Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital.

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area. Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 ("first wave"), and between September 15 and November 30, 2020 ("second wave"). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19. Results: During the "first wave," 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the "second wave" were infected with SARS-CoV-2 (p < 0.001). During the "second wave," more SU staff members were infected with COVID-19 than during the "first wave" (45.6 vs. 8.7%, p < 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p < 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p < 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60-47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04-34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed. Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the "second wave" of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

Cerebral Thrombolysis in Rural Residents Aged ≥ 80.

PURPOSE: The proportion of older people in Poland is higher in rural areas than in urban areas. Thus, we aimed to evaluate treatment rate and factors associated with outcome and safety of intravenous thrombolysis (IVT) in rural residents aged ≥80 years admitted to primary stroke centers. PATIENTS AND METHODS: This study was a retrospective, observational cohort study of 873 patients treated with recombinant tissue plasminogen activator (rt-PA) in primary stroke centers between February 1, 2009 and December 31, 2017. Among them were 527 rural residents and 231 (26.5%) were ≥80 years of age. The analyses between rural and urban patients aged ≥80 and between rural patients aged <80 and aged ≥80 were performed. RESULTS: The proportion of patients aged ≥80 treated with rt-PA was comparable in rural and urban residents (27.9% vs 24.3% p = 0.24). Rural patients aged ≥80 were also characterized by lower incidence of cardiovascular risk factors and better patients' conditions on admission to hospital. Symptomatic intracerebral hemorrhage rate among ≥80-year-old stroke patients was lower in those living in rural areas than in those living in urban areas (5.4% vs 14.3%, p = 0.02); there were no differences regarding mortality and 3-month functional outcome between both populations. The older group of rural patients was characterized by a higher 3-month mortality (28.5% vs 12.6%, p < 0.001) and lower functional independence rate (34.0% vs 50.5%, p < 0.001) than rural younger patients. Antiplatelet (OR 2.43, 95% CI 1.04-5.66, p = 0.04) and anticoagulant therapy before stroke (OR 3.64, 95% CI 1.21-10.99, p = 0.022), early ischemic changes in baseline computerized tomograprpahy (OR 2.65, 95% CI 1.03-6.82, p = 0.043) were associated with unfavorable outcome; and higher National Institute of Health Stroke Scale score on admission (OR 1.01, 95% CI 1.01-1.20, p = 0.039), higher baseline count of white blood cells (OR 1.33, 95% CI 1.10-0.62, p = 0.003) were associated with mortality in rural patients over 80. CONCLUSION: We suggest that rural patients aged ≥80 may be safely treated with IVT in routine practice. However, lower efficacy and a higher mortality must be considered in former use of Vitamin K antagonist and antiplatelet or high white blood cells count.

Cerebral thrombolysis in patients with ischemic stroke and heart failure.

BACKGROUND: Heart failure (HF) is common among patients with ischemic stroke (IS), however its impact on outcome after iv-thrombolysis has not been fully determined. Moreover, definition of HF has been recently modified, but majority of stroke studies classified patients regarding an old HF criteria. Thus, the aim of our study was to evaluate the relationship between both, newly and formerly defined HF and the long-term outcome, mortality and the presence of hemorrhagic complications in patients with acute IS treated with iv-thrombolysis. METHODS: We retrospectively evaluated data from 328 Caucasian patients with IS consecutively treated with iv-thrombolysis. HF was defined according to old and new definition; long-term outcome was assessed with modified Rankin Scale (mRS) score and mortality rate on 90th days after IS. RESULTS: The incidence of HF did not differ between patients with favorable (mRS 0-2) and unfavorable (mRS 3-6) functional outcome respectively for the old and for the new definition (10.4% vs. 15.5, p = 0.17; 17.4% vs. 18.1%, p = 0.88) and between those who survived and died within 90 days after IS (11.7% vs. 20.0%, p = 0.27; 17.2% vs. 25.0%, p = 0.38, respectively). Multivariate analysis showed no impact of HF diagnosis on outcome (p = 0.94) or mortality (p = 0.64). CONCLUSION: The presence of systolic HF, defined according to an old and a new definition, does not determine safety and efficacy of cerebral iv-thrombolysis in patients with IS.

Length of stay in emergency department and cerebral intravenous thrombolysis in community hospitals.

OBJECTIVES: Current guidelines for the early management of patients with acute ischemic stroke recommend completion of an evaluation within 60 min of the patient's arrival at the emergency department (ED) because prolongation of ED length of stay (LOS) may reduce the efficacy of acute stroke treatment. AIM: To evaluate the LOS in EDs at the community-based Polish stroke centers, to determine logistic, social, epidemiological, and clinical factors responsible for its prolongation, and to assess the association between increased LOS and the implementation of cerebral intravenous (IV) thrombolysis. MATERIALS AND METHODS: This study carried out an evaluation of the medical records of 8398 patients with stroke and transient ischemic attack who consecutively reported to the Pomeranian Stroke Registry from 2010 to 2012. RESULTS: The median ED LOS in the studied cohort was 97 (44-196) min and was prolonged (>60 min) in 63.1% of patients. Prolongation of ED LOS contributed to a low (4.9%) IV thrombolysis rate. Functional status at discharge was worse in patients with prolonged versus nonprolonged LOS [modified Rankin scale: 2 (0-3) vs. 1 (0-3) points; P<0.001]. Multivariate analysis showed that onset-to-door time more than 270 min or unknown time of symptoms onset, referral to ED in urban areas, living alone, presence of diabetes, motor, sensory, visual, and gait deficits at stroke onset, and NIHSS score on admission contributed toward prolongation of ED LOS. CONCLUSION: A prolonged ED LOS, because of ineffective prehospital logistics, ED urban location, patients' risk factors, and cohabitation profile and stroke symptoms and severity, commonly exists among patients with stroke and transient ischemic attack and contributes toward a low rate of IV thrombolysis in Polish community hospitals.

Prevalence and incidence of multiple sclerosis in central Poland, 2010-2014.

BACKGROUND: Comprehensive epidemiologic data for multiple sclerosis (MS) in Poland are limited. The aim of this cross-sectional population-based study was to determine the incidence and prevalence of MS in the Swietokrzyskie Region (central Poland). METHODS: This study identified MS cases every year between 1 January 2010 and 31 December 2014. The study area population on the prevalence day (December 31, 2014) was 1,263,176 (646,506 women and 616,670 men). A total of 1462 patients with a clinically definite diagnosis of MS according to McDonald's criteria (2005), recorded in the Polish Multiple Sclerosis Registry, were considered for estimation of crude, age- and sex-specific prevalence, and incidence. RESULTS: The overall crude prevalence rate of confirmed MS patients was 115.7/100,000 (95 % confidence interval (CI), 111.2-121.4). A significantly higher prevalence was recorded in females (159.6/100,000; 95 % CI, 151.1-165.3) than in males (69.7/100,000; 95 % CI, 62.4-77.3) (P < 0.001). Age-adjusted rates for the Polish and European Standard Population were 109.8/100,000 (95 % CI, 105.4-114.8) and 106.6/100,000 (95 % CI, 101.1-111.2), respectively. The female/male ratio was 2.4. The mean annual incidence was 4.2/100,000 (95 % CI. 3.7-4.4). CONCLUSION: The incidence and prevalence of MS in the Swietokrzyskie region confirm that central Poland is a high risk area for MS. Compared with previous epidemiologic studies from Poland, the prevalence of MS has increased during recent years.

The role of additional computed tomography in the decision-making process on the secondary prevention in patients after systemic cerebral thrombolysis.

INTRODUCTION: Patients with ischemic stroke undergoing intravenous (iv)-thrombolysis are routinely controlled with computed tomography on the second day to assess stroke evolution and hemorrhagic transformation (HT). However, the benefits of an additional computed tomography (aCT) performed over the next days after iv-thrombolysis have not been determined. METHODS: We retrospectively screened 287 Caucasian patients with ischemic stroke who were consecutively treated with iv-thrombolysis from 2008 to 2012. The results of computed tomography performed on the second (control computed tomography) and seventh (aCT) day after iv-thrombolysis were compared in 274 patients (95.5%); 13 subjects (4.5%), who died before the seventh day from admission were excluded from the analysis. RESULTS: aCTs revealed a higher incidence of HT than control computed tomographies (14.2% vs 6.6%; P=0.003). Patients with HT in aCT showed higher median of National Institutes of Health Stroke Scale score on admission than those without HT (13.0 vs 10.0; P=0.01) and higher presence of ischemic changes >1/3 middle cerebral artery territory (66.7% vs 35.2%; P<0.01). Correlations between presence of HT in aCT and National Institutes of Health Stroke Scale score on admission (rpbi 0.15; P<0.01), and the ischemic changes >1/3 middle cerebral artery (phi=0.03) existed, and the presence of HT in aCT was associated with 3-month mortality (phi=0.03). CONCLUSION: aCT after iv-thrombolysis enables higher detection of HT, which is related to higher 3-month mortality. Thus, patients with severe middle cerebral artery infarction may benefit from aCT in the decision-making process on the secondary prophylaxis.

Metabolic Syndrome in Polish Ischemic Stroke Patients.

BACKGROUND: Metabolic syndrome (MetS) predisposes individuals to cardiovascular disease or stroke development. We aimed at evaluating the prevalence of MetS in a population of acute ischemic stroke (IS) patients from central Poland and at estimating the relationship between MetS and stroke risk. METHODS: We analyzed 672 IS patients who were consecutively admitted to stroke units. The control group was composed of 612 patients with other neurologic disorders. MetS was diagnosed if 3 of 5 factors were present (obesity, increased blood pressure, increased triglycerides, low high-density lipoprotein [HDL] cholesterol, and fasting hyperglycemia) according to the Unified Criteria for Clinical Diagnosis of the Metabolic Syndrome (2009). RESULTS: MetS was diagnosed in 61.2% of stroke patients versus 18.1% of the control group (P < .001). Multiple logistic regression showed that MetS was 1.8 times more common in women than in men (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.4-2.5). The adjusted OR (95% CI) associated with MetS was 2.44 (1.48-3.64; P < .001) for IS. Hypertension and hypertriglyceridemia were the most frequent disturbances of IS patients (87.2% and 68.2%, respectively). The analysis of the interaction between MetS and its components showed significant associations with hypertension (OR, 2.15; 95% CI, .98-4.24; P < .01), high triglyceride levels (OR, 4.35; 95% CI, 2.87-9.43; P < .0001), and low HDL cholesterol levels (OR, 5.12; 95% CI, 3.15-8.20; P < .001). CONCLUSIONS: Over 60% of Polish IS patients have MetS. The prevalence of MetS was significantly higher in women than in men. Thus, MetS may be a risk factor for IS.

Intravenous Thrombolysis with Recombinant Tissue-type Plasminogen Activator for Acute Ischemic Stroke in Patients with Metabolic Syndrome.

BACKGROUND: The metabolic syndrome (MetS) is common in patients with acute ischemic stroke (IS); however, its impact on outcome after intravenous thrombolysis (iv-thrombolysis) remains unclear. Thus, we aimed at evaluating the relationship between MetS and functional long-term outcome, mortality, and the presence of hemorrhagic complications in patients with IS treated with iv-thrombolysis. METHODS: We retrospectively evaluated the demographic and clinical data of 535 Caucasian patients with acute IS who were consecutively treated with iv-thrombolysis from September 2006 to June 2013 in 2 experienced stroke centers in Poland. A favorable functional long-term outcome was defined as a modified Rankin scale score less than or equal to 2 points on day 90, and hemorrhagic complications were assessed with European Cooperative Acute Stroke Study criteria. RESULTS: MetS was recognized in 192 (35.9%) patients (44.8% men; mean age, 70.8 ± 11.1 years), diabetes in 29.7%, dyslipidemia in 79.2%, and arterial hypertension in 75.5%. At 3 months, favorable outcome was found in 55.3% of patients, symptomatic intracerebral hemorrhage (SICH) in 18.3%, and 4.4 % of patients died. There was no difference regarding the presence of favorable outcome between patients with and without MetS (52.6% versus 56.9%, P = .34). The presence of SICH and 3-month mortality were more frequent in patients with MetS than without MetS (6.8% versus 2.9%, P = .03 and 23.4% versus 15.5%, P = .02, respectively); however, a multivariate analysis showed no impact of MetS on mortality or SICH. CONCLUSIONS: Results of our study provide no data to suggest that the effect of intravenous tissue-type plasminogen activator differs based on the presence or absence of MetS.

Are there differences between rural and urban populations in long-term outcome after systemic cerebral thrombolysis in a hospital located in an agricultural region?

INTRODUCTION: It is generally considered that rural hospitals have a much lower capacity to adequately care for patients with acute ischemic stroke (AIS). Analysis of the demographic and logistic factors affecting the outcome of intravenous (IV) thrombolysis in patients with AIS in a rural hospital are presented. METHODS: The observational study included 300 patients with AIS who were consecutively treated with IV thrombolysis. Long-term outcome and hemorrhagic complication rate in patients from rural and urban populations were compared. RESULTS: A total of 60.7% of patients were transported from rural areas. In the rural patients thrombolytic therapy at night was performed less frequently compared to that for urban patients (p=0.01). There were no differences in frequency of treatment between rural and urban patients treated with IV thrombolysis on weekends and on working days (p=0.47). In rural patients mortality was higher (p=0.04). The presence of hemorrhagic transformation (HT) (p=0.87) and of symptomatic intra-cerebral hemorrhage (SICH) (p=0.61) were similar in both groups. A multivariate analysis showed no impact of place of onset on favorable outcome after 3 months (p=0.9), on the presence of (SICH) (p=0.43) or on mortality rate (p=0.69). CONCLUSIONS: Patients from rural areas are less likely to be treated with IV thrombolysis during the night. Rural and urban patients treated in the hospital located in the agricultural region had a similar efficacy and safety profile of thrombolytic treatment.

Intravenous thrombolysis with rt-PA for acute ischemic stroke within 24h of a transient ischemic attack.

BACKGROUND: Intravenous thrombolysis (iv-thrombolysis) with the use of rt-PA in patients after recent transient ischemic attack (TIA) is an important clinical problem. The aim of the study was to assess the impact of TIA within 24h preceding acute ischemic stroke (AIS) on the safety and efficacy of iv-thrombolysis. METHODS: We retrospectively evaluated the clinical and demographic data of 400 patients with AIS who were consecutively treated with iv-thrombolysis from September 2006 to May 2011 in three stroke centers. RESULTS: At three-month follow-up, 58.0% of patients were independent (modified Rankin scale; mRS 0-2), 17.8% had died, 17.0% suffered hemorrhagic transformation (HT) and 4.3% experienced symptomatic intracerebral hemorrhage (SICH). There were 29 patients (7.3%) who had a previous ipsilateral TIA within 24h before established stroke. In the TIA subgroup, there was no significant higher percentage of favorable outcome (p=0.07) and higher SICH rate (p=0.15). Multivariate analysis showed the impact of prior TIA within 24h before stroke onset in the presence of SICH (p=0.01), no impact of TIA on unfavorable outcomes after three months (p=0.25) and on the mortality rate within three months (p=0.41). CONCLUSION: TIA within 24h prior to ischemic stroke can portend severe intracerebral bleeding in patients qualified to iv-thrombolysis with the use of rt-PA.

Intravenous thrombolysis in patients aged more than 80 years in the three rural hospitals in southeast Poland: an observational study.

AIMS: Approximately 30% of acute ischemic stroke (AIS) occurs in people aged over 80 years. Older patients are increasingly receiving intravenous thrombolysis (IV-thrombolysis) for AIS; however, the majority of treatments are carried out in urban hospitals. The aim of the present study was to assess the safety and effectiveness of IV-thrombolysis in patients aged older than 80 years. METHODS: We retrospectively evaluated the clinical and epidemiological data of 409 patients with AIS who were consecutively treated with IV-thrombolysis from September 2006 to June 2012 in the three rural hospitals. RESULTS: In the analyzed group, there were 22.3% of patients who were aged over 80 years (2.4% patients aged ≥ 90 years). Among these patients we found: longer onset to door time (P = 0.04), onset to treatment time (P = 0.0003) and door to treatment time (P < 0.0001). The functional independence (modified Rankin Scale 0-2) at 90 days was lower (P = 0.0004), whereas the risk of hemorrhagic transformation (HT; P = 0.001), symptomatic intracerebral hemorrhage (SICH) according to National Institute of Neurological Disorders and Stroke (NINDS) definition (P = 0.003) and mortality rate within 3 months were higher (P < 0.0001) than in younger patients. A multivariate analysis showed no impact of older age on long-term outcome, and the presence of HT and SICH. Age over 80 years was associated with higher mortality rate. CONCLUSIONS: Older age affected the increased times for pre- and in-hospital procedures in rural patients with AIS. Older patients should not be denied the chance to benefit from IV-thrombolysis, but because of the higher mortality, the application of this therapy should be carefully decided on.

[Intravenous thrombolysis patients with acute ischemic stroke: the analysis of the 100 cases. Part I. Characteristic of the patients and effectiveness of treatment]. / Dozylne leczenie trombolityczne chorych z ostrym udarem niedokrwiennym mózgu--analiza 100 przypadków. Czesc I. Charakterystyka chorych oraz wyniki leczenia.

BACKGROUND: Intravenous thrombolytic therapy with recombinant tissue activator (rt-PA) in treating acute ischemic stroke is effective and safe in the time window 4.5 hours after symptom onset. MATERIAL AND METHODS: In the study group of patients demographic and logistic data and vascular risk factors were analysed. We also analysed status of the patients at the moment of admission, after 24 hours, one month and 3 months after symptom onset according to National Institutes of Health Stroke Scale (NIHSS) and results of treatment after 3 months according to modified Rankin Score (mRS). We compared the selective variables with data from the register SITS. RESULTS: Between September 2006 and April 2009 in the stroke unit in Sandomierz 807 patients with ischemic stroke were treated, including 100 patients (aged 42-88, mean 69.74 +/- 9.85; 55% of men) treated with rt-PA (12.39%). In 22% of patients treated rt-PA large and medium vessel disease, in 47%--cardiogenic embolism, in 4%--small vessel disease, in 3%-- other unusual causes and in 24%--infarct multiple etiology were diagnosed. The average time from the onset of the disease to the beginning of the treatment was 148.25 +/- 38.77 min. (in SITS centers--145 min.). At the moment of admission the average neurological conditions in NIHSS 12.03 +/- 4.94 (SITS--12); after 24 hours--8.51 +/- 6.09; after 7 days--6.51 +/- 6.38; after one month--4.27 +/- 5.15 and after 3 months--2.95 +/- 3.36 were evaluated. The results according to mRS were respectively: after 7 days--2.80 +/- 1.77; after 1 month--2.37 +/- 2.00 and after 3 months 2.16 +/- 2.16(SITS--2.5). After 3 months 53% of patients were functionally independent (SITS--53%), 29%--had moderate or severe disability (-32%) and 18%--died (-15%). CONCLUSIONS: In analysed time in stroke unit in Sandomierz the percentage of patients with acute ischemic stroke treated with rt-PA was high. The presentation of results of intravenous thrombolysis in patients with acute ischemic stroke performed in different centers makes the important aspect of evaluation of the effectiveness and safety of this therapy.

[Intravenous thrombolysis patients with acute ischemic stroke--the analysis of the 100 cases. Part II. Neuroimaging, the analysis of hemorrhagic complications and deaths]. / Dozylne leczenie trombolityczne chorych z ostrym udarem niedokrwiennym mózgu--analiza 100 przypadków. Czesc II. Badania obrazowe, analiza powiklan krwotocznych i zgonów.

INTRODUCTION: Computed tomography (CT) remains the basic diagnostic examination in patients with ischaemic stroke. The main purpose of CT examination is distinguishing between hemorrhagic and ischemic stroke, exclusion of other diseases and revealing early ischemic radiological changes. MATERIAL AND METHODS: The results of baseline CT scans and CT performed on 2nd and 7th days after symptom onset, in terms of patients' long-term outcome, presence of serious adverse events and deaths within 3 months were analyzed. RESULTS: The analysis included 100 patients treated with rt-PA in stroke unit from September 2006 to April 2009. More than one third of patients had normal baseline CT, in one third--old ischemic changes and in one third--early ischemic changes were revealed. After 3 months the patients who had early changes in baseline CT, and those who had extensive ischemic changes in the area of MCA (middle cerebral artery) or ICA (internal carotid artery) had the worst clinical status. In this group deaths appeared most often (in a subgroup with ischemic signs in the whole territory of MCA, p < 0.01 and in a group of patients with stroke in the ICA territory, p < 0.001), similarly to a group of patients with old changes in baseline CT (34.3% died; p < 0.001) and a group with cerebral edema in control CT (32.4%; p < 0.01). Hemorrhagic transformation appeared in 18% of patients. In this group of patients we found higher risk of death within 3 months after stroke onset(p < 0.001). CONCLUSIONS: The imaging examinations are very important in process of qualification of patients for thrombolytic treatment. Safety of intravenous thrombolysis in patients with ischemic stroke depends on the detailed analyses of the CT scans.