In-Hospital Ischemic Stroke

Effectiveness of endovascular treatment for in-hospital stroke vs. community-onset stroke: a propensity score-matched analysis

BACKGROUND

The effectiveness of endovascular treatment for in-hospital stroke remains debatable. We aimed to compare the outcomes between patients with in-hospital stroke and community-onset stroke who received endovascular treatment.

METHODS

This prospective registry-based cohort study included consecutive patients who underwent endovascular treatment from January 2013 to December 2022 and were registered in the Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy study and Yonsei Stroke Cohort. Functional outcomes at day 90, radiological outcomes, and safety outcomes were compared between the in-hospital and community-onset groups using logistic regression and propensity score-matched analysis.

RESULTS

Of 1,219 patients who underwent endovascular treatment, 117 (9.6%) had in-hospital stroke. Patients with in-hospital onset were more likely to have a pre-stroke disability and active cancer than those with community-onset. The interval from the last known well to puncture was shorter in the in-hospital group than in the community-onset group (155 vs. 355 min, p<0.001). No significant differences in successful recanalization or safety outcomes were observed between the groups; however, the in-hospital group exhibited worse functional outcomes and higher mortality at day 90 than the community-onset group (all p<0.05). After propensity score matching including baseline characteristics, functional outcomes after endovascular treatment did not differ between the groups (OR: 1.19, 95% CI 0.78-1.83, p=0.4). Safety outcomes did not significantly differ between the groups.

CONCLUSION

Endovascular treatment is a safe and effective treatment for eligible patients with in-hospital stroke. Our results will help physicians in making decisions when planning treatment and counseling caregivers or patients.

Clinical outcome of rural in-hospital-stroke patients after interhospital transfer for endovascular therapy within a telemedical stroke network in Germany: a registry-based observational study

OBJECTIVES

Little is known about in-hospital-stroke (IHS) patients with large vessel occlusion and subsequent transfer to referral centres for endovascular therapy (EVT). However, this subgroup is highly relevant given the substantial amount of IHS, the ongoing trend towards greater use of EVT and lack of EVT possibilities in rural hospitals. The study objective is to explore the clinical outcomes of this vulnerable patient group, given that both IHS and interhospital transfer are associated with worse clinical outcomes due to a higher proportion of pre-existing conditions and substantial time delays during transfer.

DESIGN AND SETTING

Prospectively collected data of patients receiving EVT after interhospital transfer from 14 rural hospitals of the Telemedical Stroke Network in Southeast Bavaria (TEMPiS) between February 2018 and July 2020 was analysed.

PARTICIPANTS

49 IHS and 274 out-of-hospital-stroke (OHS) patients were included.

OUTCOME MEASURES

Baseline characteristics, treatment times and outcomes were compared between IHS and OHS. The primary endpoint was a 3-month modified Rankin Scale (mRS).

RESULTS

In IHS patients, atrial fibrillation (55.3% vs 35.9%, p=0.012), diabetes (36.2% vs 21.1%, p=0.024) and use of oral anticoagulants (44.7% vs 20.8%, p<0.001) were more frequent. Stroke severity was similar in both groups. Treatment times from symptom onset to first brain imaging, therapy decision or EVT were shorter for IHS patients. IHS patients displayed worse clinical outcomes: 59.2% of IHS patients died within 3 months compared with 28.5% of OHS patients (p<0.001). They were less likely to achieve moderate outcomes (mRS 0-3) 3 months after stroke (20.4% vs 39.8%, p=0.010). After controlling for possible confounding variables, IHS was associated with worse clinical outcomes (adjusted OR 3.04 (95% CI 1.57 to 6.04), p<0.001).

CONCLUSIONS

The mortality of IHS patients after interhospital transfer and EVT was high and functional outcomes were worse compared with those of OHS patients. Further research is needed to ascertain whether IHS patients benefit from this therapeutic approach. A more careful selection of IHS patients for transfer and means to enable faster treatment should be considered.

TRIAL REGISTRATION NUMBER

NCT04270513; Post-results.

Mechanical Thrombectomy for In-Hospital Onset Stroke: A Comparative Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

In-hospital onset stroke (IHOS) accounts for a significant proportion of large vessel occlusion acute ischemic strokes, leading to worse outcomes due to delays in evaluation and treatment. Limited data is available on the effectiveness of mechanical thrombectomy in IHOS patients. This study aims to assess the safety and efficacy of mechanical thrombectomy for patients with IHOS and compare the outcomes with those of community-onset strokes (COS).

METHODS

We conducted a systematic review and meta-analysis following established guidelines, by searching PubMed, Scopus, Web of Science, and Embase databases up to April 11, 2023. Eligible studies reporting outcomes of interest were included, and relevant data was extracted and analyzed using Stata software version 17.0.

RESULTS

In a meta-analysis of nine studies, comprising 540 cases of IHOS and 5,744 cases of COS, IHOS cases had a significantly lower rate of good functional outcomes on follow-up (35.46% vs. 40.74%, P<0.01) and a higher follow-up mortality rate (26.29% vs. 18.08%, P<0.01) compared to COS patients. Both groups had comparable successful recanalization rates (IHOS: 79.32% vs. COS: 81.44%, P=0.11), incidence rates of periprocedural complications (IHOS: 15.10%, COS: 12.96%, P=0.78), and symptomatic intracranial hemorrhage (IHOS: 6.24%, COS: 6.88%, P=0.67). It is worth noting that much of the observed effect size for mortality and good functional outcomes on follow-up was derived from only one and two studies, respectively.

CONCLUSION

While the current literature suggests that mechanical thrombectomy is a safe and effective treatment for IHOS, further research is necessary to comprehensively evaluate its impact, particularly during follow-up.

Mechanical thrombectomy for in-hospital stroke: data from the Italian Registry of Endovascular Treatment in Acute Stroke

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.

Nursing and Institutional Responsibilities for In-Hospital Stroke

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.

Role of artificial intelligence and machine learning in the diagnosis of cerebrovascular disease

Introduction

Cerebrovascular diseases are known to cause significant morbidity and mortality to the general population. In patients with cerebrovascular disease, prompt clinical evaluation and radiographic interpretation are both essential in optimizing clinical management and in triaging patients for critical and potentially life-saving neurosurgical interventions. With recent advancements in the domains of artificial intelligence (AI) and machine learning (ML), many AI and ML algorithms have been developed to further optimize the diagnosis and subsequent management of cerebrovascular disease. Despite such advances, further studies are needed to substantively evaluate both the diagnostic accuracy and feasibility of these techniques for their application in clinical practice. This review aims to analyze the current use of AI and MI algorithms in the diagnosis of, and clinical decision making for cerebrovascular disease, and to discuss both the feasibility and future applications of utilizing such algorithms.

Methods

We review the use of AI and ML algorithms to assist clinicians in the diagnosis and management of ischemic stroke, hemorrhagic stroke, intracranial aneurysms, and arteriovenous malformations (AVMs). After identifying the most widely used algorithms, we provide a detailed analysis of the accuracy and effectiveness of these algorithms in practice.

Results

The incorporation of AI and ML algorithms for cerebrovascular patients has demonstrated improvements in time to detection of intracranial pathologies such as intracerebral hemorrhage (ICH) and infarcts. For ischemic and hemorrhagic strokes, commercial AI software platforms such as RapidAI and Viz.AI have bene implemented into routine clinical practice at many stroke centers to expedite the detection of infarcts and ICH, respectively. Such algorithms and neural networks have also been analyzed for use in prognostication for such cerebrovascular pathologies. These include predicting outcomes for ischemic stroke patients, hematoma expansion, risk of aneurysm rupture, bleeding of AVMs, and in predicting outcomes following interventions such as risk of occlusion for various endovascular devices. Preliminary analyses have yielded promising sensitivities when AI and ML are used in concert with imaging modalities and a multidisciplinary team of health care providers.

Conclusion

The implementation of AI and ML algorithms to supplement clinical practice has conferred a high degree of accuracy, efficiency, and expedited detection in the clinical and radiographic evaluation and management of ischemic and hemorrhagic strokes, AVMs, and aneurysms. Such algorithms have been explored for further purposes of prognostication for these conditions, with promising preliminary results. Further studies should evaluate the longitudinal implementation of such techniques into hospital networks and residency programs to supplement clinical practice, and the extent to which these techniques improve patient care and clinical outcomes in the long-term.

Clinical validation of in-hospital stroke diagnosis

OBJECTIVE

In-hospital stroke cases occur during hospitalization for another diagnosis and reflect a clinically distinct cohort from community-onset stroke. The objective was to validate the diagnostic accuracy of in-hospital stroke identification in stroke audit data at a large teaching hospital.

METHODS

A retrospective clinical validation of in-hospital stroke diagnoses from two linked data sources was completed for a 2-year period from January 1st 2020 to December 31st 2021. The linked data sources include the Hospital Inpatient Enquiry system which assigns coded stroke diagnoses at discharge and/or the local stroke audit coordinators who work clinically in stroke teams and input additional specific clinical data. Diagnostic sensitivity, specificity and the level of agreement using an unweighted Cohen's Kappa were calculated.

RESULTS

There were 597 strokes admitted during the 2-year period. The median age was 72 years and 55% occurred in males. In total, 88 cases of in-hospital stroke were clinically validated yielding an in-hospital stroke rate of 15%. The clinical audit coordinator identified in-hospital stroke with higher sensitivity (86%; 95% CI 77%-93%) whereas the coding process was more specific at 96% (95% CI 85% to 99%). Levels of agreement with the clinically validated gold standard sample were moderate for the audit coordinator and coding process with κ = 0.57 and K = 0.42 respectively. When both data sources were combined the level of agreement was substantial (κ = 0.65; p < .000).

CONCLUSIONS

Clinical validation studies are required to reinforce data quality within stroke registers. Combining clinical and administrative data sources improves diagnostic accuracy for in-hospital stroke identification.

Mechanisms of in-hospital acute ischemic stroke and their relevance to prognosis: A retrospective analysis

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.

Validating Existing Scales for Identification of Acute Stroke in an Inpatient Setting

Background and Purpose

A significant proportion of strokes occur while patients are hospitalized for other reasons. Numerous stroke scales have been developed and validated for use in pre-hospital and emergency department settings, and there is growing interest to adapt these scales for use in the inpatient setting. We aimed to validate existing stroke scales for inpatient stroke codes.

Methods

We retrospectively reviewed charts from inpatient stroke code activations at an urban academic medical center from January 2016 through December 2018. Receiver operating characteristic analysis was performed for each specified stroke scale including NIHSS, FAST, BE-FAST, 2CAN, FABS, TeleStroke Mimic, and LAMS. We also used logistic regression to identify independent predictors of stroke and to derive a novel scale.

Results

Of the 958 stroke code activations reviewed, 151 (15.8%) had a final diagnosis of ischemic or hemorrhagic stroke. The area under the curve (AUC) of existing scales varied from .465 (FABS score) to .563 (2CAN score). Four risk factors independently predicted stroke: (1) recent cardiovascular procedure, (2) platelet count less than 50 × 109 per liter, (3) gaze deviation, and (4) presence of unilateral leg weakness. Combining these 4 factors into a new score yielded an AUC of .653 (95% confidence interval [CI] .604-.702).

Conclusion

This study suggests that currently available stroke scales may not be sufficient to differentiate strokes from mimics in the inpatient setting. Our data suggest that novel approaches may be required to help with diagnosis in this unique population.

Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality?

OBJECTIVES

In-hospital stroke mortality is surprisingly much worse than for strokes occurring outside of the hospital. Cardiac surgery patients are amongst the highest risk groups for in-hospital stroke and experience high stroke-related mortality. Variability in institutional practices appears to play an important role in the diagnosis, management, and outcome of postoperative stroke. We therefore tested the hypothesis that variability in postoperative stroke management of cardiac surgical patients exists across institutions.

MATERIALS AND METHODS

A 13 item survey was employed to determine postoperative stroke practice patterns for cardiac surgical patients across 45 academic institutions.

RESULTS

Less than half (44%) reported any formal clinical effort to preoperatively identify patients at high risk for postoperative stroke. Epiaortic ultrasonography for the detection of aortic atheroma, a proven preventative measure, was routinely practiced in only 16% of institutions. Forty-four percent (44%) reported not knowing whether a validated stroke assessment tool was utilized for the detection of postoperative stroke, and 20% reported that validated tools were not routinely used. All responders, however, confirmed the availability of stroke intervention teams.

CONCLUSIONS

Adoption of a best practices approach to the management of postoperative stroke is highly variable and may improve outcomes in postoperative stroke after cardiac surgery.

Utility of the RIPS Scale and 2CAN Score for In-Hospital Stroke Prediction

Background

In-hospital strokes are a small but sizeable proportion of all strokes. Identification of in-hospital strokes is confounded by stroke mimics in as many as half of in-patient stroke codes. A quick scoring system based on risk factors and clinical signs during the initial evaluation of a suspected stroke might be helpful to distinguish true strokes from mimics. Two such scoring systems based on ischemic and hemorrhagic risk factors are the risk for in-patient stroke (RIPS) and the 2CAN score.

Materials and Methods

This prospective clinical study was conducted at a quaternary care hospital in Bengaluru, India. All hospitalized patients aged 18 years and above for whom a "stroke code" alert was recorded during the study period of January 2019 to January 2020 were included in the study.

Results

A total of 121 in-patient "stroke codes" were documented during the study. Ischemic stroke was the most common etiological diagnosis. A total of 53 patients were diagnosed to have ischemic stroke, 4 had intracerebral hemorrhage, and the rest were mimics. Receiver operative curve analysis was performed and at a cut-off of RIPS ≥3, it predicts stroke with a sensitivity of 77% and a specificity of 73%. At a cut-off of 2CAN ≥3, it predicts stroke with a sensitivity of 67% and a specificity of 80%. RIPS and 2CAN significantly predicted stroke.

Conclusions

There was no difference in the use of either RIPS or 2CAN for differentiating stroke from mimics, and hence they may be used interchangeably. They were statistically significant with good sensitivity and specificity, as a screening tool to determine in-patient stroke.

Intravenous thrombolysis in acute ischemic stroke after antagonization of unfractionated heparin with protamine: case series and systematic review of literature

Background and aims

Intravenous thrombolysis (IVT) is standard of care for disabling acute ischemic stroke (AIS) within a time window of ⩽ 4.5 h. Some AIS patients cannot be treated with IVT due to limiting contraindications, including heparin usage in an anticoagulating dose within the past 24 h or an elevated activated prothrombin time (aPTT) > 15 s. Protamine is a potent antidote to unfractionated heparin.

Objectives

The objective of this study was to investigate the safety and efficacy of IVT in AIS patients after antagonization of unfractionated heparin with protamine.

Methods

Patients from our stroke center (between January 2015 and September 2021) treated with IVT after heparin antagonization with protamine were analyzed. National Institutes of Health Stroke Scale (NIHSS) was used for stroke severity and modified Rankin Scale (mRS) for outcome assessment. Substantial neurological improvement was defined as the difference between admission and discharge NIHSS of ⩾8 or discharge NIHSS of ⩽1. Good outcome at follow-up after 3 months was defined as mRS 0-2. Safety data were obtained for mortality, symptomatic intracerebral hemorrhage (sICH), and for adverse events due to protamine. Second, a systematic review was performed searching PubMed and Scopus for studies and case reviews presenting AIS patients treated with IVT after heparin antagonization with protamine. The search was limited from January 1, 2011 to September 29, 2021. Furthermore, we conducted a propensity score matching comparing protamine-treated patients to a control IVT group without protamine (ratio 2:1, match tolerance 0.2).

Results

A total of 16 patients, 5 treated in our hospital and 11 from literature, [65.2 ± 13.1 years, 37.5% female, median premorbid mRS (pmRS) 1 (IQR 1, 4)] treated with IVT after heparin antagonization using protamine were included and compared to 31 IVT patients [76.2 ± 10.9 years, 45% female, median pmRS 1 (IQR 0, 2)]. Substantial neurological improvement was evident in 68.8% of protamine-treated patients versus 38.7% of control patients (p = 0.028). Good clinical outcome at follow-up was observed in 56.3% versus 58.1% of patients (p = 0.576). No adverse events due to protamine were reported, one patient suffered sICH after secondary endovascular thrombectomy of large vessel occlusion. Mortality was 6.3% versus 22.6% (p = 0.236).

Conclusion

IVT after heparin antagonization with protamine seems to be safe and, prospectively, may extend the number of AIS patients who can benefit from reperfusion treatment using IVT. Further prospective registry trials would be helpful to further investigate the clinical applicability of heparin antagonization.

Enhancing oxidative phosphorylation over glycolysis for energy production in cultured mesenchymal stem cells

OBJECTIVE

Strokes represent as one of the leading causes of death and disability in the USA, however, there is no optimal treatment to reduce the occurrence or improve prognosis. Preconditioning of tissues triggers ischemic tolerance, a physiological state that may involve a metabolic switch (i.e. from glycolysis to oxidative phosphorylation or OxPhos) to preserve tissue viability under an ischemic insult. Here, we hypothesized that metabolic switching of energy source from glucose to galactose in cultured mesenchymal stem cells (MSCs) stands as an effective OxPhos-enhancing strategy.

METHODS

MSCs were grown under ambient condition (normal MSCs) or metabolic switching paradigm (switched MSCs) and then assayed for oxygen consumption rates (OCR) and extracellular acidification rate (ECAR) using the Seahorse technology to assess mitochondrial respiration.

RESULTS

Normal MSCs showed a lower OCR/ECAR ratio than switched MSCs at baseline (P < 0.0001), signifying that there were greater levels of OxPhos compared to glycolysis in switched MSCs. By modulating the mitochondrial metabolism with oligomycin (time points 4-6), carbonyl cyanide 4-(trifluoromethoxy) phenylhydrazone (7-9), and rotenone and antimycin (time points 10-12), switched MSCs greater reliance on OxPhos was further elucidated (time points 5-12; P < 0.0001; time point 4; P < 0.001).

CONCLUSION

The metabolic switch from glycolytic to oxidative metabolism amplifies the OxPhos potential of MSCs, which may allow these cells to afford more robust therapeutic effects against neurological disorders that benefit from ischemic tolerance.

Comparing characteristics and outcomes of in-hospital stroke and community-onset stroke

BACKGROUND

In-hospital strokes account for 4-17% of all strokes and usually lead to urgent and severe conditions. However, features of in-hospital strokes have been scarcely reported in China, and the management systems of in-hospital strokes are unestablished. The study aims to analyze the characteristics of in-hospital strokes in comparison to community-onset strokes and provides evidence for the development of national in-patient stroke care systems.

METHODS

We retrospectively analyzed consecutive patients with in-hospital strokes (IHS group) and community-onset strokes (COS group) hospitalized in our hospital between June 2012, and January 2022. Clinical characteristics, care measures, and outcomes were compared between the two groups.

RESULTS

A total of 1162 patients (age 61 ± 16 and 65% male) were included, of whom 193 (16.6%) had an in-hospital stroke and 969 (83.4%) had community-onset stroke. Compared with COS group, patients in IHS group had higher NIHSS at onset (7.25 vs 5.96, P = 0.054), higher use of endovascular therapy (10.4% vs 2.0%, P < 0.001), and lower use of intravascular thrombolysis (1.6% vs 7.2%, P = 0.003). Also, in-hospital strokes were associated with lower rate of mRS0-2 at discharge (OR[95%CI] = 0.674[0.49, 0.926], P = 0.015) and increased in-hospital mobility (OR[95%CI] = 3.621[1.640, 7.996], P = 0.001), after adjusting for age, sex, and cardiovascular risk factors.

CONCLUSION

Compared with community-onset strokes, the patients with in-hospital stroke had insufficient urgent treatment and poorer outcomes, reflecting the need for increased awareness of in-patient stroke, and strategies to streamline in-hospital acute stroke care.

Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association

This scientific statement describes a path to optimizing care for patients who experience an in-hospital stroke. Although these patients are in a monitored environment, their evaluation and treatment are often delayed compared with patients presenting to the emergency department, contributing to higher rates of morbidity and mortality. Reducing delays and optimizing treatment for patients with in-hospital stroke could improve outcomes. This scientific statement calls for the development of hospital systems of care and targeted quality improvement for in-hospital stroke. We propose 5 core elements to optimize in-hospital stroke care: 1. Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts. 2. Create rapid response teams with dedicated stroke training and immediate access to neurological expertise. 3. Standardize the evaluation of patients with potential in-hospital stroke with physical assessment and imaging. 4. Address barriers to treatment potentially, including interfacility transfer to advanced stroke treatment. 5. Establish an in-hospital stroke quality oversight program delivering data-driven performance feedback and driving targeted quality improvement efforts. Additional research is needed to better understand how to reduce the incidence, morbidity, and mortality of in-hospital stroke.

Delays in the Identification and Assessment of in-Hospital Stroke Patients

OBJECTIVES

In-hospital stroke is associated with poor outcomes. Reasons for delays, use of interventions, and presence of large vessel occlusion are not well characterized.

MATERIALS AND METHODS

A retrospective single center cohort of 97 patients with in-hospital stroke was analyzed to identify factors associated with delays from last known normal to symptom identification and to stroke team alerting. Stroke interventions and presence of large vessel occlusion were also assessed.

RESULTS

Strokes were predominantly on surgery services (70%), ischemic (82%), and severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from last known normal to symptom identification (median 5.1 hours, IQR 1.0-19.7 hours), symptom identification to stroke team alerting (median 2.1 hours, IQR 0.5-9.9 hours), and total time from last known normal to alerting (median 11.4 [IQR 2.7-34.2] hours). In univariable analysis, being on a surgical service, in an ICU, intubated, and higher NIHSS were associated with delays. In multivariable analysis only intubation was independently associated with time from last known normal to symptom identification (coefficient 20 hours, IQR 0.2 - 39.8, p=0.047). Interventions were given to 17/80 (21%) ischemic stroke patients; 3 (4%) received IV tPA and 14 (18%) underwent thrombectomy. Vascular imaging occurred in 57/80 (71%) ischemic stroke patients and 21/57 (37%) had large vessel occlusion.

CONCLUSIONS

Hospitalized patients with stroke experience long delays from symptom identification to stroke team alerting. Intubation was strongly associated with delay to symptom identification. Although stroke severity was high and large vessel occlusion common, many patients did not receive acute interventions.

Increased Incidence of In-Hospital Ischemic Stroke During SARS-CoV-2 Outbreak: A Single-Center Study

BACKGROUND

Meta-analyses of observational studies report a 1.1-1.7% pooled risk of stroke among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring hospitalization, but consultations for stroke and reperfusion procedures have decreased during the outbreak that occurred during the first half of the year 2020. It is still unclear whether a true increase in the risk of stroke exists among patients with coronavirus disease 2019 (COVID-19). In-hospital ischemic stroke (IHIS) complicated the 0.04-0.06% of all admissions in the pre-COVID-19 era, but its incidence has not been assessed among inpatients with COVID-19. We aimed to compare IHIS incidence among patients with SARS-CoV-2 infection with that of inpatients with non-COVID-19 illnesses from the same outbreak period and from previous periods.

METHODS

This historical cohort study belongs to the COVID-19@Vallecas cohort. The incidence of IHIS was estimated for patients with SARS-CoV-2 hospitalized during March-April 2020 [COVID-19 cohort (CC)], for patients with non-COVID-19 medical illness hospitalized during the same outbreak period [2020 non-COVID-19 cohort (20NCC)], and for inpatients with non-COVID-19 illness admitted during March-April of the years 2016-2019 [historical non-COVID-19 cohort (HNCC)]. Unadjusted risk of IHIS was compared between the three cohorts, and adjusted incidence rate ratio (IRR) of IHIS between cohorts was obtained by means of Poisson regression.

RESULTS

Overall, 8126 inpatients were included in this study. Patients in the CC were younger and more commonly men than those from the HNCC and 20NCC. Absolute risk of IHIS was 0.05% for HNCC, 0.23% for 20NCC, and 0.36% for CC, (p = 0.004 for HNCC vs. CC). Cumulative incidence for IHIS by day nine after admission, with death as a competing risk, was 0.09% for HNCC, 0.23% for 20NCC, and 0.50% for CC. In an adjusted Poisson regression model with sex, age, needing of intensive care unit admission, and cohort (HNCC as reference) as covariates, COVID-19 was an independent predictor for IHIS (IRR 6.76, 95% confidence interval 1.66-27.54, p = 0.01). A nonsignificant increase in the risk of IHIS was observed for the 20NCC (IRR 5.62, 95% confidence interval 0.93-33.9, p = 0.06).

CONCLUSIONS

SARS-CoV-2 outbreak was associated with an increase in the incidence of IHIS when compared with inpatients from a historical cohort. Viral infection itself may be related to the increased risk of IHIS among patients with COVID-19, but in view of our results from the 20NCC, it is likely that other factors, such as hospital saturation and overwhelming of health systems, may have played a role in the increased frequency of IHIS.

Gastrodin Alleviates Cerebral Ischaemia/Reperfusion Injury by Inhibiting Pyroptosis by Regulating the lncRNA NEAT1/miR-22-3p Axis

Cerebral ischaemia/reperfusion (I/R) injury-induced irreversible brain injury is a major cause of mortality and functional impairment in ageing people. Gastrodin (GAS), derived from the traditional Chinese herbal medicine Tianma, has been reported to inhibit the progression of stroke, but the mechanism whereby GAS modulates the progression of cerebral I/R remains unclear. The middle cerebral artery occlusion method was used as a model of I/R in vivo. Rats were pretreated with GAS by intraperitoneal injection 7 days before I/R surgery and were then treated with GAS for 7 days after I/R surgery. Additionally, an oxygen-glucose deprivation/reoxygenation model using neuronal cells was established in vitro to simulate I/R injury. 2,3,5-Triphenyltetrazolium chloride and Nissl staining were used to evaluate infarct size and neuronal damage, respectively. Lactate dehydrogenase release and cell counting kit-8 assays were used to assess neuronal cell viability. Enzyme-linked immunosorbent assay, qPCR, flow cytometry and western blotting were performed to analyse the expression levels of inflammatory factors (IL-1β, IL-18), lncRNA NEAT1, miR-22-3p, NLRP3 and cleaved caspase-1. Luciferase reporter experiments were performed to verify the association between lncRNA NEAT1 and miR-22-3p. The results indicated that GAS could significantly improve the neurological scores of rats and reduce the area of cerebral infarction. Meanwhile, GAS inhibited pyroptosis by downregulating NLRP3, inflammatory factors (IL-1β, IL-18) and cleaved caspase-1. In addition, GAS attenuated I/R-induced inflammation in neuronal cells through the modulation of the lncRNA NEAT1/miR-22-3p axis. GAS significantly attenuated cerebral I/R injury via modulation of the lncRNA NEAT1/miR-22-3p axis. Thus, GAS might serve as a new agent for the treatment of cerebral I/R injury.

Workflow and Outcomes of Endovascular Thrombectomy for In-Hospital Stroke a Systematic Review and Meta-Analysis

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.

Predictive Factors of Perioperative Stroke-Related Mortality Following Vascular Surgery: A Retrospective Analysis

OBJECTIVE

Vascular surgical procedures have one of the highest risks of perioperative stroke and stroke-related mortality, yet the independent risk factors contributing to this increased mortality have not been described. Perioperative strokes are thought to result from a combination of embolism and hypoperfusion mechanisms. The purpose of this study is to describe the independent predictors of perioperative stroke-related mortality in the vascular surgical population using the Pennsylvania Health Care Cost Containment Council (PHC4) database which collects cause of death data.

METHODS

This retrospective, case-control study evaluated 4,128 patients aged 18-99 who underwent a vascular, non-carotid surgical procedure and subsequently suffered perioperative mortality. Common surgical comorbidities and risk factors for perioperative stroke, including carotid stenosis and atrial fibrillation, were evaluated in multivariate regression analysis.

RESULTS

Patients with carotid stenosis were 2.6 (aOR, 95% CI 1.4-4.5) times more likely to suffer perioperative mortality from stroke than from other causes. Additionally, in-hospital stroke, history of stroke, admission from a healthcare facility, and cancer were all positive predictive factors, whereas atrial fibrillation, emergency admission, hypertension, and diabetes were associated with decreased risk of perioperative stroke-related mortality.

CONCLUSIONS

Identification of vascular surgical population-specific predictors of stroke-related mortality can help to enhance preoperative risk-stratification tools and guide perioperative management of identified high-risk patients. Increased neurophysiologic monitoring in the perioperative period to prevent delays in diagnosis of perioperative stroke offers a strategy to reduce risk of perioperative stroke-related mortality in vascular surgical patients.

A Systematic Review of Anticoagulation Strategies for Patients with Atrial Fibrillation in Critical Care

BACKGROUND

 Atrial fibrillation (AF) is the most common cardiac arrhythmia in critically ill patients. There is a paucity of data assessing the impact of anticoagulation strategies on clinical outcomes for general critical care patients with AF. Our aim was to assess the existing literature to evaluate the effectiveness of anticoagulation strategies used in critical care for AF.

METHODS

 A systematic literature search was conducted using MEDLINE, EMBASE, CENTRAL, and PubMed databases. Studies reporting anticoagulation strategies for AF in adults admitted to a general critical care setting were assessed for inclusion.

RESULTS

 Four studies were selected for data extraction. A total of 44,087 patients were identified with AF, of which 17.8 to 49.4% received anticoagulation. The reported incidence of thromboembolic events was 0 to 1.4% for anticoagulated patients, and 0 to 1.3% in nonanticoagulated patients. Major bleeding events were reported in three studies and occurred in 7.2 to 8.6% of the anticoagulated patients and in up to 7.1% of the nonanticoagulated patients.

CONCLUSION

 There was an increased incidence of major bleeding events in anticoagulated patients with AF in critical care compared with nonanticoagulated patients. There was no significant difference in the incidence of reported thromboembolic events within studies between patients who did and did not receive anticoagulation. However, the outcomes reported within studies were not standardized, therefore, the generalizability of our results to the general critical care population remains unclear. Further data are required to facilitate an evidence-based assessment of the risks and benefits of anticoagulation for critically ill patients with AF.

Status of In-Hospital Acute Ischemic Stroke Treated by Mechanical Thrombectomy

Objective

To elucidate the current state of in-hospital acute ischemic stroke under the introduction of acute-phase mechanical thrombectomy.

Methods

The study included 18 consecutive patients with in-hospital cerebral infarction who underwent thrombectomy between April 2014 and March 2020 at St. Marianna University School of Medicine Yokohama City Seibu Hospital. We analyzed the primary disease, department responsible for treatment, modified Rankin Scale (mRS) scores before onset and on discharge, status of onset, treatment course, and so on.

Results

The mean age was 79.9 (66-93) years. There were nine females. The admission methods included scheduled admission in 5 patients and non-scheduled admission in 13 patients. The primary diseases consisted of malignant tumors in five patients and heart disease in four patients. The departments responsible for treatment consisted of the Department of Digestive Surgery for six patients and Department of Cardiology for three patients. The mRS score before admission was evaluated as 0-2 in 15 patients and 3-5 in 3 patients. The embolism was evaluated as cardiogenic in 14 patients. Antithrombotic therapy was discontinued before the onset of cerebral infarction in three patients. The mean interval from onset or last well known (LWK) until CT/MRI and puncture was 88.4 and 157.6 minutes. The median Alberta stroke program early CT score (ASPECTS; minimum-maximum) was 8 (2-10). Tissue plasminogen activator (t-PA) was administered to five patients. Concerning the degree of recanalization, the thrombolysis in cerebral infarction (TICI) grade was evaluated as 1 to 2a in 2 patients and 2b to 3 in 16. In the latter, the mean interval from onset or final onset-free confirmation until recanalization was 197.7 minutes. mRS score on discharge was evaluated as 0-2 in four patients, 3-5 in nine, and 6 in five patients. The mortality was related to a primary disease requiring admission in three patients.

Conclusion

In-hospital onset cerebral infarction was markedly influenced by the primary disease requiring admission. Even when favorable recanalization was achieved, the number of patients with a favorable outcome was small.

Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association

In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.

Impact of a Structured Response and Evidence-Based Checklist on In-hospital Stroke Outcomes

BACKGROUND

In-hospital stroke events account for 2% to 17% of all ischemic strokes in the United States. Current stroke guidelines do not provide guidance on how to care for in-hospital stroke. Use of checklists during high-acuity events reduces error and provides clarity for responding staff. We sought to determine whether the use of an evidence-based checklist to guide in-hospital stroke response improved intervention times and patient outcomes.

METHODS

This study used a retrospective chart review of patients hospitalized between January 1, 2016, and December 31, 2018, at a community hospital certified as a primary stroke center with the Joint Commission. Encounters were sorted into preintervention and postintervention groups to evaluate for change in treatment rates, new or worsened disability, and mortality. Nursing staff who respond to in-hospital stroke calls ("response staff") were also surveyed regarding their perception of benefit and firsthand experience when using the checklist.

RESULTS

A total of 168 patient charts were reviewed (18 prechecklist, 150 postchecklist). After checklist implementation, treatment with intravenous thrombolytics for in-hospital stroke events increased from 0% to 11%. All-cause mortality decreased from 23.1% to 15.0%, whereas ambulatory disability at discharge increased from 38.0% to 62.1%. The increase in disability likely reflects the reduction in mortality, improved data collection, and the increase in postimplementation reporting.

CONCLUSIONS

Use of a checklist during inpatient stroke events can potentially increase adherence to guidelines for appropriate treatment and reduce mortality. Hospital response teams should consider use of a structured response system with an evidence-based checklist for high-acuity, low-frequency events such as in-hospital stroke.

Timing of Recognition for Perioperative Strokes Following Cardiac Surgery

INTRODUCTION

More than half of reported perioperative strokes following cardiac surgery are identified beyond postoperative day one. The objective of our study was to determine preoperative and intraoperative factors that are associated with stroke following cardiac surgery and to identify factors that may contribute delayed recognition of perioperative stroke.

METHODS

Patients undergoing coronary artery bypass surgery or isolated valve surgery from January 2, 2015 to April 28, 2017 at an academic health system were identified from the Society of Thoracic Surgeons Registry. We determined preoperative and intraoperative factors associated with perioperative stroke. Two neurologists performed retrospective chart reviews on perioperative stroke patients to determine the last seen well time and the stroke cause.

RESULTS

During the study period, 2795 patients underwent coronary artery bypass surgery or isolated valve surgery (mean age 64 ± 11 years, 71% male, 72% Caucasian, 9% history of stroke), of which 43 (1.5%) had a perioperative stroke; 31 (72%) patients had an embolic mechanism of stroke based on neuroimaging. In multivariable analysis, perioperative strokes were independently associated with increasing age (OR 1.04, 95% 1.01-1.07), history of stroke (OR 2.73, 95% CI 1.47-5.06), and history of thoracic aorta disease (OR 3.36, 95% CI 1.16-9.71). Strokes were identified after postoperative day one in 32 (74%) patients of which 26 (81%) had a preoperative last seen well time.

CONCLUSION

Given the high frequency of preoperative last seen well time in perioperative stroke patients who are identified after postoperative day one, delayed stroke recognition may contribute to the bimodal distribution in timing of perioperative stroke. Frequent neurological monitoring within 24 hours after CABG or isolated valve surgery should be considered for all patients undergoing cardiac surgery, particularly elderly patients and those with a history of stroke or thoracic aorta disease, to improve early stroke recognition.

Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study

BACKGROUND

There is an increased attention to stroke following SARS-CoV-2. The goal of this study was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients.

METHODS

This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.

FINDINGS

We received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke.

INTERPRETATION

The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients.

FUNDING

None.

Knowledge on Signs and Risk Factors in Stroke Patients

Background: There is a pressing need to contribute evidence to the improvement in the early identification of signs and symptoms associated with strokes, and address the treatment-seeking delays. The objective of this study is to describe the knowledge regarding the warning signs and risk factors (RFs) among stroke patients, as well as of their attitudes toward a suspected event, and the analysis of its possible relationship with the socio-demographic and clinical characteristics of these patients. Method: A cross-sectional study was designed, in which all stroke patients admitted consecutively to the Burgos University Hospital (Spain) were included. The principal outcomes were the patient’s ability to identify two RFs and two warning signs and the patient’s hypothetical response to a possible stroke event. The possible factors associated with the knowledge of warning signs, RFs, and the correct response to a new event were studied using univariate and multivariate regression analysis. Results: A total of 529 patients were included. Having a higher education level or a history of prior stroke were associated with a greater degree of knowledge of warning signs (odds ratio (OR) 3.19, 95% confidence interval (CI) 1.70–5.74, p = 0.003; OR 3.54, 95%CI 2.09–5.99, p ≤ 0.001, respectively), RFs (OR 3.15, 95%CI 1.75–5.67, p = 0.008; OR 4.08, 95%CI 2.41–6.91, p = 0.002, respectively), and the correct response to a possible stroke (OR 1.82, 95%CI 1.16–2.86; p = 0.030; OR 2.11, 95%CI 1.29–3.46, p = 0.022, respectively). Conclusion: Knowledge of warning signs or stroke RFs is low in the hospitalized patients. A previous stroke or secondary/higher education levels are the predictor factors that increase the probability of knowledge of warning signs, RFs, or reaction to possible event.

BE-FAST: A Sensitive Screening Tool to Identify In-Hospital Acute Ischemic Stroke

BACKGROUND

Development of acute ischemic stroke in hospitalized patients represents a significant proportion of all cerebral ischemia. Several prehospital stroke scales were developed to screen for acute ischemic stroke in the community. Despite the advent of inpatient stroke alert systems, there is a lack of validated screening tools for the inpatient population. This study aims to assess the validity of BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) as a screening tool for acute ischemic stroke among inpatients.

METHODS

We retrospectively analyzed all stroke alert activations at a single academic medical center between 2012 and 2016. We classified the triggering symptom as: focal neurologic deficit, aphasia, dysarthria, ataxia/vertigo/dizziness, alteration of consciousness, acute confusion, or headache. BE-FAST was applied retrospectively, and patients were classified as BE-FAST positive or negative. The final diagnosis was classified as acute ischemic stroke, transient ischemic attack , intracranial hemorrhage or noncerebrovascular diagnosis.

RESULTS

Of 1965 stroke alerts, 489 were among inpatients. The mean age was 63 ± 16.1 years; 57% of patients were women (n = 1121). Acute ischemic stroke was diagnosed in 29% of all the activations (n = 567), transient ischemic attack in 12% (n = 232), intracranial hemorrhage in 8 % (n = 160) and noncerebrovascular in 51% (n = 1006). When comparing inpatient with community-onset stroke alerts, the sensitivity of BE-FAST for diagnosing acute ischemic stroke was 85% versus 94% (P = .005), with a specificity of 43% versus 23% (P < .001), respectively. However, when evaluating in-patients with an intact level of consciousness separately, BE-FAST sensitivity for diagnosing acute ischemic stroke was 92% compared to 94% in the community (P = .579). Among in-patients with acute ischemic stroke who were (1) candidates for reperfusion therapy and (2) diagnosed with acute large vessel occlusion, the sensitivity of BE-FAST was 83% and 94%, respectively.

CONCLUSIONS

This is the first study to analyze the performance of BE-FAST among hospitalized patients evaluated through the inpatient stroke alert system. We found BE-FAST to be a very sensitive tool for screening for all in-hospital acute ischemic strokes, including inpatients that were candidates for acute reperfusion therapy.

Venous Thromboembolism Prophylaxis: Need for Continuous Assessment Due to Changes in Risk During the Same Hospitalization

Objective

To explore the role of venous thromboembolism (VTE) risk reassessment in hospitalized medically ill patients without a change in level of care.

Patients and Methods

In this exploratory retrospective study, the medical records of 171 consecutive adult patients (≥18 years) hospitalized under the medicine service for more than 3 days without a change in the level of care from January 1, 2015, to March 1, 2015, were reviewed. The primary outcome was a change in the risk score between day 1 and day 3 of hospital stay (using the Padua Prediction Score). The secondary outcomes were changes in risk stratification class (low vs high) and cost-benefit analysis.

Results

The risk score was significantly different between day 1 and day 3 (4.7±1.7 vs 4.2±1.8; P=.008). All the patients with low risk on day 1 remained at low risk on day 3. However, 25 of 136 patients (18.4%) with high risk on day 1 were reclassified as low risk on day 3 (P<.001). No patients changed from low risk to high risk at day 3. The reclassification could have saved $35 per patient-day of inappropriate pharmacological prophylaxis in addition to patient discomfort, bleeding risk, and heparin-induced thrombocytopenia.

Conclusion

This is the first study to suggest the need for regular assessment for VTE risk on medicine wards because of changing patient risk. Regular reassessment could reduce health care waste and patient discomfort.

Other Hospital-onset Acute Ischemic Stroke Due to Large Vessel Occlusion Treated by Mechanical Thrombectomy after Inter-hospital Transfer

The purpose of this study was to investigate the in-hospital acute ischemic stroke due to large vessel occlusion (LVO) that developed in another thrombectomy-incapable hospital, treated by mechanical thrombectomy after inter-hospital transfer. In eight other hospital-onset LVO patients, clinical characteristics, treatment results, and the timeline of thrombectomy were retrospectively investigated and compared to the results of 17 patients developed LVO at our own hospital and 18 developed in the community. In the analysis of timeline, the mean recognition-to-arrival time in other hospital-onset patients was 169 ± 78 min, significantly longer than for the community-onset patients (79 ± 78 min). Arrival-to-puncture time was 42 ± 19 min, significantly shorter than for the own hospital-onset patients (166 ± 80 min) and the community-onset patients (155 ± 76 min). Recognition-to-puncture times for the other hospital-onset patients, the own hospital-onset patients, and the community-onset patients were 212 ± 74, 166 ± 80, and 216 ± 83 min, respectively, and recognition-to-recanalization times were 285 ± 73, 200 ± 81, and 275 ± 125 min. Both these times were shorter for the own hospital-onset patients. The rates of modified Rankin Scale (mRS) of 0-2 in the three groups were 12%, 30%, and 23%, respectively. The rate of mRS 0-2 was lowest in the other hospital-onset patients. In conclusion, the other hospital-onset patients required additional time for their initial management and inter-hospital transfer although arrival-to-puncture time was shorter. Favorable outcomes were observed less frequently in them. Improving inter-hospital cooperation systems and to educate the medical staff in a thrombectomy-incapable hospital concerning stroke management is important measures for other hospital-onset stroke with LVO.

Women and In-hospital Stroke Code Activation: Age, Ethnicity, and Unique Symptoms Matter

BACKGROUND

Women have worse stroke outcomes than men, and almost 17% of all stroke cases have symptom onset when admitted to the hospital for a separate condition.

OBJECTIVE

The aim of this study was to investigate the distinctive factors that impact the activation of an in-hospital stroke code and outcomes in women who have a stroke while admitted to the hospital for a separate condition.

METHODS

A retrospective observational propensity score study guided by the model for nursing effectiveness was used.

RESULTS

In-hospital stroke code was activated in 46 of 149 or 30.9% of women and 15 of 149 or 10.1% of women received thrombolytic therapy. Activation of an in-hospital stroke code was significant (P < .001) for women receiving thrombolytic therapy and significant to a home discharge status (P = .014). Age (P < .001), ethnicity (P < .001), common (P ≤ .001) and unique (P = .012) stroke symptoms, stroke risk factors (P < .001), comorbid conditions (P < .001), time last known well (P = .041), and diagnostic imaging (P < .001) were all significantly related to activation of an in-hospital stroke code.

CONCLUSIONS

Activation of an in-hospital stroke is a key indicator for women to receive thrombolytic therapy and be discharged to home. Younger married women from non-Caucasian ethnic groups and women with stroke risk factors and comorbid conditions are at a greater risk for delayed stroke symptom detection and not having an in-hospital stroke code activated. Awareness of these factors that hinder early stroke detection in women is crucial to improving stroke treatment and outcomes in women.

In-hospital Ischemic Stroke Treated by Mechanical Thrombectomy

Objective

We investigated in-hospital stroke (IHS) treated by mechanical thrombectomy in comparison with out-of-hospital stroke (OHS) to clarify the points of concern in IHS at our institution.

Methods

Between September 2015 and June 2018, 19 patients with IHS who underwent mechanical thrombectomy (IHS group) were enrolled, and compared with 154 patients with OHS (OHS group) regarding patient characteristics, technical results, and outcome. In this study, we set the detection time in the IHS group as patient arrival time, termed "Door" in the OHS group.

Results

Cardiology and gastroenterology were the two main admitting departments, including four (21%) patients of IHS group. In all, 15 (79%) patients had atrial fibrillation; however, less than one-third of them was taking anticoagulant drugs at onset. There were only two cases of direct consultation to the stroke specialists, although IHS onset was mainly recognized by nurses. The median age in the IHS group was 81 (interquartile range (IQR), 76-86.5) versus 80 in the OHS group (IQR, 73-85; p = 0.43), and the median initial National Institutes of Health Stroke Scale score was 21 (IQR, 16-23) versus 21 (IQR, 14-26; p = 0.92), respectively. Sex, Alberta Stroke Program Early CT Score, etiology, and occlusion site did not differ between groups. The rate of use of intravenous tissue plasminogen activator (IV-tPA) was 26% in the IHS group versus 49% in the OHS group (p = 0.065). The median time of detection to imaging, detection to needle for IV-tPA, and detection to puncture were 32, 69, and 87 minutes, respectively, in the IHS group, being significantly longer than those in the OHS group (11, 30, and 50 minutes; p <0.01, p <0.01, and p <0.01, respectively). The median time of puncture to reperfusion was 39 minutes, being significantly shorter than that in the OHS group (82 minutes; p <0.01). Successful reperfusion defined as thrombolysis in cerebral infarction (TICI) 2b-3 was obtained in 94.7% of the IHS group versus 83.1% of the OHS group (p = 0.19). A favorable outcome (modified Rankin Scale score 0-2) at 90 days was achieved by 36.8% (IHS) versus 35.1% (OHS) of patients (p = 0.88). The rate of symptomatic procedural complications was 0% (IHS) versus 7.1% (OHS; p = 0.23). The rate of death at 90 days was 15.8% (IHS) versus 12.3% (OHS; p = 0.67).

Conclusion

The times of detection to imaging and of detection to puncture in the IHS group were longer than those in the OHS group; however, patients in the IHS group had shorter reperfusion. The outcome of the IHS group did not differ from that of OHS group. Our study suggests that the time course of treatment should be improved and rapid stroke pathways involved in consultation with the stroke specialists for IHS should be organized.

Brain computerized tomography reading in suspected acute ischemic stroke patients: what are essentials for medical students?

BACKGROUND

Few systematic methods prioritize the image education in medical students (MS). We hope to develop a checklist of brain computerized tomography (CT) reading in patients with suspected acute ischemic stroke (AIS) for MS and primary care (PC) physicians.

METHODS

Our pilot group generated the items indicating specific structures or signs for the checklist of brain CT reading in suspected AIS patients for MS and PC physicians. These items were used in a modified web-based Delphi process using the online software "SurveyMonkey". In total 15 panelists including neurologists, neurosurgeons, neuroradiologists, and emergency department physicians participated in the modified Delphi process. Each panelist was encouraged to express feedback, agreement or disagreement on the inclusion of each item using a 9-point Likert scale. Items with median scores of 7-9 were included in our final checklist.

RESULTS

Fifty-two items were initially provided for the first round of the Delphi process. Of these, 35 achieved general agreement of being an essential item for the MS and PC physicians. The other 17 of the 52 items in this round and another two added items suggested by the panelists were further rated in the next round. Finally, 38 items were included in the essential checklist items of brain CT reading in suspected AIS patients for MS and PC physicians.

CONCLUSIONS

We established a reference regarding the essential items of brain CT reading in suspected AIS patients. We hope this helps to minimize malpractice and a delayed diagnosis, and to improve competency-based medical education for MS and PC physicians.

Comparison of Acute Ischemic Stroke Care and Outcomes Between Comprehensive Stroke Centers and Primary Stroke Centers in the United States

BACKGROUND

To improve stroke care, the Brain Attack Coalition recommended establishing primary stroke center (PSC) and comprehensive stroke center (CSC) certification. This study aimed to compare ischemic stroke care and in-hospital outcomes between CSCs and PSCs.

METHODS AND RESULTS

We analyzed patients with acute ischemic stroke who were hospitalized at stroke centers participating in Get With The Guidelines-Stroke from 2013 to 2015. Multivariable logistic regression models were generated to examine the association between stroke center certification (CSC versus PSC) and performances and outcomes. This study included 722 941 patients who were admitted to 134 CSCs and 1047 PSCs. Both CSCs and PSCs had good conformity to 7 performance measures and the summary defect-free care measure. Among emergency department admissions, CSCs had higher intravenous tPA (tissue-type plasminogen activator) and endovascular thrombectomy rates than PSCs (14.3% versus 10.3%, 4.1% versus 1.0%, respectively). Door to intravenous tPA time was shorter at CSCs (median, 52 versus 61 minutes; adjusted risk ratio, 0.92; 95% confidence interval, 0.89-0.95). More patients at CSCs had door to intravenous tPA time ≤60 minutes (79.7% versus 65.1%; adjusted odds ratio, 1.48; 95% confidence interval, 1.25-1.75). For transferred patients, CSCs and PSCs had comparable overall performance in defect-free care, except higher endovascular thrombectomy therapy rates. The overall in-hospital mortality was higher at CSCs in both emergency department admissions (4.6% versus 3.8%; adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.29) and transferred patients (7.7% versus 6.8%; adjusted odds ratio, 1.17; 95% confidence interval, 1.05-1.32). In-hospital outcomes were comparable between CSCs and PSCs in patients who received intravenous tPA or endovascular thrombectomy.

CONCLUSIONS

CSCs and PSCs achieved similar overall care quality for patients with acute ischemic stroke. CSCs exceeded PSCs in timely acute reperfusion therapy for emergency department admissions, whereas PSCs had lower risk-adjusted in-hospital mortality. This information may be important for acute stroke triage and targeted quality improvement.

Selective brain hypothermia: feasibility and safety study of a novel method in five patients

BACKGROUND/OBJECTIVE

Reduction of brain temperature remains the most common method of neuroprotection against ischemic injury employed during cardiac surgery. However, cooling delivered via the cardiopulmonary bypass circuit is brief and cooling the body core along with the brain has been associated with a variety of unwanted effects. This study investigated the feasibility and safety of a novel selective brain cooling approach to induce rapid, brain-targeted hypothermia independent of the cardiopulmonary bypass circuit.

METHODS

This first-in-human feasibility study enrolled five adults undergoing aortic valve replacement with cardiopulmonary bypass support. During surgery, the NeuroSave system circulated chilled saline within the pharynx and upper esophagus. Brain and body core temperature were continuously monitored. Adverse effects, cardiopulmonary function, and device function were noted.

RESULTS

Patient 1 received cooling fluid for an insignificant period, and Patients 2-5 successfully underwent the cooling procedure using the NeuroSave system for 56-89 minutes. Cooling fluid was 12°C for Patients 1-3, 6°C for Patient 4, and 2°C for Patient 5. There were no NeuroSave-related adverse events and no alterations in cardiopulmonary function during NeuroSave use. Brain temperature decreased by 3°C within 15 minutes and remained at least 3.5°C colder than the body core. During a brief episode of hypotension in one patient, the brain cooled an additional 4°C in 2 minutes, briefly reaching 27.4°C.

CONCLUSION

The NeuroSave system can induce rapid brain-targeted hypothermia and simultaneously maintain a favorable body-brain temperature gradient, even during hypotension. Further studies are required to evaluate the function of the system during longer periods of use.

[Analysis of intravenous thrombolysis time and prognosis in patients with in-hospital stroke]

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.

A comparison of trends in stroke care and outcomes between in-hospital and community-onset stroke - The South London Stroke Register

Background

Stroke care and outcomes have improved significantly over the past decades. It is unclear if patients who had a stroke in hospital (in-hospital stroke, IHS) experienced similar improvements to those who were admitted with stroke (community-onset stroke, COS).

Methods

Data from the South London Stroke Register were analysed to estimate trends in processes of care and outcomes across three cohorts (1995–2001, 2002–2008, 2009–2015). Kaplan-Meier survival curves were calculated for each cohort. Associations between patient location at stroke onset, processes of care, and outcomes were investigated using multiple logistic regression and Cox proportional hazards models.

Results

Of 5,119 patients admitted to hospital and registered between 1995 and 2015, 552(10.8%) had IHS. Brain imaging rates increased from 92.4%(COS) and 78.3%(IHS) in 1995–2001 to 100% for COS and IHS in 2009–2015. Rates of stroke unit admission rose but remained lower for IHS (1995–2001: 32.2%(COS) vs. 12.4%(IHS), 2002–2008: 77.1%(COS) vs. 50.0%(IHS), 2009–2015: 86.3%(COS) vs. 65.4%(IHS)). After adjusting for patient characteristics and case-mix, IHS was independently associated with lower rates of stroke unit admission in each cohort (1995–2001: OR 0.49, 95%CI 0.29–0.82, 2002–2008: 0.29, 0.18–0.45, 2009–2015: 0.22, 0.11–0.43). In 2009–2015, thrombolysis rates were lower for ischaemic IHS (17.8%(COS) vs. 13.8%(IHS)). Despite a decline, in-hospital mortality remained significantly higher after IHS in 2009–2015 (13.7%(COS) vs. 26.7%(IHS)). Five-year mortality rates declined for COS from 58.9%(1995–2001) to 35.2%(2009–2015) and for IHS from 80.8%(1995–2001) to 51.1%(2009–2015). In multivariable analysis, IHS was associated with higher mortality over five years post-stroke in each cohort (1995–2001: HR 1.27, 95%CI 1.03–1.57, 2002–2008: 1.24, 0.99–1.55, 2009–2016: 1.39, 0.95–2.04).

Conclusions

Despite significant improvements for IHS patients similar to those for COS patients, rates of stroke unit admission and thrombolysis remain lower, and short- and long-term outcomes poorer after IHS. Factors preventing IHS patients from entering evidence-based stroke-specific hospital pathways in a timely fashion need further investigation.

Improving care for acute in-hospital ischemic strokes—A narrative review

In-hospital strokes, that is new strokes occurring among hospitalized patients, account for 6.5–15% of all strokes. Compared to community-onset stroke patients, in-hospital stroke patients tend to have worse functional and mortality outcomes. This review addresses the characteristics of acute in-hospital ischemic strokes, reasons these patients have worse outcomes compared to community-onset stroke patients, and future steps to improve outcomes.

[Perioperative stroke in heart valve surgery: pathogenesis, clinical findings, diagnosis, prevention, treatment]

AIM

To study risk factors, characteristics of clinical symptoms and diagnosis, and possibilities of prevention of perioperative stroke and other clinical types of cerebral dysfunction in main types of heart valve surgery.

MATERIAL AND METHODS

The study included 83 patients, aged 63 (54; 70) years, undergoing heart valve surgery with cardiopulmonary bypass.

RESULTS

Postoperative cerebral dysfunction was diagnosed in 37.3% of cases, including perioperative stroke in 3.6% of cases. In cases of aortic stenosis, the frequency of perioperative stroke was 9.5%. The cardioembolic subtype of perioperative ischemic stroke in cardiac valve surgery was most likely. The risk factors of the symptomatic delirium of the early postoperative period are: age over 75 years, preoperative frontal dysfunction, duration of artificial respiratory care more than 20 hours after the surgery.

CONCLUSION

The results suggest the efficacy of preventive use of cytoflavin for reducing the frequency and severity of perioperative stroke and symptomatic delirium of the early postoperative period in heart valve surgery with cardiopulmonary bypass.

Factors Affecting the Effective Management of Acute Stroke: A Prospective Observational Study

Background

Stroke, characterized by sudden loss of cerebral function, is among one of the leading cause of death and disability world over. The newer treatment modalities have changed the landscape of stroke treatment but are very much time bound.

Aim

To characterize pre-hospital and in-hospital factors affecting acute stroke management thus defining lacunae in stroke management.

Subjects and Methods

A prospective observational study, conducted at the emergency department of a tertiary care center in southern India from August 2015 to July 2016. All stroke patients presenting within first 24 hours of onset were included. A pre -defined Knowledge-Attitude-Practice (KAP) questionnaire was used.

Results

Total of 133 patients were eligible out of which 28 were excluded for various reasons. Majority were >60 years age and male (61%). About 60% arrived within window. Distance from the hospital was one of the major factors for arrival within the window period. When compared by KAP questionnaire, bystanders of those arriving within window period had better awareness of stroke symptoms.

Conclusions

Improving awareness of stroke symptoms and increasing availability of EMS is likely increase chances of stroke patients receiving appropriate acute management.

Artery of Percheron Infarct: 12 Cases and Their Complex Clinical Courses

Strokes involving the artery of Percheron (AOP), an anatomic variant of thalamic vascular supply, are rare. Little is known about the inpatient hospital course for these patients. We retrospectively identified consecutive patients with AOP in their medical charts from a university-based tertiary care hospital from January 1, 2000, to August 15, 2017. A chart review identified demographics, transfer status, in-hospital versus community onset of stroke, emergency medical services (EMS) use, presenting signs/symptoms, time to radiologic diagnosis (from time of presentation to tertiary care hospital or from time of initial symptom onset in an already hospitalized patient), tissue plasminogen activator (tPA) use, intensive care unit (ICU) stays, intubation, length of stay (LOS), and discharge location. After radiologic inclusion/exclusion criteria were applied, 12 patients were included in the study. There were 7 men and 5 women, and the mean age (SD) was 68 (15). Seven were transfers, and 4 had an in-hospital stroke. Of the 8 community-onset strokes, 7 utilized EMS. Mental status changes occurred in 11 of 12 and ocular disturbances in all patients. Time to radiologic diagnosis averaged 1.9 (median = 1.1) days. One patient received tPA. Eight received care in the ICU. Four were intubated. Average LOS was 8.3 days. Four were discharged home, 3 entered inpatient rehabilitation facilities, and 5 entered skilled nursing facilities. In-hospital stroke status further complicates the already challenging diagnosis of AOP infarct, and clinicians must maintain a high suspicion for this rare stroke in order to quickly diagnose and intervene.