Dysautonomia and activity in the early stroke recovery period.

Maintaining cerebral perfusion in the early stages of recovery after stroke is paramount. Autoregulatory function may be impaired during this period leaving cerebral perfusion directly reliant on intravascular volume and blood pressure (BP) with increased risk for expanding cerebral infarction during periods of low BP and hemorrhagic transformation during BP elevations. We suspected that dysautonomia is common during the acute period related to both pre-existing vascular risk factors and potentially independent of such conditions. Thus, we sought to understand the state of the science specific to dysautonomia and acute stroke. The scoping review search included multiple databases and key terms related to acute stroke and dysautonomia. The team employed a rigorous review process to identify, evaluate, and summarize relevant literature. We additionally summarized common clinical approaches used to detect dysautonomia at the bedside. The purpose of this scoping review is to understand the state of the science for the identification, treatment, and impact of dysautonomia on acute stroke patient outcomes. There is a high prevalence of dysautonomia among persons with stroke, though there is significant variability in the type of measures and definitions used to diagnose dysautonomia. While dysautonomia appears to be associated with poor functional outcome and post-stroke complications, there is a paucity of high-quality evidence, and generalizability is limited by heterogenous approaches to these studies. There is a need to establish common definitions, standard measurement tools, and a roadmap for incorporating these measures into clinical practice so that larger studies can be conducted.

Providers' Perceptions of Neurology Care Delivered Through Telemedicine Technology.

Background: The COVID-19 pandemic and subsequent acceleration of telemedicine usage allowed many neurologists to trial telemedicine for neurological care. The purpose of this study is to explore neurology providers' experiences with delivering telemedicine care during the COVID-19 pandemic. Methods: Semistructured video interviews were conducted with 27 neurology providers who practice at a single, urban academic center. Interviews were transcribed and analyzed for content and themes. Results: Five major themes were identified: virtual examination subspecialty differences, tips and tricks for the virtual examination, improved infrastructure needs, future technologies that could support the virtual examination, and preferences for the postpandemic telemedicine protocol. Subspecialists who described their visits as more focused on behavioral examination and obtaining patient history reported fewer limitations with delivering neurological care through telemedicine platforms. Conclusions: The implementation of a telemedicine system should reflect the needs of each neurology subspecialty. Funding is needed to improve logistical infrastructure for health providers' telemedicine visits, such as technical and administrative assistance, as well as creation and testing of technologies to support physical examination in the virtual environment.

Acute Viral Illnesses and Ischemic Stroke: Pathophysiological Considerations in the Era of the COVID-19 Pandemic.

The severe acute respiratory syndrome coronavirus 2 or coronavirus disease 2019 (COVID-19) pandemic has raised concerns about the correlation with this viral illness and increased risk of stroke. Although it is too early in the pandemic to know the strength of the association between COVID-19 and stroke, it is an opportune time to review the relationship between acute viral illnesses and stroke. Here, we summarize pathophysiological principles and available literature to guide understanding of how viruses may contribute to ischemic stroke. After a review of inflammatory mechanisms, we summarize relevant pathophysiological principles of vasculopathy, hypercoagulability, and hemodynamic instability. We will end by discussing mechanisms by which several well-known viruses may cause stroke in an effort to inform our understanding of the relationship between COVID-19 and stroke.

Transcranial Doppler in Acute COVID-19 Infection: Unexpected Associations.

BACKGROUND AND PURPOSE: Stroke may complicate coronavirus disease 2019 (COVID-19) infection based on clinical hypercoagulability. We investigated whether transcranial Doppler ultrasound has utility for identifying microemboli and clinically relevant cerebral blood flow velocities (CBFVs) in COVID-19. METHODS: We performed transcranial Doppler for a consecutive series of patients with confirmed or suspected COVID-19 infection admitted to 2 intensive care units at a large academic center including evaluation for microembolic signals. Variables specific to hypercoagulability and blood flow including transthoracic echocardiography were analyzed as a part of routine care. RESULTS: Twenty-six patients were included in this analysis, 16 with confirmed COVID-19 infection. Of those, 2 had acute ischemic stroke secondary to large vessel occlusion. Ten non-COVID stroke patients were included for comparison. Two COVID-negative patients had severe acute respiratory distress syndrome and stroke due to large vessel occlusion. In patients with COVID-19, relatively low CBFVs were observed diffusely at median hospital day 4 (interquartile range, 3-9) despite low hematocrit (29.5% [25.7%-31.6%]); CBFVs in comparable COVID-negative stroke patients were significantly higher compared with COVID-positive stroke patients. Microembolic signals were not detected in any patient. Median left ventricular ejection fraction was 60% (interquartile range, 60%-65%). CBFVs were correlated with arterial oxygen content, and C-reactive protein (Spearman ρ=0.28 [P=0.04]; 0.58 [P<0.001], respectively) but not with left ventricular ejection fraction (ρ=-0.18; P=0.42). CONCLUSIONS: In this cohort of critically ill patients with COVID-19 infection, we observed lower than expected CBFVs in setting of low arterial oxygen content and low hematocrit but not associated with suppression of cardiac output.

Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage.

PURPOSE: Evidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs). METHODS: Patients admitted to the NCCU who had an EVD placed for cerebrospinal fluid drainage and intracranial pressure (ICP) monitoring underwent supine CE therapy with passive and active cycling settings. Neurologic status, ICP and hemodynamic parameters were monitored before and after each CE session. RESULTS: Twenty-seven patients successfully underwent in-bed CE in the NCCU. No clinically significant changes were recorded in neurologic or in physiological parameters before or after CE. There were no device dislodgements or other adverse effects requiring cessation of a CE session. CONCLUSION: These data suggest that supine CE in a heterogeneous cohort of neurocritical care patients with EVDs is safe and tolerable. Larger prospective studies are needed to determine the efficacy and optimal dose and timing of supine CE in neurocritical care patients.

Safety and Feasibility of a Neuroscience Critical Care Program to Mobilize Patients With Primary Intracerebral Hemorrhage.

OBJECTIVE: To measure the impact of a progressive mobility program on patients admitted to a neurocritical critical care unit (NCCU) with intracerebral hemorrhage (ICH). The early mobilization of critically ill patients with spontaneous ICH is a challenge owing to the potential for neurologic deterioration and hemodynamic lability in the acute phase of injury. Patients admitted to the intensive care unit have been excluded from randomized trials of early mobilization after stroke. DESIGN: An interdisciplinary working group developed a formalized NCCU Mobility Algorithm that allocates patients to incremental passive or active mobilization pathways on the basis of level of consciousness and motor function. In a quasi-experimental consecutive group comparison, patients with ICH admitted to the NCCU were analyzed in two 6-month epochs, before and after rollout of the algorithm. Mobilization and safety endpoints were compared between epochs. SETTING: NCCU in an urban, academic hospital. PARTICIPANTS: Adult patients admitted to the NCCU with primary intracerebral hemorrhage. INTERVENTION: Progressive mobilization after stroke using a formalized mobility algorithm. MAIN OUTCOME MEASURES: Time to first mobilization. RESULTS: The 2 groups of patients with ICH (pre-algorithm rolllout, n=28; post-algorithm rollout, n=29) were similar on baseline characteristics. Patients in the postintervention group were significantly more likely to undergo mobilization within the first 7 days after admission (odds ratio 8.7, 95% confidence interval 2.1, 36.6; P=.003). No neurologic deterioration, hypotension, falls, or line dislodgments were reported in association with mobilization. A nonsignificant difference in mortality was noted before and after rollout of the algorithm (4% vs 24%, respectively, P=.12). CONCLUSIONS: The implementation of a progressive mobility algorithm was safe and associated with a higher likelihood of mobilization in the first week after spontaneous ICH. Research is needed to investigate methods and the timing for the first mobilization in critically ill stroke patients.

Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage.

BACKGROUND: Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs. METHODS: A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions. RESULTS: All mobility interventions were completed without any adverse event or clinically detectable change in the patient's neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout. CONCLUSION: Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.

Racial and Socioeconomic Disparities in Gastrostomy Tube Placement After Intracerebral Hemorrhage in the United States.

BACKGROUND AND PURPOSE: Percutaneous endoscopic gastrostomy (PEG) tubes are widely used for enteral feeding of patients after intracerebral hemorrhage (ICH). We sought to determine whether PEG placement after ICH differs by race and socioeconomic status. METHODS: Patient discharges with ICH as the primary diagnosis from 2007 to 2011 were queried from the Nationwide Inpatient Sample. Logistic regression was used to evaluate the association between race, insurance status, and household income with PEG placement. RESULTS: Of 49 946 included ICH admissions, a PEG was placed in 4464 (8.94%). Among PEG recipients, 47.2% were minorities and 15.6% were Medicaid enrollees, whereas 33.7% and 8.2% of patients without a PEG were of a race other than white and enrolled in Medicaid, respectively (P<0.001). Compared with whites, the odds of PEG were highest among Asians/Pacific Islanders (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.32-1.99) and blacks (OR 1.42, 95% CI 1.28-1.59). Low household income (OR 1.25, 95% CI 1.09-1.44 in lowest compared with highest quartile) and enrollment in Medicaid (OR 1.36, 95% CI 1.17-1.59 compared with private insurance) were associated with PEG placement. Racial disparities (minorities versus whites) were most pronounced in small/medium-sized hospitals (OR 1.77, 95% CI 1.43-2.20 versus OR 1.31, 95% CI 1.17-1.47 in large hospitals; P value for interaction 0.011) and in hospitals with low ICH case volume (OR 1.58, 95% CI 1.38-1.81 versus OR 1.29, 95% CI 1.12-1.50 in hospitals with high ICH case volume; P value for interaction 0.007). CONCLUSIONS: Minority race, Medicaid enrollment, and low household income are associated with PEG placement after ICH.

Socialize, Eat More, and Feel Better: Communal Eating in Acute Neurological Care.

OBJECTIVE: Stroke commonly leads to feelings of isolation and loneliness, especially during the hospital period. The aim of the Communal Eating program was to support patient well-being through introducing opportunities for patients to eat lunch together. DESIGN: Patients admitted to the Brain Rescue Unit who were identified as appropriate by their attending physicians, nurses, or other clinicians were recruited to attend communal lunch. Their mood, quality of life, loneliness, communication, swallowing safety, and eating behavior were examined. RESULTS: Those who attended two or more sessions tended to have been lonelier and more psychosocially impaired at baseline. Patients who had one or fewer lunch showed no significant differences from baseline to posthospitalization on any measure. However, for those who ate two or more lunches, changes in loneliness and quality of life trended toward improvement. There was scant evidence of changes to communication or eating habits. CONCLUSION: Implementing a communal eating program in the acute hospital setting was very feasible and widely supported by patients, families, and staff. The results thus far show modest trends toward fulfilling the goal of supporting emotional well-being, while potentially supporting increased intake and, importantly, do not evidence any measurable harm.

Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity.

Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.

Fever, Cognitive Decline, and Multifocal T2 Hyperintensities on Brain MRI: A Case Report of Cytokine Release Syndrome.

Cytokine release syndrome (CRS) is a systemic inflammatory response characterized by fever, constitutional symptoms, and multiorgan dysfunction. While most commonly associated with immunotherapy, CRS can also be incited by infections or drugs. This case details the presentation and evaluation of a 71-year-old woman with a history of primary myelofibrosis and breast cancer who presented with acute onset of altered mental status. Initial vital signs were notable for severe hypertension, tachycardia, and fever. The patient was alert and oriented only to self, with little verbal output, and spontaneously moving all extremities. The patient had a submandibular gland abscess that had been diagnosed prior to presentation via a computed tomography scan of the neck. A comprehensive analysis, including blood tests, cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG), and neuroimaging, was performed. Severe leukocytosis was noted and brain MRI demonstrated scattered areas of diffusion restriction and diffuse T2 white matter hyperintensities. Serial imaging demonstrated the progression of T2 hyperintensities. Ultimately, CRS was the most likely diagnosis. In this case, the inciting event was likely an infectious etiology, suspected to be the submandibular gland abscess that was present at the time of admission. It is vital to have a high index of suspicion for CRS in patients with recent infection, drug exposure, or immune dysregulation.

Development and Implementation of a New Model of Care for Patients With Stroke, Acute Hospital Rehabilitation Intensive SErvices: Leveraging a Multidisciplinary Rehabilitation Team.

ABSTRACT: The optimal timing and intensity of early rehabilitation remain uncertain. The literature has stated that too early high-intensity mobility within 24 hours can result in poor outcomes as compared with the 24- to 48-hour poststroke (Stroke 2012;43:2389-94. Stroke 2004;35:1005-9). However, few studies have shown that mobilizing patients a few times per day can have positive results (Stroke 2004;35:1005-9. Cerebrovasc Dis 2010;29:352-60). In addition to mobility impairments, many patients after stroke have dysphagia, aphasia, and cognitive-linguistic deficits. To date, there is limited literature on early rehabilitation in these areas. Here, we describe a program of enhanced rehabilitation in the acute care hospital. In this enhanced model of care, our team delivers up to six sessions of therapy per day focused on the patient's deficits. A patient can receive up to two sessions of each discipline daily to include physical therapy, occupational therapy, and speech language pathology. The model emphasizes team collaboration between therapy disciplines, physiatry, nursing, and neurology accomplished through a daily therapy schedule, rehabilitation huddle, and direct communication before and after therapy sessions. With this model, we aim to enhance coordination of care resulting in improved patient satisfaction and, ultimately, recovery.

Feasibility of an Enhanced Therapy Model of Care for Hospitalized Stroke Patients.

INTRODUCTION: The aim of this study was to determine the safety and feasibility of an enhanced therapy model for hospitalized stroke patients. METHODS: This was a quasi-experimental cohort study of acute stroke patients from a single hospital. In the intervention group, all hospitalized patients on the acute stroke service were seen by at least two therapy disciplines daily in addition to routine stroke care. The comparison group consisted of all patients admitted to the same stroke service 1 year before who received the standard of care. The primary endpoint was the number of completed therapy sessions. Exploratory endpoints compared the length of hospital stay, hospital readmission rates, and degree of disability measured by the 90-day modified Rankin Scale score. RESULTS: A total of 1110 records were analyzed with 553 subjects in the intervention group and 557 in the control group. The intervention group received a significantly higher number of therapy sessions. There was no significant difference in length of hospital stay. However, 30-day readmission rates were lower, and the percentage of patients who achieved a good functional outcome on the modified Rankin Scale was higher during the intervention period. CONCLUSION: Increasing exposure to intensive multidisciplinary therapy comparable with that of acute inpatient rehabilitation in the hospital setting is feasible and may reduce both readmission rates and disability.

Bringing High-Dose Neurorestorative Behavioral Training Into the Acute Stroke Unit.

ABSTRACT: Stroke remains common and is a leading cause of adult disability. While there have been enormous system changes for the diagnosis and delivery of hyperacute stroke treatments at comprehensive stroke centers, few advances have been made in those same centers for treatments focused on behavioral recovery and brain repair. Specifically, during the early hospital period, there is a paucity of approaches available for reduction of impairment beyond what is expected from spontaneous biological recovery. Thus, patients in the early stroke recovery period are not receiving the kind of training needed, at the requisite intensity and dose, to exploit a potential critical period of heightened brain plasticity that could maximize true recovery instead of just compensation. Here, we describe an ongoing pilot program to reconfigure the acute stroke unit experience to allow for a new emphasis on brain repair. More specifically, we have introduced a novel room-based video-gaming intervention; restorative neuroanimation, into the acute stroke hospital setting. This new intervention provides the opportunity for an extra hour(s) of high-intensity neurorestorative behavioral treatment that is complementary to conventional rehabilitation. To accomplish this, system redesign was required to insert this new treatment into the patient day, to properly stratify patients behaviorally and physiologically for the treatment, to optimize the digital therapeutic approach itself, and to maintain the impairment reduction after discharge.

Biological Sex Differences in Risk Factors and Outcomes Among Hospitalized Adults With Stroke in Lusaka, Zambia.

OBJECTIVE: We investigated sex differences in clinical characteristics and outcomes among hospitalized adults with stroke in Zambia. METHODS: We retrospectively collected information for 324 consecutively hospitalized adults with stroke on the neurology service at the University Teaching Hospital in Lusaka, Zambia, between October 2018 and March 2019. Stroke characteristics were then compared by biological sex. RESULTS: Female participants constituted 62% (n = 200) of the cohort, were older (61 ± 19 vs 57 ± 16 years, p = 0.06), had fewer hemorrhagic stroke than male participants (22% vs 37%, p = 0.001), and had higher rates of hypertension (84% vs 74%, p = 0.04), diabetes (19% vs 13%, p = 0.04), heart disease (38% vs 27%, p = 0.04), and history of stroke (26% vs 14%, p = 0.01). Male participants had higher rates of alcohol (33% vs 4%, p < 0.001) and tobacco (19% vs 2%, p < 0.001) use. Female participants were less likely to have neuroimaging completed during their hospitalization (82% vs 94%, p = 0.002) and had higher 90 days postdischarge mortality (28% vs 10%, p = 0.002) independent of age and stroke subtype (OR 2.48, 95% CI 1.1-5.58, p = 0.03). DISCUSSION: Female participants in this Zambian stroke cohort had a higher prevalence of vascular risk factors but were less likely to have neuroimaging completed. Postdischarge mortality was markedly higher among female participants even after adjusting for age and stroke subtype. Our data highlight the need for future studies of social and socioeconomic factors that may influence stroke-related outcomes.

The Impact of Mean Arterial Pressure and Volume Contraction in With Acute Ischemic Stroke.

Background and Purpose: Hydration at the time of stroke may impact functional outcomes. We sought to investigate the relationship between blood pressure, hydration status, and stroke severity in patients with acute ischemic stroke (AIS). Methods: We evaluated hydration status, determined by blood urea nitrogen (BUN)/creatinine ratio, in consecutive patients with AIS from a single comprehensive stroke center. Baseline mean arterial pressure (MAP) was analyzed using a linear spline with a knot at 90 mmHg. Baseline stroke severity was defined based on admission NIH Stroke Scale scores (NIHSSS) and MRI diffusion-weighted imaging. Results: Among 108 eligible subjects, 55 (51%) presented in a volume contracted state. In adjusted models, in the total sample, for every 10 mmHg higher MAP up to 90 mmHg, NIHSSS was 2.8 points lower (p = 0.053), without further statistically significant association between MAP above 90 and NIHSSS. This relationship was entirely driven by the individuals in a volume contracted state: MAP was not associated with NIHSSS in individuals who were euvolemic. For individuals in a volume contracted state, each 10 mmHg higher MAP, up to 90 mmHg, was associated with 6.9 points lower NIHSSS (95% CI -11.1, -2.6). MAP values above 90 mmHg were not related to NIHSSS in either dehydrated or euvolemic patients. Conclusions: Lower MAP contributes to more severe stroke in patients who are volume contracted, but not those who are euvolemic, suggesting that hydration status and blood pressure may jointly contribute to the outcome. Hydration status should be considered when setting blood pressure goals for patients with AIS.

Stroke Outcome Related to Initial Volume Status and Diuretic Use.

Background We hypothesized that stroke outcome is related to multiple baseline hydration-related factors including volume contracted state (VCS) and diuretic use. Methods and Results We analyzed a prospective cohort of subjects with ischemic stroke <24 hours of onset enrolled in acute treatment trials within VISTA (Virtual International Stroke Trials Archive). A VCS was defined based on blood urea nitrogen-to-creatinine ratio. The primary end point was modified Rankin Scale score at 90 days. Primary analysis used generalized ordinal logistic regression over the mRS range, adjusted for Totaled Health Risks in Vascular Events score, onset-to-enrollment time, and thrombolytic use. Of 5971 eligible patients with stroke, 42% were taking diuretics at the time of hospitalization, and 44% were in a VCS. Patients in a VCS were older, had more vascular risk factors, were more likely taking diuretics, and had more severe strokes. Diuretic use was associated with both reduced chance of achieving a good functional outcome (odds ratio [OR], 0.57 [95% CI, 0.52-0.63]) and increased mortality at 90 days (OR, 2.30 [95% CI, 2.04-2.61]). VCS was associated with greater mortality 90 days after stroke (OR, 1.53 [95% CI, 1.33-1.76]). There was no evidence of effect modification among the 3 exposures of VCS, diuretic use, or hypokalemia in relation to outcome. Conclusions A VCS at the time of hospitalization was associated with more severe stroke and odds of death but not associated with worse functional outcome when accounting for relevant characteristics. Diuretic use and low serum potassium at the time of stroke onset were associated with worse outcome and may be worthy of further investigation.

Predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia.

BACKGROUND: Factors associated with stroke mortality are understudied in sub-Saharan Africa but have implications for designing interventions that improve stroke outcomes. We investigated predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia. METHODS: Data from consecutive adults admitted with stroke at University Teaching Hospital in Lusaka, Zambia between October 2018 and March 2019 were retrospectively reviewed for clinical in-hospital outcomes. Vital status at 90-days post-discharge was determined through phone calls. Factors associated with stroke mortality were included in multivariable logistic regression models utilizing multiple imputation analysis to determine independent predictors of in-hospital and 90-days post-discharge mortality. RESULTS: In-hospital mortality was 24%, and 90-day post-discharge mortality was 22% among those who survived hospitalization. Hemorrhagic and unknown strokes, ICU care, seizures, and aspiration pneumonia were significantly associated with in-hospital mortality. Among these, hemorrhagic stroke (OR 2.88, 95% CI 1.27-6.53, p = 0.01) and seizures (OR 29.5, 95% CI 2.14-406, p = 0.01) remained independent predictors of in-hospital mortality in multivariable analyses. Ninety-day post-discharge mortality was significantly associated with older age, previous stroke, atrial fibrillation, and aspiration pneumonia, but only older age (OR 1.04, 95% CI 1.01-1.06, p = 0.007) and aspiration pneumonia (OR 3.93, 95% CI 1.30-11.88, p = 0.02) remained independently associated with 90-day mortality in multivariable analyses. CONCLUSION: This Zambian stroke cohort had high in-hospital and 90-day post-discharge mortality that were associated with several in-hospital complications. Our data indicate the need for improvement in both acute stroke care and post-stroke systems of care to improve stroke outcomes in Zambia.

Risk factors and outcomes of hospitalized stroke patients in Lusaka, Zambia.

BACKGROUND: Limited data exists about stroke risk factors and outcomes in sub-Saharan African countries, including Zambia. We aim to fill this gap by describing features of hospitalized stroke patients at University Teaching Hospital (UTH), the national referral hospital in Lusaka, Zambia. METHODS: We conducted a retrospective study of consecutive adults with stroke admitted to UTH's inpatient neurology service from October 2018 to March 2019. Strokes were classified as ischemic or hemorrhagic based on CT scan results and unknown if CT scan was not obtained. Chi-square analyses and t-tests were used to compare characteristics between cohorts with differing stroke subtypes. RESULTS: Adults with stroke constituted 43% (n = 324) of all neurological admissions, had an average age of 60 ± 18 years, and 62% of the cohort was female. Stroke subtypes were 58% ischemic, 28% hemorrhagic, and 14% unknown. Hypertension was present in 80% of all strokes and was significantly associated with hemorrhagic stroke (p = 0.03). HIV was present in 18% of all strokes and did not significantly differ by stroke subtype. Diabetes (16%), heart disease (34%), atrial fibrillation (9%), and past medical history of stroke (22%) were all significantly more common in patients with ischemic stroke (p < 0.05). In-hospital mortality was 24% overall and highest among individuals with hemorrhagic strokes (33%, p = 0.005). CONCLUSIONS: This Zambian stroke cohort is notable for its young age, significant HIV burden, high in-hospital mortality, and high rates of uncontrolled hypertension. Our results demonstrate Zambia's substantial stroke burden, significant contribution of HIV to stroke, and the need to improve primary stroke prevention.

Aspiration Pneumonia in Adults Hospitalized With Stroke at a Large Academic Hospital in Zambia.

BACKGROUND AND OBJECTIVES: Preventing complications of stroke such as poststroke aspiration pneumonia (PSAP) may improve stroke outcomes in resource-limited settings. We investigated the incidence and associated mortality of PSAP in Zambia. METHODS: We conducted a prospective cohort study of adults with stroke at University Teaching Hospital (Lusaka, Zambia) between December 2019 and March 2020. NIH Stroke Scale, Glasgow Coma Scale, and Modified Rankin Scale scores and 9 indicators of possible PSAP were collected serially over each participant's admission. PSAP was defined as ≥4 indicators present, and possible PSAP as 2%-3% present. T tests and χ2 tests were used to compare clinical parameters across PSAP groups. Logistic regression was used to assess the relative effects of age, sex, PSAP status, and initial stroke severity on inpatient mortality. RESULTS: We enrolled 125 participants. Mean age was 60 ± 16 years, 61% were female, 55% of strokes were ischemic, and the baseline NIH Stroke Scale score was 19.7 ± 8.7. Thirty-eight (30%) had PSAP, and 32 (26%) had possible PSAP. PSAP was associated with older age and more adverse stroke severity scores. Fifty-nine percent of participants with PSAP died compared with 39% with possible PSAP and 8% with no PSAP. PSAP status independently predicted inpatient mortality after controlling for age, sex, and initial stroke severity. Swallow screening was not performed for any participant. DISCUSSION: PSAP is common and life threatening in Zambia, especially among older participants with severe stroke presentations. PSAP was associated with significantly increased mortality independent of initial stroke severity, suggesting that interventions to mitigate PSAP may improve stroke outcomes in Zambia and other resource-limited settings.