Sex-specific racial and ethnic variations in short-term outcomes among patients with first or recurrent ischemic stroke: Paul Coverdell National Acute Stroke Program, 2016-2020.

BACKGROUND AND PURPOSE: To understand the association of sex-specific race and ethnicity on the short-term outcomes of initial and recurrent ischemic stroke events. METHODS: Using the Paul Coverdell National Acute Stroke Program from 2016-2020, we examined 426,062 ischemic stroke admissions from 629 hospitals limited to non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic patients. We performed multivariate logistic regression analyses to assess the combined effects of sex-specific race and ethnicity on short-term outcomes for acute ischemic stroke patients presenting with initial or recurrent stroke events. Outcomes assessed include rates of in-hospital death, discharge to home, and symptomatic intracranial hemorrhage (sICH) after reperfusion treatment. RESULTS: Among studied patients, the likelihood of developing sICH after reperfusion treatment for initial ischemic stroke was not significantly different. The likelihood of experiencing in-hospital death among patients presenting with initial stroke was notably higher among NHW males (AOR 1.59 [95 % CI 1.46, 1.73]), NHW females (AOR 1.34 [95 % CI 1.23, 1.45]), and Hispanic males (AOR 1.57 [95 % CI 1.36, 1.81]) when compared to NHB females. Hispanic females were more likely to be discharged home when compared to NHB females after initial stroke event (AOR 1.32 [95 % CI 1.23, 1.41]). NHB males (AOR 0.90 [95 % CI 0.87, 0.94]) and NHW females (AOR 0.89 [95 % CI 0.86, 0.92]) were less likely to be discharged to home. All groups with recurrent ischemic strokes experienced higher likelihood of in-hospital death when compared to NHB females with the highest likelihood among NHW males (AOR 2.13 [95 % CI 1.87, 2.43]). Hispanic females had a higher likelihood of discharging home when compared to NHB females hospitalized for recurrent ischemic stroke, while NHB males and NHW females with recurrent ischemic stroke hospitalizations were less likely to discharge home. CONCLUSIONS: Sex-specific race and ethnic disparities remain for short-term outcomes in both initial and recurrent ischemic stroke hospitalizations. Further studies are needed to address disparities among recurrent ischemic stroke hospitalizations.

Feasibility of advanced composite endpoint analysis: Post-hoc insights from the vitamin intervention for stroke prevention randomized control trial.

BACKGROUND AND AIMS: Stroke is a major cause of mortality and disability, highlighting the importance of prevention. Clinical trials play an important role in evaluating interventions that can maximize stroke prevention. Traditional composite endpoints (TCE) used in clinical trials have limitations, as they pool together events of varying clinical importance. Weighted composite endpoints (WCE) have emerged as a solution to address these limitations and provide more accurate assessments of outcomes. In this study, we investigate the use of WCE in a previously reported negative clinical trial for stroke prevention. METHODS AND RESULTS: We analyzed data from the Vitamin Intervention for Stroke Prevention (VISP) trial, which compared high dose and low dose multivitamin therapy. We utilized weighted methods to analyze time-to-event outcomes with censoring. The primary outcomes of interest were time to nonfatal stroke, nonfatal coronary events, and death. We calculated modified Kaplan-Meier (KM) curves for each intervention group. We also performed a modified log-rank test to assess significant differences based on the weighted KM curves. The analysis included 3668 VISP trial participants, and most remained event-free throughout the study period. The TCE KM curve showed no significant difference in outcomes between high dose and low dose groups. Similarly, the WCE KM curves, with different weights assigned to each outcome, did not reveal significant differences in outcomes between the studied groups. CONCLUSION: This post-hoc analysis confirms the negative trial results of VISP and demonstrates the feasibility of using WCE in assessing nutrition-based interventions for stroke prevention.

Trends in intravenous thrombolysis utilization for acute ischemic stroke based on hospital size: Paul Coverdell National Acute Stroke Program, 2010-2019.

INTRODUCTION: The rate of intravenous thrombolysis (IVT) utilization in acute ischemic stroke (AIS) has been increasing, and this has coincided with improved door-to-needle times (DNTs). Smaller hospitals have been observed to utilize IVT less frequently or even not at all. Using a multistate stroke registry, we sought to determine the impact of hospital size on trends in IVT utilization for AIS. METHODS: Utilizing data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT for AIS patients between 2010 and 2019 based on hospital size. Hospitals were grouped into quartiles based on size. We studied the impact of hospital size on DNTs and overall IVT utilization. RESULTS: During the study period, there were 530,828 AIS patients (mean age 70.3 ± 0.02 years, 50.4% men) from 540 participating hospitals. We did not identify a significant trend in IVT utilization among hospitals within the first quartile (p = 0.1005), but there were significantly increased trends within the hospitals belonging to the second, third, and fourth quartiles (p < 0.001 for all). All quartiles were observed to have significantly increased trends in DNTs ≤60 min (p < 0.0001), but only hospitals within the second, third, and fourth quartiles experienced significantly increased trends in DNTs ≤45 min (p < 0.0001). CONCLUSION: In our registry-based analysis, we observed an increased trend in IVT utilization for AIS among larger hospitals. There was an overall improvement in rates of DNTs ≤60 min, but only larger hospitals were observed to have improved DNTs ≤45 min.

Validation of a neurovascular comorbidity index for risk adjustment of comorbid conditions among ischemic stroke patients receiving reperfusion treatment.

OBJECTIVE: To validate a comorbidity index specific to neurovascular patients and determine its performance relative to the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) among ischemic stroke patients receiving reperfusion treatments. METHODS: Patients with ischemic stroke were identified in the National Inpatient Sample from Quarter 4 2015 to Quarter 4 2017. Ischemic stroke patients receiving reperfusion treatment, either with intravenous thrombolysis (IVT) only or mechanical thrombectomy (MT), were studied. The accuracy of the neurovascular comorbidities index (NCI) was compared to both the CCI and ECI in predicting in-hospital death and poor outcome (defined as death prior to discharge or discharge to a short-term hospital, a skilled nursing facility, an intermediate care facility, another long-term facility, or home health care). RESULTS: There were 25,147 ischemic stroke patients who received reperfusion therapy with either IVT only or MT (with or without IVT). Approximately 6.9% of patients died during their hospitalization, and 65.4% of patients were classified as having a poor outcome based on their discharge disposition. The NCI outperformed both the CCI and ECI in predicting in-hospital death (IVT only, p<0.0001; MT, p<0.0001) and poor outcomes (IVT only, p<0.0001; MT, p<0.0001). CONCLUSION: The NCI is a more powerful predictor of in-hospital death and poor outcomes when compared to the CCI or ECI among ischemic stroke patients receiving reperfusion therapies. Further validation studies are needed to confirm the accuracy of the NCI among other neurovascular patient populations.

Contemporary Trends in the Treatment of Mild Ischemic Stroke with Intravenous Thrombolysis: Paul Coverdell National Acute Stroke Program.

BACKGROUND: Presentation with mild symptoms is a common reason for intravenous thrombolysis (IVT) nonuse among acute ischemic stroke (AIS) patients. We examined the impact of IVT on the outcomes of mild AIS over time. METHODS: Using the Paul Coverdell National Stroke Program data, we examined trends in IVT utilization from 2010 to 2019 among AIS patients presenting with National Institutes of Health Stroke Scale (NIHSS) scores ≤5. Outcomes adjudicated included rates of discharge to home and ability to ambulate independently at discharge. We used generalized estimating equation models to examine the effect of IVT on outcomes of AIS patients presenting with mild symptoms and calculated adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: During the study period, 346,762 patients presented with mild AIS symptoms. Approximately 6.2% were treated with IVT. IVT utilization trends increased from 3.7% in 2010 to 7.7% in 2019 (p < 0.001). Patients treated with IVT had higher median NIHSS scores upon presentation (IVT 3 [2, 4] vs. no IVT 2 [0, 3]). Rates of discharge to home (AOR 2.06, 95% CI: 1.99-2.13) and ability to ambulate at time of discharge (AOR 1.82, 95% CI: 1.76-1.89) were higher among those treated with IVT. CONCLUSION: There was an increased trend in IVT utilization among AIS patients presenting with mild symptoms. Utilization of IVT increased the odds of being discharged to home and the ability to ambulate at discharge independently in patients with mild stroke.

Emergency Medical Services Utilization for Acute Stroke Care: Analysis of the Paul Coverdell National Acute Stroke Program, 2014-2019.

Objective: Emergency medical service (EMS) transportation after acute stroke is associated with shorter symptom-to-arrival times and more rapid medical attention when compared to patient transportation by private vehicle. Methods: We analyzed data from the Paul Coverdell National Acute Stroke Program from 2014 to 2019 among stroke (ischemic and hemorrhagic) and transient ischemic attack (TIA) patients to examine patterns in EMS utilization. Results: Of 500,829 stroke and TIA patients (mean age 70.9 years, 51.3% women) from 682 participating hospitals during the study period, 60% arrived by EMS. Patients aged 18-64 years vs. ≥65 years (AOR 0.67) were less likely to utilize EMS. Severe stroke patients (AOR 2.29, 95%CI, 2.15-2.44) and hemorrhagic stroke patients vs. ischemic stroke patients (AOR 1.47, 95% CI, 1.43-1.51) were more likely to utilize EMS. Medicare (AOR 1.35, 95% CI, 1.32-1.38) and Medicaid (AOR 1.41, 95% CI, 1.37-1.45) beneficiaries were more likely than privately insured patients to utilize EMS, but no difference was found between no insurance/self-pay patients and privately insured patients on EMS utilization. Overall, there was a decreasing trend in the utilization of EMS (59.6% to 59.3%, p = 0.037). The decreasing trend was identified among ischemic stroke (p < 0.0001) patients but not among TIA (p = 0.89) or hemorrhagic stroke (p = 0.44) patients. There was no observed trend in pre-notification among stroke patients' arrival by EMS across the study period (56.9% to 56.5%, p = 0.99). Conclusions: Strategies to help increase stroke awareness and utilization of EMS among those with symptoms of stroke should be considered in order to help improve stroke outcomes.

COVID-19 Pandemic and Quality of Care and Outcomes of Acute Stroke Hospitalizations: the Paul Coverdell National Acute Stroke Program.

INTRODUCTION: Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic. METHODS: We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre-COVID-19 (week 11-24 in 2019) and COVID-19 (week 11-24 in 2020). We used χ2 tests for differences in categorical variables and the Wilcoxon-Mann-Whitney rank test or Kruskal-Wallis test for continuous variables. RESULTS: We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre-COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre-COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre-COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period. CONCLUSION: Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures.

Outcomes of Homeless Ischemic Stroke Patients Receiving Intravenous Thrombolysis in the United States.

BACKGROUND: Morbidity and mortality among homeless people with cardiovascular diseases and stroke in the United States is high. Adverse outcomes within the homeless population may be the result of seeking care too late to receive time-sensitive interventions. We sought to investigate the impact of homelessness on ischemic stroke patients who received intravenous thrombolysis (IVT). METHODS: We determined rates of post-thrombolytic intracranial hemorrhage (ICH), in-hospital death, and development of moderate to severe disability among homeless ischemic stroke patients treated with IVT. Patients were identified using the Nationwide (National) Inpatient Sample between 2002 and 2017. We compared rates of the various outcomes to non-homeless ischemic stroke patients treated with IVT. RESULTS: There were 514 homeless (mean age 54.7 ± 10.2 years, 20.4% women) and 364,408 non-homeless (mean age 68.6 ± 14.7 years, 49.7% women) ischemic stroke patients who received IVT. There was no difference in post-thrombolytic ICH rates between the two groups (6.6% homeless versus 8.8% non-homeless, p = 0.09). Homeless patients were more frequently discharged to self-care (p = 0.003). Homeless patients were less likely than non-homeless patients to suffer in-hospital death (AOR 0.499 [95% CI 0.30-0.84], p = 0.009) and moderate to severe disability (AOR 0.423 [95% CI 0.29 - 0.62], p < 0.001). CONCLUSION: Homeless ischemic stroke patients who receive IVT are not at an increased risk of developing post-thrombolytic ICH or in-hospital death. Efforts are needed to encourage this unique population to seek medical attention as soon as possible for time-sensitive interventions that may decrease the risk of permanent disability or death associated with ischemic stroke.

Effect of Insurance Status on Outcomes of Acute Ischemic Stroke Patients Receiving Intra-Arterial Treatment: Results from the Paul Coverdell National Acute Stroke Program.

BACKGROUND: Stroke continues to be a leading cause of death and disability in the United States. Rates of intra-arterial reperfusion treatments (IAT) for acute ischemic stroke (AIS) are increasing, and these treatments are associated with more favorable outcomes. We sought to examine the effect of insurance status on outcomes for AIS patients receiving IAT within a multistate stroke registry. METHODS: We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) from 2014 to 2019 to quantify rates of IAT (with or without intravenous thrombolysis) after AIS. We modeled outcomes based on insurance status: private, Medicare, Medicaid, or no insurance. Outcomes were defined as rates of discharge to home, in-hospital death, symptomatic intracranial hemorrhage (sICH), or life-threatening hemorrhage during hospitalization. RESULTS: During the study period, there were 486,180 patients with a clinical diagnosis of AIS (mean age 70.6 years, 50.3% male) from 674 participating hospitals in PCNASP. Only 4.3% of patients received any IAT. As compared to private insurance, uninsured patients receiving any IAT were more likely to experience in-hospital death (AOR 1.36 [95% CI 1.07-1.73]). Medicare (AOR 0.78 [95% CI 0.71-0.85]) and Medicaid (AOR 0.85 [95% CI 0.75-0.96]) beneficiaries were less likely but uninsured patients were more likely (AOR 1.90 [95% CI 1.61-2.24]) to be discharged home. Insurance status was not found to be independently associated with rates of sICH. CONCLUSIONS: Insurance status was independently associated with in-hospital death and discharge to home among AIS patients undergoing IAT.

Predictive value of discharge destination for 90-day outcomes among ischemic stroke patients eligible for endovascular treatment: Post-hoc analysis of DEFUSE 3.

BACKGROUND: The endovascular treatment (ET) for acute ischemic stroke (AIS) is increasing among eligible patients. To help address care quality, administrative data sets are utilized but do not usually include formal outcome scales. We explore the predictive ability of discharge destination from acute hospitalizations for long-term disability among AIS patients eligible for ET within a clinical trial. METHODS: We analyzed publicly available data from the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial. We evaluated patients who survived beyond the time of discharge from their acute hospitalizations. We calculated positive and negative predictive values and accompanying likelihood ratios for patients discharged to home, inpatient rehabilitation facility (IRF), or subacute nursing facility (SNF) for unfavorable outcome as defined by modified Rankin Scale (mRS) scores ≥3 at 90-days. RESULTS: Our final analysis included 127 patients (median age 67 [23-89] years, 51.2% men). There were 23.6% patients discharged home, 53.5% to IRF, and 22.8% to SNF. Approximately 61% of patients had 90-day post-stroke mRS scores ≥3. Patients discharged to SNF had the highest positive predictive value (93.1%) and positive likelihood ratio (8.77 [CI 95% 2.18-35.25]) for unfavorable outcome. Discharge to home had the highest negative likelihood ratio (2.09 [CI 95% 1.54-2.83]) for unfavorable outcome. CONCLUSIONS: Among AIS patients eligible for ET within the DEFUSE 3 trial, discharge destination can provide high predictive value of 90-day functional outcomes. A discharge to SNF is highly predictive of long-term unfavorable outcomes.

Prevalence of atrial fibrillation with insertable cardiac monitors in cryptogenic stroke: A single-center experience.

BACKGROUND: The use of insertable cardiac monitors (ICM) has increased the rate of detection of atrial fibrillation (AF) among cryptogenic stroke (CS) patients. We describe a single-center experience for AF detection among CS patients receiving ICMs upon discharge after the index stroke event and attempt to identify predictors for AF detection. METHODS: From April 2014 to October 2017, patients receiving ICMs for CS who underwent >60 days of monitoring were reviewed. Chronic underlying medical illnesses, presence of left atrial enlargement (LAE) on echocardiography, and PR interval on admission electrocardiogram were assessed as predictors of AF detection. RESULTS: A total of 234 patients (median age 72 [61, 78] years, 45% women) met inclusion criteria and were followed for a median of 536 [282, 848] days. Among studied patients, 68 patients (29%) were found to have AF at a median of 94.5 [16, 239] days from ICM placement. CS patients with AF were significantly older (p < 0.001), and there was a significantly higher proportion of women (p = 0.003) when compared to CS patients without AF. Neither presence of LAE nor prolonged PR interval was predictive of AF detection. CONCLUSION: Almost one-third of CS patients monitored with an ICM were found to have previously undiagnosed AF. CS patients found to have AF were older and more commonly women. Prospective studies are needed to better identify predictors for early AF among the broader population of all CS patients.

Patterns of treatment and associated short-term outcomes of unruptured intracranial aneurysms in children.

BACKGROUND: The rates and outcomes of treatments for intracranial aneurysms have not been exclusively determined within the pediatric population. We determined the rates of endovascular and microsurgical treatments for unruptured intracranial aneurysms (UIA) and associated rates of favorable outcome in patients aged <18 years. METHODS: We analyzed data obtained as part of the Kids' Inpatient Database between 2003 and 2009 with primary diagnosis of UIA. Patients undergoing endovascular treatment were compared to those undergoing microsurgical treatment. We determined rates of intracerebral hemorrhage, subarachnoid hemorrhage, neurological complications, and favorable outcome. RESULTS: There were 818 cases of UIA during the study period. A total of 111 patients (mean age 14 ± 6 years, 37.6 % female) underwent microsurgical treatment, and another 200 patients (mean age 13 ± 7 years, 42.5 % female) underwent endovascular treatment. A high rate of favorable outcome was observed in patients who received either treatment (microsurgical treatment 87.7 % versus endovascular treatment 91.6 %, p = 0.4). There was a trend towards a significantly shorter mean hospitalization stay among those who received endovascular treatment compared with microsurgical treatment (6 ± 12 versus 9 ± 11 days, p = 0.06). There was a significant trend towards higher utilization of endovascular treatment as opposed to microsurgical treatment from 2003 to 2009 (p = 0.02). CONCLUSIONS: Although outcomes except for length of stay were comparable between endovascular treatment and microsurgical treatment patients, there was a trend towards higher utilization of endovascular treatment among children with UIAs from 2003 to 2009.

Acute stroke reperfusion therapy trends in the expanded treatment window era.

BACKGROUND: The American Heart Association/American Stroke Association (AHA/ASA) recommended an expansion of the time window for acute ischemic stroke (AIS) reperfusion with intravenous (IV) recombinant tissue plasminogen activator (rt-PA) from 3 to 4.5 hours after symptom onset. We examine rates of IV and intra-arterial (IA) reperfusion before and after the recommendations to track guideline adoption in community practice. METHODS: Patients with AIS in the Paul Coverdell National Acute Stroke Registry spanning years 2007-2012 were identified. Trends in rates of IV rt-PA versus IA therapy were examined. Outcomes included symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, ability to ambulate at discharge, and discharge destination. RESULTS: From 2007 to 2012, there were 182,235 AIS patients (median age, 72 years; 51.5% women) in the database at the time of analysis. AIS patients receiving IV rt-PA increased significantly from 3.7% in 2007 to 5.1% in 2012 in the ≤3 hours time window and from .2% in 2007 to 1.3% in 2012 in the 3-4.5 hours time window (P < .001 for both). There was also a significant increase in the rate of IA therapy between 2007 and 2012 (P < .001). There was a significant decrease in the rate of sICH among patients who received any reperfusion between 2007 and 2012. CONCLUSIONS: There was a trend for increased utilization of IV rt-PA in the 0-3 hours and the 3-4.5 hours time windows, which began around the same time as the publication of AHA/ASA recommendations in 2009. This increase was associated with an increase in IA treatment rates along with a decrease in overall sICH rates for patients receiving any reperfusion.

Thrombolysis for ischemic stroke associated with infective endocarditis: results from the nationwide inpatient sample.

BACKGROUND AND PURPOSE: Cerebral ischemic events are highly prevalent and associated with high rates of death and disability in patients with infective endocarditis (IE). However, the role of thrombolysis in these patients remains unclear. We sought to determine the rates and outcomes of acute ischemic stroke patients with IE treated with intravenous thrombolysis (IVT). METHODS: We determined the rates of post-thrombolytic intracerebral hemorrhage and favorable outcome among acute ischemic stroke patients with IE treated with IVT. Patients were identified using Nationwide Inpatient Sample data from 2002 to 2010. We compared the rates of various outcomes with ischemic stroke patients without IE treated with IVT. RESULTS: There were 222 patients (mean age 59±18 years; 46% women) who were treated with IVT for acute ischemic stroke associated with IE and 134,048 patients (mean age 69±15 years; 49% women) who were treated for stroke without IE. The rate of post-thrombolytic intracerebral hemorrhage was significantly higher in patients with IE compared with those without IE (20% versus 6.5%; P=0.006). There was a significantly lower rate of favorable outcome in the IE group (10% versus 37%; P=0.01). CONCLUSIONS: High rates of post-thrombolytic intracerebral hemorrhage and low rates of favorable outcome mandate caution in using IVT in acute ischemic stroke patients with IE.

Adherence to guidelines by emergency medical services during transport of stroke patients receiving intravenous thrombolytic infusion.

BACKGROUND: The "drip and ship" paradigm among acute ischemic stroke (AIS) patients has resulted in expansion of thrombolytic treatment in patients eligible for intravenous (IV) recombinant tissue plasminogen activator (rt-PA). It remains controversial whether the settings within the emergency medical services (EMS) transport are adequate for IV rt-PA infusion. We sought to determine EMS adherence to guidelines during the transport of drip and ship AIS patients treated with IV rt-PA while being transferred to comprehensive stroke centers (CSCs) and the effect of nonadherence on outcome upon discharge. METHODS: A retrospective evaluation of patients transferred to our CSC was conducted to determine the rates of adherence to quality parameters during EMS transport with infusion of IV rt-PA. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 1 upon discharge. RESULTS: Among the 40 patients studied (55% men; mean age 71.9 ± 13.9 years), 38 patients received vital sign monitoring at 10- to 20-minute intervals. The mean transit time was 37.7 ± 20.2 minutes. Of the 39 patients with blood pressure (BP) monitoring, 7 patients had at least 1 episode of BP elevation above the recommended parameters (>180/105 mm Hg); only 1 of those was treated with an antihypertensive agent. Five of the 40 patients were considered to have worsened between the outside ED and CSC ED evaluations without IV rt-PA discontinuation during transfer. The rate of favorable outcome of patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP >180/105 mm Hg without antihypertensive treatment was similar to those who experienced neither event (41.7% and 35.7%; P = .736). CONCLUSIONS: Efforts are required to improve EMS adherence to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of the "drip and ship" paradigm.

Venous thromboembolism among Medicare acute ischaemic stroke patients with and without COVID-19.

BACKGROUND: COVID-19 is associated with an increased risk of venous thromboembolism (VTE). This study examined the prevalence of VTE among acute ischaemic stroke (AIS) patients with and without a history of COVID-19. METHODS: We identified AIS hospitalisations of Medicare fee-for-service (FFS) beneficiaries aged ≥65 years from 1 April 2020 to 31 March 2022. We compared the prevalence and adjusted prevalence ratio of VTE among AIS patients with and without a history of COVID-19. RESULTS: Among 283 034 Medicare FFS beneficiaries with AIS hospitalisations, the prevalence of VTE was 4.51%, 2.96% and 2.61% among those with a history of hospitalised COVID-19, non-hospitalised COVID-19 and without COVID-19, respectively. As compared with patients without a history of COVID-19, the prevalence of VTE among patients with a history of hospitalised or non-hospitalised COVID-19 were 1.62 (95% CI 1.54 to 1.70) and 1.13 (95% CI 1.03 to 1.23) times greater, respectively. CONCLUSIONS: There appeared to be a notably higher prevalence of VTE among Medicare beneficiaries with AIS accompanied by a current or prior COVID-19. Early recognition of coagulation abnormalities and appropriate interventions may help improve patients' clinical outcomes.

Effect of Intensive Glucose Control on Outcomes of Hyperglycemic Stroke Patients Receiving Mechanical Thrombectomy: Secondary Analysis of the SHINE Trial.

BACKGROUND: Hyperglycemia is common among patients presenting with acute ischemic stroke (AIS) and is associated with poor clinical outcomes. We studied the effects of intensive blood glucose control among AIS patients presenting with hyperglycemia treated with mechanical thrombectomy (MT). METHODS: We analyzed publicly available data from the Stroke Hyperglycemia Insulin Network Effort trial. In this nonpreplanned secondary analysis, we compared hyperglycemic AIS patients treated with MT who received intensive blood glucose control (80 to 130 mg/dL) with those who received standard blood glucose control (80 to 179 mg/dL). Outcomes included rates of favorable 90-day outcome (modified Rankin Scale score ≤2) and death. RESULTS: This analysis included 146 patients (74 in the intensive treatment group and 72 in the standard treatment group). Intensive blood glucose was not associated with higher rates of 90-day favorable outcomes (intensive 31.1% vs. standard 30.6%, P =1.0; odds ratio 1.025, 95% confidence interval 0.51 to 2.07) or a decrease in rates of death (intensive 20.3% vs. standard 22.2%, P =0.84; odds ratio 0.98, 95% confidence interval 0.40 to 1.97). CONCLUSIONS: Intensive blood glucose control among AIS patients presenting with hyperglycemia and treated with MT was not associated with lower rates of death or higher rates of long-term favorable outcomes when compared with standard treatment.

Quality of life among ischemic stroke patients eligible for endovascular treatment: analysis of the DEFUSE 3 trial.

BACKGROUND: The endovascular treatment (ET) for acute ischemic stroke is increasing among eligible patients. Assessing patients' perspectives on quality of life (QOL) can supplement the use of formal outcome scales and enable the assessment of outcomes across multiple domains affected by stroke. METHODS: We analyzed publicly available data from the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke (DEFUSE 3) trial. We evaluated patients who survived beyond the time of discharge from their acute hospitalizations and completed all Neuro-QOL short forms at 90-day follow-up. RESULTS: Our final analysis included 128 patients (median age 67 [range 23-90] years, 50.8% men). As modified Rankin Scale (mRS) scores increased, there was a consistent increase in the severity of Neuro-QOL measures. T-scores for mobility, cognitive function, and the ability to participate in social roles declined significantly while depression T-scores increased significantly. We found that QOL T-scores for patients with mRS 3 did not differ significantly from T-scores for patients with mRS 2 in any domain. CONCLUSIONS: Among ischemic stroke patients eligible for ET, QOL scores help validate and supplement quantitatively measured outcomes.

Trends in hospital procedure volumes for intra-arterial treatment of acute ischemic stroke: results from the paul coverdell national acute stroke program.

BACKGROUND: Rates of intra-arterial revascularization treatments (IAT) for acute ischemic stroke (AIS) are increasing in the USA. Using a multi-state stroke registry, we studied the trend in IAT use among patients with AIS over a period spanning 11 years. We examined the impact of IAT rates on hospital procedure volumes and patient outcome after stroke. METHODS: We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) and explored trends in IAT between 2008 and 2018. Patient outcomes were examined by rates of IAT procedures across hospitals. Specifically, outcomes were compared across low-volume (<15 IAT per year), medium-volume (15-30 IAT per year), and high-volume hospitals (>30 IAT per year). Favorable outcome was defined as discharge to home. RESULTS: There were 612 958 patients admitted with AIS to 687 participating hospitals within the PCNASP during this study. Only 2.9% of patients (mean age 68.5 years, 49.3% women) received IAT. The percent of patients with AIS receiving IAT increased from 1% in 2008 to 5.3% in 2018 (p<0.001). The proportion of low-volume hospitals decreased over time (p<0.001), and the proportions of medium-volume (p=0.007) and high-volume hospitals (p<0.001) increased between 2008 and 2018. When compared with medium-volume hospitals, high-volume hospitals had a higher (p<0.0001) and low-volume hospitals had a lower (p<0.0001) percent of patients discharged to home. CONCLUSION: High-volume hospitals were associated with a higher rate of favorable outcome. With the increased use of IAT among patients with AIS, the proportion of low-volume hospitals performing IAT significantly decreased.

Current trends in the acute treatment of ischemic stroke: analysis from the Paul Coverdell National Acute Stroke Program.

BACKGROUND: The intra-arterial treatment (IAT) of acute ischemic stroke (AIS) is now evidence-based and given the highest level of recommendation among eligible patients. Using a multi-state stroke registry, we studied the trend in IAT among patients with AIS over 11 years and its impact on the utilization of intravenous thrombolysis (IVT) within the same 11 years. METHODS: Using data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT and IAT for patients with AIS between 2008 and 2018. Trends over time were examined for rates of IVT only, IAT only, or a combination of IVT and IAT (IVT+IAT). Favorable outcome was defined as discharge to home. RESULTS: During the study period there were 595 677 patients (mean age 70.4 years, 50.4% women) from 646 participating hospitals with a clinical diagnosis of AIS in the PCNASP. Trends for IVT only, IAT only, and IVT+IAT all significantly increased over time (P<0.001). Total use of IVT and IAT increased from 7% in 2008 to 19.1% in 2018. The rate of patients discharged to home increased significantly over time among all treatment groups (P<0.001). CONCLUSION: In our large registry-based analysis, we observed a significant increase in the use of IAT for the treatment of AIS, with continued increases in the use of IVT. Concurrently, the percent of patients with favorable outcomes continued to increase.