E. D. W. Loh, Gabriel Yi Ren Kwok, Keith Zhi-Xian Toh, Ming-Yi Koh, Y. Teo, Y. N. Teo, B. Chan, V. Sharma, Megan Bi-Jia Ng, Hui Shi Lim, B. Soon, A. Gopinathan, Cunli Yang, C. Sia, P. Bhogal, P. Brouwer, L. Meyer, J. Fiehler, T. Andersson, B. Tan, L. Yeo
{"title":"Thrombectomy for distal medium vessel occlusion stroke: Combined vs. single-device techniques - A systematic review and meta-analysis","authors":"E. D. W. Loh, Gabriel Yi Ren Kwok, Keith Zhi-Xian Toh, Ming-Yi Koh, Y. Teo, Y. N. Teo, B. Chan, V. Sharma, Megan Bi-Jia Ng, Hui Shi Lim, B. Soon, A. Gopinathan, Cunli Yang, C. Sia, P. Bhogal, P. Brouwer, L. Meyer, J. Fiehler, T. Andersson, B. Tan, L. Yeo","doi":"10.3389/fstro.2023.1126130","DOIUrl":"https://doi.org/10.3389/fstro.2023.1126130","url":null,"abstract":"Background The optimal mechanical thrombectomy technique for acute ischaemic stroke (AIS) caused by distal, medium vessel occlusion (DMVO) is uncertain. We performed a systematic review and meta-analysis evaluating the efficacy and safety of first-line thrombectomy with combined techniques, which entail simultaneous use of a stent retriever and aspiration catheter, vs. single-device techniques, whether stent retriever or direct aspiration alone, for DMVO-AIS patients. Methods We systematically searched the PubMed, Embase and Cochrane CENTRAL databases from inception until 2 September 2022 for studies comparing combined and single-device techniques in DMVO-AIS patients. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Our outcomes were the modified first-pass effect [mFPE; modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3 at first-pass], first-pass effect (FPE; mTICI 2c-3 at first-pass), successful and complete final reperfusion (mTICI 2b-3 and 2c-3 at end of all procedures, respectively), 90-day functional independence (modified Rankin scale 0-2), 90-day mortality, and symptomatic intracranial hemorrhage (sICH). Results Nine studies were included, with 477 patients receiving combined techniques, and 670 patients receiving single-device thrombectomy. Combined techniques achieved significantly higher odds of mFPE [odds ratio (OR), 2.12; 95% confidence interval (CI), 1.12–4.02; p = 0.021] and FPE (OR, 3.55; 95% CI, 1.97–6.38; p < 0.001), with lower odds of sICH (OR, 0.23; 95% CI 0.06–0.93; p = 0.040). There were no significant differences in final reperfusion, functional independence (OR, 1.19; 95% CI 0.87–1.63; p = 0.658), or mortality (OR, 0.94; 95% CI, 0.50–1.76; p = 0.850). Conclusions In DMVO-AIS patients, mechanical thrombectomy combining stent retrievers and aspiration catheters achieved higher odds of FPE and lower odds of sICH over single-device techniques. There were no differences in functional independence and mortality. Further trials are warranted to establish these findings. Systematic review registration https://www.crd.york.ac.uk/prospero/display_recor d.php?ID=CRD42022370160, identifier: CRD42022370160.","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"65 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-01-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80350226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Paulette D. Orhii, M. Haque, M. Fujita, S. Selvaraj
{"title":"Advances in PET imaging of ischemic stroke","authors":"Paulette D. Orhii, M. Haque, M. Fujita, S. Selvaraj","doi":"10.3389/fstro.2022.1093386","DOIUrl":"https://doi.org/10.3389/fstro.2022.1093386","url":null,"abstract":"Ischemic strokes make up 87% of all cerebrovascular events. Intravenous tissue plasminogen activator (tPA), a thrombolytic agent, has been recognized as the only viable option for patients with ischemic stroke if administered within 3.5 h of onset and increases the risk of hemorrhagic transformation if administered beyond the treatment window. Acute treatment strategies are centered around rescuing salvageable penumbra. Molecular imaging using positron emission tomography (PET) has shown higher sensitivity and specificity than CT and MRI in delineating penumbral tissues. In addition, PET imaging has identified the role of key inflammatory mediators in atherosclerosis, cellular damage, and recovery. Recently, a novel PET imaging study has shown the feasibility of investigating synaptic density in subacute stroke. Lastly, novel PET radiotracers have been developed to further explore biochemical mechanisms implicated in stroke pathophysiology. Further investigation with PET is needed to understand stroke mechanisms and advance pharmacologic treatment.","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82335027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Frontiers in strokePub Date : 2023-01-01Epub Date: 2023-06-07DOI: 10.3389/fstro.2023.1172854
Youngran Kim, Maria A Parekh, Xiaojin Li, Yan Huang, Guo-Qiang Zhang, Bharti Manwani
{"title":"Age and sex-specific stroke epidemiology in COVID-19.","authors":"Youngran Kim, Maria A Parekh, Xiaojin Li, Yan Huang, Guo-Qiang Zhang, Bharti Manwani","doi":"10.3389/fstro.2023.1172854","DOIUrl":"10.3389/fstro.2023.1172854","url":null,"abstract":"<p><strong>Background: </strong>COVID-19 has emerged as an independent risk factor for stroke. We aimed to determine age and sex-specific stroke incidence and risk factors with COVID-19 in the US using a large electronic health record (EHR) that included both inpatients and outpatients.</p><p><strong>Methods: </strong>A retrospective cohort study was conducted using individual-level data from Optum<sup>®</sup> de-identified COVID-19 EHR. A total of 387,330 individuals aged ≥18 with laboratory-confirmed COVID-19 between March 1, 2020 and December 31, 2020 were included. The primary outcome was cumulative incidence of stroke after COVID-19 confirmation within 180 days of follow-up or until death. Kaplan-Meier cumulative incidence curves for acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and a composite outcome of all strokes were stratified by sex and age, and the differences in curves were assessed using a log-rank test. The relative risk of stroke by demographics and risk factors was estimated using multivariable Cox-proportional hazards regressions and adjusted hazard ratios (aHRs).</p><p><strong>Results: </strong>Of 387,330 COVID-19 patients, 2,752 patients (0.71%, 95% CI 0.68-0.74) developed stroke during the 180-day follow-up, AIS in 0.65% (95% CI 0.62-0.67), and ICH in 0.11% (95% CI 0.10-0.12). Of strokes among COVID-19 patients, 57% occurred within 3 days. Advanced age was associated with a substantially higher stroke risk, with aHR 6.92 (5.72-8.38) for ages 65-74, 9.42 (7.74-11.47) for ages 75-84, and 11.35 (9.20-14.00) for ages 85 and older compared to ages 18-44 years. Men had a 32% higher risk of stroke compared to women. African-American [aHR 1.78 (1.61-1.97)] and Hispanic patients [aHR 1.48 (1.30-1.69)] with COVID-19 had an increased risk of stroke compared to white patients.</p><p><strong>Conclusion: </strong>This study has several important findings. AIS and ICH risk in patients with COVID-19 is highest in the first 3 days of COVID-19 positivity; this risk decreases with time. The incidence of stroke in patients with COVID-19 (both inpatient and outpatient) is 0.65% for AIS and 0.11% for ICH during the 180-day follow-up. Traditional stroke risk factors increase the risk of stroke in patients with COVID-19. Male sex is an independent risk factor for stroke in COVID-19 patients across all age groups. African-American and Hispanic patients have a higher risk of stroke from COVID-19.</p>","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"163 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11600532/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86296613","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Frontiers in strokePub Date : 2023-01-01Epub Date: 2023-06-15DOI: 10.3389/fstro.2023.1192465
A Parker Ruhl, Neal Jeffries, Yu Yang, Steven D Brooks, Rakhi P Naik, Lydia H Pecker, Bryan T Mott, Cheryl A Winkler, Nicole D Armstrong, Neil A Zakai, Orlando M Gutierrez, Suzanne E Judd, Virginia J Howard, George Howard, Marguerite R Irvin, Mary Cushman, Hans C Ackerman
{"title":"Alpha globin gene copy number and incident ischemic stroke risk among Black Americans.","authors":"A Parker Ruhl, Neal Jeffries, Yu Yang, Steven D Brooks, Rakhi P Naik, Lydia H Pecker, Bryan T Mott, Cheryl A Winkler, Nicole D Armstrong, Neil A Zakai, Orlando M Gutierrez, Suzanne E Judd, Virginia J Howard, George Howard, Marguerite R Irvin, Mary Cushman, Hans C Ackerman","doi":"10.3389/fstro.2023.1192465","DOIUrl":"10.3389/fstro.2023.1192465","url":null,"abstract":"<p><strong>Introduction: </strong>People with African ancestry have greater stroke risk and greater heritability of stroke risk than people of other ancestries. Given the importance of nitric oxide (NO) in stroke, and recent evidence that alpha globin restricts nitric oxide release from vascular endothelial cells, we hypothesized that alpha globin gene (<i>HBA)</i> deletion would be associated with reduced risk of incident ischemic stroke.</p><p><strong>Methods: </strong>We evaluated 8,947 participants self-reporting African ancestry in the national, prospective Reasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Incident ischemic stroke was defined as non-hemorrhagic stroke with focal neurological deficit lasting ≥ 24 hours confirmed by the medical record or focal or non-focal neurological deficit with positive imaging confirmed with medical records. Genomic DNA was analyzed using droplet digital PCR to determine <i>HBA</i> copy number. Multivariable Cox proportional hazards regression was used to estimate the hazard ratio (HR) of <i>HBA</i> copy number on time to first ischemic stroke.</p><p><strong>Results: </strong>Four-hundred seventy-nine (5.3%) participants had an incident ischemic stroke over a median (IQR) of 11.0 (5.7, 14.0) years' follow-up. <i>HBA</i> copy number ranged from 2 to 6: 368 (4%) -α/-α, 2,480 (28%) -α/αα, 6,014 (67%) αα/αα, 83 (1%) ααα/αα and 2 (<1%) ααα/ααα. The adjusted HR of ischemic stroke with <i>HBA</i> copy number was 1.04; 95%CI 0.89, 1.21; p = 0.66.</p><p><strong>Conclusions: </strong>Although a reduction in <i>HBA</i> copy number is expected to increase endothelial nitric oxide signaling in the human vascular endothelium, <i>HBA</i> copy number was not associated with incident ischemic stroke in this large cohort of Black Americans.</p>","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"2 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10448705/pdf/nihms-1920712.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10141852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Frontiers in strokePub Date : 2023-01-01Epub Date: 2023-08-02DOI: 10.3389/fstro.2023.1238442
Hannah Gardener, Jose G Romano, Terry Derias, Carolina Gutierrez, Negar Asdaghi, Karlon Johnson, Gillian Gordon Perue, Erika Marulanda, Scott C Brown, Dianne Foster, Tatjana Rundek
{"title":"Early hospital readmission following stroke: the Florida Stroke Registry.","authors":"Hannah Gardener, Jose G Romano, Terry Derias, Carolina Gutierrez, Negar Asdaghi, Karlon Johnson, Gillian Gordon Perue, Erika Marulanda, Scott C Brown, Dianne Foster, Tatjana Rundek","doi":"10.3389/fstro.2023.1238442","DOIUrl":"10.3389/fstro.2023.1238442","url":null,"abstract":"<p><strong>Background: </strong>Hospital readmission is an important indicator of poor transition of care post-stroke. Data on characteristics of patients at highest risk for readmission is limited and necessary to inform effective interventions. The goal is to identify risk factors at hospital discharge that predict 30-day readmission in the Florida Stroke Registry (FSR).</p><p><strong>Methods: </strong>The study population included 45,877 patients discharged home or to rehabilitation with an ischemic stroke or intracerebral hemorrhage in the FSR between 2017 and 2019. The FSR is a voluntary statewide registry of stroke patients from 167 hospitals using data from Get With the Guideline-Stroke. Readmissions were ascertained by propensity matching FSR with the Florida Agency for Healthcare Administration dataset, which includes all hospital admissions in Florida. The primary outcome was 30-day hospital readmission for any cause, and secondary outcomes were vascular-related and stroke readmissions specifically. Multivariable logistic regression models identified patient characteristics that independently predicted 30-day readmissions, including sociodemographics, stroke clinical characteristics, in-hospital treatment, medical history, discharge status, and hospital characteristics.</p><p><strong>Results: </strong>A hospital readmission within 30 days was experienced in 12% of cases; 6% had a vascular-related readmission, and 3% a recurrent stroke. The following characteristics were independently associated with an increased risk of all-cause readmission: Medicare or Medicaid insurance, large artery atherosclerosis as the stroke mechanism, increased stroke severity, diabetes, atrial fibrillation, peripheral vascular disease, coronary artery disease, prior stroke, chronic renal insufficiency, and depression. The following characteristics were independently associated with a decreased risk of all-cause readmission: ambulation, treated dyslipidemia, tPA treatment, discharge mRS 0-2, and treatment at a comprehensive stroke center.</p><p><strong>Conclusions: </strong>The risk of 30-day hospital readmission was substantial, modifiable, and impacted by insurance status, medical history, stroke etiology and severity, stroke care, and functional status at discharge. These findings can inform strategies to target high-risk patients who can benefit from interventions to improve transitions of care post-stroke.</p>","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"51 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12263112/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87548725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Julia Emde, Romy Baumgart, Niklas Langguth, M. Juenemann, S. Gerner
{"title":"Intravenous thrombolysis in ischemic stroke patients based on non-contrast CT in the extended time-window","authors":"Julia Emde, Romy Baumgart, Niklas Langguth, M. Juenemann, S. Gerner","doi":"10.3389/fstro.2022.1026138","DOIUrl":"https://doi.org/10.3389/fstro.2022.1026138","url":null,"abstract":"Purpose of review Recent trials provided evidence for safety and efficacy of intravenous thrombolytic therapy (IVT) in ischemic stroke patients beyond the 4.5 h time-window if ischemic penumbra is present in multimodal imaging. However, advanced imaging by either Magnet Resonance Imaging (MRI) or Computed Tomography Perfusion (CTP) is not available 24/7 at most stroke-centers. Therefore, the current review addresses the use of non-contrast CT (NCCT) to identify ischemic stroke patients suitable for IVT in the unknown or extended time-window in terms of efficacy and safety. Recent findings The current data on NCCT based IVT strategies in ischemic stroke patients presenting in the unknown or late time-window are relatively scarce and mainly provided by small retrospective samples. One larger registry (TRUST-CT) underlines the safety and efficacy of IVT without advanced imaging with more IVT-patients reaching an excellent outcome compared to the non-IVT treated control group. Current meta-analysis provides evidence that the rate of symptomatic intracerebral hemorrhage (sICH) is similar in the wake-up and unknown onset time-window compared to the 4.5 h time-window if patients are selected by NCCT. Results of the upcoming TWIST-trial investigating Tenecteplase (TNK) for NCCT-based IVT revealed no signals regarding an increased rate of sICH, however there was no benefit regarding functional outcomes. Summary So far, it is not well-established whether advanced imaging is indispensable and NCCT could be sufficient to identify stroke patients in the extended window who would benefit from IVT-treatment. However, current data suggests the safety of NCCT-based IVT in the extended time-window. Therefore, unavailable advanced neuroimaging should not cause delay, or even exclusion of patients from IVT and other recanalizing therapies per se.","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"52 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-11-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78311950","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Linda Ma, Silin Wu, A. Gusdon, Hua Chen, Heng Hu, Atzhiry Paz, J. Aronowski, J. Savarraj, Ryan S. Kitagawa, HUIMAHN A. Choi, Xuefang Ren
{"title":"Cathepsin L and acute ischemic stroke: A mini-review","authors":"Linda Ma, Silin Wu, A. Gusdon, Hua Chen, Heng Hu, Atzhiry Paz, J. Aronowski, J. Savarraj, Ryan S. Kitagawa, HUIMAHN A. Choi, Xuefang Ren","doi":"10.3389/fstro.2022.1050536","DOIUrl":"https://doi.org/10.3389/fstro.2022.1050536","url":null,"abstract":"Ischemic stroke is a serious cerebrovascular event that results in cell death, blood-brain barrier dysfunction, tissue degradation, and inflammation, often leading to permanent disability or death. As the incidence of ischemic stroke continues to rise globally, it is crucial to examine the mechanisms of the various proteins and molecules contributing to worsened patient outcome and recovery. Cathepsin L, a cysteine protease known for degrading tissues in lysosomes and elsewhere, may play a role in brain tissue loss and inflammation after stroke. Studies have suggested that cathepsin L appears in the ischemic core shortly after stroke is induced. Using immunohistochemical staining, mass spectrometry, and other assays, the increase of cathepsin L in the brain was correlated with extracellular matrix and perlecan degradation after ischemic stroke. Additionally, injection of a cathepsin L inhibitor significantly reduced brain infarct size and improved functional scores. More research is needed to elucidate cathepsin L's role in post-stroke inflammation and brain damage, in order to further explore the factors contributing to worsened patient outcome after ischemic stroke and work toward finding better therapeutic interventions.","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"20 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78546646","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. Kamal, Shadi Aljendi, Alix J. E. Carter, E. Cora, Tania Chandler, F. Clift, P. Fok, J. Goldstein, G. Gubitz, Michael D. Hill, B. Menon, Brian Metcalfe, K. Mrklas, S. Phillips, S. Theriault, E. van der Linde, D. Volders, H. Williams
{"title":"Improving access and efficiency of ischemic stroke treatment across four Canadian provinces using a stepped wedge trial: Methodology","authors":"N. Kamal, Shadi Aljendi, Alix J. E. Carter, E. Cora, Tania Chandler, F. Clift, P. Fok, J. Goldstein, G. Gubitz, Michael D. Hill, B. Menon, Brian Metcalfe, K. Mrklas, S. Phillips, S. Theriault, E. van der Linde, D. Volders, H. Williams","doi":"10.3389/fstro.2022.1014480","DOIUrl":"https://doi.org/10.3389/fstro.2022.1014480","url":null,"abstract":"Introduction Ischemic stroke is treatable with thrombolysis and/or endovascular treatment. Both treatments are highly time dependent, as faster treatment results in better outcomes. Utilization of both of these treatments is less than optimal, and treatment times continue to exceed the recommended benchmarks. An improvement intervention was launched across Atlantic Canada, which has four provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PEI), and Newfoundland and Labrador (NL). The intervention was conducted through the ACTEAST (Atlantic Canada Together Enhancing Acute Stroke Treatment) Project, which aimed to improve access and efficiency of treatment for acute ischemic stroke patients. Intervention and methods The improvement intervention was a 6-month virtual Improvement Collaborative that consisted of each stroke center assembling an interdisciplinary team, 2 full-day Learning Sessions, five to six 1-h webinars, and a site visit for each team. The Improvement Collaborative intervention was implemented using a stepped-wedge trial design, where the intervention was delivered in 3 phases. The Improvement Collaborative was initially conducted with NS, followed by NB and PEI, and the final phase was with NL. The number of participants enrolled across all 34 hospitals were 98, 86, and 72 for NS, NB-PEI, and NL, respectively. The attendance at the Learning Sessions ranged from 43 to 81 across all 3 clusters. The attendance at webinars had a mean of 29.0 (SD 6.8), 26.0 (SD 6.3), and 19.0 (SD 8.5) for the NS, NB-PEI, and NL clusters respectively. (Anticipated) Results We anticipate that an additional 3–5% of ischemic stroke patients will receive thrombolysis, EVT, or both. Additionally, we anticipate a reduction of 10–15 min in door-to-needle times across the region. This will translate to an increase in the proportion of ischemic stroke patients that will be discharged home from acute care. Discussion High level of engagement is possible in an Improvement Collaborative Intervention when implemented using a stepped-wedge trial design. The highest level of engagement was observed in the NS cluster, which maybe because this province has the most established provincial stroke system. Physician engagement, a critical aspect of improvement, was high. COVID-19 restrictions likely led to lower attendance at site visits.","PeriodicalId":73108,"journal":{"name":"Frontiers in stroke","volume":"46 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73429870","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}