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  • 1
    Online Resource
    Online Resource
    Impact of COVID-2019 on stroke services in China: survey from the Chinese Stroke Association
    BMJ ; 2020
    In:  Stroke and Vascular Neurology Vol. 5, No. 4 ( 2020-12), p. 323-330
    Details
    In: Stroke and Vascular Neurology, BMJ, Vol. 5, No. 4 ( 2020-12), p. 323-330
    Abstract: The COVID-19 pandemic and physical distancing guidelines have compelled stroke practices worldwide to reshape their delivery of care significantly. We aimed to illustrate how the stroke services were interrupted during the pandemic in China. Methods A 61-item questionnaire designed on Wenjuanxing Form was completed by doctors or nurses who were involved in treating patients with stroke from 1 February to 31 March 2020. Results A total of 415 respondents completed the online survey after informed consent was obtained. Of the respondents, 37.8%, 35.2% and 27.0% were from mild, moderate and severe epidemic areas, respectively. Overall, the proportion of severe impact (reduction 〉 50%) on the admission of transient ischaemic stroke, acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH) was 45.0%, 32.0% and 27.5%, respectively. Those numbers were 36.9%, 27.9% and 22.3%; 36.5%, 22.1% and 22.6%; and 66.4%, 47.5% and 41.1% in mild, moderate and severe epidemic areas, respectively (all p 〈 0.0001). For AIS, thrombolysis was moderate (20%–50% reduction) or severely impacted ( 〉 50%), as reported by 54.4% of the respondents, while thrombectomy was 39.3%. These were 44.4%, 26.3%; 44.2%, 39.4%; and 78.2%, 56.5%, in mild, moderate and severe epidemic areas, respectively (all p 〈 0.0001). For patients with acute ICH, 39.8% reported the impact was severe or moderate for those eligible for surgery who had surgery. Those numbers were 27.4%, 39.0% and 58.1% in mild, moderate and severe epidemic areas, respectively. For staff resources, about 20% (overall) to 55% (severe epidemic) of the respondents reported moderate or severe impact on the on-duty doctors and nurses. Conclusion We found a significant reduction of admission for all types of patients with stroke during the pandemic. Patients were less likely to receive appropriate care, for example, thrombolysis/thrombectomy, after being admitted to the hospital. Stroke service in severe COVID-19 epidemic areas, for example, Wuhan, was much more severely impacted compared with other regions in China.
    Type of Medium: Online Resource
    ISSN: 2059-8688 , 2059-8696
    URL: Article
    DOI: 10.1136/svn-2020-000514
    Language: English
    Publisher: BMJ
    Publication Date: 2020
    detail.hit.zdb_id: 2847692-X
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  • 2
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    Online Resource
    Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial
    BMJ ; 2023
    In:  BMJ
    Details
    In: BMJ, BMJ
    Abstract: To compared the effect of early antihypertensive treatment started within 24-48 h of stroke onset versus delaying treatment until day eight on reducing dependency or death. Design Multicentre, randomised, open label trial. Setting 106 hospitals in China between 13 June 2018 and 10 July 2022. Participants 4810 patients (≥40 years) were enrolled with acute ischaemic stroke within 24-48 h of symptom onset and elevated systolic blood pressure between 140 mm Hg and 〈 220 mm Hg. Interventions Patients were randomly assigned to receive antihypertensive treatment immediately after randomisation (aimed at reducing systolic blood pressure by 10%-20% within the first 24 h and a mean blood pressure 〈 140/90 mm Hg within seven days) or to discontinue antihypertensive medications for seven days if they were taking them, and then receive treatment on day 8 (aimed at achieving mean blood pressure 〈 140/90 mm Hg). Main outcome measures The primary outcome was the combination of functional dependency or death (modified Rankin scale score ≥3) at 90 days. Intention to treat analyses were conducted. Results 2413 patients were assigned to the early treatment group and 2397 were assigned to the delayed treatment group. Mean systolic blood pressure was reduced by 9.7% (from 162.9 mm Hg to 146.4 mm Hg) in the early treatment group and by 4.9% (from 162.8 mm Hg to 154.3 mm Hg) in the delayed treatment group within 24 h after randomisation (P for group difference 〈 0.001). Mean systolic blood pressure was 139.1 mm Hg in the early treatment group and 150.9 mm Hg in the delayed treatment group on day seven (P for group difference 〈 0.001). Additionally, 54.6% of patients in the early treatment group and 22.4% in the delayed treatment group had blood pressure of less than 140/90 mm Hg (P 〈 0.001 for group difference) on day seven. At day 90, 289 trial participants (12.0%) in the early treatment group, compared with 250 (10.5%) in the delayed treatment group, had died or experienced a dependency (odds ratio 1.18 (95% confidence interval 0.98 to 1.41), P=0.08). No significant differences in recurrent stroke or adverse events were reported between the two groups. Conclusions Among patients with mild-to-moderate acute ischaemic stroke and systolic blood pressure between 140 mm Hg and 〈 220 mm Hg who did not receive intravenous thrombolytic treatment, early antihypertensive treatment did not reduce the odds of dependency or death at 90 days. Trial registration ClinicalTrials.gov Identifier NCT03479554
    Type of Medium: Online Resource
    ISSN: 1756-1833
    URL: Article
    DOI: 10.1136/bmj-2023-076448
    Language: English
    Publisher: BMJ
    Publication Date: 2023
    detail.hit.zdb_id: 1479799-9
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  • 3
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    Online Resource
    Ticagrelor plus aspirin versus clopidogrel plus aspirin for platelet reactivity in patients with minor stroke or transient ischaemic attack: open label, blinded endpoint, randomised controlled phase II trial
    BMJ ; 2019
    In:  BMJ
    Details
    In: BMJ, BMJ
    Abstract: To test the hypothesis that ticagrelor plus aspirin is safe and superior to clopidogrel plus aspirin for reducing high platelet reactivity at 90 days and stroke recurrence in patients with minor stroke or transient ischaemic attack, particularly in carriers of the CYP2C19 loss-of-function allele and patients with large artery atherosclerosis. Design Open label, blinded endpoint, randomised controlled phase II trial. Setting Prospective studies conducted at 26 centres in China, August 2015 to March 2017. Participants 675 patients with acute minor stroke or transient ischaemic attack. Intervention Ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300 mg loading dose, 75 mg daily thereafter) on a background of aspirin (100 mg daily for the first 21 days) within 24 hours of symptom onset. Main outcome measures Primary outcome was the proportion of patients with high platelet reactivity at 90 days. High platelet reactivity was defined as P2Y12 reaction units of more than 208. Secondary outcomes included high platelet reactivity at 90 days (7 days either way) in patients carrying genetic variants that would affect clopidogrel metabolism, and any stroke (ischaemic or haemorrhagic) recurrence at 90 days (7 days either way), six months, and one year. Results At 90 days, high platelet reactivity occurred in 35 (12.5%) of 280 patients in the ticagrelor/aspirin group and 86 (29.7%) of 290 patients in the clopidogrel/aspirin group (risk ratio 0.40; 95% confidence interval 0.28 to 0.56; P 〈 0.001), and in 10.8% versus 35.4% (0.31; 0.18 to 0.49; P 〈 0.001) of patients carrying CYP2C19 loss-of-function alleles. Stroke occurred in 21 (6.3%) of 336 patients in the ticagrelor/aspirin group and 30 (8.8%) of 339 patients in the clopidogrel/aspirin group (hazard ratio 0.70; 95% confidence interval 0.40 to 1.22; P=0.20). Patients with large artery atherosclerosis in the ticagrelor/aspirin group had a lower stroke recurrence at 90 days than those in the clopidogrel/aspirin group (6.0% v 13.1%; hazard ratio 0.45, 95% confidence interval 0.20 to 0.98; P=0.04). No difference was seen in the rates of major or minor haemorrhagic events between the ticagrelor/aspirin and clopidogrel/aspirin groups (4.8% v 3.5%; P=0.42). Conclusion Patients with minor stroke or transient ischaemic attack who are treated with ticagrelor plus aspirin have a lower proportion of high platelet reactivity than those who are treated with clopidogrel plus aspirin, particularly for those who are carriers of the CYP2C19 loss-of-function allele. The results of this study should be evaluated further in large scale, phase III trials and in different populations. Trial registration Clinicaltrials.gov NCT02506140 .
    Type of Medium: Online Resource
    ISSN: 0959-8138 , 1756-1833
    URL: Article
    DOI: 10.1136/bmj.l2211
    Language: English
    Publisher: BMJ
    Publication Date: 2019
    detail.hit.zdb_id: 1479799-9
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  • 4
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    Relationship between hospital performance measures and outcomes in patients with acute ischaemic stroke: a prospective cohort study
    BMJ ; 2018
    In:  BMJ Open Vol. 8, No. 7 ( 2018-07), p. e020467-
    Details
    In: BMJ Open, BMJ, Vol. 8, No. 7 ( 2018-07), p. e020467-
    Abstract: Evidence-based performance measures have been increasingly used to evaluate hospital quality of stroke care, but their impact on stroke outcomes has not been verified. We aimed to evaluate the correlations between hospital performance measures and outcomes among patients with acute ischaemic stroke in a Chinese population. Methods Data were derived from a prospective cohort, which included 120 hospitals participating in the China National Stroke Registry between September 2007 and August 2008. Adherence to nine evidence-based performance measures was examined, and the composite score of hospital performance measures was calculated. The primary stroke outcomes were hospital-level, 30-day and 1-year risk-standardised mortality (RSM). Associations of individual performance measures and composite score with stroke outcomes were assessed using Spearman correlation coefficients. Results One hundred and twenty hospitals that recruited 12 027 patients with ischaemic stroke were included in our analysis. Among 12 027 patients, 61.59% were men, and the median age was 67 years. The overall composite score of performance measures was 63.3%. The correlation coefficients between individual performance measures ranged widely from 0.01 to 0.66. No association was observed between the composite score and 30-day RSM. The composite score was modestly associated with 1-year RSM (Spearman correlation coefficient, 0.34; p 〈 0.05). The composite score explained only 2.53% and 10.18% of hospital-level variation in 30-day and 1-year RSM for patients with acute stroke. Conclusions Adherence to evidence-based performance measures for acute ischaemic stroke was suboptimal in China. There were various correlations among hospital individual performance measures. The hospital performance measures had no correlations with 30-day RSM rate and modest correlations with 1-year RSM rate.
    Type of Medium: Online Resource
    ISSN: 2044-6055 , 2044-6055
    URL: Article
    DOI: 10.1136/bmjopen-2017-020467
    Language: English
    Publisher: BMJ
    Publication Date: 2018
    detail.hit.zdb_id: 2599832-8
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  • 5
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    Online Resource
    Chinese Stroke Center Alliance: a national effort to improve healthcare quality for acute stroke and transient ischaemic attack: rationale, design and preliminary findings
    BMJ ; 2018
    In:  Stroke and Vascular Neurology Vol. 3, No. 4 ( 2018-12), p. 256-262
    Details
    In: Stroke and Vascular Neurology, BMJ, Vol. 3, No. 4 ( 2018-12), p. 256-262
    Abstract: In June 2015, the Chinese Stroke Association (CSA) initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform. This article outlines its objectives, operational structure, patient population, quality improvement (QI) intervention tools, data elements, data collection methodology and current patient and hospital data. Methods The CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and continuous QI initiative. This multifaceted intervention includes stroke centre development, written care protocols, workshops and a monitoring/feedback system of evidence-based performance measures. The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital. Results As of July 2017, 1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433 264 patients with acute stroke/transient ischaemic attacks (TIA), including 352 572 (81.38%) acute ischaemic stroke, 30 362 (7.01%) TIA, 42 080 (9.71%) spontaneous intracranial haemorrhage, 5505 (1.27%) subarachnoid haemorrhage and 2745 (0.63%) not specified stroke. Conclusion The CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and, ultimately, improve patient outcomes. It supports the CSA mission to reduce stroke burden in China.
    Type of Medium: Online Resource
    ISSN: 2059-8688 , 2059-8696
    URL: Article
    URL: Article
    DOI: 10.1136/svn-2018-000154
    DOI: 10.1136/svn-2018-000154.supp1
    Language: English
    Publisher: BMJ
    Publication Date: 2018
    detail.hit.zdb_id: 2847692-X
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  • 6
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    Online Resource
    China Antihypertensive Trial in Acute Ischemic Stroke II (CATIS-2): rationale and design
    BMJ ; 2021
    In:  Stroke and Vascular Neurology Vol. 6, No. 2 ( 2021-06), p. 286-290
    Details
    In: Stroke and Vascular Neurology, BMJ, Vol. 6, No. 2 ( 2021-06), p. 286-290
    Abstract: Increased blood pressure (BP) for patients who had an acute ischaemic stroke is associated with poor functional outcome, however the optimal timing of antihypertensive therapy is unknown. Aims We aim to compare early antihypertensive treatment to delayed antihypertensive treatment for reducing the risk of composite major disability and mortality at 3 months in acute ischaemic stroke. Design The China Antihypertensive Trial in Acute Ischemic Stroke II (CATIS-2) trial is a multicentre, randomised, open-label, blinded-endpoints trial that will be conducted in 100 hospitals in China. The primary outcome is the composite of death and major disability (modified Rankin Scale score ≥3) at 3 months of randomisation. Antihypertensive treatment will be received immediately after randomisation in the early treatment group, aimed at average systolic BP by 10%–20% reduction within the first 24 hours, and achieving an average BP level of 〈 140/90 mm Hg within 5 days. Patients in the delayed treatment group will discontinue any antihypertension medications for the first 7 days of randomisation, and will receive antihypertensive therapy achieving a BP goal of 〈 140/90 mm Hg after 7 days. Conclusion The CATIS-2 trial will be testing the hypotheses that early BP lowering leads to improved functional outcome without any other harms, and developing clinical guidelines of the BP management for patients who had an acute ischaemic stroke. Trial registration number NCT03479554 .
    Type of Medium: Online Resource
    ISSN: 2059-8688 , 2059-8696
    URL: Article
    DOI: 10.1136/svn-2020-000828
    Language: English
    Publisher: BMJ
    Publication Date: 2021
    detail.hit.zdb_id: 2847692-X
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  • 7
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    One-year direct and indirect costs of ischaemic stroke in China
    BMJ ; 2023
    In:  Stroke and Vascular Neurology
    Details
    In: Stroke and Vascular Neurology, BMJ
    Abstract: This is the first real-world study to estimate the direct costs and indirect costs of first-ever ischaemic stroke with 1-year follow-up in China, based on a nationally representative sample. Methods Patients were chosen from 20 geographically diverse sites from the nationally representative database China National Stroke Registry-III (CNSR-III). The inclusion criteria were surviving patients who were hospitalised with first-ever ischaemic stroke from February 2017 to February 2018 (the index event); aged 18–80 during the index event; no history of other stroke types. The primary endpoints were direct medical costs, direct non-medical costs, indirect costs and total cost (ie, the sum of all cost components). Patient characteristics and clinical data were extracted from CNSR-III. Stroke-related in-hospital direct medical costs were collected from hospital electronic medical records. The patient survey collected data related to out-of-hospital direct medical costs, direct non-medical costs and indirect costs. The secondary objective was to explore clinical factors associated with cost outcomes through univariate analysis and multiple regression. Results The study enrolled 520 patients. The total cost was 57 567.48 CNY, with 26 612.67 CNY direct medical costs, 2 787.56 CNY direct non-medical costs and 28 167.25 CNY indirect costs. Univariate analysis showed that longer lengths of stay during the index event, higher National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were associated with higher costs in all categories. Conversely, EuroQol 5 Dimension utility scores were associated with decreased costs except direct non-medical costs. Multiple regressions showed that higher admission NIHSS scores were independently associated with higher direct medical costs, indirect costs and total cost. Higher 3-month utilities were associated with lower total cost. Conclusion This real-world study showed substantial 1-year economic burden following first-ever ischaemic stroke in China, and that indirect costs are a non-negligible driver of costs.
    Type of Medium: Online Resource
    ISSN: 2059-8688 , 2059-8696
    URL: Article
    DOI: 10.1136/svn-2023-002296
    Language: English
    Publisher: BMJ
    Publication Date: 2023
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  • 8
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    Online Resource
    Non-contrast head CT alone for thrombectomy in acute ischemic stroke: analysis of the ANGEL-ACT registry
    BMJ ; 2022
    In:  Journal of NeuroInterventional Surgery Vol. 14, No. 9 ( 2022-09), p. 868-874
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 14, No. 9 ( 2022-09), p. 868-874
    Abstract: The goal of this study was to determine if the choice of imaging paradigm performed in the emergency department influences the procedural or clinical outcomes after mechanical thrombectomy (MT). Methods This is a retrospective comparative outcome study which was conducted from the ANGEL-ACT registry. Comparisons were made between baseline characteristics and clinical outcomes of patients with acute ischemic stroke undergoing MT with non-contrast head computed tomography (NCHCT) alone versus patients undergoing NCHCT plus non-invasive vessel imaging (NVI) (including CT angiography (with or without CT perfusion) and magnetic resonance angiography). The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included change in mRS score from baseline to 90 days, the proportions of mRS 0–1, 0–2, and 0–3, and dramatic clinical improvement at 24 hours. The safety outcomes were any intracranial hemorrhage (ICH), symptomatic ICH, and mortality within 90 days. Results A total of 894 patients met the inclusion criteria; 476 (53%) underwent NCHCT alone and 418 (47%) underwent NCHCT + NVI. In the NCHCT alone group, the door-to-reperfusion time was shorter by 47 min compared with the NCHCT + NVI group (219 vs 266 min, P 〈 0.001). Patients in the NCHCT alone group showed a smaller increase in baseline mRS score at 90 days (median 3 vs 2 points; P=0.004) after adjustment. There were no significant differences between groups in the remaining clinical outcomes. Conclusions In patients selected for MT using NCHCT alone versus NCHCT + NVI, there were improved procedural outcomes and smaller increases in baseline mRS scores at 90 days.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2021-017940
    Language: English
    Publisher: BMJ
    Publication Date: 2022
    detail.hit.zdb_id: 2506028-4
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  • 9
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    Online Resource
    Gastrointestinal bleeding during acute ischaemic stroke hospitalisation increases the risk of stroke recurrence
    BMJ ; 2020
    In:  Stroke and Vascular Neurology Vol. 5, No. 2 ( 2020-06), p. 116-120
    Details
    In: Stroke and Vascular Neurology, BMJ, Vol. 5, No. 2 ( 2020-06), p. 116-120
    Abstract: Gastrointestinal (GI) bleeding in patients who had a stroke is strongly associated with a higher risk of death and loss of independence. However, it is unknown whether GI bleeding increases risk for recurrence of stroke. In this study, we assess the potential relationship between GI bleeding and stroke recurrence in patients within 12 months of an acute ischaemic stroke (AIS), using the China National Stroke Registry (CNSR). Methods This study included 22 216 patients who had an ischaemic stroke included in the CNSR from 2007 to 2008. We analysed baseline patient characteristics, GI bleeding and outcomes of patients who had an AIS, specifically stroke recurrence at 3, 6 and 12 months. We used multivariable logistic regression to evaluate a possible association between GI bleeding and stroke recurrence. Results Of the 12 415 patients included in our study, 12.3%, 15.5% and 17.7% had a stroke recurrence at 3, 6 and 12 months, respectively. GI bleeding was an independent stroke recurrence risk factor in patients after ischaemic stroke at 3 months (adjusted OR 1.481, 95% CI 1.118 to 1.962), 6 months (adjusted OR 1.448, 95% CI 1.106 to 1.896) and 12 months (adjusted OR 1.350; 95% CI 1.034 to 1.763). Conclusion GI bleeding was associated with the increased risk of stroke recurrence after an AIS.
    Type of Medium: Online Resource
    ISSN: 2059-8688 , 2059-8696
    URL: Article
    DOI: 10.1136/svn-2019-000314
    Language: English
    Publisher: BMJ
    Publication Date: 2020
    detail.hit.zdb_id: 2847692-X
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  • 10
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    Rationale and design of a stepped wedge cluster randomised trial to improve acute reperfusion treatment quality for stroke: IMPROVE stroke care in China
    BMJ ; 2022
    In:  Stroke and Vascular Neurology Vol. 7, No. 5 ( 2022-10), p. 451-456
    Details
    In: Stroke and Vascular Neurology, BMJ, Vol. 7, No. 5 ( 2022-10), p. 451-456
    Abstract: Reperfusion therapy is the most effective treatment for acute ischaemic stroke (AIS) but remains underutilised in China. There is an urgent need to develop tailored strategies to increase adherence to intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) within the guideline-recommended time window for eligible patients. Aims This study aims to investigate the efficacy of a comprehensive quality improvement intervention on adherence to guideline-recommended reperfusion therapy for patients with AIS in China. Design The Improve Acute Reperfusion Treatment Quality for Stroke in China (IMPROVE Stroke Care in China) trial is designed as a stepped wedge cluster randomised trial within 51 hospitals. We developed the comprehensive intervention ‘STEP’ (Strategies, Toolkit, Exploration, Paradigm) to promote the reconstruction of workflow in stroke centres and shorten in-hospital delay of reperfusion treatment for patients with AIS. The participating hospitals (clusters) were randomised to three groups (cohorts) for different predefined steps to intervention implementation. The primary outcome was the adherent rate of IVT or EVT for eligible patients within the time window. The sample size was estimated to be 7644, and was determined by the number of cases to be enrolled in five study periods to detect a relative increase of 30% (from 19% to 25%) with 90% power and intraclass correlation coefficient of 0.03. All efficacy analyses will be conducted based on the intention-to-treat principle. The primary outcome will be analysed using a mixed-effects logistic regression with a random effect for the cluster (hospital), and a fixed effect for the strategy and period. Conclusions If the efficacy is well established, this targeted comprehensive intervention STEP will inform national strategies to increase adherence to guideline-recommended performance on reperfusion therapy. Trial registration number clinicaltrials.gov Identifier: NCT003578107
    Type of Medium: Online Resource
    ISSN: 2059-8688 , 2059-8696
    URL: Article
    DOI: 10.1136/svn-2021-001461
    Language: English
    Publisher: BMJ
    Publication Date: 2022
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