Quality of Care and Outcomes for In-Hospital Ischemic Stroke

A single-site retrospective review of in-hospital stroke

BACKGROUND

In-hospital stroke refers to a stroke arising in a patient during hospital admission for another condition. Between 2 and 17% of all inpatient strokes are in-hospital strokes.

AIM

To compare the outcomes and performance on quality-of-care stroke measures of in-hospital stroke cases with community-onset strokes.

METHODS

Data collected for the Irish Annual Audit of Stroke from an Irish university teaching hospital was analysed for a 2-year period from 1st January 2020 to 31st December 2021. A retrospective cohort study was conducted to compare baseline characteristics, outcomes, and performance on standardised quality-of-care measures between the cohorts.

RESULTS

The rate of IHS was 15.6%. Median age was 73 years and 72 years for in-hospital and community-onset strokes respectively. Amongst in-hospital strokes, COVID-19 co-diagnosis (9.1% versus 1.3%; p = .0004), admission to intensive care (52.3% versus 5.3%; p < .0001), discharge to long term care (6.8% versus 2.3%; p = .04), mortality (12.5% versus 7.6%; p = .13), and modified Rankin score of two or more at discharge (58.0% versus 38.1%; p = .001), were more likely compared to community-onset strokes. Thrombolysis rates were lower (7.3% versus 12.0%; p = .22) and thrombectomy rates higher (9.8% versus 6.6;% p = .32), albeit non-significantly. Median time to thrombolysis was slower amongst in-hospital strokes (105 min versus 66 min; p = .03) and they were less likely to be admitted to the stroke unit (43.2% versus 78.5%; p < .0001).

CONCLUSIONS

When compared with community-onset stroke, in-hospital stroke represents a distinct stroke subgroup with poorer outcomes and delays to thrombolysis emphasising the need for standardised approaches to evaluation and management.

Validation of the prehospital stroke scales as a tool for in-hospital large vessel occlusion stroke: whether we satisfied?

BACKGROUND

Prehospital stroke severity scales have been widely used to identify whether community stroke patients presented with large vessel occlusion (LVO) or not. However, whether these scales are also applicable to in-hospital stroke patients remains unknown.

PURPOSE

We aim to validate and compare the predictive capability of these scales for these patients.

MATERIAL AND METHODS

From January 2016 to October 2020, a total of 243 patients who activated in-hospital stroke alerts, were included in this study. The area under the curve (AUC) was used to assess the predictive ability of five scales (Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Rapid Arterial Occlusion Evaluation [RACE], Los Angeles Motor Scale [LAMS], Cincinnati Prehospital Stroke Severity Scale [CPSSS], and Prehospital Acute Stroke Severity scale [PASS]) for LVO. In addition, multivariable logistic analysis was adopted to determine the predictors of LVO in our patients cohort.

RESULTS

Finally, 94 (38.7%) patients were confirmed presence of persistent LVO. The AUC for the FAST-ED, RACE, LAMS, CPSSS, and PASS scales to predict the presence of LVO in patients activating in-hospital stroke alerts were 0.82, 0.89, 0.86, 0.81, and 0.79, respectively. After multivariable analysis, baseline NIHSS (adjusted odds ratio [OR] = 1.160, 95% confidence interval [CI] = 1.110-1.212; P < 0.001) atrial fibrillation (adjusted OR = 2.940, 95% CI = 1.387-6.230; P = 0.005) and cardiac/pulmonary procedure (adjusted OR = 6.861, 95% CI = 2.437-19.315; P < 0.001) remained independent predictors of LVO.

CONCLUSION

The prehospital stroke scales also showed good predictive capabilities in discriminating LVO among inpatients who activated stroke alerts. However, given that inpatients' history is more readily available, a specifically designed in-hospital stroke scale that combines stroke severity and history is warranted.

Clinical outcome of rural in-hospital-stroke patients after interhospital transfer for endovascular therapy within a telemedical stroke network in Germany: a registry-based observational study

OBJECTIVES

Little is known about in-hospital-stroke (IHS) patients with large vessel occlusion and subsequent transfer to referral centres for endovascular therapy (EVT). However, this subgroup is highly relevant given the substantial amount of IHS, the ongoing trend towards greater use of EVT and lack of EVT possibilities in rural hospitals. The study objective is to explore the clinical outcomes of this vulnerable patient group, given that both IHS and interhospital transfer are associated with worse clinical outcomes due to a higher proportion of pre-existing conditions and substantial time delays during transfer.

DESIGN AND SETTING

Prospectively collected data of patients receiving EVT after interhospital transfer from 14 rural hospitals of the Telemedical Stroke Network in Southeast Bavaria (TEMPiS) between February 2018 and July 2020 was analysed.

PARTICIPANTS

49 IHS and 274 out-of-hospital-stroke (OHS) patients were included.

OUTCOME MEASURES

Baseline characteristics, treatment times and outcomes were compared between IHS and OHS. The primary endpoint was a 3-month modified Rankin Scale (mRS).

RESULTS

In IHS patients, atrial fibrillation (55.3% vs 35.9%, p=0.012), diabetes (36.2% vs 21.1%, p=0.024) and use of oral anticoagulants (44.7% vs 20.8%, p<0.001) were more frequent. Stroke severity was similar in both groups. Treatment times from symptom onset to first brain imaging, therapy decision or EVT were shorter for IHS patients. IHS patients displayed worse clinical outcomes: 59.2% of IHS patients died within 3 months compared with 28.5% of OHS patients (p<0.001). They were less likely to achieve moderate outcomes (mRS 0-3) 3 months after stroke (20.4% vs 39.8%, p=0.010). After controlling for possible confounding variables, IHS was associated with worse clinical outcomes (adjusted OR 3.04 (95% CI 1.57 to 6.04), p<0.001).

CONCLUSIONS

The mortality of IHS patients after interhospital transfer and EVT was high and functional outcomes were worse compared with those of OHS patients. Further research is needed to ascertain whether IHS patients benefit from this therapeutic approach. A more careful selection of IHS patients for transfer and means to enable faster treatment should be considered.

TRIAL REGISTRATION NUMBER

NCT04270513; Post-results.

Mechanical thrombectomy for in-hospital stroke: data from the Italian Registry of Endovascular Treatment in Acute Stroke

BACKGROUND

The benefit, safety, and time intervals of mechanical thrombectomy (MT) in patients with in-hospital stroke (IHS) are unclear. We sought to evaluate the outcomes and treatment times for IHS patients compared with out-of-hospital stroke (OHS) patients receiving MT.

METHODS

We analyzed data from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) between 2015 and 2019. We compared the functional outcomes (modified Rankin Scale (mRS) scores) at 3 months, recanalization rates, and symptomatic intracranial hemorrhage (sICH) after MT. Time intervals from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were recorded for both groups, as were door-to-imaging and door-to-groin for OHS. A multivariate analysis was performed.

RESULTS

Of 5619 patients, 406 (7.2%) had IHS. At 3 months, IHS patients had a lower rate of mRS 0-2 (39% vs 48%, P<0.001) and higher mortality (30.1% vs 19.6%, P<0.001). Recanalization rates and sICH were similar. Time intervals (min, median (IQR)) from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were favorable for IHS (60 (34-106) vs 123 (89-188.5); 150 (105-220) vs 220 (168-294); 227 (164-303) vs 293 (230-370); all P<0.001), whereas OHS had lower door-to-imaging and door-to-groin times compared with stroke onset-to-imaging and onset-to-groin for IHS (29 (20-44) vs 60 (34-106), P<0.001; 113 (84-151) vs 150 (105-220); P<0.001). After adjustment, IHS was associated with higher mortality (aOR 1.77, 95% CI 1.33 to 2.35, P<0.001) and a shift towards worse functional outcomes in the ordinal analysis (aOR 1.32, 95% CI 1.06 to 1.66, P=0.015).

CONCLUSION

Despite favorable time intervals for MT, IHS patients had worse functional outcomes than OHS patients. Delays in IHS management were detected.

Nursing and Institutional Responsibilities for In-Hospital Stroke

In-hospital stroke events occur less often than stroke outside of a health care facility; yet, the need for timely evaluation and treatment is the same regardless of geographic location. During hospitalization, nurses are generally the first to recognize possible symptoms of stroke and activate emergency protocols. Such actions in response to changes in patient condition are critical to optimal patient outcomes. A recent scientific statement from the American Heart Association notes that patients with in-hospital stroke are likely to experience delayed recognition of symptoms, less likely to receive intravenous thrombolysis therapy, and have worse outcomes compared with community-occurring stroke. The aim of this article is to expand upon that scientific statement to assist nurses and acute care hospitals in the United States and elsewhere with similar health care systems to create evidence-based, nurse-driven protocols for in-hospital stroke recognition and management.

In-Hospital Versus Out-of-Hospital Stroke Onset Comparison of Process Metrics in a Community Primary Stroke Center

Objective

To examine in-hospital stroke onset metrics and outcomes, quality of care, and mortality compared with out-of-hospital stroke in a single community-based primary stroke center.

Patients and Methods

Medical records of in-hospital stroke onset were compared with out-of-hospital stroke onset alert data between January 1, 2013 and December 31, 2019. Time-sensitive stroke process metric data were collected for each incident stroke alert. The primary focus of interest was the time-sensitive stroke quality metrics. Secondary focus pertained to thrombolysis treatment or complications, and mortality. Descriptive and univariable statistical analyses were applied. Kruskal-Wallis and χ2 tests were used to compare median values and categorical data between prespecified groups. The statistical significance was set at α=0.05.

Results

The out-of-hospital group reported a more favorable response to time-sensitive stroke process metrics than the in-hospital group, as measured by median stroke team response time (15.0 vs 26.0 minutes; P≤.0001) and median head computed tomography scan completion time (12.0 vs 41.0 minutes; P=.0001). There was no difference in the stroke alert time between the 2 groups (14.0 vs 8.0 minutes; P=.089). Longer hospital length of stay (4 vs 3 days; P=.004) and increased hospital mortality (19.3% vs 7.4%; P=.0032) were observed for the in-hospital group.

Conclusions

The key findings in this study were that time-sensitive stroke process metrics and stroke outcome measures were superior for the out-of-hospital groups compared with the in-hospital groups. Focusing on improving time-sensitive stroke process metrics may improve outcomes in the in-hospital stroke cohort.

Clinical characteristics, in-hospital management, and outcomes of patients with in-hospital vs. community-onset ischaemic stroke: a hospital-based cohort study

Background

Lack of high-quality national-level data on in-hospital ischaemic stroke hinders the development of tailored strategies for this subgroup's identification, treatment, and management.

Methods

We analyzed and compared clinical characteristics, in-hospital management measures, and outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), disability at discharge, and in-hospital complications between in-hospital and community-onset ischaemic stroke enrolled in the Chinese Stroke Center Association registry from August 2015 to December 2022.

Findings

The cohort comprised 14,948 in-hospital and 1,366,898 community-onset ischaemic stroke patients. In-hospital ischaemic stroke exhibited greater stroke severity, higher prevalence of comorbidities, more pre-admission medications, and had suboptimal management measures, for example, the onset-to-needle time within 4.5 h (83.3% vs. 93.1%; difference, -9.8% [-11.4% to -8.3%]), and antithrombotics at discharge (78.6% vs. 90.0%; difference, -11.4% [95% CI, -12.1% to -10.7%]). After adjusting for covariates, in-hospital ischaemic stroke remains associated with higher risks of unfavorable outcomes, including in-hospital death/DAMA (13.9% vs. 8.6%; adjusted risk difference [aRD], 2.2% [95% CI, 1.8%-2.7%]; adjusted odds ratio [aOR], 1.35 [95% CI, 1.25-1.45]), MACE (12.6% vs. 6.5%; aRD, 4.1% [95% CI, 3.5%-4.7%]; aOR, 1.68 [95% CI, 1.52-1.85]), and complications (23.7% vs. 12.1%; aRD, 6.5% [95% CI, 5.1%-7.9%]; aOR, 1.72 [95% CI, 1.64-1.80]), except for disability at discharge (41.1% vs. 33.1%; aRD, 0.4% [95% CI, -1.7% to 2.5%]; aOR, 0.99 [95% CI, 0.88-1.11]).

Interpretation

In-hospital ischaemic stroke demonstrated more severe strokes, worse vascular risk profiles, suboptimal management measures, and worse outcomes compared to community-onset ischaemic stroke. This emphasizes the urgent need for improved hospital systems of care and targeted quality improvement initiatives for better outcomes in in-hospital ischaemic stroke.

Funding

National Key R&D Programme of China and Beijing Hospitals Authority.

Characteristics of in-hospital stroke patients in Sweden: A nationwide register-based study

INTRODUCTION

Few studies have reported the characteristics of patients with in-hospital stroke (IHS) including the reason for hospitalization and invasive procedures before the stroke. We aimed to extend current knowledge.

PATIENTS AND METHODS

All adult patients with IHS in Sweden during 2010-2019 registered in the Swedish Stroke Register (Riksstroke) were included. The cohort was cross-linked to the National Patient Register and data extracted on background diagnoses, main discharge diagnoses, and procedure codes for the hospitalization when IHS occurred and any hospital-based healthcare contacts within 30 days before IHS.

RESULTS

231,402 stroke cases were identified of which 12,551 (5.4%) were in-hospital and had corresponding entries in the National Patient Register. Of the IHS patients, 11,420 (91.0%) had ischemic stroke and 1131 (9.0%) hemorrhagic stroke; 5860 (46.7%) of the IHS patients had at least one invasive procedure prior to ictus. 1696 (13.5%) had a cardiovascular procedure and 560 (4.5%) a neurosurgical procedure. 1319 (10.5%) patients only had minimally invasive procedures such as blood product transfusion, hemodialysis, or central line insertion. Common discharge diagnosis in patients with no invasive procedures were cardiovascular disorders, injuries, and respiratory disorders.

DISCUSSION AND CONCLUSION

One in every 17 strokes in Sweden occur in a hospital. In this unselected large cohort the previously reported major causes for in-hospital stroke, cardiovascular and neurosurgical procedures, preceded IHS in only 18.0% of cases suggesting that other etiologies are more common than previously reported. Future studies should aim at determining absolute risks of stroke after surgical procedures and ways of risk reduction.

Design and Validation of a Novel Evaluation Scale to Predict Inpatient Large Vessel Occlusion Strokes: Clinical Assessment Stroke Severity for Inpatient Scale

OBJECTIVES

A large quantity of ischemic stroke events occur in patients hospitalized for non-stroke-related reason. No scale has been developed to identify the large vessel occlusion (LVO) among inpatient stroke alerts. We aimed to develop a novel evaluation scale to predict LVO from in-hospital stroke alerts.

METHODS

Data from consecutive in-hospital stroke alerts were analyzed at a single high volume stroke center between January 2016 and October 2020. We developed a predictive scale based on the first half of patients (training group) using multivariate logistic regression and evaluated it in the remaining half of patients (validation group) adopting receiver operating curve. Receiver operating characteristics of the scale were analyzed to evaluate its value for the detection of LVO.

RESULTS

A total of 243 patients were enrolled for further study, among them, 94 (38.7%) had confirmed LVO. Three risk factors independently predicted the presence of LVO: recent cardiac or pulmonary procedure (1 point), neurological deficit scale (≥1: 2 points), and history of atrial fibrillation (1 point). The CAPS scale was generated based on predictive factors and demonstrated highly effective discrimination in identifying the presence of LVO in the training group (area under curve = 0.956) and the validation group (area under curve = 0.940). When the score ≥2, CAPS scale showed 97.9% sensitivity, 79.2% specificity, 74.8% positive predictive value, and 98.3% negative predictive value for discriminating LVO.

CONCLUSIONS

CAPS scale was developed for identifying LVO among inpatient stroke alerts with high sensitivity and specificity, which may help to quickly prompt responses by appropriate stroke teams.

Stroke Characteristics in a Cohort of Hmong American Patients

Background Prior studies have indicated high rates of vascular risk factors, but little is known about stroke in Hmong. Methods and Results The institutional Get With The Guidelines (GWTG) database was used to identify patients discharged with acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage between 2010 and 2019. Hmong patients were identified using clan names and primary language. Univariate analysis was used to compare Hmong and White patients. A subarachnoid hemorrhage comparison was not conducted because of the small sample size. We identified 128 Hmong patients and 3084 White patients. Hmong patients had more prevalent hemorrhagic stroke (31% versus 15%; P<0.0016). In the acute ischemic stroke cohort, compared with White patients, Hmong patients were younger (60±13 versus 71±15 years; P<0.0001), presented to the emergency department almost 4 hours later; and had a lower thrombolysis usage rate (6% versus 14%; P=0.03496), worse lipid profile, higher hemoglobin A1C, similar stroke severity, and less frequent discharge to rehabilitation facilities. The most common ischemic stroke mechanism for Hmong patients was small-vessel disease. In the intracerebral hemorrhage cohort, Hmong patients were younger (55±13 versus 70±15 years; P<0.0001), had higher blood pressure, and had a lower rate of independent ambulation on discharge (9% versus 30%; P=0.0041). Conclusions Hmong patients with stroke were younger and had poorer risk factor control compared with White patients. There was a significant delay in emergency department arrival and low use of acute therapies among the Hmong acute ischemic stroke cohort. Larger studies are needed to confirm these observations, but action is urgently needed to close gaps in primary care and stroke health literacy.

Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke

BACKGROUND

Existing data and clinical trials could not determine whether faster intravenous thrombolytic therapy (IVT) translates into better long-term functional outcomes after acute ischemic stroke among those treated with endovascular thrombectomy (EVT). Patient-level national data can provide the required large population to study the associations between earlier IVT, versus later, with longitudinal functional outcomes and mortality in patients receiving IVT+EVT combined treatment.

METHODS

This cohort study included older US patients (age ≥65 years) who received IVT within 4.5 hours or EVT within 7 hours after acute ischemic stroke using the linked 2015 to 2018 Get With The Guidelines-Stroke and Medicare database (38 913 treated with IVT only and 3946 with IVT+EVT). Primary outcome was home time, a patient-prioritized functional outcome. Secondary outcomes included all-cause mortality in 1 year. Multivariate logistic regression and Cox proportional hazards models were used to evaluate the associations between door-to-needle (DTN) times and outcomes.

RESULTS

Among patients treated with IVT+EVT, after adjusting for patient and hospital factors, including onset-to-EVT times, each 15-minute increase in DTN times for IVT was associated with significantly higher odds of zero home time in a year (never discharged to home) (adjusted odds ratio, 1.12 [95% CI, 1.06-1.19]), less home time among those discharged to home (adjusted odds ratio, 0.93 per 1% of 365 days [95% CI, 0.89-0.98]), and higher all-cause mortality (adjusted hazard ratio, 1.07 [95% CI, 1.02-1.11]). These associations were also statistically significant among patients treated with IVT but at a modest degree (adjusted odds ratio, 1.04 for zero home time, 0.96 per 1% home time for those discharged to home, and adjusted hazard ratio 1.03 for mortality). In the secondary analysis where the IVT+EVT group was compared with 3704 patients treated with EVT only, shorter DTN times (≤60, 45, and 30 minutes) achieved incrementally more home time in a year, and more modified Rankin Scale 0 to 2 at discharge (22.3%, 23.4%, and 25.0%, respectively) versus EVT only (16.4%, P<0.001 for each). The benefit dissipated with DTN>60 minutes.

CONCLUSIONS

Among older patients with stroke treated with either IVT only or IVT+EVT, shorter DTN times are associated with better long-term functional outcomes and lower mortality. These findings support further efforts to accelerate thrombolytic administration in all eligible patients, including EVT candidates.

Prognostic value of inflammatory markers for in-hospital mortality in intensive care patients with acute ischemic stroke: a retrospective observational study based on MIMIC-IV

Background

Acute ischemic stroke (AIS) is a primary cause of death and disability worldwide. Four markers that can be readily determined from peripheral blood, namely, the systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and total bilirubin, were measured in this study. We examined the relationship between the SII and in-hospital mortality after AIS and evaluated which of the above four indicators was most accurate for predicting in-hospital mortality after AIS.

Methods

We selected patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database who were aged >18 years and who were diagnosed with AIS on admission. We collected the patients' baseline characteristics, including various clinical and laboratory data. To investigate the relationship between the SII and in-hospital mortality in patients with AIS, we employed the generalized additive model (GAM). Differences in in-hospital mortality between the groups were summarized by the Kaplan-Meier survival analysis and the log-rank test. The receiver operating characteristic (ROC) curve analysis was used to assess the accuracy of the four indicators (SII, NLR, PLR, and total bilirubin) for predicting in-hospital mortality in patients with AIS.

Results

The study included 463 patients, and the in-hospital mortality rate was 12.31%. The GAM analysis showed a positive correlation between the SII and in-hospital mortality in patients with AIS, but the correlation was not linear. Unadjusted Cox regression identified a link between a high SII and an increased probability of in-hospital mortality. We also found that patients with an SII of >1,232 (Q2 group) had a considerably higher chance of in-hospital mortality than those with a low SII (Q1 group). The Kaplan-Meier analysis demonstrated that patients with an elevated SII had a significantly lower chance of surviving their hospital stay than those with a low SII. According to the results of the ROC curve analysis, the in-hospital mortality of patients with AIS predicted by the SII had an area under the ROC curve of 0.65, which revealed that the SII had a better discriminative ability than the NLR, PLR, and total bilirubin.

Conclusion

The in-hospital mortality of patients with AIS and the SII were positively correlated, but not linearly. A high SII was associated with a worse prognosis in patients with AIS. The SII had a modest level of discrimination for forecasting in-hospital mortality. The SII was slightly better than the NLR and significantly better than the PLR and total bilirubin for predicting in-hospital mortality in patients with AIS.

Differences between patients with inpatient-onset and outpatient-onset acute lower gastrointestinal bleeding: An observational study

BACKGROUND AND AIM

The clinical severity and course of acute lower gastrointestinal bleeding (ALGIB) are believed to differ between inpatient-onset and outpatient-onset cases, but no reports have investigated these issues in detail. We aimed to evaluate the clinical differences between inpatient-onset and outpatient-onset ALGIB.

METHODS

Medical records of patients who had undergone emergency colonoscopy for ALGIB were retrospectively reviewed. The severity was evaluated using the NOBLADS score. Patients with obvious ALGIB relapse and/or persistent iron-deficiency anemia after emergency colonoscopy were considered to exhibit a poor clinical course.

RESULTS

We reviewed 723 patients with ALGIB and divided them into the inpatient-onset cohort (172 patients) and outpatient-onset cohort (551 patients). Compared with the outpatient-onset cohort, the inpatient-onset cohort had a significantly higher proportion of patients with a poor clinical course (51.2% vs 21.6%; P < 0.001) and a significantly higher mean NOBLADS score (3.6 ± 1.1 vs 2.5 ± 1.0; P < 0.001). The most common bleeding source was acute hemorrhagic rectal ulcer (52.3%) in the inpatient-onset cohort and colonic diverticular bleeding (29.4%) in the outpatient-onset cohort. Multivariate analysis showed that a platelet count < 15 × 104 /μL and albumin concentration < 3 g/dL were significantly associated with a poor clinical course in the inpatient-onset cohort.

CONCLUSIONS

The clinical course was significantly worse in the inpatient-onset cohort than in the outpatient-onset cohort. The bleeding source, clinical characteristics, and clinical course differed between the inpatient-onset and outpatient-onset cohorts. The clinical course in the inpatient-onset cohort may depend on the patient's condition at ALGIB onset.

Recognition of Strokes in the ICU: A Narrative Review

Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.

Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality?

OBJECTIVES

In-hospital stroke mortality is surprisingly much worse than for strokes occurring outside of the hospital. Cardiac surgery patients are amongst the highest risk groups for in-hospital stroke and experience high stroke-related mortality. Variability in institutional practices appears to play an important role in the diagnosis, management, and outcome of postoperative stroke. We therefore tested the hypothesis that variability in postoperative stroke management of cardiac surgical patients exists across institutions.

MATERIALS AND METHODS

A 13 item survey was employed to determine postoperative stroke practice patterns for cardiac surgical patients across 45 academic institutions.

RESULTS

Less than half (44%) reported any formal clinical effort to preoperatively identify patients at high risk for postoperative stroke. Epiaortic ultrasonography for the detection of aortic atheroma, a proven preventative measure, was routinely practiced in only 16% of institutions. Forty-four percent (44%) reported not knowing whether a validated stroke assessment tool was utilized for the detection of postoperative stroke, and 20% reported that validated tools were not routinely used. All responders, however, confirmed the availability of stroke intervention teams.

CONCLUSIONS

Adoption of a best practices approach to the management of postoperative stroke is highly variable and may improve outcomes in postoperative stroke after cardiac surgery.

Design Principle and Proofing of a New Smart Textile Material That Acts as a Sensor for Immobility in Severe Bed-Confined Patients

The immobility of patients confined to continuous bed rest continues to raise a couple of very serious challenges for modern medicine. In particular, the overlooking of sudden onset immobility (as in acute stroke) and the delay in addressing the underlying conditions are of utmost importance for the patient and, in the long term, for the medical and social systems. This paper describes the design principles and concrete implementation of a new smart textile material that can form the substrate of intensive care bedding, that acts as a mobility/immobility sensor in itself. The textile sheet acts as a multi-point pressure-sensitive surface that sends continuous capacitance readings through a connector box to a computer running a dedicated software. The design of the capacitance circuit ensures enough individual points to provide an accurate description of the overlying shape and weight. We describe the textile composition and circuit design as well as the preliminary data collected during testing to demonstrate the validity of the complete solution. These results suggest that the smart textile sheet is a very sensitive pressure sensor and can provide continuous discriminatory information to allow for the very sensitive, real-time detection of immobility.

Derivation and Validation of an Algorithm to Detect Stroke Using Arm Accelerometry Data

Background Early diagnosis is essential for effective stroke therapy. Strokes in hospitalized patients are associated with worse outcomes compared with strokes in the community. We derived and validated an algorithm to identify strokes by monitoring upper limb movements in hospitalized patients. Methods and Results A prospective case-control study in hospitalized patients evaluated bilateral arm accelerometry from patients with acute stroke with lateralized weakness and controls without stroke. We derived a stroke classifier algorithm from 123 controls and 77 acute stroke cases and then validated the performance in a separate cohort of 167 controls and 33 acute strokes, measuring false alarm rates in nonstroke controls and time to detection in stroke cases. Faster detection time was associated with more false alarms. With a median false alarm rate among nonstroke controls of 3.6 (interquartile range [IQR], 2.1-5.0) alarms per patient per day, the median time to detection was 15.0 (IQR, 8.0-73.5) minutes. A median false alarm rate of 1.1 (IQR. 0-2.2) per patient per day was associated with a median time to stroke detection of 29.0 (IQR, 11.0-58.0) minutes. There were no differences in algorithm performance for subgroups dichotomized by age, sex, race, handedness, nondominant hemisphere involvement, intensive care unit versus ward, or daytime versus nighttime. Conclusions Arm movement data can be used to detect asymmetry indicative of stroke in hospitalized patients with a low false alarm rate. Additional studies are needed to demonstrate clinical usefulness.

Intravenous thrombolysis in acute ischemic stroke after antagonization of unfractionated heparin with protamine: case series and systematic review of literature

Background and aims

Intravenous thrombolysis (IVT) is standard of care for disabling acute ischemic stroke (AIS) within a time window of ⩽ 4.5 h. Some AIS patients cannot be treated with IVT due to limiting contraindications, including heparin usage in an anticoagulating dose within the past 24 h or an elevated activated prothrombin time (aPTT) > 15 s. Protamine is a potent antidote to unfractionated heparin.

Objectives

The objective of this study was to investigate the safety and efficacy of IVT in AIS patients after antagonization of unfractionated heparin with protamine.

Methods

Patients from our stroke center (between January 2015 and September 2021) treated with IVT after heparin antagonization with protamine were analyzed. National Institutes of Health Stroke Scale (NIHSS) was used for stroke severity and modified Rankin Scale (mRS) for outcome assessment. Substantial neurological improvement was defined as the difference between admission and discharge NIHSS of ⩾8 or discharge NIHSS of ⩽1. Good outcome at follow-up after 3 months was defined as mRS 0-2. Safety data were obtained for mortality, symptomatic intracerebral hemorrhage (sICH), and for adverse events due to protamine. Second, a systematic review was performed searching PubMed and Scopus for studies and case reviews presenting AIS patients treated with IVT after heparin antagonization with protamine. The search was limited from January 1, 2011 to September 29, 2021. Furthermore, we conducted a propensity score matching comparing protamine-treated patients to a control IVT group without protamine (ratio 2:1, match tolerance 0.2).

Results

A total of 16 patients, 5 treated in our hospital and 11 from literature, [65.2 ± 13.1 years, 37.5% female, median premorbid mRS (pmRS) 1 (IQR 1, 4)] treated with IVT after heparin antagonization using protamine were included and compared to 31 IVT patients [76.2 ± 10.9 years, 45% female, median pmRS 1 (IQR 0, 2)]. Substantial neurological improvement was evident in 68.8% of protamine-treated patients versus 38.7% of control patients (p = 0.028). Good clinical outcome at follow-up was observed in 56.3% versus 58.1% of patients (p = 0.576). No adverse events due to protamine were reported, one patient suffered sICH after secondary endovascular thrombectomy of large vessel occlusion. Mortality was 6.3% versus 22.6% (p = 0.236).

Conclusion

IVT after heparin antagonization with protamine seems to be safe and, prospectively, may extend the number of AIS patients who can benefit from reperfusion treatment using IVT. Further prospective registry trials would be helpful to further investigate the clinical applicability of heparin antagonization.

Characteristics of stroke after liver and kidney transplantation

Background

The mechanism and characteristics of a post-transplantation stroke may differ between liver (LT) and kidney transplantation (KT), as the associated comorbidities and peri-surgical conditions are different. Herein, we investigated the characteristics and etiologies of stroke occurring after LT and KT.

Methods

Consecutive patients who received LT or KT between January 2005 to December 2020 who were diagnosed with ischemic or hemorrhagic stroke after transplantation were enrolled. Ischemic strokes were further classified according to the etiologies. The characteristics of stroke, including in-hospital stroke, perioperative stroke, stroke etiology, and timing of stroke, were compared between the LT and KT groups.

Results

There were 105 (1.8%) and 58 (1.3%) post-transplantation stroke patients in 5,950 LT and 4,475 KT recipients, respectively. Diabetes, hypertension, and coronary arterial disease were less frequent in the LT than the KT group. In-hospital and perioperative strokes were more common in LT than in the KT group (LT, 57.9%; KT, 39.7%; p = 0.03, and LT, 43.9%; KT, 27.6%; p = 0.04, respectively). Hemorrhagic strokes were also more common in the LT group (LT, 25.2%; KT, 8.6%; p = 0.01). Analysis of ischemic stroke etiology did not reveal significant difference between the two groups; undetermined etiology was the most common, followed by small vessel occlusion and cardioembolism. The 3-month mortality was similar between the two groups (both LT and KT, 10.3%) and was independently associated with in-hospital stroke and elevated C-reactive protein.

Conclusions

In-hospital, perioperative, and hemorrhagic strokes were more common in the LT group than in the KT group. Ischemic stroke subtypes did not differ significantly between the two groups and undetermined etiology was the most common cause of ischemic stroke in both groups. High mortality after stroke was noted in transplantation patients and was associated with in-hospital stroke.

The quality of occupational healthcare for carpal tunnel syndrome, healthcare expenditures, and disability outcomes: A prospective observational study

INTRODUCTION/AIMS

In prior work, higher quality care for work-associated carpal tunnel syndrome (CTS) was associated with improved symptoms, functional status, and overall health. We sought to examine whether quality of care is associated with healthcare expenditures or disability.

METHODS

Among 343 adults with workers' compensation claims for CTS, we created patient-level aggregate quality scores for underuse (not receiving highly beneficial care) and overuse (receiving care for which risks exceed benefits). We assessed whether each aggregate quality score (0%-100%, 100% = better care) was associated with healthcare expenditures (18-mo expenditures, any anticipated need for future expenditures) or disability (days on temporary disability, permanent impairment rating at 18 mo).

RESULTS

Mean aggregate quality scores were 77.8% (standard deviation [SD] 16.5%) for underuse and 89.2% (SD 11.0%) for overuse. An underuse score of 100% was associated with higher risk-adjusted 18-mo expenditures ($3672; 95% confidence interval [CI] $324 to $7021) but not with future expenditures (-0.07 percentage points; 95% CI -0.48 to 0.34), relative to a score of 0%. An overuse score of 100% was associated with lower 18-mo expenditures (-$4549, 95% CI -$8792 to -$306) and a modestly lower likelihood of future expenditures (-0.62 percentage points, 95% CI -1.23 to -0.02). Quality of care was not associated with disability.

DISCUSSION

Improving quality of care could increase or lower short-term healthcare expenditures, depending on how often care is currently underused or overused. Future research is needed on quality of care in varied workers' compensation contexts, as well as effective and economical strategies for improving quality.

Effect of Postoperative Stroke Timing on Perioperative Mortality After Carotid Revascularization

BACKGROUND

In-hospital stroke (IHS) has been associated with worse outcomes than out-of-hospital stroke (OHS) due to delays in diagnosis and treatment. A paucity of studies exists comparing the timing of postoperative stroke after carotid revascularization. We aimed to study the effect of IHS versus OHS on postoperative mortality in carotid revascularization patients in a large-scale national database.

METHODS

This is a retrospective cohort study of patients who underwent carotid artery stenting (CAS) and carotid endarterectomy (CEA) between 2011 and 2018 in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Statistical analysis included chi-squared test and multivariable logistic regression. Patients were divided based on postoperative stroke timing (no stroke, IHS, or OHS) as well as procedure type (CEA or CAS).

RESULTS

A total of 31,304 carotid revascularizations were performed with 420 (1.3%) IHSs and 207 (0.7%) OHSs. On adjusted analysis, there was significantly higher perioperative mortality with both IHS [odds ratio (OR): 19.75, 95% confidence interval (CI): 13.61-28.18, P < 0.001] and OHS [OR: 29.73, 95% CI: 18.76-45.82, P < 0.001]. There was no difference in mortality after OHS versus IHS [OR: 1.51, 95% CI: 0.89-2.55, P = 0.161].

CONCLUSIONS

Any postoperative stroke after carotid revascularization significantly increased the odds of 30-day mortality. In contrast to previous studies demonstrating worse outcomes after IHS than OHS, we observed similar 30-day mortality between the 2 stroke categories. Improved follow-up and early recognition with rescue within carotid revascularization patients compared to the general population could potentially contribute to these results. However, overall mortality remains high for any postoperative stroke following carotid revascularization, emphasizing the importance of vigilant in-hospital monitoring and follow-up even after discharging the patient.

Nurse's Role in Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery

Perioperative nurses have the opportunity to play a key role in prevention and recognition of stroke in patients undergoing noncardiac, nonneurological surgery and may impact this potentially devastating complication. Effective nursing care of the older adult requires a specialized knowledge base. Scientific Statements are a cornerstone of the knowledge base that informs this care. This article summarizes the recently released American Heart Association/American Stroke Association Scientific Statement entitled: Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery and discusses the nurse's role in the care of this vulnerable patient population.

Comparison of characteristics, management and outcomes in hospital-onset and community-onset stroke: a multi-centre registry-based cohort study of acute stroke

Objective

Hospital-onset stroke (HOS) is associated with poorer outcomes than community-onset stroke (COS). Previous studies have variably documented patient characteristics and outcome measures; here, we compare in detail characteristics, management and outcomes of HOS and COS.

Methods

A total of 1656 men (mean age ± SD = 73.1 years ± 13.2) and 1653 women (79.3 years ± 13.0), with data prospectively collected (2014–2016) from the Sentinel Stroke National Audit Programme, were admitted with acute stroke in four UK hyperacute stroke units (HASU). Associations between variables were examined by chi-squared tests and multivariable logistic regression (COS as reference).

Results

There were 272 HOS and 3037 COS patients with mean ages of 80.2 years ± 12.5 and 76.4 years ± SD13.5 and equal sex distribution. Compared to COS, HOS had higher proportions ≥ 80 years (64.0% vs 46.4%), congestive heart failure (16.9% vs 4.9%), atrial fibrillation (25.0% vs 19.7%) and pre-stroke disability (9.6% vs 5.1%), and similar history of stroke, hypertension, diabetes, stroke type and severity of stroke. After age, sex and co-morbidities adjustments, HOS had greater risk of pneumonia: OR (95%CI) = 1.9 (1.3–2.6); malnutrition: OR = 2.2 (1.7–2.9); immediate thrombolysis complications: OR = 5.3 (1.5–18.2); length of stay on HASU > 3 weeks: OR = 2.5 (1.8–3.4); post-stroke disability: OR = 1.8 (1.4–2.4); and in-hospital mortality: OR = 1.8 (1.2–2.4), as well as greater support at discharge including palliative care: OR = 1.9 (1.3–2.8); nursing care: OR = 2.0 (1.3–4.0), help for daily living activities: OR = 1.6 (1.1–2.2); and joint-care planning: OR = 1.5 (1.1–1.9).

Conclusions

This detailed analysis of underlying differences in subject characteristics between patients with HOS or COS and adverse consequences provides further insights into understanding poorer outcomes associated with HOS.

Comparing characteristics and outcomes of in-hospital stroke and community-onset stroke

BACKGROUND

In-hospital strokes account for 4-17% of all strokes and usually lead to urgent and severe conditions. However, features of in-hospital strokes have been scarcely reported in China, and the management systems of in-hospital strokes are unestablished. The study aims to analyze the characteristics of in-hospital strokes in comparison to community-onset strokes and provides evidence for the development of national in-patient stroke care systems.

METHODS

We retrospectively analyzed consecutive patients with in-hospital strokes (IHS group) and community-onset strokes (COS group) hospitalized in our hospital between June 2012, and January 2022. Clinical characteristics, care measures, and outcomes were compared between the two groups.

RESULTS

A total of 1162 patients (age 61 ± 16 and 65% male) were included, of whom 193 (16.6%) had an in-hospital stroke and 969 (83.4%) had community-onset stroke. Compared with COS group, patients in IHS group had higher NIHSS at onset (7.25 vs 5.96, P = 0.054), higher use of endovascular therapy (10.4% vs 2.0%, P < 0.001), and lower use of intravascular thrombolysis (1.6% vs 7.2%, P = 0.003). Also, in-hospital strokes were associated with lower rate of mRS0-2 at discharge (OR[95%CI] = 0.674[0.49, 0.926], P = 0.015) and increased in-hospital mobility (OR[95%CI] = 3.621[1.640, 7.996], P = 0.001), after adjusting for age, sex, and cardiovascular risk factors.

CONCLUSION

Compared with community-onset strokes, the patients with in-hospital stroke had insufficient urgent treatment and poorer outcomes, reflecting the need for increased awareness of in-patient stroke, and strategies to streamline in-hospital acute stroke care.

Association between hospital volume, processes of care and outcomes after acute ischaemic stroke: a prospective observational study

OBJECTIVES

There is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke.

DESIGN

A multicentre prospective cohort study.

SETTING

Two hundred and seventeen secondary or tertiary public hospitals from China.

PARTICIPANTS

A total of 17 550 patients within 7 days of acute ischaemic stroke were included.

MAIN OUTCOME MEASURES

The outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes.

RESULTS

There were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year.

CONCLUSIONS

We found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.

Stroke in the Stroke Unit: Recognition, treatment and outcomes in a single-center cohort

BACKGROUND

In-hospital strokes (IHS) are associated with longer diagnosis times, treatment delays, and poorer outcomes. Strokes occurring in the stroke unit have seldom been studied. Our aim was to assess the management of in-stroke unit ischemic stroke (ISUS) by analyzing ISUS characteristics, delays in diagnosis, treatments and outcomes.

METHODS

Consecutive patients from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) registry, from January-2003 to June-2019, were classified as ISUS, other-IHS or community-onset stroke (COS). Baseline and stroke characteristics, time-to-imaging and -to treatment, missed treatment opportunities, treatment rates and outcomes were compared using multivariate analysis with adjustment for relevant clinical, imaging and laboratory data available in ASTRAL.

RESULTS

Among the 3456 patients analyzed, 138 (4.0%) were ISUS, 214 (6.2%) other-IHS and 3104 (89.8%) COS. In multivariate analysis, patients with ISUS more frequently had known stroke onset-time than other-IHS (adjusted odds ratio [aOR] 2.44; 95% confidence interval [CI] 1.39-4.35) or COS (aOR 2.56; 95%CI 1.59-4.17), had less missed treatment opportunities than other-IHS (aOR 0.22; 95%CI 0.06-0.86) and higher endovascular treatment rates than COS (aOR 3.03; 95%CI 1.54-5.88). ISUS were associated with a favorable shift in the modified Rankin Scale at 3-months in comparison with other-IHS (aOR 1.73; 95%CI, 1.11-2.69) or COS (aOR 1.46; 95%CI, 1.00-2.12).

CONCLUSION

ISUS more frequently had known stroke onset-time than other-IHS or COS, less missed treatment opportunities than other-IHS and a higher endovascular treatment rate than COS. This readiness to identify and treat patients in the stroke unit may explain the better long-term outcome of ISUS.

Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association

This scientific statement describes a path to optimizing care for patients who experience an in-hospital stroke. Although these patients are in a monitored environment, their evaluation and treatment are often delayed compared with patients presenting to the emergency department, contributing to higher rates of morbidity and mortality. Reducing delays and optimizing treatment for patients with in-hospital stroke could improve outcomes. This scientific statement calls for the development of hospital systems of care and targeted quality improvement for in-hospital stroke. We propose 5 core elements to optimize in-hospital stroke care: 1. Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts. 2. Create rapid response teams with dedicated stroke training and immediate access to neurological expertise. 3. Standardize the evaluation of patients with potential in-hospital stroke with physical assessment and imaging. 4. Address barriers to treatment potentially, including interfacility transfer to advanced stroke treatment. 5. Establish an in-hospital stroke quality oversight program delivering data-driven performance feedback and driving targeted quality improvement efforts. Additional research is needed to better understand how to reduce the incidence, morbidity, and mortality of in-hospital stroke.

Delays in the Identification and Assessment of in-Hospital Stroke Patients

OBJECTIVES

In-hospital stroke is associated with poor outcomes. Reasons for delays, use of interventions, and presence of large vessel occlusion are not well characterized.

MATERIALS AND METHODS

A retrospective single center cohort of 97 patients with in-hospital stroke was analyzed to identify factors associated with delays from last known normal to symptom identification and to stroke team alerting. Stroke interventions and presence of large vessel occlusion were also assessed.

RESULTS

Strokes were predominantly on surgery services (70%), ischemic (82%), and severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from last known normal to symptom identification (median 5.1 hours, IQR 1.0-19.7 hours), symptom identification to stroke team alerting (median 2.1 hours, IQR 0.5-9.9 hours), and total time from last known normal to alerting (median 11.4 [IQR 2.7-34.2] hours). In univariable analysis, being on a surgical service, in an ICU, intubated, and higher NIHSS were associated with delays. In multivariable analysis only intubation was independently associated with time from last known normal to symptom identification (coefficient 20 hours, IQR 0.2 - 39.8, p=0.047). Interventions were given to 17/80 (21%) ischemic stroke patients; 3 (4%) received IV tPA and 14 (18%) underwent thrombectomy. Vascular imaging occurred in 57/80 (71%) ischemic stroke patients and 21/57 (37%) had large vessel occlusion.

CONCLUSIONS

Hospitalized patients with stroke experience long delays from symptom identification to stroke team alerting. Intubation was strongly associated with delay to symptom identification. Although stroke severity was high and large vessel occlusion common, many patients did not receive acute interventions.

Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria

This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.

In-Hospital Stroke Care: A Six-Year Community-Based Primary Stroke Center Experience

Background and purpose

In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied.

Methods

Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05.

Results

There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations.

Conclusion

The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.

Outcomes between in-hospital stroke and community-onset stroke after thrombectomy: Propensity-score matching analysis

BACKGROUND

The benefit of endovascular thrombectomy for patients with in-hospital stroke remains unclear. Thus, the aim of this study was to compare the endovascular thrombectomy outcomes between in-hospital stroke and community-onset stroke among patients with acute ischemic stroke.

METHODS

From January 2015 to July 2019, 362 consecutive patients with acute ischemic stroke with large vessel occlusion in the anterior circulation received endovascular thrombectomy in our centre. After propensity score matching with a ratio of 1:2 (in-hospital stroke:community-onset stroke), clinical characteristics and functional outcomes were compared between in-hospital stroke and community-onset stroke groups.

RESULTS

Thirty-six patients with in-hospital stroke and 72 patients with community-onset stroke were enrolled. The number of patients with New York Heart Association classification III/IV (41.7% vs. 6.9%, p < 0.001) and with underlying cancer (25.0% vs. 2.8%, p < 0.001) was higher in the in-hospital stroke than in the community-onset stroke group. The intravenous thrombolysis rate was lower in the in-hospital stroke group (13.9% vs. 43.1%, p = 0.002). No significant difference in symptom onset to puncture (p = 0.618), symptom onset to recanalisation (p = 0.618) or good reperfusion (modified thrombolysis in cerebral infarction ≥2b) rates (p = 0.852) was found between the groups. The favourable clinical outcome trend (modified Rankin scale ≤2 at 90 days) was inferior, but acceptable, in the in-hospital stroke, group compared to the community-onset stroke group (30.6% vs. 41.7%, p = 0.262).

CONCLUSION

Patients with in-hospital stroke had more disadvantageous comorbidities than those with community-onset stroke. Cardiac dysfunction seems to be associated with poor outcomes after thrombectomy. Nevertheless, endovascular thrombectomy still appears to be safe and effective for patients with in-hospital stroke.

Optimizing the Recognition and Treatment of In-Hospital Stroke: Evaluation of the 2CAN Score

OBJECTIVES

Stroke-like symptoms may be difficult to appreciate due to the high incidence of stroke mimics (e.g., delirium) in the inpatient population. Many centers have adopted inpatient-specific stroke protocols with the aim of improving time to diagnosis and treatment. We aimed to assess one of these instruments, the "2CAN" score, in our patient population.

MATERIALS AND METHODS

A retrospective chart review was conducted for all inpatients for whom our Brain Attack Team (BAT) was called between January 2015 and June 2019. Patients were excluded if they had stroke prior to current admission, were in the emergency department at the time of BAT call, or had incomplete documentation. The 2CAN score was calculated for each patient.

RESULTS

The BAT was activated 201 times, and 110 patients met inclusion criteria. Twenty percent of patients had a history of atrial fibrillation, 72% hypertension, and 36% diabetes. Median NIHSS was 14.5 (IQR 5-24). Only 18% of stroke calls occurred within 24 h of hospital admission. The mean 2CAN score was 2.8. Ninety-seven (88%) patients received a final diagnosis of ischemic stroke and 13 (12%) of stroke mimics. There was no difference between 2CAN scores in the stroke and mimic groups (P = 0.91). A 2CAN score of ≥ 2 had sensitivity 83.5%, specificity 23.1%, PPV 89.0%, and NPV 15.8% for stroke.

CONCLUSIONS

The 2CAN score was derived and validated in a single academic center as a tool to recognize inpatient stroke. The 2CAN score had good sensitivity and positive predictive value for stroke in our cohort, but poor specificity.

Trends in Reperfusion Therapy for In-Hospital Ischemic Stroke in the Endovascular Therapy Era

Importance

A significant proportion of acute ischemic strokes occur while patients are hospitalized. Limited contemporary data exist on the utilization rates of intravenous thrombolysis or endovascular therapy for in-hospital stroke.

Objective

To use a national registry to examine temporal trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke.

Design, Setting, and Participants

This retrospective cohort study analyzed data from 267 956 patients who underwent reperfusion therapy for stroke with in-hospital or out-of-hospital onset reported in the Get With the Guidelines-Stroke national registry from January 2008 to September 2018.

Exposures

In-hospital onset vs out-of-hospital onset of stroke symptoms.

Main Outcomes and Measures

Temporal trends in the use of reperfusion therapy, process measures of quality, and the association between functional outcomes and key patient characteristics, comorbidities, and treatments.

Results

Of 67 493 patients with in-hospital stroke onset, this study observed increased rates of vascular risk factors (standardized mean difference >10%) but no significant differences in age or sex in patients undergoing intravenous thrombolysis only (mean [interquartile range {IQR}] age, 72 [80-62] y; 53.2% female) or those undergoing endovascular therapy (mean [IQR] age, 69 [59-79] y; 49.8% female). Of these patients, 10 481 (15.5%) received intravenous thrombolysis and 2494 (3.7%) underwent endovascular therapy. Compared with 2008, in 2018 the proportion of in-hospital stroke among all stroke hospital discharges was higher (3.5% vs 2.7%; P < .001), as was use of intravenous thrombolysis (19.1% vs 9.1%; P < .001) and endovascular therapy (6.4% vs 2.5%; P < .001) in patients with in-hospital stroke, with a significant increase in endovascular therapy in mid-2015 (P < .001). Compared with patients who received intravenous thrombolysis for out-of-hospital stroke onset, those with in-hospital onset were associated with longer median (IQR) times from stroke recognition to cranial imaging (33 [18-60] vs 16 [9-26] minutes; P < .001) and to thrombolysis bolus (81 [52-125] vs 60 [45-84] minutes; P < .001). In adjusted analyses, patients with in-hospital stroke onset who were treated with intravenous thrombolysis were less likely to ambulate independently at discharge (adjusted odds ratio, 0.78; 95% CI, 0.74-0.82; P < .001) and were more likely to die or to be discharged to hospice (adjusted odds ratio, 1.39; 95% CI, 1.29-1.50; P < .001) than patients with out-of-hospital onset who also received intravenous thrombolysis treatment. Comparisons among patients treated with endovascular therapy yielded similar findings.

Conclusions and Relevance

In this cohort study, in-hospital stroke onset was increasingly reported and treated with reperfusion therapy. Compared with out-of-hospital stroke onset, in-hospital onset was associated with longer delays to reperfusion and worse functional outcomes, highlighting opportunities to further care for patients with in-hospital stroke onset.

In-Hospital Acute Ischemic Stroke is Associated with Worse Outcome: Experience of a Single Center in Santiago Chile

OBJECTIVES

In-hospital acute ischemic stroke (HIS) accounts for 2-17% of all acute ischemic strokes (AIS) seen in hospital and they have worse prognosis. In this study we aimed to identify the frequency of HIS and their characteristics in our center.

MATERIALS AND METHODS

Retrospective analysis of a prospective register of patients with AIS seen at Clínica Alemana de Santiago, between January 2017 and January 2019. HIS and community onset ischemic strokes patients (CIS) were compared, univariate analysis was performed, covariates with p < 0.25 were selected for multivariate analysis. Differences between, proportion of strokes treated with thrombolytic therapy, door to needle time were compared between HIS and CIS patients, as also mortality rates at 90 days.

RESULTS

During the study period 369 patients with AIS were seen; of these 20 (5.4%, 95 CI%, 3.5-8.2) corresponded to HIS. In univariate analysis, HIS compared to patients arriving form the community to the emergency room, suffered more frequently from, heart failure (p = 0.04), and active malignancies (p < 0.001). HIS patients had longer times from symptom onset to non-contrast brain tomography (540 ±150 minutes); they were also less frequently treated with intravenous thrombolysis compared to community AIS: 15% versus 30% respectively (p = 0.08). Mortality rates at 90 days were higher in HIS: 30 versus 5% (p = 0.001).

CONCLUSIONS

In this cohort, HIS patients suffered delays in their neuroimaging studies and received less intravenous thrombolysis; this underscores the need for a standardized approach to the recognition and management of inhospital acute ischemic stroke.

Predictive Factors of Perioperative Stroke-Related Mortality Following Vascular Surgery: A Retrospective Analysis

OBJECTIVE

Vascular surgical procedures have one of the highest risks of perioperative stroke and stroke-related mortality, yet the independent risk factors contributing to this increased mortality have not been described. Perioperative strokes are thought to result from a combination of embolism and hypoperfusion mechanisms. The purpose of this study is to describe the independent predictors of perioperative stroke-related mortality in the vascular surgical population using the Pennsylvania Health Care Cost Containment Council (PHC4) database which collects cause of death data.

METHODS

This retrospective, case-control study evaluated 4,128 patients aged 18-99 who underwent a vascular, non-carotid surgical procedure and subsequently suffered perioperative mortality. Common surgical comorbidities and risk factors for perioperative stroke, including carotid stenosis and atrial fibrillation, were evaluated in multivariate regression analysis.

RESULTS

Patients with carotid stenosis were 2.6 (aOR, 95% CI 1.4-4.5) times more likely to suffer perioperative mortality from stroke than from other causes. Additionally, in-hospital stroke, history of stroke, admission from a healthcare facility, and cancer were all positive predictive factors, whereas atrial fibrillation, emergency admission, hypertension, and diabetes were associated with decreased risk of perioperative stroke-related mortality.

CONCLUSIONS

Identification of vascular surgical population-specific predictors of stroke-related mortality can help to enhance preoperative risk-stratification tools and guide perioperative management of identified high-risk patients. Increased neurophysiologic monitoring in the perioperative period to prevent delays in diagnosis of perioperative stroke offers a strategy to reduce risk of perioperative stroke-related mortality in vascular surgical patients.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association

In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.

Rapid Response System for In-Hospital Large Vessel Occlusion: A Case-Control Study

Objective

Acute ischemic stroke due to large vessel occlusion (LVO) in hospitalized patients is relatively rare but important condition. However, unlike community-onset cases, there are only few time-saving protocols for in-hospital LVO. This study aimed to evaluate the time-saving effects of rapid response system (RRS) for the management of in-hospital LVO.

Methods

We retrospectively evaluated consecutive in-hospital LVO patients who underwent mechanical thrombectomy (MT) between April 2015 and January 2020. In November 2017, we added "acute hemiparesis, eye deviation, and convulsive seizures" to the activation criteria for RRS. In this protocol, the patient is immediately transported from the ward to the emergency room (ER) by Medical Emergency Team (MET). The stroke team can then start assessment in the same manner as for community-onset cases. The time metrics between those with and without RRS intervention were compared. The primary outcome was time from detection to the first assessment by stroke team and to initial CT. To investigate the validity of the revised criteria, we also analyzed all RRS-activated cases.

Results

In total, 26 patients (RRS group, 11 patients; non-RRS group, 15 patients) were included. The median time from detection to stroke team assessment (10.0 [interquartile range: IQR, 8-15] minutes vs 65.5 [18-89] minutes) and to CT (22.0 [16-31] minutes vs. 46.5 [35-93] minutes) were significantly shorter in the RRS group. RRS was activated in 34 patients (mean, 1.3/month) according to the added criteria, of whom 20 (58.8%) had cerebral infarction and 9 underwent MT. About two-thirds of the other patients developed neurological emergencies (e.g., epileptic seizure, syncope, or hypoglycemia) that required acute care.

Conclusion

RRS has the potential to shorten response time efficiently in the management of in-hospital LVO. Prompt transportation of the patient to the ER by MET enables faster intervention by the stroke team.

Impact of a Structured Response and Evidence-Based Checklist on In-hospital Stroke Outcomes

BACKGROUND

In-hospital stroke events account for 2% to 17% of all ischemic strokes in the United States. Current stroke guidelines do not provide guidance on how to care for in-hospital stroke. Use of checklists during high-acuity events reduces error and provides clarity for responding staff. We sought to determine whether the use of an evidence-based checklist to guide in-hospital stroke response improved intervention times and patient outcomes.

METHODS

This study used a retrospective chart review of patients hospitalized between January 1, 2016, and December 31, 2018, at a community hospital certified as a primary stroke center with the Joint Commission. Encounters were sorted into preintervention and postintervention groups to evaluate for change in treatment rates, new or worsened disability, and mortality. Nursing staff who respond to in-hospital stroke calls ("response staff") were also surveyed regarding their perception of benefit and firsthand experience when using the checklist.

RESULTS

A total of 168 patient charts were reviewed (18 prechecklist, 150 postchecklist). After checklist implementation, treatment with intravenous thrombolytics for in-hospital stroke events increased from 0% to 11%. All-cause mortality decreased from 23.1% to 15.0%, whereas ambulatory disability at discharge increased from 38.0% to 62.1%. The increase in disability likely reflects the reduction in mortality, improved data collection, and the increase in postimplementation reporting.

CONCLUSIONS

Use of a checklist during inpatient stroke events can potentially increase adherence to guidelines for appropriate treatment and reduce mortality. Hospital response teams should consider use of a structured response system with an evidence-based checklist for high-acuity, low-frequency events such as in-hospital stroke.

Timing of Recognition for Perioperative Strokes Following Cardiac Surgery

INTRODUCTION

More than half of reported perioperative strokes following cardiac surgery are identified beyond postoperative day one. The objective of our study was to determine preoperative and intraoperative factors that are associated with stroke following cardiac surgery and to identify factors that may contribute delayed recognition of perioperative stroke.

METHODS

Patients undergoing coronary artery bypass surgery or isolated valve surgery from January 2, 2015 to April 28, 2017 at an academic health system were identified from the Society of Thoracic Surgeons Registry. We determined preoperative and intraoperative factors associated with perioperative stroke. Two neurologists performed retrospective chart reviews on perioperative stroke patients to determine the last seen well time and the stroke cause.

RESULTS

During the study period, 2795 patients underwent coronary artery bypass surgery or isolated valve surgery (mean age 64 ± 11 years, 71% male, 72% Caucasian, 9% history of stroke), of which 43 (1.5%) had a perioperative stroke; 31 (72%) patients had an embolic mechanism of stroke based on neuroimaging. In multivariable analysis, perioperative strokes were independently associated with increasing age (OR 1.04, 95% 1.01-1.07), history of stroke (OR 2.73, 95% CI 1.47-5.06), and history of thoracic aorta disease (OR 3.36, 95% CI 1.16-9.71). Strokes were identified after postoperative day one in 32 (74%) patients of which 26 (81%) had a preoperative last seen well time.

CONCLUSION

Given the high frequency of preoperative last seen well time in perioperative stroke patients who are identified after postoperative day one, delayed stroke recognition may contribute to the bimodal distribution in timing of perioperative stroke. Frequent neurological monitoring within 24 hours after CABG or isolated valve surgery should be considered for all patients undergoing cardiac surgery, particularly elderly patients and those with a history of stroke or thoracic aorta disease, to improve early stroke recognition.

Stroke History is an Independent Risk Factor for Poor Prognosis in Ischemic Stroke Patients: Results from a Large Nationwide Stroke Registry

Background

There is some controversy whether stroke history is an independent risk factor for poor prognosis of stroke or not. This study aimed to investigate the difference of mortality, disability and recurrent rate of ischemic stroke patients without and with stroke history, as well as to explore the effect of stroke history on stroke prognosis.

Methods

We analyzed patients with ischemic stroke enrolled in the China National Stroke Registry which was a nationwide, multicenter, and prospective registry of consecutive patients with acute cerebrovascular events from 2007 to 2008. Multivariable logistic regression was performed to assess the risk of worse prognosis of stroke history in patients with ischemic stroke.

Results

A total of 8181(65.9%) patients without stroke history and 4234(34.1%) patients with stroke history were enrolled in the study. The mortality, recurrence, modified Rankin Scale (mRS) 3-6 rate was 11.4%, 14.7% and 28.5% respectively at 1 year for patients without stroke history, which was significantly lower than that of 17.3%, 23.6%, 42.1% in patients with stroke history, respectively. Multivariable analysis showed that patients with stroke history had higher risk of death [odds ratio (OR) 1.34,95% confidence interval (CI) 1.17-1.54], recurrence (OR 1.47, 95 % CI 1.31-1.65) and mRS 3-6 (OR 1.49,95% CI 1.34-1.66) at 1 year.

Conclusion

After adjusting for the potential confounders, stroke history was still an independent risk factor for poor prognosis of ischemic stroke, which further emphasizes the importance of secondary prevention of ischemic stroke. The specific causes of poor prognosis in patients with history of stroke need to be furtherly investigated.

BE-FAST: A Sensitive Screening Tool to Identify In-Hospital Acute Ischemic Stroke

BACKGROUND

Development of acute ischemic stroke in hospitalized patients represents a significant proportion of all cerebral ischemia. Several prehospital stroke scales were developed to screen for acute ischemic stroke in the community. Despite the advent of inpatient stroke alert systems, there is a lack of validated screening tools for the inpatient population. This study aims to assess the validity of BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) as a screening tool for acute ischemic stroke among inpatients.

METHODS

We retrospectively analyzed all stroke alert activations at a single academic medical center between 2012 and 2016. We classified the triggering symptom as: focal neurologic deficit, aphasia, dysarthria, ataxia/vertigo/dizziness, alteration of consciousness, acute confusion, or headache. BE-FAST was applied retrospectively, and patients were classified as BE-FAST positive or negative. The final diagnosis was classified as acute ischemic stroke, transient ischemic attack , intracranial hemorrhage or noncerebrovascular diagnosis.

RESULTS

Of 1965 stroke alerts, 489 were among inpatients. The mean age was 63 ± 16.1 years; 57% of patients were women (n = 1121). Acute ischemic stroke was diagnosed in 29% of all the activations (n = 567), transient ischemic attack in 12% (n = 232), intracranial hemorrhage in 8 % (n = 160) and noncerebrovascular in 51% (n = 1006). When comparing inpatient with community-onset stroke alerts, the sensitivity of BE-FAST for diagnosing acute ischemic stroke was 85% versus 94% (P = .005), with a specificity of 43% versus 23% (P < .001), respectively. However, when evaluating in-patients with an intact level of consciousness separately, BE-FAST sensitivity for diagnosing acute ischemic stroke was 92% compared to 94% in the community (P = .579). Among in-patients with acute ischemic stroke who were (1) candidates for reperfusion therapy and (2) diagnosed with acute large vessel occlusion, the sensitivity of BE-FAST was 83% and 94%, respectively.

CONCLUSIONS

This is the first study to analyze the performance of BE-FAST among hospitalized patients evaluated through the inpatient stroke alert system. We found BE-FAST to be a very sensitive tool for screening for all in-hospital acute ischemic strokes, including inpatients that were candidates for acute reperfusion therapy.

Identifying Gaps and Missed Opportunities for Intravenous Thrombolytic Treatment of Inpatient Stroke

Background: Inpatient stroke-codes (ISC) have traditionally seen low treatment rates with IV-thrombolytic (IVT). The purpose of this study was to identify the predictors of true stroke, prevalent IVT-treatment gap and study the factors associated with such missed treatment opportunities (MTO).

Methods: A retrospective chart review identified ISC from March 2017 to March 2018. Clinical, radiographic and demographic data were collected. Primary analysis was performed between stroke vs. non-stroke diagnoses. Dichotomous variables were analyzed using Chi-Square test of proportions and continuous variables with Wilcoxon-Ranked-Sum test. Significant factors were then tested in a multivariate logistic regression model for independence.

Results: From 211 ISC, 36% (n = 76) had an acute stroke. Hemorrhagic stroke (HS) was present in 5.7% (n = 12). Of the remaining 199, 44% (n = 87) were IVT-eligible but only 3.4% (n = 3) were treated. Of the remaining 84 IVT-eligible-but-untreated patients, 69(82.1%) were mimics, while 15 (17.9%) had an ischemic stroke (IS), constituting a MTO of 1 in 6 IVT-eligible patients, with National Institutes of Health Stroke Scale (NIHSS) ≤4 being the commonest deterrent. Independent predictors of stroke were ejection fraction (EF) <30% (p = 0.030, OR = 3.06), post-operative status (p = 0.001, OR = 3.71), visual field-cut (p = 0.008, OR = 3.70), and facial droop (p = 0.010, OR = 2.59).

Conclusion: In our study, one in three ISC were true strokes. IVT treatment rates were low with a MTO of 1 in 6 IVT-eligible patients. The most common reason for not treating was NIHSS ≤4. Knowing predictors of true stroke and the common barriers to IVT treatment can help narrow this treatment gap.

In-hospital Ischemic Stroke Treated by Mechanical Thrombectomy

Objective

We investigated in-hospital stroke (IHS) treated by mechanical thrombectomy in comparison with out-of-hospital stroke (OHS) to clarify the points of concern in IHS at our institution.

Methods

Between September 2015 and June 2018, 19 patients with IHS who underwent mechanical thrombectomy (IHS group) were enrolled, and compared with 154 patients with OHS (OHS group) regarding patient characteristics, technical results, and outcome. In this study, we set the detection time in the IHS group as patient arrival time, termed "Door" in the OHS group.

Results

Cardiology and gastroenterology were the two main admitting departments, including four (21%) patients of IHS group. In all, 15 (79%) patients had atrial fibrillation; however, less than one-third of them was taking anticoagulant drugs at onset. There were only two cases of direct consultation to the stroke specialists, although IHS onset was mainly recognized by nurses. The median age in the IHS group was 81 (interquartile range (IQR), 76-86.5) versus 80 in the OHS group (IQR, 73-85; p = 0.43), and the median initial National Institutes of Health Stroke Scale score was 21 (IQR, 16-23) versus 21 (IQR, 14-26; p = 0.92), respectively. Sex, Alberta Stroke Program Early CT Score, etiology, and occlusion site did not differ between groups. The rate of use of intravenous tissue plasminogen activator (IV-tPA) was 26% in the IHS group versus 49% in the OHS group (p = 0.065). The median time of detection to imaging, detection to needle for IV-tPA, and detection to puncture were 32, 69, and 87 minutes, respectively, in the IHS group, being significantly longer than those in the OHS group (11, 30, and 50 minutes; p <0.01, p <0.01, and p <0.01, respectively). The median time of puncture to reperfusion was 39 minutes, being significantly shorter than that in the OHS group (82 minutes; p <0.01). Successful reperfusion defined as thrombolysis in cerebral infarction (TICI) 2b-3 was obtained in 94.7% of the IHS group versus 83.1% of the OHS group (p = 0.19). A favorable outcome (modified Rankin Scale score 0-2) at 90 days was achieved by 36.8% (IHS) versus 35.1% (OHS) of patients (p = 0.88). The rate of symptomatic procedural complications was 0% (IHS) versus 7.1% (OHS; p = 0.23). The rate of death at 90 days was 15.8% (IHS) versus 12.3% (OHS; p = 0.67).

Conclusion

The times of detection to imaging and of detection to puncture in the IHS group were longer than those in the OHS group; however, patients in the IHS group had shorter reperfusion. The outcome of the IHS group did not differ from that of OHS group. Our study suggests that the time course of treatment should be improved and rapid stroke pathways involved in consultation with the stroke specialists for IHS should be organized.