Panorama Current status of acute stroke management in Korea: a report on a multicenter, comprehensive acute stroke registry Beom Joon Kim1, Moon-Ku Han1, Tai Hwan Park2, Sang-Soon Park2, Kyung Bok Lee3, Byung-Chul Lee4, Kyung-Ho Yu4, Jae Kwan Cha5, Dae-Hyun Kim5, Jun Lee6, Soo Joo Lee7, Youngchai Ko7, Jong-Moo Park8, Kyusik Kang8, Yong-Jin Cho9, Keun-Sik Hong9, Ki-Hyun Cho10, Joon-Tae Kim10, Dong-Eog Kim11, Juneyoung Lee12, Ji Sung Lee13, Myung Suk Jang1, Joseph P Broderick14, Byung-Woo Yoon15, and Hee-Joon Bae1* on the behalf of CRCS-5 investigators There are limited data on the utilization of diagnostics and the variation of treatments at the national level in acute stroke care. Clinical Research Center for Stroke – 5th division stroke registry aimed to describe stroke statistics and quality of care in Korea and to implement quality indicators. Clinical Research Center for Stroke – 5th division registry was established in April 2008 and covers pretreatment demographics, medical and stroke severity measures, diagnostic evaluation, hyperacute revascularization, in-hospital management, discharge disposition, quality indicators, and long-term functional outcomes. Consecutive stroke cases from 12 participating centers Correspondence: Hee-Joon Bae*, Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Korea. E-mail: [email protected] 1 Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea 2 Department of Neurology, Seoul Medical Center, Seoul, Korea 3 Department of Neurology, Soonchunhyang University Hospital Seoul, Seoul, Korea 4 Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, Korea 5 Department of Neurology, Dong-A University Hospital, Busan, Korea 6 Department of Neurology, Yeungnam University Medical Center, Daegu, Korea 7 Department of Neurology, Eulji University Hospital, Daejeon, Korea 8 Department of Neurology, Eulji General Hospital, Seoul, Korea 9 Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, Korea 10 Department of Neurology, Chonnam National University Hospital, Gwangju, Korea 11 Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, Korea 12 Department of Biostatistics, Korea University College of Medicine, Seoul, Korea 13 Biostatistical Consulting Unit, Soonchunhyang University Medical Center, Seoul, Korea 14 College of Medicine, University of Cincinnati, Cincinnati, OH, USA 15 Department of Neurology, Seoul National University Hospital, Seoul, Korea Received: 12 June 2013; Accepted: 25 August 2013; Published online 21 November 2013 Conflict of interest: There was no conflict of interest regarding this study. Funding: This study was supported by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Republic of Korea (HI10C2020). This study was supported by a research grant from Korean government. DOI: 10.1111/ijs.12199
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are registered to a web-based database. Meticulous data management and auditing policy were applied. A total of 14 792 ischemic stroke cases were enrolled from April 2008 to January 2012. The median National Institutes of Health Stroke Scale score was 4 at admission, with median delay of onset to arrival of 14 h. Rate of risk factor management before stroke exceeds more than 80% for hypertension and diabetes. Revascularization procedures were performed in 1736 subjects (12%), and 34% were endovascular (n = 598). Substantial variability was noted in the preferred modality of hyperacute revascularization (range of endovascular recanalization = 6–60%), use of computed tomography (30–93%), and perfusion imaging (2–96%). The Clinical Research Center for Stroke – 5th division registry documented that the current practice of acute stroke care in South Korea largely met the standard of guidelines, but variability of practice still remains. The registry would provide an opportunity to evaluate the quality of stroke care across South Korea and compare it with that of other countries. Key words: diagnosis, disparity, management, perfusion imaging, stroke registry, thrombolysis
Introduction Stroke annually affects 795 000 people in the United States and 15 million worldwide (1,2). In South Korea, there are approximately 105 000 incident or recurrent strokes and 26 000 stroke-related deaths (3). Given the growing burden of strokes, a well-designed comprehensive stroke registry is needed to monitor the current status of stroke management, evaluate the appropriateness of healthcare delivery, and support actions for quality improvement (4). We organized a prospective stroke registry involving 12 South Korean hospitals beginning in April 2008, termed the Clinical Research Center for Stroke – 5th division (CRCS-5) registry. The purposes of the registry were to (a) analyze epidemiological profiles of strokes in South Korea; (b) implement quality indicators to improve stroke care; (c) prospectively capture long-term outcomes and vascular events; and (d) provide information regarding the current status of stroke management in real-world practice.
Establishment and management of a prospective multicenter stroke registry database The CRCS was established in 2006 to facilitate multicenter collaborative clinical stroke research in Korea and to develop and implement clinical practice guidelines for stroke. In April 2008, nine stroke centers, including both academic and regional hospitals, © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
B. J. Kim et al.
Panorama
Fig. 1 Clinical Research Center for Stroke – 5th division (CRCS-5) registry organization. (a) Locations and starting dates of case registration for participating centers; (b) CRCS-5 database structure; and (c) case recruitment profile.
began to construct a web-based, prospective registry for acute stroke. As of January 2012, 12 stroke centers were registering consecutive stroke cases (Fig. 1a). All participating centers obtained approval from local institutional review boards. Written informed consent has been obtained from each patient or their next of kin to gather clinical outcomes after discharge by direct interview or linking the registry database to secondary databases. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Data collection The participating centers collect and register demographic data, stroke characteristics, vascular risk factors, etiological work-up, in-hospital management, and functional status at discharge. The CRCS-5 database was further expanded to register quality indicators, hyperacute revascularization, and functional outcomes three-months after index stroke (November 2009). In January Vol 9, June 2014, 514–518
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Panorama 2011, the registry began to prospectively collect outcome information, including early neurological deteriorations, modified Rankin Scale (mRS) score at three-months and one-year, and occurrence of vascular events or death (Fig. 1b). Case ascertainment and maintenance of data completeness The participating centers are required to register all consecutive acute stroke or transient ischemic attack cases hospitalized within seven-days of onset. To ensure consecutiveness, registration process is required to start within 48 h of hospitalization (66% registered ≤24 h; 84% ≤48 h). Research registrars entered case information into the web-based database using a standardized case report form. A central data manager monitors the number of registered cases every two-weeks and sends an inquiry to the deviated center. The data manager also checks the integrity and completeness of the database bimonthly. Prespecified queries are used, and peripheral registrars revise erroneous entries. The CRCS-5 steering committee meets monthly to review and supervise the process. Details are provided as Supporting Information. Database analysis Categorical variables were expressed as frequencies (percentages), and continuous variables as mean ± standard deviation or medians [interquartile ranges].
Characteristics of stroke cases and managements in Korea A total of 14 792 image-proven ischemic stroke cases were registered between April 2008 and January 2012 (Fig. 1c). The general characteristics are described in Table 1. The majority of hypertensive and diabetic cases had regular medication (85% and 81%, respectively). However, only 42% of hyperlipidemia and 38% of atrial fibrillation were treated before. Forty-eight percent of atrial fibrillation was newly diagnosed during hospitalization. Ischemic stroke management Brain computed tomography (CT) was performed in 65% of cases, whereas magnetic resonance (MR) image was done in 95% (Table 2). Perfusion studies were performed in 5695 cases (39%), the majority of which (82%) used MR techniques. Overall, 12% (1736) received hyperacute recanalization therapies. Intravenous (IV) thrombolysis was performed in 41% of patients who arrived within three-hours of onset, and 9% (133) of IV tissue-type plasminogen activator users arrived >4·5 h after onset. Aspirin and clopidogrel were the most commonly used antithrombotics during hospitalization and upon discharge (Table 3). Among 2852 cases with atrial fibrillation, 1860 (65%) were on warfarin at discharge. Outcomes at discharge At discharge, the median National Institutes of Health Stroke Scale (NIHSS) score was 2 [1–6] after a median 8·1 days [5·4– 13·0] of hospitalization. The median mRS score was 2 [1–4], and 39% (5720 cases) achieved functional independency. Overall, 452
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Table 1 CRCS-5 (n = 14 792) Category
database-registered
ischemic
Variable
stroke
cases
Value
Demographic variables Classification of ischemic strokes
Male 8601 (58%) Age 68 ± 13 Large artery atherosclerosis 5562 (38%) Small vessel occlusion 3009 (20%) Cardioembolism 3154 (21%) Other determined etiology 357 (2%) Undetermined etiology 2710 (18%) 4 [2–8] Characteristics NIHSS score at initial presentation 147 ± 27 of ischemic Systolic blood pressure at arrival 124 ± 54 stroke cases Random glucose at arrival Onset to door time* 14·2 [4·0–44·7] Time delay ≤3 h 3060 (21%) Time delay ≤4·5 h 4018 (27%) Time delay ≤8 h 5532 (37%) Unclear onset stroke cases 3804 (26%) Vascular risk Hypertension 10 062 (68%) factors Treatment-experienced patients† 8542 (85%) Diabetes 4914 (33%) Treatment-experienced patients† 3985 (81%) Hyperlipidemia 4637 (31%) Treatment-experienced patients† 1955 (42%) Habitual smoking 5792 (39%) Current smoker 4022 (69%) Atrial fibrillation 2852 (19%) Treatment-experienced patients† 1092 (38%) Values are presented as frequencies (percentages), means ± standard deviation, or medians [interquartile ranges], as appropriate. *Time delay after last seen normal time (LNT). †Percentages of treatmentexperienced patients and current smokers were based on total numbers of diagnosed patients with each vascular risk factor. CRCS-5, Clinical Research Center for Stroke – 5th division; NIHSS, National Institutes of Health Stroke Scale.
Table 2 Profile of etiologic work-ups for ischemic stroke cases (n = 14 792) Etiologic work-up items
Number (percentage)
CT (any sequences) Plain CT scan CT angiography CT perfusion scan MR image (any sequences) Diffusion-weighted image Gradient-echo image MR angiography (time-of-flight sequence) MR angiography (contrast-enhanced) Transthoracic echocardiography Transesophageal echocardiography 24-h electrocardiogram monitoring 24-h blood pressure monitoring Transcranial Doppler sonography Carotid Doppler sonography Single-photon emission CT
9628 (65%) 8176 (55%) 5285 (36%) 1736 (12%) 14 107 (95%) 13 888 (94%) 12 941 (88%) 12 991 (88%) 2527 (17%) 11 200 (76%) 1927 (13%) 4438 (30%) 468 (3%) 11 642 (79%) 4461 (30%) 530 (4%)
CT, computed tomography; MR, magnetic resonance.
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Panorama
B. J. Kim et al.
Fig. 2 (a) Variability in acute ischemic stroke management among participating centers regarding hyperacute revascularization procedures; (b) perfusion imaging, (c) brain computed tomography (CT); and (d) magnetic resonance (MR) imaging. IA = endovascular; IV = intravenous.
Table 3 Current status of antithrombotic medications for ischemic stroke cases in CRCS-5 database (n = 14 792)*
Medication
Prescribed at admission
Prescribed at discharge
Aspirin Clopidogrel Cilostazol Triflusal Heparin Warfarin Low-molecular-weight heparin Thrombin inhibitor Other related medications
12 074 (82%) 4835 (33%) 415 (3%) 91 (1%) 1228 (8%) 1087 (7%) 103 (1%) 43 (0%) 89 (1%)
10 252 (69%) 5556 (38%) 1024 (7%) 242 (2%) – 2707 (18%) – – 110 (1%)
*Multiple choices permitted. CRCS-5, Clinical Research Center for Stroke – 5th division.
subjects (3%) died during hospitalization after a median six-days [3–11] from onset. After discharge, 63% (9245 cases) returned to their home, and 33% (4880 cases) were referred to rehabilitation services or long-term care facilities. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Stroke management variability Distribution of gender, age, NIHSS score at admission, time interval from onset to arrival, and antithrombotic use was largely comparable among centers. However, the preferred modality for hyperacute revascularization was highly variable (Fig. 2a). Such discrepancies were also noted in the utilization of perfusion images (range = 2–96%; Fig. 2b) and head CT (range = 42–91%; Fig. 2c), whereas MR imaging is more consistent (Fig. 2d). Details were provided as Supporting Information.
Summary We described the current status of stroke management in Korea and documented substantial variability underneath, which permitted us to compare ours to the major stroke registries worldwide (see Supporting Information). Given recent emphasis on the effectiveness, benefits, and harms from various treatment options, well-designed national and regional registries for stroke patients that are linked with long-term clinical outcomes should be a priority for stroke clinicians and researchers (5). Vol 9, June 2014, 514–518
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Panorama References 1 Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The global stroke initiative. Lancet Neurol 2004; 3:391–3. 2 Go AS, Mozaffarian D, Roger VL et al. Heart disease and stroke statistics – 2013 update: a report from the American Heart Association. Circulation 2013; 127:e6–e245. 3 Hong K-S, Bang OY, Kang D-W et al. Stroke statistics in Korea: part I. Epidemiology and risk factors: a report from the Korean Stroke Society and Clinical Research Center for Stroke. J Stroke 2013; 15:2–20. 4 Bufalino VJ, Masoudi FA, Stranne SK et al. The American Heart Association’s recommendations for expanding the applications of existing and future clinical registries: a policy statement from the American Heart Association. Circulation 2011; 123:2167–79. 5 Institute of Medicine. 2009. Initial National Priorities for Comparative Effectiveness Research. Washington, DC: The National Academies Press.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Supplementary Material 1. Web registration system of the CRCS-5 registry.
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B. J. Kim et al. Supplementary Material 2. Definitions in data collection process. Supplementary Material 3. Case report form of the CRCS-5 registry. Supplementary Material 4. Immediate response to recanalization treatment. Supplementary Material 5. Details of surgical treatment. Supplementary Material 6. Distribution of mRS score at the time of discharge. Supplementary Material 7. Differences in stroke characteristics, etiologic work-ups, and management among CRCS-5 participating centers. Supplementary Material 8. Review of previous major stroke registries. References for the Supporting information.
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
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are registered to a web-based database. Meticulous data management and auditing policy were applied. A total of 14 792 ischemic stroke cases were enrolled from April 2008 to January 2012. The median National Institutes of Health Stroke Scale score was 4 at admission, with median delay of onset to arrival of 14 h. Rate of risk factor management before stroke exceeds more than 80% for hypertension and diabetes. Revascularization procedures were performed in 1736 subjects (12%), and 34% were endovascular (n = 598). Substantial variability was noted in the preferred modality of hyperacute revascularization (range of endovascular recanalization = 6–60%), use of computed tomography (30–93%), and perfusion imaging (2–96%). The Clinical Research Center for Stroke – 5th division registry documented that the current practice of acute stroke care in South Korea largely met the standard of guidelines, but variability of practice still remains. The registry would provide an opportunity to evaluate the quality of stroke care across South Korea and compare it with that of other countries. Key words: diagnosis, disparity, management, perfusion imaging, stroke registry, thrombolysis
Introduction Stroke annually affects 795 000 people in the United States and 15 million worldwide (1,2). In South Korea, there are approximately 105 000 incident or recurrent strokes and 26 000 stroke-related deaths (3). Given the growing burden of strokes, a well-designed comprehensive stroke registry is needed to monitor the current status of stroke management, evaluate the appropriateness of healthcare delivery, and support actions for quality improvement (4). We organized a prospective stroke registry involving 12 South Korean hospitals beginning in April 2008, termed the Clinical Research Center for Stroke – 5th division (CRCS-5) registry. The purposes of the registry were to (a) analyze epidemiological profiles of strokes in South Korea; (b) implement quality indicators to improve stroke care; (c) prospectively capture long-term outcomes and vascular events; and (d) provide information regarding the current status of stroke management in real-world practice.
Establishment and management of a prospective multicenter stroke registry database The CRCS was established in 2006 to facilitate multicenter collaborative clinical stroke research in Korea and to develop and implement clinical practice guidelines for stroke. In April 2008, nine stroke centers, including both academic and regional hospitals, © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
B. J. Kim et al.
Panorama
Fig. 1 Clinical Research Center for Stroke – 5th division (CRCS-5) registry organization. (a) Locations and starting dates of case registration for participating centers; (b) CRCS-5 database structure; and (c) case recruitment profile.
began to construct a web-based, prospective registry for acute stroke. As of January 2012, 12 stroke centers were registering consecutive stroke cases (Fig. 1a). All participating centers obtained approval from local institutional review boards. Written informed consent has been obtained from each patient or their next of kin to gather clinical outcomes after discharge by direct interview or linking the registry database to secondary databases. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Data collection The participating centers collect and register demographic data, stroke characteristics, vascular risk factors, etiological work-up, in-hospital management, and functional status at discharge. The CRCS-5 database was further expanded to register quality indicators, hyperacute revascularization, and functional outcomes three-months after index stroke (November 2009). In January Vol 9, June 2014, 514–518
515
Panorama 2011, the registry began to prospectively collect outcome information, including early neurological deteriorations, modified Rankin Scale (mRS) score at three-months and one-year, and occurrence of vascular events or death (Fig. 1b). Case ascertainment and maintenance of data completeness The participating centers are required to register all consecutive acute stroke or transient ischemic attack cases hospitalized within seven-days of onset. To ensure consecutiveness, registration process is required to start within 48 h of hospitalization (66% registered ≤24 h; 84% ≤48 h). Research registrars entered case information into the web-based database using a standardized case report form. A central data manager monitors the number of registered cases every two-weeks and sends an inquiry to the deviated center. The data manager also checks the integrity and completeness of the database bimonthly. Prespecified queries are used, and peripheral registrars revise erroneous entries. The CRCS-5 steering committee meets monthly to review and supervise the process. Details are provided as Supporting Information. Database analysis Categorical variables were expressed as frequencies (percentages), and continuous variables as mean ± standard deviation or medians [interquartile ranges].
Characteristics of stroke cases and managements in Korea A total of 14 792 image-proven ischemic stroke cases were registered between April 2008 and January 2012 (Fig. 1c). The general characteristics are described in Table 1. The majority of hypertensive and diabetic cases had regular medication (85% and 81%, respectively). However, only 42% of hyperlipidemia and 38% of atrial fibrillation were treated before. Forty-eight percent of atrial fibrillation was newly diagnosed during hospitalization. Ischemic stroke management Brain computed tomography (CT) was performed in 65% of cases, whereas magnetic resonance (MR) image was done in 95% (Table 2). Perfusion studies were performed in 5695 cases (39%), the majority of which (82%) used MR techniques. Overall, 12% (1736) received hyperacute recanalization therapies. Intravenous (IV) thrombolysis was performed in 41% of patients who arrived within three-hours of onset, and 9% (133) of IV tissue-type plasminogen activator users arrived >4·5 h after onset. Aspirin and clopidogrel were the most commonly used antithrombotics during hospitalization and upon discharge (Table 3). Among 2852 cases with atrial fibrillation, 1860 (65%) were on warfarin at discharge. Outcomes at discharge At discharge, the median National Institutes of Health Stroke Scale (NIHSS) score was 2 [1–6] after a median 8·1 days [5·4– 13·0] of hospitalization. The median mRS score was 2 [1–4], and 39% (5720 cases) achieved functional independency. Overall, 452
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B. J. Kim et al.
Table 1 CRCS-5 (n = 14 792) Category
database-registered
ischemic
Variable
stroke
cases
Value
Demographic variables Classification of ischemic strokes
Male 8601 (58%) Age 68 ± 13 Large artery atherosclerosis 5562 (38%) Small vessel occlusion 3009 (20%) Cardioembolism 3154 (21%) Other determined etiology 357 (2%) Undetermined etiology 2710 (18%) 4 [2–8] Characteristics NIHSS score at initial presentation 147 ± 27 of ischemic Systolic blood pressure at arrival 124 ± 54 stroke cases Random glucose at arrival Onset to door time* 14·2 [4·0–44·7] Time delay ≤3 h 3060 (21%) Time delay ≤4·5 h 4018 (27%) Time delay ≤8 h 5532 (37%) Unclear onset stroke cases 3804 (26%) Vascular risk Hypertension 10 062 (68%) factors Treatment-experienced patients† 8542 (85%) Diabetes 4914 (33%) Treatment-experienced patients† 3985 (81%) Hyperlipidemia 4637 (31%) Treatment-experienced patients† 1955 (42%) Habitual smoking 5792 (39%) Current smoker 4022 (69%) Atrial fibrillation 2852 (19%) Treatment-experienced patients† 1092 (38%) Values are presented as frequencies (percentages), means ± standard deviation, or medians [interquartile ranges], as appropriate. *Time delay after last seen normal time (LNT). †Percentages of treatmentexperienced patients and current smokers were based on total numbers of diagnosed patients with each vascular risk factor. CRCS-5, Clinical Research Center for Stroke – 5th division; NIHSS, National Institutes of Health Stroke Scale.
Table 2 Profile of etiologic work-ups for ischemic stroke cases (n = 14 792) Etiologic work-up items
Number (percentage)
CT (any sequences) Plain CT scan CT angiography CT perfusion scan MR image (any sequences) Diffusion-weighted image Gradient-echo image MR angiography (time-of-flight sequence) MR angiography (contrast-enhanced) Transthoracic echocardiography Transesophageal echocardiography 24-h electrocardiogram monitoring 24-h blood pressure monitoring Transcranial Doppler sonography Carotid Doppler sonography Single-photon emission CT
9628 (65%) 8176 (55%) 5285 (36%) 1736 (12%) 14 107 (95%) 13 888 (94%) 12 941 (88%) 12 991 (88%) 2527 (17%) 11 200 (76%) 1927 (13%) 4438 (30%) 468 (3%) 11 642 (79%) 4461 (30%) 530 (4%)
CT, computed tomography; MR, magnetic resonance.
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Panorama
B. J. Kim et al.
Fig. 2 (a) Variability in acute ischemic stroke management among participating centers regarding hyperacute revascularization procedures; (b) perfusion imaging, (c) brain computed tomography (CT); and (d) magnetic resonance (MR) imaging. IA = endovascular; IV = intravenous.
Table 3 Current status of antithrombotic medications for ischemic stroke cases in CRCS-5 database (n = 14 792)*
Medication
Prescribed at admission
Prescribed at discharge
Aspirin Clopidogrel Cilostazol Triflusal Heparin Warfarin Low-molecular-weight heparin Thrombin inhibitor Other related medications
12 074 (82%) 4835 (33%) 415 (3%) 91 (1%) 1228 (8%) 1087 (7%) 103 (1%) 43 (0%) 89 (1%)
10 252 (69%) 5556 (38%) 1024 (7%) 242 (2%) – 2707 (18%) – – 110 (1%)
*Multiple choices permitted. CRCS-5, Clinical Research Center for Stroke – 5th division.
subjects (3%) died during hospitalization after a median six-days [3–11] from onset. After discharge, 63% (9245 cases) returned to their home, and 33% (4880 cases) were referred to rehabilitation services or long-term care facilities. © 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
Stroke management variability Distribution of gender, age, NIHSS score at admission, time interval from onset to arrival, and antithrombotic use was largely comparable among centers. However, the preferred modality for hyperacute revascularization was highly variable (Fig. 2a). Such discrepancies were also noted in the utilization of perfusion images (range = 2–96%; Fig. 2b) and head CT (range = 42–91%; Fig. 2c), whereas MR imaging is more consistent (Fig. 2d). Details were provided as Supporting Information.
Summary We described the current status of stroke management in Korea and documented substantial variability underneath, which permitted us to compare ours to the major stroke registries worldwide (see Supporting Information). Given recent emphasis on the effectiveness, benefits, and harms from various treatment options, well-designed national and regional registries for stroke patients that are linked with long-term clinical outcomes should be a priority for stroke clinicians and researchers (5). Vol 9, June 2014, 514–518
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Panorama References 1 Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The global stroke initiative. Lancet Neurol 2004; 3:391–3. 2 Go AS, Mozaffarian D, Roger VL et al. Heart disease and stroke statistics – 2013 update: a report from the American Heart Association. Circulation 2013; 127:e6–e245. 3 Hong K-S, Bang OY, Kang D-W et al. Stroke statistics in Korea: part I. Epidemiology and risk factors: a report from the Korean Stroke Society and Clinical Research Center for Stroke. J Stroke 2013; 15:2–20. 4 Bufalino VJ, Masoudi FA, Stranne SK et al. The American Heart Association’s recommendations for expanding the applications of existing and future clinical registries: a policy statement from the American Heart Association. Circulation 2011; 123:2167–79. 5 Institute of Medicine. 2009. Initial National Priorities for Comparative Effectiveness Research. Washington, DC: The National Academies Press.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Supplementary Material 1. Web registration system of the CRCS-5 registry.
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B. J. Kim et al. Supplementary Material 2. Definitions in data collection process. Supplementary Material 3. Case report form of the CRCS-5 registry. Supplementary Material 4. Immediate response to recanalization treatment. Supplementary Material 5. Details of surgical treatment. Supplementary Material 6. Distribution of mRS score at the time of discharge. Supplementary Material 7. Differences in stroke characteristics, etiologic work-ups, and management among CRCS-5 participating centers. Supplementary Material 8. Review of previous major stroke registries. References for the Supporting information.
© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization
