Background Although stroke is the second leading cause of death worldwide, no comprehensive and comparable assessment of incidence, prevalence, mortality, disability, and epidemiological trends has been estimated for most regions. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the global and regional burden of stroke during 1990-2010.
Methods We searched Medline, Embase, LILACS, Scopus, PubMed, Science Direct, Global Health Database, the WHO library, and WHO regional databases from 1990 to 2012 to identify relevant studies published between 1990 and 2010. We applied the GBD 2010 analytical technique (DisMod-MR), based on disease-specific, pre-specified associations between incidence, prevalence, and mortality, to calculate regional and country-specific estimates of stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) lost by age group (<75 years, >= 75 years, and in total) and country income level (high-income, and low-income and middle-income) for 1990, 2005, and 2010.
Findings We included 119 studies (58 from high-income countries and 61 from low-income and middle-income countries). From 1990 to 2010, the age-standardised incidence of stroke significantly decreased by 12% (95% CI 6-17) in high-income countries, and increased by 12% (-3 to 22) in low-income and middle-income countries, albeit nonsignificantly. Mortality rates decreased significantly in both high income (37%, 31-41) and low-income and middle-income countries (20%, 15-30). In 2010, the absolute numbers of people with first stroke (16.9 million), stroke survivors (33 million), stroke-related deaths (5.9 million), and DALYs lost (102 million) were high and had significantly increased since 1990 (68%, 84%, 26%, and 12% increase, respectively), with most of the burden (68.6% incident strokes, 52.2% prevalent strokes, 70.9% stroke deaths, and 77.7% DALYs lost) in low-income and middle-income countries. In 2010, 5.2 million (31%) strokes were in children (aged <20 years old) and young and middle-aged adults (20-64 years), to which children and young and middle-aged adults from low-income and middle-income countries contributed almost 74 000 (89%) and 4.0 million (78%), respectively, of the burden. Additionally, we noted significant geographical differences of between three and ten times in stroke burden between GBD regions and countries. More than 62% of new strokes, 69.8% of prevalent strokes, 45.5% of deaths from stroke, and 71.7% of DALYs lost because of stroke were in people younger than 75 years.
Interpretation Although age-standardised rates of stroke mortality have decreased worldwide in the past two decades, the absolute number of people who have a stroke every year, stroke survivors, related deaths, and the overall global burden of stroke (DALYs lost) are great and increasing. Further study is needed to improve understanding of stroke determinants and burden worldwide, and to establish causes of disparities and changes in trends in stroke burden between countries of different income levels.

Stroke can be categorized as ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Awakening with or experiencing the abrupt onset of focal neurologic deficits is the hallmark of ischemic stroke diagnosis. The most common presenting symptoms for ischemic stroke are difficulty with speech and weakness on one half of the body. Many stroke mimics exist; two of the most common are a postictal seizure and hypoglycemia. Taking a detailed history and performing ancillary testing will usually exclude stroke mimics. Neuroimaging is required to differentiate ischemic stroke from intracerebral hemorrhage, as well as to diagnose entities other than stroke. The choice of neuroimaging depends on its availability, eligibility for acute stroke interventions, and the presence of patient contraindications. Subarachnoid hemorrhage presents most commonly with severe headache and may require analysis of cerebrospinal fluid when neuroimaging is not definitive. Public education of common presenting stroke symptoms is needed for patients to activate emergency medical services as soon as possible after the onset of stroke.

OBJECTIVE: With the emergency department (ED) being a high-risk site for diagnostic errors, we sought to estimate ED diagnostic accuracy for identifying acute cerebrovascular events. METHODS: MEDLINE and Embase were searched for studies (1995-2016) reporting ED diagnostic accuracy for ischemic stroke, TIA, or subarachnoid hemorrhage (SAH). Two independent reviewers determined inclusion. We identified 1,693 unique citations, examined 214 full articles, and analyzed 23 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted. We prospectively defined clinical presentation subgroups to compare odds of misdiagnosis. RESULTS: Included studies reported on 15,721 patients. Studies were at low risk of bias. Overall sensitivity (91.3% [95% confidence interval (CI) 90.7-92.0]) and specificity (92.7% [91.7-93.7]) for a cerebrovascular etiology was high, but there was significant variation based on clinical presentation. Misdiagnosis was more frequent among subgroups with milder (SAH with normal vs abnormal mental state; false-negative rate 23.8% vs 4.2%, odds ratio [OR] 7.03 [4.80-10.31]), nonspecific (dizziness vs motor findings; false-negative rate 39.4% vs 4.4%, OR 14.22 [9.76-20.74]), or transient (TIA vs ischemic stroke; false discovery rate 59.7% vs 11.7%, OR 11.21 [6.66-18.89]) symptoms. CONCLUSIONS: Roughly 9% of cerebrovascular events are missed at initial ED presentation. Risk of misdiagnosis is much greater when presenting neurologic complaints are mild, nonspecific, or transient (range 24%-60%). This difference suggests that many misdiagnoses relate to symptom-specific factors. Future research should emphasize studying causes and designing error-reduction strategies in symptom-specific subgroups at greatest risk of misdiagnosis.

BACKGROUND: Systematic reviews call for well-designed trials with clearly described intervention components to support the effectiveness of educational campaigns to reduce patient delay in stroke presentation. We herein describe the systematic development process of a campaign aimed to increase stroke awareness and preparedness. METHODS: Campaign development followed Intervention Mapping (IM), a theory- and evidence-based tool, and was articulated in two phases: needs assessment and intervention development. In phase 1, two cross-sectional surveys were performed, one aiming to measure stroke awareness in the target population and the other to analyze the behavioral determinants of prehospital delay. In phase 2, a matrix of proximal program objectives was developed, theory-based intervention methods and practical strategies were selected and program components and materials produced. RESULTS: In phase 1, the survey on 202 citizens highlighted underestimation of symptom severity, as in only 44% of stroke situations respondents would choose to call the emergency service (EMS). In the survey on 393 consecutive patients, 55% presented over 2 hours after symptom onset; major determinants were deciding to call the general practitioner first and the reaction of the first person the patient called. In phase 2, adult individuals were identified as the target of the intervention, both as potential

Despite benefit in acute ischaemic stroke, less than 3% of patients receive tissue plasminogen activator (tPA) in Australia. The FASTER (Face, Arm, Speech, Time, Emergency Response) protocol was constructed to reduce pre-hospital and Emergency Department (ED) delays and improve access to thrombolysis. This study aimed to determine if introduction of the FASTER protocol increases use of tPA using a prospective pre- and post-intervention cohort design in a metropolitan hospital. A pre-hospital assessment tool was used by ambulance services to screen potential tPA candidates. The acute stroke team was contacted, hospital bypass allowed, triage and CT radiology alerted, and the patient rapidly assessed on arrival to ED. Data were collected prospectively during the first 6 months of the new pathway and compared to a 6-month period 12 months prior to protocol initiation. In the 6 months following protocol introduction, 115 patients presented within 24 hours of onset of an ischaemic stroke: 22 (19%) received thrombolysis, significantly greater than five (7%) of 67 patients over the control period, p = 0.03. Overall, 42 patients were referred via the FASTER pathway, with 21 of these receiving tPA (50%). One inpatient stroke was also treated. Only two referrals (<5%) were stroke mimics. Introduction of the FASTER pathway also significantly reduced time to thrombolysis and time to admission to the stroke unit. Therefore, fast-track referral of potential tPA patients involving the ambulance services and streamlined hospital assessment is effective and efficient in improving patient access to thrombolysis. Crown Copyright (C) 2011 Published by Elsevier Ltd.

PURPOSE: Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. METHODS: Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. RESULTS: Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

BACKGROUND AND PURPOSE: States and counties in the US began implementing regional systems of acute stroke care in the first decade of the 21st century, whereby emergency medical services systems preferentially route acute stroke patients directly to primary stroke centers. The pace, geographic range, and population reach of regional stroke system implementation has not been previously delineated. METHODS: We performed a review of legislative archives, internet and media reports, consultation with American Heart Association/American Stroke Association and Centers for Disease Control staff, and phone interviews with state public health and emergency medical service officials from each of the 50 states. RESULTS: The first counties to adopt regional regulations supporting routing of acute stroke patients to primary stroke centers were in Alabama and Texas in 2000; the first states were Florida and Massachusetts in 2004. By 2010, 16 states had state-level legislation or regulations to enable emergency medical service routing to primary stroke centers, as did counties in 3 additional states. The US population covered by routing protocols increased substantially in the latter half of the decade, from 1.5% in 2000 to 53% of the US population by the end of 2010. CONCLUSIONS: The first decade of the 21st century witnessed a remarkable structural transformation in acute stroke care: by the end of 2010, over half of all Americans were living in states/counties with emergency medical service routing protocols supporting the direct transport of acute stroke patients to primary stroke centers. Additional efforts are needed to extend regional stroke systems of care to the rest of the US.

BACKGROUND: Computed tomographic (CT) scans are central diagnostic tests for ischemic stroke. Their inefficient use is a negative quality measure tracked by the Centers for Medicare and Medicaid Services. METHODS AND RESULTS: We performed a retrospective analysis of Medicare fee-for-service claims data for adults admitted for ischemic stroke from 2008 to 2009, with 1-year follow-up. The outcome measures were risk-adjusted rates of high-intensity CT use (>/=4 head CT scans) and risk- and price-adjusted Medicare expenditures in the year after admission. The average number of head CT scans in the year after admission, for the 327 521 study patients, was 1.94, whereas 11.9% had >/=4. Risk-adjusted rates of high-intensity CT use ranged from 4.6% (Napa, CA) to 20.0% (East Long Island, NY). These rates were 2.6% higher for blacks than for whites (95% confidence interval, 2.1%-3.1%), with considerable regional variation. Higher fragmentation of care (number of different doctors seen) was associated with high-intensity CT use. Patients living in the top quintile regions of fragmentation experienced a 5.9% higher rate of high-intensity CT use, with the lowest quintile as reference; the corresponding odds ratio was 1.77 (95% confidence interval, 1.71-1.83). Similarly, 1-year risk- and price-adjusted expenditures exhibited considerable regional variation, ranging from $31 175 (Salem, MA) to $61 895 (McAllen, TX). Regional rates of high-intensity CT scans were positively associated with 1-year expenditures (r=0.56; P<0.01). CONCLUSIONS: Rates of high-intensity CT use for patients with ischemic stroke reflect wide practice patterns across regions and races. Medicare expenditures parallel these disparities. Fragmentation of care is associated with high-intensity CT use.

PURPOSE OF REVIEW: Most strokes occur in low- and middle-income countries where resources to manage patients are limited. We explore the resources required to providing optimal acute stroke care and review barriers to implementing evidence-based stroke care in settings with limited resources using the World Stroke Organization's Global Stroke Services Action Plan framework. RECENT FINDINGS: Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.

TITLE: Stroke education for healthcare professionals: Making it fit for purpose. RESEARCH QUESTIONS: 1. What are healthcare professionals' (HCPs) educational priorities regarding stroke care? 2. Do stroke care priorities vary across the primary and secondary sectors? 3. How do HCPs conceive stroke care will be delivered in 2010? STUDY DESIGN: This was a two-year study using focus groups and interviews for instrument development, questionnaires for data collection and workshops to provide study feedback. Data were collected in 2005-06. STUDY SITE: One Scottish health board. INCLUSION CRITERIA: All National Health Service healthcare professionals working wherever stroke care occurred. POPULATION AND SAMPLE: Participants were drawn from 4 university teaching hospitals, 2 community hospitals, 1 geriatric medicine day hospital, 48 general practices (GPs), 12 care homes and 15 community teams. The sample comprised 155 doctors, 313 nurses, 133 therapists (physiotherapists, occupational therapists, speech and language therapists), and 29 'other HCPs' (14 dieticians, 7 pharmacists, 2 podiatrists and 6 psychologists). RESULTS: HCPs prefer face-to-face, accredited education but blended approaches are required that accommodate uni- and multidisciplinary demands. Doctors and nurses are more inclined towards discipline-specific training compared to therapists and other healthcare professionals (HCPs). HCPs in primary care and stroke units want more information on the social impact of stroke while those working in stroke units in particular are concerned with leadership in the multidisciplinary team. Nurses are the most interested in teaching patients and carers. CONCLUSIONS: Stroke requires more specialist stroke staff, the upskilling of current staff and a national education pathway given that stroke care is most effectively managed by specialists with specific clinical skills. The current government push towards a flexible workforce is welcome but should be educationally-sound and recognise the career aspirations of healthcare professionals.

AIMS AND OBJECTIVES: To evaluate third year student nurses' knowledge and experiences of stroke education. To identify how student nurses can develop their understanding of stroke and its application to clinical nursing practice. BACKGROUND: Stroke is an international health issue and a major cause of morbidity and mortality in many countries throughout the world. Nurses have a significant role to play in reducing death and disability in people who have suffered a stroke and it has been suggested that some nurses may not be educationally prepared to meet the challenges of this complex condition. DESIGN: This evaluative study was based on a mixed method evaluative design. These quantitative and qualitative approaches involved the implementation of focus groups and questionnaires. METHOD: The following outcomes were measured during students' final year of their nursing studies: students' profiles and an assessment of students' knowledge of stroke. RESULTS: There was a mixed picture of student nurses' knowledge of stroke; a lack of awareness of some fundamental aspects of stroke including common symptoms, complications, risk factors and the long term treatment. Reassuringly, students expressed decisively the importance for nurses to be equipped with a sound foundation of stroke knowledge for clinical practice. CONCLUSIONS: All nursing students should have experience of being in contact with people who have had a stroke - and at present this does not always happen. A national intervention study is now suggested with a view to providing stroke education which is proportionate to its significance as a major health issue. RELEVANCE TO CLINICAL PRACTICE: Nurses draw upon their fundamental clinical skills to care and treat patients who have survived a stroke. Additionally, stroke survivors also require enhanced knowledge and this is recognised in the growth of specialist stroke nurses. Improving stroke mortality and morbidity is the responsibility of all of us involved in nurse education - introducing creative evaluative interventions could hold the most promising way forward.

Stroke is the fourth leading cause of death in Canada and, each year, approximately 50,000 Canadians will suffer a stroke with a range of severities from mild, short duration symptoms to significant long-term disability or death. Of these 50,000 patients, at least 20,000 are hospitalized. Earlier this year, a core set of evidence-based performance indicators were identified by a national consensus panel that may be used to determine the quality of care provided to stroke patients in hospital during the acute phase of illness. Nurses play a critical role in stroke care across the continuum and recently published stroke assessment guidelines for nurses clearly describe key approaches to assessment and/or screening of stroke survivors. Many of the nursing assessments and/or screening actions recommended in the guidelines have direct or indirect associations with the recent performance indicators. This article describes where those relationships exist and the role nurses may play in determining overall performance for acute stroke patient care delivery during the hospitalization phase of the stroke continuum of care.