Role of Telemedicine in Prehospital Stroke Care.

PURPOSE OF REVIEW: To summarize evidence for the feasibility and the efficacy of mobile stroke units (MSUs) and telemedicine in the field to reduce time delays in offering acute stroke interventions. RECENT FINDINGS: A mobile stroke unit is a modified ambulance and includes sophisticated equipment, either trained personnel on board, or connection with skilled physicians via telemedicine. Stroke assessment and treatment agreeability between the on board and remote neurologist is high in MSUs. MSUs are the promising option to reduce stroke symptom onset to treatment time; telemedicine platform has a satisfactory audiovisual quality, high inter-rater reliability for remote stroke symptom assessment, diagnosis, and decision to treat. Use of MSU also avoids the need for inter-hospital transfers. MSUs improve prehospital stroke care and reduce delays in access to intravenous thrombolytic and mechanical thrombectomy in selective markets. Advancement in telecommunication and modern technology has the potential to make MSU telemedicine-aided management more cost-effective. Further research is needed before its widespread implementation.

Stroke Rates Following Surgical Versus Percutaneous Revascularization for Ischemic Heart Disease.

PURPOSE OF REVIEW: Coronary revascularization is a commonly performed major procedure in the hospitals. Stroke is one of the dreaded complications after coronary revascularization procedures. The focus of this review is to understand the stroke risk in percutaneous cutaneous intervention (PCI) and coronary artery bypass grafting (CABG) procedures. RECENT FINDINGS: Available data show that PCI offers less procedural stroke risk compared to CABG although the survival benefits of CABG are better in certain scenarios. Innovative advancements in techniques, pre-procedural optimum medical therapy (OMT), intraoperative neuro-monitoring, and multidisciplinary post procedural care are the few strategies in early detection and reduce stroke risk. Despite several innovations and strategies, it is evident that there is not enough data available to make concrete conclusions related to stroke risk after coronary revascularization, which warrants further investigation.

Use of a Discharge Educational Strategy Versus Standard Discharge Care on Reduction of Vascular Risk in Patients with Stroke and Transient Ischemic Attack.

PURPOSE OF THE REVIEW: The burden of ischemic stroke is disproportionally distributed between ethnic and racial subgroups in the USA, minority populations with lower socioeconomic status being at higher risk. These discrepancies are mirrored in susceptibility, primary care, and post-discharge procedures. Post-discharge strategies are of particular importance as their primary goal is to prevent recurrent stroke, which makes up about 25% of stroke cases per year in US. As disadvantaged minorities have faster growing populations, recurrent stroke poses a significant challenge not only for caretakers but also for the health care system as the whole. A number of educational strategies were employed to inform the general public of major symptoms, risk factors, and preventive measures for recurrent stroke. However, over affected subgroups did not prove responsive to such measures as these did not conform to their cultural and sociological specificities. RECENT FINDINGS: The Discharge Educational Strategies for Reduction of Vascular Events Intervention (DESERVE) is a randomized control trial with a one year follow up, set out to investigate the possibility that culturally tailored, community-centered post-discharge strategies would improve compliance to therapy and prevention against secondary stroke. The trial targeted African Americans, Hispanic, and non-Hispanic whites, adapting discharge strategies for each individual group. DESERVE accomplished a significant reduction in blood pressure in the Hispanic intervention group by 9.9 mm Hg compared with usual care. The remaining two groups were not susceptible to these measures. DESERVE holds promise for culturally tailored interventions in the future in a battle against stroke and other chronic diseases.

Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE).

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. METHODS: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. CONCLUSION: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.

Lifestyle Interventions to Prevent Cardiovascular Events After Stroke and Transient Ischemic Attack.

PURPOSE OF REVIEW: To summarize lifestyle interventions including pharmacological and non-pharmacological methods targeting modifiable risk factors and their impact on the future cardiovascular events in patients who have suffered transient ischemic attack (TIA) and/or ischemic stroke (IS). RECENT FINDINGS: The latest research indicates that secondary prevention measures can decrease the risk of recurrent stroke, cardiovascular events, and even death. Modifiable risk factors also require behavioral change which can be challenging. There is limited data demonstrating the impact of lifestyle interventions, alone or as part of an integrated care pathway, based on cardiovascular events. There is some support for lifestyle interventions such as increased exercise participation that when delivered as part of a comprehensive care package post stroke leads to minor reductions in blood pressure. High-quality, robust trials are required with longer-term follow-up and clear documentation of mortality, morbidity, and cardiovascular risk profile outcomes.

Pre-Existing Renal Failure Increases In-Hospital Mortality in Patients with Intracerebral Hemorrhage.

BACKGROUND: To determine the clinical outcome for intracerebral hemorrhage (ICH) patients with pre-existing renal failure in the United States. METHODS: We analyzed the data from Nationwide Inpatient Sample (2008-2012) for all ICH patients with or without pre-existing renal failure. Patients were identified using the International Classification of Disease, Ninth Revision, Clinical Modification codes. Baseline characteristics, in-hospital complications, and exposure to invasive procedures were compared between groups. Discharge outcomes (mortality, minimal disability, and moderate-to-severe disability) were compared between the two groups, before and after adjusting for the presence of other medical comorbidities, in-hospital complications, and exposure to invasive procedures. RESULTS: Of the 328,728 patients with ICH, 36,067 (11.8%) had pre-existing renal failure as a comorbidity. There were higher rates for in-hospital complications like myocardial infarction (3.5% versus 1.9%, P ≤ .0001), sepsis (5.4% versus 3.0%, P ≤ .0001), pneumonia (7.1% versus 5.3%, P ≤ .0001), deep venous thrombosis (1.6% versus 1.2%, P = .0041), urinary tract infections (16.9% versus 15.1%, P = .0101), and gastrointestinal bleeding (0.4% versus 0.2%, P ≤ .0154), longer hospital stay (9.4 ± 14.4 versus 7.7 ± 11.4; P < .0001), and higher mean hospital charges ($86497.9 ± 131708.1 versus $69583.4 ± 110629.1; P < .0001) in patients with pre-existing renal failure . The in-hospital mortality was also higher among patients with pre-existing renal failure as comorbidity in both univariate (26.4% versus 25.3 %, P = .0010) and multivariate analysis (odds ratio [OR] = 1.124 [1.042-1.213], P = .0025). There was no statistically significant difference for in terms of moderate to severe disability between 2 groups (OR = 1.030 [0.962-1.104], P value: .3953 in multivariate analysis when analysis was limited to alive patients. CONCLUSIONS: Patients with ICH, who present with pre-existing renal failure, have higher rates of in-hospital mortality but not for disability, the difference remained significant after adjusting for the presence of other medical comorbidities, in-hospital complications or exposure to invasive procedures.

Comparative Outcomes of Respiratory Failure Associated with Common Neuromuscular Emergencies: Myasthenia Gravis versus Guillain-Barré Syndrome.

Background and objectives: Myasthenia gravis (MG) and Guillain-Barré Syndrome (GBS) are autoimmune neuromuscular disorders that may present as neuromuscular emergencies requiring mechanical ventilation and critical care. Comparative outcomes of these disease processes, once severe enough to require mechanical ventilation, are not known. In this study, we compared the patients requiring mechanical ventilation in terms of in-hospital complications, length of stay, disability, and mortality between these two disease entities at a national level. Materials and Methods: Mechanically ventilated patients with primary diagnosis of MG (n = 6684) and GBS (n = 5834) were identified through retrospective analysis of Nationwide Inpatient Sample (NIS) database for the years 2006 to 2014. Results: Even though mechanically ventilated MG patients were older (61.0 ± 19.1 versus 54.9 ± 20.1 years) and presented with more medical comorbidities, they had lower disease severity on admission, as well as lower in-hospital complications sepsis, pneumonia, and urinary tract infections as compared with GBS patients. In the multivariate analysis, after adjusting for confounders including treatment, GBS patients had significantly higher disability (odds ratio (OR) 15.6, 95% confidence interval (CI) 10.9-22.2) and a longer length of stay (OR 3.48, 95% CI 2.22-5.48). There was no significant difference in mortality between the groups (8.45% MG vs. 10.0% GBS, p = 0.16). Conclusion: Mechanically ventilated GBS patients have higher disease severity at admission along with more in-hospital complications, length of stay, and disability compared with MG patients. Potential explanations for these findings include delay in the diagnosis, poor response to immunotherapy particularly in patients with axonal GBS variant, or longer recovery time after nerve damage.

Current Endovascular Approach to the Management of Acute Ischemic Stroke.

PURPOSE OF REVIEW: The review provides an overview of current endovascular management of patients with acute ischemic stroke in the light of recent landmark trials proving unequivocal benefit of the intervention. RECENT FINDINGS: Several randomized trials looking at selective groups of patients presenting after an acute ischemic stroke due to large vessel occlusion in the anterior circulation demonstrated an overwhelming benefit of the endovascular treatment compared to intravenous thrombolysis, leading to expedited changes in the American Heart Association/American Stroke Association guidelines. Nonetheless, there are a relative large number of patients that were not included in those trials that might still benefit from endovascular treatment (acute posterior circulation-related strokes or acute embolic occlusion of middle cerebral artery beyond the main trunk for instances) and in which further studies are needed. We also briefly discuss endovascular techniques, post-procedure care, and endovascular treatment delivery models to expedite stroke patient assessment and rapid transport using updated and improved workflow protocols to provide timely recanalization. Endovascular treatment of acute occlusion of a proximal large artery in the anterior circulation is currently the standard of care. Time and quality of recanalization are the most important variables that determine the outcome. The indication for endovascular therapy in different scenarios (acute embolic occlusion in the posterior circulation or more distal branch occlusions) has to be individualized according to each patient's particular characteristics until new evidence is provided.

Albumin-Induced Neuroprotection in Focal Cerebral Ischemia in the ALIAS Trial: Does Severity, Mechanism, and Time of Infusion Matter?

OBJECTIVE: To determine whether there is any differential benefit of albumin administration within 2 h of onset of ischemia and in settings (severe ischemia with reperfusion in cardioembolic strokes with National Institutes of Health Stroke Scale [NIHSS] ≥15), most representative of experimental models of cerebral ischemia in which albumin was effective in reducing neurological injury. BACKGROUND: High-dose intravenous (IV) albumin treatment for acute ischemic stroke (ALIAS) trial did not show overall clinical benefit in ischemic stroke patients in contrast to preclinical studies; however, models of preclinical studies were not completely followed. METHODS: A total of 1275 patients combined from ALIAS trials I and II were included in our analysis. We analyzed preclinical studies and selected patients with large ischemic stroke (NIHSS ≥15) related to cardioembolic etiology (n = 189). Outcomes were then studied including time from onset to IV albumin administration. RESULTS: The odds of excellent outcome (mRS 0-1) at 3 months was not different with high-dose IV albumin infusion (n = 100) compared with placebo (n = 89) ((odds ratio [OR]) 1.632 [0.719-3.708], p value 0.2419). When we further classified these subjects according to time of IV albumin administration, we observed significantly higher odds of excellent outcome at 3 months when patients received IV albumin within 2 h, OR 9.369 (CI 1.040-84.405), p value 0.0461, after adjusting for age, gender, baseline NIHSS score, and any therapeutic procedure. CONCLUSION: A trend for benefit is noted in ischemic stroke patients with large cardioembolic stroke (NIHSS ≥15) when high-dose albumin was initiated within 2 h, suggesting that certain ischemic stroke subgroups of patients most representative of preclinical settings may benefit from such a treatment. Additional clinical trials maybe needed to stratify subjects and treatment assignments according to NIHSS severity and timely randomization to evaluate this concept further.

Combination of noninvasive neurovascular imaging modalities in stroke patients: patterns of use and impact on need for digital subtraction angiography.

BACKGROUND: The diagnostic work-up of acute stroke relies on the use of proper imaging studies. We sought to determine the use of a combination of 2 noninvasive tests, namely magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in diagnosing vascular lesions and the necessity for a subsequent digital subtraction angiography (DSA) for the definitive diagnosis. METHODS: Patients admitted to 2 comprehensive stroke centers between January 2008 and July 2010 who had an equivocal initial noninvasive test were reviewed. The proportions of patients who underwent CTA and MRA in combination and those who required additional DSA for definitive diagnosis were determined. The diagnostic yield and impact on management in patients with CTA and MRA combination was compared with patients who underwent CTA and MRA followed by DSA. RESULTS: Among a total of 1063 patients (mean age ± SD 63 ± 16), 384 (36%) underwent >1 vascular imaging study. There was no difference in the rates of cardiovascular risk factors and stroke subtype between different combination groups. The agreement between CTA and MRA was high (concordance 81%). Among the 164 patients who underwent both CTA and MRA, a DSA was required for resolution/confirmation in only 27 (16%) patients. Among these 27, DSA findings changed the clinical decision-making in 22 (82%) patients (11 stenotic severities and 11 diagnoses of arteriovenous fistula, aneurysm, or dissection). CONCLUSIONS: In our experience, a combination of CTA and MRA was frequently used in patients in whom the initial noninvasive imaging was determined insufficient. The combination of findings from CTA and MRA were considered adequate in a large portion of patients resulting in a lower requirement for DSA and higher treatment impact from DSA.

A systematic review on the assessment of cerebral autoregulation in patients with Large Vessel Occlusion.

As the majority of large vessel occlusion (LVO) patients are not treated with revascularization therapies or efficiently revascularized, complementary management strategies are needed. In this article we explore the importance of cerebral autoregulation (CA) assessment in the prediction and/or modification of infarct growth and hemorrhagic transformation. In patients with LVO, these are important factors that affect prognosis. A systematic search of the PubMed, EMBASE databases and a targeted Google search was conducted, resulting in the inclusion of 34 relevant articles. There is an agreement that CA is impaired in patients with LVO; several factors have been identified such as time course, revascularization status, laterality, disease subtype and location, some of which may be potentially modifiable and affect outcomes. The personalized CA assessment of these patients suggests potential for better understanding of the inter-individual variability. Further research is needed for the development of more accurate, noninvasive techniques for continuous monitoring and personalized thresholds for CA.

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice.

BACKGROUND: Data derived from prospective randomized clinical trials suggest differential comparative benefit between carotid angioplasty and stent (CAS) placement and carotid endarterectomy (CEA) in various age strata. We sought to investigate the impact of age on outcomes of CAS and CEA in general practice. METHODS: We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2008. The primary end point was occurrence of stroke, cardiac complications, or death during the postprocedural period. Outcomes of interest were compared between patients aged ≥70 years and <70 years, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of age on occurrence of postoperative stroke, cardiac complications, or death. Covariates included in the logistic regression were patient's age, gender, comorbid conditions, including hypertension, diabetes mellitus (DM), chronic lung disease, coronary artery disease (CAD), congestive heart failure (CHF), and renal failure; symptom status (symptomatic vs asymptomatic status), and hospital characteristics. RESULTS: Of the total 495,331 estimated patients who received treatment for CAD during the study period, 88% underwent CEA and the remaining 12% underwent CAS. Of the total procedures, 41% of the procedures were performed in patients aged <70 years compared to the remaining 59% that were performed among patients aged ≥70 years. For patients undergoing CAS, age ≥70 years was an important predictor of postoperative stroke (P = .0025; odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.5) and cardiac complications postprocedure (P = .045; OR, 1.3; 95% CI, 1.0-1.6). For patients undergoing CEA, age ≥70 years was associated with higher cardiac complications (P < .001; OR, 1.5; 95% CI, 1.3-1.7) and higher postoperative mortality risk (P = .0008; OR, 1.4; 95% CI, 1.1-1.8) compared to patients aged <70 years. The increased risk of composite end point (postoperative stroke/cardiac complications/mortality) among patients aged ≥70 years was a significant factor for patients undergoing either CAS or CEA (OR of 1.3 for both procedures). CONCLUSION: Our analysis suggests that most CAS and CEAs are performed in patients aged ≥70 years in general practice, and higher rates of postoperative complications are observed among these patients regardless of procedure choice.

A comparison of outcomes associated with carotid artery stent placement performed within and outside clinical trials in the United States.

BACKGROUND: A discrepancy between characteristics of patients treated with carotid angioplasty and stent placement (CAS) within and outside clinical trials, particularly characteristics with direct impact on clinical outcome, may limit generalization of clinical trial results. The objective of this study was to identify differences in demographic and clinical characteristics and outcomes related to CAS in patients treated within clinical trials and those treated outside clinical trials in a large national cohort. METHODS: We determined the frequency of CAS performed within and outside clinical trials and associated in-hospital outcomes using data from the Nationwide Inpatient Survey data files from 2005 to 2009. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. RESULTS: Of the 81,638 patients who underwent CAS, 16,078 (19.6%) underwent the procedure as part of a clinical trial. The mean age of the patients was significantly lower in patients treated with CAS as part of a clinical trial than those treated with CAS outside a clinical trial. The proportion of women and nonwhites was lower among patients treated with CAS as part of a clinical trial. The in-hospital mortality was two-fold higher among patients treated with CAS outside clinical trials (1.12% vs 0.53%; P = .0005). The rate of composite endpoint of stroke, cardiac events, and death was significantly higher among patients treated with CAS outside clinical trials (P = .02). After adjusting for age, gender, presence of renal failure, and hospital bed size, CAS performed as part of a clinical trial was associated with lower rates of in-hospital mortality (odds ratio, 0.467; 95% confidence interval, 0.290-0.751; P = .0017) and composite endpoint of stroke, cardiac events, and death (odds ratio, 0.752; 95% confidence interval, 0.594-0.952; P = .0180). CONCLUSIONS: Our results suggest that CAS procedures performed as part of clinical trials was associated with lower rates of in-hospital mortality and composite endpoint of stroke, cardiac events, and death in United States. These findings highlight the need for strategies that ensure appropriate adoption of CAS to ensure that the benefits observed in clinical trials can be replicated in general practice.

Comprehensive stroke centers and the 'weekend effect': the SPOTRIAS experience.

BACKGROUND AND PURPOSE: Previous studies have found mortality among ischemic stroke patients to be higher on weekends. We sought to evaluate whether weekend admission was associated with worse outcomes in a large comprehensive stroke center (CSC) cohort. METHODS: Consecutive ischemic stroke patients presenting within 6 h of symptom onset were identified using the 8 CSC SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) database. Patients who received intra-arterial therapy or who were enrolled in a nonobservational clinical trial were excluded. All patients meeting the inclusion criteria were then divided into two groups: weekday admissions or weekend admissions. Weekend admission was defined as Friday 17:01 to Monday 08:59. The remainder were classified as weekday admissions. Multivariate logistic regression was used, adjusting for age, stroke severity on admission [according to the National Institutes of Health Stroke Scale (NIHSS)] and admission glucose, in order to compare the outcomes of the weekend versus the weekday groups. RESULTS: Eight thousand five hundred and eighty-one subjects from the combined SPOTRIAS database were screened from 2002 to 2009; 2,090 (24.4%) of these met the inclusion criteria. There was no significant difference in tissue plasminogen activator treatment rates between the weekday and weekend groups (58.5 vs. 60.4%, p = 0.397). Weekend admission was not a significant independent predictor of inhospital mortality (8.4 vs. 9.9%, p = 0.056), length of stay (4 vs. 5 days, p = 0.442), favorable discharge disposition (38.0 vs. 42.2%, p = 0.122), favorable functional outcome at discharge (41.6 vs. 43.4%, p = 0.805), favorable 90-day functional outcome (54.2 vs. 46.9%, p = 0.301), or 90-day mortality (18.2 vs. 19.8%, p = 0.680) when adjusting for age, NIHSS and admission glucose. CONCLUSIONS: In this large cohort of ischemic stroke patients treated at CSCs, we did not observe the 'weekend effect.' This may be due to access to stroke specialists 24 h a day on 365 days a year, nurses with stroke experience and the organized system for delivering care that is available at CSCs. These results suggest that EMS protocol should be reexamined regarding the preferential delivery of weekend stroke victims to hospitals that provide all levels of reperfusion therapy. This further highlights the importance of organized stroke care.

The use of vascular closure devices outside the catheterization laboratory after neurointerventional procedures is safe and effective: evidence from a retrospective study.

PURPOSE: To investigate the feasibility and safety of vascular closure device (VCD) deployment outside the catheterization laboratory. METHODS: Medical records were reviewed of all 799 patients (396 men; mean age 56 ± 16 years) who underwent deployment of 918 VCDs following diagnostic or therapeutic neurointerventional procedures over a 2-year period at 2 comprehensive stroke centers. The rates of major vascular complications in patients undergoing VCD deployment in and outside the catheterization laboratory were compared. Major vascular complications were adjudicated using definitions by the Society of Interventional Radiology; comparisons were made between different procedure types and closure devices. RESULTS: During the observation period, 103 (11.2%) of 918 VCD deployments were performed outside the catheterization laboratory. Age, gender, procedure type, and device types were not different between the groups. A total of 10 (1.1%) major vascular complications occurred, including dissection requiring angioplasty (n = 1), hematoma requiring blood transfusion (n = 4), pseudoaneurysm requiring thrombin injection (n = 2), and lower limb ischemia necessitating surgical removal of the VCD (n = 3). Rates of major vascular complications were not significantly different between VCDs deployed inside the catheterization laboratory [1.0% (8/815)] compared to outside [1.9% (2/103), p = 0.3]. CONCLUSION: VCD deployment outside the catheterization laboratory does not increase the rate of major vascular complications and may be an alternative approach for femoral artery hemostasis when VCD deployment needs to be deferred.

Increased rate of aspiration pneumonia and poor discharge outcome among acute ischemic stroke patients following intubation for endovascular treatment.

BACKGROUND: An increased risk of aspiration pneumonia among acute ischemic stroke patients following intubation for endovascular treatment may explain the higher rates of poor outcomes among patients requiring general anesthesia compared with those performed under local sedation. METHODS: Rates of aspiration pneumonia and its contribution to poor outcome at discharge (modified Rankin score ≥ 3), and in-hospital mortality were analyzed among endovascularly treated acute ischemic stroke patients at two university-affiliated comprehensive stroke centers. Logistic regression model was used to assess the contribution of intubation and aspiration pneumonia on poor outcome after adjusting for potential confounders. RESULTS: There were 136 acute ischemic stroke patients who received endovascular treatment: 83 patients received local sedation without intubation and 53 patients were intubated. The rates of aspiration pneumonia were 12 (14%) in endovascularly treated patients not intubated, and 12 (23%) in endovascularly treated intubated patients. Rates of poor outcomes were 46 (55%) in the non-intubated endovascularly treated patients, and 44 (83%) in intubated endovascularly treated patients. After adjusting for age, gender, National Institutes of Health Stroke Scale (NIHSS) score strata, poor outcome at discharge (OR 2.9, 95% CI 1.2-7.4) (P = 0.0243) and in-hospital mortality (OR 4.5, 95% CI 1.5-12.5) (P = 0. 0.0046) were significantly higher among intubated patients. After adjusting for pneumonia, the effect of intubation on poor outcome at discharge (OR 2.7, CI 1.1-7.1) (P = 0.0006) and in-hospital mortality (OR 4.4, CI 1.6-12.5) (P = 0.00051) remained significant in the multivariate model. CONCLUSIONS: Careful consideration should be exercised when emergently intubating acute ischemic stroke patients for endovascular treatment, because the rate of death and disability appears to be high. This increased rate is not explained by higher rates of subsequent aspiration pneumonia.

Outcomes after nontraumatic subarachnoid hemorrhage at hospitals offering angioplasty for cerebral vasospasm: a national level analysis in the United States.

BACKGROUND: Primary angioplasty has been introduced for the treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). The data regarding the therapeutic benefit of angioplasty in improving patient outcomes are limited, hence its utilization at hospitals remains controversial and currently is not reimbursed by Medicare or major insurance companies. METHODS: We analyzed the data from Nationwide Inpatient Sample (NIS), a nationally representative dataset of all admissions in the United States from 2005 to 2007. We analyzed the prevalence of angioplasty procedure for cerebral vasospasm at the national level. In-hospital mortality, discharge status, length of stay, and cost of hospitalization were compared between hospitals performing angioplasty with those not performing angioplasty in multivariable model, adjusted for patient's age, utilization of endovascular aneurysm obliteration, and disease severity. RESULTS: Of the 74,356 estimated patients with nontraumatic SAH, 47% (n = 35,172) were admitted to hospitals that perform angioplasty for cerebral vasospasm and only 1307 patients (3.8%) were treated with angioplasty for vasospasm. In multivariable analysis, after adjustment for patient and hospital characteristics, we found that patients admitted to hospitals performing angioplasty had higher rates of discharge to home without supervision (OR 1.3, 95% CI: 1.1-1.6). There was no difference in in-hospital mortality, length of stay, or cost of hospitalization. CONCLUSIONS: Our analysis suggests that the odds of a patient being discharged to home are better at hospitals performing angioplasty for cerebral vasospasm. Provision of angioplasty may be used as a surrogate marker of model of care in management of patients with SAH.

Impact of percutaneous transluminal angioplasty for treatment of cerebral vasospasm on subarachnoid hemorrhage patient outcomes.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) has been introduced for treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). While angiographic improvement is consistently reported, clinical improvement following the procedure varies, and limited data is available regarding overall impact on outcome. METHODS: The authors performed a retrospective analysis of all hospital admissions with aneurysmal SAH over a 6 year period. The length of stay, discharge outcomes (measured by modified Rankin scale [mRS] at discharge), and 1-year mortality among patients with SAH before (4 year period) and after (2 year period) institution of PTA for cerebral vasospasm were compared. Embolization for intracranial aneurysm was used as a therapeutic option throughout the study duration. The effect of institution of PTA for vasospasm after adjusting for age, clinical severity, and use of aneurysm embolization on both discharge outcomes and 1-year mortality in multivariate analysis was evaluated. RESULTS: A total of 146 patients with aneurysmal SAH were admitted during the study duration. There was no difference between the 89 patients admitted in pre-angioplasty period and 57 patients admitted in post-angioplasty period in regards to age, medical co-morbidities, and admission clinical severity of patients (measured by Hunt and Hess grade and Glasgow coma scale). A total of 18 (32%) patients underwent PTA with or without intra-arterial vasodilator treatment in the second period of the study. There was a non significant decrease in rates of severe disability and death (mRS 5-6) at discharge (45 vs. 33%, P = 0.09) and 1-year mortality (32 vs. 22%, P = 0.26) after introduction of PTA for cerebral vasospasm after adjusting for potential confounders. There was no significant difference between the two time periods in regards to length of stay. CONCLUSION: A non significant trend was noted with reduced rate of severe disability and mortality at discharge and 1-year mortality after the introduction of PTA for cerebral vasospasm associated with SAH without increasing the length of hospital stay.