London, United Kingdom 2013 Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854 693 654 Acute stroke: clinical patterns and practice Non-thrombolysis in acute ischemic stroke: reasons vary in subpopulation and over time T. Reiff1, M. Faouzi2, P. Michel3 Neurological Clinic University of Heidelberg, Heidelberg, GERMANY1, Institute of Social and Preventive Medicine of the Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, SWITZERLAND2, Neurology Service of the Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, SWITZERLAND3 Background : Early intravenous thrombolysis is an effective standard treatment for acute ischemic stroke (AIS), but only a minority of patients receive it. Using prospectively collected thromboly-sis exclusion data of consecutive AIS patients, we aimed at obtaining an updated view of reasons for non-thrombolysis, in particular in subpopulations of early/late arriving patients, with unknown stroke onset. Single vs. multiple reasons and time course of exclusion criteria were evaluated. Methods: We used 2003-2011 data from the Acute STroke Registry and Analysis of Lausanne (AS-TRAL), which includes all AIS admitted within 24 hours after last-well time to a single institution. Frequency of reasons for non-thrombolysis of the 2,019 non-thrombolyzed patients (77.1% of all AIS) were described, and subgroups of patients were compared with multivariate regression analy-ses. Results: The most frequent reasons for not being thrombolysed were admission delays (66.3%), followed by stroke severity (47.9%) and age (14.1%). In the group of patients arriving <180 min, the most frequent reasons were too mild stroke (OR 2.52, p=0.000), too severe stroke (OR 2.92, p=0.016), age >80 (OR 1.96, p=0.000), comorbidity/dependency (OR 1.87, p=0.021), and epileptic seizure (OR 6.14, p=0.019). In the second half of the observation period, significantly less patients were excluded because of too severe stroke (OR 3.71, p=0.028), rapid improvement of stroke symp-toms (OR 6.61, p=0.015) and age>80 (OR 2.75, p=0.000). Yearly thrombolysis rate increased from 9.7% (in 2003) to 33.6% (in 2011). Overall, 2.2% of all patients had no good reason for exclusion. Conclusions: Onset-to-admission delays remain the main exclusion criteria for thrombolysis, em-phasizing the need for better prehospital stroke care and time-independent selection criteria. Simul-taneous reasons other than time are often present, but restrictions based on age, rapidly improving symptoms, and severe stroke became less frequent during the observation period. The better imple-mentation of evidence-based criteria led to increasing thrombolysis rates in AIS. 655 Acute stroke: clinical patterns and practice Attitudes and perceptions of Singapore neurologists on the decision-making and consent pro-cess for intravenous stroke thrombolysis D.A. De Silva1, S. Menon2, A Toh3, D. Oh4, L. Talabucon5 National Neuroscience Institute, Singapore, SINGAPORE1, Duke-National University of Singa-pore, Singapore, SINGAPORE2, Singapore General Hospital, Singapore, SINGAPORE3, National Neuroscience Institute, Singapore, SINGAPORE4, National Neuroscience Institute, Singapore, SIN-GAPORE5 Introduction: Earlier treatment with intravenous stroke thrombolysis improves outcomes and lowers risk of bleeding complications. The decision-making and consent process is a rate-limiting step in the door-to-needle duration. Stroke can render patients mentally incapacitated and unable to make treatment decisions. Under the Singapore Mental Capacity Act, if a patient lacks capacity to make decisions relating to treatment that is life-sustaining or to prevent serious deterioration, the doctor is the final decision-maker. We aimed to describe the attitudes and practices of neurologists in Singa-pore on decision-making and consent processe for stroke thrombolysis. Methods: A survey of neurologists and neurologists-in-training in two large tertiary public hospitals in Singapore was conducted. Results: Of 49 physicians invited to participate, 46 (94%) completed the survey. Among the 46 re-spondents, 94% considered stroke thrombolysis an emergency treatment and 67% indicated a need for written consent. The majority (87%) knew that from a legal perspective, the doctor should be the decision-maker for emergency treatment in a mentally incapacitated patient. However, 63% report-ed it is the next-of-kin who usually makes the thrombolytic treatment decision in actual practice. If confronted with a mentally incapacitated stroke patient, 57% were willing to be the proxy deci-sion- maker, 13% were not, with the remaining 30% being ambivalent. In three commonly encoun-tered vignettes, there was no clear consensus in what the respondents thought the consent practice for stroke thrombolysis should be. Conclusions: The next-of-kin is usually the decision-maker for stroke thrombolysis for a mentally incapacitated patient despite most doctors considering thrombolysis an emergency treatment. This, together with the lack of consensus in decision-making and consent practice demonstrates the need for guidelines to standardize practices for greater consistency in health service delivery.
Karger_ESC London_2013
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