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Leitner MA, Hubert GJ, Paternoster L, Leitner MI, Rémi JM, Trumm C, Haberl RL, Hubert ND. 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. BMJ Open 2024; 14:e071975. [PMID: 38238050 PMCID: PMC10806718 DOI: 10.1136/bmjopen-2023-071975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 11/08/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
- Miriam Antonia Leitner
- Department of Medicine, Ludwig Maximilian University, Munich, Germany
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Laura Paternoster
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Moritz Immanuel Leitner
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Jan Martin Rémi
- Department of Neurology, LMU University Hospital, Munich, Germany
| | - Christoph Trumm
- Institute of Neuroradiology, LMU University Hospital, Munich, Germany
| | - Roman Ludwig Haberl
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
| | - Nikolai Dominik Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Center, München Klinik Harlaching, Academic Teaching Hospital of the Ludwig Maximilian University, Munich, Germany
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Naldi A, Pracucci G, Cavallo R, Saia V, Boghi A, Lochner P, Casetta I, Sallustio F, Zini A, Fainardi E, Cappellari M, Tassi R, Bracco S, Bigliardi G, Vallone S, Nencini P, Bergui M, Mangiafico S, Toni D. Mechanical thrombectomy for in-hospital stroke: data from the Italian Registry of Endovascular Treatment in Acute Stroke. J Neurointerv Surg 2023; 15:e426-e432. [PMID: 36882319 DOI: 10.1136/jnis-2022-019939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The benefit, safety, and time intervals of mechanical thrombectomy (MT) in patients with in-hospital stroke (IHS) are unclear. We sought to evaluate the outcomes and treatment times for IHS patients compared with out-of-hospital stroke (OHS) patients receiving MT. METHODS We analyzed data from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) between 2015 and 2019. We compared the functional outcomes (modified Rankin Scale (mRS) scores) at 3 months, recanalization rates, and symptomatic intracranial hemorrhage (sICH) after MT. Time intervals from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were recorded for both groups, as were door-to-imaging and door-to-groin for OHS. A multivariate analysis was performed. RESULTS Of 5619 patients, 406 (7.2%) had IHS. At 3 months, IHS patients had a lower rate of mRS 0-2 (39% vs 48%, P<0.001) and higher mortality (30.1% vs 19.6%, P<0.001). Recanalization rates and sICH were similar. Time intervals (min, median (IQR)) from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were favorable for IHS (60 (34-106) vs 123 (89-188.5); 150 (105-220) vs 220 (168-294); 227 (164-303) vs 293 (230-370); all P<0.001), whereas OHS had lower door-to-imaging and door-to-groin times compared with stroke onset-to-imaging and onset-to-groin for IHS (29 (20-44) vs 60 (34-106), P<0.001; 113 (84-151) vs 150 (105-220); P<0.001). After adjustment, IHS was associated with higher mortality (aOR 1.77, 95% CI 1.33 to 2.35, P<0.001) and a shift towards worse functional outcomes in the ordinal analysis (aOR 1.32, 95% CI 1.06 to 1.66, P=0.015). CONCLUSION Despite favorable time intervals for MT, IHS patients had worse functional outcomes than OHS patients. Delays in IHS management were detected.
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Affiliation(s)
- Andrea Naldi
- Neurology Unit, Ospedale San Giovanni Bosco, Torino, Piemonte, Italy
| | - Giovanni Pracucci
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Roberto Cavallo
- Neurology Unit, Ospedale San Giovanni Bosco, Torino, Piemonte, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Andrea Boghi
- Radiology and Neuroradiology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, University of the Saarland, Homburg, Germany
| | - Ilaria Casetta
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Fabrizio Sallustio
- Unità di Trattamento Neurovascolare, Ospedale dei Castelli-ASL6, Rome, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Enrico Fainardi
- Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Florence, Italy
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rossana Tassi
- Stroke Unit, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Sandra Bracco
- UO Neurointerventistica, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Guido Bigliardi
- Neurologia/Stroke Unit, Ospedale Civile di Baggiovara, AOU Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiologia, Ospedale Civile di Baggiovara, AOU Modena, Modena, Italy
| | - Patrizia Nencini
- Stroke Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mauro Bergui
- Interventional Neuroradiology Unit, Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS Neuromed, Pozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Chukwudelunzu FE, Demaerschalk B, Fugoso L, Amadi E, Dexter D, Gullicksrud A, Hagen C. In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center. Mayo Clin Proc Innov Qual Outcomes 2023; 7:402-410. [PMID: 37719772 PMCID: PMC10504462 DOI: 10.1016/j.mayocpiqo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Objective To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center. Patients and Methods Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05. Results The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group. Conclusions The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.
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Affiliation(s)
| | - Bart Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Sciences, Phoenix, AZ
| | - Leonardo Fugoso
- Department of Neurology, Mayo Clinic Health System Eau Claire, WI
| | - Emeka Amadi
- Department of Medicine, Section of Hospital Medicine, Mayo Clinic Health System Eau Claire, WI
| | - Donn Dexter
- Department of Neurology, Mayo Clinic Health System Eau Claire, WI
| | | | - Clinton Hagen
- Program for Hypoplastic Left Heart Syndrome, Mayo Clinic, Rochester, MN
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Noda K, Koga M, Toyoda K. Recognition of Strokes in the ICU: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040182. [PMID: 37103061 PMCID: PMC10145112 DOI: 10.3390/jcdd10040182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.
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Affiliation(s)
- Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
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Tongyoo S, Viarasilpa T, Vichutavate M, Permpikul C. Prevalence and independent predictors of in-hospital stroke among patients who developed acute alteration of consciousness in the medical intensive care unit: A retrospective case-control study. South Afr J Crit Care 2023; 39:10.7196/SAJCC.2023.v39i1.558. [PMID: 37521958 PMCID: PMC10378195 DOI: 10.7196/sajcc.2023.v39i1.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/09/2023] [Indexed: 08/01/2023] Open
Abstract
Background In-hospital stroke is a serious event, associated with poor outcomes and high mortality. However, identifying signs of stroke may be more difficult in critically ill patients. Objectives This study investigated the prevalence and independent predictors of in-hospital stroke among patients with acute alteration of consciousness in the medical intensive care unit (MICU) who underwent subsequent brain computed tomography (CT). Methods This retrospective study enrolled eligible patients during the period 2007 - 2017. The alterations researched were radiologically confirmed acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH). Results Of 4 360 patients, 113 underwent brain CT. Among these, 31% had AIS, while 15% had ICH. They had higher diastolic blood pressures and arterial pH than non-stroke patients. ICH patients had higher mean (standard deviation (SD) systolic blood pressures (152 (48) v. 129 (25) mmHg; p=0.01), lower mean (SD) Glasgow Coma Scale scores (4 (3) v. 7 (4); p=0.004), and more pupillary abnormalities (75% v. 9%; p<0.001) than AIS patients. AIS patients were older (65 (18) v. 57 (18) years; p=0.03), had more hypertension (60% v. 39%; p=0.04), and more commonly presented with the Babinski sign (26% v. 9%; p=0.04). Multivariate analysis found that pupillary abnormalities independently predicted ICH (adjusted odds ratio (aOR) 26.9; 95% CI 3.7 - 196.3; p=0.001). The Babinski sign (aOR 5.1; 95% CI 1.1 - 23.5; p=0.04) and alkalaemia (arterial pH >7.4; aOR 3.6; 95% CI 1.0 - 12.3; p=0.05) independently predicted AIS. Conclusion Forty-six percent of the cohort had ICH or AIS. Both conditions had high mortality. The presence of pupillary abnormalities predicts ICH, whereas the Babinski sign and alkalaemia predict AIS. Contributions of the study The present study reports that almost half (46%) of critically ill patients with alterations of consciousness had an acute stroke. Of these, two-thirds had an acute ischaemic stroke (AIS), and one-third had an intracranial haemorrhage (ICH). Multivariate analysis revealed that a pupillary abnormality was a predictor for ICH and the Babinski sign was identified as a predictor of AIS.
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Affiliation(s)
- S Tongyoo
- Faculty of Medicine, Mahidol University; Siriraj Hospital, Bangkoknoi, Bangkok, Thailand
| | - T Viarasilpa
- Faculty of Medicine, Mahidol University; Siriraj Hospital, Bangkoknoi, Bangkok, Thailand
| | - M Vichutavate
- Faculty of Medicine, Mahidol University; Siriraj Hospital, Bangkoknoi, Bangkok, Thailand
| | - C Permpikul
- Faculty of Medicine, Mahidol University; Siriraj Hospital, Bangkoknoi, Bangkok, Thailand
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Wu J, Han G, Sha Y, Tang M, Pan Z, Liu Z, Zhu Y, Zhou L, Ni J. Mechanisms of in-hospital acute ischemic stroke and their relevance to prognosis: A retrospective analysis. J Stroke Cerebrovasc Dis 2023; 32:107105. [PMID: 37054660 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES In-hospital stroke (IHS) is common and has a poor prognosis. Limited data were about the mechanisms of IHS, posing a challenge in taking measures to prevent stroke during hospitalization. This study aims to investigate the mechanisms of IHS and their relevance to prognosis. MATERIALS AND METHODS Patients with in-hospital acute ischemic stroke at Peking Union Medical College Hospital from June 2012 to April 2022 were consecutively enrolled. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification of stroke and detailed mechanisms were evaluated by two experienced neurologists. Functional outcome at discharge was evaluated. RESULTS A total of 204 IHS patients were included, with a median age of 64 (IQR 52-72) and 61.8% male. The most common mechanism was embolism (57.8%), followed by hypoperfusion (42.2%), hypercoagulation (36.3%), small vessel mechanism (19.1%), discontinuation of antithrombotic drugs (13.2%), and iatrogenic injury (9.8%). Iatrogenic injury (P = 0.001), hypoperfusion (P = 0.006), embolism (P = 0.03), and discontinuation of antithrombotic drugs (P = 0.004) were more common in perioperative stroke compared to non-perioperative stroke. Median NIHSS improvement (2 vs 1, P = 0.002) and median mRS improvement (1 vs 0.5, P = 0.02) at discharge were higher in perioperative patients. Advanced age and higher NIHSS at onset were significantly associated with a poorer prognosis, whereas embolism mechanism was associated with a better prognosis. CONCLUSIONS The etiologies and mechanisms of IHS are complex. Perioperative and non-perioperative IHS have different mechanisms and prognostic features. Determining the causes and mechanisms of IHS will help to identify the population at risk and prevent stroke appropriately during hospitalization.
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Affiliation(s)
- Juanjuan Wu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Guangsong Han
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yuhui Sha
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Mingyu Tang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ziang Pan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ziyue Liu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yicheng Zhu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lixin Zhou
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jun Ni
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Riepen B, DeAndrade D, Floyd TF, Fox A. Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality? J Stroke Cerebrovasc Dis 2023; 32:107057. [PMID: 36905744 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/11/2023] Open
Abstract
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.
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Affiliation(s)
- Blair Riepen
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA
| | - Diana DeAndrade
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA
| | - Thomas F Floyd
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA; The Department of Cardiovascular Surgery, The University of Texas Southwestern, Dallas, TX, USA.
| | - Amanda Fox
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA; The McDermott Center for Human Growth and Development / Center for Human Genetics, The University of Texas Southwestern, Dallas, TX, USA
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Iliescu BF, Mancasi VN, Ilie ID, Mancasi I, Costachescu B, Rotariu DI. Design Principle and Proofing of a New Smart Textile Material That Acts as a Sensor for Immobility in Severe Bed-Confined Patients. Sensors (Basel) 2023; 23:2573. [PMID: 36904777 PMCID: PMC10007060 DOI: 10.3390/s23052573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
The immobility of patients confined to continuous bed rest continues to raise a couple of very serious challenges for modern medicine. In particular, the overlooking of sudden onset immobility (as in acute stroke) and the delay in addressing the underlying conditions are of utmost importance for the patient and, in the long term, for the medical and social systems. This paper describes the design principles and concrete implementation of a new smart textile material that can form the substrate of intensive care bedding, that acts as a mobility/immobility sensor in itself. The textile sheet acts as a multi-point pressure-sensitive surface that sends continuous capacitance readings through a connector box to a computer running a dedicated software. The design of the capacitance circuit ensures enough individual points to provide an accurate description of the overlying shape and weight. We describe the textile composition and circuit design as well as the preliminary data collected during testing to demonstrate the validity of the complete solution. These results suggest that the smart textile sheet is a very sensitive pressure sensor and can provide continuous discriminatory information to allow for the very sensitive, real-time detection of immobility.
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Affiliation(s)
- Bogdan Florin Iliescu
- Department of Neurosurgery, “Gr T Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania
| | - Vlad Niki Mancasi
- School of Industrial Design and Business Management, Gh. Asachi University of Iasi, 700050 Iasi, Romania
| | | | | | - Bogdan Costachescu
- Department of Neurosurgery, “Gr T Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania
| | - Daniel Ilie Rotariu
- Department of Neurosurgery, “Gr T Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania
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Messé SR, Kasner SE, Cucchiara BL, McGarvey ML, Cummings S, Acker MA, Desai N, Atluri P, Wang GJ, Jackson BM, Weimer J. Derivation and Validation of an Algorithm to Detect Stroke Using Arm Accelerometry Data. J Am Heart Assoc 2023; 12:e028819. [PMID: 36718858 PMCID: PMC9973644 DOI: 10.1161/jaha.122.028819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Early diagnosis is essential for effective stroke therapy. Strokes in hospitalized patients are associated with worse outcomes compared with strokes in the community. We derived and validated an algorithm to identify strokes by monitoring upper limb movements in hospitalized patients. Methods and Results A prospective case-control study in hospitalized patients evaluated bilateral arm accelerometry from patients with acute stroke with lateralized weakness and controls without stroke. We derived a stroke classifier algorithm from 123 controls and 77 acute stroke cases and then validated the performance in a separate cohort of 167 controls and 33 acute strokes, measuring false alarm rates in nonstroke controls and time to detection in stroke cases. Faster detection time was associated with more false alarms. With a median false alarm rate among nonstroke controls of 3.6 (interquartile range [IQR], 2.1-5.0) alarms per patient per day, the median time to detection was 15.0 (IQR, 8.0-73.5) minutes. A median false alarm rate of 1.1 (IQR. 0-2.2) per patient per day was associated with a median time to stroke detection of 29.0 (IQR, 11.0-58.0) minutes. There were no differences in algorithm performance for subgroups dichotomized by age, sex, race, handedness, nondominant hemisphere involvement, intensive care unit versus ward, or daytime versus nighttime. Conclusions Arm movement data can be used to detect asymmetry indicative of stroke in hospitalized patients with a low false alarm rate. Additional studies are needed to demonstrate clinical usefulness.
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Affiliation(s)
- Steven R. Messé
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
| | - Scott E. Kasner
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
| | | | | | | | | | - Nimesh Desai
- Department of SurgeryUniversity of PennsylvaniaPhiladelphiaPA
| | - Pavan Atluri
- Department of SurgeryUniversity of PennsylvaniaPhiladelphiaPA
| | - Grace J. Wang
- Department of SurgeryUniversity of PennsylvaniaPhiladelphiaPA
| | | | - James Weimer
- Department of Computer and Information ScienceUniversity of PennsylvaniaPhiladelphiaPA
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Fluck D, Fry CH, Rankin S, Gulli G, Affley B, Robin J, Kakar P, Sharma P, Han TS. Comparison of characteristics, management and outcomes in hospital-onset and community-onset stroke: a multi-centre registry-based cohort study of acute stroke. Neurol Sci 2022; 43:4853-4862. [PMID: 35322338 PMCID: PMC9349089 DOI: 10.1007/s10072-022-06015-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 11/28/2022]
Abstract
Abstract
Objective
Hospital-onset stroke (HOS) is associated with poorer outcomes than community-onset stroke (COS). Previous studies have variably documented patient characteristics and outcome measures; here, we compare in detail characteristics, management and outcomes of HOS and COS.
Methods
A total of 1656 men (mean age ± SD = 73.1 years ± 13.2) and 1653 women (79.3 years ± 13.0), with data prospectively collected (2014–2016) from the Sentinel Stroke National Audit Programme, were admitted with acute stroke in four UK hyperacute stroke units (HASU). Associations between variables were examined by chi-squared tests and multivariable logistic regression (COS as reference).
Results
There were 272 HOS and 3037 COS patients with mean ages of 80.2 years ± 12.5 and 76.4 years ± SD13.5 and equal sex distribution. Compared to COS, HOS had higher proportions ≥ 80 years (64.0% vs 46.4%), congestive heart failure (16.9% vs 4.9%), atrial fibrillation (25.0% vs 19.7%) and pre-stroke disability (9.6% vs 5.1%), and similar history of stroke, hypertension, diabetes, stroke type and severity of stroke. After age, sex and co-morbidities adjustments, HOS had greater risk of pneumonia: OR (95%CI) = 1.9 (1.3–2.6); malnutrition: OR = 2.2 (1.7–2.9); immediate thrombolysis complications: OR = 5.3 (1.5–18.2); length of stay on HASU > 3 weeks: OR = 2.5 (1.8–3.4); post-stroke disability: OR = 1.8 (1.4–2.4); and in-hospital mortality: OR = 1.8 (1.2–2.4), as well as greater support at discharge including palliative care: OR = 1.9 (1.3–2.8); nursing care: OR = 2.0 (1.3–4.0), help for daily living activities: OR = 1.6 (1.1–2.2); and joint-care planning: OR = 1.5 (1.1–1.9).
Conclusions
This detailed analysis of underlying differences in subject characteristics between patients with HOS or COS and adverse consequences provides further insights into understanding poorer outcomes associated with HOS.
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Affiliation(s)
- David Fluck
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Christopher H. Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD UK
| | - Suzanne Rankin
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Giosue Gulli
- Department of Stroke, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Brendan Affley
- Department of Stroke, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
| | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom, KT18 7EG UK
| | - Pankaj Sharma
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London, W6 8RF UK
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX UK
| | - Thang S. Han
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, TW20 0EX UK
- Department of Endocrinology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, GU9 0PZ UK
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11
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Liu ZY, Han GS, Wu JJ, Sha YH, Hong YH, Fu HH, Zhou LX, Ni J, Zhu YC. Comparing characteristics and outcomes of in-hospital stroke and community-onset stroke. J Neurol 2022; 269:5617-5627. [PMID: 35780193 DOI: 10.1007/s00415-022-11244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/17/2022] [Accepted: 06/18/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Zi-Yue Liu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Guang-Song Han
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Juan-Juan Wu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yu-Hui Sha
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yue-Hui Hong
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Han-Hui Fu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Li-Xin Zhou
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jun Ni
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Yi-Cheng Zhu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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12
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Marto JP, Salerno A, Maslias E, Lambrou D, Eskandari A, Strambo D, Michel P. Stroke in the Stroke Unit: Recognition, treatment and outcomes in a single-center cohort. Eur J Neurol 2022; 29:2674-2682. [PMID: 35608958 DOI: 10.1111/ene.15415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND In-hospital strokes (IHS) are associated with longer diagnosis times, treatment delays, and poorer outcomes. Strokes occurring in the stroke unit have seldom been studied. Our aim was to assess the management of in-stroke unit ischemic stroke (ISUS) by analyzing ISUS characteristics, delays in diagnosis, treatments and outcomes. METHODS Consecutive patients from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) registry, from January-2003 to June-2019, were classified as ISUS, other-IHS or community-onset stroke (COS). Baseline and stroke characteristics, time-to-imaging and -to treatment, missed treatment opportunities, treatment rates and outcomes were compared using multivariate analysis with adjustment for relevant clinical, imaging and laboratory data available in ASTRAL. RESULTS Among the 3456 patients analyzed, 138 (4.0%) were ISUS, 214 (6.2%) other-IHS and 3104 (89.8%) COS. In multivariate analysis, patients with ISUS more frequently had known stroke onset-time than other-IHS (adjusted odds ratio [aOR] 2.44; 95% confidence interval [CI] 1.39-4.35) or COS (aOR 2.56; 95%CI 1.59-4.17), had less missed treatment opportunities than other-IHS (aOR 0.22; 95%CI 0.06-0.86) and higher endovascular treatment rates than COS (aOR 3.03; 95%CI 1.54-5.88). ISUS were associated with a favorable shift in the modified Rankin Scale at 3-months in comparison with other-IHS (aOR 1.73; 95%CI, 1.11-2.69) or COS (aOR 1.46; 95%CI, 1.00-2.12). CONCLUSION ISUS more frequently had known stroke onset-time than other-IHS or COS, less missed treatment opportunities than other-IHS and a higher endovascular treatment rate than COS. This readiness to identify and treat patients in the stroke unit may explain the better long-term outcome of ISUS.
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Affiliation(s)
- João Pedro Marto
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland.,Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Alexander Salerno
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Errikos Maslias
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Dimitris Lambrou
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Ashraf Eskandari
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Centre, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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13
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Nouh A, Amin-Hanjani S, Furie KL, Kernan WN, Olson DM, Testai FD, Alberts MJ, Hussain MA, Cumbler EU. Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association. Stroke 2022; 53:e165-e175. [PMID: 35137601 DOI: 10.1161/str.0000000000000402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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14
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Cummings S, Kasner SE, Mullen M, Olsen A, McGarvey M, Weimer J, Jackson B, Desai N, Acker M, Messé SR. Delays in the Identification and Assessment of in-Hospital Stroke Patients. J Stroke Cerebrovasc Dis 2022; 31:106327. [PMID: 35123276 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/07/2022] [Accepted: 01/15/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Stephanie Cummings
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Mullen
- Department of Neurology, Temple University Hospital, Philadelphia, PA, United States
| | - Andrew Olsen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael McGarvey
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - James Weimer
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Ben Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States.
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15
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Jeon SB, Lee HB, Koo YS, Lee H, Lee JH, Park B, Choi SH, Jeong S, Chang JY, Hong SB, Lim CM, Lee SA. Neurological Emergencies in Patients Hospitalized With Nonneurological Illness. J Patient Saf 2021; 17:e1332-e1340. [PMID: 32398541 DOI: 10.1097/pts.0000000000000682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We aimed to present neurological profiles and clinical outcomes of patients with acute neurological symptoms, which developed during hospitalization with nonneurological illness. METHODS We organized the neurological alert team (NAT), a neurological rapid response team, to manage in-hospital neurological emergencies. In this registry-based study, we analyzed the clinical profiles and outcomes of patients who were consulted to the NAT. We also compared the 3-month mortality of patients with acute neurological symptoms with that of patients without acute neurological symptoms. RESULTS Among the 85,507 adult patients, 591 (0.7%) activated the NAT. The most common reason for NAT activation was stroke symptoms (37.6%), followed by seizures (28.6%), and sudden unresponsiveness (24.0%). The most common diagnosis by the NAT neurologists was metabolic encephalopathy (45.5%), followed by ischemic stroke (21.2%) and seizures or status epilepticus (21.0%). Patients with NAT activation had high rates in mortality before hospital discharge (22.5%) and at 3 months (34.7%), transfer to intensive care units (39.6%), and length of hospital stay (43.1 ± 57.1 days). They also had high prevalence of poor functional status (78.1%) and recurrence of neurological symptoms at 3 months (27.2%). In a Cox proportional hazards model, patients with in-hospital neurological emergencies had a hazard ratio of 13.2 in terms of mortality at 3 months (95% confidence interval, 11.5-15.3; P < 0.001). CONCLUSIONS Occurrence of acute neurological symptoms during hospital admission was associated with high rate of mortality and poor functional status. These results call for enhanced awareness and hospital-wide strategies for managing in-hospital neurological emergencies.
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Affiliation(s)
- Sang-Beom Jeon
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
| | - Han-Bin Lee
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
| | - Yong Seo Koo
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyunjo Lee
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
| | | | - Bobin Park
- Department of Nursing, Asan Medical Center
| | | | - Suyeon Jeong
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
| | - Jun Young Chang
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ahm Lee
- From the Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine
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16
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Chukwudelunzu FE, Demaerschalk BM, Fugoso L, Amadi E, Dexter D, Gullicksrud A, Hagen C. In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience. Neurohospitalist 2021; 11:326-332. [PMID: 34567393 DOI: 10.1177/19418744211007001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and purpose In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.
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Affiliation(s)
| | - Bart M Demaerschalk
- Department of Neurology. Mayo Clinic College of Medicine and Science, Phoenix, USA
| | - Leonardo Fugoso
- Department of Neurology, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Emeka Amadi
- Department of Hospital Medicine, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Donn Dexter
- Department of Neurology, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Angela Gullicksrud
- Department of Neurology, Mayo Clinic Health System Eau Claire, Wisconsin, USA
| | - Clinton Hagen
- Program for Hypoplastic Left Heart Syndrome, Mayo Clinic Rochester Minnesota, MN Minnesota, USA
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17
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Qiu K, Zu QQ, Zhao LB, Liu S, Shi HB. Outcomes between in-hospital stroke and community-onset stroke after thrombectomy: Propensity-score matching analysis. Interv Neuroradiol 2021; 28:296-301. [PMID: 34516327 DOI: 10.1177/15910199211030769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The benefit of endovascular thrombectomy for patients with in-hospital stroke remains unclear. Thus, the aim of this study was to compare the endovascular thrombectomy outcomes between in-hospital stroke and community-onset stroke among patients with acute ischemic stroke. METHODS From January 2015 to July 2019, 362 consecutive patients with acute ischemic stroke with large vessel occlusion in the anterior circulation received endovascular thrombectomy in our centre. After propensity score matching with a ratio of 1:2 (in-hospital stroke:community-onset stroke), clinical characteristics and functional outcomes were compared between in-hospital stroke and community-onset stroke groups. RESULTS Thirty-six patients with in-hospital stroke and 72 patients with community-onset stroke were enrolled. The number of patients with New York Heart Association classification III/IV (41.7% vs. 6.9%, p < 0.001) and with underlying cancer (25.0% vs. 2.8%, p < 0.001) was higher in the in-hospital stroke than in the community-onset stroke group. The intravenous thrombolysis rate was lower in the in-hospital stroke group (13.9% vs. 43.1%, p = 0.002). No significant difference in symptom onset to puncture (p = 0.618), symptom onset to recanalisation (p = 0.618) or good reperfusion (modified thrombolysis in cerebral infarction ≥2b) rates (p = 0.852) was found between the groups. The favourable clinical outcome trend (modified Rankin scale ≤2 at 90 days) was inferior, but acceptable, in the in-hospital stroke, group compared to the community-onset stroke group (30.6% vs. 41.7%, p = 0.262). CONCLUSION Patients with in-hospital stroke had more disadvantageous comorbidities than those with community-onset stroke. Cardiac dysfunction seems to be associated with poor outcomes after thrombectomy. Nevertheless, endovascular thrombectomy still appears to be safe and effective for patients with in-hospital stroke.
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Affiliation(s)
- Kai Qiu
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, China
| | - Qing-Quan Zu
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, China
| | - Sheng Liu
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, China
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18
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Sierra-Hidalgo F, Aragón Revilla E, Arranz García P, Martínez-Acebes E, Gómez-Moreno SM, Muñoz-Rivas N, Esquivel López A. Increased Incidence of In-Hospital Ischemic Stroke During SARS-CoV-2 Outbreak: A Single-Center Study. Neurocrit Care 2021; 36:208-215. [PMID: 34268645 PMCID: PMC8281805 DOI: 10.1007/s12028-021-01286-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Fernando Sierra-Hidalgo
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain.
| | - Esther Aragón Revilla
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Paz Arranz García
- Department of Medical Administration, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Eva Martínez-Acebes
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Sonia Mayra Gómez-Moreno
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Department of Internal Medicine, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Alberto Esquivel López
- Department of Neurology, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
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Brunser A, Navia V V, Araneda P, Mazzon E, Muñoz P, Cavada G, Olavarría VV, Lavados PM. In-Hospital Acute Ischemic Stroke is Associated with Worse Outcome: Experience of a Single Center in Santiago Chile. J Stroke Cerebrovasc Dis 2021; 30:105894. [PMID: 34116490 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105894] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/05/2021] [Accepted: 05/08/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES In-hospital acute ischemic stroke (HIS) accounts for 2-17% of all acute ischemic strokes (AIS) seen in hospital and they have worse prognosis. In this study we aimed to identify the frequency of HIS and their characteristics in our center. MATERIALS AND METHODS Retrospective analysis of a prospective register of patients with AIS seen at Clínica Alemana de Santiago, between January 2017 and January 2019. HIS and community onset ischemic strokes patients (CIS) were compared, univariate analysis was performed, covariates with p < 0.25 were selected for multivariate analysis. Differences between, proportion of strokes treated with thrombolytic therapy, door to needle time were compared between HIS and CIS patients, as also mortality rates at 90 days. RESULTS During the study period 369 patients with AIS were seen; of these 20 (5.4%, 95 CI%, 3.5-8.2) corresponded to HIS. In univariate analysis, HIS compared to patients arriving form the community to the emergency room, suffered more frequently from, heart failure (p = 0.04), and active malignancies (p < 0.001). HIS patients had longer times from symptom onset to non-contrast brain tomography (540 ±150 minutes); they were also less frequently treated with intravenous thrombolysis compared to community AIS: 15% versus 30% respectively (p = 0.08). Mortality rates at 90 days were higher in HIS: 30 versus 5% (p = 0.001). CONCLUSIONS In this cohort, HIS patients suffered delays in their neuroimaging studies and received less intravenous thrombolysis; this underscores the need for a standardized approach to the recognition and management of inhospital acute ischemic stroke.
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20
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Sase T, Onodera H, Kaji T, Nakamura H, Sakakibara Y, Tanaka Y. Status of In-Hospital Acute Ischemic Stroke Treated by Mechanical Thrombectomy. J Neuroendovasc Ther 2021; 15:763-771. [PMID: 37502007 PMCID: PMC10370938 DOI: 10.5797/jnet.oa.2020-0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 02/04/2021] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Taigen Sase
- Department of Neurosurgery, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Tomohiro Kaji
- Department of Neurosurgery, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Homare Nakamura
- Department of Neurosurgery, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Yohtaro Sakakibara
- Department of Neurosurgery, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Yuichiro Tanaka
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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21
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Pines AR, Das DM, Bhatt SK, Shiue HJ, Dawit S, Vanderhye VK, Sands KA. Identifying and Addressing Barriers to Systemic Thrombolysis for Acute Ischemic Stroke in the Inpatient Setting: A Quality Improvement Initiative. Mayo Clin Proc Innov Qual Outcomes 2020; 4:657-666. [PMID: 33367211 PMCID: PMC7749238 DOI: 10.1016/j.mayocpiqo.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives To identify barriers to inpatient alteplase administration and implement an interdisciplinary program to reduce time to systemic thrombolysis. Patients and Methods Compared with patients presenting to the emergency department with an acute ischemic stroke (AIS), inpatients are delayed in receiving alteplase for systemic thrombolysis. Institutional AIS metrics were extracted from the electronic medical records of patients presenting as an inpatient stroke alert. All patients who received alteplase for AIS were included in the analysis. A gap analysis was used to assess institutional deficiencies. An interdisciplinary intervention was initiated to address these deficiencies. Efficacy was measured with pre- and postintervention surveys and institutional AIS metric analysis. Statistical significance was determined using the Student t test. We identified 5 patients (mean age, 73 years; 100% (5/5) male; 80% (4/5) white) who met inclusion criteria for the preintervention period (January 1, 2017, to December 31, 2017) and 10 patients (mean age, 71 years; 50% male; 80% white) for the postintervention period (October 31, 2018, to July 1, 2020). Results We found barriers to rapid delivery of thrombolytic treatment to include alteplase availability and comfort with bedside reconstitution. Interdisciplinary intervention strategies consisted of stocking alteplase on additional floors as well as structured education and hands-on alteplase reconstitution simulations for resident physicians. The mean time from stroke alert to thrombolysis was shorter postintervention than preintervention (57.4 minutes vs 77.8 minutes; P=.03). Conclusion A coordinated interdisciplinary approach is effective in reducing time to systemic thrombolysis in patients experiencing AIS in the inpatient setting. A similar program could be implemented at other institutions to improve AIS treatment.
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Key Words
- AHA, American Heart Association
- AIS, acute ischemic stroke
- AMDC, automated medication dispensing cabinet
- CT, computerized tomography
- DTB, decision-to-treat-to-bolus
- ED, emergency department
- EMR, electronic medical record
- IV, intravenous
- NIHSS, National Institutes of Health Stroke Scale
- PCCU, progressive cardiac care unit
- RN, registered nurse
- RRN, rapid response nurse
- STN, stroke-alert-to-needle
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Affiliation(s)
- Andrew R Pines
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Devika M Das
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Shubhang K Bhatt
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Harn J Shiue
- Department of Pharmacy, Mayo Clinic, Phoenix, AZ
| | - Sara Dawit
- Department of Neurology, Mayo Clinic, Phoenix, AZ
| | | | - Kara A Sands
- Department of Neurology, Mayo Clinic, Phoenix, AZ
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Abstract
Coronavirus disease 2019 (COVID-19) is a novel infection of which we still have much to learn. Microvascular and macrovascular complications are increasingly recognised as being among the drivers of morbidity and mortality in patients with this condition. Here we present a case of a woman with COVID-19 who suffered massive and bilateral middle cerebral artery strokes, which presented as reduced consciousness several days into admission. Clinicians need to be aware of possible causes of reduced consciousness in COVID-19 patients, particularly as delirium appears to be a common complication, and revisit working diagnoses if the clinical picture does not fully fit. Studies into both anticoagulation and the management of stroke in the context of COVID-19 are urgently needed to help inform future practice.
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Affiliation(s)
| | - Laura Balson
- Respiratory Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shyam Madathil
- Respiratory Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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23
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Jo S, Chang JY, Jeong S, Jeong S, Jeon SB. Newly developed stroke in patients admitted to non-neurological intensive care units. J Neurol 2020; 267:2961-70. [PMID: 32488294 DOI: 10.1007/s00415-020-09955-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about newly developed stroke in patients admitted to the intensive care unit (ICU). OBJECTIVE This study aimed to investigate characteristics and outcomes of newly developed stroke in patients admitted to the non-neurological intensive care units (ICU-onset stroke, IOS). METHODS A consecutive series of adult patients who were admitted to the non-neurological ICU were included in this study. We compared neurological profiles, risk factors, and mortality rates between patients with IOS and those without IOS. RESULTS Of 18,604 patients admitted to the ICU for non-neurological illness, 218 (1.2%) developed stroke (ischemic, n = 182; hemorrhagic, n = 36). The most common neurological presentation was altered mental status (n = 149), followed by hemiparesis (n = 55), and seizures (n = 28). The most common etiology of IOS was cardioembolism (50% [91/182]) for ischemic IOS and coagulopathy (67% [24/36]) for hemorrhagic IOS. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (adjusted odds ratio [AOR] = 1.04, 95% CI = 1.03-1.06, P < 0.001), prothrombin time (AOR = 0.99, 95% CI = 0.98-0.99, P = 0.013), cardiovascular surgery (AOR = 1.84, 95% CI = 1.34-2.50, P < 0.001), mechanical ventilation (AOR = 6.75, 95% CI = 4.87-9.45, P < 0.001), and extracorporeal membrane oxygenation (AOR = 2.77, 95% CI = 1.62-4.55, P < 0.001) were related to the development of IOS. Stroke was associated with increased 3-month mortality after hospital discharge (AOR, 2.20; 95% CI, 1.58-3.05; P < 0.001), after adjustment for APACHE II and comorbidities. CONCLUSIONS Patients who developed IOS had characteristics of initial critical illness and managements performed in the ICU as well as neurological presentations. The occurrence of IOS was related to high morbidity and mortality.
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Topiwala K, Tarasaria K, Staff I, Beland D, Schuyler E, Nouh A. Identifying Gaps and Missed Opportunities for Intravenous Thrombolytic Treatment of Inpatient Stroke. Front Neurol 2020; 11:134. [PMID: 32161567 PMCID: PMC7054244 DOI: 10.3389/fneur.2020.00134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background: Inpatient stroke-codes (ISC) have traditionally seen low treatment rates with IV-thrombolytic (IVT). The purpose of this study was to identify the predictors of true stroke, prevalent IVT-treatment gap and study the factors associated with such missed treatment opportunities (MTO). Methods: A retrospective chart review identified ISC from March 2017 to March 2018. Clinical, radiographic and demographic data were collected. Primary analysis was performed between stroke vs. non-stroke diagnoses. Dichotomous variables were analyzed using Chi-Square test of proportions and continuous variables with Wilcoxon-Ranked-Sum test. Significant factors were then tested in a multivariate logistic regression model for independence. Results: From 211 ISC, 36% (n = 76) had an acute stroke. Hemorrhagic stroke (HS) was present in 5.7% (n = 12). Of the remaining 199, 44% (n = 87) were IVT-eligible but only 3.4% (n = 3) were treated. Of the remaining 84 IVT-eligible-but-untreated patients, 69(82.1%) were mimics, while 15 (17.9%) had an ischemic stroke (IS), constituting a MTO of 1 in 6 IVT-eligible patients, with National Institutes of Health Stroke Scale (NIHSS) ≤4 being the commonest deterrent. Independent predictors of stroke were ejection fraction (EF) <30% (p = 0.030, OR = 3.06), post-operative status (p = 0.001, OR = 3.71), visual field-cut (p = 0.008, OR = 3.70), and facial droop (p = 0.010, OR = 2.59). Conclusion: In our study, one in three ISC were true strokes. IVT treatment rates were low with a MTO of 1 in 6 IVT-eligible patients. The most common reason for not treating was NIHSS ≤4. Knowing predictors of true stroke and the common barriers to IVT treatment can help narrow this treatment gap.
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Affiliation(s)
- Karan Topiwala
- Department of Neurology, University of Connecticut, Farmington, CT, United States
| | - Karan Tarasaria
- Department of Neurology, University of Connecticut, Farmington, CT, United States
| | - Ilene Staff
- Department of Research, Hartford Hospital, Hartford, CT, United States
| | - Dawn Beland
- Department of Neurology, Ayer Neuroscience Institute, Hartford, CT, United States
| | - Erica Schuyler
- Department of Neurology, University of Connecticut, Farmington, CT, United States.,Department of Neurology, Ayer Neuroscience Institute, Hartford, CT, United States
| | - Amre Nouh
- Department of Neurology, University of Connecticut, Farmington, CT, United States.,Department of Neurology, Ayer Neuroscience Institute, Hartford, CT, United States
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25
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Sano T, Kobayashi K, Ichikawa T, Hakozaki K, Tanemura H, Ishigaki T, Miya F. In-hospital Ischemic Stroke Treated by Mechanical Thrombectomy. JNET 2020; 14:133-140. [PMID: 37520171 PMCID: PMC10374366 DOI: 10.5797/jnet.oa.2019-0048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Takanori Sano
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Kazuto Kobayashi
- Department of Neurology, Ise Red Cross Hospital, Ise, Mie, Japan
| | | | - Koichi Hakozaki
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Hiroshi Tanemura
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Tomoki Ishigaki
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Fumitaka Miya
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
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26
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Yang SJ, Franco T, Wallace N, Williams B, Blackmore C. Effectiveness of an Interdisciplinary, Nurse Driven In-Hospital Code Stroke Protocol on In-Patient Ischemic Stroke Recognition and Management. J Stroke Cerebrovasc Dis 2019; 28:104398. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/13/2019] [Accepted: 09/08/2019] [Indexed: 11/15/2022] Open
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27
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Del Brutto VJ, Ardelt A, Loggini A, Bulwa Z, El-Ammar F, Martinez RC, Brorson J, Goldenberg F. Clinical Characteristics and Emergent Therapeutic Interventions in Patients Evaluated through the In-hospital Stroke Alert Protocol. J Stroke Cerebrovasc Dis 2019; 28:1362-1370. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022] Open
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28
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Cadilhac DA, Kilkenny MF, Lannin NA, Dewey HM, Levi CR, Hill K, Grabsch B, Grimley R, Blacker D, Thrift AG, Middleton S, Anderson CS, Donnan GA. Outcomes for Patients With In-Hospital Stroke: A Multicenter Study From the Australian Stroke Clinical Registry (AuSCR). J Stroke Cerebrovasc Dis 2019; 28:1302-1310. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 11/25/2022] Open
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Abstract
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.
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Affiliation(s)
- Shuo Chen
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ravinder-Jeet Singh
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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30
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Abstract
Purpose A major component of hospital stroke care involves prompt identification of stroke in admitted patients. Delays in recognizing stroke symptoms and initiating treatment for in-hospital stroke can adversely impact patient outcomes. This quality improvement intervention used simulation together with a traditional lecture to instruct nurses at a university hospital about a new stroke protocol being implemented to increase rapid recognition of stroke and meet Joint Commission National Hospital Inpatient Quality Measures. The paper aims to discuss these issues. Design/methodology/approach In total, 86 registered nurses from the neurology and cardiology units attended a lecture and participated in a simulation scenario with a standardized patient exhibiting stroke symptoms. Participants completed a ten-item pre-test to measure their knowledge of stroke care prior to the lecture; they repeated the test pre-simulation and once again post-simulation to evaluate changes in knowledge. Findings Overall mean stroke knowledge scores increased significantly from pre-lecture to pre-simulation, and from pre-simulation to post-simulation. Simulation plus lecture was more effective than lecture alone in increasing knowledge about hospital stroke protocol despite assigned unit (cardiology or neurology), years of experience, or previous exposure to simulation. Research limitations/implications All eligible nurses who agreed to participate received training, making it impossible to compare improvements in knowledge to those who did not receive the training. Originality/value A diverse array of nursing professionals and their patients may benefit from simulation training. This quality improvement intervention provides a feasible model for establishing new care protocols in a hospital setting.
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Affiliation(s)
- Johis Ortega
- School of Nursing and Health Studies, University of Miami , Florida, USA
| | - Juan M Gonzalez
- School of Nursing and Health Studies, University of Miami , Florida, USA
| | - Lila de Tantillo
- School of Nursing and Health Studies, University of Miami , Florida, USA
| | - Karina Gattamorta
- School of Nursing and Health Studies, University of Miami , Florida, USA
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31
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Tsivgoulis G, Katsanos AH, Kadlecová P, Czlonkowska A, Kobayashi A, Brozman M, Švigelj V, Csiba L, Fekete K, Kõrv J, Demarin V, Vilionskis A, Jatuzis D, Krespi Y, Karapanayiotides T, Giannopoulos S, Mikulik R. Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry. Eur J Neurol 2017; 24:1493-1498. [PMID: 28888075 DOI: 10.1111/ene.13450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/04/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry. METHODS We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality. RESULTS Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273). CONCLUSIONS Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.
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Affiliation(s)
- G Tsivgoulis
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,International Clinical Research Center and Neurology Department, St Anne's Hospital, Brno, Czech Republic
| | - A H Katsanos
- Second Department of Neurology, 'Attikon' Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Ioannina, Ioannina, Greece
| | - P Kadlecová
- International Clinical Research Center and Neurology Department, St Anne's Hospital, Brno, Czech Republic
| | - A Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw
| | - A Kobayashi
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw.,Department of Neuroradiology, Interventional Stroke and Cerebrovascular Disease Treatment Centre, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - M Brozman
- Department of Neurology, Faculty Hospital Nitra, Constantine University Nitra, Nitra, Slovakia
| | - V Švigelj
- Department of Vascular Neurology and Neurological Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - L Csiba
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - K Fekete
- Department of Neurology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - J Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - V Demarin
- Department of Neurology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | - A Vilionskis
- Department of Neurology and Neurosurgery, Vilnius University and Republican Vilnius University Hospital, Vilnius
| | - D Jatuzis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Y Krespi
- Neurology Department and Stroke Center, Memorial Sisli Hospital Istanbul, Istanbul, Turkey
| | - T Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - S Giannopoulos
- Department of Neurology, University of Ioannina, Ioannina, Greece
| | - R Mikulik
- International Clinical Research Center and Neurology Department, St Anne's Hospital, Brno, Czech Republic.,Medical Faculty of Masaryk University, Brno, Czech Republic
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Marszalek J, Mehrsefat S, Chi G. The risk of stroke among acutely ill hospitalized medical patients: lessons from recent trials on extended-duration thromboprophylaxis. Expert Rev Hematol 2017; 10:679-684. [PMID: 28617144 DOI: 10.1080/17474086.2017.1343662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Data from recent randomized controlled trials indicate that the incidence of stroke among acutely ill medical patients is unexpectedly high and approximates 1% at 90 days. Preliminary data suggest that betrixaban may reduce ischemic stroke in patients without atrial fibrillation. There is an unmet demand for stroke risk stratification schemes targeting hospitalized medical patients. The prognostic value of biomarkers such as natriuretic peptides and D-dimer in predicting short-term stroke remains uncertain. Future research should focus on identifying the high-risk subsets in which the benefit of anticoagulation significantly outweighs the associated hemorrhagic risk. Clinical trials: NCT00457002, NCT00571649, NCT01583218.
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Affiliation(s)
- Jolanta Marszalek
- a Department of Neurology , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Sara Mehrsefat
- b Division of Pulmonary and Critical Care Medicine , Johns Hopkins University , Baltimore , MD , USA
| | - Gerald Chi
- c Division of Cardiovascular Medicine, Department of Medicine , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , MA , USA
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Natteru P, Mohebbi MR, George P, Wisco D, Gebel J, Newey CR. Variables That Best Differentiate In-Patient Acute Stroke from Stroke-Mimics with Acute Neurological Deficits. Stroke Res Treat 2016; 2016:4393127. [PMID: 28050311 DOI: 10.1155/2016/4393127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/13/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction. Strokes and stroke-mimics have been extensively studied in the emergency department setting. Although in-hospital strokes are less studied in comparison to strokes in the emergency department, they are a source of significant direct and indirect costs. Differentiating in-hospital strokes from stroke-mimics is important. Thus, our study aimed to identify variables that can differentiate in-hospital strokes from stroke-mimics. Methods. We present here a retrospective analysis of 93 patients over a one-year period (2009 to 2010), who were evaluated for a concern of in-hospital strokes. Results. About two-thirds (57) of these patients were determined to have a stroke, and the remaining (36) were stroke-mimics. Patients with in-hospital strokes were more likely to be obese (p = 0.03), have been admitted to the cardiology service (p = 0.01), have atrial fibrillation (p = 0.03), have a weak hand or hemiparesis (p = 0.03), and have a prior history of stroke (p = 0.05), whereas, when the consults were called for “altered mental status” but no other deficits (p < 0.0001), it is likely a stroke-mimic. Conclusion. This study demonstrates that in-hospital strokes are a common occurrence, and knowing the variables can aid in their timely diagnosis and treatment.
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Yoo J, Song D, Baek JH, Lee K, Jung Y, Cho HJ, Yang JH, Cho HJ, Choi HY, Kim YD, Nam HS, Heo JH. Comprehensive code stroke program to reduce reperfusion delay for in-hospital stroke patients. Int J Stroke 2016; 11:656-62. [DOI: 10.1177/1747493016641724] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/17/2016] [Indexed: 11/15/2022]
Abstract
Background Stroke may occur during hospital admission (in-hospital stroke). Although patients with in-hospital stroke are potentially good candidates for reperfusion therapy, they often do not receive treatment as rapidly as expected. Aims We investigated the effect of a code stroke program for in-hospital stroke, which included the use of computerized physician order entry, specific evaluation and treatment protocols for in-hospital stroke patients, and regular education of medical staffs. Methods We implemented the program in the cardiology and cardiovascular surgery departments/wards (target-ward group) in November 2008. We compared time intervals from symptom onset to evaluation and reperfusion treatment before and after program implementation between the target-ward and other departments/wards (other-ward group). Results Among 70 consecutive in-hospital stroke patients who received reperfusion therapy between July 2002 and February 2015, 28 and 42 were treated before and after program implementation, respectively. After program implementation, time intervals from symptom onset to neurology notification (50 min vs. 28 min; P = 0.033), symptom onset to brain imaging (91 min vs. 41 min; P < 0.001), and symptom recognition to notification (22 min vs. 9 min; P = 0.011) were reduced in the target-ward group. Finally, times from symptom onset to intravenous tissue plasminogen activator administration and to arterial puncture were reduced by 55 min (120 min vs. 65 min; P < 0.001) and 130 min (295 min vs. 165 min; P < 0.001), respectively. However, time reductions in the other-ward group were not significant. Conclusions The comprehensive program for in-hospital stroke that included the use of computerized physician order entry was effective in reducing time intervals to evaluation and reperfusion therapy.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jang-Hyun Baek
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Kijeong Lee
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yohan Jung
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
| | - Han-Jin Cho
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Pusan National University College of Medicine, Busan, Korea
| | - Jae Hoon Yang
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ji Cho
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, The Catholic University of Korea, Incheon St. Mary’s Hospital, Incheon, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University School of Medicine, Kyung Hee University Hospital at Kangdong, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Yonsei University College of Medicine, Seoul, Korea
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Bekelis K, Missios S, Coy S, MacKenzie TA. Comparison of outcomes of patients with inpatient or outpatient onset ischemic stroke. J Neurointerv Surg 2016; 8:1221-1225. [PMID: 26733583 DOI: 10.1136/neurintsurg-2015-012145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/27/2015] [Accepted: 12/02/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Reperfusion times for ischemic stroke occurring in the outpatient setting have improved significantly in recent years. However, quality improvement efforts have largely ignored ischemic stroke occurring in patients hospitalized for unrelated indications. METHODS We performed a cohort study involving patients with ischemic stroke (with inpatient or outpatient onset) from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. A propensity score-adjusted regression analysis was used to assess the association of location of onset and outcomes. Mixed effects methods were employed to control for clustering at the hospital level. RESULTS Of the 176 571 ischemic strokes, 160 157 (90.7%) occurred outside of a hospital and 16 414 (9.3%) occurred in patients hospitalized for unrelated indications. Using a logistic regression model with propensity score adjustment, we demonstrated that inpatient stroke onset was associated with increased inpatient mortality (OR 3.09; 95% CI 2.81 to 3.38), rate of discharge to rehabilitation (OR 2.57; 95% CI 2.37 to 2.79), and length of stay (LOS) (β=11.58; 95% CI 10.73 to 12.42). In addition, it was associated with lower odds (OR 0.69; 95% CI 0.62 to 0.77) of undergoing stroke-related interventions (mechanical thrombectomy and intravenous tissue plasminogen activator) compared with outpatient stroke onset. CONCLUSIONS Using a comprehensive all-payer cohort of patients with ischemic stroke in New York State, we identified an association of inpatient stroke onset with fewer stroke-related interventions and increased mortality, rate of discharge to rehabilitation, and LOS.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Rodríguez Campello A, Cuadrado Godia E, Giralt Steinhauer E, Rodríguez Fernández E, Domínguez A, Romeral G, Muñoz E, Roquer J. Detecting in-hospital stroke: Assessment of results from a training programme for medical personnel. Neurología (English Edition) 2015. [DOI: 10.1016/j.nrleng.2014.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. These in-hospital strokes represent a unique population with different risk factors, more mimics, and substantially worsened outcomes compared to community-onset strokes. The fact that these strokes manifest during the acute care hospitalization, in patients with higher rates of thrombolytic contraindications, creates distinct challenges for treatment. However, the best evidence suggests benefit to treating appropriately selected in-hospital ischemic strokes with thrombolysis. Evidence points toward a "quality gap" for in-hospital stroke with longer in-hospital delays to evaluation and treatment, lower rates of evaluation for etiology, and decreased adherence to consensus quality process measures of care. This quality gap for in-hospital stroke represents a focused opportunity for quality improvement.
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Affiliation(s)
- Ethan Cumbler
- Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
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Garcia-santibanez R, Liang J, Walker A, Matos-diaz I, Kahkeshani K, Boniece I. Comparison of Stroke Codes in the Emergency Room and Inpatient Setting. J Stroke Cerebrovasc Dis 2015; 24:1948-50. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 05/01/2015] [Accepted: 05/07/2015] [Indexed: 11/22/2022] Open
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Abstract
Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. A response system to rapidly evaluate inpatients with acute neurologic symptoms facilitates evaluation and treatment of stroke developing during hospitalization. The National Stroke Association implemented an in-hospital stroke quality-improvement initiative from July 2010 to June 2011 in 6 certified stroke centers from Michigan, South Carolina, Pennsylvania, Colorado, Washington, and North Carolina. Three hundred ninety-three in-hospital stroke alerts were examined over a 1-year period. Of the alerts, 42.5% were for ischemic stroke, 8.7% probable or possible TIA, 2.8% intracranial hemorrhage, and 46.1% were stroke mimics. The most common stroke mimics were seizure, hypotension, and delirium. Participating hospitals had an alarm rate for diagnoses other than acute cerebrovascular events ranging from 28.0% to 66.7%. Of 194 in-hospital stroke/transient ischemic attack cases, 8.2% received intravenous thrombolysis alone, 10.3% received intra-arterial/mechanical thrombolysis alone, and 1% received both. No patient with a stroke mimic received thrombolysis. Our findings suggest that in-hospital response teams need to be prepared to respond to a range of acute medical conditions other than ischemic stroke.
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Affiliation(s)
- Ethan Cumbler
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; National Stroke Association, Centennial, Colorado
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Rodríguez Campello A, Cuadrado Godia E, Giralt Steinhauer E, Rodríguez Fernández E, Domínguez A, Romeral G, Muñoz E, Roquer J. Detecting in-hospital stroke: Assessment of results from a training programme for medical personnel. Neurologia 2014; 30:529-35. [PMID: 25224850 DOI: 10.1016/j.nrl.2014.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/29/2014] [Accepted: 06/10/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In-hospital stroke (IHS) is a frequent event, but its care priority level is not well established in many hospitals. IHS care at our centre has been redefined by implementing a training programme for medical personnel not usually involved in stroke management, in order to optimise IHS detection and treatment. This study evaluates results from the training programme. METHODS Prospective longitudinal intervention study. Neurologists experienced in vascular diseases developed a training programme for medical personnel. We recorded incidence, epidemiological data, reason for hospitalisation, department, aetiology, severity (NIHSS), time from symptom onset to neurological assessment, use of endovascular thrombolysis, exclusion criteria for untreated patients, and 90-day outcome (mortality/disability) in 2 patient groups: patients experiencing IHS in the 6 months before (PRE) and the 6 months after the training programme (POST). RESULTS Sixty patients were included (19 PRE, 41 POST) with a mean age of 75.3 ± 12.5; 41% were male. There were no differences between groups regarding assessment time, treatment administered, or morbidity/mortality. Overall, 68.3% of the patients were assessed in < 4.5hours; however, only 6 patients (10%) were able to undergo endovascular therapy. This situation was mainly due to pre-existing disability (26%) and comorbidity (13%). CONCLUSIONS More IHS code activations were recorded after the training programme. However, that increase was not accompanied by a higher percentage of treated patients or improvements in patient prognosis during the study period, and these findings could probably be explained by the high rates of pre-existing disability and comorbidity in this series.
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Affiliation(s)
- A Rodríguez Campello
- Departament de Medicina, Universitat Autònoma de Barcelona, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques); Barcelona, España.
| | - E Cuadrado Godia
- DCEXS, Universitat Pompeu Fabra, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, España
| | - E Giralt Steinhauer
- Departament de Medicina, Universitat Autònoma de Barcelona, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques); Barcelona, España
| | - E Rodríguez Fernández
- Departament de Medicina, Universitat Autònoma de Barcelona, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques); Barcelona, España
| | - A Domínguez
- Departament de Medicina, Universitat Autònoma de Barcelona, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques); Barcelona, España
| | - G Romeral
- Departament de Medicina, Universitat Autònoma de Barcelona, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques); Barcelona, España
| | - E Muñoz
- Departament de Medicina, Universitat Autònoma de Barcelona, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques); Barcelona, España
| | - J Roquer
- DCEXS, Universitat Pompeu Fabra, Unidad de Ictus, Servicio de Neurología, Hospital del Mar, Grupo de investigación Neurovascular, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, España
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Manawadu D, Choyi J, Kalra L. The impact of early specialist management on outcomes of patients with in-hospital stroke. PLoS One 2014; 9:e104758. [PMID: 25144197 PMCID: PMC4140715 DOI: 10.1371/journal.pone.0104758] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/13/2014] [Indexed: 11/18/2022] Open
Abstract
Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0–2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0–2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I. = 1.10–1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.
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Affiliation(s)
- Dulka Manawadu
- Department of Clinical Neuroscience, King’s College London, London, United Kingdom
- Acute and Emergency Medicine, King’s College Hospital, London, United Kingdom
- * E-mail:
| | - Jithesh Choyi
- Department of Clinical Neuroscience, King’s College London, London, United Kingdom
| | - Lalit Kalra
- Department of Clinical Neuroscience, King’s College London, London, United Kingdom
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Floyd CN, Ellis BH, Ferro A. The PlA1/A2 polymorphism of glycoprotein IIIa as a risk factor for stroke: a systematic review and meta-analysis. PLoS One 2014; 9:e100239. [PMID: 24988537 PMCID: PMC4079245 DOI: 10.1371/journal.pone.0100239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/19/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The PlA1/A2 polymorphism of glycoprotein IIIa (GPIIIa) has been reported to be associated with risk of stroke in some studies, although other studies suggest no such association. This meta-analysis and systematic review was conducted to investigate the hypothesis that carriage of the PlA2 allele is a risk factor for stroke. METHODS Electronic databases (MEDLINE and EMBASE) were searched for all articles evaluating carriage of the PlA2 allele and the incidence of stroke. Pooled odds ratios (ORs) were calculated using fixed-effect and random-effect models. FINDINGS A total of 35 articles were eligible for inclusion, of which 25 studies were suitable for statistical analysis. For carriage of the PlA2 allele, OR 1.12 (n = 11,873; 95% CI = 1.03-1.22; p = 0.011) was observed for the incidence of stroke in adults, with subgroup analyses identifying the association driven by stroke of an ischaemic (n = 10,494; OR = 1.15, 95% CI = 1.05-1.27; p = 0.003) but not haemorrhagic aetiology (n = 2,470; OR = 0.90, 95% CI = 0.71-1.14; p = 0.398). This association with ischaemic stroke was strongest in individuals homozygous for the PlA2 allele compared to those homozygous for wild-type PlA1 (n = 5,906; OR = 1.74, 95% CI = 1.34-2.26; p<0.001). Subgroup analysis of ischaemic stroke subtypes revealed an increased association with stroke of cardioembolic (n = 1,271; OR 1.56, 95% CI 1.14-2.12; p = 0.005) and large vessel (n = 1,394; OR = 1.76, 95% CI 1.34-2.31; p<0.001) aetiology, but not those of small vessel origin (n = 1,356; OR = 0.99, 95% CI 0.74-1.33; p = 0.950). Egger's regression test suggested a low probability of publication bias for all analyses (p>0.05). CONCLUSIONS The totality of published data supports the hypothesis that carriage of the PlA2 polymorphism of GPIIIa is a risk factor for ischaemic strokes, and specifically those of cardioembolic and large vessel origin.
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Affiliation(s)
- Christopher N. Floyd
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Benjamin H. Ellis
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Albert Ferro
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
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Cumbler E, Wald H, Bhatt DL, Cox M, Xian Y, Reeves M, Smith EE, Schwamm L, Fonarow GC. Quality of Care and Outcomes for In-Hospital Ischemic Stroke. Stroke 2014; 45:231-8. [DOI: 10.1161/strokeaha.113.003617] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Ethan Cumbler
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Heidi Wald
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Deepak L. Bhatt
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Margueritte Cox
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Ying Xian
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Mathew Reeves
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Eric E. Smith
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Lee Schwamm
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
| | - Gregg C. Fonarow
- From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary,
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Abstract
BACKGROUND AND PURPOSE In-hospital stroke (IHS) differs from out-of-hospital stroke (OHS) in risk factors and outcomes. We compared IHS and OHS treated with thrombolysis from a large national cohort in a cross-sectional study to further clarify these differences. METHODS The Nationwide Inpatient Sample for the years 2005-2010 was searched for adult acute ischemic stroke cases treated with intravenous or intra-arterial thrombolysis. Patients treated on the day of admission were classified as OHS. We compared the demographic and hospital characteristics, comorbidities, and short-term outcomes of thrombolysed IHS and OHS. RESULTS IHS included 8.7% of 11 750 thrombolysed stroke cases in this study. IHS was associated with a higher comorbidity profile and higher rates of acute medical conditions compared with OHS. IHS had higher inpatient mortality (15.7% versus 9.6%; P<0.001) and lower rate of discharge to home/self-care (22.8% versus 30.0%; P<0.001). IHS was also associated with higher mortality among endovascular treatment group (19.3% versus 13.8%; P=0.010). The difference in the rate of all intracerebral hemorrhage was not significant (5.3% versus 4.7%; P=0.361). In the multivariate analysis, inpatient mortality (adjusted odds ratio, 1.59; 95% confidence interval, 1.32-1.92; P<0.001) and favorable discharge outcome (adjusted odds ratio, 0.79; 95% confidence interval, 0.67-0.93; P=0.005) remained significantly worse in IHS. CONCLUSIONS Thrombolysed IHS is associated with worse discharge outcomes compared with thrombolysed OHS, likely because of their higher comorbidities and additional medical reasons for the index admission. Thrombolysis is not associated with a higher rate of intracerebral hemorrhage among IHS.
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Affiliation(s)
- Yogesh Moradiya
- Department of Neurology, Stroke Center, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA.
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Vera R, Lago A, Fuentes B, Gállego J, Tejada J, Casado I, Purroy F, Delgado P, Simal P, Martí-Fábregas J, Vivancos J, Díaz-Otero F, Freijo M, Masjuan J. In-hospital stroke: a multi-centre prospective registry. Eur J Neurol 2011; 18:170-6. [PMID: 20550562 DOI: 10.1111/j.1468-1331.2010.03105.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND in-hospital strokes (IHS) are relatively frequent. Avoidable delays in neurological assessment have been demonstrated. We study the clinical characteristics, neurological care and mortality of IHS. METHODS multi-centre 1-year prospective study of IHS in 13 hospitals. Demographic and clinical characteristics, admission diagnosis, quality of care, thrombolytic therapy and mortality were recorded. RESULTS we included 273 IHS patients [156 men; 210 ischaemic strokes (IS), 37 transient ischaemic attacks (TIA) and 26 cerebral haemorrhages]. Mean age was 72 ± 12 years. Cardiac sources of embolism were present in 138 (50.5%), withdrawal of antithrombotic drugs in 77 (28%) and active cancers in 35 (12.8%). Cardioembolic stroke was the most common subtype of IS (50%). Reasons for admission were programmed or urgent surgery in 70 (25%), cardiac diseases in 50 (18%), TIA or stroke in 30 (11%) and other medical illnesses in 71 (26%). Fifty-two per cent of patients were evaluated by a neurologist within 3 h of stroke onset. Thirty-three patients received treatment with tPA (15.7%). Thirty-one patients (14.7%) could not be treated because of a delay in contacting the neurologist. During hospitalization, 50 patients (18.4%) died, 41 of them because of the stroke or its complications. CONCLUSIONS cardioembolic IS was the most frequent subtype of stroke. Cardiac sources of embolism, active cancers and withdrawal of antithrombotic drugs constituted special risk factors for IHS. A significant proportion of patients were treated with thrombolysis. However, delays in contacting the neurologist excluded a similar proportion of patients from treatment. IHS mortality was high, mostly because of stroke.
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Affiliation(s)
- R Vera
- Hospital Ramón y Cajal, Madrid Hospital La Fe, Valencia Hospital La Paz, Madrid, Spain
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Abstract
Background and Purpose—
Approximately 4% to 17% of all adult strokes have onset in the hospital. Previous research indicates significant in-hospital evaluation delays and lower adherence to some measures of quality care compared to out-of-hospital strokes.
Methods—
Quality of care for in-hospital ischemic strokes compared to stroke with out-of-hospital onset was examined using cohort analysis of a statewide stroke database maintained by the Colorado Stroke Alliance.
Results—
One-hundred sixteen in-hospital strokes were compared to 4946 out-of-hospital strokes. Patients with in-hospital strokes were significantly more likely to have history of coronary artery disease (36.7% vs 26.5%;
P
=0.02), and in-hospital strokes were more severe (NIHSS score 9.5 vs 7.0;
P
=0.01). Time to brain imaging was not significantly different (54 minutes vs 43 minutes;
P
=0.13) between groups. Patients with in-hospital stroke were significantly more likely to have documentation of stroke education (90.4% vs 73.1%;
P
=0.0002) and assessment for rehabilitation (67.7% vs 45.2%;
P
<0.0001). Total deficit-free care defined as adherence to all Get With the Guidelines Stroke (GWTG-Stroke) measures was better for in-hospital strokes compared to strokes in the community (52.8% vs 32.3%;
P
<0.0001).
Conclusions—
Adherence to GWTG-Stroke performance measures was better for in-hospital strokes in this statewide registry. Variability in reporting by participating hospitals suggests in-hospital strokes are under-recognized or under-reported. In-hospital stroke evaluation times remain more than twice the recommended benchmark of 25 minutes, representing an opportunity for process improvement.
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Affiliation(s)
- Ethan Cumbler
- From the Division of General Internal Medicine (E.C.), Divisions of General Internal Medicine and Health Care Policy and Research (H.L.W.), Division of General Internal Medicine (J.S.K.), Department of Medicine, and Departments of Neurology and Neurosurgery (W.J.J.), University of Colorado Denver School of Medicine, Denver, Colo; Colorado Stroke Alliance (P.M., D.B.S.), Denver, Colo
| | - Paul Murphy
- From the Division of General Internal Medicine (E.C.), Divisions of General Internal Medicine and Health Care Policy and Research (H.L.W.), Division of General Internal Medicine (J.S.K.), Department of Medicine, and Departments of Neurology and Neurosurgery (W.J.J.), University of Colorado Denver School of Medicine, Denver, Colo; Colorado Stroke Alliance (P.M., D.B.S.), Denver, Colo
| | - William J. Jones
- From the Division of General Internal Medicine (E.C.), Divisions of General Internal Medicine and Health Care Policy and Research (H.L.W.), Division of General Internal Medicine (J.S.K.), Department of Medicine, and Departments of Neurology and Neurosurgery (W.J.J.), University of Colorado Denver School of Medicine, Denver, Colo; Colorado Stroke Alliance (P.M., D.B.S.), Denver, Colo
| | - Heidi L. Wald
- From the Division of General Internal Medicine (E.C.), Divisions of General Internal Medicine and Health Care Policy and Research (H.L.W.), Division of General Internal Medicine (J.S.K.), Department of Medicine, and Departments of Neurology and Neurosurgery (W.J.J.), University of Colorado Denver School of Medicine, Denver, Colo; Colorado Stroke Alliance (P.M., D.B.S.), Denver, Colo
| | - Jean S. Kutner
- From the Division of General Internal Medicine (E.C.), Divisions of General Internal Medicine and Health Care Policy and Research (H.L.W.), Division of General Internal Medicine (J.S.K.), Department of Medicine, and Departments of Neurology and Neurosurgery (W.J.J.), University of Colorado Denver School of Medicine, Denver, Colo; Colorado Stroke Alliance (P.M., D.B.S.), Denver, Colo
| | - Don B. Smith
- From the Division of General Internal Medicine (E.C.), Divisions of General Internal Medicine and Health Care Policy and Research (H.L.W.), Division of General Internal Medicine (J.S.K.), Department of Medicine, and Departments of Neurology and Neurosurgery (W.J.J.), University of Colorado Denver School of Medicine, Denver, Colo; Colorado Stroke Alliance (P.M., D.B.S.), Denver, Colo
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Neurology in the European Journal of Neurology. Eur J Neurol 2010; 17:1397-1406. [DOI: 10.1111/j.1468-1331.2010.03248.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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