Comparison between in-hospital stroke and community-onset stroke treated with endovascular thrombectomy

Endovascular thrombectomy after 24 hours for patients with acute ischemic stroke due to large vessel occlusion: A systematic review and meta-analysis of outcomes

OBJECTIVE

To evaluate the role of endovascular thrombectomy (EVT) in patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion in the very late window (>24 hours).

METHODS

A systematic review was conducted according to PRISMA guidelines using PubMed, CINAHL, Scopus, and Google Scholar databases till 2024. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS). Outcomes were analyzed with a single-arm meta-analysis (Sidik-Jonkman model) and a double-arm meta-analysis (Mantel-Haenszel model) to compare EVT within and after 24 hours, reporting pooled risk ratios. Analysis was performed using STATA version 18.0 and Review Manager version 5.4.1, with p<0.05 considered significant.

RESULTS

This review included 35 studies with 15,086 patients. The proportion of symptomatic intracerebral hemorrhage (sICH) in patients treated with EVT after 24 hours was 4.78 % (95 % CI: 3.20 %-6.58 %), with a risk ratio (RR) of 0.85 (95 % CI: 0.44-1.64) compared to EVT patients treated within 24 hours. The pooled percentage for functional independence (90 day mRS 0-2) was 35.73 % (95 % CI- 27.26 %, 44.64 %) with a risk ratio of 0.85 (95 % CI: 0.34, 2.09). The proportion of the 90-day mortality was 22.30 % (95 % CI: 16.12 %, 29.09 %), with a risk ratio of 1.08 (95 % CI: 0.73, 1.61). The overall proportion of intracerebral hemorrhage (ICH) was 12.23 % (95 % CI: 5.47-20.86) following EVT after 24 hours.

CONCLUSION

Patients treated with EVT after 24 hours have comparable safety and effectiveness to those treated within 24 hours. The outcomes suggest that EVT after 24 hours is a viable treatment option, offering similar benefits to earlier intervention.

Influence of Stroke-Onset Location on the Efficacy of Endovascular Thrombectomy: Comparison of Outcomes between In-Hospital versus Community-Onset Strokes

BACKGROUND AND PURPOSE

Previous studies have suggested that patients experiencing an in-hospital stroke may face delays in treatment and worse outcomes compared with patients with community-onset strokes. However, most studies occurred when IV thrombolysis was the primary treatment. This study aimed to examine the outcomes of patients experiencing an in-hospital stroke in the endovascular thrombectomy era.

MATERIALS AND METHODS

This was a single-center retrospective cohort study of patients older than 18 years of age with acute ischemic stroke treated with endovascular thrombectomy within 12 hours of stroke onset from January 1, 2015, to April 30, 2021. Patients were classified into 2 groups: in-hospital strokes and community-onset strokes. We compared the time metrics of stroke care delivery, the rate of successful reperfusion, and functional outcome as scored using the mRS score at 90 days (favorable outcome was defined as mRS 0-2). Differences in proportions were assessed using the Fisher exact and χ2 tests as appropriate. For continuous variables, differences in medians between groups were evaluated using Mann-Whitney U tests.

RESULTS

A total of 676 consecutive patients were included, with 69 (10%) comprising the in-hospital stroke group. Patients experiencing in-hospital stroke were more likely to have diabetes (36% versus 18%, P = .02) and less likely to receive thrombolysis (25% versus 68%, P < .001) than those in the community-onset stroke group, but they were otherwise similar. Patients with in-hospital stroke had significantly faster overall time metrics, most notably from stroke recognition to imaging (median, 70 [interquartile range, 38-141] minutes versus 121 [74-228] minutes, P < .001). Successful recanalization was achieved in >75% in both groups (P = .39), with a median NIHSS score at discharge of <4 (P = .18). The 90-day mRS was similar in both groups, with a trend toward higher in-hospital mortality in the in-hospital stroke group (P = .06).

CONCLUSIONS

Patients with in-hospital stroke had shorter workflow delays to initiation of endovascular thrombectomy compared with their community counterparts but with a similar rate of successful recanalization and clinical outcomes. Most important, 90-day mortality and mRS scores were equivalent between in-hospital stroke and community-onset stroke groups.

A single-site retrospective review of in-hospital stroke

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Use of the Acute Stroke Management Questionnaire to Measure Acute Care Nurses' Stroke Knowledge

ABSTRACT

BACKGROUND: Nurses are key in identifying and treating in-hospital strokes (IHSs). Delayed treatment times and poor patient outcomes are associated with IHSs. Information is needed on nurses' stroke knowledge and the objective measurement of stroke knowledge using a validated tool. The Acute Stroke Management Questionnaire (ASMaQ) was recently developed to test stroke knowledge of healthcare professionals but has not been used on a nursing-specific population. METHODS: Through online surveying and use of ASMaQ, we will measure stroke knowledge of nurses caring for adult, hospitalized patients in an urban, southeast US health system. RESULTS: Total N is 196. Most participants (74.5%, n = 146) never worked on a stroke floor; however, almost all (95.9%, n = 188) cared for a stroke patient in the past. Most participants (65.3%, n = 128) reported receiving prelicensure stroke education, and 98.5% (n = 193) received postlicensure stroke education. Acute Stroke Management Questionnaire total scores ranged from 93 to 133 (mean [SD], 117.35 [8.15]). Most participants scored in the good stroke knowledge range for all 3 ASMaQ domains and total ASMaQ score. CONCLUSION: The online delivery of the ASMaQ was successful in testing nurses' stroke knowledge, and nurses were shown to have good stroke knowledge. Future initiatives should focus on discerning whether certain nurse characteristics predict higher or lower levels of stroke knowledge to help inform educational initiatives to improve IHS outcomes.

Effectiveness of endovascular treatment for in-hospital stroke vs. community-onset stroke: a propensity score-matched analysis

BACKGROUND

The effectiveness of endovascular treatment for in-hospital stroke remains debatable. We aimed to compare the outcomes between patients with in-hospital stroke and community-onset stroke who received endovascular treatment.

METHODS

This prospective registry-based cohort study included consecutive patients who underwent endovascular treatment from January 2013 to December 2022 and were registered in the Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy study and Yonsei Stroke Cohort. Functional outcomes at day 90, radiological outcomes, and safety outcomes were compared between the in-hospital and community-onset groups using logistic regression and propensity score-matched analysis.

RESULTS

Of 1,219 patients who underwent endovascular treatment, 117 (9.6%) had in-hospital stroke. Patients with in-hospital onset were more likely to have a pre-stroke disability and active cancer than those with community-onset. The interval from the last known well to puncture was shorter in the in-hospital group than in the community-onset group (155 vs. 355 min, p<0.001). No significant differences in successful recanalization or safety outcomes were observed between the groups; however, the in-hospital group exhibited worse functional outcomes and higher mortality at day 90 than the community-onset group (all p<0.05). After propensity score matching including baseline characteristics, functional outcomes after endovascular treatment did not differ between the groups (OR: 1.19, 95% CI 0.78-1.83, p=0.4). Safety outcomes did not significantly differ between the groups.

CONCLUSION

Endovascular treatment is a safe and effective treatment for eligible patients with in-hospital stroke. Our results will help physicians in making decisions when planning treatment and counseling caregivers or patients.

Mechanical Thrombectomy for In-Hospital Onset Stroke: A Comparative Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

In-hospital onset stroke (IHOS) accounts for a significant proportion of large vessel occlusion acute ischemic strokes, leading to worse outcomes due to delays in evaluation and treatment. Limited data is available on the effectiveness of mechanical thrombectomy in IHOS patients. This study aims to assess the safety and efficacy of mechanical thrombectomy for patients with IHOS and compare the outcomes with those of community-onset strokes (COS).

METHODS

We conducted a systematic review and meta-analysis following established guidelines, by searching PubMed, Scopus, Web of Science, and Embase databases up to April 11, 2023. Eligible studies reporting outcomes of interest were included, and relevant data was extracted and analyzed using Stata software version 17.0.

RESULTS

In a meta-analysis of nine studies, comprising 540 cases of IHOS and 5,744 cases of COS, IHOS cases had a significantly lower rate of good functional outcomes on follow-up (35.46% vs. 40.74%, P<0.01) and a higher follow-up mortality rate (26.29% vs. 18.08%, P<0.01) compared to COS patients. Both groups had comparable successful recanalization rates (IHOS: 79.32% vs. COS: 81.44%, P=0.11), incidence rates of periprocedural complications (IHOS: 15.10%, COS: 12.96%, P=0.78), and symptomatic intracranial hemorrhage (IHOS: 6.24%, COS: 6.88%, P=0.67). It is worth noting that much of the observed effect size for mortality and good functional outcomes on follow-up was derived from only one and two studies, respectively.

CONCLUSION

While the current literature suggests that mechanical thrombectomy is a safe and effective treatment for IHOS, further research is necessary to comprehensively evaluate its impact, particularly during follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recognition of Strokes in the ICU: A Narrative Review

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

Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis

Background

Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results.

Methods

We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis.

Results

6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively).

Conclusions

No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.

Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with Malignancy: A Systematic Review

Background: Ischemic stroke is a common occurrence in patients with concomitant malignancy. Systemic thrombolysis is often contraindicated in these patients, and mechanical thrombectomy (MT) is the preferred method of intervention. This review aims to collect the available data on the safety and efficacy of MT in cancer patients (CPs).Methods: The PubMed/MEDLINE and SCOPUS databases were systematically searched for studies assessing safety (mortality, intracranial hemorrhage) and efficacy (reperfusion, functional outcome) indices in CPs receiving MT. Potentially relevant parameters examined in solitary studies were also extracted (e.g., stroke recurrence, brain malignancy).Results: A total of 18 retrospective studies of various methodologies and objectives were identified. Rates of in-hospital mortality, intracranial hemorrhage of any kind, reperfusion rates, and discharge condition did not seem to present any considerable differences between CPs and patients without cancer. On the contrary, 90-day mortality was higher and 90-day functional independence was lower in CPs. Three studies on cancer-related stroke (no other identifiable etiology and high D-dimer levels in the presence of active cancer) showed constant tendencies towards unfavorable conditions. Conclusions: Per the available evidence, MT appears to be a safe treatment option for CPs. It is still unclear whether the 90-day mortality and outcome rates are more heavily influenced by the malignancy and not the intervention itself, so MT can be considered in CPs with prospects of a good functional recovery, undertaking an individualized approach.

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

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

Younger age of stroke in low-middle income countries is related to healthcare access and quality

Stroke is the second leading cause of mortality globally with higher burden and younger age in low‐middle income countries (LMICs) than high‐income countries (HICs). However, it is unclear to what extent differences in healthcare access and quality (HAQ) and prevalence of risk factors between LMICs and HICs contribute to younger age of stroke in LMICs. In this systematic review, we conducted meta‐analysis of 67 articles and compared the mean age of stroke between LMICs and HICs, before and after adjusting for HAQ index. We also compared the prevalence of main stroke risk factors between HICs and LMICs. The unadjusted mean age of stroke in LMICs was significantly lower than HICs (63.1 vs. 68.6), regardless of gender (63.9 vs. 66.6 among men, and 65.6 vs. 70.7 among women) and whether data were collected in population‐ (64.7 vs. 69.5) or hospital‐based (62.6 vs. 65.9) studies (all p < 0.01). However, after adjusting for HAQ index, the difference in the mean age of stroke between LMICs and HICs was not significant (p ≥ 0.10), except among women (p = 0.048). In addition, while the median prevalence of hypertension in LMICs was 23.4% higher than HICs, the prevalence of all other risk factors was lower in LMICs than HICs. Our findings suggest a much larger contribution of HAQ to the younger mean age of stroke in LMICs, as compared with other potential factors. Additional studies on stroke care quality and accessibility are needed in LMICs.

Impact of renal impairment on short-term outcomes following endovascular thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

The impact of renal impairment on the outcomes of patients with acute ischemic stroke treated with endovascular thrombectomy was relatively limited and contradictory. We performed a systematic review and meta-analysis to investigate this.

AIMS

We registered a protocol in September 2020 and searched MEDLINE, EMBASE, and Google Scholar accordingly. Renal impairment was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m². Predefined outcomes included functional independence (defined as a modified Rankin Scale of 0, 1, or 2) at three months, successful reperfusion, mortality, and symptomatic intracerebral hemorrhage.

SUMMARY OF REVIEW

Eleven studies involving 3453 patients were included. For the unadjusted outcomes, renal impairment was associated with fewer functional independence (odds ratio (OR), 0.49; 95% confidence interval (CI), 0.39-0.62) and higher mortality (OR, 2.55; 95% CI, 2.03-3.21). Renal impairment was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63-1.00) and symptomatic intracerebral hemorrhage (OR, 1.41; 95% CI, 0.95-2.10). For the adjusted outcomes, results derived from a multivariate meta-analysis were consistent with the respective unadjusted outcomes: functional independence (OR, 0.59; 95% CI, 0.45-0.77), mortality (OR, 2.23, 95% CI, 1.45-3.43), and symptomatic intracerebral hemorrhage (OR, 1.34; 95% CI, 0.85-2.10).

CONCLUSIONS

We presented the first systematic review to demonstrate that renal impairment is associated with fewer functional independence and higher mortality. Future endovascular thrombectomy studies should publish complete renal estimated glomerular filtration rate data to facilitate prognostic studies and permit estimated glomerular filtration rate to be analyzed in a continuous variable.Systematic Review Registration: PROSPERO CRD42020191309.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Workflow and Outcomes of Endovascular Thrombectomy for In-Hospital Stroke a Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Acute strokes due to large vessel occlusion in hospitalized patients is not uncommon. We performed a systematic review and meta-analysis to investigate the timing and outcome of endovascular thrombectomy (EVT) for in-hospital stroke.

METHODS

We conducted a meta-analysis of clinical studies published in English until September 2020 in the MEDLINE and Cochrane databases. Studies reporting original data on the characteristics and outcomes of in-hospital stroke patients treated with EVT were included. We extracted data on the time-metrics from last known well (LKW) until reperfusion was achieved. We also collected data on procedural and functional outcomes.

RESULTS

Out of 5093 retrieved studies, 8 were included (2,622 patients). The median age was 71.4 years and median NIHSS score on admission was 16. Patients were mostly admitted to the cardiology service (27.3%). The pooled time from LKW to recognition by staff was 72.9 min (95% CI: 40.7 to 105 min). 25.6% received IV tPA. The mean time from stroke recognition to arterial puncture was 134.5 min (95% CI: 94.9 to 174.1). Successful reperfusion occurred in 82.8.% with a pooled mean time from detection to reperfusion of 193.1 min (95% CI: 139.5 to 246.7). The 90-day independent functional outcome was reported in 42% of patients (95% CI 29 to 55%).

CONCLUSION

EVT can be performed safely and successfully for in-hospital strokes. Noticeable delays from LKW to detection and then to puncture are noted. This calls for better stroke pathways to identify and treat these patients.

BACKGROUND

Stroke in hospitalized patients, referred to as in-hospital stroke (IHS), accounts for 2.2-17% of all strokes.¹ The majority of these are ischemic while intracranial hemorrhage represents 2-11% of all IHS.¹ These patients are expected to have a rapid diagnosis and treatment given the ongoing medical supervision, and therefore favorable outcomes.^1-3 However, existing studies report poor outcomes in patients with IHS with a mortality risk that exceeds that of community-onset stroke (COS): 24.7% vs 9.6%.⁴ Surviving IHS patients are also less likely to be discharged home compared to COS (27.7% vs 49.9%) and to be functionally independent at 3 months (31.0% vs 50.4%).^1-4.