Safety and Effectiveness of Intravenous Thrombolysis for Acute Ischemic Stroke Outside the Coverage of National Health Insurance in Taiwan.

PURPOSE: Only a small percentage of ischemic stroke patients were treated with intravenous thrombolysis in Taiwan, partly because of the narrow reimbursement criteria of the National Health Insurance (NHI). We aimed to assess the safety and effectiveness of intravenous thrombolysis not covered by the NHI. METHODS: This is a retrospective analysis of register data from four hospitals. All patients who received intravenous tissue plasminogen activator and fulfilled the American Heart Association/American Stroke Association (AHA/ASA) thrombolysis guidelines between January 2007 and June 2012 were distinguished into two groups: those in accordance (reimbursement group) and those not in accordance (non-reimbursement group) with the NHI reimbursement criteria. Primary outcome was symptomatic intracerebral hemorrhage (SICH). Secondary outcomes were dramatic improvement in the National Institutes of Health Stroke Scale (NIHSS) score at discharge, good functional outcome (modified Rankin Scale ≤2) at discharge, and all-cause in-hospital mortality. RESULTS: In 569 guideline-eligible patients, 177 (31%) were treated without reimbursement. The reasons for exclusion from reimbursement included age >80 (n=42), baseline NIHSS less than 6 (n=29), baseline NIHSS >25 (n=15), thrombolysis beyond 3 hours (n=49), prior stroke with diabetes (n=28), use of oral anticoagulant (n=2), and more than one contraindication (n=12). Overall, we observed no differences between the reimbursement and non-reimbursement groups in the rate of SICH (7% versus 6%), dramatic improvement (36% versus 36%), good functional outcome (39% versus 37%), and in-hospital mortality (8% versus 6%) Conclusion: In stroke patients treated with intravenous thrombolysis according to the AHA/ASA guidelines, the outcomes were comparable between the reimbursement and non-reimbursement groups.

Oxfordshire Community Stroke Project classification improves prediction of post-thrombolysis symptomatic intracerebral hemorrhage.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification is a simple stroke classification system with value in predicting clinical outcomes. We investigated whether and how the addition of OCSP classification to the Safe Implementation of Thrombolysis in Stroke (SITS) symptomatic intracerebral hemorrhage (SICH) risk score improved the predictive performance. METHODS: We constructed an extended risk score by adding an OCSP component, which assigns 3 points for total anterior circulation infarcts, 0 point for partial anterior circulation infarcts or lacunar infarcts. Patients with posterior circulation infarcts were assigned an extended risk score of zero. We analyzed prospectively collected data from 4 hospitals to compare the predictive performance between the original and the extended scores, using area under the receiver operating characteristic curve (AUC) and net reclassification improvement (NRI). RESULTS: In a total of 548 patients, the rates of SICH were 7.3% per the National Institute of Neurological Diseases and Stroke (NINDS) definition, 5.3% per the European-Australasian Cooperative Acute Stroke Study (ECASS) II, and 3.5% per the SITS-Monitoring Study (SITS-MOST). Both scores effectively predicted SICH across all three definitions. The extended score had a higher AUC for SICH per NINDS (0.704 versus 0.624, P = 0.015) and per ECASS II (0.703 versus 0.612, P = 0.016) compared with the SITS SICH risk score. NRI for the extended risk score was 22.3% (P = 0.011) for SICH per NINDS, 21.2% (P = 0.018) per ECASS II, and 24.5% (P = 0.024) per SITS-MOST. CONCLUSIONS: Incorporation of the OCSP classification into the SITS SICH risk score improves risk prediction for post-thrombolysis SICH.

Oral antiplatelet therapy for acute ischaemic stroke.

BACKGROUND: In people with acute ischaemic stroke, platelets become activated and can cause blood clots to form and block an artery in the brain, resulting in damage to part of the brain. Such damage gives rise to the symptoms of stroke. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and also reduce the risk of early recurrent ischaemic stroke, thereby reducing the risk of early death and improving long-term outcomes in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES: To assess the efficacy and safety of immediate oral antiplatelet therapy (that is started as soon as possible and no later than two weeks after stroke onset) in people with acute presumed ischaemic stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 16 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2013), MEDLINE (June 1998 to May 2013), and EMBASE (June 1998 to May 2013). In 1998, for a previous version of this review, we searched the register of the Antiplatelet Trialists' Collaboration, MedStrategy and contacted relevant drug companies. SELECTION CRITERIA: Randomised trials comparing oral antiplatelet therapy (started within 14 days of the stroke) with control in people with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria and assessed trial quality. For the included trials, they extracted and cross-checked the data. MAIN RESULTS: We included eight trials involving 41,483 participants. No new trials have been added since the last update.Two trials testing aspirin 160 mg to 300 mg once daily, started within 48 hours of onset, contributed 98% of the data. The risk of bias was low. The maximum follow-up was six months. With treatment, there was a significant decrease in death or dependency at the end of follow-up (odds ratio (OR) 0.95, 95% confidence interval (CI) 0.91 to 0.99). For every 1000 people treated with aspirin, 13 people would avoid death or dependency (number needed to treat 79). Antiplatelet therapy was associated with a small but definite excess of symptomatic intracranial haemorrhages, but this small hazard was significantly outnumbered by the benefit, the reduction in recurrent ischaemic stroke and pulmonary embolus. AUTHORS' CONCLUSIONS: Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in people who cannot swallow) and started within 48 hours of onset of presumed ischaemic stroke, reduced the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications; long-term outcomes were improved.

Code stroke: a mismatch between number of activation and number of thrombolysis.

BACKGROUND/PURPOSE: Code stroke systems are widely implemented to expedite acute stroke treatment. Although this system requires considerable resources, so far no reimbursement has been provided by the Bureau of National Health Insurance (BNHI) in Taiwan. We investigated how often a code stroke was initiated and the percentage of patients treated with intravenous (IV) tissue plasminogen activator, and draw attention to the resulting mismatch. METHODS: From January 2010 to September 2011, we prospectively registered all consecutive code stroke patients. Patient characteristics, including demographic data, medical history, comorbidity conditions, treatments, and discharge diagnosis were collected, together with the exact time of onset (or last known normal time) and management. The eligibility of thrombolysis for each patient recorded originally on the chart was reviewed retrospectively on the basis of two sets of criteria, namely, the BNHI reimbursement criteria and the Taiwan Stroke Society (TSS) guideline. RESULTS: During the study period, code strokes were activated for 419 patients at an average of around 20 patients per month. About 57% of code strokes were initiated outside of office hours. Stroke was diagnosed in 377 (90%) patients and 304 (73%) patients had ischemic stroke or transient ischemic attack. A total of 42 (10%) patients according to the BNHI reimbursement criteria and 101 (24%) patients by the TSS guideline were eligible for IV thrombolytic therapy. Of all the code stroke patients, only 49 (12%) were actually treated. Before each additional patient was thrombolysed, about eight patients had been evaluated and excluded from treatment. CONCLUSION: The majority of code stroke patients were stroke patients; however, most of them could not be treated with thrombolytic therapy. These findings underscore the need for further support from the BNHI in order for health-care providers to implement the code stroke systems successfully.

Comparison of risk-scoring systems in predicting symptomatic intracerebral hemorrhage after intravenous thrombolysis.

BACKGROUND AND PURPOSE: Various risk score models have been developed to predict symptomatic intracerebral hemorrhage (SICH) after intravenous thrombolysis for acute ischemic stroke. In this study, we aimed to determine the prediction performance of these risk scores in a Taiwanese population METHODS: Prospectively collected data from 4 hospitals were used to calculate probability of SICH with the scores developed by Cucchiara et al, the Hemorrhage After Thrombolysis (HAT) score, the Safe Implementation of Thrombolysis in Stroke-SICH risk score, the Glucose Race Age Sex Pressure Stroke Severity score, and the Stroke Prognostication using Age and National Institutes of Health Stroke Scale-100 index. We used logistic regression to evaluate the effectiveness of each risk model in predicting SICH and the c statistic to assess performance. RESULTS: A total of 548 patients were included. The rates of SICH were 7.3% by the National Institute of Neurological Diseases and Stroke definition, 5.3% by the European-Australasian Cooperative Acute Stroke Study II definition, and 3.5% by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study definition. The Cucchiara score, the HAT score, and the Safe Implementation of Thrombolysis in Stroke-SICH risk score were significant predictors of SICH for all 3 definitions, whereas the Glucose Race Age Sex Pressure Stroke Severity score and the Stroke Prognostication using Age and National Institutes of Health Stroke Scale-100 index predicted well only for 1 or 2 definitions of SICH. The c statistic was highest for the HAT score (range, 0.69-0.73) across the definitions of SICH. CONCLUSIONS: The Cucchiara score, the HAT score, and the Safe Implementation of Thrombolysis in Stroke-SICH risk score predicted SICH reasonably well regardless of which SICH definition was used. However, only the HAT score had an acceptable discriminatory ability.

Indwelling urinary catheterization after acute stroke.

AIMS: Prolonged indwelling urinary catheterization (IUC) increases risk of urinary tract infection. We aimed to investigate the incidence and risk factors associated with IUC following acute stroke, and its impact on stroke outcome. METHODS: We prospectively enrolled stroke patients hospitalized within 10 days after onset from August 2006 to December 2008. Kaplan-Meier method was used to estimate the cumulative incidence of IUC, and Cox regression analysis to evaluate the independent predictors. The impact of IUC on poor outcome (modified Rankin Scale >2 or dead) at 3 months was studied by logistic regression. RESULTS: Of 2,803 patients, 697 (25%) received indwelling urinary catheters. Catheterization was carried out mostly within 1-2 days of admission (86%), with estimated cumulative incidence of 13% (95% confidence interval, 11-14%) at 2 days in patients with ischemic stroke (IS), and 57% (53-61%) in patients with intracerebral hemorrhage (ICH). In IS patients, IUC was significantly associated with increasing age, baseline stroke severity, and neurological deterioration. In ICH patients, stroke severity on admission was the only significant predictor after adjustment. We assessed the 3-month outcome in 2,388 patients, after excluding 177 (6%) dead at discharge, 164 (6%) without providing informed consent, and 74 (3%) lost to follow-up. IUC during acute hospitalization was significantly associated with unfavorable 3-month outcome after adjustment. CONCLUSIONS: IUC was common in acute stroke care and associated with unfavorable outcome at 3 months. Whether judicious use of urinary catheters in acute stroke patients would improve outcomes may warrant further studies.

Changes in stroke awareness among undergraduate students after an educational intervention.

OBJECTIVE: This study investigated undergraduates'awareness about stroke, the effects of an educational intervention and the difference of measuring tests between recognition and recall. METHODS: We chose a convenient sample from two classes. One of the classes, the recognition group, was tested by a close-ended questionnaire with multiple choices. The other class, the recall group, was tested via an open-ended questionnaire. Participants completed their pretest and first posttest before and right after the education intervention. Twelve weeks after the intervention, participants were tested again to assess the knowledge retention over time. RESULTS: Fifty six participants in the recognition group and 53 participants in the recall group completed all three tests. Before the intervention, all respondents in the recognition group could recognize three or more risk factors and at least one warning sign, but in the recall group were only 32% and 72% respectively. After the intervention, the mean scores of first posttest and second posttest were all significant higher than that of pretest in both groups (P less 0.001). Comparisons of mean score of same items in both groups, the mean score of recognition group was significantly higher than that of recall group at each test (all P less 0.001). CONCLUSION: The intervention improved participants'knowledge towards stroke, even twelve weeks later. Participants obtained higher scores with a close-ended questionnaire than those with an open-ended questionnaire.

Cooling therapy for acute stroke.

BACKGROUND: Increased body temperatures are common in patients with acute stroke and are associated with poor outcome. In animal models of focal cerebral ischaemia, temperature-lowering therapy reduces infarct volume. In patients with acute stroke, lowering temperature may therefore improve outcome. This is an update of a Cochrane review first published in 1999. OBJECTIVES: To assess the effects of pharmacological and physical strategies to reduce body or brain temperature in patients with acute stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register (last searched December 2007). In addition, we searched MEDLINE and EMBASE (January 1998 to December 2007). We scanned references and contacted authors of included trials. For the previous version of this review, the authors contacted pharmaceutical companies and manufactures of cooling equipment in this field. SELECTION CRITERIA: We considered all completed randomised or non-randomised controlled clinical trials, published or unpublished, where pharmacological or physical strategies or both to reduce temperature were applied in patients with acute ischaemic stroke or intracerebral haemorrhage. Outcome measures were death or dependency (modified Rankin Scale score >/= 3) at the end of follow up, and adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted and cross-checked the data. MAIN RESULTS: We included five pharmacological temperature reduction trials and three physical cooling trials involving a total of 423 participants. We found no statistically significant effect of pharmacological or physical temperature-lowering therapy in reducing the risk of death or dependency (odds ratio (OR) 0.9, 95% confidence interval (CI) 0.6 to 1.4) or death (OR 0.9, 95% CI 0.5 to 1.5). Both interventions were associated with a non-significant increase in the occurrence of infections. AUTHORS' CONCLUSIONS: There is currently no evidence from randomised trials to support routine use of physical or pharmacological strategies to reduce temperature in patients with acute stroke. Large randomised clinical trials are needed to study the effect of such strategies.

Blood biomarkers in the diagnosis of ischemic stroke: a systematic review.

BACKGROUND AND PURPOSE: The diagnosis of ischemic stroke can be difficult. CT may be normal in the early stages of ischemic stroke or in patients with minor symptoms and MR is not always possible. Many blood markers have been proposed for the diagnosis of stroke in the acute setting. METHODS: We have systematically reviewed the diagnostic literature and found 21 studies testing 58 single biomarkers and 7 panels of several biomarkers. Although all show either a high sensitivity or specificity, there are limitations in the design and reporting of all the studies that mean no biomarker can be recommended for use in clinical practice. CONCLUSIONS: We make recommendations for the design and reporting of studies of diagnostic blood biomarkers in stroke.

Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke.

BACKGROUND: Low-molecular-weight heparins and heparinoids are anticoagulants that may be associated with lower risks of haemorrhage and more powerful antithrombotic effects than standard unfractionated heparin. This is an updated version of the original Cochrane review first published in Issue 1, 1995 and previously updated in Issue 2, 2005. OBJECTIVES: To compare the effects of low-molecular-weight heparins or heparinoids with those of unfractionated heparin in people with acute, confirmed or presumed, ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched June 2007). In addition we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2007), MEDLINE (1966 to June 2007) and EMBASE (1980 to June 2007). For previous versions of this review we searched MedStrategy (1995) and also contacted pharmaceutical companies. SELECTION CRITERIA: Randomised trials comparing heparinoids or low-molecular-weight heparins with standard unfractionated heparin in people with acute ischaemic stroke. We only included trials where treatment was started within 14 days of stroke onset. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Nine trials involving 3137 people were included. Four trials compared a heparinoid (danaparoid), four trials compared low-molecular-weight heparin (enoxaparin or certoparin), and one trial compared an unspecified low-molecular-weight heparin with standard unfractionated heparin. Allocation to low-molecular-weight heparin or heparinoid was associated with a significant reduction in the odds of deep vein thrombosis compared with standard unfractionated heparin (odds ratio (OR) 0.55, 95% confidence interval (CI) 0.44 to 0.70). However, the number of more major events (pulmonary embolism, death, intracranial or extracranial haemorrhage) was too small to provide a reliable estimate of the benefits and risks of low-molecular-weight heparins or heparinoids compared with standard unfractionated heparin for these, arguably more important, outcomes. Insufficient information was available to assess effects on recurrent stroke or functional outcome. AUTHORS' CONCLUSIONS: Since the last version of this review none of the three new relevant studies with 2397 participants have provided additional information to change the conclusions. Treatment with a low-molecular-weight heparin or heparinoid after acute ischaemic stroke appears to decrease the occurrence of deep vein thrombosis compared with standard unfractionated heparin, but there are too few data to provide reliable information on their effects on other important outcomes, including death and intracranial haemorrhage.

Antiplatelet therapy for acute ischaemic stroke.

BACKGROUND: In patients with acute ischaemic stroke, platelets become activated. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and reduce the risk of early recurrent ischaemic stroke. This might reduce the risk of early death and improve long-term outcome in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES: To assess the efficacy and safety of antiplatelet therapy in acute ischaemic stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched June 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2007), MEDLINE (June 1998 to May 2007), and EMBASE (June 1998 to May 2007). In 1998, for a previous version of this review, we searched the register of the Antiplatelet Trialists' Collaboration, MedStrategy and contacted relevant drug companies. SELECTION CRITERIA: Randomised trials comparing antiplatelet therapy (started within 14 days of the stroke) with control in patients with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria and assessed trial quality, and for the included trials, extracted and cross-checked the data. MAIN RESULTS: Twelve trials involving 43,041 participants were included. Two trials testing aspirin 160 mg to 300 mg once daily started within 48 hours of onset contributed 94% of the data. The maximum follow up was six months. With treatment, there was a significant decrease in death or dependency at the end of follow up (odds ratio 0.95, 95% confidence interval 0.91 to 0.99). For every 1000 patients treated with aspirin, 13 patients will avoid death or dependency (number needed to treat to benefit: 79). Antiplatelet therapy was associated with a small but definite excess of symptomatic intracranial haemorrhages, but this was more than offset by the reduction of recurrent ischaemic strokes and pulmonary embolus. AUTHORS' CONCLUSIONS: Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in patients who cannot swallow), and started within 48 hours of onset of presumed ischaemic stroke reduces the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications and improves long-term outcome.

Health-related quality of life after stroke: review of the literature and implications for future research.

Limits on health care resources mandate that resource-allocation decisions be guided by consideration of cost in relation to the associated expected benefits. It therefore leads to an increased demand for economic evaluation and medical technology assessment. Nowadays, cost-effectiveness analysis (CEA) has emerged as a favored analytic technique for economic evaluation in health care. Currently the leading standard in Western countries is the use of health-adjusted life years (HAYLs) in CEA of medical care and health interventions, as well as in estimating burden of disease. Being an umbrella term of a family of measures, HALYs include quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). In this review we give a concise overview on QALYs and DALYs, and examine variations in QALYs and DALYs estimates currently used in stroke studies. Given the lack of reliable and valid measurement methods in eliciting utility values in QALYs or disability values in DALYs, CEA needs to be addressed in a clear and transparent way to ensure its proper use in practice.

Stroke severity and early recovery after first-ever ischemic stroke: results of a hospital-based study in Taiwan.

OBJECTIVE: To assess the relationship between admission stroke severity and outcomes of acute hospitalization in patients with first-ever ischemic stroke in Taiwan. METHODS: Data were prospectively collected from 360 first-ever ischemic stroke patients admitted to a medical center within 48h of stroke onset. Stroke severity was evaluated with NIH stroke scale (NIHSS) and categorized as mild (0-6), moderate (7-15), or severe (16-38). We studied three prespecified discharge outcomes: (1) status based on a combination of NIHSS and modified Barthel index (MBI), (2) subsequent change in neurologic impairments, and (3) subsequent change in functional status. For each outcome, a separate polytomous logistic regression model with least favorable category as the reference group was constructed, controlling confounding factors. RESULTS: Patients (58% male) had mean age 64.9+/-12.5 (range 18-90), median NIHSS 6 and median MBI 12 on admission. Median length-of-stay was 7 (range 1-122) days; in-hospital deaths 8%. Twenty-two percent patients had excellent status outcome, 33% good. For subsequent change in neurologic impairments, 22% of patients had better outcomes; for sequent change in functional status, better outcomes were noted in 14% of patients. The NIHSS score at admission was strongly associated with outcomes of acute hospitalization after multivariate adjustment. The odds ratio (OR) for moderate (versus mild) stroke patients to achieve excellent status was 0.04 (95% CI, 0.02-0.10), and for severe stroke the OR was less than 0.01 (95% CI, 0-0.05). The OR (95% CI) for moderate stroke patients to have good or improved outcome was 0.19 (0.10-0.36), for severe stroke 0.04 (0.01-0.13). The ORs for moderate and severe (versus mild) stroke patients to have better subsequent change in neurologic impairments were 5.18 (1.94-13.85) and 4.12 (1.38-12.30); to remain stationary 0.43 (0.19-0.96) and 0.15 (0.06-0.36), respectively. CONCLUSIONS: In patients with first-ever ischemic stroke in Taiwan, admission NIHSS is predictive of outcome of acute hospitalization.

Predicting 3-month mortality among patients hospitalized for first-ever acute ischemic stroke.

BACKGROUND: The clinical course of patients with acute ischemic stroke tends to be unstable. Understanding the factors contributing to the progression of stroke is important for the appropriate management of patients. This study investigated the factors related to 3-month mortality at admission in patients with first-ever acute ischemic stroke. METHODS: Patients with first-ever acute ischemic stroke consecutively admitted to a medical center in Taiwan within 48 hours after stroke onset were prospectively followed-up for 3 months. All deaths during this 3-month post-stroke period were analyzed. We evaluated only those characteristics that could be assessed at admission. Multivariate logistic regression analysis was used to identify the main predictors of 3-month stroke-related mortality. RESULTS: In the 360 enrolled patients, the inhospital mortality rate was 7.8% (28 deaths), and the 3-month mortality rate was 9.7% (35 deaths). Twenty-seven deaths (77%) were stroke-related. Risk factors for mortality at 3 months included sex (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.08-9.41; p=0.036), National Institutes of Health Stroke Scale (NIHSS) at admission (per unit increase: OR, 1.17; 95% CI, 1.12-1.22; p<0.001), history of cardiac disease (OR, 2.73; 95% CI, 1.04-7.16; p=0.042), and posterior circulation stroke (OR, 5.25; 95% CI, 1.92-14.36; p=0.001). CONCLUSION: This study of hospital-based data on patients with first-ever acute ischemic stroke in Taiwan found that initial NIHSS, posterior circulation stroke and history of cardiac disease were risk factors for 3-month mortality.

Costs of acute care of first-ever ischemic stroke in Taiwan.

BACKGROUND AND PURPOSE: We sought to investigate the direct costs of acute hospitalization for patients with first-ever ischemic stroke in Taiwan. METHODS: Data were prospectively collected from 360 first-ever ischemic stroke patients. Hospital charges were used for analysis. Multiple linear regression analysis was used to identify the main factors influencing costs. RESULTS: Mean age was 64.9 years (median, 67.0 years), and 58% were male. Mean National Institutes of Health Stroke Scale (NIHSS) score at admission was 9.4 (median, 6.0). Mean initial score of modified Barthel Index was 10.7 (median, 12.0). Median length of stay was 7 days (range, 1 to 122 days). In-hospital mortality was 8%. Overall, median cost per patient was 26 326 New Taiwan dollars (NTD) (original currency) or 841 dollars; median cost per day was 3777 NTD or 121 dollars. Median costs for patients with initial NIHSS score 0 to 6, 7 to 15, and 16 to 38 were 20 365 NTD (650 dollars), 31 954 NTD (1020 dollars), and 62 653 NTD (2000 dollars), respectively. Daily component (physician and ward charges) accounted for approximately 38% of total costs. Initial NIHSS score, small-vessel occlusion, admission to intensive care unit, sex, and smoking had significant impacts on costs. CONCLUSIONS: Apart from providing cost estimates, we note that stroke severity strongly affects costs.

Prehospital delay after acute stroke in Kaohsiung, Taiwan.

BACKGROUND AND PURPOSE: Successful acute stroke intervention depends on early hospital presentation. Our study aimed to examine the extent of and factors associated with prehospital delays after acute stroke in Taiwan, where people are new to thrombolytic therapy for stroke. METHODS: Data were prospectively collected from 196 patients admitted with acute stroke who presented to the emergency department (ED) of the study hospital within 48 hours of symptom onset before intravenous recombinant tissue plasminogen activator was approved. Prehospital delay was defined as time from symptom onset to the ED arrival. Univariate and multivariable regression analyses were conducted to evaluate factors influencing delay in ED presentation and delay in decision to seek medical help. RESULTS: The median interval between symptom onset and decision to seek medical contact was 90 minutes; the median interval between symptom onset and ED arrival was 335 minutes. The time from symptom onset to first call for medical help accounted for 45% (95% confidence interval, 41 to 50) of the prehospital delay. Advanced age delayed the decision to seek medical help, whereas stroke severity reduced the risk for this delay. CONCLUSIONS: The time interval between symptom onset and the decision to call for medical care is far from optimal and is the underlying cause of prolonged prehospital delay. Educational efforts to reduce extent of delay are urgently needed.

Prediction of length of stay of first-ever ischemic stroke.

BACKGROUND AND PURPOSE: Accurate information about hospital resource utilization is necessary for management of healthcare service. The purpose of this study was to determine the demographic and clinical predictors of length of hospital stay (LOS) of acute care hospitalization for first-ever ischemic stroke patients. METHODS: A group of 330 patients who suffered from first-ever ischemic stroke and were consecutively admitted to a medical center in southern Taiwan were followed prospectively. Because our intention was to identify the major predictors of LOS from the information available at admission, we evaluated only those factors that could be assessed at the time of admission. Univariate analysis and multiple regression analysis were used to identify the main predictors of LOS. RESULTS: The median LOS was 7 days (mean, 11 days; range, 1 to 122 days). Among the prespecified demographic and clinical characteristics, National Institutes of Health Stroke Scale (NIHSS) score at admission, the quadratic term of the initial NIHSS score, modified Barthel Index score at admission, small-vessel occlusion stroke, sex, and smoking were the main explanatory factors for LOS. In particular, for each 1-point increase in the total score of NIHSS, LOS increased approximately 1 day for patients with mild or moderate (score 0 to 15 points) neurological impairments, while LOS decreased approximately 1 day for patients with severe (score >15 points) neurological impairments. CONCLUSIONS: The severity of stroke, as rated by the total score on NIHSS, is an important factor that influences LOS after acute stroke hospitalization.

Cost-effectiveness analysis of tissue plasminogen activator for acute ischemic stroke: a comparative review.

PURPOSE: This work was undertaken to review current evidence of cost-effectiveness analysis (CEA) on thrombolysis for acute ischemic stroke. METHODS: An electronic search via PubMed, from 1995 until May 2004, was performed. The methods undertaken by these studies were examined with particular attention to their modeling assumptions, sources of data, and outcome measures. RESULTS: Three comprehensive CEAs of rtPA (recombinant tissue plasminogen activator) for acute ischemic stroke were reviewed. These studies were from the United States, Canada, and the United Kingdom. All these studies employed the perspective of a healthcare system and used a Markov decision-analytic modelling approach. Estimates of effectiveness of rtPA were based on the National Institute of Neurological Disorders and Stroke (NINDS) rtPA Stroke Trial, literature-derived values or a stroke registry. In each study, functional outcome measured by the modified Rankin Scale was used to represent health states, and quality-adjusted life year gained was the health outcome summary measure. The cost-effectiveness of rtPA therapy varied in magnitude, but seemingly with same positive implications. CONCLUSIONS: Cost-effectiveness analysis requires information on an intervention's effectiveness and country-specific sources of epidemiological and resource utilization data, most of which are not yet available in Taiwan. Despite the limitations, CEA is essential if a healthcare system would like to contain costs while maintaining, or improving, quality of care.

Atrial fibrillation predicts good functional outcome following intravenous tissue plasminogen activator in patients with severe stroke.

OBJECTIVE: Atrial fibrillation (AF) is associated with poor outcome after intravenous thrombolysis probably due to greater pretreatment stroke severity. We conducted this retrospective study to determine whether AF is an independent predictor for clinical outcome in patients stratified by initial stroke severity. METHODS: A total of 143 acute ischemic stroke patients who received intravenous thrombolysis within 3h after onset were enrolled. The patients were categorized according to the baseline stroke severity by National Institute of Health Stroke Scale (NIHSS) score (≤10 vs. >10) and the presence of AF or not. Favorable 90-day outcome was defined as a modified Rankin Scale (mRS) score<2. RESULTS: Among the 100 patients with severe stroke (NIHSS>10), those with AF (n=52) had a higher proportion of favorable 90-day outcome than those without AF (31% vs. 8%, P=0.005). After adjustment for age, baseline glucose level, and onset to treatment time, the difference remained significant (odds ratio 5.80, 95% confidence interval 1.63-20.68). In patients with mild stroke (NIHSS≤10), no difference in clinical outcome was found between AF (n=20) and non-AF (n=23) groups. CONCLUSION: Presence of AF was associated with favorable 90-day outcome following intravenous thrombolysis in patients with severe stroke at baseline, while the association did not exist in patients with mild stroke.

Oxfordshire Community Stroke Project classification but not NIHSS predicts symptomatic intracerebral hemorrhage following thrombolysis.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification is a simple tool to categorize clinical stroke syndromes. We compared the outcomes of stroke patients after intravenous thrombolysis stratified by the baseline National Institutes of Health Stroke Scale (NIHSS) score or by the OCSP classification. METHODS: We assessed the safety of thrombolysis in consecutive stroke patients who received intravenous thrombolysis within 3h after onset. The patients were grouped by the NIHSS score into mild to moderate stroke (≤ 20) and severe stroke (>20), and also by the OCSP classification as having total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), posterior circulation infarcts (POCI), or lacunar infarcts (LACI). Symptomatic intracerebral hemorrhage (SICH) was used as the primary outcome. RESULTS: Of the 145 patients included in the study, 45 had a baseline NIHSS score>20. Their stroke syndromes were as follows: 78 with TACI, 29 with PACI, 16 with POCI, and 22 with LACI. The proportion of SICH was comparable between patients with high or low NIHSS score (11.1% vs. 9.0%, P=0.690). The chance of SICH was highest in patients with TACI (15.4%), followed by LACI (4.5%), PACI (3.4%), and POCI (0%). After adjustment for age, baseline glucose, and use of antiplatelet agents before admission, SICH was significantly increased in patients with TACI relative to those with non-TACI (odds ratio 5.92; 95% confidence interval 1.24-28.33, P=0.026). CONCLUSIONS: The OCSP clinical classification may help clinicians evaluate the risk of SICH following intravenous thrombolysis.