(Stroke. 2001;32:63.)
© 2001 American Heart Association, Inc.
Original Contributions |
Delay in Presentation and Evaluation for Acute Stroke
Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.)
From the Center for Disease Management and Clinical Outcomes, University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, New Brunswick, NJ (C.R.L., M.B., J.B.K.); Robert Wood Johnson University Hospital, New Brunswick, NJ (C.R.L., M.B., J.B.K.); Robert Wood Johnson Health System, New Brunswick, NJ (C.R.L.); and Rutgers–The State University of New Jersey, College of Pharmacy, Piscataway, NJ (C.R.L., D.-C.S.).
Correspondence to Clifton R. Lacy, MD, Division of Cardiovascular Diseases and Hypertension, UMDNJ–Robert Wood Johnson Medical School, One Robert Wood Johnson Pl, New Brunswick, NJ 08903-0019. E-mail lacycr{at}umdnj.edu
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Background and Purpose—Early treatment is a critical determinant of successful intervention in acute stroke. The study was designed to find current patterns of stroke care by determining delays in time from onset of signs or symptoms to arrival at the emergency department and to initial evaluation by physicians and by identifying factors associated with these delays.
Methods—Data were prospectively collected by nurses and physicians from patients, patients’ family members, and medical records from 10 hospitals of the Robert Wood Johnson Health System in New Jersey.
Results—A total of 553 patients who presented with signs or symptoms of acute stroke were studied. Thirty-two percent of patients arrived at the emergency department within 1.5 hours of stroke onset. Forty-six percent of patients arrived within 3 hours and 61% within 6 hours. Delays in arrival time were significantly associated with sex, race, transportation mode, and history of cardiovascular disease. Patients arriving by ambulance were more likely to present earlier (odds ratio [OR] 3.7 for arrival within 3 hours; OR 4.5 for arrival within 6 hours). Patients arriving by ambulance (OR 2.3 within 15 minutes; OR 1.7 within 30 minutes) and those requiring admission to intensive care units (OR 4.5 within 15 minutes and OR 5.2 within 30 minutes) were examined sooner by physicians.
Conclusions—Despite national efforts to promote prompt stroke evaluation and treatment, significant delays still exist. The lack of improvement throughout the past decade underscores the need for implementation of effective public health programs designed to minimize the time to evaluation and treatment of stroke.
Key Words: emergency service, hospital • registries • stroke, acute
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Stroke is one of the leading causes of death and serious, long-term disability in the United States, annually affecting
600 000 people and causing
160 000 deaths—the third most common cause of death after heart
disease and cancer.1 The
economic burden of stroke on society was estimated to be $45 billion in
1999, with direct costs (ie, hospitals, physicians, rehabilitation, and
pharmaceuticals) amounting to $29 billion and indirect costs such as
lost productivity totaling $16
billion.1 Early treatment is crucial in maximizing the benefit of stroke intervention. Effective thrombolytic therapy is dependent on timely intervention,2 3 4 5 and guidelines for use of recombinant tissue plasminogen activator recommend therapy within 3 hours after onset of stroke symptoms.6 Clinical studies suggest that cerebral ischemia persisting >6 hours results in permanent neurological damage.7 Thus, early hospital arrival is critical to successful stroke treatment.
Several studies have demonstrated delays in stroke care,2 3 4 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 but only few have attempted to study the determinants of delay. In addition, these studies were conducted in small geographic areas and yielded conflicting results. This study, conducted at 10 New Jersey hospitals, prospectively investigated factors associated with the time delay from onset of stroke signs or symptoms to arrival at the emergency department (ED) and time from arrival at the ED to patient evaluation.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Hospital Setting and Patients
The study was conducted at the 10 hospitals of the Robert Wood Johnson Health System, located in 5 counties in New Jersey, spanning the spectrum from tertiary care academic health centers to general community hospitals, and ranging in size from 134 to 453 beds.
All patients with signs or symptoms of acute stroke who arrived at the EDs of study hospitals were included. Patients whose stroke occurred during inpatient hospitalization were excluded from the analysis.
Data Collection
Data were prospectively collected by nurses and
physicians from patients, patients’ family members, and medical
records between September 1, 1996, and March 31, 1997. Time from
onset of stroke signs or symptoms to arrival at the ED was
recorded. Stroke onset was defined as the time a neurological
deficit was first noticed by the patient or an observer. If symptoms
were present on awakening, the stroke onset time was considered to
be the time the patient fell asleep. The time delay to first physician
evaluation was defined as the interval between the ED arrival time and
physician examination.
Statistical Analyses
Statistical analyses were conducted with the
use of SAS statistical
software.23 Two principal
sets of time intervals were analyzed: time from onset of stroke
signs or symptoms to arrival at the ED and time from arrival at the ED
to physician evaluation. Time windows of arrival at the ED more than 3
and 6 hours as well as time windows for evaluation at the ED after 15
and 30 minutes were prospectively determined for data
analysis.
A panel of 4 senior hospital staff prospectively classified study hospitals into 3 levels of complexity (low, middle, and high) based on size (number of beds), types of services offered (eg, open heart surgery, trauma center), case mix index for hospital services, and teaching versus nonteaching status.
Univariate odds ratios (ORs) were calculated for each patient’s demographics, mode of transportation to the ED, history of cardiovascular disease, and hospital complexity in relation to ED arrival and initial evaluation times. The number of past cardiovascular disease diagnoses was included as a proxy for the degree of cardiovascular health impairment.
Study models were constructed by means of logistic regression to evaluate the effect of patient characteristics and other variables on the likelihood of time delay to arrival and evaluation after onset of stroke. A forward stepwise logistic regression model was constructed at a significance level of 0.2 for variable entry into the model.24 When any of the variables were selected by the use of the forward procedure, then variables associated with characteristics of the variable were included in the model. ORs and 95% confidence intervals (CI) were calculated from the logistic coefficients of the variables.
Logistic regression was also used to analyze the time interval from arrival at the ED to the initial physician evaluation by means of the variables that were assumed to affect this time period.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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Patient Characteristics
Characteristics of the study patients are shown in Table 1
. A total of 553 patients were studied. As the
result of missing information, the number of patients observed in each
category was less than the total number of patients studied. Each of
the 10 hospitals contributed between 20 and 79 subjects to the study.
The mean age was 73.4 years, and 53% of patients were women. Almost
half (49%) of the patients were married, 36% were widowed, 12%
single, and 3% divorced. Eighty-one percent of patients were white,
12% were black, 3% were Hispanic, and 3% were Asian. Eighty-nine
percent of patients were not employed. Seventy-four percent of patients
were insured by Medicare, 10% by commercial insurance, 6% in managed
care, and 6% were not insured.
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Two-thirds of patients arrived at the hospital by ambulance. The most common type of stroke observed was ischemic (53%). A history of cerebrovascular accident was reported in 30%, transient ischemic attack in 16%, atrial fibrillation in 14%, myocardial infarction in 13%, and congestive heart failure in 12% of patients.
Time to Emergency Department Arrival
The
Figure
illustrates the distribution of arrival time at the ED by age.
Thirty-two percent of patients arrived at the ED within 1.5 hours of
stroke onset. Forty-six percent of patients arrived within 3 hours
after onset of symptoms, and 61% arrived within 6 hours. Forty-nine
percent of patients 
65 years of age and 34% of patients <65 years
of age arrived within 3 hours of stroke onset. Sixty-three percent of
patients 65 years of age and 52% of patients <65 years of age
arrived within 6 hours of stroke onset.
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Table 2 shows the relation between arrival time at the ED
after the onset of stroke signs or symptoms and study variables
such as age, sex, race, and mode of transportation to the ED. Marital
status, employment status, and insurance type are not presented
because these variables did not significantly influence arrival
time at the ED.
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Univariate ORs were calculated for arrival times
at the ED within 3 and 6 hours. In general, patients >55 years of age
were more likely to arrive within 3 hours than were younger patients.
Although analysis of all age groups does not show a
statistically significant difference at 6 hours, patients 65 years of
age were more likely to arrive earlier than were younger patients.
There was no statistically significant sex difference with respect to
arrival within 3 hours, but female patients were more likely than male
patients to arrive within 6 hours
(P=0.038).
Black patients had a significantly greater likelihood of arriving later than did white patients within the 3-hour time window (P=0.024) but did not arrive significantly later within the 6-hour interval. The mode of transportation significantly affected time to arrival at the ED. Patients who arrived by using their own vehicles tended to arrive later than those who arrived by ambulance at both the 3-hour and 6-hour intervals (P=0.0001).
Patients with a history of atrial fibrillation or
congestive heart failure were statistically more likely to arrive
earlier than patients with no history of these diseases at both the
3-hour (P=0.002,
P=0.001, respectively) and the
6-hour intervals (P=0.001,
P=0.002). Patients with
previous cerebrovascular accident, transient ischemic attack,
or myocardial infarction tended to have a shorter time to arrival than
those patients without such a history at the 3-hour interval, but these
trends were not statistically significant. Patients with a history of
2 cardiovascular diagnoses were more likely to arrive
within 3 hours than patients without a history of such disease
(P=0.004).
The adjusted ORs calculated by multiple logistic regression
models are also presented in
Table 2
. In general, the adjusted ORs in the model were
similar to the ORs obtained from the univariate
analysis. In this analysis, patients >55 years of age
were more likely to arrive within 3 hours than were younger patients.
Patients 65 to 74 years of age were more likely to arrive within 3
hours, which is significantly earlier than patients 
55 years of age
(P=0.039). With the 6-hour
cutoff, only patients 65 to 74 years of age were more likely to arrive
earlier than were patients <55 years, but this trend was not
statistically significant when controlling for other variables in
the model. The mode of transportation was significantly associated with
delay (P=0.0001 for 3-hour and
6-hour intervals). Patients with history of 2
cardiovascular diagnoses were more likely to arrive
earlier than patients without a history of such disease
(P=0.046 for 3 hours and
P=0.009 for 6
hours).
Waiting Time for Initial Examination by
Physicians
The univariate ORs of time interval from
arrival at the ED to initial physician evaluation are presented
in
Table 3. Because the waiting time for the initial physician
examination was not significantly influenced by patient age, this
variable was not presented in the Table. Hispanic patients
were significantly more likely to be seen by physicians later than 15
minutes after arrival than were white patients
(P=0.004). Medicaid patients
also had a higher probability of being examined by physicians beyond
the 15-minute or 30-minute mark when compared with Medicare patients
(P=0.047). Increasing hospital
complexity was significantly associated with delays in physician
examination at both 15- and 30-minute intervals.
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Patients who were admitted to the intensive care unit (ICU) were examined significantly earlier than those who were admitted to medical or surgical units at both 15- and 30-minute intervals (P=0.0001). In addition, patients who were transported by ambulance were examined earlier by physicians than were patients who had self-transport or family transport at both time intervals (P=0.0001 for 15- and 30-minute intervals).
Table 3 presents adjusted ORs calculated by the
multivariate logistic regression model including
significant variables such as race, insurance, level of hospital
complexity, admission unit, and transportation mode. Overall, when
variables in the model were controlled at both the 15- and
30-minute time windows, initial physician examination time was
significantly influenced by the same variables that had a
significant influence on physician examination time at the
univariate analysis.
Mode of Transportation to the Hospital
Because patients arriving by ambulance
presented earlier and were examined sooner, factors associated
with the use of ambulance versus other types of transportation were
analyzed. As shown in
Table 4, patients >75 years of age used ambulance
transport significantly more than did patients <55 years of age
(P=0.001 for patients 75 to 84
years of age; P=0.004 for
patients >85 years of age). Patients who were not employed were more
likely to call for an ambulance than those employed
(P=0.002). Nonwhite patients
were significantly less likely to arrive by ambulance than whites
(P=0.005 for blacks;
P=0.042 for Asians;
P=0.042 for Hispanics).
Commercial or health maintenance organization (HMO) insurance
patients were significantly less likely to use ambulance transportation
than were Medicare patients
(P=0.019,
P=0.030, respectively).
Patients with a history of atrial fibrillation or congestive heart
failure (P=0.0008,
P=0.005, respectively) and
patients with a history of >2 prior cardiovascular
disease diagnoses (P=0.002)
were more likely to use an ambulance than were those without a history
of heart disease.
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Adjusted ORs calculated by a multivariate
logistic regression model demonstrated that blacks and Asians were less
likely to use ambulance transportation than were whites
(P=0.032,
P=0.045, respectively).
Patients with a history of 2 cardiovascular diagnoses
were also identified to be significant predictors of ambulance use
(P=0.020).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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This study found that 46% of patients arrived within 3 hours of the onset of stroke signs or symptoms (the critical time for initiation of thrombolytic therapy25 ) and 61% within 6 hours. These delays have not improved from those of earlier national and international studies of stroke. Those studies found that 25% to 59% of stroke patients arrived at the ED within 3 hours and 35% to 66% of patients arrived within 6 hours.2 3 9 10 11 12 13 14 15 26
Consistent with prior investigations, this study found that sex did not significantly affect arrival time.2 3 15 Age >70 years was a factor delaying presentation in a previous study,14 whereas our study found that patients 65 to 74 years of age were likely to arrive sooner than patients <55 years of age. This may be related to the presence of organized retirement communities in the geographic areas studied. Another explanation is that older patients are more likely to perceive stroke symptoms as a serious occurrence based on personal experience or exposure to stroke patients in their communities. A significant relation between arrival time and marital status, employment, or insurance type was not observed in our study or in a previous study.3
In our study and in another recent
study,26 black patients took
longer than white patients to arrive at the ED. This was not observed
in a previous study published in the early
1990s.15 Black patients with
acute myocardial infarction have also been found to seek treatment
later than their white
counterparts.27 28
In addition, we found that black and Hispanic patients were more likely
to present to large complex hospitals than white patients, probably
because such hospitals are located in urban areas. These demographic
groups were less likely than whites to use an ambulance, a likely
explanation for the longer delay in treatment observed in these
demographic groups. The use of an ambulance was associated with earlier
arrival at the ED than self-transportation or family transportation in
this and previous
studies.15 16 17 26 29
A study of arrival time in patients with myocardial infarction yielded
similar results.27 In
addition, 78% of patients who had a history of 2 cardiac diagnoses
used an ambulance compared with 61% of patients without a history of
heart disease.
Signs and symptoms of severe stroke have been shown to favor early hospital arrival, whereas those of mild stroke often result in delayed presentation.12 A history of illness probably contributes to heightened awareness and recognition of stroke symptoms, prompting earlier pursuit of medical attention. Our data suggest that if patients realize that they are having a stroke or have symptoms comparable to previous experience, they seek medical treatment sooner.
In this study, patients who presented to more complex hospitals waited longer to be seen by a physician than those admitted to less complex hospitals. A possible explanation lies within the definition of hospital complexity, which is determined in part by the number of beds, types of services provided, level of intensity and case mix, and teaching status. Factors associated with each of these determinants may contribute to delay in physician evaluation. Further study is necessary to identify specific contributing factors.
Patients admitted to ICUs were seen earlier than those admitted to medical/surgical units, a finding that is probably related to illness severity. Patients who arrived by ambulance were seen earlier by physicians, also probably because of the perception of more severe illness. The results of this study are consistent with prior findings that patients who arrive by ambulance are seen earlier by physicians.26 30
Although this study was carefully designed and performed to ascertain patients’ arrival time at the ED and treatment time after arrival, some limitations warrant discussion. This study had potential sampling and measurement errors for time of onset of stroke to arrival at the ED, especially for those patients who awakened with neurological findings. We included patients who arrived at study hospitals with symptoms of stroke during a specific study period rather than randomly throughout the year, preventing assessment of seasonal variation and effect of inclement weather on time intervals. However, the arrival times in this study are consistent with previous studies, which also relied on information provided by patients or patient caregivers. Additional limitations of this study are that data were not collected on (1) education specific to stroke, (2) patient/family members’ understanding of signs and symptoms of stroke, and (3) changes in delay over time. Also, severity was not directly assessed other than through the surrogate of need for intensive care.
Data were collected from a wide variety of hospitals in New Jersey, but study patients’ demographics including race were consistent with general trends documented by the US Census.31 It is yet to be determined whether the results of this study can be generalized nationally.
Despite national efforts to promote public awareness
of the benefits of prompt stroke treatment, this study found that more
than half of patients with acute stroke fail to present to the ED
within the optimal time period for effective intervention. This may be
due to failure to recognize signs and symptoms or lack of awareness of
potential treatment
benefits.29 One prior study
found that patients >65 years of age were less likely to know the risk
factors for stroke than were patients 65 years of
age.32 This study did not
directly assess patient education or knowledge. Although previous
studies demonstrated that educational efforts to improve the
recognition of stroke symptoms have been shown to reduce time to
hospital arrival after symptom
onset,8 15
additional educational initiatives are still needed to increase public
awareness of warning signs and symptoms as well as risk factors for
stroke.33
In summary, this study showed that although significant delays still exist, not only were patients who were transported by ambulance brought to the ED more rapidly but that physicians examined them sooner. Use of the emergency medical system shortens arrival time as well as treatment time for stroke. The lack of improvement in delay to stroke evaluation and treatment over the past decade underscores the need for more effective public health programs. Further efforts to increase public awareness of stroke signs and symptoms, to disseminate guidelines and recommendations for stroke evaluation and treatment, and to develop initiatives (including those targeting healthcare providers, the emergency medical system, and the public at large) may reduce the time from stroke onset to treatment.
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Appendix 1 |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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The study group consisted of the following research teams of doctors, nurses, and coordinators at each collaborative study hospital and institution in alphabetical order: Bayshore Community Hospital: J. Jerome Cohen, MD, Lauren Burke, RNC; CentraState Healthcare System: Benjamin Weinstein, MD, Mary Marinaro, RN; Jersey Shore Medical Center: Carl Marchetti, MD, Robert Sweeney, MD; Medical Center of Ocean County: Morris Feitel, MD, Mary Ellen Bonczek, RN; Muhlenberg Regional Medical Center: Frances Hulse, MD, Bob Bayly, MD; Rahway Hospital: Uma Viswanathan, MD, Linda Coughlin, RN; Raritan Bay Medical Center: John Middleton, MD, Rose Gavin, RN; Robert Wood Johnson University Hospital and University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School: Clifton R. Lacy, MD, John B. Kostis, MD, Maureen Bueno, RN, PhD, Ellen A. Lacy, PsyD, Andrew Greene, MHCA, Harvey A. Holzberg, MBA; Robert Wood Johnson University Hospital at Hamilton: Edward Niewiadomski, MD, Lisa Breza, RN; Rutgers–The State University of New Jersey College of Pharmacy: Dong-Churl Suh, PhD, Joseph A. Barone, PharmD, John L. Colaizzi, PhD, Soung-Kook Shin, PhD; Southern Ocean County Hospital: William Torecki, MD, Ray Bennett, RN.
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Acknowledgments |
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This study was funded in part by an unrestricted grant from Janssen Pharmaceutica Inc, Titusville, NJ.
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Footnotes |
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1 Participating Investigators in the S.T.R.O.K.E. study are listed in the Appendix.
Received May 15, 2000; revision received September 7, 2000; accepted September 7, 2000.
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References |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1References |
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A Maestroni, C Mandelli, D Manganaro, B Zecca, P Rossi, V Monzani, and G Torgano Factors influencing delay in presentation for acute stroke in an emergency department in Milan, Italy Emerg. Med. J., June 1, 2008; 25(6): 340 - 345. [Abstract] [Full Text] [PDF]
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M. L. Sacchetti Is It Time to Definitely Abandon Neuroprotection in Acute Ischemic Stroke? Stroke, June 1, 2008; 39(6): 1659 - 1660. [Full Text] [PDF]
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 N. P. de la Ossa, J. Sanchez-Ojanguren, E. Palomeras, M. Millan, J. F. Arenillas, L. Dorado, C. Guerrero, S. Abilleira, and A. Davalos Influence of the stroke code activation source on the outcome of acute ischemic stroke patients Neurology, April 8, 2008; 70(15): 1238 - 1243. [Abstract] [Full Text] [PDF]
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B. M. Demaerschalk, B. J. Bobrow, and M. Paulsen Development of a Metropolitan Matrix of Primary Stroke Centers: The Phoenix Experience Stroke, April 1, 2008; 39(4): 1246 - 1253. [Abstract] [Full Text] [PDF]
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I. Mosley, M. Nicol, G. Donnan, I. Patrick, F. Kerr, and H. Dewey The Impact of Ambulance Practice on Acute Stroke Care Stroke, October 1, 2007; 38(10): 2765 - 2770. [Abstract] [Full Text] [PDF]
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B. Jarrell, A. Tadros, C. Whiteman, T. Crocco, and S. M. Davis National Healthline Responses to a Stroke Scenario: Implications for Early Intervention Stroke, August 1, 2007; 38(8): 2376 - 2378. [Abstract] [Full Text] [PDF]
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C. Hodgson, P. Lindsay, and F. Rubini Can Mass Media Influence Emergency Department Visits for Stroke? Stroke, July 1, 2007; 38(7): 2115 - 2122. [Abstract] [Full Text] [PDF]
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 H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, May 22, 2007; 115(20): e478 - e534. [Abstract] [Full Text] [PDF]
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H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists Stroke, May 1, 2007; 38(5): 1655 - 1711. [Abstract] [Full Text] [PDF]
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D. K. Moser, L. P. Kimble, M. J. Alberts, A. Alonzo, J. B. Croft, K. Dracup, K. R. Evenson, A. S. Go, M. M. Hand, R. U. Kothari, et al. Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke: A Scientific Statement From the American Heart Association Council on Cardiovascular Nursing and Stroke Council Circulation, July 11, 2006; 114(2): 168 - 182. [Abstract] [Full Text] [PDF]
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M. F. Giles, E. Flossman, and P. M. Rothwell Patient Behavior Immediately After Transient Ischemic Attack According to Clinical Characteristics, Perception of the Event, and Predicted Risk of Stroke Stroke, May 1, 2006; 37(5): 1254 - 1260. [Abstract] [Full Text] [PDF]
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O. Agyeman, K. Nedeltchev, M. Arnold, U. Fischer, L. Remonda, J. Isenegger, G. Schroth, and H. P. Mattle Time to Admission in Acute Ischemic Stroke and Transient Ischemic Attack Stroke, April 1, 2006; 37(4): 963 - 966. [Abstract] [Full Text] [PDF]
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P. J. Hand, J. Kwan, R. I. Lindley, M. S. Dennis, and J. M. Wardlaw Distinguishing Between Stroke and Mimic at the Bedside: The Brain Attack Study Stroke, March 1, 2006; 37(3): 769 - 775. [Abstract] [Full Text] [PDF]
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Y. Z. Deng, M. J. Reeves, B. S. Jacobs, G. L. Birbeck, R. U. Kothari, S. L. Hickenbottom, A. J. Mullard, S. Wehner, K. Maddox, A. Majid, et al. IV tissue plasminogen activator use in acute stroke: Experience from a statewide registry Neurology, February 14, 2006; 66(3): 306 - 312. [Abstract] [Full Text] [PDF]
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 L. B. Goldstein and D. L. Simel Is This Patient Having a Stroke? JAMA, May 18, 2005; 293(19): 2391 - 2402. [Abstract] [Full Text] [PDF]
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California Acute Stroke Pilot Registry (CASPR) Inv Prioritizing interventions to improve rates of thrombolysis for ischemic stroke Neurology, February 22, 2005; 64(4): 654 - 659. [Abstract] [Full Text] [PDF]
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V. C. Douglas, D. C. Tong, L. A. Gillum, S. Zhao, L. M. Brass, J. Dostal, and S. C. Johnston Do the Brain Attack Coalition's criteria for stroke centers improve care for ischemic stroke? Neurology, February 8, 2005; 64(3): 422 - 427. [Abstract] [Full Text] [PDF]
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J. P. Stansbury, H. Jia, L. S. Williams, W. B. Vogel, and P. W. Duncan Ethnic Disparities in Stroke: Epidemiology, Acute Care, and Postacute Outcomes Stroke, February 1, 2005; 36(2): 374 - 386. [Abstract] [Full Text] [PDF]
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 J. Kwan, P. Hand, and P. Sandercock Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review QJM, May 1, 2004; 97(5): 273 - 279. [Abstract] [Full Text] [PDF]
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K.-C. Chang, M.-C. Tseng, and T.-Y. Tan Prehospital Delay After Acute Stroke in Kaohsiung, Taiwan Stroke, March 1, 2004; 35(3): 700 - 704. [Abstract] [Full Text] [PDF]
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 J. E. Stahl, K. L. Furie, S. Gleason, and G. S. Gazelle Stroke: Effect of Implementing an Evaluation and Treatment Protocol Compliant with NINDS Recommendations Radiology, September 1, 2003; 228(3): 659 - 668. [Abstract] [Full Text] [PDF]
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G. J. Thomalla, T. Kucinski, V. Schoder, J. Fiehler, R. Knab, H. Zeumer, C. Weiller, and J. Rother Prediction of Malignant Middle Cerebral Artery Infarction by Early Perfusion- and Diffusion-Weighted Magnetic Resonance Imaging Stroke, August 1, 2003; 34(8): 1892 - 1899. [Abstract] [Full Text] [PDF]
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K. Nedeltchev, M. Arnold, C. Brekenfeld, J. Isenegger, L. Remonda, G. Schroth, and H. P. Mattle Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis Stroke, May 1, 2003; 34(5): 1230 - 1234. [Abstract] [Full Text] [PDF]
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J. Harbison, O. Hossain, D. Jenkinson, J. Davis, S. J. Louw, and G. A. Ford Diagnostic Accuracy of Stroke Referrals From Primary Care, Emergency Room Physicians, and Ambulance Staff Using the Face Arm Speech Test Stroke, January 1, 2003; 34(1): 71 - 76. [Abstract] [Full Text] [PDF]
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H. J. Cloft, T. A. Tomsick, D. F. Kallmes, J. H. Goldstein, and J. J. Connors Assessment of the Interventional Neuroradiology Workforce in the United States: A Review of the Existing Data AJNR Am. J. Neuroradiol., November 1, 2002; 23(10): 1700 - 1705. [Full Text] [PDF]
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F. Harraf, A. K Sharma, M. M Brown, K. R Lees, R. I Vass, and L. Kalra A multicentre observational study of presentation and early assessment of acute stroke BMJ, July 6, 2002; 325(7354): 17 - 17. [Abstract] [Full Text] [PDF]
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T. S. Field, M. D. Hill, and M. D. Connor Weather, Chinook, and Stroke Occurrence * Editorial Comment Stroke, July 1, 2002; 33(7): 1751 - 1758. [Abstract] [Full Text] [PDF]
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C. Ayala, J. B. Croft, K. J. Greenlund, N. L. Keenan, R. S. Donehoo, A. M. Malarcher, and G. A. Mensah Sex Differences in US Mortality Rates for Stroke and Stroke Subtypes by Race/Ethnicity and Age, 1995-1998 Stroke, May 1, 2002; 33(5): 1197 - 1201. [Abstract] [Full Text] [PDF]
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L. Derex, P. Adeleine, N. Nighoghossian, J. Honnorat, and P. Trouillas Factors Influencing Early Admission in a French Stroke Unit Stroke, January 1, 2002; 33(1): 153 - 159. [Abstract] [Full Text] [PDF]
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W.S. Burgin, L. Staub, W. Chan, PhD;, T.H. Wein, R.A. Felberg, J.C. Grotta, A.M. Demchuk, S.L. Hickenbottom, and L.B. Morgenstern Acute stroke care in non-urban emergency departments Neurology, December 11, 2001; 57(11): 2006 - 2012. [Abstract] [Full Text] [PDF]
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K. R. Evenson, D. L. Morris, W. D. Rosamond, J. H. Brice, S. L. Huston, and E. M. Puckett Addressing Healthy People 2010 Objectives for Stroke Stroke, July 1, 2001; 32(7): 1692 - 1692. [Full Text] [PDF]
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S. C. Johnston, L. H. Fung, L. A. Gillum, W. S. Smith, L. M. Brass, J. H. Lichtman, A. N. Brown, and D. Z. Wang Utilization of Intravenous Tissue-Type Plasminogen Activator for Ischemic Stroke at Academic Medical Centers : The Influence of Ethnicity Editorial Comment : It Is Time to Implement Stroke Practice Improvement Programs and Prevent the Racial Disparity in Stroke Care Stroke, May 1, 2001; 32(5): 1061 - 1068. [Abstract] [Full Text] [PDF]
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 Factors Associated with Delay in Delivery of Acute Stroke Care Journal Watch Neurology, March 28, 2001; 2001(328): 5 - 5. [Full Text]
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