nakayama, H, Reith, J, Raaschou, HO, Olsen, TS.Factors delaying hospital admission in acute stroke: the Copenhagen Study. Neurology. 1996;47:383–7.Google Scholar
29.Smith, MA, Doliszny, KM, Shahar, E, McGovern, PG, Arnett, DK, Luepker, RV.Delayed hospital arrival for acute stroke: the Minnesota Stroke Survey. Ann Intern Med. 1998;129:190–6.Google Scholar
30.Zweifler, RM, Mendizabal, JE, Cunningham, S, Shah, AK, Rothrock, JF.Hospital presentation after stroke in a community sample: the Mobile Stroke Project. South Med J. 2002;95:1263–8.Google Scholar
31.Kothari, R, Jauch, E, Broderick, J, Brott, T, Sauerbeck, L, Khoury, J, et al.Acute stroke: delays to presentation and emergency department evaluation. Ann Emerg Med. 1999;33:3–8.Google Scholar
32.Jorgensen, HS, Nakayama, H, Raaschou, HO, Olsen, TS.Effect of blood pressure and diabetes on stroke in progression. Lancet. 1994;344:156–9.Google Scholar
33.Lacy, CR, Suh, DC, Bueno, M, Kostis, JB.Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.). Stroke. 2001;32:63–9.Google Scholar