Stroke management in North Portugal

Acute stroke is an emergency that requires a fast, time-sensitive treatment. If not promptly treated, it may cause severe neurologic impairment, resulting in limited functional status and loss of quality of life.  Therefore, an organized system of care is essential, focusing on prevention primary prevention, prehospital care, acute phase treatment, rehabilitation and community reintegration.  

In Portugal, stroke is the leading cause of death and permanent disability, with an important socioeconomic impact affecting all regions. The Northern Regional Health Administration (ARS Norte) is a political identity responsible for strategic management of population’s health in the north of Portugal, supervising 10 hospital centres and 6 hospitals. These include 7 Primary Stroke Centres offering intravenous thrombolytic treatment and 4 Comprehensive Stroke Centres (CSC) where additionally mechanical thrombectomy can be performed.
A patient with a suspected stroke is transported by an emergency team to the nearest hospital with a structured stroke code. In the hospital the patient is evaluated by a stroke team according to a guideline based care. The patient then performs brain imaging exams and, if indicated, is treated with acute phase therapies, such as intravenous thrombolysis and mechanical thrombectomy (the last one in CSC). This chain sometimes implies hospital transfers that may last minutes to hours, depending on the distance and available means to take the patient from one PSC to a CSC. 

In order to improve the coordination between the several agents involved in the stroke care pathway, ARS Norte created a team with elements from the 11 hospitals. The conception of a local registry became an important initiative to revise current practices and propose new strategies to better treat patients in this region. The participation as an ICTUSnet partner will help to achieve these goals, especially in those patients treated with mechanical thrombectomy. 

Un vistazo a la heterogeneidad de los informes de alta hospitalaria de enfermos diagnosticados con ictus

Una de las tareas del proyecto ICTUSnet es el desarrollo de herramientas de minería de textos (TM) para asistir en el proceso de extracción de información relevante para la evaluación de la calidad asistencial. La información se extrae de los informes de alta hospitalaria de pacientes diagnosticados con ictus y se compila en un registro centralizado. La unidad de Text Mining del Barcelona Supercomputing Center lidera el desarrollo de estas herramientas dentro del proyecto.

Para esta tarea disponíamos de 2696 informes de alta de AQuAS y 611 informes del Hospital Universitario Son Espases (HUSE) y lo primero que hicimos fue seleccionar el subconjunto de informes a anotar para, después, poder entrenar y evaluar los algoritmos de TM.

HUSE da cobertura a la población de las Islas Baleares mientras que los datos de AQuAS proceden de los 26 hospitales que dan cobertura a la población de Cataluña. Así que decidimos usar la proporción de la población a la que da cobertura cada una de las fuentes, con lo que el 13% de los informes que forman el corpus se seleccionaron del HUSE y el 87% de AQuAS .

Para los datos de AQuAS, quisimos mantener también la heterogeneidad (proceden de 26 hospitales distintos), y para ello separamos los documentos en clusters (ver detalles del clustering al final). Este ejercicio nos ha permitido tener una visión de la heterogeneidad de los informes. En el gráfico siguiente podemos ver todos los informes proyectados en el plano donde los colores representan los diferentes cluster (8 en total).

Al mirar con detalle los datos, observamos que los clusters se corresponden de manera bastante fiel a la procedencia de los informes. Así, el cluster verde (2) está constituido exclusivamente por los 164 informes del HUSE, mientras que el cluster rojo (3) contiene 379 informes del hospital K3 que representan el 99.74% del cluster. A su vez, el cluster lila (4) contiene 249 informes del hospital N1 representando el 81,85% del cluster. El cluster naranja (1) está repartido (casi mitad y mitad) por documentos de los hospitales H2 y Z.

El grupo formado por los clusters 0,6 y 7 recoge informes de hasta 24 hospitales diferentes, 19 de los cuales en un porcentaje superior al 90% (es decir, más del 90% de los informes del hospital pertenecen a este grupo).

Observamos una tendencia evidente a la concentración de los informes de un determinado hospital en un único cluster. Así, de media, el 89,6% de los informes de un hospital se concentran en un mismo cluster, siendo la concentración mayor la del 100% y la menor la del 52% (72% si agrupamos los clusters 0, 6 y 7 en un único grupo).

Para realizar el clustering hemos seguidos los siguientes pasos:

Stroke care pathways at CHU de Montpellier

Background design of human feature lines and symbolic elements on the subject of human mind, consciousness, imagination, science and creativity

Multiple randomized controlled trials have recently proved the superiority of mechanical thrombectomy compared to the best medical therapy in patients with recent cerebral infarct and large vessel occlusion in the anterior circulation. There are 6 Stroke Units in the Occitanie-East region, formerly Languedoc-Roussillon. Only one of these units, the Comprehensive Stroke Center (CSC) of the Montpellier hospital, has a centre of interventional neuroradiology (NRI) that can perform mechanical thrombectomy.

Patients with a suspicion of stroke are referred to the nearest stroke unit, then the candidates for mechanical thrombectomy are transferred secondarily to the CSC in Montpellier. Currently, there is no evidence that initial management in a proximity stroke unit and a secondary transfer for a mechanical thrombectomy is associated with a less positive outcome, compared to patients initially treated at the regional stroke centre.

The objective of our local clinical research registry is to compare the clinical outcome of patients first admitted in the CSC of Montpellier with those transferred from the Proximity Stroke Unit. In this way, the implementation of a local database will allow us to generate information and knowledge about stroke patients’ management in our region in order to contribute to the achievement of Ictusnet objectives.

The aim of CHU Montpellier’s participation in ICTUSnet as partners is to describe the management of suspicion of large vessel occlusion in our region, compared to other participating regions. In order to improve stroke patients’ management, we need to evaluate the delay of mechanical thrombectomy and clinical outcome of patients after 3 months

What should we do to overcome barriers in Stroke care and urgent prehospital care?

The organization of acute stroke treatment services at the regional/national level is key to guaranteeing reperfusion therapies reach the whole population.

A recent paper published in the European Stroke Journal (1), the scientific journal of the European Stroke Organization (ESO), describes the results of a recent survey performed in 44 European countries. The majority of the countries have stroke care plans and most of them take responsibility for the organisation/implementation of stroke systems of care (86%), quality of care assessment (77%), and act as a liaison between emergency medical systems and stroke physicians (79%). As for stroke systems of care, the focus is mainly on prehospital and in-hospital acute stroke care (the Code Stroke systems are available in the 84%). The survey also shows that the preferred urgent transport is via non-medicalised ambulances. The paper highlights that the presence of stroke care plans, the availability of stroke registries, the transport of urgent stroke patients via non-medicalised ambulances, and the drip-and-ship routing (the route where patients are firstly assisted at the reference stroke centre, and then sent to the comprehensive stroke centres) of acute patients showed higher reperfusion treatment rates.

However, stroke is not yet a priority everywhere in Europe, which is a barrier to the spread and delivery of high-quality stroke care.

This April, ICTUSnet members will discuss Acute Stroke Care Plans among the different South-western regions in the first ICTUSnet workshop, to be held in Palma de Mallorca. We believe that ICTUSnet project will overcome different barriers by creating a permanent network that promotes collaborative research, incorporates new technologies for data analysis, and fosters mutual learning across SUDOE regions.

  • Abilleira S et al. Planning of stroke care and urgent prehospital care across Europe: Results of the ESO/ESMINT/EAN/SAFE Survey. European Stroke Journal 0(0) 1–8. (Available Online).

Towards a better stroke rehabilitation strategy

According to the paper “Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge” (1), there are many factors that can affect the recovery process after stroke, such as the type of brain lesion, the severity of the stroke, the age of the patient, previous health and functional abilities, social environment and personal motivation. Thus, there is an ongoing need to find the most optimal existing rehabilitation services and therapeutic interventions.

A successful stroke rehabilitation strategy is on the World Health Organisation’s (WHO) agenda. On 2017, WHO made a call for action named “Rehabilitation 2030” with the aim of bringing stakeholders together to discuss the strategic direction for coordinated actions and establishing joint commitments to stress the role of rehabilitation as a health strategy. In line with that, the European Stroke Organisation (ESO), together with the Stroke Alliance For Europe (SAFE), recently released the Action Plan for Stroke in Europe 2018 – 2030, which includes the state of art of stroke rehabilitation in Europe, the research and development priorities in the field, and the targets for 2030.

Rehabilitation is part of the ICTUSnet scope of research. One of the outcomes of the project will be an analysis and comparison of different stroke care models, including rehabilitation and secondary prevention. In particular, this study will result on a report providing detailed information on the gaps and best practices retrieved from the stroke rehabilitation plans of the ICTUSnet regions, covering an area of 20 M inhabitants where strokes are being treated daily.

(1) Richards, C. L., Malouin, F., & Nadeau, S. (2015). Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge. In Progress in brain research (Vol. 218, pp. 253-280). Elsevier.