Long-Term Survival After Stroke According to Reperfusion Therapy, Cardiovascular Therapy and Gender

Sex Disparities in the Direct Cost and Management of Stroke: A Population-Based Retrospective Study

(1) Background: Previous studies have identified disparities in stroke care and outcomes by sex. Therefore, the main objective of this study was to evaluate the average cost of stroke care and the existence of differences in care provision by biological sex. (2) Methods: This observational study adhered to the recommendations of the STROBE statement. The calculation of costs was performed based on the production cost of the service or the rate paid for a set of services, depending on the availability of the corresponding information. (3) Results: A total of 336 patients were included, of which 47.9% were women, with a mean age of 73.3 ± 11.6 years. Women were typically older, had a higher prevalence of hypertension (p = 0.005), lower pre-stroke proportion of mRS 0-2 (p = 0.014), greater stroke severity (p < 0.001), and longer hospital stays (p = 0.017), and more were referred to residential services (p = 0.001) at 90 days. Women also required higher healthcare costs related to cardiovascular risk factors, transient ischemic strokes, institutionalization, and support needs; in contrast, they necessitated lower healthcare costs when undergoing endovascular therapy and receiving rehabilitation services. The unadjusted averaged cost of stroke care was EUR 22,605.66 (CI95% 20,442.8-24,768.4), being higher in women [p = 0.027]. The primary cost concept was hospital treatment (38.8%), followed by the costs associated with dependence and support needs (36.3%). At one year post-stroke, the percentage of women not evaluated for a degree of dependency was lower (p = 0.008). (4) Conclusions: The total unadjusted costs averaged EUR 22,605.66 (CI95% EUR 20,442.8-24,768.4), being higher in women compared to men. The primary cost concept was hospital treatment (38.8%), followed by the costs associated with dependence and support needs (36.3%).

Speech-language pathologists' perspectives of dysphagia following reperfusion therapies: An Australian mixed-methods study

PURPOSE

To investigate speech-language pathologists' (SLPs) perceptions and clinical experiences of dysphagia management following reperfusion therapies.

METHOD

A multi-staged mixed approach involving a two-phase cross-sectional design was used. Data generated during phase 1 (a purpose-built, online survey) guided the development of phase 2 (semi-structured interviews). Sixty-two SLPs participated in phase 1 and six SLPs participated in phase 2.

RESULT

SLPs in both phases reported perceived changes in dysphagia presentation according to the success of reperfusion therapy administered and had concerns regarding worsened dysphagia following unsuccessful procedures. Fluctuations in dysphagia were more frequently reported in the acute stage post-stroke. SLPs reported increased workload demands due to increased interhospital transfers between ECR/thrombolysis centres and referring facilities. The optimal timing for swallowing screening and assessment was not identified, with initial SLP involvement ranging from during the administration of thrombolysis to up to 24 hours post-reperfusion therapy.

CONCLUSION

Preliminary evidence suggests that SLPs perceive that the presentation of post-stroke dysphagia is changing, with increasing fluctuations and complexities in the acute stage of post-stroke care, within the context of increasing use of reperfusion therapies. There is a critical need for research investigating the trajectory of dysphagia in the acute stage to inform dysphagia management within this patient population.

Development and validation of a nomogram model for predicting unfavorable functional outcomes in ischemic stroke patients after acute phase

Introduction

Prediction of post-stroke functional outcome is important for personalized rehabilitation treatment, we aimed to develop an effective nomogram for predicting long-term unfavorable functional outcomes in ischemic stroke patients after acute phase.

Methods

We retrospectively analyzed clinical data, rehabilitation data, and longitudinal follow-up data from ischemic stroke patients who underwent early rehabilitation at multiple centers in China. An unfavorable functional outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days after onset. Patients were randomly allocated to either a training or test cohort in a ratio of 4:1. Univariate and multivariate logistic regression analyses were used to identify the predictors for the development of a predictive nomogram. The area under the receiver operating characteristic curve (AUC) was used to evaluate predictive ability in both the training and test cohorts.

Results

A total of 856 patients (training cohort: n = 684; test cohort: n = 172) were included in this study. Among them, 518 patients experienced unfavorable outcomes 90 days after ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment classification (p = 0.024), antihypertensive agents use [odds ratio (OR) = 1.86; p = 0.041], 15-day Barthel Index score (OR = 0.930; p < 0.001) and 15-day mRS score (OR = 13.494; p < 0.001) were selected as predictors for the unfavorable outcome nomogram. The nomogram model showed good predictive performance in both the training (AUC = 0.950) and test cohorts (AUC = 0.942).

Conclusion

The constructed nomogram model could be a practical tool for predicting unfavorable functional outcomes in ischemic stroke patients underwent early rehabilitation after acute phase.

Distinctive Gut Microbiota Alteration Is Associated with Poststroke Functional Recovery: Results from a Prospective Cohort Study

Objectives

Functional prognosis is potentially correlated with gut microbiota alterations following the dysregulation of the gut-microbiota-brain axis after stroke. This study was designed to explore the poststroke alterations of gut microbiota and potential correlations between gut microbiota and global functions.

Methods

A total of thirty-eight patients with stroke and thirty-five healthy demographics-matched controls were recruited. Their fecal DNAs were extracted, and the V3-V4 regions of the conserved bacterial 16S RNA were amplified and sequenced on the Illumina MiSeq platform. Microbial composition, diversity indices, and species cooccurrence were compared between groups. Random forest and receiver operating characteristic analysis were used to identify potential diagnostic biomarkers. Relationships between discriminant bacteria and poststroke functional outcomes were estimated.

Results

Higher alpha diversity of gut microbiota was observed in poststroke patients as compared to the healthy controls (p < 0.05). Beta diversity showed that microbiota composition in the poststroke group was significantly different from that in the control group. Relative abundance of nine genera increased significantly in poststroke patients, while 82 genera significantly decreased (p < 0.05). The accuracy, specificity, and susceptibility of the optimal model consisted of the top 10 discriminant species were 93%, 100%, and 86%, respectively. Subgroup analysis showed that bacterial taxa abundant between subacute and chronic stroke patients were overall different (p < 0.05). The modified Rankin scale (mRS) (r = −0.370, p < 0.05), Fugl-Meyer assessment (FMA) score (r = 0.364, p < 0.05), water swallow test (WST) (r = 0.340, p < 0.05), and Barthel index (BI) (r = 0.349, p < 0.05) were significantly associated with alterations of distinctive gut microbiota.

Conclusions

The gut microbiota in patients with stroke was significantly changed in terms of richness and composition. Significant associations were detected between alterations of distinctive gut microbiota and global functional prognosis. It would facilitate novel treatment target selection in the context of stroke while the causal relationships between distinctive gut microbiota alterations and functional variations need to be further verified with well-designed studies.

Are there socio-economic inequities in access to reperfusion therapy: The stroke 69 cohort

BACKGROUND AND PURPOSE

Low socio-economic status of individuals has been reported to be associated with a higher incidence of stroke and influence the diagnosis after revascularization. However, whether it is associated with poorer acute stroke management is less clear. To determine whether social deprivation was associated with a poorer access to reperfusion therapy, either intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) in a population-based cohort.

METHODS

Over a 14-month period, all consecutive adult patients admitted to any emergency department or a comprehensive or primary stroke center (CSC/PSC) of the Rhône county with a confirmed ischemic stroke were included. The socioeconomic status of each patient was measured using the European Deprivation Index (EDI). The association between EDI and access to reperfusion therapy was assessed in univariate and multivariate logistic regression analyses.

RESULTS

Among the 1226 consecutive IS patients, 316 (25%) were admitted directly in a PSC or CSC, 241 (19.7%) received a reperfusion therapy; 155 IVT alone, 20 EVT alone, and 66 both therapies. Median age was 79 years, 1030 patients had an EDI level of 1 to 4, and 196 an EDI of 5 (the most deprived group). The most deprived patients (EDI level 5) did not have a poorer access to reperfusion therapy compared to all other patients in univariate (OR 1.22, 95%CI [0.85; 1.77]) nor in multivariate analyses (adjOR 0.97, 95%CI [0.57; 1.66]).

CONCLUSIONS

We did not find any significant association between socioeconomic deprivation and access to reperfusion therapy. This suggests that the implementation of EVT was not associated with increased access inequities.

C-Reactive Protein and White Blood Cell Count in Non-Infective Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Background: Previous studies on inflammatory biomarkers in acute ischemic stroke (AIS) produced divergent results. We evaluated whether C-reactive protein (CRP) and white blood cell count (WBC) measured fasting 12-24 h after intravenous thrombolysis (IVT) were associated with outcome in AIS patients without concomitant infection. Methods: The study included 352 AIS patients treated with IVT. Excluded were patients with community-acquired or nosocomial infection. Outcome was measured on discharge and 90 days after stroke onset with the modified Rankin scale (mRS) and defined as poor outcome (mRS 3-6) or death (mRS = 6). Results: Final analysis included 158 patients (median age 72 years (interquartile range 63-82), 53.2% (n = 84) women). Poor outcome on discharge and at day 90 was 3.8-fold and 5.8-fold higher for patients with CRP ≥ 8.65 mg/L (fifth quintile of CRP), respectively, compared with first quintile (<1.71 mg/L). These results remained significant after adjustment for potential confounders (odds ratio (OR) on discharge = 10.68, 95% CI: 2.54-44.83, OR at day 90 after stroke = 7.21, 95% CI: 1.44-36.00). In-hospital death was 6.3-fold higher for patients with fifth quintile of CRP as compared with first quintile and remained independent from other variables (OR = 4.79, 95% CI: 1.29-17.88). Independent predictors of 90-day mortality were WBC < 6.4 × 10⁹ /L (OR = 5.00, 95% CI: 1.49-16.78), baseline National Institute of Health Stroke Scale (NIHSS) score (OR = 1.13 per point, 95% CI: 1.01-1.25) and bleeding brain complications (OR = 5.53, 95% CI: 1.59-19.25) but not CRP ≥ 8.65 mg/L. Conclusions: Non-infective CRP levels are an independent risk factor for poor short- and long-term outcomes and in-hospital mortality in AIS patients treated with IVT. Decreased WBC but not CRP is a predictor for 90-day mortality.

Complex chronic patients as an emergent group with high risk of intracerebral haemorrhage: an observational cohort study

Background

Demographic aging is a generalised event and the proportion of older adults is increasing rapidly worldwide with chronic pathologies, disability, and complexity of health needs. The intracerebral haemorrhage (ICH) has devastating consequences in high risk people. This study aims to quantify the incidence of ICH in complex chronic patients (CCP).

Methods

This is a multicentre, retrospective and community-based cohort study of 3594 CCPs followed up from 01/01/2013 to 31/12/2017 in primary care without a history of previous ICH episode. The cases were identified from clinical records encoded with ICD-10 (10th version of the International Classification of Diseases) in the e-SAP database of the Catalan Health Institute. The main variable was the ICH episode during the study period. Demographic, clinical, functional, cognitive and pharmacological variables were included. Descriptive and logistic regression analyses were carried out to identify the variables associated with suffering an ICH. The independent risk factors were obtained from logistic regression models, ruling out the variables included in the HAS-BLED score, to avoid duplication effects. Results are presented as odds ratio (OR) and 95% confidence interval (CI). The analysis with the resulting model was also stratified by sex.

Results

161 (4.4%) participants suffered an ICH episode. Mean age 87 ± 9 years; 55.9% women. The ICH incidence density was 151/10000 person-years [95%CI 127–174], without differences by sex. Related to subjects without ICH, presented a higher prevalence of arterial hypertension (83.2% vs. 74.9%; p = 0.02), hypercholesterolemia (55.3% vs. 47.4%, p = 0.05), cardiovascular disease (36.6% vs. 28.9%; p = 0.03), and use of antiplatelet drugs (64.0% vs. 52.9%; p = 0.006). 93.2% had a HAS-BLED score ≥ 3. The independent risk factors for ICH were identified: HAS-BLED ≥3 [OR 3.54; 95%CI 1.88–6.68], hypercholesterolemia [OR 1.62; 95%CI 1.11–2.35], and cardiovascular disease [OR 1.48 IC95% 1.05–2.09]. The HAS_BLED ≥3 score showed a high sensitivity [0.93 CI95% 0.89–0.97] and negative predictive value [0.98 (CI95% 0.83–1.12)].

Conclusions

In the CCP subgroup the incidence density of ICH was 5–60 times higher than that observed in elder and general population. The use of bleeding risk score as the HAS-BLED scale could improve the preventive approach of those with higher risk of ICH.

Trial registration

This study was retrospectively registered in ClinicalTrials.gov (NCT03247049) on August 11/2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02004-4.

Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands

Background

The effectiveness of endovascular treatment (EVT) for large vessel occlusion (LVO) stroke severely depends on time to treatment. However, it remains unclear what the value of faster treatment is in the years after index stroke. The aim of this study was to quantify the value of faster EVT in terms of health and healthcare costs for the Dutch LVO stroke population.

Methods

A Markov model was used to simulate 5-year follow-up functional outcome, measured with the modified Rankin Scale (mRS), of 69-year-old LVO patients. Post-treatment mRS was extracted from the MR CLEAN Registry (n=2892): costs per unit of time and Quality-Adjusted Life Years (QALYs) per mRS sub-score were retrieved from follow-up data of the MR CLEAN trial (n=500). Net Monetary Benefit (NMB) at a willingness to pay of €80 000 per QALY was reported as primary outcome, and secondary outcome measures were days of disability-free life gained and costs.

Results

EVT administered 1 min faster resulted in a median NMB of €309 (IQR: 226;389), 1.3 days of additional disability-free life (IQR: 1.0;1.6), while cumulative costs remained largely unchanged (median: -€15, IQR: −65;33) over a 5-year follow-up period. As costs over the follow-up period remained stable while QALYs decreased with longer time to treatment, which this results in a near-linear decrease of NMB. Since patients with faster EVT lived longer, they incurred more healthcare costs.

Conclusion

One-minute faster EVT increases QALYs while cumulative costs remain largely unaffected. Therefore, faster EVT provides better value of care at no extra healthcare costs.

Statins in Stroke

BACKGROUND

Stroke is a major cause of mortality and disability in modern societies. Statins are effective medications in decreasing cardiovascular events through lipid lowering and pleiotropic effects.

OBJECTIVE

To summarize current evidence regarding the role of statins in the prevention and management of stroke.

METHODS

A narrative review of current evidence regarding the effect of statins in stroke management. Electronic searches of MEDLINE, EMBASE and Cochrane Databases were performed.

RESULTS

In primary prevention of stroke in patients with risk factors but no established cardiovascular disease, potent statins such as atorvastatin and rosuvastatin have shown some benefits, but the clinical relevance of this effect is questionable. In populations at higher risk of stroke, such as patients with established coronary heart disease, the majority of relevant studies have shown a beneficial effect of statins in preventing stroke. Similarly, in patients with a previous cerebrovascular event, there is a clear benefit of statins for the prevention of recurrent events. The use of statins is not associated with an increased risk of intracranial bleeding in primary prevention studies. There may be an increased incidence of non-fatal hemorrhagic stroke with high dose statins in patients with a previous cerebrovascular event. Patients who experience a stroke while on statins should not discontinue statins. In addition, statins are associated with better survival and improved functional outcome when administered during the acute phase of stroke in statin-naive patients. In contrast, statins do not confer any benefit in patients with acute ischemic stroke who receive thrombolysis.

CONCLUSION

Treatment with statins prevents ischemic stroke, especially in patients with high cardiovascular risk and established atherosclerotic disease. It seems that both lipid lowering and pleiotropic effects contribute to these effects.