Prestroke Disability Predicts Adverse Poststroke Outcome: A Registry-Based Prospective Cohort Study of Acute Stroke

External validation of clinical risk prediction score for elderly treated with endovascular thrombectomy

BACKGROUND AND AIM

The thrombectomy in the elderly prediction score (TERPS) for functional outcome after anterior circulation endovascular therapy (EVT) in patients ≥ 80 years was recently developed. The aim of this study was to assess predictors of functional outcome in the elderly and validate the prediction model.

METHODS

Consecutive patients treated with EVT from the Oslo Acute Reperfusion Stroke Study were evaluated for inclusion. Clinical and radiological parameters were used to calculate the TERPS, and functional outcome were assessed at 3-month follow-up.

RESULTS

Out of 1028 patients who underwent EVT for acute ischemic stroke from January 2017 to July 2022, 218 (21.2%) patients ≥ 80 years with anterior ischemic stroke were included. Fair outcome, defined as modified Rankin scale ≤ 3 (mRS), was achieved in 117 (53.7%). In bivariate analyses, male sex (p 0.035), age (p 0.025), baseline National Institute of Health Stroke Scale (NIHSS, p < 0.001), pre-stroke mRS (p 0.002) and Alberta Stroke Program Early Computed Tomography score (ASPECTS, p 0.001) were associated with fair outcome. Significant predictors for fair outcome in regression analyses were lower pre-stroke mRS, adjusted odd ratio, (aOR) 0.67 (95% CI 0.50-0.91, p 0.01), NIHSS, aOR 0.92 (95% CI 0.87-0.97, p 0.002), and higher ASPECTS, aOR 1.22 (95% CI 1.03-1.44, p 0.023). The area under the curve (AUC) using TERPS was 0.74 (95% CI 0.67-0.80).

CONCLUSIONS

The risk prediction score TERPS showed moderate performance in this external validation. Other variables may still be included to improve the model and validation using other cohorts is recommended.

TRIAL REGISTRATION

NCT06220981.

Predictors of functional outcome after stroke: Sex differences in older individuals

BACKGROUND

Sex differences in stroke are well documented, with females being older at onset, with more severe strokes and worse outcomes than males. Females receive less comprehensive stroke unit treatment. Similarly, older individuals receive poorer quality care than younger ones. There is limited research on sex differences in factors that impact 3-month poststroke functional outcome in people older than 80 years.

METHODS

This register-based and cross-sectional study analyzed data from two stroke quality registers in Sweden from 2014 through 2019. The study included patients aged ≥80 with a diagnosis of ischemic or hemorrhagic stroke. Sociodemographic features, prestroke condition, stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]), stroke unit care, rehabilitation plans, and 3-month poststroke functional outcome measured with the modified Rankin Scale were analyzed. Ordinal regression analyses stratified by sex were conducted to assess sex differences in factors that impact poststroke functional outcome 3 months after the stroke.

RESULTS

A total of 2245 patients were studied with the majority (59.2%) being females. Females experienced more severe strokes (NIHSS median 4 vs. 3, p = 0.01) and were older at stroke onset than males (87.0 vs. 85.4, p < 0.001). Females were also less independent prestroke (69.9% vs. 77.4%, p < 0.001) and a higher proportion of females lived alone (78.2% vs. 44.2%, p < 0.001). Males received intravenous thrombolysis more often than females (16.3% vs. 12.0%, p = 0.005). Regarding 3-month functional outcome, males benefited more from thrombolysis (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.83), whereas females benefited more from thrombectomy (OR 0.40, 95% CI 0.20-0.71).

CONCLUSION

Stroke care should be adapted to sex disparities in older individuals, while clinicians should be aware of these sex disparities. Further research could clarify the mechanisms behind these disparities and lead to a more personalized approach to stroke care of the older population.

Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors

BACKGROUND

Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes.

METHODS

In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes.

RESULTS

Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts.

CONCLUSIONS

Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Sex differences in acute stroke metrics and outcome dependent on COVID status

BACKGROUND AND PURPOSE

Biological sex is known to have an impact on quality metrics of acute stroke. We aimed to determine whether COVID positivity accentuates this effect and constitutes worse outcome.

METHODS

The present analysis was based on the Global COVID-19 Stroke Registry, a retrospective, international, cohort study of consecutive ischemic stroke patients receiving intravenous thrombolysis and/or endovascular thrombectomy between 1 March 2020 and 30 June 2021. We investigated differences between the sexes in patient characteristics, acute stroke metrics as well as post-stroke outcome in COVID-positive and COVID-negative stroke patients undergoing acute revascularization procedures.

RESULTS

A total of 15,128 patients from 106 centers were recorded in the Global COVID-19 Stroke Registry, 853 (5.6%) of whom were COVID-positive. Overall, COVID-positive individuals were treated significantly slower according to every acute stroke metric compared to COVID-negative patients. We were able to show that key quality indicators in acute stroke treatment were unfavorable for COVID-negative women compared to men (last-seen-well-to-door time + 11 min in women). Furthermore, COVID-negative women had worse 3-month outcomes (3-month modified Rankin Scale score [interquartile range] 3.0 [4.0] vs. 2.0 [3.0]; p < 0.01), even after adjusting for confounders. In COVID-positive individuals no such difference between the sexes, either in acute management metrics or in 3-month outcome, was seen.

CONCLUSION

Known sex-related differences in acute stroke management exist and extend to times of crisis. Nevertheless, if patients were COVID-19-positive at stroke onset, women and men were treated the same, which could be attributed to structured treatment pathways.

Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

BACKGROUND AND PURPOSE

We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability.

METHODS

In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1).

RESULTS

A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995).

CONCLUSION

A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.

The added value of frailty assessment as the premorbid stroke status on activities of daily living in patients with acute stroke, stratified by stroke severity

BACKGROUND

The modified Rankin scale (mRS) is extensively used for premorbid evaluation in patients with stroke; however, its limited capacity to assess functional status highlights the need for additional indicators such as frailty.

AIMS

This study aimed to assess the impact of the premorbid mRS score and frailty on daily living (ADL) activities at hospital discharge, focusing on varying stroke severities.

METHODS

This single-centre, prospective cohort study included patients with acute stroke aged ≥60 years. Key metrics included the frailty index for frailty assessment or mRS for functional status premorbid and the functional independence measure of the motor domain (FIM-M) at discharge for ADL outcomes. The patients were categorized into mild (0-4), moderate (5-15), and severe (16-42) groups based on the National Institute of Health Stroke Scale. Multiple hierarchical linear regression analyses were performed for each group to evaluate the influence of mRS and frailty on FIM-M scores.

RESULTS

In the mild stroke group, significant associations were observed with premorbid mRS3 (β = -0.183, p = 0.004), mRS4 (β = -0.234, p < 0.001), and frailty status (β = -0.227, p = 0.005) and FIM-M scores. Premorbid frailty did not show a significant association with the FIM-M scores in the moderate or severe stroke group. Frailty status notably contributed to changes in R², particularly in the mild stroke group (R² change = 0.031, p = 0.002). However, such changes were not evident in the other stroke severity groups.

CONCLUSION

This study emphasizes the importance of incorporating frailty assessments into premorbid evaluations, particularly when considering ADL outcomes in patients with mild stroke. Conversely, the significance of frailty in moderate-to-severe stroke was less evident.

Impact of dementia status on intravenous thrombolysis and endovascular treatment for acute ischemic stroke: Retrospective study

INTRODUCTION

Individuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia.

METHOD

A retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching.

RESULTS

Altogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes.

DISCUSSION

Our results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care.

Sex-specific independent risk factors of urinary incontinence in acute stroke patients: A multicentre registry-based cohort study

BACKGROUND

The presence of urinary incontinence (UI) in acute stroke patients indicates poor outcomes in men and women. However, there is a paucity and inconsistency of data on UI risk factors in this group and hence we conducted a sex-specific analysis to identify risk factors.

METHODS

Data were collected prospectively (2014-2016) from the Sentinel Stroke National Audit Program for patients admitted to four UK hyperacute stroke units. Relevant risk factors for UI were determined by stepwise multivariable logistic regression, presented as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The mean (±SD) age of UI onset in men (73.9 year ± 13.1; n = 1593) was significantly earlier than for women (79.8 year ± 12.9; n = 1591: p < 0.001). Older age between 70 and 79 year in men (OR = 1.61: CI = 1.24-2.10) and women (OR = 1.55: CI = 1.12-2.15), or ≥80 year in men (OR = 2.19: CI = 1.71-2.81), and women (OR = 2.07: CI = 1.57-2.74)-reference: <70 year-both predicted UI. In addition, intracranial hemorrhage (reference: acute ischemic stroke) in men (OR = 1.64: CI = 1.22-2.20) and women (OR = 1.75: CI = 1.30-2.34); and prestroke disability (mRS scores ≥ 4) in men (OR = 1.90: CI = 1.02-3.5) and women (OR = 1.62: CI = 1.05-2.49) (reference: mRS scores < 4); and stroke severity at admission: NIHSS scores = 5-15 in men (OR = 1.50: CI = 1.20-1.88) and women (OR = 1.72: CI = 1.37-2.16), and NIHSS scores = 16-42 in men (OR = 4.68: CI = 3.20-6.85) and women (OR = 3.89: CI = 2.82-5.37) (reference: NIHSS scores = 0-4) were also significant. Factors not selected were: a history of congestive heart failure, hypertension, atrial fibrillation, diabetes and previous stroke.

CONCLUSIONS

We have identified similar risk factors for UI after stroke in men and women including age >70 year, intracranial hemorrhage, prestroke disability and stroke severity.

Sex Differences in the Role of Multimorbidity on Poststroke Disability: The Taiwan Stroke Registry

BACKGROUND AND OBJECTIVES

Multimorbidity is common in patients who experience stroke. Less is known about the effect of specific multimorbidity patterns on long-term disability in patients with stroke. Furthermore, given the increased poststroke disability frequently seen in female vs male patients, it is unknown whether multimorbidity has a similar association with disability in both sexes. We assessed whether specific multimorbidity clusters were associated with greater long-term poststroke disability burden overall and by sex.

METHODS

In the Taiwan Stroke Registry, an ongoing nationwide prospective registry, patients with first-ever ischemic stroke were enrolled; this analysis is restricted to those individuals surviving to at least 6 months poststroke. Using a hierarchical clustering approach, clusters of prestroke multimorbidity were generated based on 16 risk factors; the algorithm identified 5 distinct clusters. The association between clusters and 12-month poststroke disability, defined using the modified Rankin Scale (mRS), was determined using logistic regression models, with additional models stratified by sex. The longitudinal association between multimorbidity and functional status change was assessed using mixed-effects models.

RESULTS

Nine-thousand eight hundred eighteen patients with first-ever ischemic stroke were included. The cluster with no risk factors was the reference, "healthier" risk group (N = 1,373). Patients with a cluster profile of diabetes, peripheral artery disease (PAD), and chronic kidney disease (CKD) (N = 1882) had significantly greater disability (mRS ≥ 3) at 1 month (OR [95% CI] = 1.36 [1.13-1.63]), 3 months (OR [95% CI] = 1.27 [1.04-1.55]), and 6 months (OR [95% CI] = 1.30 [1.06-1.59]) but not at 12 months (OR [95% CI] = 1.16 [0.95-1.42]) than patients with a healthier risk factor profile. In the sex-stratified analysis, the associations with this risk cluster remained consistent in male patients (OR [95% CI] = 1.42 [1.06-1.89]) at 12 months, who also had a higher comorbidity burden, but not in female patients (OR [95% CI] = 0.95 [0.71-1.26]), who had higher proportions of severe strokes and severe disability (p-interaction = 0.04).

DISCUSSION

Taiwanese patients with multimorbidity, specifically the concurrent presence of diabetes, PAD, and CKD, had higher odds of a worse functional outcome in the first 6 months poststroke. Clusters of multimorbidity may be less informative for long-term disability in female patients. Further studies should evaluate other mechanisms for worse disability in female patients poststroke.

One-Year Disability Trajectories and Long-Term Cardiovascular Events, Recurrent Stroke, and Mortality After Ischemic Stroke

BACKGROUND

Patients with stroke are often affected by varying degrees of functional disability and have different evolution patterns in functional disability. However, little is known about the predictive usefulness of disability changes after stroke. We aimed to describe 1-year disability trajectories and to assess the associations of longitudinal disability trajectories with 24-month clinical outcomes after ischemic stroke.

METHODS AND RESULTS

A total of 3533 patients with ischemic stroke from CATIS (China Antihypertensive Trial in Acute Ischemic Stroke) were studied. Distinct trajectories of disability were identified by the group-based trajectory model, as measured by modified Rankin Scale score within 12 months. Cox proportional hazards regression models were used to examine the associations of disability trajectories with 24-month cardiovascular events and all-cause mortality. We identified 4 distinct disability trajectories: no significant disability (562 participants [15.9%]), slight disability to recovery (1575 participants [44.6%]), severe to moderate disability (1087 participants [30.8%]), and persistent severe disability (309 participants [8.7%]). Compared with no significant disability trajectory, the multivariable adjusted hazard ratios (95% CIs) of patients within the persistent heavy-severe trajectory were 2.63 (1.20-5.76) for cardiovascular events, 2.55 (1.12-5.79) for recurrent stroke, and 6.10 (2.22-16.72) for all-cause mortality; notably, the hazard ratios (95% CIs) for patients within the severe to moderate disability trajectory were 1.99 (1.01-3.94) for cardiovascular events and 1.85 (1.03-3.33) for the composite outcome of cardiovascular events and all-cause mortality.

CONCLUSIONS

Functional disability trajectories within 12 months after stroke onset were associated with the risk of 24-month adverse outcomes. Patients with persistent severe disability or severe to moderate disability had higher risk of cardiovascular events and all-cause mortality.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01840072.

Pre-stroke activities of daily living do not predict functional decline after stroke in a cohort of community dwelling older subjects at risk for vascular disease

BACKGROUND & PURPOSE

Pre-stroke impairment of activities of daily living (ADL) is considered a major determinant for functional outcome after stroke. However, findings are based on studies in stroke patients in which pre-stroke information is gathered retrospectively, with inherent risks of selection and recall bias. The objective of this study was to verify the predictive value of pre-stroke ADL with respect to ADL decline in a large prospective cohort of community dwelling older subjects with known vascular risk factors or vascular disease, thereby minimizing selection and recall bias.

METHODS

Within the four-year study follow-up of a cohort including 5,804 community dwelling older subjects from three countries at risk for vascular disease, incident stroke survivors were identified. Incident myocardial infarction (MI) survivors and the remaining study survivors without incident vascular events served as comparison groups. Multivariate logistic regression analyses for each of the aforementioned groups were performed to assess associations between pre-stroke ADL by the Barthel Index (BI) and Instrumental Activities of Daily Living (IADL) scale and risk for ADL decline.

RESULTS

In stroke survivors, neither pre-event BI (n = 230, OR 1.00 (95% CI 0.83-1.23)) nor IADL (OR 1.07 (95% CI 0.94 - 1.20)) predicted risk of post-stroke ADL decline in contrast to ADL decline after MI (n = 443, OR 0.83 (95% CI 0.70-0.98) and 0.87 (95% CI 0.78-0.97) respectively) and the group without vascular events (n = 4336, OR 0.85 (95% CI 0.78-0.92) and 0.87 (95% CI 0.83-0.92) respectively).

CONCLUSIONS

In the present prospective cohort of community dwelling older subjects with known vascular risk factors, pre-stroke ADL measured by BI and IADL scale did not predict post-stroke ADL decline.

Effects of multicomponent exercise on quality of life, depression and anxiety among stroke survivors: A systematic review and meta-analysis

BACKGROUND

Current guidelines stress the importance of exercise, especially multicomponent exercise to older adults with chronic conditions.

AIM

To critically synthesise evidence that evaluates the effects of multicomponent exercise on quality of life, depression and anxiety after stroke.

DESIGN

Systematic review and meta-analysis followed the PRISMA 2020 statement.

METHODS

A systematic search of PubMed, Embase, Web of Science, Cochrane Library, CINAHL and PsycINFO from inception to 12 June 2023 was performed. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Meta-analyses were conducted using Review Manager 5.4 and narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall certainty of the evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Of 15,351 records identified, nine were eligible and data were available for seven randomised controlled trials, three of which were identified as having a high risk of bias, one as low risk, and five as having some concerns. Subgroup pooled analyses indicated that multicomponent exercise engaged in longer exercise sessions (>60 min) was effective in improving quality of life immediately post-intervention and through 3-6 months post-intervention. However, multicomponent exercise did not significantly affect depression and anxiety.

CONCLUSIONS

Multicomponent exercise with longer duration of exercise sessions has promising effects on both short- to medium-term quality of life among stroke survivors.

PATIENT OR PUBLIC CONTRIBUTION

This does not apply to our work as it is a review paper.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers could consider encouraging the patients to participate in multicomponent exercise sessions for more than 60 min. It is important to note that stroke survivors should be supervised by trained personnel at the beginning of the training.

REGISTRATION

The protocol was registered on PROSPERO.

Efficacy and safety of short-term high dosage dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis for acute ischemic stroke

OBJECTIVE

To evaluate the efficacy and safety of short-term high-dose of dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis for acute ischemic stroke (AIS).

METHODS

All 208 patients with AIS were randomized into group 1 (103 cases, after 0.6 mg/kg rt-PA, 300 mg of oral aspirin(ASP) q.d. and 225 mg of oral clopidogrel (CLO) q.d. for for 5 days, then 100 mg of oral ASP q.d. for the next 85 days and 75 mg of oral CLO q.d. for the next 16 days) and group 2 (105 cases, after 0.9 mg/kg rt-PA, 100 mg of oral ASP q.d. for 90 days and 75 mg of oral CLO q.d. for 21 days).The efficacy index was the mRS score, NIHSS score and recurrence risk of stroke, while the safety index was the incidence of bleeding events and mortality. All parameters were evaluated at 30 and 90 days after thrombolysis. Patients whose characteristics may provide the best treatment benefit were further analyzed using the logistic regression model in group 1.

RESULTS

The proportion of mRS scores between 0 and 1 in group 1 was higher than that in group 2 at both 30 days (44.7% vs 32.4%, P < .05) and 90 days (50.5% vs 35.2%, P < .05). Compared to group 2, the proportion of NIHSS scores less than 4 was significantly higher in group 1 at both 30 days (37.9% vs 25.7%, P < .05) and 90 days (46.6% vs 30.5%, P < .05). At 90 days, Group 1 had a lower stroke recurrence risk than Group 2 (3.9% vs 10.5%, P < .05). The incidence of SICH was significantly different between the 2 groups at both 30 days (2.9% vs 9.5%, P < .05) and 90 days (2.9% vs 10.5%, P < .05). However, other bleeding events and mortality rates were not significantly different between the 2 groups. The lower the baseline NIHSS score and the shorter the OTT, the more favorable the outcomes obtained at 90 days.

CONCLUSIONS

Compared to standard doses, short term high-dose dual antiplatelet therapy after 0.6 mg/kg rt-PA intravenous thrombolysis may be a good choice for AIS patients.

Development and validation of a model predicting mild stroke severity on admission using electronic health record data

OBJECTIVE

Initial stroke severity is a potent modifier of stroke outcomes but this information is difficult to obtain from electronic health record (EHR) data. This limits the ability to risk-adjust for evaluations of stroke care and outcomes at a population level. The purpose of this analysis was to develop and validate a predictive model of initial stroke severity using EHR data elements.

METHODS

This observational cohort included individuals admitted to a US Department of Veterans Affairs hospital with an ischemic stroke. We extracted 65 independent predictors from the EHR. The primary analysis modeled mild (NIHSS score 0-3) versus moderate/severe stroke (NIHSS score ≥4) using multiple logistic regression. Model validation included: (1) splitting the cohort into derivation (65%) and validation (35%) samples and (2) evaluating how the predicted stroke severity performed in regard to 30-day mortality risk stratification.

RESULTS

The sample comprised 15,346 individuals with ischemic stroke (n = 10,000 derivation; n = 5,346 validation). The final model included 15 variables and correctly classified 70.4% derivation sample patients and 69.4% validation sample patients. The areas under the curve (AUC) were 0.76 (derivation) and 0.76 (validation). In the validation sample, the model performed similarly to the observed NIHSS in terms of the association with 30-day mortality (AUC: 0.72 observed NIHSS, 0.70 predicted NIHSS).

CONCLUSIONS

EHR data can be used to construct a surrogate measure of initial stroke severity. Further research is needed to better differentiate moderate and severe strokes, enhance stroke severity classification, and how to incorporate these measures in evaluations of stroke care and outcomes.

Endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis

BACKGROUND

Trials of endovascular thrombectomy (EVT) for acute stroke have excluded patients with pre-morbid disability. Observational studies may help inform consideration of EVT in this population. We aimed to assess the effectiveness and safety of EVT in patients with pre-morbid disability.

METHODS

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and Embase for studies describing outcomes in patients with pre-morbid disability (modified Rankin Scale (mRS) 2-5), treated with EVT or medical management (MM). Random-effects meta-analysis was used to pool outcomes including 90-day return to baseline mRS, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

RESULTS

We analyzed 14 studies of patients with pre-morbid disability (mRS 2-5, 1373 EVT and 253 MM). The rate of return to baseline mRS was 30.0% (95% CI 25.3% to 34.7%) in patients treated with EVT. Compared with medical therapy, EVT was associated with a higher likelihood of return to baseline mRS (OR 2.37, 95% CI 1.39 to 4.04) and a trend towards lower mortality (OR 0.68, 95% CI 0.46 to 1.02), with similar odds of sICH (OR 1.01, 95% CI 0.49 to 2.08). In studies comparing patients with versus without pre-morbid disability treated with EVT, similar results were found except that pre-morbid disability, when defined more strictly as mRS 3-5, was associated with mortality (OR 3.49, p<0.001).

CONCLUSION

In eligible patients with pre-morbid disability, observational studies suggest that EVT carries a higher chance of return to baseline mRS compared with patients treated with MM or without pre-morbid disability, although with higher mortality than patients without pre-morbid disability. These findings argue against the routine exclusion of such patients from EVT and merit validation with randomized trials.

Chronic Phase Survival Rate in Stroke Patients With Severe Functional Limitations According to the Frequency of Rehabilitation Treatment

OBJECTIVE

To investigate the chronic phase survival rate according to the frequency of rehabilitation treatment in the acute and subacute phases in stroke patients with severe functional limitations.

DESIGN

A retrospective longitudinal cohort study.

SETTING

Population-based study using the Korean National Health Insurance Database from 2007 to 2018.

PARTICIPANTS

We enrolled 593 patients who experienced stroke in 2009 with national disability registration (NDR) grade of 3 or less (N=593).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The frequencies of rehabilitation treatment within 24 months after stroke were categorized into none, 1-50, 51-200, 201-400, and >400 treatments based on requests made to the Health Insurance Review and Assessment Service. As a dependent variable, we assessed all-cause mortality from 24 to 120 months after stroke.

RESULTS

The study enrolled 283 patients in NDR grade 1 (the most severe), 158 in grade 2, and 152 in grade 3. Groups with more severe functional limitations showed a lower chronic phase survival rate (P<.001). The groups with higher frequencies of rehabilitation treatment in the acute and subacute phases showed a higher chronic phase survival rate (P<.001). In the Cox regression analysis, a higher degree of functional limitation, lower frequency of rehabilitation treatment, older age, male sex, and chronic kidney disease were independent risk factors for chronic phase mortality in stroke patients with severe functional limitations.

CONCLUSIONS

A high frequency of rehabilitation treatment in the acute and subacute phases was associated with the long-term survival of stroke patients with severe functional limitations.

Association between premorbid sarcopenia and neurological deterioration in patients with acute ischemic stroke

OBJECTIVE

Sarcopenia is associated with poor outcomes in patients with stroke. This study aimed to investigate the association between premorbid sarcopenia and neurological deterioration (ND) in patients with acute ischemic stroke. To the best of our knowledge, there have been no studies on this topic.

METHODS

In this prospective longitudinal study, we assessed premorbid sarcopenia using the SARC-F questionnaire, and the incidence of ND was defined by an increase of ≥ 1 point on the National Institutes of Health Stroke Scale (NIHSS) or the occurrence of any new neurological symptoms/signs. Logistic regression analysis was used to investigate the relationship between premorbid sarcopenia and ND.

RESULTS

Of the 290 patients enrolled, 46 and 244 patients experienced and did not experience ND 1 week after admission (ND and non-ND groups, respectively). The prevalence of sarcopenia was significantly higher in the ND group than in the non-ND group (39% vs. 17%). In the adjusted model, premorbid sarcopenia was significantly associated with ND (adjusted odds ratio: 3.06, 95% confidence interval: 1.11-8.40; p = 0.03).

CONCLUSION

Premorbid sarcopenia is independently associated with ND in patients with acute ischemic stroke. Therefore, it is necessary to detect premorbid sarcopenia to predict ND in these patients.

Endovascular thrombectomy in acute ischemic stroke patients with prestroke disability (mRS ≥2): A systematic review and meta-analysis

Objective

The effect of endovascular thrombectomy (EVT) in acute ischemic stroke patients with prestroke disability (modified Rankin Scale score, mRS) ≥2) has not been well-studied. This study aimed to assess the safety and benefit of EVT in patients with prestroke disability.

Methods

According to PRISMA guidelines, literature searching was performed using PubMed, Embase, and Cochrane databases, for a series of acute ischemic stroke patients with prestroke mRS ≥2 treated by EVT. Random-effects meta-analysis was used to pool the rate of return to prestroke mRS and mortality at 3-month follow-up.

Results

In total, 13 observational studies, with 2,625 patients, were analyzed. The rates of return to prestroke mRS in patients with prestroke mRS of 2–4 were 20% (120/588), 27% (218/827), and 31% (34/108), respectively. Patients with prestroke disability treated by EVT had a higher likelihood of return to prestroke mRS (relative risk, RR, 1.86; 95% CI 1.28–2.70) and a lower likelihood of mortality (RR 0.75; 95%CI 0.58–0.97) compared with patients with standard medical treatment. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) after EVT gave a higher likelihood of return to prestroke mRS (RR 2.04; 95% CI 1.17–3.55) and lower mortality (RR 0.72; 95% CI 0.62–0.84) compared with unsuccessful reperfusion.

Conclusions

Acute ischemic stroke patients with prestroke disability may benefit from EVT. Withholding EVT on the sole ground of prestroke disabilities may not be justified.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/.

Efficacy and safety of mechanical thrombectomy in acute stroke patients with pre-morbid disability

INTRODUCTION –

Patients with pre-morbid disability have been generally excluded from randomized controlled trials of mechanical thrombectomy for acute ischemic stroke. However, stroke physicians commonly encounter such patients in practice, and face challenging treatment decisions when caring for them.

AREAS COVERED –

We review the literature on the safety and efficacy of thrombectomy in patients with pre-morbid disability. Recent clinical-epidemiological studies have highlighted the adverse outcomes that come with each increment of additional post-stroke disability in these patients. Several observational studies - both case series and registry-based studies - have helped demonstrate the comparable safety of thrombectomy in patients with pre-morbid disability as in those without, complementing similar data on thrombolysis. These data also suggest similar rates of successful recanalization, symptomatic intracerebral hemorrhage, and return to pre-stroke level of disability when treated with mechanical thrombectomy, although they have higher mortality.

EXPERT OPINION –

In the absence of high-quality evidence, we recommend pursuing shared decision-making with patients or family members and being upfront about the uncertain evidence. Available observational data underline the potential for a substantial proportion of these patients to return to their pre-morbid state, do not indicate a greater rate of treatment-related complications, and do not support routinely excluding these patients from thrombectomy.

Automatic Segmentation and Quantitative Assessment of Stroke Lesions on MR Images

Lesion studies are crucial in establishing brain-behavior relationships, and accurately segmenting the lesion represents the first step in achieving this. Manual lesion segmentation is the gold standard for chronic strokes. However, it is labor-intensive, subject to bias, and limits sample size. Therefore, our objective is to develop an automatic segmentation algorithm for chronic stroke lesions on T1-weighted MR images. Methods: To train our model, we utilized an open-source dataset: ATLAS v2.0 (Anatomical Tracings of Lesions After Stroke). We partitioned the dataset of 655 T1 images with manual segmentation labels into five subsets and performed a 5-fold cross-validation to avoid overfitting of the model. We used a deep neural network (DNN) architecture for model training. Results: To evaluate the model performance, we used three metrics that pertain to diverse aspects of volumetric segmentation, including shape, location, and size. The Dice similarity coefficient (DSC) compares the spatial overlap between manual and machine segmentation. The average DSC was 0.65 (0.61−0.67; 95% bootstrapped CI). Average symmetric surface distance (ASSD) measures contour distances between the two segmentations. ASSD between manual and automatic segmentation was 12 mm. Finally, we compared the total lesion volumes and the Pearson correlation coefficient (ρ) between the manual and automatically segmented lesion volumes, which was 0.97 (p-value < 0.001). Conclusions: We present the first automated segmentation model trained on a large multicentric dataset. This model will enable automated on-demand processing of MRI scans and quantitative chronic stroke lesion assessment.

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.

Association between the coexistence of premorbid sarcopenia, frailty, and disability and functional outcome in older patients with acute stroke

AIM

To investigate the effects of coexisting conditions such as premorbid sarcopenia, frailty, and disability on functional outcomes in older patients with acute stroke.

METHODS

This prospective cohort study included older patients (aged ≥65 years) hospitalized for acute stroke at a single neurosurgical hospital. Premorbid sarcopenia, frailty, and disability were diagnosed using the strength, assistance with walking, rising from a chair, climbing stairs, and falls (SARC-F) questionnaire, frailty index, and modified Rankin Scale (mRS) on admission. The primary outcome was the mRS score 3 months after stroke, and a poor outcome was defined as mRS ≥4.

RESULTS

This study included 317 older patients with acute stroke (median [interquartile range] age: 76 [12] years). Premorbid sarcopenia, frailty, and disability (mRS = 2 or 3) were identified in 59 (19%), 27 (9%), and 54 (17%) patients, respectively. Two coexisting conditions were observed in 26 patients (8%), and three were observed in 18 patients (6%). Adjusted logistic regression analysis revealed that coexisting conditions were independently associated with poor outcomes (one condition, adjusted OR: 3.20 [95%CI: 0.98-10.45]; two conditions, adjusted OR: 6.57 [95%CI: 1.74-24.87]; three conditions, adjusted OR: 12.70 [95%CI: 2.65-60.91]).

CONCLUSIONS

The coexistence of premorbid sarcopenia, frailty, and disability was associated with poor functional outcomes in older patients with acute stroke. Geriatr Gerontol Int 2022; ••: ••-••.

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Introduction

Endovascular thrombectomy (EVT) is a well-established and effective therapeutic option for patients that meet certain criteria. However, this modality is not well studied in patients with pre-existing disability. The aim of the present study was to investigate the impact of mechanical thrombectomy in patients with acute onset ischemic stroke and pre-stroke dependency (PSD) in regard to their clinical outcome and mortality.

Materials and Methods

The MEDLINE, Scopus, and Cochrane Library databases were comprehensively searched with a cut-off date of December 11th, 2021. We performed meta-analysis to investigate the 90-day clinical outcome, the 90-day mortality, and the rate of symptomatic intracerebral hemorrhage (sICH) between the PSD (modified Rankin Scale score ≥ 3) and non-PSD (modified Rankin Scale score = 0-2) groups who underwent EVT for acute onset ischemic stroke.

Results

Six studies were included in the meta-analysis involving 4,543 cases with no PSD and 591 cases with PSD. The non-PSD group showed a statistically significant better clinical outcome at 90 days compared to the PSD group [RR (95% CI) = 1.44 (1.06, 1.85); p z = 0.02]. The non-PSD group demonstrated a statistically significant lower risk of death at 90 days in comparison to the PSD group [RR (95% CI) = 0.45 (0.41, 0.50); p z < 0.01]. Lastly, the rate of sICH was comparable between the two groups [RR (95% CI) = 0.89 (0.64, 1.24); p z = 0.48].

Discussion

We report a higher rate of unfavorable clinical outcome and a higher mortality rate in patients with PSD undergoing EVT compared to those with no previous disability. However, there was a significant proportion of PSD cases who fared well post-procedurally, indicating that PSD patients should not be routinely excluded from mechanical thrombectomy.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021284181, identifier: CRD42021284181.

Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association

Patients with premorbid disability or dementia have generally been excluded from randomized controlled trials of reperfusion therapies such as thrombolysis and endovascular therapy for acute ischemic stroke. Consequently, stroke physicians face treatment dilemmas in caring for such patients. In this scientific statement, we review the literature on acute ischemic stroke in patients with premorbid disability or dementia and propose principles to guide clinicians, clinician-scientists, and policymakers on the use of acute stroke therapies in these populations. Recent clinical-epidemiological studies have demonstrated challenges in our concept and measurement of premorbid disability or dementia while highlighting the significant proportion of the general stroke population that falls under this umbrella, risking exclusion from therapies. Such studies have also helped clarify the adverse long-term clinical and health economic consequences with each increment of additional poststroke disability in these patients, underscoring the importance of finding strategies to mitigate such additional disability. Several observational studies, both case series and registry-based studies, have helped demonstrate the comparable safety of endovascular therapy in patients with premorbid disability or dementia and in those without, complementing similar data on thrombolysis. These data also suggest that such patients have a substantial potential to retain their prestroke level of disability when treated, despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials. By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population.

Pre-fracture Mobility Using Standardized Scale as an Early Indicator of High Health Risk in Patients with a Hip Fracture

Hip fracture in older adults is associated with poor prognosis. We tested the hypothesis that a single standardized measure, pre-fracture mobility, can be used as an early indicator of patients at high health risk after a hip fracture. Analysis of prospectively collected data of older adults admitted with a hip fracture between April-2009 and June-2019 in a single NHS hospital, UK. Pre-fracture mobility status (freely mobile, mobilising outdoors with one aid or with two aids, and limited to indoors), was used to predict length of stay (LOS) and mortality in hospital, and discharge destination. Among 3073 (2231 women, 842 men) admitted from their own home (mean ± SD age = 82.7 ± 9.3 yr), 159 died and 2914 survived to discharge: 1834 back to their home, 772 to rehabilitation, 66 to residential care, 141 to nursing care and 101 to unknown destinations. Compared with LOS of 15.9 ± 15.6 days in patients who mobilised freely before fracture (reference), those who were able to mobilise outdoors with one aid stayed 3.5 days, and those with two aids or confined to indoor mobility stayed one week longer in hospital. In-patient mortality was increased among patients who mobilised outdoors with two aids: OR = 2.1 (95%CI = 1.3–3.3), and those limited to indoors: OR = 2.1 (1.3–1.5). Finally, a change in residence on discharge was more likely in those who mobilised outdoors with two aids (OR = 1.8, 95%CI = 1.2–2.6), and those limited to indoors (OR = 1.9, 95%CI = 1.2–2.9). In conclusion, pre-fracture mobility may be a useful early indicator for identifying patients at increased risk of adverse outcomes after an acute hip fracture.

Previous Disability and Benefit of Acute Phase Therapy in Functional Prognosis of Selected Patients with Ischemic Stroke

OBJECTIVES

Patients' previous disability (PD) is a key factor when considering acute stroke therapy. PD's exact impact on functional prognosis of patients with acute ischemic stroke remains not entirely clarified. We aimed to analyze PD's influence on functional outcome three months after ischemic stroke.

MATERIALS AND METHODS

Retrospective analysis of prospectively collected data concerning patients with acute ischemic stroke admitted to Stroke Unit of a tertiary center who underwent acute phase therapy between 2017 and 2019. Modified Rankin Scale (mRS) was used to define PD (with previous mRS≥3). Patients with PD were selected for treatment based on similar baseline characteristics to patients without PD. Patients were classified into two groups according to previous mRS: mRS<3 and mRS≥3. We defined bad outcome at three months after stroke as mRS≥3 for patients with previous mRS<3, and as a higher score than baseline mRS for patients with previous mRS≥3.

RESULTS

We identified 1169 eligible patients - 1016 patients with previous mRS<3 and 153 patients with previous mRS≥3. Most baseline characteristics did not differ significantly between them. For patients ≤75 years old, PD was associated with worse outcome (odds ratio estimate [OR] 4.50, p < 0.001). For patients >75 years old, PD was protective against worse outcome (OR 0.42, p < 0.001). In patients with previous mRS≥3 and >75 years old, there was a higher proportion of women (p = 0.005).

CONCLUSIONS

PD might not be a relevant factor when considering acute stroke therapy in selected patients >75 years old, especially women. Further studies are needed to clarify these findings.

Predicting Stroke Complications in Hospital and Functional Status at Discharge by Clustering of Cardiovascular Diseases a Multi-Centre Registry-Based Study of Acute Stroke

OBJECTIVE

Indicators for outcomes following acute stroke are lacking. We have developed novel evidence-based criteria for identifying outcomes of acute stroke using the presence of clusters of coexisting cardiovascular disease (CVD).

MATERIALS AND METHODS

Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme (SSNAP). A total of 1656 men (mean age ±SD=73.1yrs±13.2) and 1653 women (79.3yrs±13.0) were admitted with acute stroke (83.3% ischaemic, 15.7% intracranial haemorrhagic), 1.0% unspecified) in four major UK hyperacute stroke units (HASU) between 2014 and 2016. Four categories from cardiovascular disease Congestive heart failure, Atrial fibrillation, pre-existing Stroke and Hypertension (CASH).were constructed: CASH-0 (no coexisting CVD); CASH-1 (any one coexisting CVD); CASH-2 (any two coexisting CVD); CASH-3 (any three or all four coexisting CVD). These were tested against outcomes, adjusted for age and sex.

RESULTS

Compared to CASH-0, individuals with CASH-3 had greatest risks of in-hospital mortality (11.1% vs 24.5%, OR=1.8, 95%CI=1.3-2.7) and disability (modified Rankin Scale score ≥4) at discharge (24.2% vs 46.2%, OR=1.9, 95%CI=1.4-2.7), urinary tract infection (3.8% vs 14.6%, OR= 3.3, 95%CI= 1.9-5.5), and pneumonia (7.1% vs 20.6%, OR= 2.6, 95%CI= 1.7-4.0); length of stay on HASU >14 days (29.8% vs 39.3%, OR=1.8, 95%CI=1.3-2.6); and joint-care planning (20.9% vs 29.8%, OR=1.4, 95%CI=1.0-2.0).

CONCLUSIONS

We present a simple tool for estimating the risk of adverse outcomes of acute stroke including death, disability at discharge, nosocomial infections, prolonged length of stay, as well as any joint care planning. CASH-0 indicates a low level and CASH-3 indicates a high level of risk of such complications after stroke.

Association of risk of malnutrition with adverse outcomes and early support on discharge in acute stroke patients without prestroke disability: A multicenter, registry-based cohort study

BACKGROUND

Malnutrition in hospitals remains highly prevalent. As part of quality improvement initiatives, the Royal College of Physicians recommends nutrition screening for all patients admitted with acute stroke. We aimed to examine the associations of patients at risk of malnutrition with poststroke outcomes.

METHODS

We analyzed prospectively collected data from four hyperacute stroke units (HASUs) (2014-2016). Nutrition status was screened in 2962 acute stroke patients without prestroke disability (1515 men, [mean ± SD] 73.5 years ± 13.1; 1447 women, 79.2 ± 13.0 years). The risk of malnutrition was tested against stroke outcomes and adjusted for age, sex, and comorbidities.

RESULTS

Risk of malnutrition was identified in 25.8% of patients). Compared with well-nourished patients, those at risk of malnutrition had, within 7 days of admission, increased risk of stay on the HASU of >14 days (odds ratio [OR]: 9.9 [7.3-11.5]), disability on discharge (OR: 8.1 [6.6-10.0]), worst level of consciousness in the first 7 days (score ≥ 1) (OR: 7.5 [6.1-9.3]), mortality (OR: 5.2 [4.0-6.6], pneumonia (OR: 5.1 [3.9-6.7]), and urinary tract infection (OR: 1.5 [1.1-2.0]). They also required palliative care (OR: 12.3 [8.5-17.8]), discharge to new care home (OR: 3.07 [2.18-4.3]), activities of daily living support (OR: 1.8 [1.5-2.3]), planned joint care (OR: 1.5 [1.2-1.8]), and weekly visits (OR: 1.4 [1.1-1.8]).

CONCLUSION

Patients at risk of malnutrition more commonly have multiple adverse outcomes after acute stroke and greater need for early support on discharge.

Relationships between Pre-Stroke SARC-F Scores, Disability, and Risk of Malnutrition and Functional Outcomes after Stroke-A Prospective Cohort Study

SARC-F is a screening tool for sarcopenia; however, it has not yet been established whether SARC-F scores predict functional outcomes. Therefore, we herein investigated the relationship between SARC-F scores and functional outcomes in stroke patients. The primary outcome in the present study was the modified Rankin Scale (mRS) 3 months after stroke. The relationship between SARC-F scores and poor functional outcomes was examined using a logistic regression analysis. Furthermore, the applicability of SARC-F scores to the assessment of poor functional outcomes was analyzed based on the area under the receiver operating curve (ROC). Eighty-one out of the 324 patients enrolled in the present study (25%) had poor functional outcomes (mRS ≥ 4). The results of the multivariate analysis revealed a correlation between SARC-F scores (OR = 1.29, 95% CI = 1.05–1.59, p = 0.02) and poor functional outcomes. A cut-off SARC-F score ≥ 4 had low-to-moderate sensitivity (47.4%) and high specificity (87.3%). The present results suggest that the measurement of pre-stroke SARC-F scores is useful for predicting the outcomes of stroke patients.

Early emergency readmission frequency as an indicator of short-, medium- and long-term mortality post-discharge from hospital

Frequent emergency readmissions, an indicator of quality of care, has been rising in England but the underlying reasons remain unclear. We examined the association of early readmissions with subsequent mortality in adults, taking into account the underlying presenting diagnoses and hospital length of stay (LOS). Data of alive-discharge episodes were prospectively collected between 01/04/2017 and 31/03/2019 in an National Health Service hospital, comprising 32,270 patients (46.1% men) aged 18-107 years (mean = 64.0, ± SD = 20.5 years). The associations of readmission frequency within 28 days of discharge and mortality within 30 days and 6 months of hospital discharge, and over a 2-year period were evaluated, adjusted for presenting diagnoses, LOS, age and sex during the first admission. Analysis of all patients 18-107 years (reference: no readmission) showed mortality within 30 days was increased for 1 readmission: event rate = 9.2%, odds ratio (OR) = 3.4 (95% confidence interval (CI) = 2.9-4.0), and ≥ 2 readmissions: event rate = 10.0%, OR = 2.6 (95%CI = 2.0-3.3), and within 6 months for 1 readmission: event rate = 19.6%, OR = 3.0 (95%CI = 2.7-3.4), and ≥ 2 readmissions: event rate = 27.4%, OR = 3.4 (95%CI = 2.9-4.0), and over a 2-year period for 1 readmission: event rate = 25.5%, hazard ratio = 2.2 (95%CI = 2.0-2.4), and ≥ 2 readmissions: event rate = 36.1%, hazard ratio = 2.5 (95%CI = 2.2-2.8). Within the age groups 18-49, 50-59, 60-69, 70-79 and ≥ 80 years, readmissions were also associated with increased risk of mortality within 3 months and 6 months of discharge, and over 2-year period. In conclusion, early hospital readmission predicts short-, medium- and long-term mortality post-discharge from hospital in adults aged 18-107 years, independent of underlying presenting conditions, LOS, age and sex. Further research focussing on safe discharge and follow-up patient care may help reduce preventable readmissions and post-discharge mortality.

Prognostic factors of functional outcome in post-acute stroke in the rehabilitation unit

BACKGROUND/PURPOSE

This retrospective study aimed to determine which factors, such as cognition, motor recovery, swallowing function, and bladder and bowel functions, significantly predicted independence in the activities of daily living (ADL) at hospital discharge in a domestic population of patients experiencing post-acute stroke who received in-hospital rehabilitation.

METHODS

We reviewed medical records that were retrieved from the Integrated Medical Database, National Taiwan University Hospital (NTUH-iMD) of 3000 patients who suffered from stroke and were admitted to NTUH from 2014 to 2017. The main outcome measure was independence in the basic ADL (modified Barthel index [mBI]) at discharge. Regression analyses were used to identify prognostic factors for the basic ADL (mBI).

RESULTS

The total mBI improved from 40.7 ± 33.0 to 63.1 ± 34.1 in eligible 2538 patients during their hospital stay. The baseline daily activity function (R² change = 0.042) was the most important prognostic factor associated with independence at discharge, followed by dependence in sitting up (R² change = 0.014), impaired sitting balance (R² change = 0.010), the Brunnstrom stage of hemiplegic lower limb (R² change = 0.006), and the presence of bladder incontinence (R² change = 0.006) assessed by physician upon rehabilitation admission (R² = 0.53, p < 0.05). Dependency in sitting up, impaired sitting balance, and the presence of urinary incontinence were negative prognostic factors of ADL independence at discharge (p < 0.05). By contrast, the Brunnstrom stage of hemiplegic lower limb and baseline mBI scores at rehabilitation admission were positive prognostic factors of ADL independence at discharge (p < 0.05).

CONCLUSION

Baseline ADL function was the most important prognostic factor of functional independence in post-acute stroke. Moreover, the activity limitation of dependency on sitting up and motor function impairment of hemiplegic lower limb prognosticated functional independence.

Adverse consequences of immediate thrombolysis-related complications: a multi-centre registry-based cohort study of acute stroke

Complications following thrombolysis for stroke are well documented, and mostly concentrated on haemorrhage. However, the consequences of patients who experience any immediate thrombolysis-related complications (TRC) compared to patients without immediate TRC have not been examined. Prospectively collected data from the Sentinel Stroke National Audit Programme were analysed. Thrombolysis was performed in 451 patients (52.1% men; 75.3 years ± 13.2) admitted with acute ischaemic stroke (AIS) in four UK centres between 2014 and 2016. Adverse consequences following immediate TRC were assessed using logistic regression, adjusted for age, sex and co-morbidities. Twenty-nine patients (6.4%) acquired immediate TRC. Compared to patients without, individuals with immediate TRC had greater adjusted risks of: moderately-severe or severe stroke (National Institutes of Health for Stroke Scale score ≥ 16) at 24-h (5.7% vs 24.7%, OR 3.9, 95% CI 1.4-11.1); worst level of consciousness (LOC) in the first 7 days (score ≥ 1; 25.0 vs 60.7, OR 4.6, 95% CI 2.1-10.2); urinary tract infection or pneumonia within 7-days of admission (13.5% vs 39.3%, OR 3.2, 95% CI 1.3-7.7); length of stay (LOS) on hyperacute stroke unit (HASU) ≥ 2 weeks (34.7% vs 66.7%, OR 5.2, 95% CI 1.5-18.4); mortality (13.0% vs 41.4%, OR 3.7, 95% CI 1.6-8.4); moderately-severe or severe disability (modified Rankin Scale  score ≥ 4) at discharge (26.8% vs 65.5%, OR 4.7, 95% CI 2.1-10.9); palliative care by discharge date (5.1% vs 24.1%, OR 5.1, 95% CI 1.7-15.7). The median LOS on the HASU was longer (7 days vs 30 days, Kruskal-Wallis test: χ² = 8.9, p = 0.003) while stroke severity did not improve (NIHSS score at 24-h post-thrombolysis minus NIHSS score at arrival = - 4 vs 0, χ² = 24.3, p < 0.001). In conclusion, the risk of nosocomial infections, worsening of stroke severity, longer HASU stay, disability and death is increased following immediate TRC. The management of patients following immediate TRC is more complex than previously thought and such complexity needs to be considered when planning an increased thrombolysis service.

Frequent identical admission-readmission episodes are associated with increased mortality

Frequent emergency readmissions may associate with health consequences. We examined the association between readmissions within 28 days of hospital discharge and mortality in 32,270 alive-discharge episodes (18-107 years). Data collected between 1 April 2017 and 31 March 2019 are presented as age- and sex-adjusted hazard ratios (HR) with 95% confidence interval (CI).Compared with no readmission, mortality risk over a 2-year period was increased with one non-identical admission-readmission (AR) episode: HR = 2.4 (2.2-2.7), two or more non-identical AR episodes: HR = 3.0 (2.7-3.4), one identical AR episode: HR = 4.7 (3.6-6.1) and two or more identical AR episodes: HR = 5.0 (3.8-6.7). Eight conditions associated with AR episodes had increased risk of mortality including congestive heart failure: HR = 2.7 (2.2-3.2), chronic pulmonary obstructive disease: HR = 3.0 (2.5-3.6), pneumonia: HR = 2.0 (1.8-2.3), sepsis: HR = 2.2 (1.9-2.5), endocrine disorders: HR = 1.9 (1.6-2.3), urinary tract infection: HR = 1.5 (1.3-1.7), psychiatric disorders: HR = 1.5 (1.1-2.1) and haematological disorders: HR = 1.5 (1.2-1.9). Frequent identical AR episodes, particularly from chronic and age-related conditions, are associated with increased mortality.

LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge

Background

The LACE index scoring tool (Length of stay, Acuity of admission, Co-morbidities and Emergency department visits) has been designed to predict hospital readmissions. We evaluated the ability of the LACE index to predict age-specific frequent admissions and mortality.

Methods

Analysis of prospectively collected data of alive-discharge episodes between 01/04/2017 and 31/03/2019 in an NHS hospital. Data on 14,878 men and 17,392 women of mean age 64.0 years, SD = 20.5, range 18.0–106.7 years were analysed. The association of the LACE index with frequency of all-cause readmissions within 28 days of discharge and over a 2-year period, and with all-cause mortality within 30 days or within 6 months after discharge from hospital were evaluated.

Results

Within LACE index scores of 0–4, 5–9 or ≥ 10, the proportions of readmission ≥ 2 times within 28 days of discharge were 0.1, 1.3 and 9.2% (χ² = 3070, p < 0.001) and over a 2-year period were 1.7, 4.8 and 19.1% (χ² = 3364, p < 0.001). Compared with a LACE index score of 0–4, a score ≥ 10 increased the risk (adjusted for age, sex and frequency of admissions) of death within 6 months of discharge by 6.8-fold (5.1–9.0, p < 0.001) among all ages, and most strongly in youngest individuals (18.0–49.9 years): adjusted odds ratio = 16.1 (5.7–45.8, p < 0.001). For those aged 50–59.9, 60–69.9, 70–79.9 and ≥ 80 years, odds ratios reduced progressively to 9.6, 7.7, 5.1 and 2.3, respectively. Similar patterns were observed for the association of LACE index with mortality within 30 days of hospital discharge.

Conclusions

The LACE index predicts short-term and long-term frequent admissions and short-term and medium-term mortality, most pronounced among younger individuals, after hospital discharge.

[Influence of prior ischemic events on the nutritional status of patients hospitalized for stroke]

Introduction

Background and aims: a poor nutritional status may worsen the prognosis of stroke. We assessed which factors were associated with a worse nutritional status in patients with stroke at the time of hospitalization. Methods: a cross-sectional study in patients with stroke needing enteral nutritional support, from January 2014 to September 2016. Nutritional status was evaluated by the Mini-Nutritional Assessment tool, and the Subjective Global Assessment. We performed a multivariate regression analysis including demographic, baseline disability (modified Rankin scale), and clinical and anthropometric variables, and we stratified the sample based on median age. Results: we included 226 patients, 58.3 % male, with a median age of 77 (66.7-83) years. Forty-four percent were at risk of malnutrition, and 24 % were malnourished. The factors that were associated with a worse nutritional status were age (odds ratio (OR): 1.03; 95 % CI: 1.01-1.08) and modified Rankin scale score (OR: 1.96; 95 % CI: 1.32-2.67). In the stratified analysis, associated factors were, in the subgroup of patients older than 77 years, the baseline degree of disability (OR: 1.88; 95 % CI: 1.26-2.80), whereas in the subgroup of patients younger than 77 years, it was a prior history of ischemic events (OR: 2.86; 95 % CI: 1.01-8.16). Conclusion: in patients hospitalized due to stroke, older age and worse functional status were associated with a worse nutritional status at the time of hospitalization. In elderly patients, the main factor was prior functional status, while in younger patients it was a prior history of ischemic events.