Neuroimaging in acute ischemic stroke: Trends, disparities, and clinical impact.

INTRODUCTION: Clinical studies over the past decade expanded the eligibility criteria for endovascular therapy, with advanced imaging selection and new devices leading to higher rates of good outcomes. Herein, we explore the current trends in neuroimaging, associated factors, and impact on treatment and clinical outcomes. MATERIALS AND METHODS: This is a retrospective study of consecutive acute ischemic stroke patients, admitted to a comprehensive stroke center from 2016 to 2020. Patient characteristics, including age, sex, race, arrival method, admission National Institutes of Health Stroke Scale score and last known well to arrival time; imaging and treatment utilization; and discharge outcome by modified Rankin Scale and disposition were extracted from medical records. Trend and multivariable logistic regression analyses were performed, and trends were stratified by patient characteristics. RESULTS: Of 4,125 acute ischemic stroke episodes, 15.1% received intravenous thrombolysis only, and 7.5% received endovascular thrombectomy from 2016 to 2020. Neuroimaging utilization trends significantly increased for computed tomography angiography (CTA) (48.7% to 75.2%, p < 0.001) and computed tomography perfusion (CTP) (0.26% to 32.9%, p < 0.001), and decreased for magnetic resonance angiography (MRA) (43.2% to 24.7%, p < 0.001). These trends held after adjusting for patient characteristics. Endovascular thrombectomy and intravenous thrombolysis were significantly more common in patients with CTA and CTP (p < 0.0001), and these treatments were associated with good clinical outcomes after controlling for patient characteristics. CONCLUSION: We found significantly increased trends in CTA and CTP imaging, which were associated with endovascular thrombectomy and intravenous thrombolysis utilization, in acute ischemic stroke patients from 2016 to 2020.

Striving for Socioeconomic Equity in Ischemic Stroke Care: Imaging and Acute Treatment Utilization From a Comprehensive Stroke Center.

PURPOSE: Prior studies have shown socioeconomic disparities in advanced neuroimaging and acute treatment utilization in patients with ischemic stroke. The authors analyzed whether socioeconomic factors were associated with stroke neuroimaging and acute treatment utilization at a comprehensive stroke center. METHODS: A retrospective study of consecutive acute ischemic stroke discharges from 2012 to 2020 at a comprehensive stroke center was performed. Differences in neuroimaging (CT angiography [CTA], CT perfusion, MRI, and MR angiography [MRA]) and acute treatment (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]) utilization were evaluated on the basis of socioeconomic factors of age, sex, race, insurance type, and neighborhood-level median household income. Chi-square tests were used for bivariate analyses. Multivariable logistic regression analyses were performed to determine associations between socioeconomic factors and neuroimaging or treatment utilization while controlling for stroke-specific factors and comorbidities. RESULTS: Among 6,140 ischemic stroke discharges, race and insurance type were not significantly associated with lower utilization of neuroimaging (CTA, CT perfusion, MRI, and MRA) or acute stroke treatment (IVT and EVT) after controlling for stroke-specific factors and comorbidities. However, median household income < $80,000/year was associated with lower IVT use (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.63-0.87). In addition, age ≥ 80 years had lower CTA (OR, 0.62; 95% CI, 0.51-0.75) and EVT (OR, 0.53; 95% CI, 0.39-0.73) utilization, and female sex had lower CTA (OR, 0.78; 95% CI, 0.65-0.93) utilization. Significantly higher utilization was observed for MRI in Asian (OR, 1.33; 95% CI, 1.04-1.69) and uninsured (OR, 1.64; 95% CI, 1.07-2.50) patients and for MRA (OR, 1.24; 95% CI, 1.04-1.49) and EVT (OR, 1.62; 95% CI, 1.20-2.20) in privately insured patients. CONCLUSIONS: Once access to a comprehensive stroke center is achieved, socioeconomic disparities in the utilization of health care resources, particularly advanced neuroimaging and acute treatment, may be improved in patients with ischemic stroke.

Evaluation of direct-to-angiography suite (DTAS) and conventional clinical pathways in stroke care: a simulation study.

BACKGROUND: Rapid time to reperfusion is essential to minimize morbidity and mortality in acute ischemic stroke due to large vessel occlusion (LVO). We aimed to evaluate the workflow times when utilizing a direct-to-angiography suite (DTAS) pathway for patients with suspected stroke presenting at a comprehensive stroke center compared with a conventional CT pathway. METHODS: We developed a discrete-event simulation (DES) model to evaluate DTAS workflow timelines compared with a conventional CT pathway, varying the admission NIHSS score treatment eligibility criteria. Model parameters were estimated based on 2 year observational data from our institution. Sensitivity analyses of simulation parameters were performed to assess the impact of patient volume and baseline utilization of angiography suites on workflow times utilizing DTAS. RESULTS: Simulation modeling of stroke patients (SimStroke) demonstrated door-to-reperfusion time savings of 0.2-3.5 min (p=0.05) for a range of DTAS eligibility criteria (ie, last known well to arrival <6 hours and National Institutes of Health Stroke Scale ≥6-11), when compared with the conventional stroke care pathway. Sensitivity analyses revealed that DTAS time savings is highly dependent on baseline utilization of angiography suites. CONCLUSIONS: The results of the SimStroke model showed comparable time intervals for door-to-reperfusion for DTAS compared with a conventional stroke care pathway. However, the DTAS pathway was very sensitive to baseline angiography suite utilization, with even a 10% increase eliminating the advantages of DTAS compared with the conventional pathway. Given the minimal time savings modeled here, further investigation of implementing the DTAS pathway in clinical care is warranted.

Impact of the COVID-19 Pandemic on Acute Ischemic Stroke Presentation, Treatment, and Outcomes.

INTRODUCTION: The World Health Organization declared COVID-19 a global pandemic last year. While a clear impact of COVID-19 on the declining stroke volume has been reported, its overall impact on stroke presentation and clinical outcomes has not been established. The purpose of this study was to assess the impact of COVID-19 on acute ischemic stroke volume, presentation, treatment, and outcomes at comprehensive stroke centers. METHODS: A retrospective review of patients with a discharge diagnosis of acute ischemic stroke from the Get With The Guidelines database was performed from January 1, 2019, to July 1, 2020. The following time periods were defined: Pre-COVID (January/February), Peak-COVID (March/April), and Post-COVID (May/June). Bivariate analyses were performed comparing the 2020 and 2019 time periods to determine differences in stroke volume, presentation, treatment, and outcomes. RESULTS: Stroke volumes were significantly lower during the Peak-COVID period in 2020 compared to that in 2019, with an absolute decline of 49.5% (P < 0.001). Patients were more likely to present after 24 hours from last known well during the 2020 Peak-COVID period (P = 0.03). However, there was not a significant difference in the rate of treatment with either the tissue plasminogen activator (tPA) or mechanical thrombectomy during the Peak-COVID period. Interestingly, relative treatment rates increased during the 2020 Post-COVID period to 11.4% (P = 0.01). CONCLUSIONS: The overall ischemic stroke volume decreased during the pandemic, and patients had a tendency to present later, beyond eligible treatment windows. However, rates of treatment, patient demographics, and stroke outcomes did not significantly change when compared to the prior year.

Predicting 90-day modified Rankin Scale score with discharge information in acute ischaemic stroke patients following treatment.

OBJECTIVES: To understand variability in modified Rankin Scale scores from discharge to 90 days in acute ischaemic stroke patients following treatment, and examine prediction of 90-day modified Rankin Scale score by using discharge modified Rankin Scale and discharge disposition. MATERIALS AND METHODS: Retrospective analysis of acute ischaemic stroke patients following treatment was performed from January 2016 to March 2020. Data collection included demographic and clinical characteristics and outcomes data (modified Rankin Scale score at discharge, 30 days and 90 days and discharge disposition). Pearson's χ2 test assessed statistical differences in distribution of modified Rankin Scale scores at discharge, 30 days and 90 days. The predictive power of discharge modified Rankin Scale score and disposition quantified the association with 90-day outcome. RESULTS: A total of 280 acute ischaemic stroke patients (65.4% aged ≥65 years, 47.1% female, 60.7% white) were included in the analysis. The modified Rankin Scale score significantly changed between 30 and 90 days from discharge (p<0.001) after remaining stable from discharge to 30 days (p=0.665). The positive and negative predictive values of an unfavourable long-term outcome for discharge modified Rankin Scale scores of 3-5 were 67.7% (95% CI 60.4% to 75.0%) and 82.0% (95% CI 75.1% to 88.8%), and for non-home discharge disposition were 72.4% (95% CI 64.5% to 80.2%) and 74.5% (95% CI 67.8% to 81.3%), respectively. CONCLUSIONS: Discharge modified Rankin Scale score and non-home discharge disposition are good individual predictors of 90-day modified Rankin Scale score for ischaemic stroke patients following treatment.

Cerebrovascular Complications of COVID-19.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) evolved quickly into a global pandemic with myriad systemic complications, including stroke. We report the largest case series to date of cerebrovascular complications of COVID-19 and compare with stroke patients without infection. METHODS: Retrospective case series of COVID-19 patients with imaging-confirmed stroke, treated at 11 hospitals in New York, between March 14 and April 26, 2020. Demographic, clinical, laboratory, imaging, and outcome data were collected, and cases were compared with date-matched controls without COVID-19 from 1 year prior. RESULTS: Eighty-six COVID-19-positive stroke cases were identified (mean age, 67.4 years; 44.2% women). Ischemic stroke (83.7%) and nonfocal neurological presentations (67.4%) predominated, commonly involving multivascular distributions (45.8%) with associated hemorrhage (20.8%). Compared with controls (n=499), COVID-19 was associated with in-hospital stroke onset (47.7% versus 5.0%; P<0.001), mortality (29.1% versus 9.0%; P<0.001), and Black/multiracial race (58.1% versus 36.9%; P=0.001). COVID-19 was the strongest independent risk factor for in-hospital stroke (odds ratio, 20.9 [95% CI, 10.4-42.2]; P<0.001), whereas COVID-19, older age, and intracranial hemorrhage independently predicted mortality. CONCLUSIONS: COVID-19 is an independent risk factor for stroke in hospitalized patients and mortality, and stroke presentations are frequently atypical.

Emergency Medical Services Providers' Knowledge, Practices, And Barriers To Stroke Management.

PURPOSE: Many strokes are not recognized by emergency medical services (EMS) providers and many providers do not prenotify emergency departments (EDs) of incoming stroke patients. The objectives of this project were to survey EMS providers to (1) assess knowledge of prehospital care related to stroke identification, time window for intravenous tissue plasminogen activator (IV tPA) administration, and comprehensive stroke centers in our health system, (2) gain insight from EMS providers regarding barriers to providing prenotification, information they provide for a prenotification, and optimal methods of providing feedback, and (3) provide EMS providers with stroke care and management information. METHODS: A survey was administered to EMS providers at four hospital EDs. The survey included questions related to knowledge of prehospital stroke care and barriers to providing prenotification. EMS providers were also provided a one-page flyer with information related to prehospital stroke care. Descriptive statistics were used to describe results. RESULTS: Of 301 EMS providers surveyed, 96.0% report that they use the Cincinnati Prehospital Stroke Scale to identify stroke, and 11.0% correctly identified the time window for IV tPA administration for acute ischemic stroke as within 4.5 hrs from the last known well time. The majority (82.7%) correctly identified the comprehensive stroke center in our health system. Barriers to providing prenotification included short transport time (40.5%), information being lost in dispatch (39.5%), and not having direct communication with ED staff (30.2%). Most reported wanting to receive feedback on the stroke patients they transported (93.7%), and 49.5% reported that the optimal method of providing feedback is via a mobile application. CONCLUSION: Deficits in stroke care knowledge among EMS providers were identified. Short transport time, inability to communicate with ED staff, and information lost in dispatch were cited as barriers to providing prenotification. Most EMS providers desire real-time feedback regarding patients via a mobile application.

Occult paroxysmal atrial fibrillation in non-cryptogenic ischemic stroke.

OBJECTIVE: To determine the prevalence and risk factors for paroxysmal atrial fibrillation (PAF) diagnosis in non- cryptogenic ischemic stroke (CIS) patients. METHODS: In this pilot-prospective cohort study of non-CIS patients from September 2014 to September 2017, 53 patients were enrolled. 51/53 patients were implanted within 10 days of stroke onset with the Reveal LINQ insertable cardiac monitor and monitored until PAF detection or a minimum of 12 months. Inclusion required diagnosis of a non-AF stroke etiology, age ≥ 40, and either a virtual CHADS2 score ≥ 3 or ≥ 2 PAF-related comorbidities. RESULTS: Over a median monitoring period of 398 days, PAF was detected in 6/51 (11.8%) patients and anticoagulation was initiated in 5/6 (83.3%). Median time to PAF detection was 87 days (range 0-356 days). Median longest PAF episode was 96 min (range 1 to 1122 min), and 4/6 had multiple PAF recordings. Mean left atrial volume index was significantly higher in PAF patients (31.0 vs. 23.2 cc/m2; p = 0.04). CONCLUSION: Long-term monitoring of non-CIS patients detected PAF in a clinically relevant proportion of patients, resulting in stroke prevention therapy optimization. Further study to confirm these findings and refine the subset that would benefit from long-term cardiac monitoring is warranted.