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Leach CT, Bolin LP, Swanson MS, Burch AE, Woltz PC. The Use of the Acute Stroke Management Questionnaire to Measure Acute Care Nurses' Stroke Knowledge. J Neurosci Nurs 2024; 56:80-85. [PMID: 38598850 DOI: 10.1097/jnn.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
ABSTRACT BACKGROUND: Nurses are key in identifying and treating in-hospital strokes (IHSs). Delayed treatment times and poor patient outcomes are associated with IHSs. Information is needed on nurses' stroke knowledge and the objective measurement of stroke knowledge using a validated tool. The Acute Stroke Management Questionnaire (ASMaQ) was recently developed to test stroke knowledge of healthcare professionals but has not been used on a nursing-specific population. METHODS: Through online surveying and use of ASMaQ, we will measure stroke knowledge of nurses caring for adult, hospitalized patients in an urban, southeast US health system. RESULTS: Total N is 196. Most participants (74.5%, n = 146) never worked on a stroke floor; however, almost all (95.9%, n = 188) cared for a stroke patient in the past. Most participants (65.3%, n = 128) reported receiving prelicensure stroke education, and 98.5% (n = 193) received postlicensure stroke education. Acute Stroke Management Questionnaire total scores ranged from 93 to 133 (mean [SD], 117.35 [8.15]). Most participants scored in the good stroke knowledge range for all 3 ASMaQ domains and total ASMaQ score. CONCLUSION: The online delivery of the ASMaQ was successful in testing nurses' stroke knowledge, and nurses were shown to have good stroke knowledge. Future initiatives should focus on discerning whether certain nurse characteristics predict higher or lower levels of stroke knowledge to help inform educational initiatives to improve IHS outcomes.
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Naldi A, Pracucci G, Cavallo R, Saia V, Boghi A, Lochner P, Casetta I, Sallustio F, Zini A, Fainardi E, Cappellari M, Tassi R, Bracco S, Bigliardi G, Vallone S, Nencini P, Bergui M, Mangiafico S, Toni D. Mechanical thrombectomy for in-hospital stroke: data from the Italian Registry of Endovascular Treatment in Acute Stroke. J Neurointerv Surg 2023; 15:e426-e432. [PMID: 36882319 DOI: 10.1136/jnis-2022-019939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The benefit, safety, and time intervals of mechanical thrombectomy (MT) in patients with in-hospital stroke (IHS) are unclear. We sought to evaluate the outcomes and treatment times for IHS patients compared with out-of-hospital stroke (OHS) patients receiving MT. METHODS We analyzed data from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) between 2015 and 2019. We compared the functional outcomes (modified Rankin Scale (mRS) scores) at 3 months, recanalization rates, and symptomatic intracranial hemorrhage (sICH) after MT. Time intervals from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were recorded for both groups, as were door-to-imaging and door-to-groin for OHS. A multivariate analysis was performed. RESULTS Of 5619 patients, 406 (7.2%) had IHS. At 3 months, IHS patients had a lower rate of mRS 0-2 (39% vs 48%, P<0.001) and higher mortality (30.1% vs 19.6%, P<0.001). Recanalization rates and sICH were similar. Time intervals (min, median (IQR)) from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were favorable for IHS (60 (34-106) vs 123 (89-188.5); 150 (105-220) vs 220 (168-294); 227 (164-303) vs 293 (230-370); all P<0.001), whereas OHS had lower door-to-imaging and door-to-groin times compared with stroke onset-to-imaging and onset-to-groin for IHS (29 (20-44) vs 60 (34-106), P<0.001; 113 (84-151) vs 150 (105-220); P<0.001). After adjustment, IHS was associated with higher mortality (aOR 1.77, 95% CI 1.33 to 2.35, P<0.001) and a shift towards worse functional outcomes in the ordinal analysis (aOR 1.32, 95% CI 1.06 to 1.66, P=0.015). CONCLUSION Despite favorable time intervals for MT, IHS patients had worse functional outcomes than OHS patients. Delays in IHS management were detected.
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Affiliation(s)
- Andrea Naldi
- Neurology Unit, Ospedale San Giovanni Bosco, Torino, Piemonte, Italy
| | - Giovanni Pracucci
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Roberto Cavallo
- Neurology Unit, Ospedale San Giovanni Bosco, Torino, Piemonte, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Andrea Boghi
- Radiology and Neuroradiology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, University of the Saarland, Homburg, Germany
| | - Ilaria Casetta
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Fabrizio Sallustio
- Unità di Trattamento Neurovascolare, Ospedale dei Castelli-ASL6, Rome, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Enrico Fainardi
- Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Florence, Italy
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rossana Tassi
- Stroke Unit, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Sandra Bracco
- UO Neurointerventistica, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Guido Bigliardi
- Neurologia/Stroke Unit, Ospedale Civile di Baggiovara, AOU Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiologia, Ospedale Civile di Baggiovara, AOU Modena, Modena, Italy
| | - Patrizia Nencini
- Stroke Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mauro Bergui
- Interventional Neuroradiology Unit, Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS Neuromed, Pozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Snavely J, Thompson HJ. Nursing and Institutional Responsibilities for In-Hospital Stroke. Stroke 2023; 54:2926-2934. [PMID: 37732490 DOI: 10.1161/strokeaha.123.042868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
In-hospital stroke events occur less often than stroke outside of a health care facility; yet, the need for timely evaluation and treatment is the same regardless of geographic location. During hospitalization, nurses are generally the first to recognize possible symptoms of stroke and activate emergency protocols. Such actions in response to changes in patient condition are critical to optimal patient outcomes. A recent scientific statement from the American Heart Association notes that patients with in-hospital stroke are likely to experience delayed recognition of symptoms, less likely to receive intravenous thrombolysis therapy, and have worse outcomes compared with community-occurring stroke. The aim of this article is to expand upon that scientific statement to assist nurses and acute care hospitals in the United States and elsewhere with similar health care systems to create evidence-based, nurse-driven protocols for in-hospital stroke recognition and management.
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Affiliation(s)
- Josh Snavely
- Virginia Mason Franciscan Health, Tacoma, WA (J.S.)
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Wu J, Han G, Sha Y, Tang M, Pan Z, Liu Z, Zhu Y, Zhou L, Ni J. Mechanisms of in-hospital acute ischemic stroke and their relevance to prognosis: A retrospective analysis. J Stroke Cerebrovasc Dis 2023; 32:107105. [PMID: 37054660 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES In-hospital stroke (IHS) is common and has a poor prognosis. Limited data were about the mechanisms of IHS, posing a challenge in taking measures to prevent stroke during hospitalization. This study aims to investigate the mechanisms of IHS and their relevance to prognosis. MATERIALS AND METHODS Patients with in-hospital acute ischemic stroke at Peking Union Medical College Hospital from June 2012 to April 2022 were consecutively enrolled. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification of stroke and detailed mechanisms were evaluated by two experienced neurologists. Functional outcome at discharge was evaluated. RESULTS A total of 204 IHS patients were included, with a median age of 64 (IQR 52-72) and 61.8% male. The most common mechanism was embolism (57.8%), followed by hypoperfusion (42.2%), hypercoagulation (36.3%), small vessel mechanism (19.1%), discontinuation of antithrombotic drugs (13.2%), and iatrogenic injury (9.8%). Iatrogenic injury (P = 0.001), hypoperfusion (P = 0.006), embolism (P = 0.03), and discontinuation of antithrombotic drugs (P = 0.004) were more common in perioperative stroke compared to non-perioperative stroke. Median NIHSS improvement (2 vs 1, P = 0.002) and median mRS improvement (1 vs 0.5, P = 0.02) at discharge were higher in perioperative patients. Advanced age and higher NIHSS at onset were significantly associated with a poorer prognosis, whereas embolism mechanism was associated with a better prognosis. CONCLUSIONS The etiologies and mechanisms of IHS are complex. Perioperative and non-perioperative IHS have different mechanisms and prognostic features. Determining the causes and mechanisms of IHS will help to identify the population at risk and prevent stroke appropriately during hospitalization.
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Affiliation(s)
- Juanjuan Wu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Guangsong Han
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yuhui Sha
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Mingyu Tang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ziang Pan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ziyue Liu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yicheng Zhu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lixin Zhou
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jun Ni
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Abstract
ABSTRACT BACKGROUND: Early recognition of inpatient stroke is critical in reducing poor outcomes. A gap in knowledge and recognition of stroke by nursing staff was observed; protocols did not incorporate the Balance, Eyes, Face, Arms, Speech, and Time (BE-FAST) symptom mnemonic, and code stroke documentation was frequently incomplete. PURPOSE: This initiative aimed to improve timely recognition, evidence-based treatment, and nursing documentation of stroke-related symptoms. METHODS: This quality improvement initiative implemented an inpatient nurse-driven code stroke bundle. A pre-post prospective intervention design was implemented over 3 months. Code stroke bundle components included an evidence-based protocol, algorithm, visual aids, and education. Nursing communication and documentation used the BE-FAST mnemonic in a Situation, Background, Assessment, Recommendation format. RESULTS: Nursing stroke knowledge improved 8% (88% vs 96%, P < .001); stroke response times improved 15 minutes (25.9 vs 11 minutes, P = .383), although not significant; the code stroke documentation completion rate was increased 48.1% (0 [0%] vs 13 [48.1%], P < .001); and improved utilization of the BE-FAST tool with Situation, Background, Assessment, Recommendation communication (0 [0%] vs 20 [47.6%], P = < .001) was observed. The code stroke cancelation rate slightly worsened (10 [26.3%] vs 14 [26.9%], P = .949), code stroke notifications for altered mental status improved (15 [39.5%] vs 8 [15.7%], P = .015), and the stroke mimic rate improved (27 [71.1%] vs 35 [67.3%], P = .708). CONCLUSION: Nurses provide hospital patient care continuously and are in a key position to intervene when patients present changes in symptoms. Through education and creating an evidence-based protocol, nurses can impact patient outcomes in early recognition and activation of the code stroke system. Further studies are warranted to refine strategies leading to continued improvement in early stroke identification.
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Workflow and Outcomes of Endovascular Thrombectomy for In-Hospital Stroke a Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:105937. [PMID: 34174516 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/23/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute strokes due to large vessel occlusion in hospitalized patients is not uncommon. We performed a systematic review and meta-analysis to investigate the timing and outcome of endovascular thrombectomy (EVT) for in-hospital stroke. METHODS We conducted a meta-analysis of clinical studies published in English until September 2020 in the MEDLINE and Cochrane databases. Studies reporting original data on the characteristics and outcomes of in-hospital stroke patients treated with EVT were included. We extracted data on the time-metrics from last known well (LKW) until reperfusion was achieved. We also collected data on procedural and functional outcomes. RESULTS Out of 5093 retrieved studies, 8 were included (2,622 patients). The median age was 71.4 years and median NIHSS score on admission was 16. Patients were mostly admitted to the cardiology service (27.3%). The pooled time from LKW to recognition by staff was 72.9 min (95% CI: 40.7 to 105 min). 25.6% received IV tPA. The mean time from stroke recognition to arterial puncture was 134.5 min (95% CI: 94.9 to 174.1). Successful reperfusion occurred in 82.8.% with a pooled mean time from detection to reperfusion of 193.1 min (95% CI: 139.5 to 246.7). The 90-day independent functional outcome was reported in 42% of patients (95% CI 29 to 55%). CONCLUSION EVT can be performed safely and successfully for in-hospital strokes. Noticeable delays from LKW to detection and then to puncture are noted. This calls for better stroke pathways to identify and treat these patients. BACKGROUND Stroke in hospitalized patients, referred to as in-hospital stroke (IHS), accounts for 2.2-17% of all strokes.1 The majority of these are ischemic while intracranial hemorrhage represents 2-11% of all IHS.1 These patients are expected to have a rapid diagnosis and treatment given the ongoing medical supervision, and therefore favorable outcomes.1-3 However, existing studies report poor outcomes in patients with IHS with a mortality risk that exceeds that of community-onset stroke (COS): 24.7% vs 9.6%.4 Surviving IHS patients are also less likely to be discharged home compared to COS (27.7% vs 49.9%) and to be functionally independent at 3 months (31.0% vs 50.4%).1-4.
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Kawano H, Ebisawa S, Ayano M, Kono Y, Saito M, Johno T, Maruoka H, Ryoji N, Yamashita H, Nakanishi K, Honda Y, Amano T, Unno Y, Komatsu Y, Ogawa Y, Shiokawa Y, Hirano T. Improving Acute In-Hospital Stroke Care by Reorganization of an In-Hospital Stroke Code Protocol. J Stroke Cerebrovasc Dis 2021; 30:105433. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/17/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022] Open
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ZHANG C, LOU M, CHEN Z, CHEN H, XU D, WANG Z, HU H, WU C, ZHANG X, MA X, WANG Y, HU H. [Analysis of intravenous thrombolysis time and prognosis in patients with in-hospital stroke]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:260-266. [PMID: 31496157 PMCID: PMC8800745 DOI: 10.3785/j.issn.1008-9292.2019.06.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/16/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare the time delay between in-hospital stroke and out-of-hospital stroke patients, and to explore the influence factors for the prognosis of in-hospital stroke patients treated by intravenous thrombolysis. METHODS Clinical data of 3050 patients with ischemic stroke who received intravenous thrombolysis in 71 hospitals in Zhejiang province from June 2017 to September 2018 were analyzed. Differences of time delay including door to imaging time (DIT), imaging to needle time (INT) and door to needle time (DNT) between in-hospital stroke (n=101) and out-of-hospital stroke (n=2949) were observed. The influencing factors for the outcome at 3 month after intravenous thrombolysis in patients with in-hospital stroke were analyzed using binary logistic regression analysis. RESULTS Patients with in-hospital stroke had longer DIT[53.5 (32.0-79.8) min vs. 20.0 (14.0-28.0) min, P<0.01], longer IDT[47.5(27.3-64.0)min vs. 36.0(24.0-53.0)min, P<0.01], and longer DNT[99.0 (70.5-140.5) min vs. 55.0 (41.0-74.0) min, P<0.01], compared with patients with out-of-hospital stroke; patients in comprehensive stroke center had longer DIT[59.5(44.5-83.3) min vs. 37.5(16.5-63.5) min, P<0.01], longer DNT[110.0(77.0-145.0) min vs. 88.0 (53.8-124.3) min, P<0.05], but shorter INT[36.5(23.8-60.3)min vs. 53.5 (34.3-64.8) min, P<0.05], compared with patients in primary stroke center. Age (OR=0.934, 95%CI: 0.882-0.989, P<0.05) and baseline National Institute of Health Stroke Scale score (OR=0.912, 95%CI: 0.855-0.973, P<0.01) were independent risk factors for prognosis of in-hospital stroke patients. CONCLUSIONS In-hospital stroke had longer DIT and DNT than out-of-hospital stroke, which suggests that a more smooth thrombolysis process of in-hospital stroke should be established.
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Affiliation(s)
| | - Min LOU
- 楼敏(1976-), 女, 博士, 主任医师, 教授, 博士生导师, 主要从事神经病学研究; E-mail:
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https://orcid.org/0000-0002-6627-064X
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Cadilhac DA, Kilkenny MF, Lannin NA, Dewey HM, Levi CR, Hill K, Grabsch B, Grimley R, Blacker D, Thrift AG, Middleton S, Anderson CS, Donnan GA. Outcomes for Patients With In-Hospital Stroke: A Multicenter Study From the Australian Stroke Clinical Registry (AuSCR). J Stroke Cerebrovasc Dis 2019; 28:1302-1310. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 11/25/2022] Open
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Kawabata Y, Nakajima N, Miyake H, Fukuda S, Tsukahara T. Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients. Neuroradiol J 2019; 32:303-308. [PMID: 30987508 DOI: 10.1177/1971400919840847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0-2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46-79 years, n = 40) and octogenarians and nonagenarians (aged 80-97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome (P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.
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Affiliation(s)
- Yasuhiro Kawabata
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan.,2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Norio Nakajima
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan
| | | | - Shunichi Fukuda
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Tetsuya Tsukahara
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
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