***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Community awareness of stroke , especially the risk factors and warning signs is important in the control of the disease . In sub-Saharan Africa , little is known about community awareness of stroke though the brunt of stroke is currently borne in this region . The aim of the study was to evaluate stroke awareness in Accra ( capital city of Ghana ) particularly , the risk factors and warning signs . Methods This was a cross-sectional study involving systematic sampling of 63 households in each of the 11 sub metropolitan areas of Accra . A structured question naire was used to collect stroke awareness data from respondents r and omly sample d in the selected households .  Logistic regression analyses were done to identify predictors of the main outcome variables including recognition of stroke risk factors , stroke warning signs and the organ affected by stroke . Results Only 40 % ( n = 277 ) of the 693 respondents correctly identified the brain as the organ affected in stroke . Similarly , less than half of the respondents could recognize any of the established stroke risk factors as well as any of the established stroke warning signs . Over 70 % ( n > 485 ) of the respondents either believed that stroke is a preventable disease , or lifestyle alterations can be made to reduce the risk of stroke , or stroke requires emergency treatment . In multivariate analysis , predictors of stroke awareness were : age < 50 years ( OR = 0.56 , CI = 0.35 - 0.92 , p = 0.021 ) , presence of a stroke risk factor ( OR = 2.37 , CI = 1.52 - 3.71 , p < 0.001 ) and Christian Religion ( OR = 14.86 , CI = 1.37 - 161.01 , p = 0.03 ) . Conclusion Though stroke is perceived as a serious and preventable disease in Accra , community awareness of the risk factors and warning signs is sub-optimal . This indicates that community-based education programs to increase public awareness of stroke could contribute to decreasing the risk of stroke and to increasing the speed of hospital presentation after stroke onset Background Only 1 - 3 % of ischemic stroke patients receive thrombolytic therapy . Provider barriers to adhering with guidelines recommending tPA delivery in acute stroke are not well known . The main objective of this study was to describe barriers to thrombolytic use in acute stroke care . Methods Twenty-four hospitals were r and omly selected and matched into 12 pairs . Barrier assessment occurred at intervention sites only , and utilized focus groups and structured interviews . A pre-specified taxonomy was employed to characterize barriers . Two investigators independently assigned themes to transcribed responses . Seven facilitators ( three emergency physicians , two nurses , and two study coordinators ) conducted focus groups and interviews of emergency physicians ( 65 ) , nurses ( 62 ) , neurologists ( 15 ) , radiologists ( 12 ) , hospital administrators ( 12 ) , and three others ( hospitalists and pharmacist ) . Results The following themes represented the most important external barriers : environmental and patient factors . Important barriers internal to the clinician included familiarity with and motivation to adhere to the guidelines , lack of self-efficacy and outcome expectancy . The following themes were not substantial barriers : lack of awareness of the existence of acute stroke guidelines , presence of conflicting guidelines , and lack of agreement with the guidelines . Conclusions Healthcare providers perceive environmental and patient-related factors as the primary barriers to adherence with acute stroke treatment guidelines . Interventions focused on increasing physician familiarity with and motivation to follow guidelines may be of highest yield in improving adherence . Improving self-efficacy in performing guideline concordant care may also be useful . Trial Registration Clinical Trials.gov identifier : Background Intracerebral hemorrhage ( ICH ) accounted for 9 % to 27 % of all strokes worldwide in the last decade , with high early case fatality and poor functional outcome . In view of recent r and omized controlled trials ( RCTs ) of the management of ICH , the European Stroke Organisation ( ESO ) has up date d its evidence -based guidelines for the management of ICH . Method A multidisciplinary writing committee of 24 research ers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach . Results We found moderate- to high- quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit , avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use , avoiding graduated compression stockings , using intermittent pneumatic compression in immobile patients , and using blood pressure lowering  for secondary prevention . We found moderate- quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to < 140 mmHg within six-hours of ICH onset , early surgery for patients with a Glasgow Coma Scale score 9–12 , and avoidance of corticosteroids . Conclusion These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs . Outcome after ICH remains poor , prioritizing further RCTs of interventions to improve outcome Purpose — The aim of this guideline is to provide a focused up date of the current recommendations for the  endovascular  treatment of  acute ischemic stroke . When there is overlap , the recommendations made here supersede those of previous guidelines . Methods — This focused up date analyzes results from 8 r and omized , clinical trials of endovascular treatment and other relevant data published since 2013 . It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations . Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council ’s Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee . Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process . Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence . Prerelease review of the draft guideline was performed by 6 expert peer review ers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee . Results — Evidence -based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment , for the endovascular procedure , and for systems of care to facilitate endovascular treatment . Conclusions — Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke . Systems of care should be organized to facilitate the delivery of this care BACKGROUND Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke , but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established . We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke . METHODS After exclusion of patients with a brain hemorrhage or major infa rct ion , as detected on a computed tomographic scan , we r and omly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase ( 0.9 mg per kilogram of body weight ) or placebo . The primary end point was disability at 90 days , dichotomized as a favorable outcome ( a score of 0 or 1 on the modified Rankin scale , which has a range of 0 to 6 , with 0 indicating no symptoms at all and 6 indicating death ) or an unfavorable outcome ( a score of 2 to 6 on the modified Rankin scale ) . The secondary end point was a global outcome analysis of four neurologic and disability scores combined . Safety end points included death , symptomatic intracranial hemorrhage , and other serious adverse events . RESULTS We enrolled a total of 821 patients in the study and r and omly assigned 418 to the alteplase group and 403 to the placebo group . The median time for the administration of alteplase was 3 hours 59 minutes . More patients had a favorable outcome with alteplase than with placebo ( 52.4 % vs. 45.2 % ; odds ratio , 1.34 ; 95 % confidence interval [ CI ] , 1.02 to 1.76 ; P=0.04 ) . In the global analysis , the outcome was also improved with alteplase as compared with placebo ( odds ratio , 1.28 ; 95 % CI , 1.00 to 1.65 ; P<0.05 ) . The incidence of intracranial hemorrhage was higher with alteplase than with placebo ( for any intracranial hemorrhage , 27.0 % vs. 17.6 % ; P=0.001 ; for symptomatic intracranial hemorrhage , 2.4 % vs. 0.2 % ; P=0.008 ) . Mortality did not differ significantly between the alteplase and placebo groups ( 7.7 % and 8.4 % , respectively ; P=0.68 ) . There was no significant difference in the rate of other serious adverse events . CONCLUSIONS As compared with placebo , intravenous alteplase administered between 3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke ; alteplase was more frequently associated with symptomatic intracranial hemorrhage . ( Clinical Trials.gov number , NCT00153036 . BACKGROUND The Quality in Acute Stroke Care ( QASC ) trial evaluated systematic implementation of clinical treatment protocol s to manage fever , sugar , and swallow ( FeSS protocol s ) in acute stroke care . This cluster-r and omised controlled trial was conducted in 19 stroke units in Australia . AIM To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocol s and , postimplementation , to determine which of these barriers eventuated as actual barriers . METHODS Preimplementation : Workshops were held at the intervention stroke units ( n = 10 ) . The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocol s , the second workshop involved bedside clinicians . Postimplementation , an online survey with stroke champions from intervention sites was conducted . RESULTS A total of 111 clinicians attended the preimplementation workshops , identifying 22 barriers covering four main themes : ( a ) need for new policies , ( b ) limited workforce ( capacity ) , ( c ) lack of equipment , and ( d ) education and logistics of training staff . Preimplementation enablers identified were : support by clinical champions , medical staff , nursing management and allied health staff ; easy adaptation of current protocol s , care-plans , and local policies ; and presence of specialist stroke unit staff . Postimplementation , only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocol s , namely , no previous use of insulin infusions ; hyperglycaemic protocol s could not be commenced without written orders ; medical staff reluctance to use the ASSIST swallowing screening tool ; poor level of engagement of medical staff ; and doctors ' unawareness of the trial . LINKING EVIDENCE TO ACTION The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change . As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial , this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers BACKGROUND Malignant infa rct ion of the middle cerebral artery ( MCA ) is associated with an 80 % mortality rate . Non-r and omised studies have suggested that decompressive surgery reduces this mortality without increasing the number of severely disabled survivors . To obtain sufficient data as soon as possible to reliably estimate the effects of decompressive surgery , results from three European r and omised controlled trials ( DECIMAL , DESTINY , HAMLET ) were pooled . The trials were ongoing when the pooled analysis was planned . METHODS Individual data for patients aged between 18 years and 60 years , with space-occupying MCA infa rct ion , included in one of the three trials , and treated within 48 h after stroke onset were pooled for analysis . The protocol was design ed prospect ively when the trials were still recruiting patients and outcomes were defined without knowledge of the results of the individual trials . The primary outcome measure was the score on the modified Rankin scale ( mRS ) at 1 year dichotomised between favourable ( 0 - 4 ) and unfavourable ( 5 and death ) outcome . Secondary outcome measures included case fatality rate at 1 year and a dichotomisation of the mRS between 0 - 3 and 4 to death . Data analysis was done by an independent data monitoring committee . FINDINGS 93 patients were included in the pooled analysis . More patients in the decompressive-surgery group than in the control group had an mRS < or=4 ( 75%vs 24 % ; pooled absolute risk reduction 51 % [ 95 % CI 34 - 69 ] ) , an mRS < or=3 ( 43%vs 21 % ; 23 % [ 5 - 41 ] ) , and survived ( 78%vs 29 % ; 50 % [ 33 - 67 ] ) , indicating numbers needed to treat of two for survival with mRS < or=4 , four for survival with mRS < or=3 , and two for survival irrespective of functional outcome . The effect of surgery was highly consistent across the three trials . INTERPRETATION In patients with malignant MCA infa rct ion , decompressive surgery undertaken within 48 h of stroke onset reduces mortality and increases the number of patients with a favourable functional outcome . The decision to perform decompressive 
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Conclusions Despite considerable evidence supporting various specific therapies for stroke care , uptake of these therapies is compromised by barriers across organisational , patients , guideline interventions and health professionals ’ domains .