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Comprehensive stroke centre Primary stroke centre • Advanced thrombolytic capability, including endovascular treatment • Capability to provide acute medical thrombolysis (i.e., intravenous administration of tissue plasminogen activator) • Neurosurgical capability • Stroke unit care • Stroke unit care • Interdisciplinary stroke team (but may not be as complete or available as in a comprehensive centre) • Advanced neurovascular imaging capability • Computed tomography on site • Interdisciplinary stroke team • Responsibility for stroke service within a site • Responsibility for stroke service coordination across a region - Table 1: Numbers of hospitals and patients with stroke identified in a national chart audit involving all 10 Canadian provinces during the study period
Province Total Eligible hospitals only Final sample No. of hospitals No. of admissions for stroke No. of hospitals No. of admissions for stroke British Columbia 81 5 690 46 5 446 1 198 Alberta 88 3 668 22 3 194 880 Saskatchewan 61 1 787 13 1 385 271 Manitoba 57 1 633 7 1 030 231 Ontario 145 16 589 103 15 076 2 567 Quebec 101 10 633 66 8 773 1 621 New Brunswick 22 1 419 12 1 293 1 007 Nova Scotia 32 1 191 12 1 108 998 Prince Edward Island 7 231 4 239 212 Newfoundland and Labrador 30 810 10 666 603 Totals 624 43 651 295 38 210 9 588 - Table 2: Proportion of patients with stroke who presented to Canadian hospitals who received thrombolysis during the study period
Type of stroke, hospital Unweighted Weighted sample n/N n/N* % (95% CI) Overall 480/9 588 2 049/38 206 5.4 (5.1–5.6) Ischemic stroke† 480/8 464 2 049/33 561 6.1 (5.8–6.4) Comprehensive stroke centre 297/3 175 1 364/12 400 11.0 (10.4–11.6) Primary stroke centre 162/2 869 569/10 008 5.7 (5.2–6.2) Other 21/2 420 116/11 153 1.0 (0.8–1.2) Note: CI = confidence interval. *Weighted sample. †Ischemic stroke = all stroke less hemorrhagic stroke types.
- Table 3: Clinical and treatment characteristics of Canadian patients presenting with acute ischemic stroke who received thrombolysis during the study period
Characteristic Proportion of patients, %* Comprehensive stroke centre
n = 297
N, weighted = 1363.8 (66.5%)Primary stroke centre
n = 162
N, weighted = 569.4 (27.8%)Other n = 21
N, weighted = 116.3 (5.7%)Overall
n = 480
N, weighted = 2049.5Age ≥ 70 yr 60.2 55.1 73.9 59.5 Female sex 45.4 45.2 48.7 45.5 Hypertension, % 67.0 65.2 77.3 67.1 Atrial fibrillation 21.4 16.7 14.1 19.7 Diabetes mellitus 22.0 14.3 15.1 19.4 Previous stroke 16.1 23.2 11.5 17.8 Coronary artery disease 31.5 15.5 67.2 29.1 Current smoker 15.5 10.0 36.4 16.1 Peripheral vascular disease 2.4 1.3 18.1 3.0 Prestroke independence 73.8 71.5 55.7 72.1 CNS score ≤ 8 70.9 70.9 55.7 70.0 Arrival by ambulance 96.2 83.4 69.7 91.2 Interval, h, mean ± SE Onset to arrival 3.3 ± 1.1† 5.1 ± 0.8† 32.2 ± 5.7† 5.4 ± 0.8 Arrival to imaging 0.7 ± 0.1 3.4 ± 2.7 4.4 1.5 ± 0.7 Onset to treatment 4.6 ±1.1 3.4 ± 0.3 2.9 ± 0.1 4.2 ± 0.7 Interval, min, mean ± SE Imaging to treatment 79.0 ± 8.6 71.9 ± 4.9 84.4 77.2 ± 6.3 Arrival to treatment 138.1 ± 17.7 100.9 ± 15.3 112.7 ± 1.9 121.1 ± 11.4 Note: CAD = coronary artery disease, CNS = Canadian neurological scale, SE = standard error. *Unless otherwise stated. †Statistically significant difference between the 3 groups (p < 0.001). Primary centre compared with comprehensive centre (p = 0.05). Other intervals were not significantly different.
- Table 4: Outcomes in Canadian patients presenting with acute ischemic stroke who received thrombolysis during the study period
Proportion of patients, %* Outcome Comprehensive stroke centre
n = 297
N, weighted = 1363.8 (66.5%)Primary stroke centre
n = 162
N, weighted = 569.4 (27.8%)Other
n = 21
N, weighted = 116.3 (5.7%)All hospitals
n = 480
N, weighted = 2049.5p value† In-hospital death at 7 d 7.2 8.3 5.2 7.4 0.5 In-hospital death at 30 d 13.3 15.1 10.8 13.6 0.4 Hemorrhagic transformation 8.0 7.2 — 7.3 0.006 Length of stay, d, mean ± SE 15.7 ± 1.3 16.7 ± 4.7 15.7 ± 2.5 16 ± 1.6 < 1.0 Note: SE = standard error. *Unless otherwise stated †Test of proportions among 3 groups; length of stay was assessed by analysis of variance. The only difference between groups was seen on hemorrhagic transformation because no hemorrhages occurred in one group with a very small sample.
- Table 5: Reasons documented for not giving thrombolysis to patients with ischemic stroke presenting to Canadian hospitals during the study period, by hospital type
Reasons Proportion of patients, % Comprehensive stroke centre
n = 2878
N, weighted = 11036.8Primary stroke centre
n = 2707
N, weighted = 9439.1Other
n = 2399
N, weighted = 11036.6All hospitals
n = 7984
N, weighted = 31512.5Interval from onset of symptoms to arrival > 4.5 h* 48.8 35.3 41.6 42.3 Neurological deficit judged too mild 26.6 22.0 24.3 24.4 Neurological deficit judged too severe 3.4 2.7 3.5 3.2 Clear medical contraindication 6.6 4.3 3.4 4.8 Delayed decision 0.2 0.3 0.3 0.3 Documented physician decision 6.4 8.0 5.3 6.5 Not documented 20.0 29.7 26.9 25.3 *During the study period, guidelines changed from a 3-hour window for stroke thrombolysis to a 4.5-hour window based on new randomized trials. Thus, the proportion of patients who received treatment may be appropriately conservative.