Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry

Effects of Social Determinants of Health on Acute Stroke Care Among Patients With Acute Ischemic Stroke: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Social determinants of health (SDOH) are important contributors to poor stroke-related outcomes. While some have suggested that this association is driven by the increased incidence of stroke observed with poor SDOH, others have raised concerns regarding disparities in acute stroke care. This study aimed to determine the association between SDOH and the administration of thrombolytic therapy and mechanical thrombectomy among patients with acute ischemic stroke.

METHODS

A retrospective cohort analysis was conducted using Texas Emergency Department Public Use Data (2016-2019), including adult patients diagnosed with acute ischemic stroke. The risk ratios (RRs) of administering thrombolysis and thrombectomy based on variables representing SDOH and a collective measure (Social Vulnerability Index [SVI]) were computed using mixed-effects Poisson regression models accounting for the nested nature of patients in hospitals and neighborhoods. The Charlson comorbidity score was considered as a covariate.

RESULTS

Of the 139,852 patients with ischemic stroke (female, 51.7%; White, 67.2%; Black, 16.6%; Hispanic, 25.1%), 16,831 (12.3%) received thrombolytic therapy and 5,951 (4.3%) received mechanical thrombectomy. Age older than 65 years (RR 0.578 [0.537-0.621]) vs 18-45 years, Black (RR 0.801 [0.761-0.844]) vs White, Hispanic (RR 0.936 [0.895-0.98]) vs non-Hispanic, Medicare/Medicaid/Veterans Affairs (VA) (RR 0.917 [0.882-0.954]) or uninsured (RR 0.883 [0.833-0.935]) vs private insurance, and rural (RR 0.782 [0.723-0.845]) vs urban dwelling were less likely to be associated with thrombolysis. Patients in the highest quintile based on the SVI were less likely to receive thrombolysis than those in the lowest quintile (RR 0.926 [0.867-0.989]). Patients were less likely to receive thrombectomy if they were 65 years and older (RR 0.787 [0.691-0.895]), belonged to the Black race (RR 0.745 [0.679-0.818]) or Hispanic ethnicity (RR 0.919 [0.851-0.992]), had Medicare/Medicaid/VA insurance (RR 0.909 [0.851-0.971]), or were from a rural area (RR 0.909 [0.851-0.971]). Similarly, SVI decreased the likelihood of undergoing mechanical thrombectomy (RR 0.842 [0.747-0.95]).

DISCUSSION

Despite many improvements in stroke management, SDOH continue to be a significant driver of treatment access for acute ischemic stroke. While our findings are limited to Texas, our results should raise awareness and promote more studies regarding the effects of these SDOH at the national and international levels.

Optical coherence tomography enables longitudinal evaluation of cell graft-directed remodeling in stroke lesions

Stem cell grafting can promote glial repair of adult stroke injuries during the subacute wound healing phase, but graft survival and glial repair outcomes are perturbed by lesion severity and mode of injury. To better understand how stroke lesion environments alter the functions of cell grafts, we employed optical coherence tomography (OCT) to longitudinally image mouse cortical photothrombotic ischemic strokes treated with allogeneic neural progenitor cell (NPC) grafts. OCT angiography, signal intensity, and signal decay resulting from optical scattering were assessed at multiple timepoints across two weeks in mice receiving an NPC graft or an injection of saline at two days after stroke. OCT scattering information revealed pronounced axial lesion contraction that naturally occurred throughout the subacute wound healing phase that was not modified by either NPC or saline treatment. By analyzing OCT signal intensity along the coronal plane, we observed dramatic contraction of the cortex away from the imaging window in the first week after stroke which impaired conventional OCT angiography but which enabled the detection of NPC graft-induced glial repair. There was moderate, but variable, NPC graft survival at photothrombotic strokes at two weeks which was inversely correlated with acute stroke lesion sizes as measured by OCT prior to treatment, suggesting a prognostic role for OCT imaging and reinforcing the dominant effect of lesion size and severity on graft outcome. Overall, our findings demonstrate the utility of OCT imaging for both tracking and predicting natural and treatment-directed changes in ischemic stroke lesion cores.

Racial and ethnic differences in access to care and treatment in patients with suspected acute stroke: A retrospective, observational, cohort study

BACKGROUND

Data regarding unequal diagnostic and therapeutic access in patients with acute stroke based on ethnicity and race are inconclusive in Europeans. The objectives of our study were to evaluate the effect of race/ethnicity on access to acute stroke care and treatments and outcomes.

METHODS

In this retrospective cohort study, we enrolled adult patients admitted to the emergency department of a comprehensive stroke center for suspected stroke. Based on race/ethnicity, patients were divided into two main groups: Western European Whites (WEW) and non-Western European Whites (nWEW). We also divided the nWEW group into four subgroups based on the Office of Management and Budget classification of human races and ethnicities (White-Others, Hispanic, Asian, Black). Univariate comparisons and logistic regression analyses were also performed.

RESULTS

9167 patients were enrolled in the study: 582 in the nWEW and 8585 in the WEW group. Patients with ischemic stroke in the nWEW group were significantly younger than those in the other group (p < 0.001). Once adjusted for possible confounders, belonging to the nWEW group was found to be an independent predictor of a lower likelihood of receiving revascularization treatments (p = 0.006), regardless similar onset-to-door times. There were no differences in stroke outcomes and prevalence of stroke mimic diagnosis between the groups.

CONCLUSIONS

Racial/ethnic disparities in healthcare represent a challenging issue, even in universal healthcare systems, that should be addressed promptly through education campaigns of healthcare personnel and implementation measures, such as integrating readily available interpreter staff for medical emergencies.

Trends in sex differences of functional outcome after intravenous thrombolysis in patients with acute ischemic stroke

BACKGROUND

Intravenous thrombolysis (IVT) is an approved treatment for patients with acute ischemic stroke irrespective of sex. However, the current literature on sex differences in functional outcomes following IVT is inconsistent. So far, a number of studies-including a previous analysis based on data from the Austrian Stroke Unit Registry (ASUR)-detected significant sex-related differences in functional outcome, while others did not report any differences between women and men. In addition, currently there is a lack of data on how sex-related differences evolve over time.

AIMS

To assess time trends of sex-related differences in functional outcome of ischemic stroke in a large nationwide cohort and to investigate associations of patient characteristics with functional outcome post thrombolysis in women and men. These data will offer crucial insights into whether sex differences in functional outcome persist despite the large advances in acute stroke treatment.

METHODS

We analyzed retrospective data of consecutive patients with acute ischemic stroke treated with IVT in 39 stroke centers contributing to the ASUR between 2006 and 2021. We included patients over 18 years of age diagnosed with an acute ischemic stroke who received IVT and with available data on functional outcome at 3 months after treatment. The primary outcome parameter was favorable functional outcome (modified Rankin Scale (mRS) of 0-2) at 3 months. Multivariable logistic regression analysis was performed in the overall population and stratified by sex to assess associations of baseline characteristics with functional outcome.

RESULTS

Among 11,840 patients receiving IVT, 2489 of 5503 (45.4%) women achieved favorable functional outcome compared to 3787 of 6337 (59.8%) men. Overall, female sex was a statistically significant predictor of functional outcome after thrombolysis, but additional predictors of outcome differed between women and men. Female sex was independently associated with decreased chances of achieving functional independency (adjusted odds ratio (adjOR) = 0.87, 95% confidence interval (CI) = 0.79-0.96, p = 0.005) and we detected a statistically significant improvement in functional outcome over time only in men (year of treatment, adjOR (per year) = 1.04, 95% CI = 1.02-1.06, p < 0.001) but not in women (adjOR (per year) = 1.01, 95% CI = 0.99-1.03, p = 0.280). Hypertension, smoking, and longer or unknown onset-to-door times were statistically significant predictors of outcome only in male patients, whereas atrial fibrillation, prior myocardial infarction, and longer door-to-needle times were significantly associated with outcome only in women.

CONCLUSIONS

Sex differences in functional outcome after IVT for acute ischemic stroke are persisting over the past years. Results of our analysis can increase awareness and a resulting focus on sex differences in predictors of outcome could be helpful in mitigating these differences in the future by supporting a more individualized patient care in clinical routine. Follow-up analyses are needed to assess this potential impact and its effect in the future.

DATA ACCESS STATEMENT

Data from the Austrian Stroke Unit Registry can only be accessed by the employed statistician (D.M.), access inquiries have to be addressed to the registry's academic review board.

Intravenous alteplase in minor nondisabling ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Minor ischemic stroke, defined as National Institute of Health Stroke Scale score of 0-5 on admission, represents half of all acute ischemic strokes. The role of intravenous alteplase (IVA) among patients with minor stroke is inconclusive; therefore, we evaluated clinical outcomes of these patients treated with or without IVA.

MATERIALS AND METHODS

We searched Medline, Embase, Scopus, and the Cochrane library until August 1, 2023. Inclusion was restricted to the English literature of studies that reported on minor nondisabling stroke patients treated with or without IVA. Odds ratios (ORs) with their corresponding 95% CIs were utilized using a random-effects model. Efficacy outcomes included rates of excellent (modified Rankin scale [mRS] of 0-1) and good (mRS of 0-2) functional outcome at 90 days. The main safety outcome was symptomatic intracerebral hemorrhage (sICH).

RESULTS

Five eligible studies, two RCTs and three observational studies, comprising 2764 patients (31.8% female) met inclusion criteria. IVA was administered to 1559 (56.4%) patients. Pooled analysis of the two RCTs revealed no difference between the two groups in terms of 90-days excellent functional outcomes (OR 0.76 [95% CI, 0.51-1.13]; I2 = 0%) and sICH rates (OR 3.76 [95% CI, 0.61-23.20]). No significant differences were observed between the groups in terms of good functional outcomes, 90-day mortality, and 90-day stroke recurrence.

CONCLUSION

This meta-analysis of minor nondisabling stroke suggests that IVA did not prove more beneficial compared to no-IVA.

Prevention and treatment of ischaemic and haemorrhagic stroke in people with diabetes mellitus: a focus on glucose control and comorbidities

Diabetes mellitus is a significant risk factor for both ischaemic and haemorrhagic stroke, affecting up to a third of individuals with cerebrovascular diseases. Beyond being a risk factor for stroke, diabetes and hyperglycaemia have a negative impact on outcomes after ischaemic and haemorrhagic stroke. Hyperglycaemia during the acute ischaemic stroke phase is associated with a higher risk of haemorrhagic transformation and poor functional outcome, with evidence in favour of early intervention to limit and manage severe hyperglycaemia. Similarly, intensive glucose control nested in a broader bundle of care, including blood pressure, coagulation and temperature control, can provide substantial benefit for clinical outcomes after haemorrhagic stroke. As micro- and macrovascular complications are frequent in people with diabetes, cardiovascular prevention strategies also need to consider tailored treatment. In this regard, the broader availability of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists can allow tailored treatments, particularly for those with heart failure and chronic kidney disease as comorbidities. Here, we review the main concepts of hyperacute stroke management and CVD prevention among people with diabetes, capitalising on results from large studies and RCTs to inform clinicians on preferred treatments.

Racial and Ethnic Disparities in Neurological Care in the United States

The burden of neurological disease is increasing globally. In the United States, this burden is disproportionally greater for Black and Latino communities who have limited access to neurological care. Health services researchers have attempted to identify racial and ethnic disparities in neurological care and possible solutions. This article reviews the most current literature on racial and ethnic disparities in commonly encountered neurological conditions, including Stroke, Alzheimer's Disease, Multiple Sclerosis, Epilepsy, Parkinson's Disease, and Migraine. Disparities exist in disease incidence, diagnosis, access to care, treatment, outcomes, and representation in epidemiologic studies and clinical trials. Many of the disparities observed in neurological care in the United States are a consequence of longstanding racist and discriminatory policies and legislation that increase risk factors for the development of neurological disease or lead to disparities in accessing quality neurological care. Therefore, additional efforts on the legislative, community health, and healthcare system levels are necessary to prevent the onset of neurological disease and achieve equity in neurological care.

Analysis of electrode arrangements for brain stroke diagnosis via electrical impedance tomography through numerical computational models

Objective.Rapid stroke-type classification is crucial for improved prognosis. However, current methods for classification are time-consuming, require expensive equipment, and can only be used in the hospital. One method that has demonstrated promise in a rapid, low-cost, non-invasive approach to stroke diagnosis is electrical impedance tomography (EIT). While EIT for stroke diagnosis has been the topic of several studies in recent years, to date, the impact of electrode placements and arrangements has rarely been analyzed or tested and only in limited scenarios. Optimizing the location and choice of electrodes can have the potential to improve performance and reduce hardware cost and complexity and, most importantly, diagnosis time.Approach.In this study, we analyzed the impact of electrodes in realistic numerical models by (1) investigating the effect of individual electrodes on the resulting simulated EIT boundary measurements and (2) testing the performance of different electrode arrangements using a machine learning classification model.Main results.We found that, as expected, the electrodes deemed most significant in detecting stroke depend on the location of the electrode relative to the stroke lesion, as well as the role of the electrode. Despite this dependence, there are notable electrodes used in the models that are consistently considered to be the most significant across the various stroke lesion locations and various head models. Moreover, we demonstrate that a reduction in the number of electrodes used for the EIT measurements is possible, given that the electrodes are approximately evenly distributed.Significance.In this way, electrode arrangement and location are important variables to consider when improving stroke diagnosis methods using EIT.

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Importance

Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.

Objective

To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.

Design, Setting, and Participants

This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.

Exposures

TS phases I (2010-2013), II (2014-2018), and III (2019-2021).

Main Outcomes and Measures

The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.

Results

Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.

Conclusions and Relevance

In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

Applied machine learning for stroke differentiation by electrical impedance tomography with realistic numerical models

Electrical impedance tomography (EIT) may have potential to overcome existing limitations in stroke differentiation, enabling low-cost, rapid, and mobile data collection. Combining bioimpedance measurement technologies such as EIT with machine learning classifiers to support decision-making can avoid commonly faced reconstruction challenges due to the nonlinear and ill-posed nature of EIT imaging. Therefore, in this work, we advance this field through a study integrating realistic head models with clinically relevant test scenarios, and a robust architecture consisting of nested cross-validation and principal component analysis. Specifically, realistic head models are designed which incorporate the highly conductive layers of cerebrospinal fluid in the subarachnoid space and ventricles. In total, 135 unique models are created to represent a large patient population, with normal, haemorrhagic, and ischemic brains. Simulated EIT voltage data generated from these models are used to assess the classification performance of support vector machines. Parameters explored include driving frequency, signal-to-noise ratio, kernel function, and composition of binary classes. Classifier accuracy at 60 dB signal-to-noise ratio, reported as mean and standard deviation, are (79.92% ± 10.82%) for lesion differentiation, (74.78% ± 3.79%) for lesion detection, (77.49% ± 15.90%) for bleed detection, and (60.31% ± 3.98%) for ischemia detection (after ruling out bleed). The results for each method were obtained with statistics from 3 independent runs with 17,280 observations, polynomial kernel functions, and feature reduction of 76% by PCA (from 208 to 50 features). While results of this study show promise for stroke differentiation using EIT data, our findings indicate that the achievable accuracy is highly dependent on the classification scenario and application-specific classifiers may be necessary to achieve acceptable accuracy.

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.

Racial and ethnic disparities in the usage and outcomes of ischemic stroke treatment in the United States

OBJECTIVES

This study explores racial and ethnic differences in 1) receiving tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) as treatment for ischemic stroke and 2) outcomes and quality of care after use of tPA or EVT in the US.

MATERIALS AND METHODS

An observational analysis of 89,035 ischemic stroke patients from the 2019 National Inpatient Sample was conducted. We performed weighted logistic regressions between race and ethnicity and 1) tPA and EVT utilization and 2) in-hospital mortality. We also performed a weighted Poisson regression between race and ethnicity and length of stay (LOS) after tPA or EVT.

RESULTS

Non-Hispanic (NH) Black patients had significantly lower odds of receiving tPA (Adjusted odds ratio [AOR] = 0.85, 95 % Confidence Internal [C.I.]: 0.80-0.91) and EVT (AOR = 0.75, 95 % CI: 0.70-0.82) than NH White patients. Minority populations (including but not limited to NH Black, Hispanic, Pacific Islander, Native American, and Asian) had significantly longer hospital LOS after treatment with tPA or EVT. We did not find a significant difference between race/ethnicity and in-hospital mortality post-tPA or EVT.

CONCLUSIONS

While we failed to find a difference in in-hospital mortality, racial and ethnic disparities are still evident in the decreased usage of tPA and EVT and longer LOSs for racial and ethnic minority patients. This study calls for interventions to expand the utilization of tPA and EVT and advance quality of care post-tPA or EVT in order to improve stroke care for minority patients.

Multidimensional Outcomes of IV Thrombolysis in Minor Ischemic Stroke: Motor, Psychocognitive, and Dependence

Background

The presence of mild deficit is the most common reason for nonuse of intravenous alteplase in ischemic stroke. We analyzed within a national prospective cohort on whether patients with minor stroke can benefit from intravenous alteplase.

Methods

This observational study included patients with acute ischemic stroke with a National Institutes of Health Stroke Scale (NIHSS) score 0 to 5 at admission. The short-term outcomes at discharge and 3-month were analyzed including the modified Rankin Scale score, gait speed, Montreal Cognitive Assessment, Patient Health Questionnaire-9, General Anxiety Disorder-7 and Stroke Impact Scale-16. Multivariate regression models were performed to evaluate the association between intravenous thrombolysis and clinical outcomes.

Results

A total of 1876 consecutive patients were included in the current analyses with 102 patients (5.4%) received alteplase and 1774 patients (94.5%) were in non-alteplase group. We found that 10.9% patients presented unfavorable functional outcome with a mRS ≥ 2 at 3-month. Patients with alteplase treatment had a more favorable outcome in SIS-16 at discharge (OR, 5.45; 95% CI, 2.22-8.68) and 3-month after stroke (OR, 2.34; 95% CI, 0.17-4.50). There was an association of alteplase with better gait speed in the restricted sample of age >60 (OR,0.14; 95% CI, 0.02-0.25), while an unfavorable effect was found in anxiety (OR, 2.23; 95% CI, 2.23, 0.91-3.55) and depression (OR, 1.54; 95% CI, 0.17-2.91) in female.

Conclusion

Alteplase showed a suggestive benefit in function and motor outcomes in patients with low NIHSS score of 0-5. Meanwhile, female seemed more inclined to post-stroke emotional problems after alteplase treatment, which should be further explored in the future.

Air Medical Transport for Acute Ischemic Stroke Patients: A Retrospective Cohort Study of National Trends Over an 8-Year Period

OBJECTIVE

Optimal management of ischemic stroke is time dependent. An understanding of patterns of air medical transport may identify disparities that could affect patient care.

METHODS

In this 8-year (2007-2014) observational, retrospective, cohort study, we abstracted a 20% national sample of Medicare data from patients ≥ 66 years of age hospitalized with a primary diagnosis of acute ischemic stroke who presented to the emergency department by ambulance (air or ground).

RESULTS

Among 149,751 hospitalized stroke patients who arrived by ambulance, the mean age was 81.6 years (standard deviation = 8.0 years), 62.1% were female (n = 93,007), and 86.3% were White (n = 129,268). Of these, 5,534 patients (3.7%) used any form of air ambulance. Air ambulance use (2007: 2.5%, 2014: 4.9%; P < .001) and arrival at certified stroke centers (2007: 40.3%, 2014: 63.2%; P < .001) increased over time. Air ambulance use was less likely among older patients (76-85 years and >85 years vs. 66-75 years; odds ratio [OR] = 0.68; 95% confidence interval [CI], 0.64-0.72 and OR = 0.34; 95% CI, 0.32-0.37, respectively) and all racial minorities except American Natives (OR = 2.07; 95% CI, 1.57-2.73) and more likely among sicker patients (Charlson Comorbidity Index ≥ 2 vs. 1, OR = 1.23; 95% CI, 1.09-1.38) and rural residents (OR = 1.34; 95% CI, 1.09-1.64). After adjustment for covariates, air ambulance use was associated with higher odds of thrombolysis (adjusted OR = 2.57; 95% CI, 2.38-2.79).

CONCLUSION

Air ambulance use is independently associated with increased thrombolysis use for stroke, but disparities exist in both air ambulance and thrombolysis use. Further research into underlying causes for these disparities would be beneficial for systems and public health-based interventions for improving outcomes for ischemic stroke.

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach

BACKGROUND

Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer.

METHODS

This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center.

RESULTS

Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer.

CONCLUSIONS

Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Current evidence for J147 as a potential therapeutic agent in nervous system disease: a narrative review

Curcumin has anti-inflammatory, antioxidant, and anticancer effects and is used to treat diseases such as dermatological diseases, infection, stress, depression, and anxiety. J147, an analogue of curcumin, is designed and synthesized with better stability and bioavailability. Accumulating evidence demonstrates the potential role of J147 in the prevention and treatment of Alzheimer's disease, diabetic neuropathy, ischemic stroke, depression, anxiety, and fatty liver disease. In this narrative review, we summarized the background and biochemical properties of J147 and discussed the role and mechanism of J147 in different diseases. Overall, the mechanical attributes of J147 connote it as a potential target for the prevention and treatment of neurological diseases.

Medical Management of Acute Cerebral Ischemia

This review article discusses medical management of acute cerebral ischemia including recent advances. Expansion of the thrombolysis eligibility criteria are discussed. Tenecteplase as a promising new thrombolytic is explored and the evidence supporting the use of Mobile Stroke Units is presented.

The burden of suspected strokes in uMgungundlovu - Can biomarkers aid prognostication?

Background

The burden of stroke is increasing worldwide. The hierarchical healthcare referral system in South Africa (SA) poses unique challenges to clinicians when caring for people with suspected strokes (PsS). To improve health outcomes, novel strategies are required to provide adequate care, including prognostication, in SA.

Aim

To determine the subjective burden of and challenges posed by suspected stroke cases and the potential usefulness of biomarkers in prognostication.

Setting

This study was conducted in the uMgungundlovu Health District (UHD), KwaZulu-Natal, SA.

Methods

An online questionnaire was distributed to doctors within the UHD. Demographic data and answers to a series of 5-point-Likert-type statements were collected.

Results

Seventy-seven responses were analysed. A third of doctors worked in primary healthcare facilities (PHCare) and saw ≥ 2.15 suspected strokes-per-doctor-per-week, compared to ≥ 1.38 seen by doctors working in higher levels of healthcare. Neuroimaging was relied upon by > 85% of doctors, with nearly half of PHCare doctors having to refer patients to facilities 5 km - 20 km away, with resultant delays. Knowledge about prognostic biomarkers in strokes was poor, yet most doctors believed that a biomarker would assist in the prognostication process and they would use it routinely.

Conclusion

Doctors in this study faced a significant burden of strokes and rely on neuroimaging to guide their management; however, many challenges exist in obtaining such imaging, especially in the PHCare setting. The need for prognostic biomarkers was clear.

Contribution

This research lays the platform for further studies to investigate prognostic biomarkers in stroke in our clinical setting.

Intra-arterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients in the United States: A case control analysis

BACKGROUND

Although observational studies have reported favorable clinical outcomes associated with intra-arterial thrombolysis as adjunct to mechanical thrombectomy, the cost and length of hospitalization associated with this intervention has not been studied.

METHODS

We analyzed the nationally representative data of the United States data from Nationwide Inpatient Sample (NIS) to compare hospitalization cost and duration in addition to other outcomes in patients receiving (n = 1990) with those not receiving intra-arterial thrombolysis (n = 1990) in acute ischemic stroke patients undergoing mechanical thrombectomy using a case control design matched for age, gender, and presence of aphasia, hemiplegia, neglect, coma/stupor, hemianopsia and dysphagia.

RESULTS

There was no difference in the median hospitalization cost in patients treated with intra-arterial thrombolysis compared with those not treated with intra-arterial thrombolysis: $36,992 [28,361 to 54,336] versus $35,440 [24,383 to 50,438], (regression coefficient 2,485 [-1,947 to 6,917], p = 0.27). There was no difference in the median length of hospitalization in patients treated with intra-arterial thrombolysis compared with those not treated with intra-arterial thrombolysis: 6 days [3 to 10] versus 6 days [4 to 10], (regression coefficient -0.34 [-1.47 to 0.80], p = 0.56). There was no difference in odds of home-discharge (OR 1.02 95%CI 0.72-1.43, p = 0.93) or post-procedural intracranial hemorrhage (OR 1.16 95%CI 0.83-1.64, p = 0.39) between the two groups.

CONCLUSIONS

We did not observe an increase in the cost or length of hospitalization associated with the use of intra-arterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients. If the ongoing randomized clinical trials demonstrate therapeutic efficacy in reducing death or disability, this intervention has a high likelihood of being beneficial overall.

Intravenous Thrombolysis or Medical Management for Minor Strokes

OBJECTIVE

 To evaluate the outcomes of acute ischemic stroke patients with minor deficits treated with either intravenous thrombolysis (IVT) or routine medical management (MM).

METHODS

 The study included patients with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less who were treated with IVT within 4.5 hours from symptom onset and were classified as the IVT group. The MM group consisted of an equal number of patients with minor strokes, matched for sex, age, and severity, who did not receive thrombolysis. Data on patient information were collected for both groups.

RESULTS

 A total of 26,236 patients were included in this study (13,208 in IVT and 13,208 in MM). Of these patients, 67.9% were men, and the mean age was 67.1 years (standard deviation: 10.9). At 3 months, the IVT group had a higher rate of stroke-independent outcome (Rankin Scale score of 0-2) compared with the MM group (IVT vs. MM: 91.6 vs. 88.6%, absolute difference: 2.5%, 95% confidence interval [CI]: 1.6-3.4%, p = 0.008; adjusted hazard ratio [HR]: 1.2, 95% CI: 1.1-1.4, p = 0.003). Furthermore, there was no significant difference in 3-month mortality rates between the IVT and MM groups (IVT vs. MM: 2.1 vs. 2.5%, absolute difference: -0.6%, 95% CI: -1.1 to 0.3%, p = 0.11; adjusted HR: 0.9, 95% CI: 0.8-1.2, p = 0.09).

CONCLUSION

 Compared with MM, IVT does not reduce mortality in minor ischemic stroke but improves functional outcomes in minor stroke with an NIHSS score of 3 to 5.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Sex Differences in Functional Outcomes Following Endovascular Treatment for Acute Ischemic Stroke

BACKGROUND

Sex disparities have been reported across many aspects of acute ischemic stroke (AIS) care; however, there is a relative paucity of research examining sex differences in outcomes following endovascular treatment (EVT). Some studies report worse functional independence for females following EVT. Few, if any of these studies account for differences in age, baseline function, and comorbidity burden. This retrospective cohort study aimed to assess for sex differences in functional outcomes following EVT by comparing 90-day modified Rankin Scale (mRS) of males and females while controlling for baseline function and comorbidity burden.

METHODS

Baseline demographic and clinical data, and stroke severity were compared for 230 consecutive patients undergoing EVT for AIS between October 2014 and July 2019 at a tertiary stroke centre in Toronto, Canada. Effect of sex on likelihood of functional independence post-EVT was assessed using regression analysis with and without correction for age, baseline mRS, and Charlson Comorbidity Index (CCI).

RESULTS

Females undergoing EVT for AIS were older (75 ± 13 vs. 66 ± 15, p < 0.0001), with worse clinical and functional baselines. Unadjusted, males were more functionally independent (90-day mRS < 3) [OR = 1.831, 95%CI 1.082-3.098]. After controlling for age, baseline mRS and CCI, there was no difference between groups [OR 1.21, 95%CI 0.61-2.37].

CONCLUSIONS

This study provides evidence that prior findings of sex disparities in function after EVT may be accounted for by differences in age, baseline clinical status and functional independence between males and females when a comprehensive measure of comorbidity burden is utilized.

A new clinical score to predict the possibility of stroke patients receiving intravenous thrombolysis

BACKGROUND

We aimed to develop and validate a clinical score to identify the factors which contribute to variation in, and influence clinician's decision-making about treating acute ischemic stroke (AIS) patients with Intravenous thrombolysis (IVT).

METHODS

We retrospectively included consecutive AIS patients within 4.5 hours after onset in the emergency department (ED), who were admitted to a comprehensive stroke center in Jiangsu province, China. The patients were randomly divided into derivation (60%) and validation data sets (40%) to develop and validate the clinical score. Multivariable stepwise forward logistic regression was performed to identify the independent predictors of IVT offering in the derivation data.

RESULTS

Out of 526 included patients, 418 patients received thrombolytic therapy. Nine patient factors were associated with the likelihood of thrombolysis (age, time to hospital, National Institute of Health stroke scale (NIHSS) score, great vessel, facial paralysis, dizziness, headache, history of stroke, and neutrophil ratio). The c-statistics of the Intravenous Thrombolysis Score in the derivation cohort (n= 316) and validation cohort(n = 210) were 0.795 and 0.751, respectively. The performance of the scoring model was validated with a calibration plot showing good predictive accuracy for the scores in the derivation data (calibrated P = 0.861) and validation data (calibrated P = 0.876).

CONCLUSIONS

The Intravenous Thrombolysis Score for predicting the possibility of offering IVT to AIS patients indicates that clinicians differ in their thresholds for the treatment across a number of patient-related factors, which will be linked to training professional development programmes and address the impact of non-medical influences on decision-making using evidence-based strategies.

A Machine Learning Approach to Support Urgent Stroke Triage Using Administrative Data and Social Determinants of Health at Hospital Presentation: Retrospective Study

BACKGROUND

The key to effective stroke management is timely diagnosis and triage. Machine learning (ML) methods developed to assist in detecting stroke have focused on interpreting detailed clinical data such as clinical notes and diagnostic imaging results. However, such information may not be readily available when patients are initially triaged, particularly in rural and underserved communities.

OBJECTIVE

This study aimed to develop an ML stroke prediction algorithm based on data widely available at the time of patients' hospital presentations and assess the added value of social determinants of health (SDoH) in stroke prediction.

METHODS

We conducted a retrospective study of the emergency department and hospitalization records from 2012 to 2014 from all the acute care hospitals in the state of Florida, merged with the SDoH data from the American Community Survey. A case-control design was adopted to construct stroke and stroke mimic cohorts. We compared the algorithm performance and feature importance measures of the ML models (ie, gradient boosting machine and random forest) with those of the logistic regression model based on 3 sets of predictors. To provide insights into the prediction and ultimately assist care providers in decision-making, we used TreeSHAP for tree-based ML models to explain the stroke prediction.

RESULTS

Our analysis included 143,203 hospital visits of unique patients, and it was confirmed based on the principal diagnosis at discharge that 73% (n=104,662) of these patients had a stroke. The approach proposed in this study has high sensitivity and is particularly effective at reducing the misdiagnosis of dangerous stroke chameleons (false-negative rate <4%). ML classifiers consistently outperformed the benchmark logistic regression in all 3 input combinations. We found significant consistency across the models in the features that explain their performance. The most important features are age, the number of chronic conditions on admission, and primary payer (eg, Medicare or private insurance). Although both the individual- and community-level SDoH features helped improve the predictive performance of the models, the inclusion of the individual-level SDoH features led to a much larger improvement (area under the receiver operating characteristic curve increased from 0.694 to 0.823) than the inclusion of the community-level SDoH features (area under the receiver operating characteristic curve increased from 0.823 to 0.829).

CONCLUSIONS

Using data widely available at the time of patients' hospital presentations, we developed a stroke prediction model with high sensitivity and reasonable specificity. The prediction algorithm uses variables that are routinely collected by providers and payers and might be useful in underresourced hospitals with limited availability of sensitive diagnostic tools or incomplete data-gathering capabilities.

Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt

Background

Reducing pre- and in-hospital delays plays an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate.

Aim

The study aimed to investigate the factors associated with pre- and in-hospital delays of IVT among patients with acute ischemic stroke coming from urban and rural communities.

Methods

This prospective, multicenter, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited from three large university stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients, and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent the National Institutes of Health Stroke Scale and full neurological assessment, urgent laboratory investigations, and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis. The patients were subjected to a structured questionnaire that was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions.

Results

A total of 618 patients were included in the study, of which 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. Approximately 73.3% of patients who arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis, and presentation to non-stroke-ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration.

Conclusion

The limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural patients with acute stroke.

National Patterns and Outcomes of Neurologist Care in Acute Ischemic Stroke

Background & Purpose

Specialist care of acute ischemic stroke patients has been associated with improved outcomes but is not well-characterized. We sought to elucidate the involvement and influence of neurologists on acute ischemic stroke care.

Methods

Using 100% Medicare datasets, index acute ischemic stroke admissions from 2016-2018 were identified with International Classification of Diseases, 10th Revision codes. Neurologists were identified by NPI code. Neurologist involvement in care was defined as: "neurologist involved in care"; "hospital with a neurologist"; and "percent of acute ischemic stroke treated by neurologist." Adjusted logistic regression models summarized exposure to neurologists and their association with outcomes (inpatient mortality, good outcome, and 30-day readmission).

Results

Among 647838 index AIS admissions from 2016-2018, 15.6% included a neurologist involved in care, associated with receiving intravenous thrombolysis (19.1% vs 6.5%), endovascular thrombectomy (13.2% vs 1.4%), treatment at a teaching hospital (87.7% vs 55.5%), and treatment at a hospital in the highest volume quartile (95.3% vs 75.6%). Of 4797 hospitals, 36.1% had a neurologist, among which the mean percent of admissions treated by a neurologist was 14.7% (SD 24.4). Neurologist involvement was associated with increased inpatient mortality (OR 1.81; 95% CI 1.75-1.86), decreased odds of a good outcome (OR .92; 95% CI .90-.93), and increased 30-day readmission (OR 1.04; 95% C: 1.01-1.06).

Conclusions

The minority of acute ischemic stroke admissions among the elderly in the US are treated by neurologists. Neurologist involvement in care is associated with worse outcomes, possibly from the allocation of severe cases to neurologists.

Immunologic Implications for Stroke Recovery: Unveiling the Role of the Immune System in Pathogenesis, Neurorepair, and Rehabilitation

Stroke is a debilitating neurologic condition characterized by an interruption or complete blockage of blood flow to certain areas of the brain. While the primary injury occurs at the time of the initial ischemic event or hemorrhage, secondary injury mechanisms contribute to neuroinflammation, disruption of the blood-brain barrier (BBB), excitotoxicity, and cerebral edema in the days and hours after stroke. Of these secondary mechanisms of injury, significant dysregulation of various immune populations within the body plays a crucial role in exacerbating brain damage after stroke. Pathological activity of glial cells, infiltrating leukocytes, and the adaptive immune system promote neuroinflammation, BBB damage, and neuronal death. Chronic immune activation can additionally encourage the development of neurologic deficits, immunosuppression, and dysregulation of the gut microbiome. As such, immunotherapy has emerged as a promising strategy for the clinical management of stroke in a highly patient-specific manner. These strategies include regulatory T cells (Tregs), cell adhesion molecules, cytokines, and monoclonal antibodies. However, the use of immunotherapy for stroke remains largely in the early stages, highlighting the need for continued research efforts before widespread clinical use.

Too risky, too large, too late, or too mild-Reasons for not treating ischemic stroke patients and the related outcomes

Background

Despite effective treatments, many patients are still not offered reperfusion therapy for acute ischemic stroke.

Methods

We present a single-center observational study on acute ischemic stroke patients, who presented as candidates for reperfusion therapy but were deemed ineligible after work-up. Reasons for non-treatment were obtained by studying patient files and subsequently grouped into "too risky" (e.g., anticoagulant use, comorbidities), "too large" (large infarct), "too late" (late presentation of stroke and wake-up strokes), or "too mild" (clinically mild/remitting symptoms). Modified Rankin scale (mRS) score was prospectively collected in all patients by a structured telephone interview. All non-treated patients with a National Institute of Health Stroke Scale (NIHSS) score of 0-5 were compared with a similar cohort that was treated.

Results

Of 529 patients with acute ischemic stroke arriving as reperfusion therapy candidates, 198 (37.4%) were not treated. The majority (42%) were not treated due to admission outside the treatment window (too late) and 24% had absolute contraindications (too risky). Only 8% was excluded because their infarct was too large [median Alberta Stroke Program Early CT score 3 (2-4)]. In the "too mild" group (14%) the percentage of patients not being independent at 90 days was 30%. The adjusted odds ratio for a better outcome (lower mRS) among treated patients with NIHSS 0-5 compared with non-treated was 1.93 (95% confidence interval 1.15-3.23).

Conclusion

Presenting outside the treatment window is still the most common reason for not receiving therapy. Our study suggests a benefit of thrombolysis for patients with mild symptoms.

Factors associated with functional disability in patients with acute stroke excluded from alteplase administration due to minor non-disabling neurological deficits

Background

Although the PRISMS study did not demonstrate the benefit of intravenous alteplase administration in patients with mild stroke within 3 h, about 30% of patients presenting with mild symptoms showed unfavorable functional outcomes. We investigated the factors predictive of functional disability at 90 days in patients who were excluded from alteplase administration due to the National Institutes of Health Stroke Scale (NIHSS) scores of 0-5 and a score between 0 and 2 for each NIHSS score item.

Methods

All patients were diagnosed with acute ischemic stroke or transient ischemic attack within 4.5 h of admission to a tertiary hospital and did not receive alteplase due to a minor stroke between January 2013 and December 2020. Radiological data and clinical information were collected, including baseline and discharge NIHSS scores and modified Rankin Scale (mRS) scores at 90 days. Early neurological deterioration (END) was defined as an increase of two or more NIHSS scores. We defined moderate motor weakness as a NIHSS limb motor score of more than 3 and defined a favorable outcome as a mRS score at 90 days that was 0 or 1.

Results

During the investigation period, 400 patients did not receive alteplase. END occurred significantly more frequently in patients with large artery disease (LAD) than in those with other TOAST classifications. In the multivariate regression analysis, NIHSS per 1-point increase, presenting as moderate motor weakness, and LAD were independent predictors of poor functional outcome (OR, 1.811 NIHSS per 1-point increase; 95% confidence interval [CI], 1.503-2.182; P < 0.0001; OR, 2.173 moderate motor weakness; 95% CI 1.028-4.595; P = 0.042; OR, 2.033 LAD; 95% CI 1.099-3.762; P = 0.024, respectively).

Conclusion

Moderate motor weakness presentation and LAD may be important factors associated with poor functional outcomes in patients with acute stroke excluded from alteplase administration due to mild symptoms.

Analysis of Mortality in Intracerebral Hemorrhage Patients with Hyperacute Ischemic Stroke Treated Using Thrombolytic Therapy: A Nationwide Population-based Cohort Study in South Korea

This study investigated the impact of intracerebral hemorrhage (ICH) on the cumulative mortality of patients with hyperacute ischemic stroke. This population-based retrospective cohort study used claims data from the National Health Insurance Service customized database of South Korea. The recruitment period was 2005−2018. The study population included patients with hyperacute ischemic stroke who had received intravenous thrombolysis. The primary endpoint was 12-month cumulative mortality, which was analyzed in both the ICH and no-ICH groups. Of the 50,550 patients included, 2567 (5.1%) and 47,983 (94.9%) belonged to the ICH and no-ICH groups, respectively. In the univariable analysis for 12-month mortality, ICH patients were substantially more prevalent among dead patients than among patients who survived (11.6% versus 3.6%; p < 0.001). The overall 12-month cumulative mortality rate was 18.8%. Mortality in the ICH group was higher than that in the no-ICH group (42.8% versus 17.5%; p < 0.001). In the multivariable analysis, the risk of 12-month cumulative mortality was 2.97 times higher in the ICH group than in the no-ICH group (95% confidence interval, 2.79−3.16). The risk of 12-month cumulative mortality in hyperacute ischemic stroke can increase approximately threefold after the occurrence of spontaneous ICH following intravenous thrombolysis.

Neurocritical Care Performance Measures Derived from Electronic Health Record Data are Feasible and Reveal Site-Specific Variation: A CHoRUS Pilot Project

BACKGROUND

We evaluated the feasibility and discriminability of recently proposed Clinical Performance Measures for Neurocritical Care (Neurocritical Care Society) and Quality Indicators for Traumatic Brain Injury (Collaborative European NeuroTrauma Effectiveness Research in TBI; CENTER-TBI) extracted from electronic health record (EHR) flowsheet data.

METHODS

At three centers within the Collaborative Hospital Repository Uniting Standards (CHoRUS) for Equitable AI consortium, we examined consecutive neurocritical care admissions exceeding 24 h (03/2015-02/2020) and evaluated the feasibility, discriminability, and site-specific variation of five clinical performance measures and quality indicators: (1) intracranial pressure (ICP) monitoring (ICPM) within 24 h when indicated, (2) ICPM latency when initiated within 24 h, (3) frequency of nurse-documented neurologic assessments, (4) intermittent pneumatic compression device (IPCd) initiation within 24 h, and (5) latency to IPCd application. We additionally explored associations between delayed IPCd initiation and codes for venous thromboembolism documented using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) system. Median (interquartile range) statistics are reported. Kruskal-Wallis tests were measured for differences across centers, and Dunn statistics were reported for between-center differences.

RESULTS

A total of 14,985 admissions met inclusion criteria. ICPM was documented in 1514 (10.1%), neurologic assessments in 14,635 (91.1%), and IPCd application in 14,175 (88.5%). ICPM began within 24 h for 1267 (83.7%), with site-specific latency differences among sites 1-3, respectively, (0.54 h [2.82], 0.58 h [1.68], and 2.36 h [4.60]; p < 0.001). The frequency of nurse-documented neurologic assessments also varied by site (17.4 per day [5.97], 8.4 per day [3.12], and 15.3 per day [8.34]; p < 0.001) and diurnally (6.90 per day during daytime hours vs. 5.67 per day at night, p < 0.001). IPCds were applied within 24 h for 12,863 (90.7%) patients meeting clinical eligibility (excluding those with EHR documentation of limiting injuries, actively documented as ambulating, or refusing prophylaxis). In-hospital venous thromboembolism varied by site (1.23%, 1.55%, and 5.18%; p < 0.001) and was associated with increased IPCd latency (overall, 1.02 h [10.4] vs. 0.97 h [5.98], p = 0.479; site 1, 2.25 h [10.27] vs. 1.82 h [7.39], p = 0.713; site 2, 1.38 h [5.90] vs. 0.80 h [0.53], p = 0.216; site 3, 0.40 h [16.3] vs. 0.35 h [11.5], p = 0.036).

CONCLUSIONS

Electronic health record-derived reporting of neurocritical care performance measures is feasible and demonstrates site-specific variation. Future efforts should examine whether performance or documentation drives these measures, what outcomes are associated with performance, and whether EHR-derived measures of performance measures and quality indicators are modifiable.

Call to Action for Cardiovascular Disease in Women: Epidemiology, Awareness, Access, and Delivery of Equitable Health Care: A Presidential Advisory From the American Heart Association

Addressing the pervasive gaps in knowledge and care delivery to reduce sex-based disparities and achieve equity is fundamental to the American Heart Association's commitment to advancing cardiovascular health for all by 2024. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders around the globe to identify and remove barriers to health care access and quality for women. A concise and current summary of existing data across the areas of risk and prevention, access and delivery of equitable care, and awareness and education provides a framework to consider knowledge gaps and research needs critical toward achieving significant progress for the health and well-being of all women.

Utilization of Telestroke Prior to and Following the COVID-19 Pandemic

For over two decades, telestroke has been utilized as a means for improving acute access to a stroke specialist when this expertise is otherwise unavailable. During this time, telestroke use has increased and improvements in care metrics have been widely reported. Several telestroke model variations are utilized; each has different workflow implications. A successful telestroke system should include adequate protocols and training, equipment, documentation system, and tracking of quality metrics. Upfront costs of needed technology and devices, credentialing hurdles, and limited reimbursement are all reported barriers to the utilization of telestroke. Emphasis on safety measures during the COVID-19 pandemic resulted in the dramatic upscaling of telehealth utilization, although overall stroke volumes declined in many areas in the early phases of the pandemic. Going forward, continued reduction in cost of required devices and broadband connections, increased use of automated and advanced analytical software, and a universal licensing and credentialing system are needed to continue the expansion of telestroke use.

Ultrashort Door‐to‐Needle Time for Intravenous Thrombolysis Is Safer and Improves Outcome in the Czech Republic: Nationwide Study 2004 to 2019

Background

The benefit of intravenous thrombolysis is time dependent. It remains unclear, however, whether dramatic shortening of door‐to‐needle time (DNT) among different types of hospitals nationwide does not compromise safety and still improves outcome.

Methods and Results

Multifaceted intervention to shorten DNT was introduced at a national level, and prospectively collected data from a registry between 2004 and 2019 were analyzed. Generalized estimating equation was used to identify the association between DNT and outcomes independently from prespecified baseline variables. The primary outcome was modified Rankin score 0 to 1 at 3 months, and secondary outcomes were parenchymal hemorrhage/intracerebral hemorrhage (ICH), any ICH, and death. Of 31 316 patients treated with intravenous thrombolysis alone, 18 861 (60%) had available data: age 70±13 years, National Institutes of Health Stroke Scale at baseline (median, 8; interquartile range, 5–14), and 45% men. DNT groups 0 to 20 minutes, 21 to 40 minutes, 41 to 60 minutes, and >60 minutes had 3536 (19%), 5333 (28%), 4856 (26%), and 5136 (27%) patients. National median DNT dropped from 74 minutes in 2004 to 22 minutes in 2019. Shorter DNT had proportional benefit: it increased the odds of achieving modified Rankin score 0 to 1 and decreased the odds of parenchymal hemorrhage/ICH, any ICH, and mortality. Patients with DNT ≤20 minutes, 21 to 40 minutes, and 41 to 60 minutes as compared with DNT >60 minutes had adjusted odds ratios for modified Rankin score 0 to 1 of the following: 1.30 (95% CI, 1.12–1.51), 1.33 (95% CI, 1.15–1.54), and 1.15 (95% CI, 1.02–1.29), and for parenchymal hemorrhage/ICH: 0.57 (95% CI, 0.45–0.71), 0.76 (95% CI, 0.61–0.94), 0.83 (95% CI, 0.70–0.99), respectively.

Conclusions

Ultrashort initiation of thrombolysis is feasible, improves outcome, and makes treatments safer because of fewer intracerebral hemorrhages. Stroke management should be optimized to initiate thrombolysis as soon as possible optimally within 20 minutes from arrival to a hospital.

Influence of Hospital Characteristics on Hospital Transfer Destinations for Patients With Stroke

BACKGROUND

Patients with stroke are frequently transferred between hospitals. This may have implications on the quality of care received by patients; however, it is not well understood how the characteristics of sending and receiving hospitals affect the likelihood of a transfer event. Our objective was to identify hospital characteristics associated with sending and receiving patients with stroke.

METHODS

Using a comprehensive statewide administrative dataset, including all 78 Massachusetts hospitals, we identified all transfers of patients with ischemic stroke between October 2007 and September 2015 for this observational study. Hospital variables included reputation (US News and World Report ranking), capability (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliation. We included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with transfers. This method decomposes a series of patient transfers into a sequence of decisions characterized by transfer initiations and destinations, modeling them using a discrete-choice framework.

RESULTS

Among 73 114 ischemic stroke admissions there were 7189 (9.8%) transfers during the study period. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital (in descending order of relative effect size) included shared hospital affiliation (5.8× higher), teaching hospital status (4.2× higher), stroke center status (4.3× and 3.8× higher when of the same or higher status), and hospitals of the same or higher reputational ranking (1.5× higher).

CONCLUSIONS

After accounting for distance and structural network characteristics, in descending order of importance, shared hospital affiliation, hospital capabilities, and hospital reputation were important factor in determining transfer destination of patients with stroke. This study provides a starting point for future research exploring how relational coordination between hospitals may ensure optimized allocation of patients with stroke for maximal patient benefit.

Reasons and predictors of non-thrombolysis in patients with acute ischemic stroke admitted within 4.5 h

Objectives

Thrombolytic treatment in acute ischemic stroke (AIS) reduces stroke‐related disability. Nearly 40% of all patients with AIS (<4.5 h) receive thrombolysis, but there is a large variation in the use between hospitals. Little is known about reasons and predictors for not giving thrombolytic treatment. Therefore, we aimed to investigate reasons for non‐thrombolysis in patients admitted within 4.5 h.

Methods

All patients with AIS (<4.5 h) admitted to Akershus University Hospital, Norway, between January 2015 and December 2017 were examined. Patient characteristics and reasons for not giving thrombolysis were registered. Descriptive statistics and logistic regression analyses were performed.

Results

Of 535 patients admitted with AIS (<4.5 h), 250 (47%) did not receive thrombolysis and of these only 26% had an absolute contraindication to treatment. Among the 74% with relative contraindications, the most common reasons given were mild and improving symptoms. Previous stroke (OR 3.32, 95%CI 1.99–5.52), arriving between 3 h and 4.5 h after onset (OR 7.76, 95%CI 3.73–16.11) or having mild symptoms (OR 2.33, 95%CI 1.56–3.49) were all significant predictors of not receiving thrombolytic treatment in the multivariable logistic regression model.

Conclusion

A large proportion of patients with AIS do not receive thrombolysis. This study highlights up‐to‐date findings that arriving late in the time window, mild symptoms, and previous stroke are strong predictors of non‐treatment. It is uncertain whether there is an underuse of thrombolysis in AIS. Increasing the utility of thrombolysis in the 4.5 h time window must be weighed against possible harms.

Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression

Introduction

The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions.

Methods

We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria.

Results

A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4–15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1–10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window.

Conclusions

The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.

The impact of a comprehensive national policy on improving acute stroke patient care in Lithuania

Introduction:

Reperfusion therapy (RT) is a mainstay treatment for acute ischemic stroke (AIS). We aimed to evaluate the impact of a comprehensive national policy (CNP) to improve access to RT for AIS patients across Lithuania.

Patients and methods:

Aggregated anonymized data on AIS cases treated in Lithuanian hospitals between 2006 and 2019 were retrospectively obtained from the Institute of Hygiene and the Stroke Integrated Care Management Committee. Through an interrupted time series analysis, we examined the trends in AIS hospital admissions, RT, and in-hospital case fatality rates prior to the enactment of CNP in 2014, changes immediately after the intervention, and differences in trends between the pre- and post-intervention periods. Mean yearly door-to-needle times were calculated post-intervention.

Results:

114,436 cases were treated for AIS in Lithuanian hospitals before, and 65,084 after the government intervention. We observed a significant decreasing post-intervention trend change in AIS hospital admission rate per 100,000 population (regression coefficient ± standard error: β = –16.47 ± 3.95, p = 0.002) and an increasing trend change in the proportion of AIS patients who received reperfusion treatment: intravenous thrombolysis (β = 1.42 ± 0.96, p < 0.001) and endovascular therapy (β = 0.85 ± 0.05, p < 0.001). The proportion of patients treated in stroke centers increased immediately after the intervention (β = 4.95 ± 1.14, p = 0.001), but the long-term post-intervention trend did not change. In addition, there was a significant decreasing trend in all cause in-hospital case fatality rate within primary and comprehensive stroke centers after the intervention (β = –0.60 ± 0.18, p = 0.008) despite its prompt initial immediate increase (β = 1.68 ± 0.73, p = 0.043). The mean countrywide door-to-needle time decreased from 68 min in 2014 to 43 min in 2019.

Conclusion:

The comprehensive national stroke patient care policy could be associated with an immediate increase in stroke center treatment rate, increased access to RT, and improved stroke care performance measures.

Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms

Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.

Clinical Outcomes and Costs of Recurrent Ischemic Stroke: A Systematic Review

OBJECTIVE

Recurrent stroke patients suffer significant morbidity and mortality, representing almost 30% of the stroke population. Our objective was to determine the clinical outcomes and costs of recurrent ischemic stroke (recurrent-IS).

METHODS

Our study protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020192709). Following PRISMA guidelines, our medical librarian conducted a search in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL (last performed on August 25, 2020).

INCLUSION CRITERIA

(1) Studies reporting clinical outcomes and/or costs of recurrent-IS; (2) Original research published in English in year 2010 or later; (3) Study participants aged ≥18 years.

EXCLUSION CRITERIA

(1) Case reports/studies, abstracts/posters, Editorial letters/reviews; (2) Studies analyzing interventions other than intravenous thrombolysis and thrombectomy. Four independent reviewers selected studies with review of titles/abstracts and full-text, and performed data extraction. Discrepancies were resolved by a senior independent arbitrator. Risk-of-bias was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Initial search yielded 20,428 studies. Based on inclusion/exclusion criteria, 9 studies were selected, consisting of 24,499 recurrent-IS patients. In 5 studies, recurrent-IS ranged from 4.4-56.8% of the ischemic stroke cohorts at 3 or 12 months, or undefined follow-up. Mean age was 60-80 years and female proportions were 38.5-61.1%. Clinical outcomes included mortality 11.6-25.9% for in-hospital, 30-days, or 4-years (3 studies). In one study from the U.S., mean in-hospital costs were $17,121(SD-$53,693) and 1-year disability costs were $34,639(SD-$76,586) per patient.

CONCLUSIONS

Our study highlights the paucity of data on clinical outcomes and costs of recurrent-IS and identifies gaps in existing literature to direct future research.

The relationship between stroke system organization and disparities in access to stroke center care in California

Background

There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access.

Methods

Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient- and hospital-level characteristics and outcomes of interest.

Results

Of 336,247 ischemic stroke patients, 55.4% were non-Hispanic White, 19.6% Hispanic, 10.6% non-Hispanic Asian/Pacific Islander, and 10.3% non-Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non-Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non-Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81).

Conclusions

There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.

Lessons Learned From the Historical Trends on Thrombolysis Use for Acute Ischemic Stroke Among Medicare Beneficiaries in the United States

Background

The most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization.

Methods

We built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014.

Results

Use of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65-0.83), Black (aOR 0.73, 95% CI 0.61-0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77-1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38-3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68-2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05-1.54).

Conclusions

Between 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.

Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability and coverage

BACKGROUND

Major disparities have been reported in recombinant tissue Plasminogen Activator (rtPA) availability among countries of different socioeconomic status.

AIMS

To characterize variability of rtPA price, its availability, and its association with and impact on each country's health expenditure (HE) resources.

METHODS

We conducted a global survey to obtain information on rtPA price (50mg vial, 2020 US Dollars) and availability. Country-specific data, including Low, Lower Middle (LMIC), Upper Middle (UMIC) and High-Income Country (HIC) classifications, and Gross Domestic Product (GDP) and HE, both nominally and adjusted for purchasing power parity (PPP), were obtained from World Bank Open Data. To assess the impact of rtPA cost, we computed the rtPA price as percentage of per capita GDP and HE and examined its association with the country income classification.

RESULTS

rtPA is approved and available in 109 countries. We received surveys from 59 countries: 27 (46%) HIC, 20 (34%) UMIC and 12 (20%) LMIC. Although HIC have significantly higher per capita GDP and HE compared to UMIC and LMIC (p<0.0001), the median price of rtPA is non-significantly higher in LMICs [USD 755, IQR (575-1300)] compared to UMICs [USD 544, IQR (400-815)] and HIC [USD 600, IQR (526-1000)]. In LMIC, rtPA cost accounts for 217.4% (IQR (27.1-340.6%) of PPP-adjusted per capita HE, compared to 17.6% (IQR [11.2-28.7%], p<0.0001) for HICs.

CONCLUSIONS

We documented significant rtPA availability and variability in its price among countries. Relative costs are higher in lower income countries, exceeding the available HE. Concerted efforts to improve rtPA affordability in low-income settings are necessary.

Telestroke for the Treatment of Ischemic Stroke in Western China During the COVID-19 Pandemic: A Multicenter Observational Study

Background

Intravenous thrombolysis is still underutilized in patients with acute ischemic stroke (AIS) in China. A promising strategy for addressing this issue, especially in situations, such as the global pandemic of coronavirus disease 2019 (COVID-19), is the telestroke mode, which remains to be widely implemented in China. The present study aimed to assess the effects of telemedicine for patients with stroke in Western China, as well as the impact of the pandemic on telestroke services in 1 year after the COVID-19 outbreak.

Methods

In this 2-year multicenter observational study, we retrospectively collected data from 10 hospitals within the Sichuan Telestroke and Telethrombolysis Network. Demographic and clinical characteristics of patients with IS and those relevant to thrombolysis were compared between the pre-telestroke and post-telestroke phases, and between the periods before and after declaration of the COVID-19 pandemic.

Results

A total of 11,449 admissions with a primary diagnosis of IS were recorded during the study period. Prior to telestroke implementation, 6.7% of patients (n = 367) received intravenous thrombolysis, and the proportion increased to 7.4% (n = 443; p = 0.084) in the post-telestroke phase. The thrombolysis rate was 7.4% during the COVID-19 pandemic and in the latter half of the year when the viral spread was better controlled in China. The mean door-to-needle time (DNT) was significantly shorter after implementation of the telestroke network (63.76 ± 13.50 vs. 52.66 ± 25.49 min; p < 0.001).

Conclusions

Telemedicine is effective in improving the thrombolysis administration among patients with IS in Western China. Implementation of the telestroke network should be promoted, especially when access to care is affected by public health emergencies, such as the COVID-19 pandemic.

Lean six sigma and stroke in rural hospital - The case of Baruch Padeh Medical Center

PURPOSE

This case study aims to demonstrate the strengths of the Lean Six Sigma (LSS) methodology to improve the acute ischemic stroke (AIS) treatment rates and reduce process lead time at Baruch Padeh Medical Center (BPMC), a rural hospital in the Galilee region of Northern Israel. The LSS project redefined the BPMC stroke care pathway and increased its efficacy.

DESIGN/METHODOLOGY/APPROACH

The LSS methodology was implemented in September 2017 by integrating lean principles and the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control). Existing procedures, field observation, ad hoc measurement and in-depth interviews were utilized, and the GEMBA method was implemented to identify root cause and improve actions optimizing the stroke pathway.

FINDINGS

The presented case shows the usefulness of the LSS methodology in improving quality performance in a rural hospital. The intervention allowed the BPMC to improve the intravenous tissue plasminogen activator (IV-tPA) administration rate (+15.2%), reducing the process lead time. The lead time of door-to-computer tomography decreased from 52 to 26 min, and the door-to-needle time decreased from 94 to 75 min.

ORIGINALITY/VALUE

The present case study shows the implementation of the LSS methodology aimed to improve the IV-tPA administration rate and reduce the stroke pathway lead time in a rural hospital. The case demonstrates the potential for the LSS methodology to support the AIS pathway optimization and represents a guide for healthcare organizations located in rural areas.