National trends in stroke and TIA care in U.S. emergency departments and inpatient hospitalizations (2006-2014)

Barriers to Enrollment in a Post-Stroke Neuromodulation and Walking Study: Implications for Recruiting Women

BACKGROUND

Women have a higher risk of stroke and related disability than men but are underrepresented in stroke clinical trials. Identifying modifiable recruitment and enrollment barriers for women can improve study generalizability, statistical power, and resource utilization.

OBJECTIVE

In a post-stroke neuromodulation study, we determined the impact of sex on the occurrence of exclusion criteria and compared the sex distribution of screened and enrolled individuals with a broader stroke-affected population.

METHODS

A total of 335 individuals with chronic stroke were screened for a study examining how neuromodulation and high-intensity treadmill training affect walking speed and corticomotor excitability. Demographics and exclusions were retrospectively gathered as a secondary dataset. Exclusion criteria consisted of 6 categories (not target population, unable to do treadmill protocol, unable to do non-invasive brain stimulation, insufficient ankle motion and disinterest, and cognitive impairment). Incidence of each exclusion criterion was compared between women and men. The sex distribution was compared to a dataset from Chicago primary stroke centers.

RESULTS

A total of 81 individuals were enrolled and 254 were not. The percentage of women excluded was significantly greater than that of men (P = .04). No individual exclusion criterion or categories excluded women more frequently than men. Screened and enrolled individuals had a lower proportion of women and younger age than a representative stroke population (P < .001).

CONCLUSIONS

We identified exclusion criteria (ie, headaches, cognitive scores, and age) that are modifiable barriers to enrollment of women in this post-stroke neuromodulation study. Addressing underrepresentation of women in stroke research is pivotal for enhancing generalizability, achieving statistical power, and optimizing resources.

Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke

Background and Objectives

Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging.

Methods

As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months.

Results

We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge.

Discussion

Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.

Acute Onset of Movement Disorders Accompanying Common Emergency Room Neurologic Disease Processes

Emergency departments (EDs) of hospitals accredited for trauma and/or comprehensive stroke care treat a large volume of high-acuity patients. In this fast-paced environment, the primary focus is appropriate triage, rapid stabilization, diagnosis, and acute intervention for life-threatening conditions such as cerebral vascular accident (CVA). However, this approach may result in subtle or atypical neurologic signs and symptoms being overlooked. Often, these oversights are innocuous in terms of their influence on overall patient outcomes. They are, in the vernacular, "of academic interest only". These cases provide ED clinicians with a unique opportunity to witness signs and symptoms not classically associated with common neurologic maladies. These unusual manifestations may be fleeting as they often either resolve with intervention or are overshadowed by progressive clinical decline. If such findings are recognized, they can at a minimum provide fascinating insights into neuroanatomic function. At a maximum, early recognition can influence immediate treatments and long-term outcomes. We report three ED patient presentations that shed light on functional neuroanatomical pathways and, in one case, significantly affected a patient's immediate algorithmic care. Two such cases involved acute middle cerebral artery distribution ischemic strokes, which typically present with focal contralateral sensorimotor and potential language deficits. Such events less commonly initially present with involuntary motor movements (dyskinesias). Failure to recognize these less common ictal signs may delay appropriate ED intervention or yield etiologic misdiagnoses. A third case involved a loss of consciousness ictal event secondary to a frontotemporal lobe tumor. This case presented with aphasic stroke-like symptoms along with new acute orofacial dyskinesias. Imaging before and after medical, surgical, and endovascular intervention provided important clinico-anatomic lessons. Furthermore, proposed neurophysiologic mechanisms and review of pertinent literature are provided.

Impact of Telestroke Implementation on Emergency Department Transfer Rate

BACKGROUND

and Purpose: Telestroke networks are associated with improved outcomes from acute ischemic stroke(AIS) patient and facilitate greater access to care, particularly in underserved regions. These networks also have the potential to influence patient disposition through avoiding unnecessary interhospital transfers. This study examines the impact of implementation of the VA National Telestroke Program (NTSP) on interhospital transfer among Veterans.

METHODS

We analyzed AIS patients presenting to the emergency department 21 VA hospitals before and after telestroke implementation. Transfer rates were determined through review of administrative data and chart review and patient and facility level characteristics were collected to identify predictors of transfer. Comparisons were made using t-test, Wilcoxon rank sum, and chi-square analysis. Multivariable logistic regression with sensitivity analyses were conducted to assess the influence of telestroke implementation on transfer rates.

RESULTS

We analyzed 3,488 stroke encounters (1,056 pre-NTSP and 2,432 post-NTSP). Following implementation, we observed an absolute 14.4% decrease in transfers across all levels of stroke center designation. Younger age, higher stroke severity, and shorter duration from symptom onset were associated with transfer. At the facility level, hospitals with lower annual stroke volume were more likely to transfer although only one hospital actually saw an increase in transfer rates following implementation. After adjusting for patient and facility characteristics, the implementation of VA NTSP resulted in a nearly 60% reduction in odds of transfer (OR = 0.39, [0.19, 0.77]).

CONCLUSIONS

In addition to improving treatment in acute stroke, telestroke networks have the potential to positively impact the efficiency of interhospital networks through disposition optimization and the avoidance of unnecessary transfers.

Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series

BACKGROUND

Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques.

OBJECTIVE

To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA.

METHODS

Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival.

RESULTS

Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion.

CONCLUSION

Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.

National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010-2016

BACKGROUND

Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists.

AIMS

To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan.

METHODS

This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models.

RESULTS

Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95-0.99), 0.97 (0.95-0.998), 1.07 (1.04-1.10), and 1.21 (1.14-1.28), respectively).

CONCLUSIONS

This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

Association of office-based provider visits with emergency department utilization among publicly insured stroke survivors

OBJECTIVE

To evaluate the association between visits to office-based providers and Emergency Department (ED) utilization among stroke survivors.

METHODS

We analyzed 12-years of data representing a weighted sample of 3,317,794 publicly insured US adults aged ≥18 years with stroke, using the Medical Expenditure Panel Survey Household Component (MEPS-HC), 2003-2014 dataset. We used a negative binomial regression model that accounts for dispersion to estimate the association between office-based and ED visits controlling for covariates. We used a multivariate logistic regression model to identify independent predictors of ED visits.

RESULTS

Annual mean (SD) ED visits and office based visits for publicly insured stroke survivors were 0.60 (1.10) and 12.2 (19.9) respectively. Each unit increase in office based visits was associated with a 1% increase in ED visit (p = 0.008). Being unmarried (adjusted OR = 1.26; 95% CI: 1.015-1.564) and having several comorbidities (adjusted OR = 1.93; 95% CI: 1.553-2.412) were associated with a higher likelihood of at least one ED visit. The odds for an ED visit for individuals aged 45-64, those aged 65 years and above, and those with a college or higher level of education were respectively 34% (OR = 0.66; 95% CI: 0.454-0.965), 52% (OR = 0.48; 95% CI: 0.330-0.701), and 36% (OR = 0.64; 95% CI: 0.497-0.834) lower than their counterparts.

CONCLUSIONS

Contrary to our expectations, there was a direct relationship between ED visits and office base visits among U.S. stroke survivors. This finding may reflect the difficulties associated with managing stroke survivors with multiple co-morbidities or complex psycho-socio-economic issues.