Validation of ICD-10-CM Diagnosis Codes for Identification of Patients with Acute Hemorrhagic Stroke in a National Health Insurance Claims Database

Association Between Cerebral Amyloid Angiopathy and Nontraumatic Subdural Hemorrhage

BACKGROUND AND OBJECTIVES

Cerebral amyloid angiopathy (CAA) is a common cause of intracerebral hemorrhage (ICH) in older patients. Whether CAA is associated with isolated subdural hemorrhage (SDH), without an accompanying ICH, remains unclear. We, therefore, tested this relationship in a large, heterogeneous sample of patients across the United States.

METHODS

We performed a retrospective cohort study using administrative claims data from all admissions to nonfederal acute care hospitals in 11 states in the United States between 2016 and 2021. Among hospitalized patients, we included only those aged 50 years or older, a threshold necessary to meet Boston criteria v2.0 for CAA. We divided this population into 3 groups: those with a diagnosis of CAA, those with other cerebrovascular diseases (CVDs) but without CAA, and those with neither CAA nor other CVDs. The main outcome was a first-documented, isolated, nontraumatic SDH; we did not count SDH cases with a concurrent traumatic brain injury. The exposures and outcome were identified using previously validated ICD-10-CM diagnosis codes. Using Cox regression analyses, we compared the risk of incident SDH among the 3 groups after adjustment for demographics and comorbidities. In prespecified sensitivity analyses, patients with a baseline diagnosis of dementia were excluded.

RESULTS

Among 8.5 million hospitalized patients aged 50 years or older, 2,335 had CAA and 600,646 had other CVDs. During a median follow-up of 2.0 years (interquartile range 1.0-3.9), incident SDH occurred in 34 patients with CAA (1.5%), 3,552 patients with other CVDs (0.6%), and 35,425 patients without CAA or other CVDs (0.4%). In adjusted Cox regression analysis, there was an increased risk of incident SDH seen with CAA (hazard ratio [HR] 3.1; 95% CI 2.2-4.4) and with prevalent CVD (HR 1.4; 95% CI 1.3-1.5). Findings were similar in sensitivity analyses excluding patients with dementia.

DISCUSSION

In a large, heterogeneous cohort, we found that CAA was associated with a 3-fold heightened risk of SDH, higher than the increased risk seen in patients with other CVDs. These findings support the emerging hypothesis that CAA is a risk factor of isolated nontraumatic SDH.

Feasibility of Identifying Acute Nontraumatic Intracerebral Hemorrhage Events Using Diagnostic Coding Among Veterans with Mild Cognitive Impairment or Alzheimer's Dementia

INTRODUCTION

Based on manual review of clinical notes of using the International Classification of Diseases, Tenth Revision coding, we evaluated the feasibility and validity for monitoring, recording, and reporting intracerebral hemorrhage (ICH) events in patients with all-cause mild cognitive impairment or Alzheimer's dementia including, but not limited to, patients eligible for anti-amyloid therapy.

METHODS

Principal and first-position hospital discharge codes for ICH events for 200 patients were identified from the Veterans Affairs Health System structured administrative database. Clinician manual review of discharge summary notes assessed and confirmed the presence of coded events. Available documentation of bleed locations was further reviewed, and the extent of event adjudication for potential etiology was assessed. Additionally, 25 acute ICH cases were randomly identified by reviewing discharge notes to confirm corresponding diagnostic code-based reporting.

RESULTS

Of the 200 identified patients, 161 with acute ICH events were confirmed, resulting in a positive predictive value (PPV) of 80.5% for ICH event presence identified by diagnostic coding. Bleed locations were described for 151 of 161 patients with confirmed events. Of 110 cases whose diagnostic codes indicated an event location, 79 had location descriptions in discharge summaries that were consistent with the coding (PPV = 71.8%). Possible etiology was described in 56/161 patients' discharge summaries. Among the 25 acute ICH cases identified from discharge notes, 8 had corresponding ICH diagnostic codes.

CONCLUSION

This study supports the feasibility and validity of the ICD-10 coding system for monitoring, recording, and reporting ICH event presence. When location is specified in the codes, the ICD-10 coding has an acceptable PPV. Overall, the current diagnostic coding system provides a reasonable framework for initial reporting and may allow for only limited inference of etiology such as differentiating nontraumatic versus traumatic events. Coding accuracy for ICH can be expected to further improve with the availability of guidelines, training, and standardization across clinical practices.

Aspirin does not modify cardiovascular event risk in endometriosis in the California Teachers Study

Aims

Endometriosis frequently affects reproductive aged females and is associated with increased cardiovascular disease risk. The aims of this study were (i) to confirm the relationship between cardiovascular disease and endometriosis and (ii) to test whether aspirin modified the effect of endometriosis on cardiovascular disease risk.

Methods and results

A longitudinal cohort study was conducted using data from the California Teachers Study from enrolment (1995-1996) through the current administrative end follow-up (31 December 2020). Primary outcome was any incident major adverse cardiovascular event (MACE) defined using validated ICD-9/ICD-10 codes for stroke, myocardial infarction, and coronary heart disease. Inverse probability (IP) weights were used to estimate the causal effect of self-reported endometriosis on cardiovascular events. Of the included 120 435 participants, 13 754 (11.4%) reported history of endometriosis. There were 2159 admissions for MACE in the endometriosis group vs. 16 632 in the non-endometriosis group. After controlling for demographics and vascular comorbidities, risk of MACE was higher in the endometriosis group than in the non-endometriosis group [IP-weighted hazard ratio (HR) 1.10, confidence interval (CI) 1.04-1.15], particularly in participants < 40 years of age (IP-weighted HR 1.48, CI 1.08-2.02). Aspirin use did not modify the effect of endometriosis on MACE (P interaction = 0.467). Among participants taking aspirin, the adjusted HR for endometriosis was 1.07 (95% CI, 0.96-1.19) whereas among participants not taking aspirin, adjusted HR was 1.10 (95% CI, 1.04-1.17).

Conclusion

In a large American cohort, endometriosis was associated with increased risk of adverse cardiovascular events, especially in younger participants. Aspirin did not modify this risk. Research to determine how to best reduce cardiovascular risk in endometriosis is warranted.

Global, regional, and national burden and trends of intracerebral hemorrhage among adolescents and young adults aged 15-39 years from 1990 to 2021: a comprehensive trend analysis based on the global burden of disease study 2021

Background

Intracerebral hemorrhage (ICH) poses a significant health challenge, notably affecting adolescents and young adults (AYAs) aged 15-39 years. Despite advancements in medical technology, the global burden of ICH remains substantial, influenced by lifestyle factors, socioeconomic conditions, and disparities in healthcare access. This study leverages data from the 2021 Global Burden of Disease (GBD) to conduct a comprehensive analysis of ICH trends and burdens at global, regional, and national levels, emphasizing the role of the Social Development Index (SDI).

Methods

We utilized data from the GBD 2021 to assess the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) associated with ICH from 1990 to 2021, covering 204 countries and regions. Age-standardized rates were calculated to ensure comparability. Temporal trends were evaluated using Joinpoint regression analysis, and future projections were made using a Bayesian Age-Period-Cohort model.

Results

In 2021, ~246,938 new cases of ICH were reported among the global AYAs population, reflecting a decline in age-standardized incidence rates from 11.85 per 100,000 in 1990 to 8.14 in 2021. Prevalence rates also decreased from 124.44 to 94.58 per 100,000. Mortality rates and DALYs exhibited similar downward trends. Significant regional disparities were observed, with high SDI regions experiencing lower ICH burdens than low SDI regions, highlighting the influence of socioeconomic factors and healthcare access.

Conclusion

While the global burden of ICH among AYAs has declined, significant disparities persist, particularly in regions with lower SDI. To further mitigate the impact of ICH, public health initiatives should focus on enhancing healthcare infrastructure, promoting health education, and addressing socioeconomic inequalities.

Accuracy of posthospitalization stroke detection following carotid revascularization in Medicare claims

BACKGROUND

Stroke after carotid revascularization is a key effectiveness and quality metric relevant to patients, clinicians, and policymakers. To date, the accuracy of stroke rates reported from Medicare claims-based datasets for patients who underwent carotid revascularization remain unknown. The objective of this study was to validate the accuracy of using International Classification of Diseases, Tenth Revision (ICD-10) codes to detect stroke after carotid artery revascularization.

METHODS

We retrospectively reviewed all patients who underwent carotid revascularization at two institutions from January 2016 to December 2019. We used a list of ICD-10 codes to detect stroke that we derived previously and validated in two prospective cohorts with atherosclerosis. We applied the list to all patients who underwent carotid revascularization at the two institutions to identify patients with an ICD-10 code for stroke, either as the indication for the index procedure or after the procedure. We then performed a comprehensive medical record review for all stroke patients, as well as a 1:1 random sample of patients who underwent revascularization during the same time interval and did not have an ICD-10 code for stroke. Our primary outcome was the sensitivity and specificity of the ICD-10 codes to detect posthospitalization stroke (ie, after the index hospitalization) compared with a gold standard of chart review.

RESULTS

We performed a comprehensive medical record review of a cohort oversampled for stroke that included 199 patients (mean age, 73.5±7.6 years; 62.3% male; 95.0% non-Hispanic White; 61.8% symptomatic) who underwent carotid revascularization during the study interval. The majority of patients underwent carotid endarterectomy (82.4%), followed by transcarotid artery revascularization (12.1%) and transfemoral carotid artery stenting (5.5%). Twelve patients had a stroke during their index hospitalization, creating a final cohort of 187 patients eligible for assessment of posthospitalization stroke. After a median follow-up time of 453 days (interquartile range, 82-803 days), 10 asymptomatic patients and 10 symptomatic patients had a posthospitalization stroke based on chart review. Among asymptomatic patients, the sensitivity and specificity of ICD-10 codes to detect a posthospitalization stroke were 100% (95% CI, 69.2%-100.0%) and 96.8% (95% CI, 88.8%-99.6%), respectively, when considering all linked diagnosis codes. Among symptomatic patients, the sensitivity and specificity of ICD-10 codes to detect a posthospitalization stroke were 80.0% (95% CI, 44.4%-97.5%) and 94.3% (95% CI, 88.0%-97.9%), respectively, when considering all diagnosis codes.

CONCLUSIONS

Posthospitalization stroke can be measured accurately after carotid revascularization using ICD-10 codes in Medicare claims data. The reliability of the algorithm is better among asymptomatic patients than symptomatic patients.

Nationwide Trends in Stroke Among Patients Undergoing Hemodialysis by Sex and Race: An Analysis From the US Renal Database

BACKGROUND

The risk of ischemic stroke hospitalization in patients with end-stage kidney disease has declined over time, but data are limited, especially for hemorrhagic stroke trends. Race- and sex-based differences have not been well studied.

METHODS AND RESULTS

We conducted a retrospective cohort study using the US Renal Data System to examine the incidence of stroke among incident patients undergoing hemodialysis from 2006 to 2016. We identified 391 195 new patients undergoing hemodialysis (mean age, 70.1 years; 44.8% women) between 2006 and 2016. The incidence of any stroke per 100 000 patients decreased from 2746 cases at 1 year and 6823 cases at 3 years during 2006 to 2009 to 1983 cases at 1 year and 5162 cases at 3 years in 2014 to 2016 (P<0.001). Women had higher stroke incidence than men (P<0.001). White adults had higher incidence compared with Black adults, Hispanic adults, and Other (Native American participants and those whose racial and ethnic identification did not align with the classifications) race (P<0.001). The risk decreased over the study period for both sexes and races, except "Other" race. Hemorrhagic stroke incidence was 409 cases at 1 year and 1125 at 3 years per 100 000. No sex difference was observed at 1 year, but women had higher 3-year rates (P=0.005). Black and Hispanic adults had higher 3-year hemorrhagic stroke rates than White adults (P<0.001). Decreases occurred only for women, Black adults, and Hispanic adults at 1 year.

CONCLUSIONS

While the overall risk of stroke remains high after hemodialysis initiation, significant reductions in stroke risk have occurred over the past decade across sexes and racial groups.

Mechanical Thrombectomy vs Catheter-Directed Thrombolysis for High-Risk Pulmonary Embolism: A Target Trial Emulation

BACKGROUND

Evidence is limited regarding the comparative effectiveness and safety of mechanical thrombectomy (MT) vs catheter-directed thrombolysis (CDT) for high-risk pulmonary embolism (PE).

OBJECTIVES

This observational study aimed to compare the outcomes of older adults with high-risk PE treated with MT vs CDT using a target trial emulation framework.

METHODS

We included Medicare fee-for-service beneficiaries aged 65 to 99 years admitted with high-risk PE (defined by cardiac arrest, shock, and vasopressor use) who underwent MT/CDT from 2017 to 2020. We evaluated 1-year mortality using an inverse probability of treatment weighting approach, controlling for 62 baseline covariates. We also evaluated readmissions and in-hospital outcomes, including intracranial hemorrhage. Patients were followed from the date of the index procedure to the outcomes of interest, 1 year, or December 2020.

RESULTS

We included 235 and 484 patients in the MT and CDT groups, respectively. The absolute risk of 1-year mortality was 48.4% (95% CI: 34.1%-63.3%) in the MT group and 45.4% (95% CI: 37.8%-55.8%) in the CDT group, with an adjusted HR of 1.16 (95% CI: 0.84-1.59). We found no evidence that all-cause readmission (MT vs CDT; subdistribution HR: 0.89; 95% CI: 0.56-1.40), intracranial hemorrhage (adjusted OR: 0.36; 95% CI: 0.07-1.77), or transfusions (adjusted OR: 0.96; 95% CI: 0.52-1.76) differed significantly between the 2 groups.

CONCLUSIONS

Among older adults with high-risk PE treated with catheter-based therapies, the clinical outcomes were similar between the patients treated with MT vs CDT. Randomized trials are needed to confirm our findings.

Differences in intervention for patients with acute stroke according to the manpower of neurosurgeons

BACKGROUND AND OBJECTIVES

Stroke, a leading global cause of death, poses a substantial health burden. The incidence of stroke is high in an aging society. Appropriate healthcare resources are crucial for providing prompt interventions to patients with stroke. We investigated the factors associated with the choice between conservative and interventional treatments, including an analysis of the number of neurosurgeons required for interventional care, for patients with acute stroke.

METHODS

We utilized health insurance claims data from hospitals submitted to the Health Insurance Review and Assessment Service in 2018 and 2021. The data covered 60,661 patients with acute stroke admitted to the emergency room in tertiary or general hospitals. The number of hospital neurosurgeons was the key variable of interest; conservative and interventional treatments were the independent variables. Using a multi-level analysis, we identified the individual- and hospital-level factors associated with interventional treatment by constructing four models.

RESULTS

The odds of patients with hemorrhage and ischemic stroke receiving intervention were 0.60 [95% confidence interval (CI), 0.31-0.52] and 0.51 [95% CI, 0.39-0.65] times lower, respectively, in the group with fewer neurosurgeons. We categorized the number of neurosurgeons and indicated an association between a minimum of three neurosurgeons and stroke treatment.

CONCLUSION

We demonstrated an association between individual- and hospital-level factors and the intervention for patients with different types of stroke. We predicted the number of neurosurgeons needed for intervention. These findings can be used for the efficient distribution and utilization of healthcare resources to improve public health.

Cardiovascular Safety of Romosozumab vs PTH Analogues for Osteoporosis Treatment: A Propensity-Score-Matched Cohort Study

CONTEXT

Romosozumab, a monoclonal sclerostin antibody, is a recently approved highly potent antiosteoporotic agent with osteoanabolic properties. Clinical use of romosozumab is hindered by the fear of adverse cardiovascular (CV) events raised following the pivotal ARCH trial.

OBJECTIVE

This work aimed to assess real-world CV safety of romosozumab vs alternative osteoanabolic therapies used for treatment of severe osteoporosis.

METHODS

Data were obtained from TriNetX, a global federated health research network including real-time electronic medical records from 113 health care organizations with 136 460 930 patients across 16 countries at time of analysis. Inclusion criteria were age 40 years or older, a diagnosis of osteoporosis and prescription of romosozumab or a parathyroid hormone (PTH) analogue (teriparatide/abaloparatide) during August 2019 through August 2022. Propensity-score-matched cohorts were created 1:1 using demographic variables, comorbidities, and medications. Kaplan-Meier analysis was used to estimate the probability of the outcomes. Outcome measures included incident 3-point major adverse CV event or death (3P-MACE) during 1-year of follow-up after the initial prescription.

RESULTS

A total of 5626 and 15 986 patients met the criteria for romosozumab and PTH analogue cohorts, respectively, with 5610 patients per group following propensity score matching. 3P-MACE was significantly less frequent in the romosozumab vs PTH analogue cohort (158 vs 211 patients with an outcome; P = .003) with reductions in the individual components of the composite outcome: myocardial ischemic events (31 vs 58; P = .003); cerebrovascular events 56 vs 79; P = .037; deaths (83 vs 104; P = .099).

CONCLUSION

In a diverse, real-world setting, prescription of romosozumab for osteoporosis is associated with fewer adverse CV events when compared to PTH analogue therapy.

Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine

Importance

Monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) or its receptor (anti-CGRP mAbs) offer effective migraine-specific preventive treatment. However, concerns exist about their potential cardiovascular risks due to CGRP blockade.

Objective

To compare the incidence of cardiovascular disease (CVD) between Medicare beneficiaries with migraine who initiated anti-CGRP-mAbs vs onabotulinumtoxinA in the US.

Design, Setting, and Participants

This retrospective, sequential cohort study was conducted among a nationally representative population-based sample of Medicare claims from May 2018 through December 2020. Data analysis was performed from August to December 2023. This study included fee-for-service Medicare beneficiaries aged 18 years or older with migraine who initiated either anti-CGRP mAbs or onabotulinumtoxinA. Beneficiaries who had a history of myocardial infarction (MI), stroke, cluster headache, malignant cancer, or hospice service within a 1-year baseline period prior to treatment initiation were excluded. To minimize channeling bias from new drug introductions and time-related bias due to the COVID-19 pandemic, 5 cohorts were established, representing sequential 6-month calendar intervals based on the initial prescription or date of index anti-CGRP mAbs or onabotulinumtoxinA use.

Exposure

Anti-CGRP mAbs vs onabotulinumtoxinA.

Main Outcomes and Measures

The primary outcome was time to first MI or stroke. Secondary outcomes included hypertensive crisis, peripheral revascularization, and Raynaud phenomenon. The inverse probability of treatment-weighted Cox proportional hazards models were used to compare outcomes between the 2 treatment groups.

Results

Among 266 848 eligible patients with migraine, 5153 patients initiated anti-CGRP mAbs (mean [SD] age, 57.8 [14.0] years; 4308 female patients [83.6%]) and 4000 patients initiated onabotulinumtoxinA (mean [SD] age, 61.9 [13.7] years; 3353 female patients [83.8%]). Use of anti-CGRP mAbs was not associated with an increased risk of composite CVD events (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.44-1.77), hypertensive crisis (aHR, 0.46; 95% CI, 0.14-1.55), peripheral revascularization (aHR, 1.50; 95% CI, 0.48-4.73), or Raynaud phenomenon (aHR, 0.75; 95% CI, 0.45-1.24) compared with onabotulinumtoxinA. Subgroup analyses by age group and presence of established non-MI or stroke CVD showed similar findings.

Conclusions and Relevance

In this cohort study, despite initial concerns regarding the cardiovascular effects of CGRP blockade, anti-CGRP mAbs were not associated with an increased risk of CVD compared with onabotulinumtoxinA among adult Medicare beneficiaries with migraine, who were predominantly older adults or individuals with disability. Future studies with longer follow-up periods and in other populations are needed to confirm these findings.

Characterization of bleeding in thrombotic thrombocytopenic purpura in the precaplacizumab era: a retrospective nationwide analysis

Background

The addition of caplacizumab to immune thrombotic thrombocytopenia (iTTP) treatment options has led to a renewed interest in characterizing the epidemiology and risk factors for bleeding in iTTP. Limited data exist on the bleeding risk in iTTP due to systemic underreporting in earlier cohorts.

Objectives

To describe the incidence, patterns, and predictors of bleeding in hospitalized iTTP patients independent of caplacizumab use.

Methods

We retrospectively analyzed the National Inpatient Sample database (2012-2019) and identified adult patients with a diagnosis of iTTP. Predictors of bleeding were determined by multivariable logistic regression analysis.

Results

We identified 3103 iTTP hospitalizations; bleeding occurred in 594 (19.1%), and 157 (5.1%) were characterized by major bleeding. Mucocutaneous bleeding (7.6%) was the most frequent type of bleeding and included heavy menstrual bleeding (2.6%), gingival (2.3%), epistaxis (1.4%), and skin/procedure-related bleeding (1.3%). This was followed closely by gastrointestinal bleeding (5.6%). Patients with bleeding were more likely to be Hispanic, have a weekend admission, and have a higher prevalence of comorbidities. In the multivariable analysis, Hispanic race (odds ratio [OR], 1.48; 1.14-1.91), Asian/Pacific Islander/Native American race (OR, 2.04; 1.51-2.76), coronary artery disease (OR, 1.70; 1.38-2.11), heart failure (OR, 1.39; 1.13-1.72), autoimmune disease (OR, 2.61; 2.08-3.26), Charlson Comorbidity Index ≥ 3 (OR, 2.08; 1.66-2.61), weekend admission (OR, 1.45; 1.22-1.72), and delay ≥2 days in plasma exchange initiation (OR, 1.63; 1.38-1.92), were significantly associated with major bleeding.

Conclusions

Bleeding is a relatively common issue in acute iTTP that has not been adequately addressed in existing literature. Further studies are needed to elucidate this risk and associated factors, especially given the incorporation of caplacizumab in the treatment of iTTP.

Constipation and risk of death and cardiovascular events in patients on hemodialysis

BACKGROUND

Constipation is a common gastrointestinal disorder and is often accompanied by alteration in the gut microbiota. Recently, several studies have disclosed its association with an increased risk of cardiovascular disease and mortality in the general population. Despite the high prevalence of constipation, data on the clinical impact of constipation in patients with chronic kidney disease are limited. We aimed to explore the prevalence of constipation and its association with cardiovascular disease in chronic kidney disease using a nationally representative cohort of hemodialysis patients.

METHODS

This study used hemodialysis quality assessment and health insurance claims data from patients undergoing maintenance hemodialysis in South Korea. Chronic constipation was defined using the total number of laxatives prescribed during the 1-year baseline period. The primary outcome was a composite of acute ischemic stroke, hemorrhagic stroke, myocardial infarction, or all-cause death. Secondary outcomes were the individual components of the primary outcome.

RESULTS

Among 35,230 patients on hemodialysis, 9,133 (25.9%) were identified as having constipation. During a median follow-up of 5.4 years, patients with constipation had a 15% higher incidence of the composite outcome, 16% higher incidence of ischemic stroke, and 14% higher all-cause mortality, after multivariate adjustment.

CONCLUSION

Chronic constipation requiring laxatives was associated with a higher risk of the composite outcome of cardiovascular events or all-cause death in patients on hemodialysis. Further studies are needed to confirm whether constipation is an independent predictor or a possible causal factor of cardiovascular disease.

Incidence and Risk of Cardiovascular Outcomes in Patients With Anorexia Nervosa

Importance

Anorexia nervosa (AN) is commonly associated with cardiovascular complications.

Objective

To investigate the trajectories of the risk of cardiovascular conditions in a nationwide cohort of patients with AN in Taiwan.

Design, Setting, and Participants

From a population-based health insurance database from January 1, 2011, to December 31, 2021, this longitudinal cohort study identified patients with AN and controls through propensity score matching at a 1:10 ratio according to sex, age, urbanization level of residence, socioeconomic status, and year of diagnosis. Data were analyzed from June 27, 2023, to February 23, 2024.

Exposure

First-time diagnosis of AN by psychiatrists during the study period.

Main Outcomes and Measures

Incidence and risk of composite cardiovascular conditions. Kaplan-Meier curves were used to estimate the cumulative incidence of major adverse cardiovascular events (MACE) and any cardiovascular condition. With adjustment for psychiatric comorbidities, conditional Cox proportional hazards regression analyses were performed to estimate the risk of cardiovascular events, which were presented as hazard ratios (HRs) and 95% CIs, relative to the comparison group. Risks of individual cardiovascular conditions were calculated during 3 follow-up periods after AN diagnosis.

Results

The study population included 2081 patients with AN and 20 810 matched controls, for a total of 22 891 participants (mean [SD] age, 24.9 [9.9] years; 91.3% female). In total, 99 patients with AN (4.8%) had MACE vs 175 (0.8%) in controls, and 124 patients with AN (6.0%) had any cardiovascular condition vs 483 controls (2.3%). At the 5-year follow-up, the cumulative incidence rate of MACE was 4.82% (95% CI, 3.85%-6.02%) and of any cardiovascular condition was 6.19% (95% CI, 5.19%-7.53%). Compared with the control group, the AN group had significantly higher risks of MACE (adjusted HR [AHR], 3.78; 95% CI, 2.83-5.05) and any cardiovascular condition (AHR, 1.93; 95% CI, 1.54-2.41). The significantly increased risks of congestive heart failure, conduction disorder, and structural heart disease occurred in the initial follow-up period and disappeared after 60 months of follow-up. Notably, patients with AN did not have an increased risk of ischemic heart disease until after 60 months of follow-up (AHR, 3.01; 95% CI, 1.48-6.13).

Conclusions and Relevance

In this national matched cohort study, increased risk of cardiovascular conditions was found in different periods after AN diagnosis. Clinicians should monitor comorbid cardiovascular conditions among patients with AN at initial presentation, during treatment, and at follow-up.

Comparison of the Safety of Aspirin Monotherapy and Aspirin and P2Y12 Inhibitor Combination Therapy in Patients Post Coil Embolization During Admission: A Cross-Sectional Study Using a Nationwide Inpatient Database

BACKGROUND

Some aspects regarding the use of antiplatelet agents after coil embolization for subarachnoid hemorrhage during admission remain unclear. This study used diagnostic procedure combination (DPC) data to investigate the safety and prognostic effects of aspirin monotherapy and aspirin and P2Y12 inhibitor combination therapy on bleeding events.

METHODS

This cross-sectional study used Japanese DPC data to assess patients who were hospitalized with subarachnoid hemorrhage and received aspirin monotherapy and aspirin and P2Y12 inhibitor combination therapy between April 2016 and March 2020 (n = 4421). The aspirin monotherapy (A group, n = 2848) and aspirin and P2Y12 inhibitor combination therapy (AP group, n = 1573) groups were compared. The primary and secondary endpoints were the incidence of bleeding events and proportion of patients with a modified Rankin Scale (mRS) score ≤ 2 at discharge, respectively. Data was analyzed using multivariable adjusted logistic regression (significance level, 5%).

RESULTS

The adjusted odds ratio in AP group, with A group as the reference, for bleeding events and the proportion of patients with mRS score ≤ 2 at discharge were 0.97 (95% confidence interval [95% CI]: 0.75-1.26, p = 0.839) and 1.09 (95% CI: 0.92-1.29, p = 0.302), respectively.

CONCLUSIONS

There are no differences in the incidence of bleeding events or good clinical outcomes (mRS score ≤ 2 at discharge) between aspirin monotherapy and aspirin and P2Y12 inhibitor combination therapy.

Cataract Surgery and Incidence of Retinal Vascular Occlusion: Population-Based Cohort Study Using a Target Trial Emulation Framework

BACKGROUND

Previous studies suggested an association between cataract surgery and retinal vascular occlusion. However, the association may be attributable to detection bias because postoperative monitoring may be more frequent for those who receive cataract surgery than for those who do not.

DESIGN

Population-based cohort study using target trial emulation framework.

METHODS

We included patients with cataract aged 50 years and older receiving cataract surgery or nonsurgical interventions identified from the Taiwan National Health Insurance Research Database between 2003 and 2018, matched by propensity score. The primary outcome was retinal vascular occlusion. Cox proportional hazards models were used to compare surgery and control groups. Additional analyses were restricted to patients who had undergone fundoscopic examination within 6 months prior to cataract surgery to address the issue of detection bias.

RESULTS

We included 577,129 cataract surgery and control pairs. We found the hazard ratio (HR) for retinal vascular occlusion after cataract surgery was 1.23 (95% confidence interval (CI): 1.17-1.29), compared with the control group. Secondary outcome analyses yielded similar results for retinal artery occlusion (HR: 1.13, 95% CI: 1.02-1.26) and retinal vein occlusion (HR: 1.26, 95% CI: 1.20-1.33). However, no risk of retinal vascular occlusion was observed among patients who had received fundoscopic examinations (HR: 1.06, 95% CI: 0.98-1.15) at baseline.

CONCLUSIONS

Our study underscored the importance of conducting complete baseline fundoscopic examinations before cataract surgery to clarify whether postoperative conditions are due to patients' underlying diseases or unintended complications of cataract surgery.

Fasudil hydrochloride and ozagrel sodium combination therapy for patients with aneurysmal subarachnoid hemorrhage: a cross-sectional study using a nationwide inpatient database

BACKGROUND

Fasudil and ozagrel are drugs with the same indications for the treatment of cerebral vasospasm in Japan. However, there have been no definitive conclusions on the clinical efficacy of fasudil hydrochloride and ozagrel sodium monotherapy or their combination. Therefore, we aimed to investigate the effectiveness of the combined administration of fasudil hydrochloride and ozagrel sodium in Japanese patients with subarachnoid hemorrhage (SAH).

METHODS

This cross-sectional study used Diagnosis Procedure Combination data to assess patients who were hospitalized with SAH and received fasudil hydrochloride or ozagrel sodium between April 2016 and March 2020 (n = 17,346). The participants were divided into three groups based on the treatment received: fasudil hydrochloride monotherapy (F group, n = 10,484), ozagrel sodium monotherapy (O group, n = 465), and fasudil hydrochloride and ozagrel sodium combination therapy (FO group, n = 6,397). The primary outcome was in-hospital mortality. Multivariable adjusted logistic regression analysis (significance level, 5%) was used for data analyses.

RESULTS

The results of the multivariable analysis, adjusted for factors considered to impact prognosis, showed that the adjusted odds ratio (OR) with the F group as the reference for in-hospital mortality was 0.94 in the FO group (95% confidence interval [CI]: 0.81-1.08, p = 0.355), with no differences compared to the F group.

CONCLUSION

Fasudil hydrochloride and ozagrel sodium had different mechanisms of action, suggesting a synergistic effect of combination therapy. However, a comparison of fasudil hydrochloride monotherapy and combination therapy of fasudil hydrochloride and ozagrel sodium showed no difference in the prognostic effect. Therefore, it was suggested that fasudil hydrochloride monotherapy may be sufficient.

Characteristics and risk of stroke in emergency department patients with acute dizziness

Background

Acute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %-5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit.

Methods

We identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke.

Results

Out of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34-9.68) to 2.03 (95 % CI, 1.65-2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory.

Conclusions

The risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.

Risk Factors and Temporal Patterns of Poststroke Epilepsy across Stroke Subtypes: Insights from a Nationwide Cohort Study in Korea

INTRODUCTION

We aimed to investigate the risk factors associated with poststroke epilepsy (PSE) among patients with different subtypes of stroke, focusing on age-related risk and time-varying effects of stroke subtypes on PSE development.

METHODS

A retrospective, nationwide, population-based cohort study was conducted using Korean National Health Insurance Service-National Sample Cohort data. Patients hospitalized with newly diagnosed stroke from 2005 to 2015 were included and followed up for up to 10 years. The primary outcome was the development of PSE, defined as having a diagnostic code and a prescription for anti-seizure medication. Multivariable Cox proportional hazard models were used to estimate PSE hazard ratios (HRs), and time-varying effects were also assessed.

RESULTS

A total of 8,305 patients with ischemic stroke, 1,563 with intracerebral hemorrhage (ICH), and 931 with subarachnoid hemorrhage (SAH) were included. During 10 years of follow-up, 4.6% of patients developed PSE. Among patients with ischemic stroke, significant risk factors for PSE were younger age (HR = 1.47), living in rural areas (HR = 1.35), admission through the emergency room (HR = 1.33), and longer duration of hospital stay (HR = 1.45). Time-varying analysis revealed elevated HRs for ICH and SAH, particularly in the first 2 years following the stroke. The age-specific HRs also showed an increased risk for those under the age of 65, with a noticeable decrease in risk beyond that age.

CONCLUSION

The risk of developing PSE varies according to stroke subtype, age, and other demographic factors. These findings underscore the importance of tailored poststroke monitoring and management strategies to mitigate the risk of PSE.

Risk of Bleeding Following Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Acute Ischemic Stroke Treated With Alteplase

Importance

Current guidelines advise against intravenous alteplase therapy for treatment of acute ischemic stroke in patients previously treated with non-vitamin K antagonist oral anticoagulants (NOACs).

Objective

To evaluate the risk of bleeding and mortality after alteplase treatment for acute ischemic stroke among patients treated with NOACs compared to those not treated with NOACs.

Design, Setting, and Participants

This nationwide, population-based cohort study was conducted in Taiwan using data from Taiwan's National Health Insurance Research Database from January 2011 through November 2020 and included 7483 patients treated with alteplase for acute ischemic stroke. A meta-analysis incorporating the results of the study with those of previous studies was performed, and the review protocol was prospectively registered with PROSPERO.

Exposures

NOAC treatment within 2 days prior to stroke, compared to either no anticoagulant treatment or warfarin treatment.

Main Outcomes and Measures

The primary outcome was intracranial hemorrhage after intravenous alteplase during the index hospitalization (the hospitalization subsequent to alteplase administration). Secondary outcomes were major bleeding events and mortality during the index hospitalization. Propensity score matching was used to control potential confounders. Logistic regression was used to estimate the odds ratio (OR) of outcome events. Meta-analysis was performed using a random-effects model.

Results

Of the 7483 included patients (mean [SD] age, 67.4 [12.7] years; 2908 [38.9%] female individuals and 4575 [61.1%] male individuals), 91 (1.2%), 182 (2.4%), and 7210 (96.4%) received NOACs, warfarin, and no anticoagulants prior to their stroke, respectively. Compared to patients who were not treated with anticoagulants, those treated with NOACs did not have significantly higher risks of intracranial hemorrhage (risk difference [RD], 2.47% [95% CI, -4.23% to 9.17%]; OR, 1.37 [95% CI, 0.62-3.03]), major bleeding (RD, 4.95% [95% CI, -2.56% to 12.45%]; OR, 1.69 [95% CI, 0.83-3.45]), or in-hospital mortality (RD, -4.95% [95% CI, -10.11% to 0.22%]; OR, 0.45 [95% CI, 0.15-1.29]) in the propensity score-matched analyses. Furthermore, the risks of bleeding and mortality were not significantly different between patients treated with NOACs and those treated with warfarin. Similar results were obtained in the meta-analysis.

Conclusions and Relevance

In this cohort study with meta-analysis, compared to no treatment with anticoagulants, treatment with NOACs prior to stroke was not associated with a higher risk of intracranial hemorrhage, major bleeding, or mortality in patients receiving intravenous alteplase for acute ischemic stroke.

Validation of ICD-10 hospital discharge diagnosis codes to identify incident and recurrent ischemic stroke from a US integrated healthcare system

PURPOSE

This study validated incident and recurrent ischemic stroke identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) hospital discharge diagnosis codes.

METHODS

Using electronic health records (EHR) of adults (≥18 years) receiving care from Kaiser Permanente Southern California with ICD-10 hospital discharge diagnosis codes of ischemic stroke (I63.x, G46.3, and G46.4) between October 2015 and September 2020, we identified 75 patients with both incident and recurrent stroke events (total 150 cases). Two neurologists independently evaluated validity of ICD-10 codes through chart reviews.

RESULTS

The positive predictive value (PPV, 95% CI) for incident stroke was 93% (95% CI: 88%, 99%) and the PPV for recurrent stroke was 72% (95% CI: 62%, 82%). The PPV for recurrent stroke improved after applying a gap of 20 days (PPV of 75%; 95% CI: 63%, 87%) or removing hospital admissions related to stroke-related procedures (PPV of 78%; 95% CI: 68%, 88%).

CONCLUSION

The ICD-10 hospital discharge diagnosis codes for ischemic stroke showed a high PPV for incident cases, while the PPV for recurrent cases were less optimal. Algorithms to improve the accuracy of ICD-10 codes for recurrent ischemic stroke may be necessary.

Severe lupus flare is associated with a much higher risk of stroke among patients with SLE

BACKGROUND AND AIM

There are few data on the influence of lupus flare on stroke risk in systemic lupus erythematosus (SLE). In this study, we examined whether a severe lupus flare further increases the risk of stroke among SLE patients.

METHODS

Using the Taiwan's National Health Insurance Research Database, we conducted a retrospective population-based cohort study from 2000 to 2016. Each patient with SLE was matched to a non-SLE subject in age, sex, and index date. A severe flare of lupus was identified when an SLE patient was admitted for pulse therapy with intravenous methylprednisolone greater than 250 mg in a single hospitalization. SLE patients were divided into severe flare and non-severe flare groups.

RESULTS

In total, 334 of 10,006 patients with SLE had a severe lupus flare, and the remaining 9672 patients were assigned to the non-severe flare group. Ischemic stroke occurred in 29 (8.7%), 485 (5%), and 384 (3.8%) of the patients in the severe flare, non-severe flare, and control groups, respectively. Hemorrhagic stroke occurred in 9 (2.7%), 123 (1.3%), and 37 (0.4%) of patients in the severe flare, non-severe flare, and control groups, respectively. Compared with patients in the non-severe flare group, patients with severe flare had a significantly higher risk of ischemic stroke (adjusted hazard ratio (aHR) = 7.44, 95% confidence interval (CI): 4.93-11.25 vs aHR = 1.52, 95% CI: 1.26-1.83) and hemorrhagic stroke (aHR = 22.49, 95% CI: 10.09-50.12 vs aHR = 4.47, 95% CI: 2.90-6.90).

CONCLUSION

Severe lupus flare is associated with a much higher risk of ischemic and hemorrhagic strokes among SLE patients.

Herpes zoster associated with stroke incidence in people living with human immunodeficiency virus: a nested case-control study

BACKGROUND

The incidence of stroke is increasing among younger people with human immunodeficiency virus (HIV). The burden of stroke has shifted toward the young people living with HIV, particularly in low- and middle-income countries. People infected with herpes zoster (HZ) were more likely to suffer stroke than the general population. However, the association of HZ infection with the incidence of stroke among patients with HIV remains unclear.

METHODS

A nested case-control study was conducted with patients with HIV registered in the Taiwan National Health Insurance Research Database in 2000-2017. A total of 509 stroke cases were 1:10 matched to 5090 non-stroke controls on age, sex, and date of first stroke diagnosis. Logistic regression models were used to estimate the odds ratio and 95% confidence intervals (CI) of stroke incidence.

RESULTS

The odds ratio of stroke was significantly higher in the HIV-infected population with HZ (adjusted odds ratio [AOR]: 1.85, 95% CI: 1.42-2.41). A significantly increased AOR of stroke was associated with hypertension (AOR: 3.53, 95% CI: 2.86-4.34), heart disease (AOR: 2.32, 95% CI: 1.54-3.48), chronic kidney disease (AOR: 1.82, 95% CI: 1.16-2.85), hepatitis C virus infection (AOR: 1.49, 95% CI: 1.22-1.83), hyperlipidemia (OR: 1.41, 95% CI: 1.12-1.78), and treatment with protease inhibitors (AOR: 1.33, 95% CI: 1.05-1.69).

CONCLUSIONS

Our findings suggest that HZ concurrent with HIV may increase the risk of stroke. The incidence rates of stroke were independent of common risk factors, suggesting strategies for early prevention of HZ infection among people living with HIV.

Racial and Ethnic Differences in the Risk of Ischemic Stroke After Nontraumatic Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with an increased risk of ischemic stroke. Whether there are racial and ethnic disparities in the risk of ischemic stroke after ICH is poorly understood. We therefore aimed to test the hypothesis that non-Hispanic Black and Hispanic ICH patients have a higher risk of ischemic stroke compared with non-Hispanic White ICH patients.

METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP) on all hospitalizations at all nonfederal hospitals in Florida from 2005 to 2018 and New York from 2006 to 2016. Race and ethnicity were coded as a single variable in HCUP. We included patients with an ICH, and without a prior or concomitant diagnosis of ischemic stroke, ascertained using validated International Classification of Diseases-Clinical Modification-9 and 10 diagnosis codes. Using Cox proportional hazard models, we studied the relationship between race and risk of ischemic stroke starting from the time of discharge from ICH hospitalization, after adjustment of demographics and vascular comorbidities.

RESULTS

We included 91 342 patients with ICH-62% non-Hispanic White, 18% non-Hispanic Black, and 12% Hispanic patients. Non-Hispanic Black and Hispanic patients were younger and had a higher prevalence of cardiovascular comorbidities; however, atrial fibrillation was more prevalent among non-Hispanic White patients. During a median follow-up period of 4.4 years (interquartile range, 1.5-8.1), an incident ischemic stroke occurred in 3377 (6%) non-Hispanic White, 1323 (8%) non-Hispanic Black, and 844 (8%) Hispanic patients. In adjusted Cox models, the risk of an ischemic stroke was significantly higher among non-Hispanic Black patients (hazard ratio, 1.6 [95% CI, 1.5-1.8]) and Hispanic patients (hazard ratio, 1.4 [95% CI, 1.3-1.5]), compared with non-Hispanic White patients. Similar results were obtained in sensitivity analyses when using death as a competing risk and after excluding patients with atrial fibrillation and valvular heart disease.

CONCLUSIONS

In a large heterogeneous cohort of patients with ICH, we found that non-Hispanic Black and Hispanic patients had a significantly higher risk of ischemic stroke compared with non-Hispanic White patients.

Hospital Discharge and Readmissions Before and During the COVID-19 Pandemic for California Acute Stroke Inpatients

BACKGROUND

Acute stroke therapy and rehabilitation declined during the COVID-19 pandemic. We characterized changes in acute stroke disposition and readmissions during the pandemic.

METHODS

We used the California State Inpatient Database in this retrospective observational study of ischemic and hemorrhagic stroke. We compared discharge disposition across a pre-pandemic period (January 2019 to February 2020) to a pandemic period (March to December 2020) using cumulative incidence functions (CIF), and re-admission rates using chi-squared.

RESULTS

There were 63,120 and 40,003 stroke hospitalizations in the pre-pandemic and pandemic periods, respectively. Pre-pandemic, the most common disposition was home [46%], followed by skilled nursing facility (SNF) [23%], and acute rehabilitation [13%]. During the pandemic, there were more home discharges [51%, subdistribution hazard ratio 1.17, 95% CI 1.15-1.19], decreased SNF discharges [17%, subdistribution hazard ratio 0.70, 95% CI 0.68-0.72], and acute rehabilitation discharges were unchanged [CIF, p<0.001]. Home discharges increased with increasing age, with an increase of 8.2% for those ≥85 years. SNF discharges decreased in a similar distribution by age. Thirty-day readmission rates were 12.7 per 100 hospitalizations pre-pandemic compared to 11.6 per 100 hospitalizations during the pandemic [p<0.001]. Home discharge readmission rates were unchanged between periods. Readmission rates for discharges to SNF (18.4 vs. 16.7 per 100 hospitalizations, p=0.003) and acute rehabilitation decreased (11.3 vs. 10.1 per 100 hospitalizations, p=0.034).

CONCLUSIONS

During the pandemic a greater proportion of patients were discharged home, with no change in readmission rates. Research is needed to evaluate the impact on quality and financing of post-hospital stroke care.

Validation of diagnosis codes in healthcare databases in Taiwan, a literature review

PURPOSE

To compile validation findings of diagnosis codes and related algorithms for health outcomes of interest from National Health Insurance (NHI) or electronic medical records in Taiwan.

METHODS

We carried out a literature review of English articles in PubMed® and Embase from 2000 through July 2022 with appropriate search terms. Potentially relevant articles were identified through review of article titles and abstracts, full text search of methodology terms "validation", "positive predictive value", and "algorithm" in Subjects & Methods (or Methods) and Results sections of articles, followed by full text review of potentially eligible articles.

RESULTS

We identified 50 published reports with validation findings of diagnosis codes and related algorithms for a wide range of health outcomes of interest in Taiwan, including cardiovascular diseases, stroke, renal impairment, malignancy, diabetes, mental health diseases, respiratory diseases, viral (B and C) hepatitis, and tuberculosis. Most of the reported PPVs were in the 80% ~ 99% range. Assessment of algorithms based on ICD-10 systems were reported in 8 articles, all published in 2020 or later.

CONCLUSIONS

Investigators have published validation reports that may serve as empirical evidence to evaluate the utility of secondary health data environment in Taiwan for research and regulatory purpose.

Intracranial bleeding and associated outcomes in atrial fibrillation patients undergoing percutaneous left atrial appendage occlusion: Insights from National Inpatient Sample 2016-2020

Background

Percutaneous left atrial appendage occlusion (LAAO) has proved to be a safer alternative for long-term anticoagulation; however, patients with a history of intracranial bleeding were excluded from large randomized clinical trials.

Objective

The purpose of this study was to determine outcomes in atrial fibrillation (AF) patients with a history of intracranial bleeding undergoing percutaneous LAAO.

Methods

National Inpatient Sample and International Classification of Diseases, Tenth Revision, codes were used to identify patients with AF who underwent LAAO during the years 2016-2020. Patients were stratified based on a history of intracranial bleeding vs not. The outcomes assessed in our study included complications, in-hospital mortality, and resource utilization.

Result

A total of 89,300 LAAO device implantations were studied. Approximately 565 implantations (0.6%) occurred in patients with a history of intracranial bleed. History of intracranial bleeding was associated with a higher prevalence of overall complications and in-patient mortality in crude analysis. In the multivariate model adjusted for potential confounders, intracranial bleeding was found to be independently associated with in-patient mortality (adjusted odds ratio [aOR] 4.27; 95% confidence interval [CI] 1.68-10.82); overall complications (aOR 1.74; 95% CI 1.36-2.24); prolonged length of stay (aOR 2.38; 95% CI 1.95-2.92); and increased cost of hospitalization (aOR 1.28; 95% CI 1.08-1.52) after percutaneous LAAO device implantation.

Conclusion

A history of intracranial bleeding was associated with adverse outcomes after percutaneous LAAO. These data, if proven in a large randomized study, can have important clinical consequences in terms of patient selection for LAAO devices.

Antiplatelet use and CADASIL: a retrospective observational analysis

OBJECTIVES

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is hallmarked by age-dependent accumulation of microangiopathy with antiplatelet medications commonly used for stroke prevention though without known therapeutic benefit. Our objective was to identify whether antiplatelet therapy impacted the incidence of acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH) in those with reported CADASIL.

MATERIALS AND METHODS

Owing to the rarity of the disease, we performed a retrospective study of anonymized data from the international TriNetX Research Network (Oct 2015 through January 2021). Individuals had an ICD-10 code (I67.850) for CADASIL. The primary outcome was incidence of validated ICD-10 codes for AIS (I63) and ICH (I61) linked with unique hospital admission encounters. The primary exposure was use of an antiplatelet medication for at least 1 month prior to the primary outcome. Age-adjusted logistic regression was used for likelihood ratios.

RESULTS

We identified 455 individuals: 36% female, 40 (8.8%) antiplatelet exposed. Those with antiplatelet use were older (antiplatelet: 61±12 years vs. unexposed: 57±14 years, p = 0.034) with similar rates of AIS [antiplatelet: 23%(9/40) vs. unexposed: 14%(60/415); p=0.18] and ICH [antiplatelet: 3%(1/40) vs. unexposed: 5%(19/415); p = 0.54) and without significant impact on age-adjusted AIS likelihood (OR 1.62, 95%CI 0.73-3.60, p=0.23). Sample size precluded ICH regression analyses.

CONCLUSIONS

Our data suggests that antiplatelet use did not significantly impact incidence of AIS or ICH within a group of individuals with suspected CADASIL This study highlights the need for further understanding of the pathophysiology of CADASIL to lead to disease modifying treatments.

Do Weight Changes Affect the Association between Smoking Cessation and the Risk of Stroke Subtypes in Korean Males?

(1) Background: We investigated whether weight changes affect the association between smoking cessation and stroke risk; (2) Methods: Overall, 719,040 males were categorized into eight groups according to smoking status (sustained smokers, non-smokers, long-term quitters (quit > 4 years), and recent quitters (quit < 4 years)) and post-cessation weight change (-5 kg, -5.0 to 0.1 kg, maintainers, 0.1-5.0 kg, and >5.0 kg). The hazard ratios (HR) and 95% confidence intervals (CI) for incident total, ischemic, and hemorrhagic strokes, including subarachnoid and intracerebral hemorrhage, were calculated using Cox proportional hazard models; (3) Results: We detected 38,730 strokes (median follow-up, 25.7 years), including 30,609 ischemic and 9055 hemorrhagic strokes. For recent quitters with a >5.0 kg or 0.1-5.0 kg weight increase, maintainers, or those who lost 0.1-5 kg, the multivariable HR for total stroke was 0.73 (95% CI, 0.67-0.79), 0.78 (95% CI, 0.74-0.82), 0.77 (95% CI, 0.69-0.85), 0.84 (95% CI, 0.77-0.90), and 1.06 (95% CI, 0.92-1.23), respectively, compared with that of sustained smokers; (4) Conclusions: Comparable patterns were obtained for stroke subtypes. Thus, we strongly recommend quitting smoking, as weight gain after quitting smoking does not alter the stroke-related benefits.

Outcomes of Transcatheter Aortic Valve Replacement in Patients With Coexisiting Amyloidosis: Mortality, Stroke, and Readmission

Background

Cardiac amyloidosis can coexist in patients with severe aortic stenosis. There are limited outcomes data on whether this impacts the risk of transcatheter aortic valve replacement (TAVR).

Objectives

The authors aimed to investigate the effect of amyloidosis on outcomes of TAVR.

Methods

We used the Nationwide Readmissions Database to identify hospitalizations for TAVR between 2016 and 2019. The presence of a diagnosis of amyloidosis was identified. Propensity score-weighted regression analysis was used to identify the association of amyloidosis with in-hospital mortality, acute ischemic stroke, and 30-day readmission rate after TAVR.

Results

We identified 245,020 hospitalizations for TAVR, including 273 in patients with amyloidosis. The mean age was 79.4 ± 8.4 years. There was no difference in in-hospital mortality or 30-day readmission rate in patients with and without amyloidosis (1.8% vs 1.5%, P = 0.622; and 12.9% vs 12.5%, P = 0.858; respectively). However, there was a higher rate of acute ischemic stroke in patients with amyloidosis (6.2% vs 1.8%, P < 0.001). Propensity score-weighted logistic regression analysis showed the presence of amyloidosis was associated with greater odds of acute ischemic stroke (odds ratio: 3.08, 95% CI: 1.41-6.71, P = 0.005), but no difference in mortality (odds ratio: 0.79, 95% CI: 0.28-2.27, P = 0.666) or 30-day readmission rate after TAVR (HR: 0.72, 95% CI: 0.41-1.25, P = 0.241).

Conclusions

This analysis suggests amyloidosis may be associated with a higher thromboembolic risk after TAVR that merits further investigation.

Long-term risk of seizure after posterior reversible encephalopathy syndrome

OBJECTIVE

Patients with posterior reversible encephalopathy syndrome (PRES) can develop seizures during the acute phase. We sought to determine the long-term risk of seizure after PRES.

METHODS

We performed a retrospective cohort study using statewide all-payer claims data from 2016-2018 from nonfederal hospitals in 11 US states. Adults admitted with PRES were compared to adults admitted with stroke, an acute cerebrovascular disorder associated with long-term risk of seizure. The primary outcome was seizure diagnosed during an emergency room visit or hospital admission after the index hospitalization. The secondary outcome was status epilepticus. Diagnoses were determined using previously validated ICD-10-CM codes. Patients with seizure diagnoses before or during the index admission were excluded. We used Cox regression to evaluate the association of PRES with seizure, adjusting for demographics and potential confounders.

RESULTS

We identified 2095 patients hospitalized with PRES and 341,809 with stroke. Median follow-up was 0.9 years (IQR, 0.3-1.7) in the PRES group and 1.0 years (IQR, 0.4-1.8) in the stroke group. Crude seizure incidence per 100 person-years was 9.5 after PRES and 2.5 after stroke. After adjustment for demographics and comorbidities, patients with PRES had a higher risk of seizure than patients with stroke (HR, 2.9; 95% CI, 2.6-3.4). Results were unchanged in a sensitivity analysis that applied a two-week washout period to mitigate detection bias. A similar relationship was observed for the secondary outcome of status epilepticus.

INTERPRETATION

PRES was associated with an increased long-term risk of subsequent acute care utilization for seizure compared to stroke.

Exploring Stroke Risk Factors and Outcomes in Sexual and Gender Minority People

Background and Objectives

Cerebrovascular disease in sexual and gender minority (SGM) people remains poorly understood. Our primary objective was to describe the epidemiology and outcomes in a sample of SGM people with stroke. As a secondary objective, we compared this group with non-SGM people with stroke to assess for significant differences in risk factors or outcomes.

Methods

This was a retrospective chart review study of SGM people admitted to an urban stroke center with primary diagnosis of stroke (ischemic or hemorrhagic). We evaluated stroke epidemiology and outcomes, summarizing with descriptive statistics. We then matched 1 SGM person to 3 non-SGM people by year of birth and year of diagnosis to compare demographics, risk factors, inpatient stroke metrics, and outcomes.

Results

A total of 26 SGM people were included in the analysis: 20 (77%) had ischemic strokes, 5 (19%) intracerebral hemorrhages, and 1 (4%) subarachnoid hemorrhage. Compared with non-SGM people (n = 78), stroke subtypes showed a similar distribution (64 (82%) ischemic strokes, 12 (15%) intracerebral hemorrhages, 1 (1%) subarachnoid hemorrhage, and 1 nontraumatic subdural hematoma, p > 0.05) but suspected ischemic stroke mechanisms had a different distribution (χ2 = 17.56, p = 0.01). Traditional stroke risk factors were similar between the 2 groups. The SGM group seemed to have higher rates of nontraditional stroke factors, including HIV (31% vs 0%, p < 0.01), syphilis (19% vs 0%, p < 0.01), and hepatitis C (15% vs 5%, p < 0.01) but were more likely to be tested for these risk factors (χ2 = 15.80, p < 0.01; χ2 = 11.65, p < 0.01; χ2 = 7.83, p < 0.01, respectively). SGM people were more likely to have recurrent strokes (χ2 = 4.39, p < 0.04) despite similar follow-up rates.

Discussion

SGM people may have different risk factors, different mechanisms of stroke, and higher risk of recurrent stroke compared with non-SGM people. Standardized collection of sexual orientation and gender identity would enable larger studies to further understand disparities, leading to secondary prevention strategies.

Variation in electroencephalography and neuroimaging for children receiving extracorporeal membrane oxygenation

BACKGROUND

Seizures, strokes, and intracranial hemorrhage are common and feared complications in children receiving extracorporeal membrane oxygenation (ECMO) support. Researchers and clinicians have proposed and deployed methods for monitoring and detecting neurologic injury, but best practices are unknown. We sought to characterize clinicians' approach to electroencephalography (EEG) and brain imaging modalities in children supported by ECMO.

METHODS

We performed a retrospective observational cohort study among US Children's Hospitals participating in the Pediatric Health Information System (PHIS) from 2016 to 2021. We identified hospitalizations containing ECMO support. We stratified these admissions by pediatric, neonatal, cardiac surgery, and non-cardiac surgery. We characterized the frequency of EEG, cranial ultrasound, brain computed tomography (CT), magnetic resonance imaging (MRI), and transcranial Doppler during ECMO hospitalizations. We reported key diagnoses (stroke and seizures) and the prescription of antiseizure medication. To assess hospital variation, we created multilevel logistic regression models.

RESULTS

We identified 8746 ECMO hospitalizations. Nearly all children under 1 year of age (5389/5582) received a cranial ultrasound. Sixty-two percent of the cohort received an EEG, and use increased from 2016 to 2021 (52-72% of hospitalizations). There was marked variation between hospitals in rates of EEG use. Rates of antiseizure medication use (37% of hospitalizations) and seizure diagnoses (20% of hospitalizations) were similar across hospitals, including high and low EEG utilization hospitals. Overall, 37% of the cohort received a CT and 36% received an MRI (46% of neonatal patients). Stroke diagnoses (16% of hospitalizations) were similar between high- and low-MRI utilization hospitals (15% vs 17%, respectively). Transcranial Doppler (TCD) was performed in just 8% of hospitalizations, and 77% of the patients who received a TCD were cared for at one of five centers.

CONCLUSIONS

In this cohort of children at high risk of neurologic injury, there was significant variation in the approach to EEG and neuroimaging in children on ECMO. Despite the variation in monitoring and imaging, diagnoses of seizures and strokes were similar across hospitals. Future work needs to identify a management strategy that appropriately screens and monitors this high-risk population without overuse of resource-intensive modalities.

Positive Predictive Value of Non-Traumatic Bleeding Diagnoses in the Danish National Patient Register

Purpose

The majority of bleeding diagnoses in the Danish National Patient Registry have not been validated despite extensive use in epidemiological research. Therefore, we examined the positive predictive value (PPV) of non-traumatic bleeding diagnoses in the Danish National Patient Registry.

Study Design

Population-based validation study.

Patients and Methods

Based on a manual review of electronic medical records, we estimated the PPV of diagnostic coding (International Classification of Diseases, Tenth Revision (ICD-10)) for non-traumatic bleeding for all patients ≥65 years of age with any hospital contact in the North Denmark Region during March-December 2019 as registered in the Danish National Patient Registry. We calculated PPVs and associated 95% confidence intervals (CI) for non-traumatic bleeding diagnoses overall and stratified according to primary or secondary diagnosis, and according to major anatomical sites.

Results

A total of 907 electronic medical records were available for review. The population mean age was 79.33 years (standard deviation (SD)=7.73) and 57.6% were males. Primary bleeding diagnoses accounted for 766 of the records and 141 were secondary bleeding diagnoses. The overall PPV for bleeding diagnoses was 94.0% (95% CI: 92.3-95.4). The PPV was 98.7% (95% CI: 97.6-99.3) for the primary diagnoses and 68.8% (95% CI: 60.7-75.9) for the secondary diagnoses. When stratified according to subgroups of major anatomical sites, the PPVs ranged between 94.1% and 100% for the primary diagnoses, and between 53.8% and 100% for secondary diagnoses.

Conclusion

The overall validity of non-traumatic bleeding diagnoses in the Danish National Patient Registry is high and considered acceptable for epidemiological research. However, PPVs were substantially higher for primary than for secondary diagnosis.

Risk of Stroke After Posterior Reversible Encephalopathy Syndrome

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) can cause short-term cerebrovascular complications, such as brain infarction and hemorrhage. We hypothesized that PRES is also associated with an increased long-term risk of stroke.

METHODS

We performed a retrospective cohort study in the United States using statewide all-payer claims data from 2016 to 2018 on all admissions to nonfederal hospitals in 11 states. Adults with PRES were compared with adults with renal colic (negative control) and transient ischemic attack (TIA; positive control). Any stroke and the secondary outcomes of ischemic and hemorrhagic stroke were ascertained using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We excluded prevalent stroke. We used time-to-event statistics to calculate incidence rates and Cox proportional hazards analyses to evaluate the association between PRES and stroke, adjusting for demographics and stroke risk factors. In a sensitivity analysis, outcomes within 2 weeks of index admission were excluded.

RESULTS

We identified 1606 patients with PRES, 1192 with renal colic, and 38 216 with TIA. Patients with PRES had a mean age of 56±17 years; 72% were women. Over a median follow-up of 0.9 years, the stroke incidence per 100 person-years was 6.1 (95% CI, 5.0-7.4) after PRES, 1.0 (95% CI, 0.62-1.8) after renal colic, and 9.7 (95% CI, 9.4-10.0) after TIA. After statistical adjustment for patient characteristics and risk factors, patients with PRES had an elevated risk of stroke compared with renal colic (hazard ratio [HR], 2.3 [95% CI, 1.7-3.0]), but lower risk than patients with TIA (HR, 0.67 [95% CI, 0.54-0.82]). In secondary analyses, compared with TIA, PRES was associated with hemorrhagic stroke (HR, 2.0 [95% CI, 1.4-2.9]). PRES was associated with ischemic stroke when compared with renal colic (HR, 1.9 [95% CI, 1.4-2.7]) but not when compared with TIA (HR, 0.49 [95% CI, 0.38-0.63]). Results were similar with 2-week washout.

CONCLUSIONS

Patients with PRES had an elevated risk of incident stroke.

Oral anticoagulant decreases stroke recurrence in patients with atrial fibrillation detected after stroke

Background

Atrial fibrillation detected after stroke (AFDAS) has a lower risk of ischemic stroke recurrence than known atrial fibrillation (KAF). While the benefit of oral anticoagulants (OAC) for preventing ischemic stroke recurrence in KAF is well established, their role in patients with AFDAS is more controversial. This study aimed to evaluate the association between OAC use and the risk of recurrent ischemic stroke in patients with AFDAS in a real-world setting.

Methods

This nationwide retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. Patients hospitalized with a first-ever ischemic stroke and AFDAS confirmed within 30 days after hospitalization were assigned to OAC and non-OAC cohorts. Inverse probability of treatment weighting was applied to balance the baseline characteristics of the cohorts. The primary outcome was ischemic stroke recurrence. Secondary outcomes were intracranial hemorrhage (ICH), death, and the composite outcome of "ischemic stroke recurrence, ICH, or death." Multivariate Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI).

Results

A total of 4,508 hospitalized patients with stroke and AFDAS were identified. Based on OAC use, 2,856 and 1,652 patients were assigned to the OAC and non-OAC groups, respectively. During the follow-up period (median duration, 2.76 years), the OAC cohort exhibited a lower risk of ischemic stroke recurrence (aHR, 0.84; 95% CI, 0.70-0.99), death (aHR, 0.65; 95% CI, 0.58-0.73), and composite outcome (aHR, 0.70; 95% CI, 0.63-0.78) than did the non-OAC cohort. The risk of ICH (aHR, 0.96; 95% CI, 0.62-1.50) was not significantly different between the two cohorts.

Conclusion

OAC use in patients with AFDAS was associated with reduced risk of ischemic stroke recurrence, without an increased risk of ICH. This supports current guidelines recommending OACs for secondary stroke prevention in patients with AF, regardless of the time of diagnosis.

Health benefits of astaxanthin against age-related diseases of multiple organs: A comprehensive review

Age-related diseases are associated with increased morbidity in the past few decades and the cost associated with the treatment of these age-related diseases exerts a substantial impact on social and health care expenditure. Anti-aging strategies aim to mitigate, delay and reverse aging-associated diseases, thereby improving quality of life and reducing the burden of age-related pathologies. The natural dietary antioxidant supplementation offers substantial pharmacological and therapeutic effects against various disease conditions. Astaxanthin is one such natural carotenoid with superior antioxidant activity than other carotenoids, as well as well as vitamins C and E, and additionally, it is known to exhibit a plethora of pharmacological effects. The present review summarizes the protective molecular mechanisms of actions of astaxanthin on age-related diseases of multiple organs such as Neurodegenerative diseases [Alzheimer's disease (AD), Parkinson's disease (PD), Stroke, Multiple Sclerosis (MS), Amyotrophic lateral sclerosis (ALS), and Status Epilepticus (SE)], Bone Related Diseases [Osteoarthritis (OA) and Osteoporosis], Cancers [Colon cancer, Prostate cancer, Breast cancer, and Lung Cancer], Cardiovascular disorders [Hypertension, Atherosclerosis and Myocardial infarction (MI)], Diabetes associated complications [Diabetic nephropathy (DN), Diabetic neuropathy, and Diabetic retinopathy (DR)], Eye disorders [Age related macular degeneration (AMD), Dry eye disease (DED), Cataract and Uveitis], Gastric Disorders [Gastritis, Colitis, and Functional dyspepsia], Kidney Disorders [Nephrolithiasis, Renal fibrosis, Renal Ischemia reperfusion (RIR), Acute kidney injury (AKI), and hyperuricemia], Liver Diseases [Nonalcoholic fatty liver disease (NAFLD), Alcoholic Liver Disease (AFLD), Liver fibrosis, and Hepatic Ischemia-Reperfusion (IR) Injury], Pulmonary Disorders [Pulmonary Fibrosis, Acute Lung injury (ALI), and Chronic obstructive pulmonary disease (COPD)], Muscle disorders (skeletal muscle atrophy), Skin diseases [Atopic dermatitis (ATD), Skin Photoaging, and Wound healing]. We have also briefly discussed astaxanthin's protective effects on reproductive health.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Positive Predictive Value of ICD-10 Codes for Cerebral Venous Sinus Thrombosis in Taiwan's National Health Insurance Claims Database

Objective

This study aims to determine the positive predictive value (PPV) of case definitions for cerebral venous sinus thrombosis (CVST) in Taiwan’s National Health Insurance claims database based on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnostic codes.

Study Design and Setting

Inpatient records with ICD-10-CM codes of G08, I629, I636, or I676 were retrieved from the claims data of all hospital branches of Chang Gung Medical Foundation. Manual review of the medical records and images was performed in order to ascertain the diagnosis. The PPV of various case definitions for CVST was estimated.

Results

Of the 380 hospitalizations, 166 and 214 were determined to be true-positive and false-positive episodes of acute CVST, respectively. The PPV of the ICD-10-CM codes of G08, I629, I636, and I676 was 88.2%, 2.0%, 100.0%, and 91.3%, respectively. The PPV generally increased when acute CVST was defined as a primary diagnosis or as ICD-10-CM codes plus anticoagulant use. Miscoding in other conditions, tentative diagnosis, and remote episode of CVST were determined as the main reasons for false-positive diagnosis of acute CVST.

Conclusion

This study determined the PPV of ICD-10-CM codes for identifying CVST, which may offer a reference for future claims-based research.

Utilization of screening and treatment for osteoporosis among stroke survivors

BACKGROUND

Stroke survivors are prone to osteoporosis and fractures. However, bone mineral density (BMD) testing and osteoporosis treatment were underutilized in patients with recent stroke. We aimed to examine whether stroke has an impact on the utilization of BMD testing and osteoporosis treatment as well as the determinants of their utilization in stroke patients using nationwide population-based data in Taiwan.

METHODS

We identified patients aged 55 years and older who were hospitalized for hemorrhagic or ischemic stroke as the stroke cohort, and age- and sex-matched patients hospitalized for reasons other than stroke, fracture, or fall as the non-stroke cohort. We used the Fine-Gray sub-distribution hazard competing risk regression model to determine the predictors for BMD testing and osteoporosis treatment.

RESULTS

A total of 32997 stroke patients and 32997 age- and sex-matched controls comprised the stroke and non-stroke cohorts, respectively. BMD testing and osteoporosis treatment were performed in 1.0% and 5.2% of the stroke patients, respectively, within one year after hospitalization while these measures were performed in 0.8% and 4.7% of the controls. Stroke patients were more likely to receive BMD testing (adjusted hazard ratio [HR] 1.33; 95% confidence interval [CI] 1.11-1.58) and osteoporosis treatment (adjusted HR 1.19; 95% CI 1.11-1.29). Female sex, osteoporosis, prior BMD testing, and low-trauma fractures after stroke increased the likelihood of using BMD testing and osteoporosis treatment whereas greater stroke severity reduced the likelihood of receiving both measures.

CONCLUSIONS

Both BMD testing and osteoporosis treatment were underutilized among stroke survivors even though they had a higher chance of receiving both measures than non-stroke patients.

Prevalence and Predictors of Stroke in Patients with Crohn's Disease: A Nationwide Study

OBJECTIVES

Mounting evidence points to the microbiome as a susceptibility factor for neurological disorders. Patients with Crohn's disease (CD) are at higher ischemic stroke (IS) risk, but no large scale epidemiologic studies have identified risk factors for stroke in this population.

MATERIALS AND METHODS

We analyzed the 2017 Nationwide Inpatient Sample (NIS) dataset to identify patients with a discharge diagnosis of Crohn's disease using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code K50.X. We identified patients with a primary/secondary discharge diagnosis of IS using ICD-10-CM code I63.X. We compared sociodemographic and clinical variables between stroke and non-stroke patients with CD. Logistic regression analysis was applied to identify factors associated with IS.

RESULTS

Of 30,212 patients with CD, 369 (1.2 %) had a discharge diagnosis of IS. Older age (odds ratio [OR], 1.03 [95% CI, 1.02-1.04], top quartile income (OR, 1.58 [95% CI, 1.10-2.30]), and hospitalization in a South Atlantic (OR, 1.82 [95% CI, 1.11-3.14]), East South Central (OR, 2.30 [95% CI, 1.28-4.25]), or West South Central hospital (OR, 2.40 [95% CI, 1.39-4.28]) were independently associated with IS. Clinical variables independently associated with IS in patients with CD included: atrial fibrillation (OR, 1.66 [95% CI, 1.15-2.33]), atherosclerosis (OR, 2.41 [95% CI, 1.32-4.10]), hyperlipidemia (OR, 1.69 [95% CI, 1.33-2.15]), hypertension (OR, 1.53 [95% CI, 1.18-1.98]) and valvular disease (OR, 1.62 [95% CI, 1.01-2.48).

CONCLUSION

A subset of traditional stroke risk factors are associated with IS in patients with CD. CD patients with these conditions could be targeted for vascular risk reduction and surveillance.

Sex-related disparities in the incidence and outcomes of hemorrhagic stroke among type 2 diabetes patients: a propensity score matching analysis using the Spanish National Hospital Discharge Database for the period 2016-18

Background

To analyze incidence, use of therapeutic procedures, use of oral anticoagulants (OACs) and antiplatelet agents prior to hospitalization, and in-hospital outcomes among patients who were hospitalized with hemorrhagic stroke (HS) according to the presence of type 2 diabetes mellitus (T2DM) in Spain (2016–2018) and to assess the role of sex differences among those with T2DM.

Methods

Using the Spanish National Hospital Discharge Database we estimated the incidence of HS hospitalizations in men and women aged ≥ 35 years with and without T2DM. Propensity score matching (PSM) was used to compare population subgroups according to sex and the presence of T2DM.

Results

HS was coded in 31,425 men and 24,975 women, of whom 11,915 (21.12%) had T2DM. The adjusted incidence of HS was significantly higher in patients with T2DM (both sexes) than in non-T2DM individuals (IRR 1.15; 95% CI 1.12–1.17). The incidence of HS was higher in men with T2DM than in T2DM women (adjusted IRR 1.60; 95% CI 1.57–1.63). After PSM, men and women with T2DM have significantly less frequently received decompressive craniectomy than those without T2DM. In-hospital mortality (IHM) was higher among T2DM women than matched non-T2DM women (32.89% vs 30.83%; p = 0.037), with no differences among men. Decompressive craniectomy was significantly more common in men than in matched women with T2DM (5.81% vs. 3.33%; p < 0.001). IHM was higher among T2DM women than T2DM men (32.89% vs. 28.28%; p < 0.001). After adjusting for confounders with multivariable logistic regression, women with T2DM had a 18% higher mortality risk than T2DM men (OR 1.18; 95% CI 1.07–1.29). Use of OACs and antiplatelet agents prior to hospitalization were associated to higher IHM in men and women with and without T2DM.

Conclusions

T2DM is associated with a higher incidence of HS and with less frequent use of decompressive craniectomy in both sexes, but with higher IHM only among women. Sex differences were detected in T2DM patients who had experienced HS, with higher incidence rates, more frequent decompressive craniectomy, and lower IHM in men than in women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01334-2.