Inpatient TIA and stroke care in adult patients in Germany - retrospective analysis of nationwide administrative data sets of 2011 to 2017

FAST4D-A New Score to Reduce Missed Strokes in Emergency Medical Service: A Prospective, Multicentric Observational Proof-of-Concept Trial

Background: Undoubtedly, overlooking a stroke can result in severe disability or even death. However, identifying stroke patients in the prehospital setting poses a significant challenge. While the Face-Arm-Speech-Time (FAST) score is widely used, its effectiveness has been questioned because of its focus on symptoms primarily associated with anterior circulation strokes. In response to this limitation, we developed the innovative FAST4D score and conducted a comparative analysis of stroke detection rates between the novel FAST4D score and the FAST score. Methods: This prospective, multicenter proof-of-concept study aimed to assess stroke detection rates using both the FAST score and the new FAST4D score, which incorporates additional items such as the acute onset of diplopic images, deficit in the field of vision, dizziness/vertigo, and dysmetria/ataxia. Following their presentation to emergency medical services, all patients suspected of having a stroke and those diagnosed with a stroke upon discharge were included in this study. The diagnostic performance of the novel FAST4D score was evaluated and compared with that of the FAST score. Results: Between May 2019 and June 2021, a total of 1469 patients (749 female) were enrolled, with 1035 patients discharged with the diagnosis of stroke. Notably, 259 patients were identified solely through the FAST4D score. This resulted in a significantly higher rate of correctly identified as having had a stroke (stroke detection rate, sensitivity) with the new FAST4D score (93%) compared with the established FAST score (78%) (p < 0.001). This resulted in a reduction in false negative diagnoses by 65%. Conclusions: The novel FAST4D score demonstrated a 15-percentage increase in the stroke detection rate. This heightened detection rate holds the potential for more accurate patient allocation to stroke units, consequently reducing the time to revascularization.

[Intracerebral Hemorrhage]

Intracerebral hemorrhage (ICB) causes approximately 12% of all strokes in Germany and 9-27% of all strokes worldwide 1 2. Epidemiological studies show a decrease in younger individuals mainly due to better antihypertensive management, but there is also an increase in incidence in older individuals due to cerebral amyloid angiopathy and increasing use of anticoagulants 3.

Post-stroke Rehabilitation of Severe Upper Limb Paresis in Germany - Toward Long-Term Treatment With Brain-Computer Interfaces

Severe upper limb paresis can represent an immense burden for stroke survivors. Given the rising prevalence of stroke, restoration of severe upper limb motor impairment remains a major challenge for rehabilitation medicine because effective treatment strategies are lacking. Commonly applied interventions in Germany, such as mirror therapy and impairment-oriented training, are limited in efficacy, demanding for new strategies to be found. By translating brain signals into control commands of external devices, brain-computer interfaces (BCIs) and brain-machine interfaces (BMIs) represent promising, neurotechnology-based alternatives for stroke patients with highly restricted arm and hand function. In this mini-review, we outline perspectives on how BCI-based therapy can be integrated into the different stages of neurorehabilitation in Germany to meet a long-term treatment approach: We found that it is most appropriate to start therapy with BCI-based neurofeedback immediately after early rehabilitation. BCI-driven functional electrical stimulation (FES) and BMI robotic therapy are well suited for subsequent post hospital curative treatment in the subacute stage. BCI-based hand exoskeleton training can be continued within outpatient occupational therapy to further improve hand function and address motivational issues in chronic stroke patients. Once the rehabilitation potential is exhausted, BCI technology can be used to drive assistive devices to compensate for impaired function. However, there are several challenges yet to overcome before such long-term treatment strategies can be implemented within broad clinical application: 1. developing reliable BCI systems with better usability; 2. conducting more research to improve BCI training paradigms and 3. establishing reliable methods to identify suitable patients.

The level of urbanization influences acute ischemic stroke care: A nationwide ecological study from Germany

BACKGROUND AND PURPOSE

Regional differences in acute ischemic stroke (AIS) care are still reported for Germany but not fully understood. We aimed to analyze the impact of the level of urbanization on the application of proved treatment procedures and the incidence of hospitalized AIS cases in Germany.

METHODS

The level of urbanization of the 401 districts and district-free cities in Germany was defined according to the Federal Institute for Building, Urban Affairs and Spatial Research classification. Using nationwide administrative data, the application of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and the incidence of hospitalizations for AIS, were analyzed according to the place of residence of the patients. Data included all patients hospitalized for AIS in 2019 (n = 224,274) and sociodemographic information of 83,019,213 residents in Germany.

RESULTS

Sparsely populated districts had a significantly higher incidence of hospitalizations for AIS than cities (age-standardized: 271.8 versus 242.3 per 100,000 inhabitants, P < 0.001), but a lower use of MT (5.7% versus 8.4%, P < 0.001). In the adjusted negative binomial regression model, rurality remained an independent predictor for MT use and the incidence of AIS hospitalizations. The proportion of IVT did not significantly differ between sparsely populated districts and cities (15.6% versus 17.2%, P = 0.021).

CONCLUSIONS

Although there is a dense network of stroke units in Germany, the level of urbanization still influences AIS care, as we found a lower proportion of MT and a higher incidence of AIS hospitalizations in Germany's rural areas.

Isolated thalamic stroke - analysis of clinical characteristics and asymmetry of lesion distribution in a retrospective cohort study

Background

More patients with left-hemispheric than right-hemispheric strokes are admitted to hospitals. This is due to the easier recognition of cortical symptoms of the dominant-hemisphere. The thalamus constitutes a “micro-model” of the brain cortex with structure-function relationships known to be asymmetric, especially for language, memory, and visuo-spatial neurocognitive functions. The goal of this study was to characterize clinical symptoms and lesion distribution patterns of patients with acute isolated thalamic stroke (ITS) and to evaluate whether left-sided lesions are overrepresented in the hospital.

Methods

We performed a radiological database search including all brain scans performed in the Center of Neurology and Neurosurgery of the University Hospital Frankfurt between 2010 and 2019. A total of 5733 patients presenting with acute ischemic stroke were screened for ITS. Based on the MRI data, a lesion-overlap map was then generated to visualize the ITS lesion distribution.

Results

Fifty-eight patients with unilateral ITS were identified. A majority of 38 patients (65.5%) showed left-sided ITS, whereas only 20 patients (34.5%) had right-sided ITS (p = 0.012). A particular difference was found for ITS lesions in the anterior thalamus of the anterolateral (n = 10) and anteromedian (n = 3) vascular territory, which were located in the left thalamus in 85% of patients (p = 0.011). No distribution difference was found for ITS lesions in the inferomedial (n = 7), central (n = 8), inferolateral (n = 23) and posterior (n = 7) vascular territories. The neuropsychological symptoms of thalamic aphasia (n = 8), neurocognitive impairment (n = 6), behavioral changes (n = 2), neglect (n = 2) and memory deficits (n = 3) were described predominantly in patients with left-sided ITS (p < 0.01). In contrast, other stroke symptoms (e.g., sensorimotor hemi-syndromes) did not reveal a side preponderance.

Conclusions

The better recognizability of left anterior compared to right anterior thalamic stroke symptoms may have an impact on the frequency in which ITS patients are admitted to the hospital. Clinical characteristics of right anterior thalamic stroke should therefore be further investigated, and diagnostic instruments towards their detection be identified.

Incidence and Outcomes of Hemorrhagic Stroke among Adults in Spain (2016-2018) According to Sex: A Retrospective, Cohort, Observational, Propensity Score Matched Study

(1) Background: We aim to analyze sex differences in the incidence, clinical characteristics and in-hospital outcomes of hemorrhagic stroke (HS) in Spain (2016–2018) using the National Hospital Discharge Database. (2) Methods: Retrospective, cohort, observational study. We estimated the incidence of HS in men and women. We analyzed comorbidity, treatments, procedures, and hospital outcomes. We matched each woman with a man by age, type of HS and medical conditions using propensity score matching. (3) Results: HS was coded in 57,227 patients aged ≥18 years (44.3% women). Overall, men showed higher incidence rates (57.3/10⁵ vs. 43.0/10⁵; p < 0.001; IRR = 1.60; 95% CI: 1.38–1.83). Women suffered more subarachnoid hemorrhages (25.2% vs. 14.6%), whereas men more often had intracerebral hemorrhages (55.7% vs. 54.1%). In-hospital mortality (IHM) was higher for intracerebral hemorrhage in both men and women. Women underwent decompressive craniectomy less often than men (5.0% vs. 6.2%; p < 0.001). After matching, IHM among women was higher (29.0% vs. 23.7%; p < 0.001). Increments in age, comorbidity and use of anticoagulants and antiplatelet agents prior to hospitalization were associated were higher IHM, and decompressive craniectomy was associated with lower IHM in both sexes. After multivariable adjustment, women had higher IHM (OR = 1.23; 95% CI: 1.18–1.28). (4) Conclusion: Men had higher incidence rates of HS than women. Women less often underwent decompressive craniectomy. IHM was higher among women admitted for HS than among men.

Effect of a modern stroke unit combined with recombinant human tissue-type plasminogen activator intravenous thrombolysis on ischemic cerebral infarction and its influence on limb motor function and activity of daily living

OBJECTIVE

To observe the effect of a modern stroke unit combined with recombinant human tissue-type plasminogen activator (rt-PA) intravenous thrombolysis on ischemic cerebral infarction and its impact on limb motor function and activity of daily living.

METHODS

In this prospective study, 82 patients with ischemic cerebral infarction who received treatment in our hospital were divided into two groups (41 cases in each group) according to the principle of randomized control. In the control group, patients received rt-PA intravenous thrombolysis. In the study group, patients received the modern stroke unit care combined with rt-PA intravenous thrombolysis. Before and after treatment, the clinical treatment efficacy, changes of serum inflammatory cytokines (hypersensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6)), nerve factors (NSE, S100β), nerve function (neurologic impairment score (NIHSS)), limb motor function (Fugl-Meyer scale score (FMA)) and activity of daily living (Barthel Index score) and adverse reactions were compared between the two groups.

RESULTS

The total effective rate in the study group (92.68%) was higher than that in the control group (73.17%, P<0.01). Compared with those before treatment, the scores of NIHSS, FMA and Barthel indexes, and the levels of serum hs-CRP, IL-6, NSE and S100β were improved in both groups after treatment, and the improvement in the study group was better than that in the control group (all P<0.001). There was no statistically significant difference in the incidence of adverse reactions between the two groups (9.76% vs. 12.20%, P>0.05).

CONCLUSION

A modern stroke unit combined with rt-PA intravenous thrombolysis can effectively improve the clinical treatment efficacy, ameliorate the neurological function and limb motor function, reduce inflammatory reactions, promote the recovery of neurological function, and enhance the activity of daily living in the treatment of patients with ischemic cerebral infarction. Therefore, it is safe and worthy of further promotion.

Sex-related disparities in the incidence and outcomes of hemorrhagic stroke among type 2 diabetes patients: a propensity score matching analysis using the Spanish National Hospital Discharge Database for the period 2016-18

Background

To analyze incidence, use of therapeutic procedures, use of oral anticoagulants (OACs) and antiplatelet agents prior to hospitalization, and in-hospital outcomes among patients who were hospitalized with hemorrhagic stroke (HS) according to the presence of type 2 diabetes mellitus (T2DM) in Spain (2016–2018) and to assess the role of sex differences among those with T2DM.

Methods

Using the Spanish National Hospital Discharge Database we estimated the incidence of HS hospitalizations in men and women aged ≥ 35 years with and without T2DM. Propensity score matching (PSM) was used to compare population subgroups according to sex and the presence of T2DM.

Results

HS was coded in 31,425 men and 24,975 women, of whom 11,915 (21.12%) had T2DM. The adjusted incidence of HS was significantly higher in patients with T2DM (both sexes) than in non-T2DM individuals (IRR 1.15; 95% CI 1.12–1.17). The incidence of HS was higher in men with T2DM than in T2DM women (adjusted IRR 1.60; 95% CI 1.57–1.63). After PSM, men and women with T2DM have significantly less frequently received decompressive craniectomy than those without T2DM. In-hospital mortality (IHM) was higher among T2DM women than matched non-T2DM women (32.89% vs 30.83%; p = 0.037), with no differences among men. Decompressive craniectomy was significantly more common in men than in matched women with T2DM (5.81% vs. 3.33%; p < 0.001). IHM was higher among T2DM women than T2DM men (32.89% vs. 28.28%; p < 0.001). After adjusting for confounders with multivariable logistic regression, women with T2DM had a 18% higher mortality risk than T2DM men (OR 1.18; 95% CI 1.07–1.29). Use of OACs and antiplatelet agents prior to hospitalization were associated to higher IHM in men and women with and without T2DM.

Conclusions

T2DM is associated with a higher incidence of HS and with less frequent use of decompressive craniectomy in both sexes, but with higher IHM only among women. Sex differences were detected in T2DM patients who had experienced HS, with higher incidence rates, more frequent decompressive craniectomy, and lower IHM in men than in women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01334-2.

Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice

BACKGROUND

The prehospital identification of stroke patients with large-vessel occlusion (LVO), that should be immediately transported to a thrombectomy capable centre is an unsolved problem. Our aim was to determine whether implementation of a state-wide standard operating procedure (SOP) using the Los Angeles Motor Scale (LAMS) is feasible and enables correct triage of stroke patients to hospitals offering (comprehensive stroke centres, CSCs) or not offering (primary stroke centres, PSCs) thrombectomy.

METHODS

Prospective study involving all patients with suspected acute stroke treated in a 4-month period in a state-wide network of all stroke-treating hospitals (eight PSCs and two CSCs). Primary endpoint was accuracy of the triage SOP in correctly transferring patients to CSCs or PSCs. Additional endpoints included the number of secondary transfers, the accuracy of the LAMS for detection of LVO, apart from stroke management metrics.

RESULTS

In 1123 patients, use of a triage SOP based on the LAMS allowed triage decisions according to LVO status with a sensitivity of 69.2% (95% confidence interval (95%-CI): 59.0-79.5%) and a specificity of 84.9% (95%-CI: 82.6-87.3%). This was more favourable than the conventional approach of transferring every patient to the nearest stroke-treating hospital, as determined by geocoding for each patient (sensitivity, 17.9% (95%-CI: 9.4-26.5%); specificity, 100% (95%-CI: 100-100%)). Secondary transfers were required for 14 of the 78 (17.9%) LVO patients. Regarding the score itself, LAMS detected LVO with a sensitivity of 67.5% (95%-CI: 57.1-78.0%) and a specificity of 83.5% (95%-CI: 81.0-86.0%).

CONCLUSIONS

State-wide implementation of a triage SOP requesting use of the LAMS tool is feasible and improves triage decision-making in acute stroke regarding the most appropriate target hospital.

Acute ischemic stroke care in Germany - further progress from 2016 to 2019

Background

Stroke Unit Care (SUC), intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are evidence-based treatment options for acute ischemic stroke (AIS). Using nationwide comprehensive administrative data from Germany, we recently reported nationwide development of AIS admissions, SUC rates, IVT rates and MT rates in Germany between 2010 and 2016. In this update paper, we analyze data on the further development of these data to 2019 after publication of time window extensions for recanalization therapies.

Methods

We considered all hospitalized cases with the main diagnosis of the ICD-10-GM code I63 (AIS) for the year 2019. We identified stroke therapies by using the corresponding Operating and Procedure Keys for IVT, MT and SUC out of the DRG statistics. Regional analyses are based on data from the 412 German administrative districts and cities. We compared the results with those from 2016.

Results

Number of hospitalized AIS patients showed a mild decrease in 2019 (n = 225,531) compared with 2016 (n = 227,687), with significant more AIS patients treated on a stroke unit in 2019 (n = 167,799; 74.4% vs. n = 164,270; 72.1%, p < 0.001). The rate of IVT further increased from 14.9% (n = 33,916) in 2016 to 16.3% (n = 36,745) in 2019 (p < 0.001). Similarly, the MT rate increased from 4.3% (n = 9795) in 2016 to 7.2% (n = 16,135) in 2019 (p < 0.001). There was still a high regional variability for MT (1.4 to 15.2%) according to the place of residence of the AIS patients.

Conclusions

In Germany, the rates of recanalization therapies in patients with AIS continued to increase from 2016 to 2019. Compared to IVT-rates and numbers, the respective data for MT procedures showed an even more pronounced increase.

Hospitalized with stroke at the weekend: Higher cost and risk of early death?

OBJECTIVES

Previous studies have shown that weekend hospitalizations are associated with poorer health outcomes and higher mortality ("weekend effect"). However, few of these studies have adjusted for disease severity and little is known about the effect on costs. This work investigates the weekend effect and its costs for patients with cerebral infarction in Germany, adjusting for patient characteristics and proxies of stroke severity.

METHODS

Adult patients with a cerebral infarction hospitalization 10th revision of the International statistical classification of diseases and related health problems (ICD-10: I63) between 01 January 2014 and 30 June 2017 were included from German health claims (AOK PLUS dataset). Propensity score matching was used to match patients hospitalized on weekends or on public holidays (weekend group) with patients hospitalized during the working week (workday group), based on baseline characteristics and proxies for disease severity such as concomitant diagnoses of aphasia, ataxia, and coma, or peg tube at index hospitalization. Matched cohorts were compared in terms of in-hospital, 7-day, and 30-day mortality, as well as risk and costs of stroke and rehabilitation stays in the year after first stroke.

RESULTS

Of 32,311 patients hospitalized with cerebral infarction between 01 January 2014 and 30 June 2017, 8409 were in the weekend group and 23,902 in the workday group. After propensity score matching, 16,730 patients were included in our study (8365 per group). Matched cohorts did not differ in baseline characteristics or stroke severity. In the weekend group, the risk of in-hospital death (11.2%) and the seven-day mortality rate (6.8%) were 13.1% and 17.2% higher than in the workday group, respectively (both p < 0.01). The hazard ratio for death in the weekend group was 1.1 (p = 0.043). The risks of subsequent stroke hospitalization and rehabilitation stays for a stroke were 8.4% higher and 5.5% higher in the weekend group (both p = 0.02). As a result, the stroke-related hospitalization and rehabilitation costs per patient year were, respectively, 5.6% and 8.0% higher in the weekend group (both p = 0.01).

CONCLUSIONS

A significant weekend effect emerged after controlling for observable patient characteristics and proxies of stroke severity. This effect also resulted in higher costs for patients admitted on weekends.

[Comparability of different data sources on stroke care in Germany]

This article reviews different methodological approaches for determining treatment reality of ischemic stroke patients in acute care hospitals. Considering specific advantages and disadvantages of two different epidemiologic approaches, a specific comparison was carried out of cases from a structured analysis of the nationwide German diagnosis-related groups (DRG) statistics and data from the acute stroke treatment in Hesse (SA_HE) for 2018 collated by the office for quality management. According to the DRG statistics and the SA_HE data, 16,267 and 15,643 acute ischemic stroke patients (ICD code I63) were treated in Hesse in 2018, with 53.7% and 54.5% males, respectively. The overall age distribution did not show significant differences between the two data sources; however, stroke patients over the age of 70 years were registered significantly more often in the DRG statistics. The rates of systemic thrombolysis were 16.5% in both data sources and the rates of mechanical thrombectomy were 5.6% and 5.9%, respectively. The analysis shows that after a rational limitation of the included cases and based on the place of treatment, there were no statistically significant differences concerning the number of hospitalized patients with ischemic stroke, distribution of gender and age as well as the documented rates of systemic thrombolysis and mechanical thrombectomy. It can therefore be concluded that the well-controlled stroke quality register examined is able to capture a sufficient number of hospitalized acute ischemic stroke cases and treatment rates. Therefore, it appears to be recommendable to adopt the strict Hessian guidelines for data acquisition and control nationwide. In this way a nationwide combined analysis of data from the working group of German stroke registers and the DRG statistics would be possible.

[Nationwide treatment reality of patients with acute ischemic stroke in Germany : Update of the regionalized analysis on use of recanalization treatment procedures and stroke complex treatment]

BACKGROUND

The guidelines of the German Society for Neurology regarding the diagnostics and treatment of acute ischemic stroke contain the general recommendation of treatment on a stroke unit (SU) and the use of recanalizing treatment (intravenous thrombolysis, IVT; mechanical thrombectomy, MT) in appropriate patients. The nationwide availability of all three components represents a large organizational and healthcare political challenge.

OBJECTIVE

Updated nationwide analysis of treatment rates in Germany based on a regionalized evaluation.

METHODS

Based on the patient's place of residence, nationwide data of all hospitalized patients were evaluated using the German diagnosis-related groups (DRG) statistics from 2018 and compared with previous years. The rates for SU treatment, IVT and MT in the 412 German regional districts were analyzed. The 412 regions were grouped according to the degree of urbanization.

RESULTS

Nationwide, a total of 224,647 patient cases with a main diagnosis of acute ischemic stroke were treated in 1382 hospitals in Germany in 2018. Overall, relatively high treatment rates were determined (SU = 73.3%; IVT = 16.4%; MT = 6.5%). Only 10.2% of treatments in the SU were performed on a SU located at a hospital with no neurology department. The regionalized analysis showed large treatment ranges for all three therapeutic components, with significantly lower treatment rates in regions with a lower degree of urbanization (SU, IVT, MT rates: urban = 75.4%, 17.4%, 7.5% and rural = 67.1%; 15.4%, 5.3%, respectively).

CONCLUSION

Hospitalized healthcare in Germany shows high treatment rates for both SU admission and acute recanalization treatment in patients with acute ischemic stroke; however, there is further optimization potential in rural regions.