Relationship of National Institutes of Health Stroke Scale to 30-Day Mortality in Medicare Beneficiaries With Acute Ischemic Stroke

Efficacy of endovascular therapy for stroke in developing country: A single-centre retrospective observational study in Indonesia from 2017 to 2021

Background

Indonesia as a developing nation faces a plethora of challenges in applying endovascular therapy (EVT), mostly due to the lack of physicians specialized in neuro-intervention, high operational cost, and time limitation. The efficacy of EVT in improving functional outcomes of stroke in developing countries has not been previously studied.

Methods

This retrospective cohort study was conducted at Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) from January 2017 to December 2021. Large vessel occlusion (LVO) diagnosis was established based on a combination of clinical and imaging characteristics. We assessed patients' functional independence on day-90 based on modified Rankin Scale (mRS) between the endovascular treatment group and the conservative group (those receiving intravascular thrombolysis or medical treatment only). Functional independence was defined as mRS ≤2.

Results

Among 111 stroke patients with LVO, we included 32 patients in the EVT group and 50 patients in the conservative group for this study. Patients with younger age (p = 0.004), lower hypertension rate (p < 0.001), higher intubation rate (p = 0.014), and earlier onset of stroke were observed in the EVT group. The proportion of mRS ≤2 at day-90 in the EVT group was higher than the conservative group (28.1 % vs. 18.0 %; p = 0.280). Patients within mRS ≤2 group had earlier onset-to-puncture time (p = 0.198), onset-to-recanalization time (p = 0.341), lower NIHSS (p = 0.026) and higher ASPECTS (p = 0.001) on admission. In multivariate analysis, ASPECTS (aOR 2.43; 95%CI 1.26-4.70; p = 0.008) defined functional independence in the EVT group.

Conclusion

The endovascular therapy group had a higher proportion of mRS ≤2 at day-90 than the conservative group despite its statistical insignificance.

Development and validation of a model predicting mild stroke severity on admission using electronic health record data

OBJECTIVE

Initial stroke severity is a potent modifier of stroke outcomes but this information is difficult to obtain from electronic health record (EHR) data. This limits the ability to risk-adjust for evaluations of stroke care and outcomes at a population level. The purpose of this analysis was to develop and validate a predictive model of initial stroke severity using EHR data elements.

METHODS

This observational cohort included individuals admitted to a US Department of Veterans Affairs hospital with an ischemic stroke. We extracted 65 independent predictors from the EHR. The primary analysis modeled mild (NIHSS score 0-3) versus moderate/severe stroke (NIHSS score ≥4) using multiple logistic regression. Model validation included: (1) splitting the cohort into derivation (65%) and validation (35%) samples and (2) evaluating how the predicted stroke severity performed in regard to 30-day mortality risk stratification.

RESULTS

The sample comprised 15,346 individuals with ischemic stroke (n = 10,000 derivation; n = 5,346 validation). The final model included 15 variables and correctly classified 70.4% derivation sample patients and 69.4% validation sample patients. The areas under the curve (AUC) were 0.76 (derivation) and 0.76 (validation). In the validation sample, the model performed similarly to the observed NIHSS in terms of the association with 30-day mortality (AUC: 0.72 observed NIHSS, 0.70 predicted NIHSS).

CONCLUSIONS

EHR data can be used to construct a surrogate measure of initial stroke severity. Further research is needed to better differentiate moderate and severe strokes, enhance stroke severity classification, and how to incorporate these measures in evaluations of stroke care and outcomes.

Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study

BACKGROUND

Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs.

FINDINGS

Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77).

INTERPRETATION

Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted.

FUNDING

US National Institutes of Health.

TRANSLATIONS

For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.

Real-World Outcomes of Endovascular Thrombectomy for Basilar Artery Occlusion: Results of the BArONIS Study

OBJECTIVE

To evaluate clinical outcomes of endovascular thrombectomy (EVT) for acute basilar artery occlusion (BAO) using population-level data from the United States.

METHODS

Weighted discharge data from the National Inpatient Sample were queried to identify adult patients with acute BAO during the period of 2015 to 2019 treated with EVT or medical management only. Complex samples statistical methods and propensity-score adjustment using inverse probability of treatment weighting (IPTW) were performed to assess clinical endpoints.

RESULTS

Among 3,950 BAO patients identified, 1,425 (36.1%) were treated with EVT [mean age 66.7 years, median National Institute of Health Stroke Scale (NIHSS) score 22]. On unadjusted analysis, 155 (10.9%) EVT patients achieved favorable functional outcomes (discharge disposition to home without services), while 515 (36.1%) experienced in-hospital mortality, and 20 (1.4%) developed symptomatic intracranial hemorrhage (sICH). Following propensity-score adjustment by IPTW accounting for age, stroke severity, and comorbidity burden, EVT was independently associated with favorable functional outcome [adjusted odds ratio (aOR) 1.25, 95% confidence interval (CI) 1.07, 1.46; p = 0.004], but not with in-hospital mortality or sICH. In an IPTW-adjusted sub-group analysis of patients with NIHSS scores >20, EVT was associated with both favorable functional outcome (discharge disposition to home or to acute rehabilitation) (aOR 1.55, 95% CI 1.24, 1.94; p < 0.001) and decreased mortality (aOR 0.78, 95% CI 0.69, 0.89; p < 0.001), but not with sICH.

INTERPRETATION

This retrospective population-based analysis using a large national registry provides real-world evidence of a potential benefit of EVT in acute BAO patients. ANN NEUROL 2023.

No short-term mortality from benzodiazepine use post-acute ischemic stroke after accounting for bias

BACKGROUND AND OBJECTIVES

Older adults receive benzodiazepines for agitation, anxiety, and insomnia after acute ischemic stroke (AIS). No trials have been conducted to determine if benzodiazepine use affects poststroke mortality in the elderly.

METHODS

We examined the association between initiating benzodiazepines within 1 week after AIS and 30-day mortality. We included patients ≥65 years, admitted for new nonsevere AIS (NIH-Stroke-Severity[NIHSS]≤ 20), 2014-2020, with no recorded benzodiazepine use in the previous 3 months and no contraindication for use. We linked a stroke registry to electronic health records, used inverse-probability weighting to address confounding, and estimated the risk difference (RD). A process of cloning, weighting, and censoring was used to avoid immortal time bias.

RESULTS

Among 2,584 patients, 389 received benzodiazepines. The crude 30-day mortality risk from treatment initiation was 212/1,000 among patients who received benzodiazepines, while the 30-day mortality was 34/1,000 among those who did not. When follow-up was aligned on day of AIS admission and immortal time was assigned to the two groups, the estimated risks were 27/1,000 and 22/1,000, respectively. Upon further adjustment for confounders, the RD was 5 (-12 to 19) deaths/1,000 patients.

CONCLUSION

The observed higher 30-day mortality associated with benzodiazepine initiation within 7 days was largely due to bias.

Predictors of 30-day mortality among patients with stroke admitted at a tertiary teaching hospital in Northwestern Tanzania: A prospective cohort study

Background

Stroke is the second leading cause of death worldwide, with the highest mortality rates in low- to middle-income countries, particularly in sub-Saharan Africa. We aimed to investigate the predictors of 30-day mortality among patients with stroke admitted at a tertiary teaching hospital in Northwestern Tanzania.

Methods

This cohort study recruited patients with the World Health Organization's clinical definition of stroke. Data were collected on baseline characteristics, the degree of neurological impairment at admission (measured using the National Institutes of Health Stroke Scale), imaging and electrocardiogram (ECG) findings, and post-stroke complications. The modified Rankin scale (mRS) was used to assess stroke outcomes. Kaplan-Meier analysis was used to describe survival, and the Cox proportional hazards model was used to examine predictors of mortality.

Results

A total of 135 patients were enrolled, with a mean age of 64.5 years. Hypertension was observed in 76%, and 20% were on regular anti-hypertensive medications. The overall 30-day mortality rate was 37%. Comparing patients with hemorrhagic and ischemic stroke, 25% had died by day 5 [25th percentile survival time (in days): 5 (95% CI: 2-14)] versus day 23 [25th percentile survival time (in days): 23 (95% CI: 11-30) (log-rank p < 0.001)], respectively. Aspiration pneumonia was the most common medical complication, occurring in 41.3% of patients. ECG abnormalities were observed in 54.6 and 46.9% of patients with hemorrhagic and ischemic stroke, respectively. The most common patterns were as follows: ST changes 29.6 vs. 30.9%, T-wave inversion 34.1 vs. 38.3%, and U-waves 18.2 vs. 1.2% in hemorrhagic and ischemic stroke, respectively. Independent predictors for case mortality were as follows: mRS score at presentation (4-5) [aHR 5.50 (95% CI: 2.02-15.04)], aspiration pneumonia [aHR 3.69 (95% CI: 1.71-13.69)], ECG abnormalities [aHR 2.28 (95% CI: 1.86-5.86)], and baseline stroke severity [aHR 1.09 (95% CI: 1.02-1.17)].

Conclusion

Stroke is associated with a high 30-day mortality rate in Northwestern Tanzania. Concerted efforts are warranted in managing patients with stroke, with particular attention to individuals with severe strokes, ECG abnormalities, and swallowing difficulties to reduce early morbidity and mortality.

The Effects of Adding Di-Tan Decoction (DTD) and/or Electroacupuncture (EA) to Standard Swallowing Rehabilitation Training (SRT) for Improving Poststroke Dysphagia (PSD): A Pilot, Single-Centred, Randomized Trial

OBJECTIVES

To evaluate the effect of adding Di-tan decoction (DTD) and/or electroacupuncture (EA) to standard swallowing rehabilitation training (SRT) on improving PSD.

METHODS

In total, 80 PSD patients were enrolled and randomly assigned to the DTD, EA, DTD + EA or control group at a 1 : 1 : 1 : 1 ratio. All patients received basic treatment and standard SRT. The DTD group received DTD orally, the EA group received EA, the DTD + EA group received both DTD and EA simultaneously, and the control group received only basic treatment and standard SRT. The interventions lasted for 4 weeks. The outcome measurements included the Standardized Swallowing Assessment (SSA) and Swallowing-Quality of Life (SWAL-QOL), performed and scored from baseline to 2, 4, and 6 weeks after intervention, and the Videofluoroscopic Dysphagia Scale (VDS), scored at baseline and 4 weeks after intervention. Scores were compared over time by repeated-measures analysis of variance (ANOVA) among all groups. Interactions between interventions were explored using factorial design analysis.

RESULTS

(1) The effective rates (ERs) for PSD treatment were higher in the DTD, EA and DTD + EA groups than in the control group (all P < 0.05). The ER was higher in the DTD + EA group than in the DTD or EA group (both P < 0.05). (2) There were significant group effects, time effects and interactions for the SSA and SWAL-QOL scores (all P < 0.05). All groups showed decreasing trends in SSA scores and increasing trends in SWAL-QOL scores over time from baseline to 6 weeks after intervention (all P < 0.01). (3) Factorial design analysis for ΔVDS showed that there was a significant main effect for DTD intervention (F = 11.877, P < 0.01) and for EA intervention (F = 29.357, P < 0.01). However, there was no significant interaction effect between DTD and EA (F = 0.133, P = 0.717). Multiple comparisons showed that the DTD, EA and DTD + EA groups all had higher ΔVDS values than the control group (P < 0.05). The DTD + EA group had a higher ΔVDS than the DTD or EA group (both P < 0.05). (4) Most adverse reactions were mild and transient.

CONCLUSIONS

Adding DTD or EA to SRT can better improve PSD than applying SRT alone. Adding DTD and EA simultaneously can accelerate and amplify the recovery of swallowing function versus DTD or EA alone, and both are effective and safe treatments, alone or jointly, for PSD and are a powerful supplement to routine treatments.

Case fatality rate and its determinants among admitted stroke patients in public referral hospitals, Northwest, Ethiopia: A prospective cohort study

According to the global burden of disease 5.5 million deaths were attributable to stroke. The stroke mortality rate is estimated to be seven times higher in low-income countries compared to high-income countries. The main aim of the study was to assess the 28 days case fatality rate and its determinants among admitted stroke patients in public referral hospitals, in Northwest Ethiopia. A hospital-based prospective cohort study was conducted from December 2020 to June 2021. The study population was 554 stroke patients. Based on Akakian Information Criteria, the Gompertz model was fitted to predict the hazard of death. The study included admitted stroke patients who were treated in the general medical ward and neurology ward. The mean age of the participants was 61 ± 12.85 years and 53.25% of the patients were female. The 28-days case fatality rate of stroke was 27.08%. The results from Gompertz parametric baseline hazard distribution revealed that female sex adjusted hazard rate (AHR = 0.27, 95% CI:0.18–0.42), absence of a family history of chronic disease (AHR = 0.50, 95%CI:0.29–0.87), good GCS score (AHR = 0.21, 95% CI:0.09–0.50) and the absence of complication during hospital admission (AHR = 0.16, 95% CI:0.08–0.29) were factors which decrease hazard of 28 days case fatality rate. While, hemorrhagic stroke sub-type (AHR = 1.38, 95% CI:1.04–3.19), time from symptom onset to hospital arrival (AHR = 1.49, 95% CI:1.57–2 .71), time from confirmation of the diagnosis to initiation of treatment (AHR = 1.03, 95% CI:1.01–1.04), a respiratory rate greater than 20 (AHR = 7.21, 95% CI:3.48–14.9), and increase in NIHSS score (AHR = 1.16, 95% CI:1.10–1.23) were factors increasing hazard of 28 days case fatality rate of stroke. At 28-days follow-up, more than one-fourth of the patients have died. The establishment of separate stroke centers and a network of local and regional stroke centers with expertise in early stroke evaluation and management may address challenges.

External validation of the Passive Surveillance Stroke Severity Indicator

BACKGROUND

The Passive Surveillance Stroke Severity (PaSSV) Indicator was derived to estimate stroke severity from variables in administrative datasets but has not been externally validated.

METHODS

We used linked administrative datasets to identify patients with first hospitalization for acute stroke between 2007-2018 in Alberta, Canada. We used the PaSSV indicator to estimate stroke severity. We used Cox proportional hazard models and evaluated the change in hazard ratios and model discrimination for 30-day and 1-year case fatality with and without PaSSV. Similar comparisons were made for 90-day home time thresholds using logistic regression. We also linked with a clinical registry to obtain National Institutes of Health Stroke Scale (NIHSS) and compared estimates from models without stroke severity, with PaSSV, and with NIHSS.

RESULTS

There were 28,672 patients with acute stroke in the full sample. In comparison to no stroke severity, addition of PaSSV to the 30-day case fatality models resulted in improvement in model discrimination (C-statistic 0.72 [95%CI 0.71-0.73] to 0.80 [0.79-0.80]). After adjustment for PaSSV, admission to a comprehensive stroke center was associated with lower 30-day case fatality (adjusted hazard ratio changed from 1.03 [0.96-1.10] to 0.72 [0.67-0.77]). In the registry sample (N = 1328), model discrimination for 30-day case fatality improved with the inclusion of stroke severity. Results were similar for 1-year case fatality and home time outcomes.

CONCLUSION

Addition of PaSSV improved model discrimination for case fatality and home time outcomes. The validity of PASSV in two Canadian provinces suggests that it is a useful tool for baseline risk adjustment in acute stroke.

A novel nomogram to predict mortality in patients with stroke: a survival analysis based on the MIMIC-III clinical database

Background

Stroke is a disease characterized by sudden cerebral ischemia and is the second leading cause of death worldwide. We aimed to develop and validate a nomogram model to predict mortality in intensive care unit patients with stroke.

Methods

All data involved in this study were extracted from the Medical Information Mart for Intensive Care III database (MIMIC-III). The data were analyzed using multivariate Cox regression, and the performance of the novel nomogram, which assessed the patient’s overall survival at 30, 180, and 360 days after stroke, was evaluated using Harrell’s concordance index (C-index) and the area under the receiver operating characteristic curve. A calibration curve and decision curve were introduced to test the clinical value and effectiveness of our prediction model.

Results

A total of 767 patients with stroke were randomly divided into derivation (n = 536) and validation (n = 231) cohorts at a 7:3 ratio. Multivariate Cox regression showed that 12 independent predictors, including age, weight, ventilation, cardiac arrhythmia, metastatic cancer, explicit sepsis, Oxford Acute Severity of Illness Score or OASIS score, diastolic blood pressure, bicarbonate, chloride, red blood cell and white blood cell counts, played a significant role in the survival of individuals with stroke. The nomogram model was validated based on the C-indices, calibration plots, and decision curve analysis results.

Conclusions

The plotted nomogram accurately predicted stroke outcomes and, thus may contribute to clinical decision-making and treatment as well as consultation services for patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01836-3.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity

IMPORTANCE

Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes.

OBJECTIVE

To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022.

EXPOSURES

Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other.

MAIN OUTCOMES AND MEASURES

Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke.

RESULTS

Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.

Subclinical thyroid dysfunction and autoantibodies in acute ischemic and hemorrhagic stroke patients: relation to long term stroke outcome

Background

Data regarding the relation between both subclinical thyroid dysfunction, thyroid autoantibodies and clinical outcomes in stroke patients are limited. This study aimed to evaluate subclinical thyroid dysfunction and thyroid autoantibodies production in acute stroke patients and their relation to long term stroke outcome. We recruited 138 patients who were subjected to thorough general, neurological examination and brain imaging. Blood samples were collected for measurement of levels of serum thyroid function [free tri-iodothyronine (FT3), free thyroxin (FT4), thyroid stimulating hormone (TSH)], thyroid autoantibodies within 48 h after hospital admission. FT4 and TSH after 1 year were done. The stroke severity was assessed at admission by the National Institutes of Health Stroke Scale (NIHSS). The stroke outcome was assessed at 3 months and after 1 year by the modified Rankin Scale (mRS). We divided the patients into two groups according to thyroid autoantibodies (positive and negative groups).

Results

Subclinical hyperthyroidism was found in 23% of patients, and subclinical hypothyroidism in 10% of patients. Euthyroidism was detected in 67% of patients. 34% patients had positive thyroid autoantibody. Positive thyroid autoantibodies were commonly found in those with subclinical hyperthyroidism (28%), followed by subclinical hypothyroidism (21%) and euthyroidism (14%). 73% and 59% of stroke patients had poor outcomes (mRS was > 2) at 3 months and 1 year respectively with no significant difference between ischemic and hemorrhagic stroke patients. In the positive group final TSH level, NIHSS score at admission, and disability at 1 year were significantly higher compared with the negative group. Poor outcome was significantly associated with higher NIHSS score at admission, positive thyroid autoantibodies, subclinical hyperthyroidism, and atrial fibrillation.

Conclusions

Subclinical thyroid dysfunction could be found in stroke patients with positive thyroid autoantibodies. Subclinical hyperthyroidism and thyroid autoantibodies were associated with a poor outcome at 1 year in first-ever acute stroke patients especially in those presented with atrial fibrillation and higher NIHSS score at admission.

Prehospital Notification Using a Mobile Application Can Improve Regional Stroke Care System in a Metropolitan Area

BACKGROUND

Acute ischemic stroke is a time-sensitive disease. Emergency medical service (EMS) prehospital notification of potential patients with stroke could play an important role in improving the in-hospital medical response and timely treatment of patients with acute ischemic stroke. We analyzed the effects of FASTroke, a mobile app that EMS can use to notify hospitals of patients with suspected acute ischemic stroke at the prehospital stage.

METHODS

We conducted a retrospective observational study of patients diagnosed with acute ischemic stroke at 5 major hospitals in metropolitan Daegu City, Korea, from February 2020 to January 2021. The clinical conditions and time required for managing patients were compared according to whether the EMS employed FASTroke app and further compared the factors by dividing the patients into subgroups according to the preregistration received by the hospitals when using FASTroke app.

RESULTS

Of the 563 patients diagnosed with acute ischemic stroke, FASTroke was activated for 200; of these, 93 were preregistered. The FASTroke prenotification showed faster door-to-computed-tomography times (19 minutes vs. 25 minutes, P < 0.001), faster door-to-intravenous-thrombolysis times (37 minutes vs. 48 minutes, P < 0.001), and faster door-to-endovascular-thrombectomy times (82 minutes vs. 119 minutes, P < 0.001). The time was further shortened when the preregistration was conducted simultaneously by the receiving hospital.

CONCLUSION

The FASTroke app is an easy and useful tool for prenotification as a regional stroke care system in the metropolitan area, leading to reduced transport and acute ischemic stroke management time and more reperfusion treatment. The effect was more significant when the preregistration was performed jointly.

Presence of Thrombectomy-capable Stroke Centers Within Hospital Service Areas Explains Regional Variation in the Case Fatality Rate of Acute Ischemic Stroke in Korea

OBJECTIVES

This study aimed to explore the status of regional variations in acute ischemic stroke (AIS) treatment and investigate the association between the presence of a thrombectomy-capable stroke center (TSC) and the case fatality rate (CFR) of AIS within hospital service areas (HSAs).

METHODS

This observational cross-sectional study analyzed acute stroke quality assessment program data from 262 hospitals between 2013 and 2016. TSCs were defined according to the criteria of the Joint Commission. In total, 64 HSAs were identified based on the addresses of hospitals. We analyzed the effects of structure factors, process factors, and the presence of a TSC on the CFR of AIS using multivariate logistic regression.

RESULTS

Among 262 hospitals, 31 hospitals met the definition of a TSC. Of the 64 HSAs, only 20 had a TSC. At hospitals, the presence of a stroke unit, the presence of stroke specialists, and the rate of endovascular thrombectomy (EVT) treatment were associated with reductions in the CFR. In HSAs, the rate of EVT treatment (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and the presence of a TSC (OR, 0.93; 95% CI, 0.88 to 0.99) significantly reduced the CFR of AIS.

CONCLUSIONS

The presence of a TSC within an HSA, corresponding to structure and process factors related to the quality of care, contributed significantly to lowering the CFR of AIS. The CFR also declined as the rate of treatment increased. This study highlights the importance of TSCs in the development of an acute stroke care system in Korea.

Acute stroke treatment and outcome in the oldest old (90 years and older) at a tertiary care medical centre in Germany-a retrospective study showing safety and efficacy in this particular patient population

Background

Stroke is among the most common causes of death and disability worldwide. Despite the relevance of stroke-related disease burden, which is constantly increasing due to the demographic change in industrialized countries with an ageing population and consecutively an increase in age-associated diseases, there is sparse evidence concerning acute stroke treatment and treatment-related outcome in the elderly patient group. This retrospective study aimed at analysing patient characteristics, therapy-related complications and functional outcome in stroke patients aged 90 years or older who underwent acute stroke treatment (i.e. intravenous thrombolysis, mechanical thrombectomy, or both).

Methods

We identified files of all inpatient stays at the Department of Neurology at Saarland University Medical Center (tertiary care level with a comprehensive stroke unit) between June 2011 and December 2018 and filtered for subjects aged 90 years or older at the time of admission. We reviewed patient files for demographic data, symptoms upon admission, (main) diagnoses, comorbidities, and administered therapies. For patients admitted due to acute stroke we reviewed files for therapy-related complications and functional outcome. We compared the modified Rankin scale (mRS) scores upon admission and at discharge for these patients.

Results

We identified 566 inpatient stays of subjects aged 90 years or older. Three hundred sixty-seven of the 566 patients (64.8%) were admitted and discharged due to symptoms indicative of stroke. Two hundred eleven patients received a diagnosis of ischaemic stroke. These 211 patients were analysed subsequently. Sixty-four patients qualified for acute stroke treatment (intravenous thrombolysis n = 22, mechanical thrombectomy n = 26, intravenous thrombolysis followed by mechanical thrombectomy n = 16) and showed a significant improvement in their functional status as measured by change in mRS score (admission vs. discharge, p 0.001) with 7 (10.9%) observed potentially therapy-related complications (relevant drop in haemoglobin n = 2, subarachnoidal haemorrhage n = 1, cerebral haemorrhage n = 3, extracranial bleeding n = 1). One intravenous thrombolysis was stopped because of an uncontrollable hypertensive crisis. Patients who did not qualify for these treatments (including those declining acute treatment) did not show a change of their functional status between admission and discharge (p 0.064).

Conclusion

Our data indicate that acute stroke treatment is effective and safe in the oldest old. Age alone is no criterion to withhold an acute intervention even in oldest old stroke patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02566-3.

Rapid Risk Stratification of Acute Ischemic Stroke Patients in the Emergency Department: The Incremental Prognostic Role of Left Atrial Reservoir Strain

OBJECTIVES

To determine the prognostic value of positive global left atrial strain (LA-GSA+), measured by two-dimensional speckle tracking echocardiography (2D-STE) in a population of acute ischemic stroke (AIS) patients without atrial fibrillation (AF), in the setting of Emergency Department (ED).

METHODS

All consecutive AIS patients with sinus rhythm on ECG and without AF history entered this prospective study. All patients underwent complete blood tests and transthoracic echocardiography implemented with 2D-STE analysis of LA strain parameters within 6-12 h after symptoms onset. At 6-months follow-up, we evaluated the composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations.

RESULTS

A total of 102 AIS patients (76.4 ± 10.8 yrs, 47% males) were prospectively included. LA-GSA+ was markedly reduced in AIS patients (20.8 ± 7.7%), without any statistically significant difference between the stroke subtypes. At 6-months follow-up, 7 deaths and 27 re-hospitalizations occurred. On multivariate Cox regression analysis, variables independently associated with outcome were: LA-GSA+ (per unit) (HR 0.29, 95% CI 0.19-0.39) and C-reactive protein (CRP) (per 0.1 mg/dl) (HR 1.45, 95% CI 1.15-1.75) as continuous variables; statin therapy (HR 0.45, 95%CI 0.28-0.62), and type 2 diabetes (HR 1.65, 95% CI 1.15-2.35) as categorical variables. A LA-GSA+ ≤20.0% predicted the occurrence of the above-mentioned outcome at 6-months follow-up with 94% sensitivity and 81% specificity (AUC=0.84). Interestingly, GSA+ showed a strong inverse correlation with CRP levels (r = -0.86).

CONCLUSIONS

A LA-GSA+ ≤20% reflects a more advanced atrial cardiomyopathy and might provide a rapid and reliable prognostic risk stratification of AIS patients without AF history in the setting of ED.

Workforce Attachment after Ischemic Stroke - The Importance of Time to Thrombolytic Therapy

OBJECTIVES

The ability to remain in employment addresses an important consequence of stroke beyond the usual clinical parameters. However, data on the association between time to intravenous thrombolysis and workforce attachment in patients with acute ischemic stroke are sparse.

MATERIALS AND METHODS

In this nationwide cohort study, stroke patients of working age (18-60 years) treated with thrombolysis (2011-2016) who were part of the workforce prior to admission and alive at discharge were identified using the Danish Stroke Registry. The association between time to thrombolysis and workforce attachment one year later was examined with multivariable logistic regression.

RESULTS

The study population comprised 1,329 patients (median age 51 years [25^th-75^th percentile 45-56], 67.3% men). The median National Institutes of Health Stroke Scale score at presentation was 4 (25^th-75^th percentile 2-8), and the median time from symptom-onset to initiation of thrombolysis was 140min (25^th-75^th percentile 104-196min). The proportion of patients who were part of the workforce at one-year follow-up was 64.6%, 64.3%, 64.9%, and 60.0% in patients receiving thrombolysis within 90min, between 91-180min, between 181-270min, and after 270min, respectively. In adjusted analysis, time to thrombolysis between 91-180min, 181-270min, and >270min was not significantly associated with workforce attachment compared with thrombolysis received ≤90min of symptom-onset (ORs 0.89 [95%CI 0.60-1.31], 0.93 [0.66-1.31], and 0.80 [0.43-1.52], respectively).

CONCLUSIONS

In patients of working age admitted with stroke and treated with thrombolysis, two out of three were part of the workforce one year after discharge. There was no graded relationship between time to thrombolysis and the likelihood of workforce attachment.

Acute Routine Leukocyte and Neutrophil Counts Are Predictive of Poststroke Recovery at 3 and 12 Months Poststroke: An Exploratory Study

Background and Aims. White blood cell (WBC) and neutrophil counts (NC) are common markers of inflammation and neurological stroke damage and could be expected to predict poststroke outcomes. Objective. The aim of this study was to explore the prognostic value of early poststroke WBC and NC to predict cognition, mood, and disability outcomes at 3 and 12 months poststroke. Methods. Routine clinical analyses WBC and NC were collected at 3 time points in the first 4 days of hospitalization from 156 acute stroke patients. Correlations using hierarchical or ordinal regressions were explored between acute WBC and NC and functional recovery, depression, and cognition at 3 and 12 months poststroke, after covarying for age and baseline stroke severity. Results. We found significant increases in NC between <12 hours and 24 to 48 hours time points (P = .05). Hierarchical regressions, covaried for age and baseline stroke severity, found that 24 to 48 hours WBC (P = .05) and NC (P = .04) significantly predicted 3-month cognition scores. Similarly, 24 to 48 hours WBC (P = .05) and NC (P = .02) predicted cognition scores at 12 months. Increases in WBC and NC were predictive of increased cognition scores at both 3 and 12 months (positive recovery) though there were no significant associations between WBC and NC and disability or depression scores. Conclusions. Routine acute stroke clinical laboratory tests such as WBC and NC taken between 24 and 48 hours poststroke are predictive of cognition poststroke. It is interpreted that higher rapid immunological activation in the acute phase is an indicator for the trajectory of positive stroke recovery.

Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

Prognostic Significance of Fragmented QRS in Patients with Acute Ischemic Stroke

OBJECTIVES

There are studies in the literature showing the clinical importance of fragmented QRS (fQRS) in many systemic diseases. In this study, we aimed to investigate the frequency and prognostic value of fQRS on electrocardiogram (ECG) in patients with acute ischemic stroke.

MATERIALS AND METHODS

We prospectively enrolled 241 patients with acute ischemic stroke between January 2018 and January 2020. ST depression and elevation, QRS duration, PR interval, RR interval, QTc interval, QTc dispersion (QTcd), T negativity, Q wave, and fQRS were evaluated on ECG. Brain computed tomography (CT) and diffusion magnetic resonance imaging (MRI) images were obtained in the acute period and the National Institute of Health Stroke Scale (NIHSS) score was calculated for each patient. Patients were followed up for a period of two years.

RESULTS

The 241 patients comprised 121 (50.2%) men and 120 (49.8%) women with a mean age of 67.52 ± 13.00 years. In Cox regression analysis, age, NIHSS, QTcd, and fQRS were found to be independent predictors of mortality (age, hazard ratio [HR]: 1.063, p < 0.001; NIHSS, HR: 1.116, p = 0.006; QTcd, HR: 1.029, p = 0.042; fQRS, HR: 2.048, p = 0.037). Two-year mortality was higher in patients with fQRS than in patients without fQRS (31% vs. 9%, p = 0.001).

CONCLUSIONS

The fQRS is associated with poor prognosis in patients with acute ischemic stroke.

Nursing Home Admission and Initiation of Domiciliary Care After Ischemic Stroke - The Importance of Time to Thrombolysis

OBJECTIVES

There is a paucity of data on the risk of nursing home admission or domiciliary care initiation according to time to intravenous thrombolysis for ischemic stroke. We investigated the association between time to intravenous thrombolysis and the composite of nursing home admission or domiciliary care initiation in patients with acute ischemic stroke.

MATERIALS AND METHODS

In this nationwide cohort study, all stroke patients treated with intravenous thrombolysis (2011-2015) and alive at discharge were identified from the Danish Stroke Registry and other nationwide registries. The composite of nursing home admission or domiciliary care initiation one year post-discharge according to time to thrombolysis was examined with multivariable Cox regression.

RESULTS

The study population comprised 4,349 patients (median age 67 years [25^th-75^th percentile 57-75], 65.2% men). The median National Institutes of Health Stroke Scale score at presentation was 5, and the median time from symptom-onset to initiation of thrombolysis was 143 min. The absolute 1-year risk of the composite endpoint was 14.0% (95%CI, 11.5-16.8%) in the ≤90 min group, 16.6% (15.1-18.1%) in the 91-180min group, and 16.0% (14.0-18.2%) in the 181-270 min group. Compared with thrombolysis ≤90 min, time to thrombolysis between 91-180 min and 181-270 min was associated with a significantly higher risk of the composite endpoint (hazard ratio 1.31 [1.04-1.65] and 1.47 [1.14-1.91], respectively).

CONCLUSIONS

In patients admitted with ischemic stroke, increasing time to thrombolysis was associated with a greater risk of the composite of nursing home admission or domiciliary care initiation. Continued efforts to shorten the time delay from symptom-onset to initiation of thrombolysis are warranted.

Distributional Validity and Prognostic Power of the National Institutes of Health Stroke Scale in US Administrative Claims Data

Importance

Comparative assessment of acute ischemic stroke care quality provided by hospitals in the United States has been hampered by the unavailability of the National Institutes of Health Stroke Scale (NIHSS) in administrative data sets, preventing adequate adjustment for variations in patient case-mix risk. In response to stakeholder concerns, the US Centers for Medicare & Medicaid Services in 2016 implemented optional reporting of NIHSS scores.

Objective

To analyze the distributional, convergent, and predictive validity of nationally submitted NIHSS values in the National Inpatient Sample.

Design, Setting, and Participants

This population-based retrospective cross-sectional study took place from October 1 to December 31, 2016. The nationally representative sample included US adults who had ischemic stroke hospitalizations during the first calendar quarter in which optional NIHSS reporting was implemented. Analysis began September 2019.

Main Outcomes and Measures

Distribution of NIHSS scores, functional independence at discharge, inpatient mortality, and administrative reporting of NIHSS.

Results

Among 154 165 ischemic stroke hospitalizations during the first 3 months of the reporting policy, NIHSS scores were reported in 21 685 patients (14%) (10 925 women [50.4%]; median [interquartile range] age, 72 [61-82] years). Median (interquartile range) NIHSS score was 4 (2-11), and frequency of severity categories included absent (NIHSS score, 0) in 2080 patients (9.6%), minor (NIHSS score, 1-4) in 8760 patients (40.4%), and severe (NIHSS score, 21-42) in 1930 patients (8.9%). National Institutes of Health Stroke Scale score of 10 or more, an indicator of possible large vessel occlusions, was present in 6290 patients (29%). Presenting NIHSS score was higher in very elderly patients (age ≥80 y) and women and also in patients receiving endovascular thrombectomy vs intravenous thrombolysis alone vs no reperfusion therapy (median [interquartile range], 17 [12-22] vs 6 [4-12] vs 4 [2-9], respectively) (P < .001). National Institutes of Health Stroke Scale scores were similarly higher for discharge outcomes of mortality vs discharge to skilled nursing facility vs discharge home (median [interquartile range], 19 [12-25] vs 7 [3-15] vs 2 [1-5], respectively) (P < .001). Likelihood of NIHSS scores being reported independently increased with interfacility transfer, receipt of acute reperfusion therapies, larger hospital size, academic centers, and region other than the West.

Conclusions and Relevance

In the initial national optional reporting period in the United States, NIHSS scores were reported in nearly 1 in 7 ischemic stroke hospitalizations. The distribution of NIHSS scores was similar to that from narrow population-based studies and registries, and NIHSS scores were powerfully associated with discharge outcome, supporting the validity and potential to aid care quality assessment.

Troponin-I elevation predicts outcome after thrombolysis in ischemic stroke patients

Background

Prognostic significance of troponin-I (T-I) elevation for poor short-term outcome in thrombolyzed ischemic stroke patients remains uncertain.

Objectives

To evaluate its role as a predictive biomarker of short-term outcome in thrombolyzed ischemic stroke patients.

Methods

This study included 72 acute ischemic stroke patients who were treated with intravenous thrombolytic therapy. All patients were subjected to clinical assessment and measurement of serum T-I level on admission. Outcome was assessed 3 months after stroke onset using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale.

Results

Thirteen patients had elevated serum T-I level (group 1) and the remaining 59 were classified as group 2. Group 1 had a higher statistically significant older age, history of diabetes mellitus (DM), previous stroke, atrial fibrillation (AF), and admission NIHSS score, with significant decrease in high-density lipoprotein cholesterol (P < 0.05). Regarding the outcome of both groups, good outcome was significantly less common among group 1. Also, death was significantly more common among group I. Poor outcome in group 1 were significantly associated with older age, DM, AF, elevated serum T-I level at admission, and higher admission NIHSS score (P = 0.03, 0.04, 0.02, 0.05, and 0.001 respectively). The predictors of poor outcome in group 1 were elevated serum T-I level at admission, higher admission NIHSS score, and DM (P = 0.001, 0.02, and 0.05 respectively).

Conclusion

Elevated serum T-I levels on admission is a reliable prognostic predictor of poor outcome in thrombolyzed ischemic stroke patients.

Trial registration

ClinicalTrials.govNCT03925298 (19 April 2019) “retrospectively registered,”

Healthcare costs before and after stroke in patients with non-valvular atrial fibrillation who initiated treatment with rivaroxaban or warfarin

AIMS

Rivaroxaban reduces stroke compared with warfarin in patients with non-valvular atrial fibrillation (NVAF). This study compared healthcare costs before and after stroke in NVAF patients treated with rivaroxaban or warfarin.

MATERIALS AND METHODS

Using de-identified IBM MarketScan Commercial and Medicare databases, this retrospective cohort study (from 2011 to 2019) included patients with NVAF who initiated rivaroxaban or warfarin within 30 days after initial NVAF diagnosis. Patients who developed stroke were identified, and stroke severity was determined by the National Institutes of Health Stroke Scale (NIHSS) score, imputed by a random forest method. Total all-cause per-patient per-year (PPPY) costs of care were determined for patients: (1) who developed stroke during the pre- and post-stroke periods and (2) who remained stroke-free during the follow-up period. Treatment groups were balanced using inverse probability of treatment weighting.

RESULTS

A total of 13,599 patients initiated rivaroxaban and 39,861 initiated warfarin, of which 272 (2.0%) and 1,303 (3.3%), respectively, developed stroke during a mean follow-up of 28 months. Among patients who developed stroke, PPPY costs increased from the pre-stroke to post-stroke period, with greater increases in the warfarin cohort relative to the rivaroxaban cohort. Overall, the costs increased by 1.78-fold for rivaroxaban vs 3.07-fold for warfarin; for less severe strokes (NIHSS < 5), costs increased 0.88-fold and 1.05-fold, respectively. Cost increases for more severe strokes (NIHSS ≥ 5) among rivaroxaban patients were half those for warfarin patients (3.19-fold vs 6.37-fold, respectively). Among patients without stroke, costs were similar during the follow-up period between the two treatment groups.

CONCLUSIONS

Total all-cause costs of care increased in the post-stroke period, and particularly in the patients treated with warfarin relative to those treated with rivaroxaban. The lower rate of stroke in the rivaroxaban cohort suggests that greater pre- to post-stroke cost increases result from more strokes occurring in the warfarin cohort.

Modification of Acute Stroke Pathway in Korea After the Coronavirus Disease 2019 Outbreak

Background: Since the global pandemic of coronavirus disease 2019 (COVID-19), the process of emergency medical services has been modified to ensure the safety of healthcare professionals as well as patients, possibly leading to a negative impact on the timely delivery of acute stroke care. This study aimed to assess the impact of the COVID-19 pandemic on the acute stroke care processes and outcomes in tertiary COVID-19-dedicated centers in South Korea.

Methods: We included 1,213 patients with acute stroke admitted to three centers in three cities (Seoul, Seongnam, and Daegu) through the stroke critical pathway between September 2019 and May 2020 (before and during the COVID-19 pandemic). In all three centers, we collected baseline characteristics and parameters regarding the stroke critical pathway, including the number of admitted patients diagnosed with acute stroke through the stroke critical pathway, door to brain imaging time, door to intravenous recombinant tissue plasminogen activator time, door to groin puncture time, and door to admission time. We performed an interrupted time series analysis to determine the impact of the COVID-19 outbreak on outcomes and critical pathway parameters.

Results: Three centers modified the protocol of the stroke critical pathway during the COVID-19 pandemic. There was an immediate decrease in the number of patients admitted with acute ischemic stroke after the outbreak of COVID-19 in Korea, especially in the center of Daegu, an epicenter of the COVID-19 outbreak. However, the number of patients with stroke soon increased to equal that before the Covid-19 outbreak. In several critical pathway parameters, door to imaging time showed a temporary increase, and door to admission was transiently decreased after the COVID-19 outbreak. However, there was no significant effect on the timely trend. Moreover, there was no significant difference in the baseline characteristics and clinical outcomes between the periods before and during the COVID-19 pandemic.

Conclusion: This study demonstrated that the COVID-19 outbreak immediately affected the management process. However, it did not have a significant overall impact on the trends of stroke treatment processes and outcomes. The stroke management process should be modified according to changing situations for optimal acute management.

Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea

BACKGROUND

Neurocritical care by dedicated neurointensivists may improve outcomes of critically ill patients with severe brain injury. In this study, we aimed to validate whether neurointensive care could improve the outcome in patients with critically ill acute ischemic stroke using the linked big dataset on stroke in Korea.

METHODS

We included 1,405 acute ischemic stroke patients with mechanical ventilator support in the intensive care unit after an index stroke. Patients were retrieved from linking the Clinical Research Center for Stroke Registry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge and at 3 months after an index stroke. The main outcomes were compared between the centers with and without dedicated neurointensivists.

RESULTS

Among the included patients, 303 (21.6%) were admitted to the centers with dedicated neurointensivists. The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, P = 0.002) as well as lower mortality at 3-month (38.0% vs. 49.1%, P < 0.001) than those who were treated without neurointensivists. After adjusting for confounders, a treatment without neurointensivists was independently associated with higher in-hospital mortality (odds ratio [OR], 1.59; 95% confidence intervals [CIs], 1.13-2.25; P = 0.008) and 3-month mortality (OR, 1.48; 95% CIs, 1.12-1.95; P = 0.005).

CONCLUSION

Treatment by dedicated neurointensivists is associated with lower in-hospital and 3-month mortality using the linked big datasets for stroke in Korea. This finding stresses the importance of neurointensivists in treating patients with severe ischemic stroke.

30-day and 60-day rates and predictors of mortality among adult stroke patients: Prospective cohort study

Stroke is one of the most common medical emergencies and the leading cause of preventable death and long-term disability worldwide. A prospective cohort study was conducted at the stroke unit of Jimma university medical center for four consecutive months (from March 10 to July 10, 2017). Of the total 116 study patients, 60 (51.7%) had an ischemic stroke. At 30-day follow-up, 81 (69.8%) patients were alive, 34 (29.3%) were died, and one patient (0.9%) was lost to follow-up. Elevated alanine aminotransferase (ALT) level (AHR: 3.77, 95% CI: 1.34-10.57), diagnosis of stroke clinically alone (AHR: 3.90, 95 CI: 1.49-10.26), brain edema (AHR: 4.28, 95% CI: 1.61-11.37), and National Institute of Health Stroke Scale (NIHSS) ≥ 13 during hospital arrival (AHR: 6.49, 95% CI: 1.90-22.22) were the independent predictors of 30-day mortality. At 60-day follow-up, 68 (58.6%) patients were alive, 46 (39.7%) were died, and 2 (1.7%) were lost to follow-up. Discharge against medical advice (AHR: 6.40, 95% CI: 2.31-17.73) and severe modified Rankin score/mRS (4-5) at discharge (AHR: 3.64, 95% CI: 1.01-13.16) were the independent predictors of 60-day mortality. The median (IQR) length of survival after hospital admission for patients died within 30 and 60 days were 4.65 (2.34-11.80) and 9.3 (3.93-33) days, respectively. Stroke significantly affects the morbidity and mortality in Ethiopia. There is a need to provide better care and future planning for stroke patients as an emergency diagnosis and treatment to minimize mortality and disability.

Predicting Functional Outcome Based on Linked Data After Acute Ischemic Stroke: S-SMART Score

Prediction of outcome after stroke may help clinicians provide effective management and plan long-term care. We aimed to develop and validate a score for predicting good functional outcome available for hospitals after ischemic stroke using linked data. A total of 22,005 patients with acute ischemic stroke from the Clinical Research Center for Stroke Registry between July 2007 and December 2014 were included in the derivation group. We assessed functional outcomes using a modified Rankin scale (mRS) score at 3 months after ischemic stroke. We identified predictors related to good 3-month outcome (mRS score ≤ 2) and developed a score. External validations (geographic and temporal validations) of the developed model were performed. The prediction model performance was assessed using the area under the receiver operating characteristic curve (AUC) and the calibration test. Stroke severity, sex, stroke mechanism, age, pre-stroke mRS, and thrombolysis/thrombectomy treatment were identified as predictors for 3-month good functional outcomes in the S-SMART score (total 34 points). Patients with higher S-SMART scores had an increased likelihood of a good outcome. The AUC of the prediction score was 0.805 (0.798-0.811) in the derivation group and 0.812 (0.795-0.830) in the geographic validation group for good functional outcome. The AUC of the model was 0.812 (0.771-0.854) for the temporal validation group. Moreover, they had good calibration. The S-SMART score is a valid and useful tool to predict good functional outcome following ischemic stroke. This prediction model may assist in the estimation of outcomes to determine care plans after stroke.

Predicting Death After Thrombectomy in the Treatment of Acute Stroke

Introduction: Treatments for acute stroke have significantly improved in the past decade, with emergent thrombectomy emerging as the standard of care. Despite these advancements, death after successful thrombectomy continues to pose a significant problem. Identifying patients least likely to benefit from thrombectomy would improve use of a limited resource and management of patient expectations.

Method: We retrospectively reviewed the medical records of patients who underwent emergent thrombectomy of either anterior or posterior circulation strokes between January 2012 and January 2017. Relevant patient clinical data was collected and analyzed in a multivariable regression with a primary outcome of death at 90 days.

Results: A total of 134 patients underwent emergent endovascular thrombectomy during the study period; sufficient clinical data was available in 111 of the them. Of these, 42 patients died during the 90 day post-procedural period and 69 patients survived this period. The mean NIHSS score at presentation was 14.9 in surviving patients and 19.6 in non-surviving patients (p < 0.002). Surviving patients were less likely to have a history of cancer (4.4% vs. 26.2%, p < 0.002), achieved higher rates of revascularization (78.3% vs. 50.0%, p < 0.003), had a lower rate of hemorrhagic conversion (21.7% vs. 47.6%, p < 0.004), and experienced fewer technical complications during their treatment (7.4% vs. 26.2%, p < 0.01). Overall, there were 16 intraprocedural complications and no procedural deaths.

Conclusion: As emergent thrombectomy for the treatment of acute stroke becomes more prevalent, appropriate patient selection will be crucial in the utilization of a limited and costly intervention. Death within 90 days after thrombectomy appears to be more prevalent among patients with higher NIHSS at presentation, those with postprocedural hemorrhage or intraprocedural complications, and those with a history of cancer.

The impact of acute kidney injury on fatality of ischemic stroke from a hospital-based population in Joinville, Brazil

Introduction:

The occurrence of acute kidney injury (AKI) after ischemic stroke has been associated to a worse prognosis. There is a lack of Brazilian studies evaluating this issue. This study aimed to describe the impact of AKI after a first-ever ischemic stroke in relation to fatality rate in 30 days.

Methods:

This was a retrospective hospital-based cohort. We included patients who had their first ischemic stroke between January to December 2015. AKI was defined by an increase of serum creatinine in relation to baseline value at admission ≥ 0.3 mg/dL or a rise in serum creatinine level by 1.5 times the baseline value at any point in the first week after admission. We performed a univariate and multivariate analysis to evaluate the presence of AKI with fatality in 30 days.

Results:

The final study population (n=214) had mean age of 66.46 ± 13.73 years, 48.1% were men, the mean NIHSS was 6.33 ± 6.27 and 20 (9.3%) presented AKI. Patients with AKI were older, had a higher score on the NIHSS, and had higher creatinine values on hospital discharge. The 30-day mortality was higher in the AKI subgroup compared to non-AKI (35% vs. 6.2%, p < 0.001). AKI was an independent predictor of fatality after an ischemic stroke but limited by severity of stroke (NIHSS).

Conclusion:

The presence of AKI is an important complication after ischemic stroke. Despite its impact on 30-day fatality, the predictive strength of AKI was limited by the severity of stroke.

Assessing stroke severity using electronic health record data: a machine learning approach

Background

Stroke severity is an important predictor of patient outcomes and is commonly measured with the National Institutes of Health Stroke Scale (NIHSS) scores. Because these scores are often recorded as free text in physician reports, structured real-world evidence databases seldom include the severity. The aim of this study was to use machine learning models to impute NIHSS scores for all patients with newly diagnosed stroke from multi-institution electronic health record (EHR) data.

Methods

NIHSS scores available in the Optum© de-identified Integrated Claims-Clinical dataset were extracted from physician notes by applying natural language processing (NLP) methods. The cohort analyzed in the study consists of the 7149 patients with an inpatient or emergency room diagnosis of ischemic stroke, hemorrhagic stroke, or transient ischemic attack and a corresponding NLP-extracted NIHSS score. A subset of these patients (n = 1033, 14%) were held out for independent validation of model performance and the remaining patients (n = 6116, 86%) were used for training the model. Several machine learning models were evaluated, and parameters optimized using cross-validation on the training set. The model with optimal performance, a random forest model, was ultimately evaluated on the holdout set.

Results

Leveraging machine learning we identified the main factors in electronic health record data for assessing stroke severity, including death within the same month as stroke occurrence, length of hospital stay following stroke occurrence, aphagia/dysphagia diagnosis, hemiplegia diagnosis, and whether a patient was discharged to home or self-care. Comparing the imputed NIHSS scores to the NLP-extracted NIHSS scores on the holdout data set yielded an R² (coefficient of determination) of 0.57, an R (Pearson correlation coefficient) of 0.76, and a root-mean-squared error of 4.5.

Conclusions

Machine learning models built on EHR data can be used to determine proxies for stroke severity. This enables severity to be incorporated in studies of stroke patient outcomes using administrative and EHR databases.

Cardio embolic stroke and blood biomarkers: diagnosis and predictors of short-term outcome

Background

The brain is a productive source of a variety of enzymes and any brain injury like a stroke to brain tissue could similarly result in an increase in these enzymes in cerebrospinal fluid and serum. Evaluation of these enzymes represents a simple method for the ischemic stroke subtype diagnosis and prognosis. Objective: This study aimed to determine the role of brain natriuretic peptide (BNP), d-dimer, creatine–kinase-MB (CK-MB), C-reactive protein (CRP) serum levels, and globulin/albumin ratio in the diagnosis of CES stroke and its ability to predict short-term outcome.

Methods

This study was conducted on 96 patients with acute ischemic stroke, subdivided into two groups: group Ι was 48 patients with cardio-embolic stroke and group ΙΙ was 48 patients with non-cardio-embolic. All patients were subjected to the assessment of serum BNP, d-dimer and CK-MB, and CRP and globulin/albumin ratio within the first 24 h of stroke. In the third week, they were assessed by mRS.

Results

The mean levels of BNP, d-dimer level, and CK-MB were significantly higher in patients with cardio-embolic stroke than in patients with non-cardio-embolic stroke (P < 0.001) and also were associated with poor short-term outcome.

Conclusion

Elevated plasma levels of BNP, d-dimer levels, and CK-MB can be used as surrogate biomarkers for the diagnosis of cardio-embolic stroke and prediction of poor short-term outcomes.

Randomized Controlled Trial of the Lateral Push-Off Skater Exercise for High-Intensity Interval Training vs Conventional Treadmill Training

OBJECTIVE

To examine the therapeutic effects of the lateral push-off skater exercise vs conventional treadmill training on health-related quality of life, cardiorespiratory fitness (CRF), and balance.

DESIGN

Single-blinded, randomized controlled trial.

SETTING

Outpatient clinic at a tertiary hospital.

PARTICIPANTS

Patients after minor stroke (N=36) with National Institutes of Health Stroke Scale scores≤3 between 20 and 65 years of age were randomly assigned to the intervention group (n=18) or the control group (n=18).

INTERVENTIONS

Thirty-minute sessions of the skater exercise were performed 3 times weekly for 12 weeks in the intervention group. Conventional treadmill aerobic exercise was conducted in the control group at the same frequency and duration as the experimental group exercise.

MAIN OUTCOME MEASURES

The primary outcome was measured using the European Quality of Life-5 Dimension (EQ-5D). Secondary outcomes included CRF and balance indicators. Assessments were performed at baseline (T0), 12 weeks from T0 (T1), and 16 weeks from T0 (T2).

RESULTS

Significant improvements in EQ-5D, peak oxygen uptake (VO₂peak), peak oxygen pulse, peak minute ventilation (VE), Dynamic Gait Index (DGI), and Berg Balance Scale (BBS) were found in the intervention group after performing the skater exercise (P<.05, all), and these improvements were sustained at T2 (P<.05, all). Between-group comparisons demonstrated greater improvements in EQ-5D, VO₂peak, peak oxygen pulse, peak VE, DGI, and BBS in the intervention group than those in the control group at both T1 (P<.05, all) and T2 (P<0.05, all). Correlation analysis showed significant relationships between EQ-5D and VO₂peak, peak VE, DGI, and BBS (P<.05, all).

CONCLUSIONS

The skater exercise improved health-related quality of life, CRF, and balance in patients after minor stroke more effectively than conventional treadmill-based aerobic exercise. We recommend the skater exercise as a high-intensity interval training program for patients after minor stroke.

The Costs of Hepatitis C by Liver Disease Stage: Estimates from the Veterans Health Administration

BACKGROUND

The release of highly effective but costly medications for the treatment of hepatitis C virus combined with a doubling in the incidence of hepatitis C virus have posed substantial financial challenges for many healthcare systems. We provide estimates of the cost of treating patients with hepatitis C virus that can inform the triage of pharmaceutical care in systems with limited healthcare resources.

METHODS

We conducted an observational study using a national US cohort of 206,090 veterans with laboratory-identified hepatitis C virus followed from Fiscal Year 2010 to 2014. We estimated the cost of: non-advanced Fibrosis-4; advanced Fibrosis-4; hepatocellular carcinoma; liver transplant; and post-liver transplant. The former two stages were ascertained using laboratory result data; the latter stages were ascertained using administrative data. Costs were obtained from the Veterans Health Administration's activity-based cost accounting system and more closely represent the actual costs of providing care, an improvement on the charge data that generally characterizes the hepatitis C virus cost literature. Generalized estimating equations were used to estimate and predict costs per liver disease stage. Missing data were multiply imputed.

RESULTS

Annual costs of care increased as patients progressed from non-advanced Fibrosis-4 to advanced Fibrosis-4, hepatocellular carcinoma, and liver transplant (all p < 0.001). Post-liver transplant, costs decreased significantly (p < 0.001). In simulations, patients were estimated to incur the following annual costs: US $17,556 for non-advanced Fibrosis-4; US $20,791 for advanced Fibrosis-4; US $46,089 for liver cancer; US $261,959 in the year of the liver transplant; and US $18,643 per year after the liver transplant.

CONCLUSIONS

Cost differences of treating non-advanced and advanced Fibrosis-4 are relatively small. The greatest cost savings would be realized from avoiding progression to liver cancer and transplant.

Genetic and lifestyle predictors of ischemic stroke severity and outcome

BACKGROUND

Different models that include clinical variables and blood markers have been investigated to predict acute ischemic stroke treatment course and recovery.

AIM

The aim of the study was to investigate associations between lipid levels, lifestyle factors, hemostatic (F5, F2, SERPINE1, F13A1, and FGB), and atherogenic (APOA5 and ACE) gene variants and acute ischemic stroke (AIS) severity.

MATERIALS AND METHODS

This study included 250 patients with AIS in which F5, F2, SERPINE1, F13A1, FGB, APOA5, and ACE genotypes were determined. Total cholesterol (TC), high-density cholesterol, low-density cholesterol, and triglycerides concentrations were measured within 24 h of the AIS onset. Examination of the neurological deficit was done using National Institutes of Health Stroke Scale/Score (NIHSS).

RESULTS

APOA5 genotype [TC + CC] was more frequent (P = 0.026) in patients with the NIHSS score ≥ 21. Univariate regression analysis has shown that triglycerides (OR 0.55, 95% CI 0.34-0.91; P = 0.019), obesity (0.28, 95% CI 0.10-0.73; P = 0.010), age (OR 1.08, 95% CI 1.04-1.13; P < 0.001), and APOA5 genotype (TC + CC) (OR 2.40, 95% CI 1.10-5.25; P = 0.034) are significantly associated with a severe stroke. When all variables were included in model age (OR 1.06, 95% CI 1.01-1.11; P = 0.018), obesity (OR 0.25, 95% CI 0.08-0.77; P = 0.016) and APOA5 genotype (TC + CC) (OR 3.26, 95% CI 1.29-8.23; P = 0.012) remained significant for the risk of severe AIS.

CONCLUSION

APOA5 genotype (TC + CC), age, and obesity could be used as prognostic risk factors for a very severe stroke (NIHSS ≥ 21).

Prediction of the Lethal Outcome of Acute Recurrent Cerebral Ischemic Hemispheric Stroke

Background and objectives. Stroke-induced mortality is the third most common cause of death in developed countries. Intense interest has focused on the recurrent ischemic stroke, which rate makes up 30% during first 5 years after first-ever stroke. This work aims to develop criteria for the prediction of acute recurrent cerebral ischemic hemispheric stroke (RCIHS) outcome on the basis of comprehensive baseline clinical, laboratory, and neuroimaging examinations. Materials and Methods. One hundred thirty-six patients (71 males and 65 females, median age 74 (65; 78)) with acute RCIHS were enrolled in the study. All patients underwent a detailed clinical and neurological examination using National Institutes of Health Stroke Scale (NIHSS), computed tomography of the brain, hematological, and biochemical investigations. In order to detect the dependent and independent risk factors of the lethal outcome of the acute period of RCIHS, univariable and multivariable regression analysis were conducted. A receiver operating characteristic (ROC) analysis with the calculation of sensitivity and specificity was performed to determine the prediction variables. Results. Twenty-five patients died. The independent predictors of the lethal outcome of acute RCIHS were: Baseline NIHSS score (OR 95% CІ 1.33 (1.08-1.64), p = 0.0003), septum pellucidum displacement (OR 95% CI 1.53 (1.17-2.00), p = 0.0021), glucose serum level (OR 95% CI 1.28 (1.09-1.50), p = 0.0022), neutrophil-to-lymphocyte ratio (OR 95% CI 1.11 (1.00-1.21), p = 0.0303). The mathematical model, which included these variables was developed and it could determine the prognosis of lethal outcome of the acute RCIHS with an accuracy of 86.8% (AUC = 0.88 ± 0.04 (0.88-0.93), p < 0.0001).

Effect of prior stroke on long-term outcomes of percutaneous coronary interventions in Chinese patients: A large single-center study

OBJECTIVES

To evaluate the effect of prior stroke on long-term outcomes in patients undergoing percutaneous coronary interventions (PCI).

BACKGROUND

Patients with coronary heart disease (CHD) and prior stroke history have more serious clinical and angiographic conditions, which make the choice of treatment strategy complex.

METHODS

A total of 10,724 consecutive patients who underwent PCI from January 2013 to December 2013 were enrolled. 2-Year clinical outcomes between patients with prior stroke (n = 1150) and those with no prior stroke (n =9574) were compared.

RESULTS

The proportion of patients with prior stroke was 10.72%. These patients had higher clinical risks (age, sex, and cardiovascular risk factors) and more extensive coronary disease (higher pre-PCI and residual SYNTAX scores). During the 2-year follow-up, patients with prior stroke had a higher incidence of major adverse cardiac and cerebrovascular events (MACCE), all-cause death, stent thrombosis and stroke than those without prior stroke (14.3% vs. 11.8%, p = 0.02; 2.3% vs. 1.1%, p < 0.01; 1.6% vs. 0.8%, p < 0.01; 3.3% vs. 1.1%, p < 0.01, respectively). Multivariable regression analyses identified a positive association between prior stroke and risk of stroke (HR = 2.07, 95%CI: 1.35-3.19, p < 0.01). Propensity score matched analyses (962 pairs) indicated that the only primary end point that differed in incidence between the groups was stroke and prior stroke was the only independent predictor of stroke (HR = 2.31, 95%CI: 1.20-4.45, p = 0.01).

CONCLUSIONS

Prior stroke history was the only predictor of risk of post-PCI stroke. The noncerebrovascular adverse events were not increased after adjusted analyses of baseline characteristics and propensity analyses.

Validation and comparison of two stroke prognostic models for in hospital, 30-day and 90-day mortality

INTRODUCTION

We aimed to validate and compare two clinical prognostic models for mortality which include the National Institutes of Health Stroke Scale (NIHSS); the Age and NIHSS Score (ANS) and case mix model (CMM) of the Sentinel Stroke National Audit Program (SSNAP). The NIHSS on admission was also tested as a prognostic score.

PATIENTS AND METHODS

Prospectively collected data from the SSNAP register for a cohort of patients (ischaemic and haemorrhagic stroke) admitted over 1 year to Gloucestershire Royal Hospital, England were accessed. The ANS and CMM were calculated and tested for in hospital, 30-day and 90-day mortality using calibration plots with Hosmer-Lemeshow tests, receiver operating characteristics curves and other measures of prognostic accuracy.

RESULTS

Of 848 patients, 110 (12.9%) died in hospital, 112 (13.2%) at 30 days and 164 (19.2%) at 90 days. Calibration for all three scores was good, although Hosmer-Lemeshow test p values were <0.05 with the NIHSS alone for in hospital and 30-day deaths, suggesting deviation from good fit. The c-statistics for in hospital, 30-day and 90-day mortality were ANS (0.783, 0.782, 0.779) and CMM (0.783, 0.774, 0.758), respectively. The NIHSS alone showed fair discrimination but performed less well. A NIHSS score ≥6 was associated with significant mortality (p < 0.0001) in comparison to a score <6.

CONCLUSION

A simple prognostic model containing age and admission NIHSS only, performed as well as a more complex score at predicting in hospital, 30-day and 90-day mortality. Admission NIHSS recording should be encouraged for stroke registries.

A comparison of stroke severity proxy measures for claims data research: a population-based cohort study

PURPOSE

Confounding by disease severity has been viewed as an intractable problem in claims-based studies. A novel 7-variable stroke severity index (SSI) was designed for estimating stroke severity by using claims data. This study compared the performance of mortality models with various proxy measures of stroke severity, including the SSI, in patients hospitalized for acute ischemic stroke (AIS).

METHODS

Data from the Taiwan National Health Insurance Research Database (NHIRD) were analyzed. Three proxy measures of stroke severity were evaluated: Measure 1, the SSI; Measure 2, intensive care unit admission and length of stay; and Measure 3, surgical operation, mechanical ventilation, hemiplegia or hemiparesis, and residual neurological deficits. We performed logistic regression by including age, sex, vascular risk factors, Charlson comorbidity index, and one of the proxy measures as covariates to predict 30-day and 1-year mortality after AIS. Model discrimination was evaluated using the area under the receiver-operating characteristic curve (AUC).

RESULTS

We identified 7551 adult patients with AIS. Models using the SSI (Measure 1) outperformed models using the other proxy measures in predicting 30-day mortality (AUC 0.892 vs 0.851, p < 0.001 for Measure 2; 0.892 vs 0.853, p < 0.001 for Measure 3) and 1-year mortality (AUC 0.816 vs 0.784, p < 0.001 for Measure 2; 0.816 vs 0.782, p < 0.001 for Measure 3).

CONCLUSIONS

Using the SSI facilitated risk adjustment for stroke severity in mortality models for patients with AIS. The SSI is a viable methodological tool for stroke outcome studies using the NHIRD.

Functional outcomes and recanalization rates of stent retrievers in acute ischaemic stroke: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Intra-arterial therapy for acute ischaemic stroke has evolved rapidly in the last few years. Stent retrievers have now replaced 'first-generation' devices, which have been the principle devices tested in stroke trials.Our aims were to determine the rates of successful recanalization and functional independence in acute stroke patients treated with stent retrievers. We also sought to assess the safety outcomes of stent retrievers by assessing the rates of mortality and intra-cranial haemorrhage.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis of studies which utilized stent retrievers as sole treatment or as part of a multi-modal approach in acute ischaemic stroke.

RESULTS

We identified 20 eligible studies: 17 on Solitaire (ev3/Covidien, Irvine, California, USA) (n = 762) and three on Trevo (Stryker, Kalamazoo, Michigan, USA) (n = 210). The mean age of participants was 66.8 (range 62.1-73.0) years and the M:F ratio was 1.1:1. The average stroke severity score (National Institutes of Health Stroke Scale (NIHSS)) at presentation was 17.2. The weighted mean symptom onset to arterial puncture and procedural duration were 265.4 minutes and 54.8 minutes, respectively.Successful recanalization was achieved in 84.5% of patients with a weighted mean of 2.0 stent retriever passes. Independent functional outcome was achieved in 51.2% and the mortality rate was 16.8%.

CONCLUSION

Stent retrievers have the potential to achieve a high rate of recanalization and functional independence whilst being relatively safe. They should be assessed in well-designed randomized controlled trials to determine their efficacy and assess whether they compare favourably with 'standard treatment' in stroke.

Predictors of in-hospital death and symptomatic intracranial hemorrhage in patients with acute ischemic stroke treated with thrombolytic therapy: Paul Coverdell Acute Stroke Registry 2008-2012

BACKGROUND

Limited studies exist on the outcome of thrombolytic therapy of acute ischemic stroke patients outside of clinical trials.

AIM

To assess the possible risk factors associated with in-hospital death and symptomatic intracerebral hemorrhage among patients who received intravenous tissue plasminogen activator.

METHODS

A total of 7193 patients with a clinical diagnosis of acute ischemic stroke and a documented National Institutes of Health Stroke Scale score were treated with intravenous tissue plasminogen activator within 4·5 hours of time last known to be well. Generalized estimating equations modeling was used to assess the associations of in-hospital death and symptomatic intracerebral hemorrhage with clinical characteristics.

RESULTS

Among 7193 patients treated with intravenous tissue plasminogen activator, 516 (7·2%) died during hospitalization. Factors associated with in-hospital death were older age, male gender, National Institutes of Health Stroke Scale score, history of myocardial infarction or coronary artery disease, and history of nonvalvular atrial fibrillation. Increasing age, higher National Institutes of Health Stroke Scale score, and history of dyslipidemia were associated with symptomatic intracerebral hemorrhage. There was no difference in the rates of in-hospital death or symptomatic intracerebral hemorrhage among patients treated with intravenous tissue plasminogen activator within three-hours of time last known to be well and those treated between three and 4·5 hours after this time.

CONCLUSIONS

In this study of acute ischemic stroke patients, older age, male gender, National Institutes of Health Stroke Scale score, history of myocardial infarction or coronary artery disease, and history of atrial fibrillation were associated with increased in-hospital death among patients receiving intravenous tissue plasminogen activator. Among patients treated with intravenous tissue plasminogen activator, in-hospital mortality and symptomatic intracerebral hemorrhage rates were similar between those treated within three-hours of time last known to be well and those treated between three and 4·5 hours after this time.